Reconstruction

Reconstruction Examples

1. Expander/implant reconstruction

Advantages

- Least amount of surgery
- No additional scars
- Advantages greater with bilateral reconstruction  

Disadvantages
- Two step procedure: temporary expander at initial surgery followed by permanent implant at a later time
- May be difficult to match opposite side  
- Greater risk of infection and overlying skin loss
- Difficult to get normal tear drop (ptotic) shape of breast (too round)                   


         
Implant Reconstruction - Right is the reconstructed breast and the left is after an implant to achieve symmetry.  Note round shape without normal ptosis (droopiness) on right.


 


Bilateral Implant Reconstruction images: implants can look more natural when performed on both breasts (better symmetry)



2. DIEP/TRAM flap reconstruction

- Muscle and skin from the lower abdomen is used to fill the space created by removing all the breast tissue from beneath the skin 
- Variations include pedicled, free, DIEP and muscle-sparing

Advantages:
- One stage
- Most natural shape and feel
- Also get abdominoplasty (tummy tuck)

Disadvantages:
- Most surgery, longest recovery
- Abdominal scar
- Can get fat necrosis of tissue (lumpiness) 
- Disadvantages magnified by bilateral DIEP/TRAM reconstruction

  
                                   
DIEP/TRAM Reconstruction images:
1. Skin from lower abdomen. Areola tattoo and nipple created.No sensation.
2. Lower abdominal incision.
3. Without nipple reconstruction



3. Latisimus flap reconstruction

Advantages
- Intermediate surgery
- One stage reconstruction
- Intermediate result

Disadvantages
- Scar on back
- Usually requires an implant beneath in addition to flap for adequate size
- Infection risk with implant
- Muscle and nerve division



Latissimus flap reconstruction images
Bellow, step-by-step patient photos of Latisimus flap reconstruction


Prior to masectomy


After Latissimus flap, before nipple creation


After nipple and areola creation         

Back scar 
Photo courtesy of Dr. Kevin Bethke    



4. Nipple-sparing mastectomy

With a nipple-sparing mastectomy the nipple-areolar complex is preserved rather than removed as in a standard skin-sparing mastectomy. In both types of mastectomy all of the breast tissue from the lower fold of the breast to the collar bone and from the mid chest (sternum) to the lateral chest is removed.
Nipple-sparing mastectomies are a relatively new concept. There has always been some concern about a higher risk of the cancer coming back in the nipple-areolar area if it is preserved. So far, research has not shown this to be a problem if used for prophylactic mastectomies or in patients with small cancers located a distance from the nipple.

Advantage of nipple-sparing mastectomy:
- Best cosmetic result

Disadvantages of nipple-sparing mastectomy:
- Theoretical higher risk of cancer recurrence
- Literature shows about a 15% risk of the nipple-areolar skin dying. In that case the nipple and areola is removed and you end up with a skin-sparing mastectomy
- Nipple has no sensation (there is always a strip of numbness across the chest with any mastectomy)
- The nipple loses its protrusion and the areola color fades over time.


Before surgery

After surgery (with implants)
Nipple sparing mastectomy images:
Lateral incision gives best surgical exposure and least risk of nipple-areolar healing problems.

All images on this page courtesy of Dr. Kevin Bethke and Dr. Abhay Gupta.