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In essence, there are two materials used in reconstructing the female breast. One is implants, usually containing saline or silicone. The other is your own tissue, also known as autologous tissue.
Regardless of which material you choose, it is important that your cancer surgeon and plastic surgeon work together. If they carefully plan the mastectomy incision, they can preserve skin and tissue to make your reconstruction easier, safer and more attractive.
When adequate soft tissue remains, an implant filled with silicone and/or saline can effectively recreate the breast mound. This may be the final, permanent implant or it can serve as an initial spacer.
A spacer saves the patient and plastic surgeon time and effort for the next phase of reconstruction. Placed under the chest wall muscle, the spacer conserves valuable skin, shapes the overlying soft tissue, and opens the pocket to hold the final implant or an autologous tissue flap.
Sometimes, adequate soft tissue coverage isn’t available after surgery and tissue must be added. Tissue expansion and autologous flap reconstruction are two ways of doing this. For tissue expansion, you will have an inflatable prosthesis inserted in your breast area, called an expander. This helps the soft tissue stretch until there is adequate coverage for an implant. To facilitate stretching, the implant is injected with saline at regular intervals in the doctor’s office. After a minimum of three months, the expander is surgically removed and replaced with the permanent implant.
A variation of this approach employs a "permanent expander" as the final implant. In many situations, especially in patients who are relatively small-breasted and who opt for a skin-sparing type of mastectomy, expansion can be accomplished with serial implants.
In general, breast implant reconstruction is easier and simpler than autologous tissue reconstruction. These surgeries require shorter hospitalization and recovery time and carry less surgical risk. However, there is the potential for complications. These include risks of implant hardening, rupture, leakage or displacement, rippling and wrinkling. Long-term effects include risks of soft tissue compression, thinning and the need for corrective surgeries. Implants usually require replacement after 10-15years.
The other method of reconstruction uses your own (autologous) tissue rather than implants. Two types of tissue can be employed. Pedicle flaps are always kept connected to the body with muscle and blood vessels. They typically come from the back (latissimus dorsi myocutaneous flap) or the abdomen (transverse rectus abdominus myocutaneous or TRAM flap).
Free flaps are completely detached from the body and then transplanted. Blood vessels are re-attached using microsurgery. These flaps most commonly come from the abdomen, but can also come from the buttocks, thigh, or groin.
Autologous tissue reconstruction is generally more difficult to perform, requires 4-7 days of hospitalization and 4-8 hours or more of operating time, and carries a significant risk of partial or complete flap loss and additional scars. The advantage of the flap procedure is that when it works it is completely natural, requires no further surgeries and tends to afford an improved body image and proportion.
A TRAM (transverse rectus abdominis muscle) flap is a breast reconstruction technique using the patient's own excess abdominal fat tissue. The advantages of this operation are that it avoids the use of an implant and accomplishes a tummy tuck at the same time. The disadvantages are the long abdominal scar, as well as a much longer recovery period. For some patients, tissue can be transferred from the back muscles or even the buttocks.
Complete breast reconstruction also includes rebuilding the nipple-areola complex. It is the final touch on a uniform, artistic, and identifiable breast that looks like the opposite breast. Local flaps, with or without skin grafts, are used. Tattooing makes the color match. Nipple-areola reconstruction is usually an outpatient surgery or office procedure. While it is not necessary, it is the step that brings you closest to your natural form.