There are many methods of breast reconstruction, and they fall into two main categories: autologous tissue breast reconstruction and prosthetic breast reconstruction. As the name implies, prosthetic breast reconstruction is the use of breast implants to reconstruct the breast, while autologous tissue breast reconstruction is the use of the patient’s own tissue to reconstruct the breast, the latter can be divided into skin flap breast reconstruction and fat graft breast reconstruction, depending on the tissue used. The latter can be divided into skin flap breast reconstruction and fat graft breast reconstruction depending on the tissue used.
Flap Breast Reconstruction
This method involves transferring skin, fat, and sometimes some muscle from other parts of the body to the breast, and this tissue, called a flap, is shaped into a breast. The area where the flap is provided is called the donor area. Directly cutting off said tissue and placing it in the breast is not viable, and the flap needs to retain some muscle that cannot be cut off, or the major blood vessels within the flap are anastomosed with those in the reconstructed area through microsurgical techniques, all of which are used to provide an adequate blood supply to the flap to ensure its survival. Flaps commonly used for breast reconstruction include the following.
- The latissimus dorsi muscle flap. This flap is taken from one side of the back and is transferred to the chest. In order to supply blood to the flap, the muscle (latissimus dorsi) connection between the flap and the donor area is preserved and cannot be severed. The advantage of choosing this flap is that the blood supply to the muscle is excellent and vascularly constant, so there is little chance of postoperative blood supply disturbance, which means that the reconstructed breast will easily survive, or there is less chance of necrosis. However, the small amount of tissue that can be provided by this flap is usually insufficient to reconstruct the shape of the breast, and sometimes an auxiliary prosthesis is required. In addition, the donor area providing the flap can result in asymmetry on both sides of the back and can leave scars on the back, and upper extremity function may be somewhat compromised.
- Abdominal flap. The abdomen is the area that can provide the greatest amount of tissue of any part of the body, and an abdominal flap can be used when a large amount of tissue is needed, including 2 modalities.
- The transverse rectus abdominis muscle flap (TRAM flap), which transfers a flap from the lower abdomen to the chest to complete breast reconstruction, leaves part of the muscle on one side of the abdomen (rectus abdominis muscle) uncut for the purpose of supplying blood to the flap. This flap provides sufficient tissue, but has the disadvantage of losing some muscle, so there is a high likelihood of postoperative abdominal wall hernia or abdominal wall bulge, and the scar under the abdomen is usually more than 30 cm.
- The inferior abdominal artery perforator flap (DIEP flap), in which the desired flap tissue is removed completely from the abdomen and the vessels within the flap are microscopically anastomosed to the chest vessels to provide blood for the reconstructed breast. This method is the least invasive of the abdominal flaps because no abdominal muscle is lost, and is considered the “gold standard” for breast reconstruction, but it also leaves a long wound in the abdomen.
Breast reconstruction using the above-mentioned autologous flap will necessarily cause some degree of damage to the donor area, or what is commonly referred to as “repairing one wound with another”. However, the breast reconstructed with an autologous flap feels softer and conforms to the physiological changes of normal breast sagging over time, so there is less likelihood of asymmetry with the contralateral side later on.
Fat graft breast reconstruction
Breast reconstruction using only one’s own fat for grafting or autologous fat combined with prosthesis is a relatively new approach that has emerged in recent years. The fat can come from the patient’s own “obese” areas such as the waist, abdomen, or thighs, allowing for both liposuction and breast reconstruction, and this method does not cause long wounds in the donor area.
However, several procedures may be required to achieve satisfactory results with fat grafting.
Breast reconstruction with implants
From a purely donor-area perspective, breast reconstruction with implants is the least damaging approach to the donor area.
However, the surface of the implant needs to have adequate tissue coverage, otherwise the implant may protrude into the subcutaneous area and have too pronounced an outline, so it is sometimes necessary to increase the tissue thickness to cover the implant in combination with the aforementioned latissimus dorsi flap and autologous fat grafting. In addition, due to its own characteristics, the breast implant does not gradually sag with age, thus showing asymmetry with the opposite breast, which may require another surgical adjustment.
In conclusion, there are many options for breast reconstruction, and the decision of which method to use will require the surgeon to make a decision based on the patient’s specific situation.