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Breast reconstruction techniques vary greatly. Some procedures use breast implants, others use your body's own tissue (known as autologous tissue transfer), and some procedures use a combination. Our surgeons will discuss each technique with you and determine which type can best meet your needs and goals.

"I feel better, and that's what it's all about."

Free Flap (Autologous) Breast Reconstruction

Autologous tissue reconstruction methods require the transplantation of living skin, fat and some muscle from a different part of the body to replace the breast tissue removed in the mastectomy. Once successfully transplanted, the tissue can be sculpted to create optimal shape and size fully restoring breast symmetry. At Penn Medicine, the most common flaps performed are the free TRAM, DIEP and SIEA flaps, which use tissue from the abdomen.

Free flap breast reconstruction uses tissues from your own body to reconstruct the breasts after mastectomy. This is also called "autologous tissue reconstruction." Penn Medicine performs the largest volume of free flap reconstruction surgeries in the United States.

Advantages of free flap breast reconstruction:

  • Your own tissue is used to reconstruct your breast.
  • Flap reconstruction does not require maintenance or additional surgeries. Breast implants may need to be replaced.
  • Typically, flap reconstruction produces a more natural-looking result, with tissue that will change with you as your body changes.
  • It tolerates radiation better than an implant.
  • If tissue is removed from the lower abdomen, the cosmetic result may be similar to a "tummy tuck."

Disadvantages of free flap breast reconstruction:

  • The surgery time during the operation, which includes mastectomy, is long. Unilateral (one breast) surgery is approximately four to five hours, and bilateral (both breasts) surgery may take seven to nine hours.
  • There will be scars on your abdomen and each reconstructed breast. There is also a small risk of hernia.

Types of Free Flap Breast Reconstruction

There are several different types of free flap breast reconstruction. Usually the tissue is taken from your lower abdomen. There are three possible types of free flap reconstruction from the lower abdomen. The decision of which of these three is best for you is not finalized until the surgery is started and we can look at the anatomy of your abdominal wall. It is important to speak to your plastic surgeon to decide the best type of reconstruction for you.

  • Free TRAM flap = Free Transverse Rectus Abdominis Myocutaneous Flap. In this surgery skin, fat, blood vessels and a small piece of muscle are used.
  • DIEP flap = Deep Inferior Epigastric Perforator flap. In this surgery the abdominal muscle is cut in order to get the vessels but no muscle is used.
  • SIEA flap = Superficial Inferior Epigastric Artery flap. In this surgery no incisions are made to the abdominal muscle, all vessels taken are from on top of the muscle.
  • S-GAP flap = Superior Gluteal Artery Perforator Flap. In this surgery, the upper portion of your buttock is used.
  • I-GAP flap = Inferior Gluteal Artery Perforator Flap. In this surgery the lower portion of your buttock is used.
  • TUG/TMG flap = Transverse Upper Gracilis or Transverse Myocutaneous Gracilis Flap. In this surgery, the upper portion of your thighs are used. If you have had a previous major abdominal surgery such as an abdominoplasty (tummy tuck), or if you do not have enough tissue on your lower abdomen to reconstruct your breast, we may be able to use tissue from your buttocks or inner thighs. Many abdominal operations, such as Cesarean sections, do not limit our ability to use the tissue of the lower abdomen.
  • mi-DIEP = Minimally Invasive Deep Inferior Epigastric Perforator. This new, two-part, minimally invasive procedure includes a radical reduction in pain, quicker results to normal function and the virtual elimination of the need for perioperative pain medications.

Breast Reconstruction with Implants

Implant reconstruction, also called mammoplasty, is the surgical placement of breast implants to reconstruct the breast size and shape. Breast implants come in a variety of shapes and sizes to create a natural-looking result. Implant shells are made of silicone, and can contain silicone or saline. The implant your plastic surgeon recommends will depend on your body and desired results.

Breast reconstruction with implants can involve one or two surgeries:

Direct to implant breast reconstruction: Also called “single stage” implant-based breast reconstruction, this method involves placing the breast implant at the same time as the mastectomy. Unlike two-stage implant reconstruction, there is no use of tissue expanders and the reconstruction is completed in one surgery.

Two-stage implant reconstruction: This method requires two surgeries. During the first surgery, which may take place during mastectomy, a balloon-like device called a tissue expander is placed underneath the skin and muscles of the chest wall. The tissue expanders will be gradually filled with saline over a period of time. Once they are full, a second surgery is scheduled to remove the tissue expander and place the implants. The entire process can take between three to six months.

Breast implants can be made out of saline (salt water) or silicone gel. Both are approved by the FDA. Your plastic surgeon will help you to make the choice of permanent implants that are best for you.

Common Questions About Breast Reconstruction with Implants

Why is tissue expansion needed? After a mastectomy, your breast surgeon needs to make sure that all breast tissue is removed. In order to do this, you are left with only a very thin layer of breast skin. This breast skin must be handled slowly and gently in order to stretch around the implant.

Do breast implants last forever? No. Both saline and silicone implants will rupture at some point. Replacement is recommended every 10-15 years

I may need chemotherapy. Can I still have implants? Women who need post-mastectomy chemotherapy are still candidates for implants. However, chemotherapy may affect your healing rate. Your surgeon will work with your oncologist to schedule your second stage surgery (to remove the tissue expanders and place the implants) at a time when it is safe to proceed.

I may need (or have already had) radiation to my breast area. Can I still have implants? Women who have or have had radiation are at higher risk for multiple complications from breast reconstruction, including infection and delayed healing of incisions. You and your surgeon will discuss your options, risks, and benefits and decide what is best for you.

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