Breast Reconstruction: Implants vs. Flap

Reconstruction Q&A with Dr. Ariel Rad

Exploring options for breast reconstruction after a diagnosis of breast cancer can add unwanted stress to a patient overwhelmed by choices of treatment in general. We asked Dr. Ariel N. Rad, a nationally-renowned board certified plastic surgeon in Washington, DC, and Clinical Assistant Professor in the Department of Plastic Surgery at Johns Hopkins, to explain options.

Question: What are my options for breast reconstruction if I have a mastectomy?

Dr. Rad: The simplest way for you to think about your options is to consider two different paths: implants or your own tissue. Each has pros and cons, and many different techniques may be used to achieve great results.

On one hand, implants are ideal for women who are very thin and athletic since they don’t have much extra body fat to spare. Implants are easy to use, involve the least down time, are safe, have a natural feel, and last a long time. The down side is that if radiation is part of your cancer treatment plan, implants are associated with problems like capsular contracture (abnormal scarring around the implant).

Using your own tissue solves the dilemmas associated with implants. This generally involves borrowing skin and fat from the abdomen, although other tissue sources are available (the buttock region, inner thighs and back.)

One technique that I employ frequently is the DIEP flap. This is a highly complex microsurgical operation whereby the abdominal skin and fat (not muscle!) is carefully removed and then transferred to the breast where the blood vessels are connected under a microscope with tiny sutures that are thinner than a human hair. Patients also have a tummy tuck in the process, which is a bonus! There are easier ways to transfer the abdominal tissue (such as the TRAM flap), but these remove the rectus abdominus muscles (the “core” or “6-pack” muscles), which significantly compromises core strength, making it more difficult to rise out of bed or chair — I generally don’t recommend this. While the down sides of using your own tissue are longer scars and recovery times, the great advantage is that it lasts forever and has the most natural feel.

Question: Can I have reconstruction if I only had a lumpectomy?

Dr. Rad: Any cancer-removing surgery, including lumpectomy, may result in a breast deformity that requires reconstruction.

“Breast conserving” techniques like lumpectomy are popular because they’re curative, quick outpatient procedures with minimal downtime, but a drawback to lumpectomy surgery is that it can result in a deformed contour (as well as the fact that it commits patients to radiation therapy which can cause other problems.)

One reconstructive technique that works well for certain patients having a lumpectomy is called “oncoplastic breast surgery.” The ideal patient has large breasts, would like to have smaller, more lifted breasts, and has a favorable location of the lump (usually in the inner or outer regions of the breast). Using breast reshaping and lifting techniques, patients can have a very aesthetic breast lift and reduction at the same time as their cancer removal.

Question: What are the risks associated with breast reconstruction?

Dr. Rad: Breast reconstruction is generally safe. As with any surgery, there are risks associated with the operation and with anesthesia, and these relate to how many medical illnesses a patient has.

The most important risk factor is smoking. A review study published this year in the American Journal of Medicine showed that non-smokers had a 41 percent reduction of complications compared to active smokers!

Aside from this, other risks of breast surgery include asymmetry and scars—while it is the plastic surgeon’s goal to create symmetry and minimize scars, everyone heals differently so it’s hard to predict.

Question: What if my natural breast does not match my reconstructed breast?

Dr. Rad: Trying to make a reconstructed breast look similar to a normal breast is very difficult, particularly if a non-nipple sparing mastectomy (i.e. the nipple has been removed) was performed. While restoring normal contour, shape and projection are achievable goals, we don’t have perfect solutions for nipple reconstructions—and to the casual eye, it is apparent when one nipple is normal and the other has been reconstructed.

Nonetheless, nipple reconstruction techniques are generally very good and can give a natural result. If the normal breast has significant ptosis (or “droop”) then doing a mastopexy (or lifting) procedure is an excellent way to rejuvenate the breast and obtain better symmetry. Also, reconstructing both nipples “tricks” the eye because they are both symmetrical.