Improving Breast Reconstruction Results after Preventative Mastectomy

By Dr. David Sayah

Reconstructive breast surgery is one of the most challenging procedures for plastic surgeons, and one of the most emotionally weighted for women. As the number of women choosing prophylactic mastectomies increases, especially since reconstruction is typically covered by most health insurance policies, the determination to craft results that look and feel more natural is growing as well. Breast reconstruction has seen a number of technical advances in recent years, and there are now a few different ways that surgeons can improve breast reconstruction results after a preventative mastectomy.

Challenges in Reconstruction
There are several reasons why reconstructive breast surgery is so technically complex:

• Tissue Limitations: Depending on the approach that was taken in the initial mastectomy, there may be very little remaining natural tissue for plastic surgeons to work with during reconstruction.
• Scar Tissue: Existing scar tissue from the mastectomy is tougher and more fibrous than normal breast tissue, making it more difficult to achieve surgical finesse during the reconstruction.
• Realistic Results: While the focus in reconstructive breast surgery is always on delivering beautiful, natural results, this possibility may be limited as well, depending on the firmness and texture of the implant used combined with the aforementioned elements of tissue limitations.

None of these challenges is the fault of either the patient or the surgeon; the bottom line is that breast implants were designed to enhance an existing breast rather than create a new breast from scratch. Common concerns include palpable or visible implant edges, breast texture that feels more like an implant than breast tissue, and a breast shape and profile that are adequate under clothing, but still feel subpar when unclothed.

A Combination Approach for Realistic Results
Although breast implants alone remain the go-to approach for surgeons and patients following preventative mastectomy, that doesn’t mean the most popular choice yields the most superior results in terms of aesthetics or physicality. In fact, the best plastic surgeons turn toward a combination of flap reconstruction and lipofilling, either with or without the inclusion of implants, for a more optimal outcome.

Flap reconstruction relocates a flap of soft tissue and/or muscle to the breast from elsewhere on the body to shape a breast profile. There are three different options in common use today:

• TRAM Flap: The transverse rectus abdominus muscle flap relocates skin, fat and muscle from the lower abdomen to the breast area.
• Latissimus Dorsi Flap: This approach relocates fat and muscle from the back to the breast area. While a TRAM flap reconstruction is not recommended for a bilateral mastectomy, a latissimus dorsi reconstruction will not leave the patient with significant weakness at the donor site if used in both breasts.
• DIEP Flap: The deep interior epigastric perforator flap relocates abdominal fat and skin to the breast, but little to no muscle.

As is so often the case in cosmetic or reconstructive procedures, combining efforts has proved to be the best approach overall. An implant may be used to restore volume loss after preventative mastectomy, forming the foundation of the reconstructed breast, while the flap tissue addresses the need for a transitional cushion over the implants for a softer profile that feels more like natural breast tissue. As a finishing touch, lipofilling can be incorporated to further sculpt the final contours of the reconstructed breast for smooth, even results. Despite the undeniably greater technical commitment to a flap reconstruction compared to simply using an implant, the final results look and feel superior.