When is breast reconstruction performed?
Breast reconstruction may take place immediately following a mastectomy or may be delayed. Advantages of immediate breast reconstruction include: fewer number of operations, possibly increased cosmetic results, and less risk of emotional difficulty. Delayed breast reconstruction may be completed anytime following a mastectomy and is the appropriate option for most women requiring radiation therapy, as well as for women unsure about reconstruction at the time of the mastectomy. There are many personal and health related factors that also contribute to the time the reconstruction takes place.

How many operations will be needed to obtain desired results?
The number of operations needed for breast reconstruction varies for each individual and may range on average from one to three procedures, which are spread over the course of several months. Typically the first operation forms the breast. This is the biggest operation and usually has an overnight stay in the hospital of one to four days, depending on the type of reconstruction done. Another operation is generally needed for refinement of the breast shape, as well as nipple reconstruction. This is a relatively minor operation and is performed as same day, outpatient surgery. A third procedure is completed for nipple tattooing. This is an office procedure similar to a cosmetic tattoo. 

Is it an option to have surgery on the unaffected breast?
There are a variety of surgical procedures available for the unaffected breast to obtain symmetry. This procedure may be completed during the reconstruction process. These procedures include: breast augmentation, breast lift, and breast reduction. Your surgeon will discuss the procedure that is the best option for you during your consultation.

What does insurance cover?
All medical insurance policies, including Medicare, must cover reconstruction of the breast after mastectomy and the procedure performed on the other breast for symmetry. This is a federal law. Therefore, insurance covers all procedures related to the breast reconstruction process.

Tips to prepare for breast reconstruction
It is appropriate to begin to explore reconstruction options as soon as you are diagnosed with breast cancer and it is equally important to determine why reconstruction is an important option for you and what your goal of reconstruction might be. When diagnosed with breast cancer, it is every woman’s right to know about reconstruction. A consult with a plastic surgeon prior to any treatment is certainly appropriate.

During your consultation, your surgeon will spend time discussing reconstruction as well as procedure options that he recommends for you based on: your personal desires and needs, physical examination and your health history.

They will spend time reviewing photographs with you of patients who have undergone a similar procedure as the one proposed for you. He will also discuss your recovery time and what to expect following the surgery.

You also will be given an opportunity to discuss your insurance coverage and scheduling options with our patient care coordinator following your consultation.

Reconstruction procedures
There are several types of reconstruction procedures performed by UF Health plastic and reconstructive surgeons. Breast tissue expanders allow the skin and underlying tissue to gradually stretch in size to allow for an implant to be placed as a secondary procedure. Silicone or saline implants may be used for breast reconstruction. Tissue flaps (a portion of your own skin and muscle) are often used for breast reconstruction to actually replace tissue that was removed with the mastectomy. Tissue flaps are sometimes used with breast tissue expanders or implants; each of these types of implants will be reviewed in detail during your consultation.

Deep Inferior Epigastric Artery Perforator Flap (DIEP Flap)
A now commonly used flap by microsurgeons to reconstruct a breast mound, this refers to the Deep Inferior Epigastric Perforators. This flap is composed of tissue taken from your lower abdomen (the same tissue taken in a “tummy tuck”), to make a breast mound. This is the same tissue from the lower abdomen, as in a TRAM flap, but it consists of skin and fat only; no muscle is used. Because of this, the abdominal wall will normally remain strong and have good muscular tone. This is a more complicated flap to perform than the pedicled or free TRAM because it involves increased dissection of the flap vessels to save muscle and abdominal wall function. Not all patients are candidates for this procedure, but if you are a candidate, this will usually make your long-term recovery from surgery easier.

Latissimus Dorsi Flap
The latissimus dorsi muscle is the muscle that runs from the back of the armpit and across the back. Utilizing this muscle for breast reconstruction following a mastectomy is a preferred reconstructive technique by Dr. Mast. This type of reconstruction can be used for immediate or delayed breast reconstruction and has excellent outcomes, even following radiation therapy. This procedure is considered less complicated than several other flap procedures because the muscle and skin remain attached to their natural blood supply. The latissimus dorsi flap is often used with a breast implant which provides size or projection that is individualized for each patient. This procedure takes about two hours in the operating room and most patients go home from the hospital within 48 hours. Patients should expect three to four weeks of recovery time to return to normal activities.

Nipple and Areola Reconstruction
Nipple and areola reconstruction is completed during the final stage of reconstruction and is typically preformed three to four months after the breast mound is created and the breast has healed. The nipple is shaped from the tissue that is present at the reconstructed breast. No skin grafting is needed. UF surgeons are able to reconstruct the nipple and areola to a natural size, shape, and projection. This procedure is performed in an outpatient setting and requires very minimal recovery time. Following this procedure, nipple tattooing may be done to provide a natural color to the nipple and areola; this is completed in the office after the reconstructed nipple and areola has healed.

Oncoplastic Reconstruction
Oncoplastic surgery combines the latest plastic surgery techniques with breast surgical oncology. When a partial breast resection is required that would otherwise leave the breast distorted, the remaining tissue is sculpted and rearranged to restore a more natural appearance to the breast shape and oftentimes nipple areola complex. The opposite breast will also be modified to create symmetry. Generally, different techniques similar to the ones used in breast reduction and/or breast lift surgery are used to create natural and symmetric breasts.

Superior Gluteal Artery Perforator Flap (SGAP Flap)
SGAP flaps tend to make the most sense for women who are having both breasts reconstructed but can’t use tissue from the abdomen, either because the abdomen is thin or has been damaged by other previous major surgeries there, such as a tummy tuck.

In the SGAP or hip flap surgery, fat, skin and blood vessels are cut from your upper buttocks/hip and moved up to your chest to rebuild your breasts. Your surgeon carefully reattaches the blood vessels of the flap to blood vessels in your chest using microsurgery. Because skin and fat are moved from the buttocks to the chest, having the SGAP flap can mean your buttocks will be tighter, as if you had a buttock lift. The SGAP flap leaves a scar near the top of your buttocks, but it’s almost always covered by a bikini bottom or underwear.

TAP flap
The thoracodorsal artery perforator or TAP flap is a skin flap harvested from the back, much like the latissimus dorsi skin flap but preserving the muscle by carefully dissecting out the small vessels going to the skin. The TAP flap is generally used only for partial breast reconstruction such as after lumpectomy where only a small amount of tissue is required. It can be especially useful in women that are not good candidates for oncoplastic reconstruction or patients with a history of lumpectomy with radiation.

Transverse Rectus Abdominis Muscle Flap (TRAM Flap)
The TRAM flap is a type of flap that uses a portion of the abdominal tissue to create the breast mound. This type of flap provides a generous amount of tissue in a properly selected patient. Therefore, it does not require an implant. However, this procedure is not recommended for patients with a history of previous abdominal surgery or for patients with little excess abdominal tissue. Also, patients who are very overweight or who have other complicating medical problems may not be well suited for the TRAM operation. This procedure typically takes between three to four hours in the operating room and most patients go home from the hospital in three to four days. Patients should expect four weeks of recovery time to return to normal activities.

The advantage to using the lower abdominal tissue for surgery is that women get a flatter midsection, like a “tummy tuck”. In cases where women have excess lower abdominal tissue, this is a very good operation because the reconstructed breast mound is natural feeling and projecting, and ages with you despite your body type. Sensation will never be normal as your breast has been removed, but the flap will gain protective (temperature and pain) sensation over time. Because it is made of your own tissue, it is a very natural type of reconstruction.

Transverse Upper Gracilis (TUG) Flap
The TUG flap, or Gracilis flap, is the most modern of the free flaps or autologous tissue flaps (natural or own tissue flaps) for breast reconstruction. This procedure takes tissue from the inner thigh of the patient and makes a breast mound just like the other tissue flaps. The tissue is taken from the upper, inner thigh of the patient and the scar from the donor site is easily concealed and infrequently seen. The advantage of this type of flap is that there is no abdominal wall incision, which makes the recovery faster for patients. The TUG also has the advantage of giving the patient natural breast mounds through a concealed hidden incision. Because of the redundancy of adductor muscles in the inner thigh, the gracilis muscle can be taken for the TUG flap reconstruction without any functional impairment.