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General Surgery

Types of Breast Reconstruction including Acellular Dermal Matrix

Breast reconstruction is a surgery performed to restore the shape of breasts after the tissue is removed during mastectomy (conducted to treat or prevent breast cancer).

Breast reconstruction is performed by three methods:

  • Using a tissue expander/implant
  • Tissue flap reconstruction: using your own tissue (autologous)
  • Combination of both

Tissue Expanders and Implants

This is a common 2-stage procedure. The first stage is the positioning of a tissue expander in a pocket formed in the breast after mastectomy. The expander is a saline (salt water) or silicon-filled balloon that is gradually inflated over a couple of weeks or months to allow breast muscles and skin to stretch to the desired breast size. This is then replaced by the permanent implant, which can also be filled with either silicone or saline. This preliminary procedure is done to ensure cosmetically desirable outcomes and avoid the risk of it bursting out through the surgical incision or skin itself.

This method is suggested for women with small to medium-sized breasts with mild ptosis (sag), undergoing bilateral mastectomy, and having healthy mastectomy flaps. The outcomes may not be so favorable for women who are obese, have large breasts, smokers or those who have had breast radiotherapy.

Expander/implant and Acellular Dermal Matrix (ADM)

More recently, expander/implant reconstruction is augmented with a surgical mesh called acellular dermal matrix, which cradles the implant and gives the breasts a natural shape, contour and droop. The matrix is a very thin white leather made from human or pig skin that is extensively processed and preserved to ensure the safe insertion among human tissues.

The mesh can be used with or without the expander in a one-stage implant reconstruction, most often in conjunction with nipple-sparing mastectomy. This method may be more useful following preventive mastectomy in younger women.

Autologous Tissue Reconstruction using Own Tissue

Women who are not comfortable with the use of implants have the option of using their own tissue to reconstruct their breasts. Autologous reconstruction uses tissues taken from the patient’s stomach, back, buttocks or thigh (wherever there is excess tissue) to shape the new breast. This method of reconstruction allows the creation of breast sag. There are two types of reconstructions: pedicled and free flaps. Pedicled flaps are supported by their local blood supply, but free flaps would be completely separated from their existing blood vessels and reattached through microvascular reconstruction at new positions. This is a more complex process.

Sometimes the reconstruction would combine an implant with a back muscle and skin, for example, to create the breast.

Nipple and Areola Reconstruction

The nipple and areola can be reconstructed at a later stage. A small elevation is made keeping the other nipple as reference. The normal pigmentation of an areola can be tattooed using a dye, which is carried out as an office procedure.

Symmetry in breast shape and size

A small difference may exist in the size and shape of the two breasts following reconstruction, but may not be noticeable under a bra. However, for the more noticeable ones, women may surgically reduce, enlarge or lift the remaining breast to maintain symmetry.

Conclusion

One of the above procedures can be chosen based on the following criteria:

  • your preference
  • body shape and overall build
  • current breast size and preference of new breast size
  • general health, including habits like smoking
  • extent of tissue removed
  • scars from prior surgeries
  • quality of skin that is remaining
  • requirement for radiotherapy

Popularity of implants was found to be about 60% for immediate reconstructions (2008 US findings), and 40% for autologous reconstruction. Two factors that may be fueling the popularity of implant reconstructions include a shift towards bilateral mastectomies and the increasing number of younger patients (49 years and younger) undergoing reconstruction, who generally do not have adequate tissue for autologous reconstruction. Among the implants, ADMs are being used widely by more than 50% of the American Society of Plastic Surgeons.

Whatever method you choose, you should confirm that your surgeon is knowledgeable and experienced in all reconstructive techniques, and not biased by any one. As your reconstructive surgeon will be a vital point of contact for onward referrals to other specialists like the plastic surgeon, this initial decision will make all the difference in your treatment and recovery process.