Dr. Allison Claire Nauta, MD

There are a few different methods used to create the round shape of the breast on the chest. A flap of fat, skin, and muscle can be taken from the side, abdomen or buttock and implanted on the chest to create a breast from the patient's own tissue. Alternatively, the skin over the chest may be gradually stretched to allow for the placement of an implant. Stretching of the skin is done using expanders, which are similar to breast implants, except they increase in size when saltwater solution is injected into them. Many women also choose to combine the flap procedure with implant placement to achieve their desired result. Once the new breast shape is formed, a nipple can be created and even tattooed to match the other side.

Reconstruction may be done in a single surgery or broken up into multiple procedures:

• Immediate reconstruction rebuilds the breast right after mastectomy. This method is not recommended if additional chemotherapy or radiation is needed after surgery.
• Delayed reconstruction occurs after chemotherapy or radiation has been given. These treatments may decrease the volume or alter the color of the reconstructed breast, so they should be completed before the breast is rebuilt. This type of reconstruction may happen weeks, months, or even years after mastectomy.
• Staged reconstruction splits the reconstructive process into two parts. The first part inserts temporary expanders to stretch the skin and is done immediately after breast removal surgery. The second part replaces the expanders with implants after chemotherapy or radiation treatments have been given.

Breast reconstruction is not perfect. The two breasts may not always look exactly identical, although they will be close. There may be small scars, and a loss of sensation in the reconstructed breast. A reconstructed breast will not produce milk, so patients may have trouble breastfeeding. Still, reconstruction is a great option for women who want that part of their appearance back.

Flaps are used to reconstruct large or deep wounds, as well repair physical deformities. For example, some nasal defects can be corrected using forehead flaps. Another common procedure that uses flaps is breast reconstruction, which is surgery to restore the appearance of the breast after mastectomy (breast removal). The ability to use musculocutaneous tissue makes flaps ideal for this type of reconstructive surgery. In addition, the included blood supply in flaps brings needed oxygen and nutrients to the recipient site, promoting healing.

During flap surgery, an enormous amount of attention needs to be paid to the blood vessels (arteries, veins, and capillaries). To retain the flap's blood supply, the surgeon might form a pedicle, which is a bridge of tissue and blood vessels that connects the flap to the site it originates from. The flap is connected to its blood supply through this pedicle. It is removed only after the surgical team has made sure that the flap has healed enough to survive without it. This type of flap is called a pedicled flap.

Blood vessels may also be detached from the flap when it is harvested, and then reattached at the new location. Since the flap is not pedicled to its donor site, it is referred to as a free flap. To be able to connect blood vessels with accuracy, surgeons must use very tiny tools and special microscopes. For this reason, this type of flap reconstruction is also often called microvascular flap surgery. One advantage of free or microvascular flaps is that they are ideal for repairing larger areas, like an extensive wound or defect on the leg.

Depending on how involved a patient's flap reconstruction is, they may have to stay in the hospital for several days after the procedure. It may take six to eight weeks for the incisions to heal, and a year or more for the scars to fully fade.