Reshaping of the breast should be tailored to each individual patient’s desired outcome. The choice of reconstruction method depends largely on individual preferences and the cancer treatment plan. It may take several procedures to achieve the final desired aesthetic results. With delayed reconstruction, the surgeon will rebuild a natural breast shape after the chest has healed from the mastectomy or lumpectomy and after completing adjuvant therapy. A nipple can also be recreated.

Delayed reconstruction takes place weeks, months or even years after your chest has healed and the timing often depends on whether you are undergoing chemotherapy and/or radiation therapy, among other factors. Some patients who may have had fewer reconstruction decisions originally, may reconsider a delayed reconstruction several years after treatment, as new techniques become available. Delayed reconstruction can use either an implant based reconstruction, or autologous tissue based reconstruction.

Advantages of delayed reconstruction: Cancer is fully treated before dealing with reconstruction and may require fewer reconstruction procedures; a mastectomy alone (no immediate recon) has half the complication rate when compared to skin sparing mastectomy with immediate reconstruction; avoiding radiation on the reconstructed breast.

Disadvantages of delayed reconstruction: Mourning the loss of a breast; surgical operation room wait time for delayed reconstruction can be extensive, up to 2 years, depending on your location; and in a flap reconstruction one may have increased complications because two surgical sites are involved; longer surgery time and a longer hospital stay are usually involved.

Delayed reconstruction procedures involve:
In a delayed implant based reconstruction, a plastic surgeon uses a tissue expander, which is gradually filled with saline over several weeks to stretch the skin and create a pocket of skin to the desired size for the permanent implant. In a second operation the expander is removed and the permanent implant is placed. Implants may be either saline, or silicone gel implants.

Delayed Implant Based Reconstruction Advantages: Less surgical time and recovery time; fewer scars; satisfactory shape in clothing.

Delayed Implant Based Reconstruction Disadvantages: Many appointments for the expansion process; two steps for procedure (i.e., tissue expander and implant); potential problems with implant including infection may require more surgery (less than 5% and most will respond to antibiotics); often difficult to achieve appearance of a natural breast; visual or physical distortions such as capsular contracture, rippling or bursting; pain is also possible in patients undergoing reconstruction with implants; one may need to replace implants periodically, although most implants will last a lifetime. Implant Based Reconstruction best fits a patient who: has no history of previous radiation to the breast or chest wall or will not need radiation; does not have enough fatty tissue in stomach area for flap options; does not desire a tissue flap operation; has a good skin “pocket” for implant; has minimal compromised tissue at the mastectomy site; prefers shorter surgical time and recovery times, wants a more perky (augmented) looking reconstruction; does not smoke.

Autologous tissue reconstruction:   

A plastic surgeon will use tissue from a donor site on your body like your abdomen, buttock or thigh, and move this flap to the chest to reshape into a breast. The donor tissue flap may be kept connected (or pedicled) to its place of origin to preserve the blood flow. Another method is to cut the flap free and position it at the proper site of the breast. Here blood flow is reestablished by microsurgery. With all delayed reconstruction flaps of autologous tissue may be the preferred option if your surgeon is not able to stretch the skin enough to make room for an implant. Flap reconstruction is often recommended in the radiation setting as this procedure bypasses some of the tissue damage caused by radiation and replaces damaged skin with healthy skin.

Latissimus dorsi flap + implant:  In a lat flap procedure a muscle from the back (latissimus dorsi), with connected skin, fat, and blood vessels, are passed through a tunnel under the skin to the chest to form a new breast or to shape the pocket for a breast implant. The transferred tissue remains attached to its original blood supply making the lat flap procedure less complicated than other flap procedures.

   images courtesy of NCI

In the delayed reconstruction setting the lat flap is only used with an expander due to the limitations of available skin. This makes the lat flap plus implant a staged procedure, replacing the expander for an implant at a later surgery, after the skin has been stretched.

Advantages of lat flap: Muscle can act like acellular dermal matrix to protect the implant in immediate reconstruction; vessels remain connected so no reattachment is required, lessening the potential for vessel failure; no microsurgery required; less risk of flap failure; shorter procedure and hospital stay compared to other flaps.
Disadvantages of lat flap: Scarring on the back; loss of muscle function — not significant but some patients notice when performing extreme activity such as rock climbing. This type of reconstruction best fits a patient who has a smaller body framed or has insufficient tissue for other flaps but would like to have a one stage reconstruction direct to implant bypassing the expander stage who would like to avoid abdominal surgery and has a preference for a delayed setting.

Abdominal Flap:  The most common flap reconstruction surgeries will use tissue from the lower abdomen, such as a TRAM flaps, DIEP and SIEA.

      images courtesy of NCI

TRAM removes muscle, often requires a mesh to reinforce the abdominal wall; may require microsurgery.

DIEP muscle preserved but injured; less abdominal wall weakness compared to the TRAM; not all surgeons offer this procedure, depending on training and experience; requires microsurgery.
SIEA potentially complicated vascular anatomy, not all surgeons offer this procedure; requires microsurgery.

Advantages of abdominal flap: From patient’s own tissue; more natural look; tummy tuck; reconstruction is completed in one procedure; less muscle damage in DIEP and SIEA (as no muscle is removed) compared to TRAM. In SIEA all abdominal muscles are undamaged because no muscle is moved or even manipulated (however, this flap success varies depending on surgeon performing the procedure).

Disadvantages of abdominal flap: Long surgery, ranging from 4 to 12 hours (bilateral i.e. two sides); complex surgery requiring microsurgery for connecting blood vessels; likely removal of a section of rib (to expose blood vessels needed to connect blood supply to flap); long hospital stay 4 to 5 days; drain are required and pain management; flap must be monitored; more incisions bring a greater risk of complications such as wound infection; prolonged healing.

This reconstruction best fits a patient who is concerned about using implants, has had radiation or will require radiation or desires fewer surgical procedures.

Other flap reconstruction surgeries:
SGAP (Superior Gluteal Artery Perforator) take tissue from the buttocks.
IGAP (Inferior Gluteal Artery Perforator) take tissue from the buttocks.
TUG (transverse upper gracilis) tissue from inside of thigh.

Advantages of  SGAP/IGAP:  No chance of abdominal wall weakness or scarring; tissue quality is enhanced; IGAP has a scar in the crease of buttock area and may be less visible; TUG avoids abdominal area; good quality tissue; scarring is hidden in groin.
Disadvantages of  SGAP/IGAP:  Longer  more complex procedure; less frequently performed as many surgeons may not offer this; asymmetry at the donor site due to removal of tissue from one side and not other; TUG scar in buttock crease may be irritating to some; in a bilateral procedure the labia may be repositioned through stretching to close incision; less tissue available in a TUG.

This reconstruction best fits a patient who is not a candidate for expander reconstruction of any form, does not want implants, has insufficient abdominal tissue or is not a candidate to use abdominal tissue, and wants to avoid an abdominal scar.