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Breast Reconstruction

Breast Reconstruction Surgeries by Tri Valley Plastic Surgery

Breast reconstruction surgery restores the appearance of a woman's breast, usually after mastectomy for breast cancer. There are an array of breast reconstruction options available ranging from implants to "autologous" techniques which use the patient's own tissue to recreate a "natural", warm, soft breast. The nipple and areola (the darker area surrounding the nipple) can also be restored. The variety of techniques available and Dr. Williams' experience with the vast majority of them allows him to tailor a solution that fits your needs.

Breast reconstruction options

There are many techniques available for restoring a woman's breasts after mastectomy. Dr. Williams is a board certified plastic surgeon who has taken a leadership role in breast reconstruction and is experienced in performing all types of reconstruction, including microsurgical breast reconstruction.

Breast implant reconstruction

One of the most straight forward types of breast reconstruction involves the use of implants. This is usually a staged procedure. The first step can sometimes be completed at the time of mastectomy and includes placing a special implant called an expander.

The expander is injected over time to create the size breast mound desired. After that a permanent implant is placed.

Pedicled TRAM

The pedicled TRAM flap uses of one of the rectus abdominus muscles (sit-up muscle) for breast reconstruction. The surgery begins with an incision from hip to hip. Then, a “flap” of skin, fat and one of the patient’s abdominal muscles is tunneled under the skin to the chest to create a new breast. Sometimes preliminary "delay" surgery needs to be performed to improve the flap survivability. This procedure uses a patient's own tissue to create a natural breast. It can be associated with abdominal wall weakness but typically has a quicker recovery than microsurgical techniques.

Like microsurgical TRAMs, DIEP and SIEA flaps provide the added benefit of a tummy tuck.

It is important to recognize that not everyone will be a good surgical candidate. Previous abdominal surgery, a history of smoking, other medical issues and many other factors can make other breast reconstruction options more appropriate. Dr. Williams will take the time to discuss each patient's options in detail.

Free TRAM

Breast reconstruction: Microsurgery

Pioneered in the early 1990's, free TRAM and perforator flap breast reconstruction represents the state of the art in breast reconstruction surgery after mastectomy. The tissue removed at the time of mastectomy may be replaced with the patient's own warm, soft, living tissue to recreate a "natural" breast.

In the case of a free TRAM, skin, fatty tissue, and a small portion of the abdominal muscle is taken from the abdomen and used to reconstruct the breast. In perforator flaps, skin, fatty tissue, and the tiny blood vessels that supply nutrients to the tissue ("perforators") can be taken from the patient's abdomen (SIEA flap and DIEP flap procedures) or buttocks (SGAP flap).

Unlike conventional tissue reconstruction techniques (like the pedicled TRAM flap), these microsurgical perforator flap techniques carefully preserve most or all of the patient's underlying musculature. The tissue is then transplanted to the patient's chest and reconnected using microsurgery.

Preserving underlying muscles lessens postoperative discomfort making the recovery easier and shorter, and also enables the patient to maintain muscle strength long-term. This is particularly important for active women. Sparing the abdominal muscle also decreases the chance of abdominal hernia in the future.

As with all types of breast reconstruction, 2 or 3 procedures performed a few months apart are often required to complete the reconstruction process and to obtain the best cosmetic result.

While muscle sparing free tram or perforator flap breast reconstruction offers many advantages to the patient, the surgeries are very complex and time-consuming and specialized training is required. Dr. Williams performs these reconstructions and has been a leader in microsurgical breast reconstruction.

Insurance companies are federally mandated to pay for the cost of breast reconstruction - this includes microsurgical breast reconstruction. It is important to recognize that secondary to the complexity of these surgeries not everyone will be a candidate. Previous abdominal surgery, a history of smoking, other medical issues and many other factors can make other breast reconstruction options more appropriate. Dr. Williams will take the time to discuss each patient's options in detail.

DIEP (deep inferior epigastric perforator) flap breast reconstruction

The DIEP flap procedure is one of the most advanced form of breast reconstruction surgery available today. It uses the patient's own abdominal tissue to reconstruct a natural, soft breast after mastectomy without sacrificing any abdominal muscle. Most practioners who perform all types of breast reconstruction believe that in the right patient this provides the best long-term natural looking breast.

The DIEP flap is similar to the muscle-sparing free TRAM flap except that all the abdominal muscle is preserved. Only abdominal skin and fat are removed. The blood vessels ("perforators") required to keep the skin and fat alive lie just beneath or within the abdominal muscle. A small incision is made in the abdominal muscle to access these vessels.

After the skin, tissues and perforators (collectively known as the "flap") have been dissected, the tissue is transplanted and connected to the patient's chest using microsurgery. The surgeons then shape the tissue to create the new breast. As all abdominal muscle is preserved patients experience less pain after the surgery, enjoy a faster recovery and maintain their abdominal strength long-term with decreased incidence of abdominal hernia.

Many women who undergo this operation enjoy the added benefit of a flatter abdomen with results that mimic a “tummy tuck” procedure. The risk of abdominal complications such as bulging and hernia is also very small, much smaller than with the TRAM method of breast reconstruction.

The DIEP flap is one of the most common method of breast reconstruction performed by Dr. Williams. There are many doctors in the United States performing reconstructive breast surgery, however only about 100 US plastic surgeons routinely perform the DIEP procedure due to the technical difficulty of the surgery.

It is important to recognize that secondary to the complexity of these surgeries not everyone will be a candidate. Previous abdominal surgery, a history of smoking, other medical issues and many other factors can make other breast reconstruction options more appropriate. Dr. Williams will take the time to discuss each patient's options in detail.

SIEA (superficial inferior epigastric artery) flap breast reconstruction

The SIEA flap is very similar to the DIEP flap procedure. Both techniques use the lower abdominal skin and fatty tissue to reconstruct a natural, soft breast following mastectomy.

The main difference between the SIEA flap and the DIEP flap is the artery used to supply blood flow to the new breast. The SIEA blood vessels are found in the fatty tissue just below skin whereas the DIEP blood vessels run below and within the abdominal muscle. While the surgical preparation is slightly different, both procedures spare the abdominal muscle and only use the patient's skin and fat to reconstruct the breast.

Though the SIEA is similar to the DIEP, it is used less frequently since the arteries required are generally too small to sustain the flap in most patients. Less than 10% of patients have the anatomy required to allow this procedure, sometimes gastic bypass patients are good candidates for this procedure as the vessels are more likely to be adequate. Unfortunately, there are no reliable pre-operative tests to show which patients have the appropriate anatomy. The decision as to which type of reconstruction to perform is therefore made intra-operatively by the plastic surgeon based on the patient's anatomy. Dr. Williams always inspects the vessels to determine if an SIEA flap is appropriate.

As with the DIEP procedure, patients receive an abdominoplasty (tummy tuck) at the same time as an added benefit to SIEA flap breast reconstruction.


The American Society of Plastic Surgeons (ASPS) American Board of Plastic Surgery Yale University Plastic Surgery Yale School of Medicine American Society for Aesthetic Plastic Surgery Expert Reviewer of California Medical Board
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