Tissue(Flap)-based vs. Implant-based Reconstruction Options
Are considering tissue vs. implant reconstruction? In the past, the most common breast reconstruction option available to patients after breast cancer surgery was breast implants – known as implant-only breast reconstruction (without a donor site). While still a popularly relied upon method for restoring aesthetic symmetry and shape to a woman’s bust, this technique is becoming less common for reconstruction as newer, more advanced procedures emerge. These superior techniques are commonly referred to as autologous tissue-based (using one’s own tissue) or “flap” breast reconstruction and include a variety of different methods. These procedures are categorized this way because the patient’s own skin, muscle and fat is harvested and used to rebuild or cover the breast(s).
Flap-based breast reconstruction is further broken down into two separate categories.
- Pedicled Flap – In pedicle flap procedures, tissue detached from the back or abdominal region is transferred (or tunneled) to the intended site of attachment under the skin, so as not to be disconnected from its original blood supply.
- Free Flap – In this more advanced method, tissue is actually separated from its blood source and blood vessels are cut. The tissue is then repositioned in the chest region and the breast reconstruction surgeon carefully sews and reconnects the donor tissue’s blood vessels to the blood supply in the mastectomy pocket with the aid of a microscope. This method is much more complex in nature and requires the hands of a skilled breast reconstruction surgeon who is extensively trained in microsurgical techniques.
Older tissue flap techniques, like the pedicled TRAM flap, while still more natural looking than implants, can have negative effects on the abdominal wall donor site. Some of these include weakening of the abdominal muscle, possibility of bulging and increased risk for hernia – due to the partial removal of abdominal muscle in addition to skin and fat.
The newest “free” flap microsurgical reconstruction technique is the DIEP flap. This is known as a perforator flap because only skin, fat, and blood vessels are removed from the donor site, no muscle. In this procedure, the tissue is completely removed from the stomach area and then reattached in the breast region.
These procedures are longer, as they require microsurgical transfer of tissue from one area of the body to another, and re-connection of blood vessels. If this approach is not desired or indicated, a simpler flap can be performed using muscle and skin from the back area, just underneath the shoulder blade. This pedicled flap procedure is called the latissimus flap and is usually combined with an implant. For small defects, the perforator TAP flap can also be used from the back area, but this does not include the back muscle; only a small amount of skin and fatty tissue is transferred.
Flap procedures that use the patient’s own tissue are very popular because not only does the patient receive a fringe benefit of a tummy tuck procedure (with the DIEP flap), but flap procedures tent to offer a longer-lasting solution, as opposed to implants that usually have to be replaced after about 10-15 years. Furthermore, because the patient’s own tissue is used, the new breast looks and feels much more natural than an implant.
For patients wishing to have implant-only reconstruction, it is usually performed in two stages, with a tissue expander being inserted first to expand the remaining skin since there is no skin replacement with a flap. Once the skin is adequately stretched, the expander is removed and an implant is placed.