BREAST RECONSTRUCTION

RECONSTRUCTION OF BREAST.

For aesthetic considerations, as well as to correct defects from extended removal of the breast for malignancy, reconstruction or repair is used. This includes the option:
• Derma-fat-fascia graft reconstruction for replacing breasts contour.
• Trans-rectus [longitudinal] abdominal muscle [TRAM] Flap breast reconstruction.
• Breast Implants
• Breast Prostheses.

DERMA-FAT-FASCIA GRAFT RECONSTRUCTION.

This method includes:
• Skin grafting
• Various flap operations
• A number of more extended plastic procedures.
This method describes an abdominal plastic operation based on transposing flaps from the upper abdomen to the defect on the chest.
The doctor has found that a fat graft, covered by a layer of derma on one side and with fascia as its base, will attach itself more firmly to the recipient base. Since this type of graft is easily invaded by capillaries, there is an increase in the vitality of the fat tissue and a tendency to regenerate very satisfactorily.

Fig. 17:

Coronal section of the breast before and after implantation of derma-fat-fascial graft.

This method greatly reduces the amount of absorption of the fat and renders the graft more resistant to infection and may completely healed.
Fat grafts without the attachment of the derma and fascia absorb at least from one-third to one-half of their volume.This method is more satisfactory than the pedicle clap method of rebuilding the contour of the breast; it eliminates extra stages of operation and unnecessary scarring; moreover, the resulting contour is more pleasing. Berson emphasizes the precaution that, before the reconstruction is undertaken, the area to be operated on must be free from any infection and completely healed.

Fig. 18:

Derma-fat-fascial graft for replacing breast contours.

TRAM FLAP BREAST RECONSTRUCTION .

TRAM [Trans-rectus [longitudinal] abdominal muscle], which is located in the lower abdomen between the waist and the pubic bone.
TRAM flap reconstruction is the most popular of all reconstruction options, especially for a woman with excess belly fat or an abdomen that has been stretched out by pregnancy.
You end up with a “tummy tuck“ as a fringe benefit of surgery.


Figure 19: TRAM Flap breast reconstruction preparation.

Woman after mastectomy, showing trans-rectus abdominal muscle [TRAM] and surrounding tissues in preparation for reconstruction.

A Mastectomy site

B Right trans rectus abdominal muscle

C Left trans rectus abdominal muscle

D Segment of abdominal tissues: skin and fat, to be transferred along with muscle to create the new breast

Figure 20: TRAM Flap breast reconstruction-process.

Woman in process of trans-rectus abdominal muscle tram]

Reconstruction:

A Lines of reconstructed breast incisions

B Right-trans rectus abdominal muscle

C Left TRAM muscle is swung over to recreate the new

breast

D Incision circle of repositioned "belly button" incision

E Line of abdominal surgery.

How does Tram work ?
An oval section of skin , fat and muscle is taken from the lower half of the abdomen and slid up though a tunnel under the skin to the breast area. Blood vessels remain attached whenever is possible. The tissue is shaped into a natural looking breast and sewn into place.
If blood vessels have been cut, the surgeon reattaches them to blood vessels in the chest area using a microscope to sew the tiny, delicate attachments. The procedure takes about 3 hours. The new breast can also be made during this surgery, with an implant underneath your own tissue.

Figure 21: Tram Flap breast reconstruction-lines of incision. Woman with lines of trans-rectus abdominal muscle [TRAM] reconstruction incisions.

A Line of reconstructed breast incisions

B Circle of re-positioned "belly button" incision

C Line of abdominal surgery incision.

The TRAM is not a good choice for:
• Thin women who don’t have enough abdominal tissue
• W0men who smoke and therefore have blood vessels that are narrow and less flexible.
• Women who have multiple surgical scars on the abdomen.

BREAST IMPLANTS.

Breast Implants involve the least amount of surgery of all your reconstruction options. Slim, small-breast women tend to do best with breast implants, because they often don’t have enough excess belly tissue to form a good tissue transplant. Also, it’s easy to achieve a smaller breast size with implants.

Fig. 22: Breast implant

Filled tissue expander, side view of breast area with filled tissue expander in place.

A Tissue expander-filled

B Port

C Catheter

D Syringe

E Ribs

F Pectoral major muscle

G Other muscles of the chest wall [3 lines to one letter]

Breast implants only come in three sizes [small, medium and large] and the largest is a size 12-14.
For most women, the skin that remains after mastectomy must be stretched or expanded to make room for an implant. To stretch the skin, the surgeon inserts a balloon-type device called a tissue expander under the chest muscle. The expander has a port [a metal or plastic plug, valve, or coil].The port allows the surgeon to add increasing amounts of liquid over time [about six months], without extra surgery.
Gradually, your skin and soft tissue are stretched to achieve your desired appearance.
The final steps, when stretching is done and you’re your other treatments [chemotherapy, radiation or both] are completed, the expander is usually replaced with a permanent implant. Breast implants are filled with either saline [saltwater] or silicone gel.

BREAST PROSTHESES.

Breast prostheses come in many shapes, sizes and materials: silicon gel, foam, or fiberfill interior, weighted or not. The ideal product will have the shape, weight, balance, motion and simulated nipple of a real breast.
You can choose among ready-made products to match your remaining breast or your former shape. There’s even a breast prostheses that comes with adhesive patches that attach to the upper edge of your breast area, allowing you to go bra-less if you like.

Fig. 23: Breast prostheses