breast reconstruction options

Are you currently navigating breast reconstruction options during (or after a mastectomy, known as delayed reconstruction) due to breast cancer or high risk of breast cancer? Learn about the different options to consider for breast reconstruction. 

We encourage patients to get multiple opinions from surgeons to make an informed decision. 
In the United States single mastectomy (and double mastectomy) are covered through the Women’s Health and Cancer Rights Act and all stages of reconstruction. That said, you do operate within the confines of your specific insurance plan such as in-network/out-of-network, out-of-pocket maximums, and limitations in your plan.

Breast Reconstruction Options

Aesthetic Flat Closure (Going Flat)

Aesthetic flat closure (AFC, also called “going flat”) is a reconstructive option for patients facing mastectomy that avoids multiple surgeries, minimizes medical risk, and avoids implants. With AFC, instead of reconstructing breast mounds, your surgeon will remove all excess skin and fat from around your breast area, leaving a smooth, flat natural chest wall contour. 

After AFC, patients can present flat-chested or they can choose to wear prosthetics to present breasted, if they are so inclined. Just about all mastectomy patients are good candidates for AFC! Many patients who choose AFC report feeling “light,” “free,” and “streamlined” after their mastectomy. Of course, there is an adjustment period, as with any reconstructive choice, and losing one’s breasts can involve a significant grief process. But on the other side of that process is the flat and fabulous lifestyle! 

It’s important to get multiple opinions when finding your surgeon. Learn about questions to ask your surgeon if considering Aesthetic Flat Closure. 

Look up flat-friendly surgeons in this directory. 
Learn more about how to ask for an aesthetic flat closure at www.NotPuttingonaShirt.org/GoingFlat

going flat aesthetic flat closure
Photo Credit: Scars of Beauty (www.ScarsofBeauty.org)

Goldilocks Mastectomy

Goldilocks mastectomy uses a patient’s tissue without implants to create breast mounds, but blood vessels are not moved from a donor site like DIEP. This procedure is better for individuals with larger breasts. During the mastectomy, the skin is preserved, the breast tissue is removed and the remaining skin and fat are rearranged to form a natural breast mound, avoiding the need for implants or complex microsurgery. This technique provides a reconstructed shape while minimizing additional scars and recovery time.

Learn more about Goldilocks Mastectomy at Notputtingonashirt.org/goldilocks/

View Result Photos

Autologous Flap Reconstruction (Using Your Tissue to Reconstruct)

If considering reconstructing with your own tissue, we highly recommend looking into options that don’t compromise the muscle such as DIEP Flap, SGAP, TDAP. There are surgeons that are still using muscle to reconstruct such as TRAM, MS-TRAM, and Latissimus Flaps. We highly recommend getting multiple opinions so you can make an informed decision and keep your muscle intact. 

Contrary to popular belief, most women are eligible to reconstruct using their own tissue. It’s important to get multiple opinions with a surgeon who is skilled in multiple flaps that don’t compromise the muscle. Ideally, a surgeon that specializes only in breast reconstruction.

Surgical groups to look into include:

DIEP Flap

There is a way to reconstruct your breasts using your own tissue without implants. The most common way to do this is with a DIEP flap (Deep Inferior Epigastric Perforator) which reconstructs the breast using blood vessels and tissue from your abdomen. It is considered the gold standard of reconstruction. For many this can be done at the same time as mastectomy (immediate reconstruction) or it can be delayed reconstruction (done at a later time). Even women who chose to go flat who later changed their minds can have a DIEP flap. 

It is important to get multiple opinions and go to a DIEP surgeon who performs this surgery often and a surgeon skilled in APEX or SIEA (and wouldn’t convert to an MS-TRAM, which takes muscle) due to complex blood vessel anatomy. Find out the questions to ask your DIEP flap surgeon when getting multiple opinions to make an informed decision. It’s not uncommon to travel for this surgery. 

Note if you’ve had a prior tummy tuck it does make you ineligible for DIEP. Read on for more alternative flap options. 

Surgical groups to look into include:

Before DIEP and Double Mastectomy and 6 Weeks After DIEP Revision (Patient from CRBS)

before and after mastectomy and diep flap

The above patient photo of before/after DIEP and mastectomy showcases surgery results from the Center for Restorative Breast Surgery in New Orleans.

Watch Video on DIEP and Apex Flap

SGAP Flap

SGAP (superior gluteal artery perforator) is an alternative donor site that transfers blood vessels from the upper buttock for reconstruction. This is considered a great alternative site if you are very thin or have had a prior tummy tuck.SGAP does not compromise the muscle and full strength is preserved. This is not a widely performed flap across the United States and if looking to travel for surgery out-of-network, it is worth looking into a Single Case Agreement to be treated in-network. Dr. Sullivan at the Center for Restorative Breast Surgery pioneered the SGAP technique. They do offer free remote consults.

Surgical Groups to Research Offering SGAP

View SGAP Result Photos

TDAP/TAP Flap

A TDAP (also called TAP) flap stands for Thoracodorsal Artery Perforator. The TDAP/TAP flap preserves the muscle and strength of the patient. This donor site is an improvement over the Latissimus Flap (which takes muscle) and can be used as an alternative donor site if you have extra fat along your bra line. TDAP can also be used in a stacked flap to increase volume.

Surgical Groups to Research Offering TDAP/TAP

PAP Flap

PAP flaps (Profunda Artery Perforator) use tissue and blood vessels from a patient’s thigh to reconstruct the breast. It is considered an improvement over the TUG flap which takes muscle.  The scar/incision may vary significantly by surgeon; it is important to get multiple opinions. This procedure preserves the muscle but the Center for Restorative Breast Surgery mentions on their SGAP page that a PAP may cut through sensory nerves (posterior femoral cutaneous nerve). It is important to ask your prospective surgeons about the risks involved. Some surgeons offer stacked PAP flaps using both thighs for one breast reconstruction.

Surgical Groups to Research Offering PAP Flaps

There are additional options such as Body Lift Flaps, SHAep Flap, LAP Flap, and Stacked Flaps.

Watch Video on Pap Flap

Implant Reconstruction (DTI, OTM, UTM, Hybrid Flap + Implant)

For many patients seeking breast reconstruction, implants are a viable option. Implant-based reconstruction involves the placement of a silicone or saline implant to recreate the breast mound after mastectomy. This can be done as part of immediate or delayed reconstruction, depending on the patient’s situation and preferences. Implant-based reconstruction offers a range of options depending on the placement and the use of additional tissue for support. Below, we explore some of the main implant reconstruction techniques.

It’s important to get multiple opinions from surgeons who offer different techniques to learn the pros and cons to make an informed decision. Note if you are dealing with radiated skin, it is worth looking into an autologous flap like DIEP, SGAP, PAP, or Stacked Flaps.

Direct-to-Implant (DTI)

Direct-to-implant (DTI) reconstruction is a technique in which the implant is placed immediately during mastectomy, without the need for a tissue expander (a device used to stretch the skin before the final implant is placed). DTI is often possible for patients with sufficient skin and tissue coverage following their mastectomy. This method is commonly chosen for patients undergoing immediate reconstruction, and it may require less overall surgery and recovery time compared to staged reconstruction (which involves a tissue expander placed initially).

This approach can provide a more natural appearance and feel, and for many patients, it may be a simpler and quicker option. However, DTI may not be suitable for all patients, especially those with limited skin or tissue coverage, or for those who require more volume than can be achieved through the initial implant.

OTM Vs UTM Breast Reconstruction

There are pros and cons to OTM vs UTM. Generally, surgeons prefer one over the other, it’s worth getting multiple opinions from surgeons who specialize in each to make an informed decision. The below video showcases the pros and cons of each method.

Over the Muscle (OTM) Implant Reconstruction

In over-the-muscle (OTM) implant reconstruction, the breast implant is placed on top of the chest muscles, under the skin and tissue. This technique is typically used for patients who do not have enough tissue to cover the implant and are not undergoing autologous tissue reconstruction (using their own tissue). OTM reconstruction is quicker and less invasive than under-the-muscle (UTM) techniques, as it avoids cutting through the chest muscle.

OTM reconstruction may be appropriate for women with adequate skin coverage and softer tissue. However, it can sometimes lead to less natural-looking results compared to UTM, as the implant can be more noticeable due to less tissue coverage. Another consideration is that the implant may move over time, especially for patients with less soft tissue to support it.

Under the Muscle (UTM) Implant Reconstruction

Under-the-muscle (UTM) implant reconstruction involves placing the breast implant beneath the chest muscle (pectoralis major). This technique is often chosen for its ability to create a more natural look by using the muscle and tissue to help disguise the edges of the implant. UTM placement is considered more suitable for women with minimal remaining tissue post-mastectomy or those with thinner skin.

While the final aesthetic outcomes can be favorable, UTM reconstruction generally requires a longer recovery time due to the manipulation of the chest muscles. It may also cause additional discomfort in the early stages post-surgery. However, it has a lower likelihood of complications such as visible rippling of the implant, which can sometimes occur with OTM reconstruction.

Hybrid Implant Plus Flap (Autologous Breast Reconstruction + Implant)

Hybrid implant plus flap reconstruction combines the use of implants with autologous tissue from either the DIEP (Deep Inferior Epigastric Perforator) flap or SGAP (Superior Gluteal Artery Perforator) flap. This hybrid approach is often utilized when a patient has a large amount of tissue removed or if there is not enough skin or tissue left to adequately cover an implant on its own.

In a DIEP flap plus implant reconstruction, tissue from the abdomen is used to create a natural breast mound, while an implant is placed underneath for additional volume and projection. The SGAP plus implant method follows a similar approach, but tissue is taken from the upper buttocks for those who may have insufficient abdominal tissue or a history of prior abdominal surgery (like a tummy tuck).

Hybrid approaches can result in a more natural feel and appearance compared to implant-only methods, and they also provide the benefit of preserving the skin quality while enhancing breast volume. However, the surgery is more complex, and recovery times may be extended.

View Result Photos

Do You have a Botched or Failed Reconstruction?

There are options to restore your body after mastectomy if you have results that are less than optimal.

Important to Get Multiple Opinions to Make an Informed Decision

Each of these implant-based approaches has unique advantages and challenges, depending on your individual body type, medical history, and aesthetic preferences. It’s crucial to have a detailed discussion with your reconstructive surgeon to weigh these factors and determine the best path forward for you and get multiple opinions from different plastic surgeons to make an informed decision.

References

  1. Breast Reconstruction with SGAP Flap. Breastcenter.com. https://www.breastcenter.com/breast-reconstruction-procedures/sgap/
  2. DIEP Flap Breast Reconstruction. Breastcancer.org. https://www.breastcancer.org/treatment/surgery/breast-reconstruction/types/autologous-flap/diep
  3. What is the Difference Between Breast Reconstruction with Implants Under the Muscle or Over the Muscle? LearnLookLocate.com. https://learnlooklocate.com/what-is-the-difference-between-breast-reconstruction-with-implants-under-the-muscle-or-over-the-muscle/
  4. Losken A, Jones G, Carlson GW, et al. DIEP flap breast reconstruction: a comparison of outcomes in unilateral versus bilateral breast reconstruction. Ann Plast Surg. 2014;72(5):518-524.
  5. Myth Busting the DIEP Flap and an Introduction to the Next Generation of Flaps. Breastcenter.com. https://www.breastcenter.com/wp-content/uploads/2023/03/Myth_Busting_the_DIEP_Flap_and_an_Introduction_to.5.pdf
  6. PAP Flap Breast Reconstruction. Microsurgeon.org. https://www.microsurgeon.org/pap
  7. Breast Reconstruction with TDAP Flap. Breastcenter.com. https://www.breastcenter.com/breast-reconstruction-procedures/tdap/
  8. Hybrid Breast Reconstruction. Breastcenter.com. https://www.breastcenter.com/breast-reconstruction-procedures/hybrid-breast-reconstruction/
  9. The Goldilocks Mastectomy. Notputtingonashirt.org. https://notputtingonashirt.org/goldilocks/

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Aesthetic Flat ClosureAlternative FlapsDIEP Preparation

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