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Breast Reconstruction Goals

Dr. Cook discussses breast reconstruction goals, particularly when we consider long-term issues.
Breast Reconstruction Goals, John Q. Cook, M.D.
Charles Joshua Chaplin, A Beauty with Doves





John Q. Cook, M.D.

Chicago 312-751-2112
Winnetka 847-446-7562

Breast Reconstruction Goals Are More Involved Than Immediately Apparent, Particularly When We Consider Long-Term Issues

Each person may choose to put these different goals in an order of priority that makes sense to her, but it is important that all of the goals be considered. I came up with these breast reconstruction goals through a critical analysis of my own surgical results as well conversations with my patients.

Since I have a referral practice, I also have the privilege of evaluating patients who previously underwent reconstruction by a variety of plastic surgeons who have different preferred methods of reconstruction.

Breast Reconstruction Goal 1: A Breast that Has a Soft and Natural Look and Shape

When everything goes perfectly, reconstruction with autologous flaps, particularly those from the abdomen, comes closest to meeting this goal. There are, however, significant trade-offs (in terms of the other goals) that should not be dismissed lightly. Recent advances in implant-based reconstruction, which I will discuss later, have significantly improved the quality of results, so that the best implant based reconstructions now come very close to achieving the same natural results that can be obtained with abdominal flaps.

Breast Reconstruction Goal 2: A Breast That Is Balanced with The Body and with The Opposite Breast

It is often said that the best results with breast reconstruction surgery come with bilateral reconstructions. It is much more likely that a surgeon will achieve a good degree of symmetry with a double reconstruction than when it is necessary to match an opposite natural breast.

The importance of this goal depends very much on your priorities. Patients with a reasonable degree of balance in a bra or swimsuit are often happy with the result. For others it is very important to achieve as much balance and symmetry as possible in the unclothed state.

If unclothed symmetry is important, it is usually necessary to balance the opposite breast with the reconstructed breast with the appropriate procedure: breast augmentation surgery, breast reduction, breast lift, or a combined augmentation and lift.

One important point is that even if the natural and reconstructed breasts are brought into good balance, they will tend to behave differently over time. For fastidious patients it will often be necessary to rebalance the breasts a number of years after the initial surgery. This is particularly true for people who go through significant cycles of weight gain and weight loss.


Breast Reconstruction Goal 3: A Breast that Will Need to Undergo the Least Number of Revisional Procedures

Here I think the autologous flap reconstructions have an edge, due to the inherent characteristics of breast implants. With all surgeries that involve breast implants it is important to consider two important issues: breakage of the implant and capsular contracture.

All of the newer implants are filled with what is known as cohesive gel; this means that the gel sticks together, even if the shell of the implant is broken. Still, it is desirable to replace that implant if it is broken, and this will require an additional surgery.
A condition called capsular contracture develops around the implants of some patients who undergo breast reconstruction. Capsular contracture is characterized by the formation of an unusual amount of scar tissue around the breast implant. This scar can tighten and make the implant firm and alter the breast shape. Surgery is necessary to fix this condition.

It is important to mention that not all autologous reconstructions go smoothly. Not infrequently, portions of the flap don’t survive, and revisional procedures will be necessary to remove the firm tissue that results from this and to bring the breast into a better shape.

Breast Reconstruction Goal 4: A Breast with Natural-Appearing Skin and Limited Scar

For some patients, the mastectomy will involve the removal of a significant amount of breast skin. With tissue expander reconstruction it is possible to stretch the remaining skin in order to compensate for this. With flaps from the abdomen or back an ellipse of skin is carried with the flap in order to replace the missing skin. The problem with this approach is that the skin of the back and the skin of the abdomen have different color, thickness, and texture from the skin of the breast. This may produce a “patched” appearance that can be quite noticeable.

Some patients may undergo more limited mastectomies, such as skin-sparing and nipple-sparing procedures, in which case the patched appearance can be avoided or minimized.

Breast Reconstruction Goal 5: Avoid a Difficult or Complex Recovery from Surgery

If this is the goal, implant- and expander-based breast reconstructions generally have an advantage over flap-based reconstructions, because the patient only has to recover in one area of her body. With flap reconstructions there is generally a significant recovery from surgery in the area where the flap was taken. There may be local complications in the back and abdomen that require treatment and/or potentially delay chemotherapy, if this is needed.

Sometimes it is possible to obtain an excellent result with an abdominal flap, so that no further surgeries are necessary. Now with skin-sparing mastectomies this may be possible with implant-based reconstructions as well. As a practical matter, no matter which reconstructive method you choose, there is a high probability of additional surgery to refine the result and balance the two breasts.

Breast Reconstruction Goal 6: Do Not Affect Function of the Body in a Negative Way

The main negative effect of implant reconstructions in regards to function of the body takes place in the area of the reconstructed breast. There can be tightness around the implant, which affects range of motion of the shoulder, and this may require physical therapy.

This is the goal where, in my opinion, flap reconstructions have the greatest probability of falling short and having significant long-term consequences. With the back flap (latisimus dorsi flap), the large muscle that sits below the scapula and hooks into the upper arm is released from its attachments near the spine and brought around to the mastectomy defect along with some overlying fat and skin. Some people consider this muscle expendable, but I do not agree. The latisimus muscle is very important in sports; for example, when pushing off with a ski pole and during many yoga poses. Proper function of this muscle is also important for people using crutches or a walker (e.g., some older people and those who have recently had certain types of surgery.

The abdominal flaps are even more problematic. There are three main versions of this flap. With the TRAM flap, one of the sit-up (rectus) muscles is detached at its bottom end, and the entire muscle is released except at the very top so that it can carry the fat and skin from the middle of the abdomen to the chest. There are vessels connected to the upper end of the muscle which provide a blood supply to the entire flap. With the FREE TRAM flap, a smaller portion of the muscle is sacrificed and the blood vessels that flow into the lower end of the rectus are detached and sewn to vessels near the breast. With the DIEP flap, a smaller vessel that comes through the rectus muscle is used to provide circulation to the flap when it is sewn to the breast area.

In general, the DIEP flap has less long-term effects on the strength of the abdominal muscles than the other abdominal flaps, but all of these operations involve a disruption of the function of a very important section of the body. Everyone who has ever had back pain knows that the first line of therapy is to strengthen the sit-up muscles with physical therapy and exercise. If function of the rectus muscle is significantly affected, this will have long-term effects on body mechanics. The DIEP flaps have their proponents who claim that rectus function is preserved, but I have seen too many examples to the contrary. These include people with abdominal bulges and significant weakness of the rectus muscle. One example is a yoga instructor who can no longer teach many of the poses that involve tightening the core muscles.

Breast Reconstruction Goal 7: Minimize Scar and Deformity in Areas other than the Breast

One of the key advantages of tissue-expander and implant reconstruction is that the only area involved by the surgery is the breasts. With flap reconstructions it is a matter of “robbing Peter to pay Paul.” At the very least there will be scars in areas of the body other than the breasts, and these scars may be difficult to camouflage in swimsuits and certain cuts of dresses.

The abdominal flaps are sometimes described as having the advantage of a tummy tuck along with the breast surgery. This is true to a degree, but there are significant limitations. First of all, the scar sits at a much higher level than would be present with a true tummy tuck (abdominoplasty). Second, abdominal flaps may weaken the abdominal support mechanism, unlike a true abdominoplasty, which is designed to improve abdominal wall support.

There are surgeons who use flaps from the buttock or from the outer thigh to reconstruct breasts. There may be special circumstances where this makes sense, but in general there will be a significant negative effect on the area where the flap is taken from, both in contour and in scar.

Breast Reconstruction Goal 8: Avoid Big Complications

I often tell my patients that there are big “C” complications and little “c” complications. Little “c” complications can be disheartening, but are not a serious threat to health and well-being. Big “C” complications may involve time in intensive care and long hospitalizations.

In general I have found that implant reconstructions tend to have little “c” complications, while flap reconstructions can occasionally produce more significant problems. Perhaps this is because these are long, complex operations that tend to involve more than one body area.