Your doctor will begin with a complete medical history and may order tests to determine your fitness for surgery. Depending on your age and state of health, these tests could include an electrocardiograph (ECG), chest x-ray, spirometry (lung function test), and possibly a screening test for Hepatitis and HIV as well.

Take this opportunity to ask all the questions you have about the surgery, and ask to see photos of the doctor’s recent patients, before and after surgery. Also ask for, and follow up on, patient references. Learning everything you can about your options, risks and benefits is the key to making an informed decision. See Questions to ask your doctor.

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There are two major types of reconstruction surgery: breast implants and flap reconstruction:

• Breast implants

  The most common breast reconstruction surgery technique, implants are rubber shells filled with either silicone gel or a saline solution. Breast implants are typically inserted through the use of a tissue expander. In this technique, a silicone balloon or bag is surgically placed beneath the chest muscle. Through a valve buried under the skin, the surgeon injects a sterile saline solution into the bag, expanding it. The “expander” stays in place for several weeks or months, during which time weekly or twice-weekly injections are administered. Once the skin has expanded sufficiently, the bag is replaced with a permanent implant during a second surgery.

  A third surgery may be recommended to reconstruct the nipple and areola. In order to ensure proper placement of the nipple, this operation is normally performed at least three weeks after breast implant surgery, giving time for the new breast time to settle into its permanent position. The nipple is usually fashioned from a small piece of skin drawn from the breast mound. A separate skin graft forms the areola. About six weeks later, the nipple and areola will be colored to match the other side using a medical tattoo technique.

• Flap reconstruction

  This technique creates a new breast using a section of muscle, skin and fat taken from another area of the body. It requires a longer hospital stay and more recovery time than implant reconstruction, and it also leaves scars at both the breast site and the donor site. But because the new breast is made of natural tissue, it looks, feels and ages more like a normal breast -- which many patients prefer. In addition, the use of natural tissue eliminates the complications that can arise when foreign objects such as implants are inserted into the body. Flap reconstruction may also be recommended when the skin won’t expand enough to cover an implant.

  Flap reconstruction may be performed using a pedicle flap or a free flap. The pedicle flap allows the tissue used in reconstruction to remain attached to its original blood source. The tissue is moved to the breast area through a tunnel under the skin. In the free flap technique, the flap tissue is completely removed and reattached to the breast area, where its blood vessels are connected to those in the chest area through microsurgical techniques.

• Types of flap reconstruction:
  
  
  1. Transverse abdominus musculocutaneous flap
     The TRAM procedure can be performed as either a pedicle flap or a free flap. A section of muscle, fat and skin is surgically removed from the abdomen and used to form the new breast. Sometimes referred to as “tummy-tuck” reconstruction, this procedure flattens the stomach and reconstructs the breast simultaneously. After the surgery, the abdominal muscles are temporarily weakened, and in rare cases, this weakness becomes permanent. If you are considering future pregnancy, be sure to tell your doctor because this sort of abdominal weakness can affect future pregnancy.
  2. Latissimus Flap
     In this technique, a section of the latissimus dorsi (the back muscle arising from the top of the hip to the arm just below the shoulder) is removed to form a new breast. This tissue is often quite thin, so a small implant may be required as well.
  3. Other flaps
     If the abdominal or latissimus tissue is unsatisfactory, a flap can be taken from the upper, middle or lower part of the buttock. However, this technique tends to weaken the gluteal muscle, restricting an athletic patient’s activities. It also requires the surgical removal of a vein from one leg, since the gluteal blood vessels often aren’t long enough to stretch from the chest area to the armpit where they must be reattached. If all other methods are unsatisfactory, tissue can be taken from the upper hip or “love handle” area. This technique is usually a last resort, since this tissue does not lend itself well to shaping a breast. Taking a flap from this area can also leave the hips uneven.

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