Innovations in breast reconstruction

Breast cancer reconstruction is one of the most common surgeries plastic surgeons perform. This week, to kick off Breast Cancer Awareness Month, I’m writing about innovations in breast reconstruction. What are the newest techniques? New implants? New types of flaps? Are the new options better than the older ones, and if so, why?

Cut to the chase:

tl;dr
  • Reconstruction is more easily available today, but over half of women with mastectomies still don’t get a reconstruction
  • There are two types of reconstruction – with or without an implant
  • Gummy-bear implants, and single-surgery implant reconstruction are two major advances on the implant front
  • New techniques can use extra skin or fat from other areas of the body to make a new breast. This is a bit like getting a tummy tuck as a side effect of the breast reconstruction
  • There is ongoing research into performing reconstruction using only liposuction and fat injections

Breast reconstruction is becoming more common

Breast cancer is very common – 1 out of every 8 women will be diagnosed with breast cancer during her lifetime. Fortunately, as the chart shows, survival after breast cancer has been gradually improving.

Breast cancer incidence and mortalityBreast cancer mortality is decreasing

In 1998, the Women’s Health and Cancer Rights Act was passed by Congress. It mandated that all health insurance plans had to provide coverage for breast reconstruction after mastectomy. Since then, the percentage of women who undergo breast reconstruction after a mastectomy has doubled. However, over half of women with mastectomies don’t get any reconstruction.

Percent of patients with mastectomies
who underwent reconstruction

Two types of reconstruction

Reading about breast reconstruction becomes very complicated very quickly. There’s a lot of “types” of reconstruction, and a lot of acronyms. It doesn’t have to be complicated. There are really only two types of reconstruction:

  1. Reconstruction with implants, and
  2. Without implants

I won’t get into the litany of sub-options here. So suffice it to say that there are new techniques being developed for both types.

Gummy bear implants or teardrop implants can hold their shapeTear-drop implants keep their shape like a
drop of water on a slippery surface

What’s new in implant reconstruction

Teardrop implants and gummy-bear implants

These terms are used somewhat interchangeably by people, although they refer to slightly different things. Silicone breast implants were invented in the 1960s and have gone through several generations of improvement. The most recent versions use a type of silicone that is highly cohesive or form stable. This means that it holds its shape. The older versions of silicone implants were very flexible – their shape was determined by gravity, and the shape of the surrounding skin. The new versions are stiffer, and they hold their shape, and will actually mold the breast tissues around them. By making the implants breast-shaped (i.e. like a teardrop), they can provide excellent results for breast reconstruction patients. This has been a significant leap forward in implant breast reconstruction, and teardrop implants are now being used more and more often.

Direct implant reconstruction lets you skip the waiting lineDirect to implant reconstruction lets you skip the wait

One-step “direct to implant” reconstruction

The most common method of implant reconstruction actually requires two separate surgeries. The first surgery is combined with the mastectomy. In this procedure, a temporary implant is placed under the breast skin.Then, in a second surgery, the temporary implant is replaced with a permanent silicone implant.

The paradigm has changed a bit recently. There have been improvements in mastectomy techniques (like nipple sparing mastectomy). In addition, dermal matrix products like Alloderm have proliferated. Now we can sometimes skip the first step completely. The result is a mastectomy and implant reconstruction in a single surgery. Ideally, you go under anesthesia with breast cancer, and wake up with new breasts and no cancer. Not all patients can have this one-step procedure of course – it depends on the type of mastectomy, your breast shape, skin thickness, and many other factors. But it’s increasingly becoming an option.

What’s new in non-implant reconstruction

Operating microscope DIEP flapUsing a microscope for a DIEP flap

Microsurgery and perforator flaps (DIEP)

In non-implant reconstruction, tissues from other body areas are shaped into a new breast. The first attempts at doing this used a combination of muscle, fat, and skin. Microsurgery allowed these tissues to be taken from areas very far from the breasts (e.g., the buttocks). The results were good, but removing muscles could cause problems, like an abdominal hernia, or prolonged pain.
In 1989, a Japanese surgeon developed a way to use just fat and skin, leaving the muscles unharmed. This was called a perforator flap.
The DIEP flap is a microsurgical perforator flap that uses skin and fat from the abdomen. It removes belly skin and fat (almost like a tummy tuck), without hurting any muscles or causing functional problems. Although this is a great option for reconstruction, it is not yet common. Implant reconstruction is 20 times more common than DIEP. This is partly because significant technical skill and training in microsurgery is necessary to perform this procedure well.

Other new flaps

After the invention of the DIEP flap, other similar techniques were invented. The TUG flap and the PAP flap use skin and fat from the inner thigh area. The MSLD flap uses skin from the back in the bra line. The benefit of having all of these options is that it lets your plastic surgeon customize a solution for you. For example, a patient may not have enough available excess belly skin for a DIEP flap, but may have enough thigh tissue for a PAP flap.

Fat grafting in actionFat grafting in progress

Fat grafting and BRAVA

One of the greatest advances in Plastic Surgery has been the technique of fat grafting. The basic concept is very intuitive. Fat grafting removes fat from areas where you don’t want it, and injects it in areas where you do want it. For a long time, we have been using fat grafting as an adjunct to improve the results of implant or flap reconstruction. In the last decade, a new technique was developed, called BRAVA. This promises breast reconstruction using only fat injections. An external bra-like device worn for 10-12 hours each day uses a vacuum to slowly enlarge and shape the breast skin and tissues. The surgeon will then carefully and precisely inject fat into the breasts, slowly enhancing their size and shape. The process requires several surgeries, but each surgery is relatively minor. It appeals to some patients because it avoids both implants and a major surgery like a DIEP flap.

Conclusion

There has been a lot of innovation in breast reconstruction recently. Thankfully, more and more women are realizing that reconstruction is an option for them. At UT Southwestern Plastic Surgery, we are constantly pushing the science of breast reconstruction forward. We have published articles in the major peer-reviewed journals on most of the new techniques described here, and we continue to explore new ways of improving breast reconstruction outcomes daily.