breast reconstruction

After Your Mastectomy: Body Tissue (Autologous) Reconstruction

PJ Hamel Health Guide August 22, 2009
  • Q. I’ve decided to have breast reconstruction after my mastectomy, and I’d like to do one of those reconstructions where they use your own body tissue, rather than have an implant. Since the surgeon will be using my body tissue, will my new breast be just like my original one?

    A. Autologous (or body tissue) reconstruction uses your own body–muscle, fat, and skin–to build a new breast where your original breast once lived. Your new breast will have a more natural look and feel than it would with an implant. It will never have the sensation of your original breast–some of the nerves are cut, and your new breast may tingle and/or feel numb; you’ll also totally lose any erogenous zones. But it’ll pretty much “hang” like your old breast, feel breast-like to the touch, and look much like your original breast, if all goes well.

    Q. Where do they take the tissue from? Do I have a choice?

    A. Fat and muscle will be taken most commonly from your belly (a TRAM flap, which stands for transverse rectus abdominis muscle); or from your upper back (a LAT flap, latissimus dorsi flap). When you hear doctors or other women who’ve had the operation referring to their “tram” or “lat,” that’s what they’re talking about: where the tissue came from.

    In some cases, tissue can be taken from your buttocks, hips or thighs. But these locations are much less common; chances are you’ll be getting a TRAM flap or LAT flap, with the TRAM flap the first choice offered, if you qualify.

    Q. How do I qualify for a TRAM flap?

    A. Easy–you have to have sufficient belly fat, something most of us aren’t lacking! And that’s the really great thing with a TRAM flap–you get a tummy tuck at the same time. Trying to exercise away that annoying roll around your middle? Have a TRAM flap, and it disappears from your belly, and becomes your new breast–cool, huh?

    If you don’t have sufficient belly fat, you’ll probably be offered a LAT flap, which takes tissue from your upper back, over your shoulder blades–just about where someone would pat you on the back, if they were congratulating you.

    If, for some reason, neither a TRAM flap nor LAT flap is right for you, your surgeon will discuss other parts of your body–probably buttocks, hips, or perhaps thighs–that might be suitable to use.

    Q. What does “flap” refer to?

    A. The most common method of rebuilding a breast with body tissue is to cut a piece of muscle and fat (from belly or shoulders), but leave it attached on one end, so it retains its original blood supply. The surgeon then “tunnels” this piece of tissue under the skin to its new location on your chest. This is called a “pedicle flap.” If the tissue is completely cut, and then reattached in its new location, it’s called a “free flap.”  Free flaps are a newer procedure, and much less commonly performed, as they require a very skilled surgeon, one who’ll spend hours reattaching blood vessels. (Obviously, only tissue from your belly or back is close enough to your chest to become a pedicle flap; if it’s from another location, it would have to be a free flap.)

  • Q. So OK, let’s assume I’ll have a TRAM flap or LAT flap. It sounds very involved. How long is the surgery, and how long is the recovery?

    A. This is a major operation. Surgery will probably last 5 to 8 hours; and you’ll spend 4 to 7 days in the hospital. Recovery time is upwards of six weeks, though that’s highly personal; I had a free TRAM flap and felt able to go back to work on a limited basis after 2 weeks, while other women I know, who’ve had the same surgery, struggle for months afterwards trying to feel “normal.” Talk to your surgeon about what kind of recovery YOU might expect; he or she, knowing your medical history and your body, should be able to give you an estimate.

    In addition, if you want a nipple reconstruction, that’s a separate operation, and it’ll be done afterwards–either several days latger, or sometime in the future. Don’t worry, it’s MUCH less involved; it should be done under a local anesthetic, and probably take an hour or less. The surgeon will use some of the skin on your breast, or perhaps take a tiny bit from your thigh, to build a nipple. Later, you can have the areola (the dark part around it) tattooed on, if you like.

    There’s a much, MUCH greater level of detail about the actual surgery I could go into here, but as each surgeon and each cancer center or hospital approaches this surgery somewhat differently, it’s best for you to speak to your surgeon in depth about your particular procedure.

    Q. What happens once I’m out of surgery?

    A. You’ll spend some time in the recovery room, then be brought back to your room. You’ll see a lot of swelling in your chest. You’ll probably feel more pain in the place where the tissue was cut from, than from your breast; there just aren’t that many nerves around your chest area. But don’t worry, you’ll be on pain medication.

    Your chest will be swathed in bandages, and you’ll see tubes, with a reservoir at the end of each, coming out of the area the tissue was taken from, as well as from around your new breast. These are the infamous drains you may have heard about. They’re draining excess fluid from your incisions. And the reason women talk about them so much is that they’re a pain in the neck, and you’ll be anxious to get rid of them! Drains make it difficult to bathe, awkward to get dressed, and just hard to move around in general. They’ll be in place for a week to several weeks after surgery, and you’ll be asked to measure how much fluid collects each day. When the amount of fluid is small enough, the drains can come out, and you’ll feel like you can really begin healing in earnest.

    Q. Once I go home, what happens then?

    A. You’ll come back regularly to have the incisions and your new breast checked; or a visiting nurse may come to your home. The surgeon wants to make sure the new tissue has “taken,” which means it has a healthy blood supply and isn’t in danger of dying.

  • You’ll obviously have to take it easy for awhile: no pushing a heavy vacuum, no lifting, nothing that could disturb your new breast from healing. The surgeon may tell you not to drive a car for 6 weeks–a burden, for sure. And it’s not so much that you’re too “weak” to drive; it’s more that the seat belt across your midsection could very well injure your healing breast, were you to stop suddenly.

    Eventually, if all goes well, your breast will settle in: the drains will be removed, the swelling disappear, and you’ll be on your way to a happy result from your reconstruction.

    Q. What might prevent a successful result?

    A. Well… lots of things, actually. To begin with, you may not even be a candidate for body tissue reconstruction; since your blood vessels play such an important role in the outcome, generally you’re not eligible if you have diabetes, connective tissue or vascular disease, or if you’re a smoker.

    The new breast might not exactly match the old one; you may want to have the surgeon go back in and do some tweaks, to one or both breasts. Remember, this is relatively new surgery, and requires a top-notch surgeon. With that in mind, understand that there may not be a surgeon in your area who can perform this surgery, particularly a free flap; it’s incredibly specialized. 

    The new breast tissue may die, in which case it has to be removed and you’re back to where you started, post-mastectomy. You may have complications in the area the tissue was taken from: a weakened abdomen or shoulders, enough to affect some of the physical activities you enjoy (tennis, perhaps, or Pilates or yoga). If you have a TRAM flap, you may be more prone to a future hernia. Cosmetically, you’ll have some pretty major scars in the area the tissue was taken from.

    WOW, you’re probably thinking–I might go through all this, and not be happy with the result? Truthfully–yes. But surgeons are getting more and more skilled all the time. Ask your surgeon to show you his or her photo album; they generally keep a record of the surgeries they’ve done, with before and after pictures. Ask to see both the successful, and not-so-successful results, so you have an idea of the range of results you might expect.

    In the end, I believe there are many more women pleased with their results, than displeased. So, just as with any other part of your cancer treatment–think positive!

    One final word of advice: well, two. First, be sure to check with your insurance company before you begin any of this. It’s incredibly expensive surgery, and you want to make sure it’s covered. And second, ask to be referred for physical therapy once you’re sufficiently recovered. You’ll regain the use of your arm and shoulder much more quickly, and also hopefully avoid some potential complications, which might include minor loss of range of motion; a more serious and painful condition, called “frozen shoulder;” or lymphedema.

  • Good luck as you embark on this journey. Hopefully you’ll be as pleased with your reconstruction as I am with mine!