There are many breast reconstruction alternatives from which to choose. Therefore, it is important for patients to discuss their individual options with their physicians, including the medical oncologist and plastic surgeon before reconstruction. A plastic surgeon performs breast reconstructive surgery and works closely with the patient’s cancer care team.  The breast reconstruction can be immediate (at the time of mastectomy) or it can be done later after the patient has completed treatment.

Prior to a mastectomy, the plastic surgeon will explain that the two most common types of breast reconstruction in the United States – implants and autologous tissue flaps:

• Implants. In implant reconstruction, a temporary tissue expander is placed under the skin and muscle where the breast was located at the time of mastectomy. The expander is similar to a balloon with a small valve placed beneath the skin. During follow-up visits, the physician will periodically inject sterile saline (salt water) via a small tube. The expander stretches the muscles over a period of weeks or months until the breast area is stretched enough to accommodate an implant.
  
  Just as the uterus stretches the lower abdominal wall during pregnancy, the chamber stretches with saline and forms an extra amount of skin tissue. In a second procedure, the tissue expander is removed and replaced with a permanent saline implant. At that time, a symmetrizing (equalizing) contralateral (opposite side) breast procedure can be performed. This helps to ensure the proper position and also helps match the reconstructed breast to the other healthy breast. Not all women require breast tissue expansion before receiving an implant. For these candidates, the permanent implant is inserted during the first step.
  
  The implants that are selected can be filled with saline or silicone. There is a common belief that silicone breast implants are unsafe and should be banned. Some controversy remains as to whether silicone implants cause autoimmune disease. Several large scientific studies have not found such a connection. Many women still choose implants that consist of a silicone shell filled with a saline solution instead of silicone. However, saline implants do not feel as natural as silicone gel implants.
  
  

  In 1992, silicone implants were removed from the market in the United States by the U.S, Food and Drug Administration (FDA) due to safety concerns, particularly about the potential link between implants and autoimmune conditions. Use of silicone implants were restricte and only approved for reconstructive surgery in women. They could not be used for breast augmentation. In addition, the women could receive silicone implants only if they were enrolled in an investigational exemption study.
  
  However, in 2006, the FDA lifted a 14-year ban on silicone breast implants. Two companies were granted approval for silicone breast implants. The implants were approved for women of any age undergoing breast reconstruction and in women age 22 and older for breast augmentation. All other silicone-filled breast implants are considered investigational by the FDA. If a woman wishes to receive one of the non-approved implants in the United States, she must be enrolled in a clinical study.
  

• TRAM flap. Another common procedure is the TRAM flap, which was pioneered in the early 1980s. TRAM is an acronym for transverse rectus abdominus muscle. The transverse refers to the skin orientation, which is transverse, or horizontal. The rectus abdominus muscle and skin are used for the flap to create the new breast. 
  
  This procedure relocates abdominal fat with the lower abdominal skin attached to the rectus abdominus (stomach) muscle. The flap is removed, but the feeding artery and vein remain, and the site from which the tissue is removed is sewn closed. The flap is tunneled under the skin and pulled up into the mastectomy site. Since the blood vessels are not cut, there is a blood supply that remains in the flap. One option in the TRAM flap procedure involves removing the breast tissue, but leaving the skin in position. At the time of a planned mastectomy, very small, keyhole-type skin excisions of the breast can be made, allowing access to the axilla (armpit). The nipple and breast tissue are removed, but the actual skin of the breast remains. This contrasts with traditional TRAM flaps in that the skin of the lower abdominal wall is not used. Instead, the fat and muscle are placed beneath the original skin of the breast, which produces a very natural contour and recreates the illusion of having breast tissue.
  
  In addition, there are three variations of flap procedures:
  
  
• • Latissimus dorsi flap. For women who do not have adequate lower abdominal skin or who have had previous surgeries, but desire a flap procedure, there is another option: the latissimus dorsi flap, which is an older procedure that has been used for years. It is similar to the TRAM flap, but requires the placement of an implant underneath the flap. The disadvantages of the procedure are that there is an oblique (slanted) scar on the back. It also requires harvesting the large latissimus dorsi muscle, which is muscle from the patient's back on the opposite side of the mastectomy. The benefit is that the latissimus dorsi is a very hearty muscle and seems to respond very well after surgery. Additionally, there is no lower abdominal wound that needs to heal. These procedures cannot construct large breasts, but can make medium-sized breasts.
    
    
  • DIEP flap. Another type of abdominal flap is the DIEP (deep inferior epigastric perforator) flap. This is a newer alternative to the TRAM flap and similar in many ways. Unlike the TRAM, however, a flap of only skin and fat (not muscle) are removed. The advantage is that muscle strength is retained in the abdomen. The disadvantage is that the surgery may take longer to perform.
    
    
  • Gluteal flap. Another option is the buttocks (gluteal) flap. This is a free-flap procedure that uses muscle from the buttocks and transplanting it to create a breast mound.

Regardless of which flap procedure is used, the type of surgery is more complicated than reconstruction using a tissue expander and implant. There will be scars from the donated site as well as on the breast. In addition, the recovery time is longer with flap procedures.