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Exploring reconstructive-surgery options after mastectomy

Whether you had a mastectomy (or lumpectomy) many years ago or will need one in the future, reconstructive surgery may be an option for you—and you won’t necessarily need breast implants. Today’s techniques allow surgeons to transplant tissue from one body site to the mastectomy site.

The TRAM flap approach

One popular technique is the TRAM (transverse rectus abdominis myocutaneous) flap surgery. During TRAM flap surgery, the surgeon removes skin, fat and muscle from the abdomen and tunnels it under the skin. He or she then rotates the tissue flap, repositions it under the mastectomy wound and sutures it to the edges of the breast incision.

TRAM surgery can involve a “free” flap, in which the surgeon cuts away an island of tissue from the abdomen. Or the surgeon can leave one or two stalks of tissue (called pedicles) connected to the original abdominal site.

In cases when women have too little abdominal fat or too many abdominal scars, doctors may recommend using buttocks, back or thigh tissue. Additional surgeries may be necessary to create a nipple or to refine the results.

When is the right time for reconstructive surgery?

TRAM surgery can be performed during mastectomy surgery or many years later. It also may be appropriate after a lumpectomy in which the surgeon has removed a large amount of breast tissue. Since the goal is to create a balanced look, a breast lift or a reduction of the healthy breast may also be helpful. Women who have breast reconstruction at the time of the mastectomy may have longer operations and more wound-healing problems. On the other hand, immediate reconstruction may soften the emotional impact of the mastectomy, limit the total number of surgeries and reduce medical expenses.

If you are unsure about reconstructive surgery, it may be better to wait. Additionally, you may need to postpone reconstructive surgery if you plan to undergo chemotherapy. Be sure to let your surgeon know if you’re considering future reconstructive surgery.

Why do it?

A woman may choose not to undergo reconstructive surgery. For example, she may want to avoid additional operations. She may be content with her current appearance. Or she may decide that in her case, the risks outweigh the potential benefits.

On the other hand, she may feel less whole after her mastectomy. She may feel self-conscious, dislike wearing a prosthesis or feel constrained by her clothing options. Surgery may restore her sense of self.

What can I expect?

The operation may last from six to eight hours. Hospital stays of up to a week are not uncommon. As with any surgery, swelling, infection or blood clots may occur. Because some abdominal muscle is removed during TRAM flap surgery, weakened abdominal walls may bulge or lead to back pain. For these reasons, some surgeons strengthen the abdominal wall with synthetic mesh during the surgery.

Poor wound healing is another risk. Transplanted skin may die, and fatty tissue sometimes breaks down into painful lumps. These complications occur more frequently in women who smoke, are overweight or are in poor health. Radiation treatments also may put women at greater risk for complications.

For these high-risk patients, surgeons may advise an outpatient procedure one to two weeks before surgery. This procedure, a ligation (constriction) of abdominal blood vessels, helps improve postsurgical circulation and decrease the risk of complications.

Surgeries that use buttocks tissue are more complicated. Side effects include leg pain, numbness or weakness, sciatic nerve damage and hip problems. Surgeries using back tissue leave large scars and may cause shoulder problems.

How will I look and feel?

Your new breast will appear normal under clothing. Often the surgeon can sculpt the tissue to closely match the opposite breast. Outwardly, the new breast may feel natural, but it will not have the same sensation as your original breast. However, you may recover some feeling, usually beginning about six months after surgery. Until then, doctors advise extra caution, particularly when sunbathing. Some women have been severely sunburned on the breast and/or abdomen.

What else should I know?

Ask your doctor to connect you with the American Cancer Society’s Reach to Recovery program. Through this program, you may talk to someone who had the operation you’re considering. Also, obtain a second surgical opinion and check your insurance coverage.

Armed with the facts, you’ll be able to make the best decision for your physical and emotional health.