There are many methods for breast reconstruction. The two most common are:

1) Skin expansion By far the most common method, the surgeon inserts a small balloon expander beneath the skin and periodically, over weeks or months, injects a saline solution to slowly expand the overlaying skin (see tissue expansion). Once the expander has reached an acceptable size, it may be removed and replaced with a more permanent implant. Reconstruction of the areola and nipple are performed in a separate operation after the skin has stretched to its final size.

2) Flap reconstruction The second most common procedure uses tissue from other parts of the patient's body, such as the back, buttocks, thigh or abdomen. This procedure may be performed by leaving the donor tissue connected to the original site to retain its blood supply (the vessels are tunnelled beneath the skin surface to the new site) or it may be cut off and new blood supply may be connected. This procedure has the downside of leaving scar tissue in both the donor and breast area, but avoids the risks of breast implants. Flaps generally tolerate radiotherapy better than implants which tend to develop capsule when irradiated.
The latissimus dorsi muscle is the donor available on the back. It is a large flat muscle which can be employed without loss of function. It can be moved into the breast defect still attached to its blood supply under the arm pit (axilla). The amount of tissue available is not enough to reconstruct a large breast so an implant may be required as well.

The abdominal flap for breast reconstruction is the TRAM flap or its technically distinct variant the DIEP flap. Both use the tummy bulge between the belly button and the pubic hair. The DIEP always and the TRAM usually requires microsurgical techniques. Both can provide loads of tissue to reconstruct large breasts.

3) Nipple Reconstruction:- Nipple reconstruction is usually delayed until after the breast mound reconstruction is completed so that the positioning can be planned precisely. Usually a nipple is made from local tissue and a skin graft is used for the areola. The new areola will require tattooing to get colour match with the other side.

4) The other breast One of the challenges in breast reconstruction is to match the reconstructed breast to the mature breast on the other side (often fairly 'ptotic' - droopy.) This often requires a lift (mastopexy) or reduction of the other breast. Occasionally women may request an augmentation of the other breast at the same time as their cancer reconstruction.

Follow-up

Recovery from skin expansion is generally faster than with flap reconstruction, but both take three to six weeks to recover from and both require follow-up surgeries in order to construct a new areola and nipple. Most scars will not disappear completely, but the better the quality of the reconstruction, the less noticeable and distracting the scars will be. All recipients of these operations should refrain from strenuous sports, overhead lifting and sexual activity during the recovery period (three to six weeks).

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