Maurice Nahabedian, MD, FACS
Director: Center of Aesthetic and Reconstructive Surgery of the Breast
Johns Hopkins Medical Institutions

Women diagnosed with breast cancer are confronted with many decisions regarding management. One of the decisions is whether or not to proceed with breast reconstruction following mastectomy. Due to the variety of options that are currently available, this can be difficult, confusing, and stressful. Current reconstructive options include the free TRAM, pedicle TRAM, implants, latissimus dorsi flap, DIEP flap, and the S-GAP flap. Information regarding the indications, options, and recovery from breast reconstruction is provided.

Marilyn Yalom in her book A History of the Breast states, "How a woman regards her breast is a good indicator of her personal self-esteem, as well as the collaborative status of women in general." Being diagnosed with breast cancer can be a significant threat to ones' self esteem and self image. Fear of the cancer and the possibility of losing a breast can result in depression, withdrawal, and loss of control. Our goal at the Johns Hopkins Breast Center is to restore ones' self-esteem and confidence in order to re-enter society with strength, confidence, and vigor. For many women, the decision to proceed with breast reconstruction facilitates this transition as approximately 50% of women following mastectomy elect to have breast reconstruction at our institution. Some women, however, choose not to proceed with breast reconstruction for a variety of reasons that include fear of additional surgery, tumor recurrence, cultural factors, and the feeling that reconstruction is simply not necessary.

Advances in breast reconstruction over the past few years have generated numerous options. Women can now choose between a variety of autologous tissues that include the TRAM flap, Latissimus Dorsi flap, DIEP flap, and the S-GAP flap; all of which can produce outstanding results. Refinements in implant reconstruction can also yield excellent results. The most commonly performed operation for breast reconstruction at Johns Hopkins is the free TRAM flap. This technique utilizes the skin and fat from the abdomen to create a soft and beautifully shaped breast. The advantage of the free TRAM is that only a very small portion of muscle is used; thus preserving the function of the abdominal musculature. The pedicled TRAM, also known as the tunnel TRAM, can also create a soft and nicely shaped breast; however, a greater amount of muscle is required which may result in weakening of abdominal strength. When the TRAM flap is not an option due to an inadequate amount of abdominal fat or high risk, other options become available. The latissimus dorsi flap uses skin, fat, and muscle from the back that is rotated around to the chest to create a breast. This flap often requires the use of an implant to obtain symmetry with the opposite breast. New flaps now available for breast reconstruction at Johns Hopkins include the DIEP flap and the S-GAP flap. The DIEP uses skin and fat from the abdomen without taking any muscle; whereas, the S-GAP flap uses skin and fat from the upper buttock region. Both of these flaps can yield aesthetic and function results. Implant reconstruction following mastectomy is an excellent option for many women. This operation requires less operating time, has a quicker recovery time, and can yield an excellent aesthetic outcome. The operation usually requires two stages. During the first stage a temporary tissue expander is placed to stretch the skin. Following the expansion phase that usually requires 2 to 3 months, the expander is removed and a permanent implant is inserted in its place. Implant reconstruction can also be performed in a single stage using a post-operatively adjustable implant. Currently, the FDA allows for either saline or silicone gel implants to be used for breast reconstruction.

The journey from becoming a breast cancer victim to a breast cancer survivor can be frightening and difficult. The mission of our breast cancer team is to make this journey a smooth and strengthening experience. My goal is to evaluate each woman, discuss all options in a simple fashion with photographs, and provide the best reconstruction that will satisfy their emotional, psychological, and physical requirements.