While I was writing notes from my busy clinic the other day, it dawned on me that the way we describe breast cancer treatments and the various reconstructions can be very confusing. In this article, I will try to offer a summary of some of the more common types of surgical and reconstructive interventions. I will also try to provide an approach to stringing the procedures together to create phrases that are clear and easy to understand.
Since I am a plastic surgeon, this summary will focus on breast reconstruction procedures. But to accurately describe a reconstruction, it is important to also specify the type of operation that was used to remove the breast cancer and/or breast tissue. This is because the reconstruction essentially builds on this initial operation. Therefore, part of the aesthetic outcome and symmetry will rely on how the breast is removed. In other words, the same reconstructive operation may give a very different appearance if it did immediately after a modified radical mastectomy rather than a nipple-sparing mastectomy.
The example above also highlights another very important variable that should be included when communicating reconstructive procedures: the timing of reconstruction relative to the mastectomy. For cases where other treatments are not likely, it is generally accepted that performing the reconstruction immediately after the mastectomy (same day as part of one surgery) will lead to an aesthetically superior result. Of course, this is dependent on several variables, and should not be applied to every scenario. For example, many plastic surgeons would recommend holding off on some types of reconstruction if the patient is expected to undergo radiation therapy after mastectomy. In this setting, the reconstruction would be considered “delayed” instead of “immediate”.
The table below provides an easy reference for naming some of the surgical procedures used for removing and reconstructing the breast. Ideally, one word from each column would be used to give a complete description. With so many websites and forums using abbreviations, these are included as well.
| Indication | Mastectomy Technique | Timing | Laterality | Technique |
|---|---|---|---|---|
| Therapeutic (Cancer) | Nipple Sparing (NSM) | Immediate | Unilateral Right | No Reconstruction |
| Prophylactic (Protective) | Skin Sparing (SSM) | Delayed | Unilateral Left | Tissue Expander (TE) |
| Total (TM) | Bilateral (Double) | Tissue Expander with Acellular Dermal Matrix (TE + ADM) | ||
| Modified Radical (MRM) | Single Stage / Direct to Implant (DTI) | |||
| Fat Grafting (FG ) | ||||
| Fat Grafting with External Expansion (Brava) | ||||
| Latissimus Dorsi Flap (LD) | ||||
| Latissimus Dorsi Flap with Tissue Expander (LD + TE) | ||||
| Latissimus Dorsi Flap with Implant (LD + Implant) | ||||
| Transverse Rectus Abdominus Myocutaneous Flap (TRAM) | ||||
| Transverse Rectus Abdominus Myocutaneous Free Flap (fTRAM) | ||||
| Muscle Sparing TRAM Free Flap (msTRAM) | ||||
| Deep Inferior Epigastric Artery Perforator Flap (DIEP) | ||||
| Superior Gluteal Artery Perforator Flap (SGAP) | ||||
| Inferior Gluteal Arter Perforator Flap (IGAP) | ||||
| Transverse Upper Gracilis Flap (TUG) | ||||
| Profunda Artery Perforator Flap (PAP) | ||||
| Stacked Free Flaps |
With so many different surgical options for removing the breasts and reconstructing them available, it is critical to emphasize that no single path is better than the rest. As I’ve written in a previous article, several different reconstructive options might have the potential to create acceptable results. But, each path has associated risks and benefits that are unique. It is the duty of the reconstructive surgeon to educate patients about these options in an unbiased fashion and guide them in choosing the “right reconstruction” that best suits the patient’s goals.
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