There are two techniques of breast reconstruction: tissue expander and tram flap. The tram flap is a brilliant application of surgical principles, but the relative simplicity and low morbidity of the tissue expander has made it my preferred method of breast reconstruction.

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There are two current surgical techniques of breast reconstruction. The first is based on surgical placement of a chest wall tissue expander to be followed at a later interval by exchange of the expander for a permanent breast implant. In the second technique, called a Tram Flap, a skin plus fat paddle is surgically transferred from the patient's lower abdomen on a pedicle of rectus muscle which is placed in the chest wall to simulate a breast form. Either technique can recreate an aesthetically pleasing breast when performed by a skilled plastic surgeon. Either may be done at the time of mastectomy or at a later interval to allow completion of chemotherapy or for any other reason leading to delay.

The Tram Flap is a brilliant application of surgical principles designed to solve a defecit of natural tissue at the operated mastectomy site. It has specific indications for a large chest wall wound, or a thin patient without adequate skin flaps remaining after mastectomy. It may be done at a patient's request for other than its actual surgical indications. It does not spare the patient a foreign implant as marlex mesh sheeting must be sewn in to repair the internal abdominal wall weakness which results from the transfer of muscle. Some surgeons use a breast implant under the flap as well! The surgery takes an added five to eight hours following mastectomy with increased blood loss and prolongs the postoperative healing time. Long-term studies have not yet determined whether the loss of one or both rectus muscles may affect posture or muscular support of the back.

Placement of a breast-shaped tissue expander beneath the pectoral muscle and chest wall takes about an hour. Blood loss is minimal. Post surgery, patients leave the hospital as they would following their mastectomy. The partially filled expander provides an immediate breast form so that the patient may wear normal clothing. The complete 'breast' volume is added over several weeks by injecting additional saline at weekly office visits. This has an advantage of allowing the patient to determine her desired final size. It also permits the chest wall tissue to gradually expand into a breast shape. The body makes new skin by a process of stretching-induction much as a woman's abdomen expands in the final months of pregnancy. After four to six months of shaping, the patient is returned to the operating room where a permanent anatomically breast-shaped implant is exchanged for the expander. The now formed muscle-skin envelope accommodates the predetermined volume implant. The relative simplicity and low morbidity of this technique has made it my preferred method of breast reconstruction. In the majority of women undergoing mastectomy there is adequate soft tissue and skin cover to permit an excellent aesthetic result by expander-implant technique.

All breast reconstructions will be aesthetically enhanced by surgery to the opposite non-mastectomy side. The goal is to restore a natural symmetrical balance. A woman's individual anatomy will determine which balancing procedure will bring about the most natural match. This may vary from mastopexy to reduction or even in rare cases to an augmentation of an opposite small breast.

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