Welcome back to an introduction to breast cancer. I'm Dr. Anees Chagpar. In the previous session we talked about surgical options for how to get rid of breast cancer that's in the breast. We talked about partial mastectomy, just removing a portion of the breast versus mastectomy, removing the whole breast. And we said that the survival rates were the same. Now historically the only option that was available was a mastectomy. But these days we have a lot more options and mastectomys are not as disfiguring as they once were. In part, that's because we have a lot of great reconstructive options. Our plastic surgeons can often reconstruct a breast to make it look really cosmetically appealing. Let's take a look at some of those reconstructive options. Remember that reconstruction can occur either in a delayed fashion after a conventional mastectomy sometime down the line. Or it can happen at the same time as the mastectomy, when we do either a skin sparing or a nipple sparing mastectomy, leaving an empty skin envelope for the plastic surgeons to fill. Now how they fill that envelope, that's what we're going to talk about today. There are really two main options. The first is what we call tissue expanders and implants. This is essentially putting in a water balloon or an internal prosthesis to reconstruct the breast. The second Is autologous tissue. Using your own tissue, either from your tummy, or from your back, or your backside to reconstruct the breast all at the same time. Now, it's a bit of an alphabet soup when we think about all of these different autologous reconstructive options, but we'll talk about each of them in turn. First, let's look at tissue expanders and implants. Often times before a plastic surgeon places a definitive implant, they'll use what's called a tissue expander. It's a spacer that they place in between your two pectoralis muscles, your pectoralis major and the pectoralis minor. Those are the chest press muscles. And they'll put this spacer in and they'll blow it up in the office, putting in saline until they get the space to a big enough area that they can then put in a definitive implant. Now, for those patients who don't particularly want to use a foreign body, and who have sufficient tissue from other parts of their body to recreate a breast, autologous options are available. For a long time the workhorse of autologous reconstruction was what's called the pedicled TRAM flap. TRAM stands for transverse rectus abdominis myocutaneous flap. Your rectus abdominis is your sit-up muscle. It's the muscle that runs up and down through the midline of your abdomen. So what plastic surgeons did, is they would take that muscle, along with some fat and the skin on top, and they would flip that underneath the skin of your abdomen to reconstruct the breast. Kind of like you see in this picture here. A different off take of the TRAM flap is what's called the DIEP. DIEP stands for deep inferior epigastric perforator flap. So for a lot of patients, they really didn't want to cut the muscle and have some stomach weakness. So instead what plastic surgeons decided to do was just take the fat and the skin. But in order to keep that fat and skin alive, it needs to travel on a blood supply. That's where those perforator vessels come in. So plastic surgeons would actually take this fat out of the patient on these little blood vessels and then under a microscope, hook up the blood vessels from the flap, which comes from the tummy, up into the blood vessels in the chest. This takes a particular kind of plastic surgeon who can do what's called microvascular anastamoses, or actually sewing these blood vessels with a microscope in the operating room. It's a bigger procedure, but for many patients well worth it. Other options include a latissimus dorsi flap, taking tissue from your back and essentially turning it around to cover the area in the front. For a lot of patients this is used in conjunction with an implant, so that you can get a little bit more tissue if you want to be a little bigger. Finally, a gap flap is taking gluteal artery perforators. So that's the tissue from your backside, which can either travel on the superior gluteal artery or the inferior gluteal artery. Taking that tissue, essentially just the fat and the skin on those little blood vessels, same as a deep flap, and hooking these blood vessels up in the chest under the microscope. So there are many different options now available for women to really get wonderful cosmetic results. What are some considerations when thinking about what type of reconstruction is right for you? Or in fact, whether you should opt for reconstruction? There are a number of issues that plastic surgeons think about. Things like smoking, obesity, previous history of radiation or anticipated radiation, diabetes, other comorbidities. All of these factors increase your complication rate with reconstruction. Ultimately however, in terms of picking the type of reconstruction that's best for you, it's a conversation you have with your plastic surgeon. In part, it's related to your preference. Would you rather have a tissue expander implant? Would you rather use your own tissue? But it also depends on your body habitus. Some patients just simply don't have enough tissue to reconstruct a breast that would be of the size that they're most interested in. Wan to learn more? Well I hope you join me for our guest interview. I'm really excited to host Alex Au. He's the director of breast reconstruction here at Yale. He's a breast reconstructive surgeon, works with me a lot in the operating room as you can see in this picture, and we're going to talk to him about how he decides what kind of reconstructive approach to offer different patients. How he decides whether to do reconstruction followed by radiation, if he knows that radiation is in a patient's future or how he deals with patients who have had previous radiation, who still want reconstruction. We're going to have a really fascinating conversation with him. I hope you'll join me. For now, I'm Dr. Anees Chagbar. Thanks for joining me.