Timing of Reconstruction
Breast reconstruction can be immediate (at the time of mastectomy) or delayed (weeks to years later). Immediate reconstruction is oncologically safe in most patients not requiring radiation and provides significant psychological benefits — the patient wakes without experiencing a flat chest. Delayed reconstruction is often preferable when postmastectomy radiation is planned, as radiation significantly affects reconstruction outcomes.
Implant-Based Reconstruction
Implant-based reconstruction is the most common approach globally. In direct-to-implant (DTI) reconstruction, a permanent implant is placed at the time of mastectomy, typically supported by acellular dermal matrix (ADM) — processed biological mesh that creates an inferolateral sling for the implant. In two-stage reconstruction, a tissue expander is placed initially, expanded over months, then exchanged for a permanent implant — the same tissue expansion principle described for cosmetic extreme augmentation, here applied medically.
Autologous Flap Reconstruction
Autologous reconstruction uses the patient's own tissue, typically transferred as a pedicled or free flap. The TRAM flap (transverse rectus abdominis myocutaneous) transfers abdominal skin, fat, and the rectus muscle on its blood supply. The DIEP flap (deep inferior epigastric perforator) is a technically superior variant that preserves the rectus muscle while using only skin and fat — reducing abdominal wall morbidity. The LD flap (latissimus dorsi) is smaller but reliably available. Autologous results are often considered more natural long-term but involve a longer initial surgery and recovery.
Nipple Reconstruction and Tattooing
Nipple-areola reconstruction is typically performed as a final stage 3–6 months after breast mound reconstruction. Local flap nipple construction followed by 3D areola tattooing is the most common approach. The results can be aesthetically excellent with modern tattooing techniques.
