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Surgical options and what patients should consider


Developed in 1981 by Atlanta plastic surgeon Carl Hartrampf, the TRAM-flap procedure for breast reconstruction tunnels tissue and muscle from the patient's abdomen beneath the skin to the chest to construct a new breast mound. Subsequent outpatient surgery creates a nipple and areola, the pigmented area around the nipple.

The benefits of the TRAM-flap procedure (the acronym stands for transverse rectus abdominus muscle) include gaining a breast that feels and moves naturally and adjusts itself to the body's weight loss or weight gain. The surgery also provides

TC "tummy tuck," which flattens out the abdomen.

Drawbacks include a recovery of several weeks, which is common to major surgery, and a higher risk of complications than the risks posed by implants. Patients often forfeit abdominal strength; some women have difficulty doing sit-ups after this surgery.

Many insurance companies will not pay for the operation to adjust the size of the healthy breast -- which is often visibly larger -- to the size of the reconstructed breast.

Not all women are good candidates for this surgery, either. Conditions such as obesity, hypertension and diabetes may mitigate against the success of this procedure. Heavy smokers are advised against it. Extremely thin women may not have enough tissue to make a breast.

In addition to the TRAM-flap procedure, some plastic surgeons employ a surgical flap technique that uses muscle from the back, often in conjunction with an breast implant.

The simplest form of reconstruction is the breast implant. In most instances, surgeons use a system to expand the chest tissue after a mastectomy. Then they can insert the implant.

The most common problem with implants is capsular contracture, caused by the tightening of the scar or capsule around the implant. This squeezing can cause the breast to feel hard and may require removal of the scar tissue or replacement of the implant itself.

Breast reconstruction usually requires more than one operation. These carry the usual hazards of surgery, such as bleeding, fluid collection, excessive scar tissue or difficulties with anesthesia. If an implant is used, an infection may develop that requires the device's removal until the infection clears.

Patients may wait months, even years, before deciding to rebuild their breasts.

Planning reconstruction along with mastectomy has positive benefits, says plastic surgeon William Crawley of the Greater Baltimore Medical Center.

"Patients do not have to go through the period of mourning and loss," he says. "It's hard to know how much of a patient's depression is loss of body image and how much is fear of cancer, but there's a big difference in mastectomy versus mastectomy with reconstruction."

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