Tissue-based breast reconstruction: Using your own tissue to restore your breasts

Some women who have undergone a mastectomy feel like they have lost a part of themselves. From dealing with the distress of the procedure itself to coping with changes in their bodies and self-confidence, this process can be exhausting to endure. Luckily, the specialty of plastic surgery offers hope and renewal with breast reconstruction.

Breast reconstruction can take many forms and use a variety of tools and techniques to achieve truly amazing results. From reconstruction with implants to tissue-based reconstruction, there are more and more options available for women who are looking to restore their breasts post-mastectomy.

Implant-based reconstruction has historically been very popular among patients, but tissue-based autologous reconstruction is quickly gaining momentum and popularity among women around the world. Surgeons utilize actual tissue from the patients to shape and reconstruct the breasts rather than rely on implants.

How does this procedure work, and what are the results that can be expected? Is the recovery time different from reconstruction with implants? How can patients set themselves up for success with this type of procedure? To learn more about breast reconstruction and better understand the process of tissue-based autologous reconstruction, we reached out to ASPS Member Surgeon Tomer Avraham, MD.

ASPS: What is tissue-based autologous breast reconstruction, and how does it differ from implant-based reconstruction?

Dr. Avraham: When a woman has a mastectomy and opts to have breast reconstruction, there are essentially two basic options – implants or her own tissue, also known as autologous. What that usually entails is using extra tissue – usually skin and fat from other parts of the body – to reconstruct the breast. In some ways, it can be thought of as a skin and fat transplant.

You can't just move large pieces of tissue from one part of the body to the other and expect it to survive – it needs a large blood supply. Today, this procedure is performed via free tissue transfer. Simply put, we find the tissue, locate its blood supply and then we hook up the blood vessels that feed the tissue to the other blood vessels in the transfer site. This allows the tissue to live in the new location.

Some women are just really uncomfortable with having an implant or the idea of having a foreign body in them. Implants can also carry some inherent problems. They are medical devices, and no device can be expected to last forever. Patients will need to understand that they will have to have additional surgery later to replace them. In addition, implants are not the most natural-looking form of reconstruction.

ASPS: What are the most common techniques used within tissue-based autologous breast reconstruction?

Dr. Avraham: The most common form of tissue-based autologous breast reconstruction nowadays is the DIEP (deep inferior epigastric perforator) flap procedure. The reason we use the DIEP flap – using skin and fat from the lower belly – is that many patients undergoing this type of reconstructive procedure have been pregnant in the past and thus have some extra tissue and fat in the lower belly. The tissue is removed through an incision somewhat similar to a tummy tuck. Instead of just throwing it out, we dissect it and repurpose it to reconstruct the breast tissue.

ASPS: Can you explain the types of tissue commonly used for this procedure?

Dr. Avraham: When thinking about tissue, it's important to remember one of the most basic tenets of plastic surgery: "Replace like with like." Autologous-based reconstruction gets really close to that – belly fat feels very close to what breast tissue actually feels like.

In addition to harvesting tissues from the stomach, we'll often use alternative sites, such as the inner thigh, the back of the thigh or the flanks. Not all women have enough tissue available in the lower belly.

ASPS: What is the recovery process typically like for this type of breast reconstruction?

Dr. Avraham: Following autologous breast reconstruction, most of my patients spend about two nights in the hospital. Then, depending on the type of work they do, they can expect about three to six weeks off. This has been different recently, of course, as more and more people work from home.

One important note is that a tissue-based reconstruction will involve a week or two more out of work than an implant-based reconstruction. However, tissue reconstruction is often done in a single stage rather than in two stages, like an implant reconstruction. It is also important to remember that a woman who is interested in the best possible aesthetic result will require additional adjustment surgery down the line, with little nips and tucks to make things as perfect as possible with either type of surgery.

ASPS: Are there any risks or downsides to tissue-based autologous breast reconstruction?

Dr. Avraham: There are some downsides to this type of procedure. One, it is a much bigger operation that takes longer and has a longer recovery. We're also making incisions to harvest tissue where there isn't necessarily anything wrong. For example, the patient may have had a mastectomy but is not looking for a plastic surgeon to do a tummy tuck.

In terms of risks, the specific risk with tissue-based autologous reconstruction is that you are hooking up blood vessels, which is technically very complicated and can fail. Luckily, the failure rate is really low, anywhere from 1 percent to 2.5 percent. It is actually lower than the risk of failure with implant reconstruction.

ASPS: What advice would you give patients considering this procedure to help them make an informed decision?

Dr. Avraham: First and foremost, make sure your surgeon is a board-certified plastic surgeon who can offer you all the different types of reconstruction so you can make an informed decision together. Additionally, deciding between implants and your own tissue is a complex decision that the patient must make for themselves. You have to ask if you are willing to take on more of an upfront surgery with a longer recovery in order to achieve longer-lasting results.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.