Examqo › Examqo library › Plastic surgery › Breast

Breast reconstruction

Breast reconstruction is done with an implant (usually via a tissue expander) or with the patient's own tissue (DIEP, latissimus dorsi), immediately at mastectomy or later; the key factor in the choice is radiation — an implant in an irradiated breast has more complications, so when radiation is expected own tissue is usually preferred.

לקריאה בעברית

Why it matters in the exam

The breast's arterial supply comes mostly (about 60%) from the internal mammary artery, and the nipple is supplied mainly by the lateral cutaneous branch of the fourth intercostal nerve. Reconstructive options: a two-stage implant (expander then implant) or direct-to-implant with acellular dermal matrix (ADM), above or below the pectoral muscle; a free DIEP flap of lower abdominal skin and fat on the deep inferior epigastric vessels, with a long pedicle (about 10 cm) and preservation of the rectus muscle; TRAM — with muscle; a pedicled latissimus dorsi on the thoracodorsal artery, usually with an implant, whose common complication is donor-site seroma; and thigh or buttock flaps when abdominal tissue is lacking. Post-mastectomy radiation is given for 4 or more positive nodes, T3 or T4 tumours and positive margins, and considered for 1 to 3 nodes.

Nipple-sparing mastectomy (NSM) suits a tumour far from the nipple; contraindications: nipple involvement, Paget disease, inflammatory cancer and bloody nipple discharge, and a very ptotic breast is a relative contraindication. The typical complication is nipple necrosis. After breast-conserving surgery deformities can be corrected with oncoplastic techniques — volume displacement (reduction techniques) or volume replacement (a small latissimus flap, LICAP or TDAP from chest wall perforators) — and with fat grafting. Nipple reconstruction is done last with local flaps and tattooing. In a patient with normal BMI and enough abdominal tissue who is expected to receive radiation, DIEP is a good choice; in a slim patient without radiation, an implant suits.

Key points

Implant or own tissue; immediate or delayed.
Radiation — usually own tissue.
DIEP — rectus preserved, long pedicle.
Latissimus — donor-site seroma.
NSM — typical complication nipple necrosis.

Summary table

Method	Advantage	Drawback or complication	Suits
Expander then implant	Short operation, no donor site	Capsular contracture, especially after radiation	No radiation expected, small to medium breast
Free DIEP	Own tissue, rectus preserved	Microsurgery, fat necrosis	Enough abdominal tissue, radiation
TRAM	Own tissue	Abdominal wall weakness and hernia	When suitable perforators are absent
Latissimus dorsi	Pedicled, reliable	Donor-site seroma	After radiation, with an implant
NSM	Nipple preserved	Nipple necrosis	Tumour far from the nipple, mild ptosis

In the full version for subscribers

A simple algorithm
Memory aid
Exam traps
5 review cards
Enough for IMLE

The full version is open to subscribers of: Plastic surgery, General surgery, Oncology.

Subscriber? Read the full topic Plans and prices 25 free questions

Sources

NCCN Guidelines: Breast Cancer, 2025 — Principles of breast reconstruction following surgery; Principles of radiation therapy
American Society of Plastic Surgeons Evidence-Based Clinical Practice Guideline: Breast reconstruction with expanders and implants, 2017 — Radiation and timing
ASCO/ASTRO/SSO focused guideline on postmastectomy radiotherapy, 2016 — Indications in 1 to 3 positive nodes

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.