An experienced first-assistant or co-surgeon is very desirable in any microsurgical case, increasing operative speed and facilitating the overall reconstruction. Similarly, an intraoperative team of nurses and surgical technologists familiar with breast surgery, and/or microsurgery is very desirable.

Tissue Expanders and Implants

Expanders and implants are a common breast restoration option because of the simple nature of the procedure. It adds minimal time to the oncologic procedure and has a shorter recovery period. Another benefit is there is no donor site, so there are no complications from donor-site surgery. There can be significant pain associated with tissue expanders, and there is close follow-up needed. This particular option is a good choice for patients who will not need radiation therapy. It is also a good alternative for thin patients who are undergoing a unilateral mastectomy with little to no ptosis of the remaining breast, as implants decrease the natural fall of the breast. Major disadvantages of this option include implant infection, capsular contracture, and especially, frequent visits for tissue expansion. It is also unwise, though not completely contra-indicated, in the irradiated breast as the radiation causes capsular contractures, infection, and risks skin necrosis. Many different implants are available including saline or silicone gel, round or anatomically shaped, and smooth or textured. The risks and benefits of each implant should be thoroughly addressed with the patient and the specifics of this choice are beyond the scope of this article. 

The procedure can be performed as an immediate adjunct after initial mastectomy, using the skin flap left by the breast surgeon. If performed during delayed reconstruction, most surgeons will access the flap through the initial scar. This can also be performed via previous scars, via an inframammary incision, or via circum-areolar incisions.  The pectoralis major muscle is incised and lifted from the chest wall. Some plastic surgeons will then augment the muscle by adding an acellular dermal matrix to create a larger pocket, or to re-enforce the soft tissue, particularly to re-enforce the inferior aspect of the breast. After the pocket is created, using careful technique, a tissue expander is inserted and the muscle is reapproximated over this. These expanders have a port that is implanted as to be easily accessible through the skin in order to perform subsequent expansion in the clinic. After the skin envelope is expanded appropriately, which will take several weeks, the patient returns to the operating room at a later date to exchange the expander for the final implant. During the exchange procedure, issues such as capsular contracture and contralateral asymmetry can be addressed.[11]

TRAM Flaps

The transverse rectus abdominis musculocutaneous (TRAM) flap is an excellent option for healthy candidates who have the anatomy desired for the procedure, and is a workhorse for breast reconstruction. The anatomy includes a sufficient amount of abdominal fat, though not an excessive amount, and otherwise fair core musculature. This flap isolates an island of skin, fat, and a portion of the rectus muscle, and transposes it to the mastectomy site. Ideal candidates for this surgery are patients without significant comorbidities such as uncontrolled hypertension or diabetes, as this would compromise the blood supply to the flap. Cigarette smoking is a relative contraindication to this flap as it compromises the vasculature of the flap, and many plastic surgeons will require patients to refrain from any nicotine-containing products for at least two weeks prior to surgery, thou maybe longer. The body habitus is also of particular importance. This procedure is best for patients with a moderate amount of excess abdominal subcutaneous tissues, though not the obese, which would translate to ideal volumes for breast symmetry. This option has an added bonus of creating a natural fall appearance to the new breast mound and performing a lipectomy of the abdomen at the same time. The drawbacks of this procedure are similar to those in most flaps, and the vasculature of the flap is of vital importance. If the vasculature is compromised, the flap will fail and result in necrosis. Since this is a musculocutaneous flap, there is a defect in the abdominal wall that is at higher risk for hernia formation. Similar postoperative care and positioning is adopted as with an abdominoplasty.[12]

TRAM flaps are classified by the blood supply to the flap. The most conventional of all TRAM flaps is the pedicled TRAM which uses a pedicled arterial supply from the deep superior epigastric artery, and rotates the flap island superiorly to create the new breast mound. This is the simplest of the TRAM flaps as the artery is not dissected and the flap is merely rotated into its new position. The muscle-sparing free TRAM flap was developed to minimize the amount of muscle taken from the abdomen. This option dissects out the deep inferior epigastric artery perforator and a small area of muscle leaving a majority of the rectus behind in situ in the abdomen. The deep inferior epigastric perforator (DIEP) and superior epigastric inferior perforator (SIEP) TRAM flap variants are perforator flaps based on the deep inferior epigastric perforator and superficial inferior epigastric vessels, respectively, and have gained prominence as relative "workhorse" flaps in autologous breast reconstruction. They add the benefit of taking little muscle and not violating the rectus fascia respectively. However, the use of these flaps requires specialized training to anastomose these fine vessels, typically performed under a microscope, and adds to operative time, though these procedures are performed safely and routinely at most major breast reconstruction centers.

Latissimus Dorsi Flap

The latissimus dorsi is a broad muscle that extends across a significant portion of the back. This creates a flap with extensive uses. It may be an option for patients who wish to have autologous tissue but are too thin, have previous failed abdominal flaps, or are obese. [13]It may, however, require the use of implants or fat grafting because the shape and thickness of the flap may not provide the necessary volume. This flap is typically supplied in a pedicled fashion from the thoracodorsal artery though can be used as a free flap[14].  In the modern era of breast reconstruction with the widespread utility of the DIEP flap, this is typically relegated to a secondary option.[14]

Nipple Areolar Complex Reconstruction

Although not necessary, the nipple-areolar complex (NAC) completes the breast reconstruction process and is very important psychologically for breast cancer patients. There are many different techniques used to create a new nipple, but the basis of all techniques is to create projection and/or appearance symmetric to its counterpart, whether a unilateral or bilateral mastectomy is performed. If the NAC cannot be spared and subsequently incorporated into the final reconstruction, medical tattooing is a common, and often extremely effective, technique to recreate the previous pigmentation of the areola and nipple[15].

Immediate

• Bruising and bleeding
• Build up of fluid
• Tissue necrosis 
• Moderate to severe pain
• Asymmetry of breast

Long-term

• Loss of sensitivity
• Fat necrosis
• Unevenness
• Undesirable scar
• Hernia formation at donor site of muscle flap
• Cancer recurrence

For patients, breast reconstruction surgery can help improve confidence in regards to appearance, restore self-confidence, allow comfort in wearing clothing including swimsuits and bras. It also eliminates the need for uncomfortable prosthetics.

Breast reconstruction is primarily done by the plastic surgeon but in many cases, the follow up is by the primary care proivder, nurse practitioner and internist. These healthcare professionals need to know the different types of breast construction procedures and how to follow the patient for breast cancer screening. Breast reconstruction is only done after the patient has complete the treatment course for breast cancer and is deemed free of the malignancy. Finally, prior to breast reconstruction the primary care givers should encourage the patient to discontinue smoking, so that there are no problems with healing after the surgery. The overall outcomes after breast reconstruction are good. [16]