Breast Reconstruction

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BREAST RECONSTRUCTION

In the United States today, about one in eight women develops breast cancer over their lifetime. There are many theories about the increased incidence of breast cancer relating to diet and environment, but no single factor dominates; it is a combination of causes. In the past many women avoided treatment for breast cancer because they thought that they would be deformed, that their breasts would be removed. They waited until the disease was far advanced before they sought therapy. The development of reconstructive breast surgery and breast conservation treatment has helped ease those fears. We are now diagnosing breast cancer earlier, which gives us better cure rates and the possibility of preserving the breast. Lumpectomy (removal of the cancer and just the tissue around it, leaving the rest of the breast) and radiation to the remaining breast can have a similar cure rate to the removal of the whole breast in many instances.

Not all breast cancers need a total mastectomy. If a breast must be removed, reconstruction is an option. Reconstruction can be performed immediately at the time of a mastectomy, or delayed (after the mastectomy is healed). The choice of immediate or delayed reconstruction depends on your health and the type of reconstruction you prefer.

One advantage to immediate reconstruction is that it allows you to concentrate on something positive instead of just the cancer. Immediate reconstruction could mean you need one less operation. If you have no complications, immediate reconstruction will not interfere with any chemotherapy you may need. Depending on the type of reconstruction, you may even have a breast mound when you wake up from anesthesia.

Nothing is without potential problems. With immediate reconstruction, if you have a complication it may interfere with the timing of your chemotherapy or radiation therapy. Chemotherapy for breast cancer often works best within a window of time. If you have a major problem, with your immediate reconstruction you could miss that window. Current testing of cancer cells for DNA and immune markers allows your physicians insight into how aggressive your cancer may be in the future, but this information is only available weeks after your surgery. You may have opted for a mastectomy and immediate reconstruction and your oncologists may decide, based on these tests, to add radiation to the site of your mastectomy and reconstruction to improve your chances of survival.

If these markers indicate that you need radiation then your reconstruction will be at risk in terms of loss of the reconstruction or less than ideal shape and size of the reconstructed breast mound. If I knew that you would need radiation to the site of your breast for instance, I would recommend delayed reconstruction. You cannot always know before the mastectomy that you may need adjuvant radiation therapy. If you elect immediate reconstruction, then it is a little bit of a gamble that you will not need radiation therapy. It is not necessarily disastrous if you need radiation after the reconstruction, it just might keep you from the optimal result.

An advantage of delayed reconstruction is that you have time to consider the different types of breast reconstruction and you are not in a hurry when you choose one. Often women have a difficult time making a well thought out decision right after they hear that they have cancer. It is hard to concentrate on so many choices with your thoughts on survival from the cancer. Another advantage of delayed reconstruction is that you have time to bank your own blood, if needed, for surgery. It also allows you time to recover from any chemotherapy and radiation therapy that you may need.

Autologous breast reconstruction uses your own tissue moved to the breast site to mimic the breast mound. This may be the only procedure available for the reconstruction of your breast if your chest wall tissues have been damaged or scarred from radiation or burns. Lower abdominal tissue, back tissue and even thigh or buttock tissue can be moved to your breast site to recreate the breast mound. If this flap of tissue is moved and the blood vessels are left intact it is called a pedicle flap. A TRAM flap (lower abdominal fat and skin) or the back (a latissimus dorsi flap) are the most common pedicle flaps. Free tissue transfer is possible at certain large medical centers. It involves taking the fat and skin from one area of your body, disconnecting it from its blood supply, and using a microscope to reconnect it to the blood vessels on the chest wall. It involves a stay in the intensive care unit, a longer hospital stay than the traditional pedicle flaps, and has some extra risks associated with it. The free tissue transfer is usually performed by a team of surgeons.

Autologous tissue breast reconstruction, either a pedicle reconstruction or a free tissue transfer, takes a few months (three to six) for you to feel totally recovered. There is scarring from the donor site (abdomen/back/thigh). You must be highly motivated and healthy to be a candidate for autologous reconstruction. The surgery usually takes several hours and often involves a blood transfusion. Smoking, being very overweight, having had previous surgery in the flap site or being very thin may keep you from being a candidate for this surgery.

Reconstruction can also be done with implants. Many women do not have enough tissue on their stomach or back for breast reconstruction, or they may not want the risks associated with autologous reconstruction, so they elect to have an implant placed. Most women will not have enough skin left after a mastectomy to cover an implant. A tissue expander is a balloon of silicone plastic that can be inserted under the muscle and skin of the breast site. Saline is injected into a port in the expander on a weekly basis to stretch the skin. This is similar to the abdominal wall skin stretching to make room for pregnancy. This new skin eventually grows large enough to cover a permanent implant. In the second stage of this surgery, the final implant is placed about three months after the final expansion. Sometimes a single stage tissue expander breast reconstruction can be performed. In this instance, a special saline filled tissue expander is used, one with a port that can be removed after the right size breast mound is achieved.

Unfortunately, as with all prostheses (like heart valves, knee and hip replacements) breast prostheses will not last forever, and eventually need to be replaced. If a saline implant is used, it deflates when it leaks, maybe in about ten years or so. Your body absorbs the saline that leaks out of the implant and the breast mound is lost. The saline implant can be replaced fairly easily, in most cases as an outpatient surgery. If a silicone implant is used, it may leak undetected, and surgery to remove it is a little more extensive. The silicone implant has a more natural feel to it, and it is less likely to show any ripples on the breast mound than the saline implant. There is no known systemic illness caused by silicone, but it can cause local problems if it leaks out of the implant envelope.

The opposite breast can also be an issue in reconstruction. Unfortunately, we are unable to replicate the appearance of a real breast. Women's breasts come in all shapes and sizes. If a breast is particularly large or droopy we will not be able to match it even closely. We may have to reduce a large breast, lift a droopy breast or augment a small breast to better match the reconstruction. Insurance coverage for breast reconstruction and for a balancing procedure on the opposite breast was mandated in 1998, although Medicare and Medicaid may not allow for a balancing procedure in every patient. If both breasts are involved and lost to cancer, tissue expanders and implants make an excellent choice as the same implants can be used on each side and the result will be more symmetrical.

Nipples can be reconstructed on the new breast mound. Sometimes this is performed at the time of the main reconstruction, and sometimes after the reconstruction has had time to settle into place. The new nipple should project out from the skin and may need to be tattooed for the correct color. This part of the reconstruction can often be done under local anesthesia.

Reconstruction and breast conservation treatments are very personal choices. Nancy Reagan, Betty Ford and Happy Rockefeller chose mastectomies over lumpectomies and chose not to have reconstruction when they were first diagnosed with breast cancer. They were criticized by some for not becoming role models for breast conservation or reconstruction. Every woman with breast cancer must decide what is best for her own life and lifestyle. Some women do not want to be bothered with breast prostheses, so they choose reconstruction. Some women have had enough of doctors and surgery and choose no more surgery. Some women are too busy with their families and businesses to take time right away for reconstruction and will get it done years later. Some women do not feel whole again until their breast is restored. There is no wrong answer, and there is no time limit to your decision for reconstruction. It can be done years after a mastectomy, or never.

There are many types of breast prostheses available if you choose not to be reconstructed. Some can be attached to your chest wall for a few days with special adhesive. Many prostheses feel like breast tissue, and if someone hugs you, the prosthesis is soft and very natural feeling. They may be made of polyester fiber, foam rubber, liquid, or even gel, and some come with nipples. Most insurance companies and Medicare will cover the prosthesis and mastectomy brassiere.

There is support for women diagnosed with breast cancer and their families. The American Cancer Society (www.cancer.org) is a great source of information, and they have a volunteer group of women in Reach to Recovery. These women have had breast cancer and are trained volunteers. Some may have had breast reconstruction and they are a wonderful source of support. This is a free service and they can even visit you while you are in the hospital after your cancer surgery and can bring temporary prostheses. The American Cancer Society also has programs like Look Good....Feel Better and I Can Cope for cancer patients and family members. It helps some patients and their families to talk to others about fears of cancer, the impact of cancer on their body image, and their future. There are many books to help with the fears of cancer such as Bernie Segal's Love, Medicine and Miracles. Most communities have their own support groups in religious institutions, hospitals and wellness centers. You only need to look and ask and you will find many willing to help.