Breast cancer continues to be a devastating occurrence for 1 out of every 9 women in the United States. For most women, the oncologic aspects of dealing with a cancer are more emotionally overwhelming than the potential for reconstruction if a mastectomy or lumpectomy is required. However, once the oncologic aspects are understood, it is important to understand the many options that now exist for breast reconstruction. The purpose of this article is to review the newest advances in breast reconstruction, and to highlight advances in “oncologic” reconstruction for patients who are undergoing a lumpectomy but may face aesthetic differences in their breasts despite breast conservation therapy.
Most plastic surgeons in the United States prefer to perform breast reconstruction immediately following a skin sparing mastectomy. The advantages of this approach include better preservation of the skin envelope providing the surgeon a better chance to match the shape and droop (ptosis) of the opposite breast. Immediate reconstruction also saves the patient another anesthetic and is more cost efficient than delayed reconstruction. Most importantly, many studies have highlighted the positive psychological advantages of immediate reconstruction. There are a few factors that may prevent immediate reconstruction. These include tumor size, nodal involvement, need for post-operative radiation therapy and co-existing medical condition.
There are now at least 5 different types of breast reconstruction that we offer. These include expander reconstruction with or without ALLODERM, IMMEDIATE ONE STAGE IMPLANT RECONSTRUCTION with or without ALLODERM, Latissimus flap reconstruction, Tram flap reconstruction, and finally, PERFORATOR FLAP reconstruction. The types in bold print represent the newest advances in breast reconstruction.
Expander reconstruction involves the use of a saline breast tissue expander placed under the pectoralis muscle at the time of mastectomy and then inflated serially in clinic for 6-8 weeks. A second outpatient procedure is then required for removal of the expander and placement of a permanent saline or silicone implant. The newest generation of silicone implants are felt to be safe, and participation in the FDA outcome study is now on a voluntary basis. Silicone implants are felt to be softer than saline implants and provide a more natural feel of the breast. Most surgeons have started using Alloderm (Processed cadaver dermis) at the time of placement of the expander to reduce the time required to completely fill the expander, and to reduce the pain that may be associated with expansion. A third and final outpatient procedure under local anesthesia is required for nipple reconstruction. The majority of breast reconstruction done in the United States is done using expanders and implants.
Immediate one stage implant reconstruction is now possible for selected patients. The IUSCC breast cancer reconstruction team is one of the few centers in the United States offering this type of reconstruction. A permanent implant (preferably silicone) is place under the pectoralis muscle and a piece of Alloderm sewn to the pectoralis to provide complete coverage of the implant. This type of reconstruction is better for non smoking patients who are medium to large breasted prior to mastectomy and prefer to end up with a slightly smaller breast post-operatively. As our experience has grown with this technique, our results have improved; however, it is sometimes difficult to obtain a perfect appearing result with one operation. A second outpatient procedure is also required for nipple reconstruction and to revise the shape of the breast if needed.
Latissimus muscle flap breast reconstruction has been available since the 1970’s. The latissimus dorsi muscle is the muscle that lies in your back-if you stand against a wall and push with your hands, you can contract this muscle. An expander or sometimes a permanent implant is almost always required with this type of reconstruction. This is an excellent type of reconstruction for patients who continue to smoke or who are overweight and have a droopy opposite breast.
The TRAM (transverse rectus abdominis flap) has been the mainstay of breast reconstruction since the 1980’s. It involves use of abdominal tissue (skin and fat-same as removed in a tummy tuck) based on the rectus abdominus muscle (pedicled TRAM). Variations of the tram flap including the “Free” tram which involves use of only a small part of the rectus muscle- “muscle sparing”- provides the same tissue but minimizes the impact on the abdomen. In general, the pedicled tram flap may leave the abdomen weaker, with a potential for hernia formation post-operatively. Some surgeons repair the abdominal wall with Alloderm and mesh to provide strength. Since we have started using this technique, we have had a significant reduction in these complications following TRAM surgery. The advantages of the tram flap are that it allows the surgeon to create a more natural appearing breast which is made of skin and fat (much the same as a natural breast) and prevents the need for an implant. A tummy tuck is an added advantage of this type of reconstruction. Patients usually stay in the hospital for 2 to 3 days following this type of reconstruction with full recovery in 4-6 weeks and have a 10 pound lifting restriction for at least 4-6 weeks following surgery.
Perforator flaps represent the newest advance in breast reconstruction. These flaps are based on a single blood vessel and do not require removal of a muscle to supply the skin and fat. Microsurgical techniques are required to connect the very small blood vessels of the flap to blood vessels in the axilla or usually ribs. This technique usually takes longer than other techniques. Any woman who is a candidate for tissue reconstruction is a candidate for perforator flap reconstruction. In general, any woman who will require radiation should probably wait at least 6 months following radiation to optimize the cosmetic results. The big drawback of this type of reconstruction is that the results are an all or none phenomenon. The breast reconstruction may fail in 2-5% of all patients due to a variety of reasons including the fragility of the anastamoses which may need to be redone in 20% if all cases. Total loss of the reconstruction may occur in up to 5% of all reconstructions. Potential donor sites for perforator flap breast reconstruction include the abdomen (DIEP), the lower abdomen (SIEA), the superior buttock (SGAP), the inferior buttock (IGAP), and the lateral thigh (ALT.)
Regardless of the type of reconstruction you choose, you will need a sufficient amount of time to recover. It may take you up to six weeks to recover from a combined mastectomy and reconstruction or from a flap reconstruction alone. If implants are used without flaps and reconstruction is done apart from the mastectomy, your recovery time may be less.
Reconstruction cannot restore normal sensation to your breast, but in time, some feeling may return. It is important to realize most scars will fade substantially over time, though it may take as long as one to two years, but they'll never disappear entirely. The better the quality of your overall reconstruction, the less distracting you'll find those scars.
Please check with Dr. Sood on when to begin stretching exercises and normal activities. As a general rule, you'll want to refrain from any overhead lifting, strenuous sports, and sexual activity for three to six weeks following reconstruction.
Your reconstructed breast will look different from you natural breasts. The reconstructed breast may feel firmer and look rounder or flatter than your natural breast. It may not have the same contour as your breast before mastectomy, nor will it exactly match your opposite breast. Occasionally it is necessary to perform a procedure on your natural breast to make it more closely resemble your reconstructed breast. Dr. Sood may do a procedure such as breast lift, breast reduction, or breast augmentation to achieve better symmetry between the two breasts. For most mastectomy patients, breast reconstruction dramatically improves their appearance and quality of life following surgery.
Dr. Sood's primary goal is to provide excellent clinical results along with a high level of patient care and service. Patient satisfaction is our highest concern. We are dedicated to providing every patient with a pleasant experience, beginning with the first visit and continuing on through surgical procedures and treatments and postoperative care. We encourage patients to evaluate the benefits as well as the risks of each procedure within the confines of realistic expectations.