Breast reconstruction isn’t for everyone, but it is an option everyone has the right to consider. Those who choose to undergo breast reconstruction after mastectomy have several reconstructive options ranging from breast implants to using their own tissue. The procedure is usually covered by insurance in the US thanks to a 1998 Federal Mandate.
Generally speaking, reconstruction can be performed at the same time as the mastectomy (“immediate reconstruction”), or any time after (“delayed reconstruction”). Immediate reconstruction is usually an option for patients with early stage breast cancer (stage I or II). When the mastectomy and reconstruction are performed at the same time, a skin-sparing mastectomy should be performed whenever possible. This removes all the breast tissue but saves the overlying natural breast skin envelope (except the nipple-areola). The reconstruction then “fills” this empty skin envelope. Immediate reconstruction with skin-sparing mastectomy typically provides better cosmetic results than delayed reconstruction as the scarring is more limited.
Reasons to delay reconstruction include patient preference, advanced breast cancer (stage III or IV), inflammatory breast cancer, and lack of access to a reconstructive plastic surgeon. Most plastic surgeons also recommend delaying reconstruction if there is a plan for radiation therapy after the mastectomy.
In some cases, a nipple-sparing mastectomy (NSM) can be performed. This preserves the nipple and areola as well as all the breast skin. NSM is an option for patients with smaller cancers located several centimeters away from the nipple-areola. Patients who need a significant breast lift for the best cosmetic results are not ideal candidates, though when NSM is performed in conjunction with flap reconstruction, a breast lift can usually be performed at a subsequent surgery.
If the blood supply to the nipple and areola is damaged too much during the mastectomy, part or all of the nipple-areola can die. Thankfully this is very uncommon when the mastectomy is performed by surgeons experienced with the technique.
Patients must be prepared to lose all nipple sensation after NSM. In cases where some nipple-areola sensation is preserved or returns over time, the feeling is typically well short of what Mother Nature provided. The preserved nipple-areola often continues to respond to tactile and temperature stimuli despite the lack of feeling.
When combined with immediate breast reconstruction in appropriate candidates, nipple-sparing mastectomy provides superior cosmetic results without compromising cancer treatment 1.
Implant reconstruction is usually performed as a multiple-step procedure starting with tissue expanders. In certain cases, it can be performed in a single-stage (“one-step”). Implant procedures limit scarring to the chest (no scars on the abdomen or other areas of the body), involve shorter surgery and hospital stays, and are associated with quicker recovery (average 3-4 weeks) compared to flaps. Most plastic surgeons offer implant-based breast reconstruction. In terms of risks, implants can get infected or exposed and require removal. Long-term, implants can rupture or become hard due to scar tissue around the implant (capsular contracture). Rippling is common (visible “waves” through the skin), and they often move unnaturally with chest activity (“breast animation”). Many women also complain that the breasts feel cold to the touch. Significant capsular contracture can cause breast deformity and pain, and 40% of patients need more surgery within the first 10 years due to implant related problems. The FDA also recommends implants be replaced every 10 years.
Flap procedures involve removing tissue from one part of the body (abdomen, back, buttock or thigh) and transferring it to the chest. These surgeries therefore create scars on other parts of the body. Flaps require longer surgery, a couple more days stay in the hospital, and a longer recovery time (average 4-6 weeks).
Many plastic surgeons offer “pedicled” flaps like the latissimus (“lat flap”) and TRAM that do not require microsurgery. Far fewer surgeons offer the more complex microsurgical flap procedures that preserve muscle function (eg DIEP, SIEA, GAP, PAP). In terms of risks, the flap can “fail” 1% of the time (or less) in experienced hands. In this situation, the tissue is removed and further reconstruction can be performed. Flaps that sacrifice muscle, like the latissimus flap and TRAM flap, are associated with some loss of strength of the shoulder region and core respectively, but most patients do not feel this affects everyday activities. Abdominal flaps can lead to an abdominal bulge (“pooch”) or hernia, though again, these are much more common after TRAM flap surgery since the abdominal muscle isn’t preserved as it is with the DIEP and SIEA procedures.
Additional risks of any breast reconstruction procedure include: bleeding, infection, wound healing complications, mastectomy skin flap necrosis, loss of sensation and ugly scarring.
Fat grafting involves removing fat using liposuction, purifying it, and re-injecting it into the reconstruction site. It is mostly used in conjunction with the other procedures to improve cosmetic results, and also for small to moderately sized lumpectomy defects. Some surgeons are now advocating performing entire reconstructions in women with fat grafting. The chest is pre-treated with an external expansion device, known as “BRAVA”, worn for several weeks at a time prior to each fat grafting session. Multiple repeat surgeries are required with this approach but implants and flaps are avoided altogether. Fat grafting is the most common method of reconstruction in male breast cancer patients.
The nipple and areola can also be recreated in conjunction with any breast reconstruction technique, often as an office or outpatient procedure.
While some options are better than others in certain situations, there is no “best technique” when it comes to breast reconstruction. The best option is the one that most suits the patient’s desires, needs, situation and overall medical health.
Regardless of the reconstructive approach chosen, reconstruction usually involves multiple stages for the best results and symmetry, and can be a prolonged process extending over several months. There is no “quick and easy approach” unfortunately.
According to American Society of Plastic Surgeons (ASPS) statistics 2, a total of 102,215 reconstructive breast procedures were performed in 2014 in the US. While the DIEP flap is widely considered to be the most “advanced” procedure, tissue expanders and implants remain by far the most common approach:
Radiation therapy is often recommended as part of breast cancer treatment. Patients undergoing lumpectomy receive radiation routinely once they’ve healed from surgery. Some mastectomy patients also need radiation after mastectomy depending on the characteristics of the tumor and staging.
While radiation can complicate breast reconstruction, it does not preclude it. Radiation can cause toughening (fibrosis) and shrinking (contracture) of the patient’s tissue. The tissue loses its elasticity and can become very firm and rigid, making it difficult to expand. Skin color changes are also very common.
Flaps tolerate radiation much better than implants. Studies have shown that flaps have fewer complications than implants in patients receiving radiation after mastectomy and immediate reconstruction 3. Also, when radiation is planned, delayed reconstruction with flaps yields higher patient satisfaction, and fewer complications than immediate reconstruction with implants or flaps 4. Delayed reconstruction with implants in patients who have had mastectomy and radiation yields the poorest results and has a high failure rate.
Anyone interested in breast reconstruction should consult with a board certified plastic surgeon, preferably one specializing in breast reconstruction. If possible, this should be very soon after the diagnosis, before any cancer surgery is scheduled, so that the option of immediate reconstruction can be considered.
This short animated video provides an excellent overview for those interested in learning more about breast reconstruction and the options available.
ABOUT THE AUTHOR:
Dr. Minas Chrysopoulo is a board-certified plastic surgeon, breast reconstruction surgeon and microsurgeon. He was educated at the University College London Medical School, the University of Texas Health Science Center, and the University of Wisconsin. In addition to plastic surgery training, he has completed fellowships training in burn research, hand surgery, and microsurgery. He is part of PRMA Center For Advanced Breast Reconstruction in San Antonio, TX and is the author of The Breast Reconstruction Blog. Follow him on Twitter: @mchrysopoulo Follow PRMA Plastic Surgery on Twitter: @diepflapbreast
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