Speaking at a recent national meeting of plastic surgeons, a physician recounted the story of a patient undergoing removal of her breast following the detection of breast cancer. Because of the disfiguring effect of mastectomy on her own mother, she had considered avoiding cancer detection altogether for fear she too would be left deformed. Now that there were so many options for reconstruction, she told him, she didn't fear the outcome so much. When given the news of her own breast cancer she immediately sought a consultation with a plastic surgeon to discuss her reconstructive options.
According to a recent press release by the American Society of Plastic Surgeons (ASPS), 82,975 women underwent breast reconstruction in 1999 as compared to 29,607 in 1992, reflecting a 180 percent increase. In this same period, breast reconstruction was the third most frequently performed reconstructive procedure by plastic surgeons. As suggested by the current ASPS president, two factors have contributed to this dramatic increase—insurance coverage and patient education.
If I Need Breast Reconstruction, Where Do I Begin?
Optimal results are best achieved through coordination between your general surgeon and your plastic surgeon. Only by establishing clear lines of communication between yourself and your physicians can you achieve an end-result with which you will be truly happy. During your initial consultation, your plastic surgeon will explain the most appropriate reconstructive options for you based on your overall health, anatomy, and your reconstructive goals, as well as any associated risks.
Breast Reconstruction Options
Women can choose from more than one option for reconstructive breast surgery.
Implant reconstruction
Excellent results can be obtained by placement of an implant beneath the chest wall muscle and skin. For small-breasted women, placement of a permanent implant after mastectomy in a single-stage reconstruction can also provide very good results. More commonly, however, a tissue expander will be placed at the time of surgery. A tissue expander will allow the skin to stretch to approximately the size of the opposite breast. In a separate procedure, a permanent implant will be placed to achieve more effective symmetry.
Tissue expansion involves placement of a balloon-like device beneath the skin and muscle of the breast. Over the next few weeks after surgery, the expander is gradually filled with salt water until the desired size is achieved. Expansion is unique in that it allows for tissue over the expander to grow and enlarge so that it can replace breast skin previously removed with the mastectomy. This is important because the new tissue will be similar in appearance and texture to the original tissue and can minimize the number of scars required for reconstruction of the breast.
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At a second operation, your doctor will remove this expander through the original incision replacing it with a permanent implant. Any minor procedures needed for adjustment of the breast can be performed during this out-patient procedure. Many surgeons feel that this two-stage approach allows for better creation of a more natural appearing breast and one that achieves better symmetry with your other breast. The nipple and areola will be reconstructed at a later date when the breast has adequately healed.
Tissue expansion and implant reconstruction of the breast are generally safe procedures, although they are not recommended for those patients either anticipating or with a history of radiation therapy to their chest wall. In this case, there is a very high risk of dense scar formation around the implant, called capsular contracture, which can then lead to a firm, constricted breast. For these patients, reconstruction with your own tissue provides a much better long-term result and tends to minimize both the short- and long-term effects of radiation therapy.
Reconstruction Using Your Own Tissue
Breast reconstruction with your own tissue can be an excellent option. The most popular procedures in this category use the TRAM Flap and the Latissimus Dorsi Flap.
The Transverse Rectus Abdominis Myocutaneous Flap or TRAM procedure uses muscle, skin, and fat from your abdominal wall to reconstruct a breast mound. This tissue remains attached to its blood supply and is tunneled beneath the chest wall skin. Here it is adjusted into place and arranged in such a way that its shape, size, and projection approximate the appearance of your other breast. By removing tissue from your abdominal wall, you essentially undergo a tummy-tuck procedure and awake from surgery with a reconstructed breast as well as a tighter, flatter abdomen. While this is an excellent option, it is generally reserved for those patients with moderate abdominal wall laxity and cannot be performed on the excessively thin patient.
The Latissimus Dorsi Flap uses skin and muscle from your back, which is then brought around to reconstruct your breast. Because this provides less overall tissue, it is generally combined with placement of an implant below the muscle to achieve adequate breast proportion and symmetry. Removal of this muscle from your back should not dramatically impact on the function or strength of your remaining muscles and should not limit your activity.
In patients who have had prior abdominal surgery or are not candidates for the Latissimus Flap, another option is the transfer of "free" tissue from a distant site. With this procedure, tissue is taken from either your abdominal wall or your buttock, removed from its blood supply, and then rejoined to a new blood supply using an operating microscope. While this technique is highly effective in a select group of patients, it is more technically demanding and associated with a higher risk of complications.
Regardless of the type of autologous (use of your own tissue) breast reconstruction, the need for additional incisions entails more scarring than with implant reconstruction. The tradeoff is that with this particular type of reconstruction, the results tend to be more natural and avoids problems associated with either silicone or saline breast implants.
While excellent results may be obtained by autologous or implant reconstruction, the best route for you is an individual decision and one that should be arrived at in consultation with your plastic surgeon.
Can Other Procedures Be Performed to My Other Breast During Reconstructive Surgery?
Many women request simultaneous surgery on their other breast to better match the reconstructed side. Commonly performed procedures include reduction of the other breast, lifting the other breast (mastopexy), or augmentation to achieve more adequate symmetry with the reconstructed breast.
How Will My Current Health Affect My Outcome?
Breast reconstruction is generally a safe procedure though several medical conditions may compromise your outcome. Patients on medications affecting blood clotting may be asked to stop these medications one or two weeks before surgery to minimize bleeding risks. Smokers and patients with a history of difficult wound-healing may have problems healing their wounds. Those patients with prior difficulties with anesthesia are also at an increased risk for problems during surgery.
Although complications are rare, in general they are the same types associated with other major surgical procedures. These may include infection, bleeding, fluid collections beneath your skin (seroma), excessive bruising, wound-healing problems, and difficulties related to anesthesia.
Is There Anything I Can Do to Prepare for Surgery?
Your doctor will give you detailed instructions on avoiding various vitamins and herbal supplements which may increase your risk for bleeding. You will be asked to limit your intake of alcohol (including red wine) as this may also cause excessive bleeding. If you smoke, you will be asked to stop two to three weeks prior to surgery. Any blood-thinning medications should be held at least seven to ten days before surgery. Although blood loss is generally minimal, you may want to discuss with your physician the option of donating your own blood before surgery, should a blood transfusion become necessary.
You may wish to arrange for extra help for the early recovery period when you arrive home from the hospital and should ask someone to drive you for at least two to three weeks after surgery.
What Other Surgical Procedures Will I Need?
Construction of a nipple and areola (the darker-colored skin surrounding your nipple) will generally be performed three to six months after your general reconstruction. This usually entails use of local tissue to build a projecting nipple followed by tattooing several weeks later to fashion an areola.
Some women will request additional procedures to further refine their reconstructed breast. These procedures are generally minor and performed on an out-patient basis.
Should I Have the Surgery Done Immediately or Should I Wait?
This is a personal decision. In 1999, 45 percent of patients undergoing reconstruction did so at the time of their mastectomy while 39 percent underwent delayed reconstruction. While delaying reconstruction allows you to adapt to the removal of your breast, immediate reconstruction reduces the total number of major surgeries and allows you to wake up from surgery with a newly reconstructed breast.
What Can I Expect After Surgery?
This is highly individual and influenced by the type of reconstruction you choose.
Aftereffects of reconstruction using your own tissue
Because the TRAM procedure removes skin from your lower abdominal wall, you are effectively getting a tummy-tuck. Expect to feel like you're getting bear-hugged for the first six to eight weeks. Chest wall discomfort is generally minimal since most of the skin will be numb after surgery. Overall, the first 24 hours are the most difficult in terms of stiffness and general discomfort. After this initial period, you should do quite well. Expect to stay in the hospital four to five days. You may have surgical drains and will be taught to measure the output at home. These drains will be removed as the output decreases.
Anticipate some discomfort in your back with the Latissimus Dorsi Flap procedure but very little chest wall discomfort. Hospital stay for this procedure is also commonly around four to five days. If you choose to have an implant placed beneath the flap, you'll undergo routine injections (in your doctor's office) of saline into the expander. The number of these sessions is determined by the desired size of your new breast. This procedure will also require surgical drains.
Implant reconstruction Immediate placement of a permanent implant can be performed as an out-patient or short-stay (24 hour) procedure with discomfort ranging from minimal to moderate. This may also require the use of surgical drains, depending on the surgeon's discretion.
With staged tissue expander reconstruction, you can expect a similar postoperative course. In about two weeks, expect to return to your doctor's office to begin expansion. Later, when the expander has reached the desired skin, your doctor will arrange removal of the expander and exchange for a permanent implant. This is a minor procedure and will be performed on an outpatient basis through your previous surgical incisions.
Implant Reconstruction Risks
With increasing technical refinements, breast reconstruction has become progressively safer, though it still associated with the usual risks of surgery. As previously described, these include bleeding, infection, wound-healing problems, as well as complications associated with anesthesia.
In those patients undergoing implant reconstruction, infection at the surgical site may require temporary removal of the implant until the infection has effectively cleared. In addition, dense scarring around the implant, called capsular contracture, can be easily treated with either scoring of this firm capsule or total removal. And while implant durability has dramatically improved over the last few years, they do have a five to ten percent rate of rupture after ten years. Rupture of a saline implant is benign and the salt water is simply absorbed by your body. Like the previously mentioned procedures, this is a minor operation and can easily be performed on an outpatient basis through your previous surgical incisions.
Long-Term Results
Dramatic improvements in surgical technique and the various options offered have allowed for excellent long-term results. A select sub-group of patients require additional minor procedures to correct small deficiencies in their reconstructed breast. These are minor and can be extremely effective in matching the reconstructed breast to your other breast.
Breast reconstruction procedures will usually leave you with numbness over areas where the surgery was performed. This may improve with time and varies from patient to patient. Scars will generally soften and fade and be less noticeable as the healing process continues. The shape of your reconstructed breast will also improve over time to better resemble your other breast.
Although you will have little to no remaining breast tissue on the reconstructed side, your surgeon will probably recommend continuing routine yearly mammograms. Reconstruction does not significantly affect your ability to obtain these studies, although if your reconstruction involved placement of an implant, you will want to utilize a radiology center familiar with obtaining mammograms in breasts containing implants.
Most important, reconstruction has no known long-term effects on breast cancer recurrence. If your doctor has recommended chemotherapy or radiation therapy, reconstruction should not delay or interfere with these treatments.
Does Insurance Cover Breast Reconstruction?
Yes. Coverage for breast reconstruction for women who have undergone a mastectomy is mandated by the Women's Health and Cancer Rights Act and should be covered by your insurance provider.
More Information on Breast Reconstruction Options
For more information on breast reconstructive options, you may call the Plastic Surgery Information Service at 1-800-635-0635 for a listing of local Board Certified Plastic Surgeons in your area.
Other helpful links include the following:
American Medical Association: http://www.ama-assn.org
National Cancer Institute: http://www.nci.nih.gov
National Breast Cancer Coalition: http://www.natlbcc.org
Society for Women's Health Research: http://www.womens-health.org
American Cancer Society: http://www.cancer.org
Breast Cancer Lighthouse: http://www.commtechlab.msu.edu/sites/bcl
Y-Me National Breast Cancer Organization: http://www.y-me.org
Cleveland Clinic Foundation: http://www.ccf.org
Susan G. Komen Breast Cancer Foundation: http://www.komen.org
National Alliance of Breast Cancer Organizations: http://www.nabco.org
In addition, your doctor can also be an excellent resource for local support networks. Ask for a list of previous patients who you can contact for more information.
Conclusion
Breast reconstruction outcome continues to improve as a result of refinements in surgical technique and patient education. With better access to information regarding their options, patients are more prepared to discuss these options with their healthcare providers. Empowered with this information, patients are able to decide which options are best for them and which ones will provide them with the long-term results they demand. Better informed, patients know what to expect both before and after surgery thus reducing the fear of the unknown.
