You are probably wondering why you are in a plastic surgeon?s office when you have a diagnosis of breast cancer. Some plastic surgeons devote a substantial part of their practice to making the treatment of breast cancer easier by offering breast reconstruction surgery to women who require mastectomies. Reconstructive surgery in this setting is different than cosmetic surgery. It is about trying to make the patient feel whole again. It can enable her to regain control of her life. So much of breast cancer treatment is dictated to a patient by the stage of her disease. Breast reconstruction can give a woman a voice in her treatment: does she want reconstruction? If so, how and when? You had no choice in having breast cancer, but you do have some say in how you to choose to respond to it.
If you are interested in surgery, contact our Dallas office to schedule your breast reconstruction consultation.
The Breast Cancer Treatment Process
First, a biopsy is done to establish that you definitely have breast cancer. You most likely have already had a breast biopsy, which demonstrated that you have either non-invasive (in situ) breast cancer or invasive breast cancer. Non-invasive breast cancer means the tumor is still in your milk ducts. Invasive breast cancer has usually originated in the milk ducts and has penetrated the wall of the duct and moved into the surrounding breast tissue. These cancers can be treated with either a lumpectomy and radiation or with a mastectomy; your survival would be the same with either treatment. If you are being advised to have a mastectomy, it is generally because your tumor is too large, relative to the size of your breast, to be adequately removed and leave your breast with an acceptable cosmetic result. Some patients who would otherwise be poor candidates for lumpectomy can be converted into good candidates by having an Oncologic Breast Reconstrution (See below.) Alternatively, you may not wish to have a lumpectomy and radiation, and therefore you have chosen a mastectomy by default in that you do not wish to have lumpectomy followed by radiation.
Invasive cancer can spread, and if it was found in your initial biopsy, you will have a separate outpatient procedure known as a "sentinel node biopsy" to see if the cancer has spread to the lymph nodes in your axilla (armpit). If it has, additional lymph nodes will be removed during your mastectomy. This finding will also mean you will definitely need chemotherapy after your mastectomy.
This step begins with either a lumpectomy or a mastectomy. If it is a simple lumpectomy, it will be done solely by your breast surgeon. If it is a complicated lumpectomy, the plastic surgeon will perform an "Oncologic Breast Reconstruction" immediately following your lumpectomy (Again, see below.)
Alternatively, you will proceed with a mastectomy. In a "Skin-sparing mastectomy" the entire breast is removed along with the nipple and areola, and no other skin is removed. If your tumor is a more favorable size and location, you may be eligible for a "Nipple-sparing mastectomy," which removes the entire breast but leaves the nipple and the areola. Learn more about "Nipple-Sparing Mastectomy". Both of these procedures are called a "simple mastectomy" or a "total mastectomy". If you had a positive sentinel node biopsy, you will have additional lymphatic tissue removed from your axilla, making this procedure a "modified radical mastectomy". You may have heard the term "radical mastectomy". This refers to a procedure where the breast, lymphatic tissue, and pectoralis major muscle are removed. This procedure was common at one time, but research has shown it offers no treatment advantage and is therefore seldom performed.
If you choose to have breast reconstruction, the first phase is frequently begun right after the mastectomy and is therefore called "immediate reconstruction". It allows you to have your mastectomy and to begin your breast reconstruction in one operation. Patients with extensive disease are advised to delay reconstruction until their cancer is firmly in remission.
A pathologist will examine your breast after your lumpectomy or mastectomy. The information provided will allow your oncologist to "stage" your disease so it can be decided how much further treatment you need. If your initial biopsy showed non-invasive cancer, and this was again the only finding after your mastectomy, then you will not need further treatment.
If, however, you are found to have invasive cancer, several factors will be considered to determine if you should have chemotherapy. When a tumor is over 1 inch, has spread to the lymph nodes, or has some other negative biological characteristics such as rapid growth, post-operative chemotherapy is recommended to destroy small groups of cancer cells that may have spread to the rest of your body. This treatment will reduce the risk of your cancer returning. Occasionally, if your tumor is unexpectedly large (over 2 inches) or has spread to more than four lymph nodes, postoperative radiation will be employed, usually following the completion of your chemotherapy.
In summary, the tumor in your breast will be treated with either a lumpectomy and radiation or a mastectomy. Cancer that has spread to your lymph nodes will be identified with a sentinel node biopsy and, when present, will usually be treated with removal of more lymphatic tissue during your mastectomy. Following your mastectomy, the pathologist will analyze all the tissue removed, and the extent of your cancer will be determined or "staged". If it is felt you have a significant risk of residual cancer elsewhere in your body, chemotherapy will be recommended.
Breast Reconstruction Surgery:
Once your cancer treatment is complete, it is usually permissible to continue the reconstruction process started at your mastectomy. If you had no reconstruction at the time of your mastectomy, you can begin reconstruction at this point. This can commonly be done within two to three months after finishing chemotherapy. If you also had radiation therapy, it may take longer for your body to be ready for breast reconstruction. The good news is that breast reconstruction surgery is financially your choice. Federal law compels your health insurance company to cover breast reconstruction following mastectomy. Even procedures on the opposite breast that might be needed to achieve symmetry are covered.
This patient was a 27 year old with the BRCA 1 gene mutation who decided to have bilateral "nipple sparing" mastectomies.+ See Full Case
Breast Reconstruction Techniques
The type of reconstruction you choose will depend on your preferences, your body shape, the amount of cancer you seem to have, and the expected treatments you will require.
Ocologic Breast Reconstruction
Oncoplastic surgery is a fancy name for a procedure that makes it easier for women with breast cancer to avoid a mastectomy by having a lumpectomy and a breast lift/reduction at the same time.
Normally, a breast cancer can be treated by a lumpectomy only if the tumor is in a good location and is small compared to the size of the breast. If a lumpectomy and radiation is done under non-ideal circumstances, as with a relatively large tumor, the woman?s breast can be permanently deformed. Oncoplastic techniques allow a larger lumpectomy to be performed by the breast surgeon and then the plastic surgeon will sculpt the remaining breast tissue into a normal appearing breast. This is done by performing a breast reduction or lift on the remaining tissue and on the opposite breast to create symmetry.
A breast reduction involves the classic ?anchor? incisions: around the areola, down the front of the breast and in the fold beneath the breast. In most cases, sensation to the nipple is preserved. Occasionally, due to a lack of blood supply, the nipple may need to be removed and replaced as a free graft. In these cases, there is a permanent loss of sensation to the nipple.
There are several advantages to Oncoplastic Surgery:
- A breast cancer patient who might otherwise be a bad candidate for keeping her breast can now do so;
- The post-operative radiation is better tolerated in a smaller breast;
- Pre-operative symptoms of breast enlargement are usually relieved;
- It is much safer than trying to ?fix? a breast that is distorted following radiation therapy.
This type of procedure is applicable to patients who have extra skin and breast tissue at the time of their cancer diagnosis. Smaller-breasted patients can still have a standard lumpectomy.
Primary Breast Implant:
The simplest way to reconstruct a breast is to place an implant immediately after the mastectomy. This is not commonly done for several reasons. It is extremely difficult to place the implant in the proper position.
Probably the most common form of breast reconstruction in the United States involves the placement of a tissue expander at the time of the mastectomy. Tissue expanders are rubber implants that can be slowly inflated with saline in the plastic surgeon's office once a patient is healed from their mastectomy. When done patiently, there is little discomfort associated with the expansion, which can take anywhere from several weeks to several months to be completed.
Once the expansion is completed and the patient is done with chemotherapy, an outpatient surgical procedure is performed to replace the expander with either a saline or silicone filled implant. Generally, a new nipple and areola is usually created at the same time. Procedures to modify the opposite breast in order to attain symmetry are also done at the same time.
A tissue expander placement typically adds less than an hour to the mastectomy procedure. Most of our Dallas breast reconstruction patients are discharged from the hospital within one to two days. Recovery from the second and final procedure is usually rapid, and most patients are able to return to office work within a week. Tissue expander breast reconstruction is relatively simple, safe, and has reliable results, particularly in patients with smaller breasts. This technique does require breast implants, which have a finite life span (90 percent of saline implants last 10 years) and can require revision for asymmetry and malposition. Moreover, breast implants placed after tissue expanders have very little tissue coverage, and therefore it can be easy to feel the implant. This form of breast reconstruction is the most common, in part because it is the easiest for the plastic surgeon. However, when it comes to the quality of the result, most patients feel the results are somewhat inferior to other types of breast reconstruction.
Latissimus Flap Breast Reconstruction:
The next most common type of reconstruction is called a latissimus flap. This operation is like the tissue expander procedure except a muscle from your back with a small piece of skin is placed over the expander. The additional tissue and muscle ultimately makes your reconstructed breast look and feel more natural. The piece of skin is used to replace your nipple and areola, and therefore does a more effective job at preserving your breast shape.
The muscle used in latissimus flap reconstruction is seldom missed even by the most athletic of patients. Recent studies have shown that at one year after surgery, there is no discernible difference in shoulder function. Compared to a tissue expander alone, the hospital stay is usually a day longer on average. However, in Dr. Pin?s opinion, even though a latissimus flap involves some additional surgery, it generally provides a significantly higher quality result. After a latissimus flap reconstruction, the reconstructed breast feels much more like a natural breast than one reconstructed with a tissue expander alone. It is the best operation Dr. Pin most frequently recommends to patients who want the best possible reconstructive outcome.
Abdominal Flap Breast Reconstruction:
It is possible to use excess lower abdominal tissue to reconstruct a breast. Originally, this was called a TRAM flap and the tissue was tunneled into the breast area while still attached to the patient by an abdominal muscle. This muscle would supply blood to the flap and was called its ?pedicle". Though dramatic results are possible with a "pedicled TRAM," it is not commonly performed due to a propensity for serious complications such as abdominal hernias and loss of the tissue.
The TRAM flap has been modified many times, so now the lower abdominal tissue can be transplanted to the breast with little or no muscle being sacrificed, making abdominal weakness less of an issue. These operations now require the surgeon to use microsurgery to reconnect small blood vessels supplying the abdominal tissue to other vessels in the chest to make the transplantation successful. Due to the complexity of the procedure, it will usually add an average of at least four hours to the reconstruction. The advantage of this operation is that the breast is reconstructed with your own tissue. The major disadvantage is that between 5 to 10 percent of the time, the entire operation fails and another avenue must be pursued. Such a loss is particularly devastating for patients who are already struggling with their new diagnosis of breast cancer and its treatment. Since Dr. Pin does not perform microvascular surgery, he does not do breast reconstruction with abdominal flaps; if you are interested in this procedure, Dr. Pin will try to help you find a surgeon who does.
Shortcomings of Reconstruction
Breast reconstruction has the obvious benefit of allowing a woman to feel whole after a mastectomy. Nevertheless, there are drawbacks. Breast reconstruction, no matter how well planned and executed, will always involve at least some permanent scarring. Due to the mastectomy, the sensation of your breast will never be normal, though hopefully over time the numbness may be less perceptible. Regardless of the technique used, there will always be some degree of asymmetry between your breasts, both in terms of volume and feel. Finally, there are the risks associated with any surgical procedure such as bleeding, infection, and delayed healing. Sometimes, additional surgery is needed to treat these complications. The probability of these risks is related to your general health, whether you are overweight, and whether you smoke. Dr. Pin tries not to do breast reconstruction on patients until they completely stop smoking because the complications from smoking can be devastating and irreparable.
Being a breast cancer patient can be extremely difficult. There is so much information to absorb and so many new terms to learn while somehow dealing with emotions ranging from fear to anger to confusion. The good news is you are not alone. You will find strength in family and friends and, most surprisingly, in yourself. Over the next year, you will be amazed by your own determination. When you complete your treatment, you will know a new sense of accomplishment. You will be stronger, more compassionate, and more understanding than you are now. But, most of all, you will be proud of yourself!
Dallas Breast Reconstruction Consultations
Contact our Dallas office to schedule your breast reconstruction consultation with us.
Surgery for breast reconstruction is real surgery and involves risks such as bleeding, infection, and scarring. Results vary. Dr. Pin will be happy to discuss these and other risks of surgery for breast reconstruction.