BY OLYA FESSARD OCT 2016
The Ins and Outs of Breast Reconstruction
Treatment for breast cancer is a journey. Fortunately, women can turn to breast reconstruction to put a positive spin on an otherwise negative situation. Breast reconstruction is a mentally, emotionally, and physically rewarding procedure for most women who choose it after one or both breasts are removed. It can even be a choice after certain lumpectomies and for those who are BRCA gene positive. It rebuilds the breast to match the size and shape of the healthy breast or to replace both breasts because of disease or prevention of disease. Reconstruction can be done either with implants or with a woman’s own tissue and followed by nipple and areola reconstruction.
The American Cancer Society urges women facing breast surgery to talk about reconstruction with their surgeon. If then they are considering reconstruction, they should also talk with a plastic surgeon experienced in breast reconstruction before the surgery to remove the tumor or breast. This process allows the surgical teams to work out the best treatment plan for you before the surgery for the best outcome—even if you want to wait until after you have healed from the mastectomy.
According to a 2014 study published by JAMA Surgery, only 42% of women choose reconstruction after mastectomy. More than 48% of those who decide against reconstruction say they don’t want to undergo additional surgery, almost 34% say reconstruction isn’t important, and 36% cite a fear of breast implants. The study said that many patients who forego it fear that reconstruction could interfere with the detection of a reoccurence of cancer. Breast cancer experts say that this fear is unfounded and should not affect the decision about whether or not to have reconstruction.
“Someone who is being cured of breast cancer has a deformity on her chest from the mastectomy, which is devastating and a long-term reminder of what happened,” says Dr. Philip Beegle of Atlanta Plastic Surgery. “If you can {obtain} a reasonable facsimile of a breast that is just as good as or better than you started out with, you should do it.”
There are many reasons to consider reconstruction for women with breast cancer. Aside from providing symmetrical weight balance of the breasts, for fashion conscious women, the visual symmetry in swim suits or most other clothing is improved. The avoidance of physical changes of the weight carried on each side, such as some loss of sense of balance and shoulder and back pain, is a key advantage of reconstruction. Dr. Beegle adds, “Gathering knowledge and planning ahead for reconstruction gives women something to look forward to.“
As you gather information, be sure to include several expert resources, not just one. Major cancer centers in the U.S. offers the most reliable, up-to-date information on breast cancer and reconstruction. Some of the best are:
- Memorial Sloan Kettering (MSK) Cancer Center, New York City
- University of Texas M.D. Anderson Cancer Center, Houston
- Mayo Clinic, Rochester, Minnesota
- Dana-Farber/Brigham and Women’s Cancer Center, Boston
- Johns Hopkins Hospital, Baltimore
Additionally, the National Cancer Institute (cancer.gov), a part of the National Institutes of Health, and merckmanuals.com, both offer impeccable information. Just because a cancer organization is huge doesn’t necessarily translate into the most recent research.
For example, the American Cancer Society (cancer.org) offers four ‘advantages’ of reconstruction and 12 negative factors to consider to help women determine if reconstruction is right for them. This seems odd, since most cancer experts recommend it for women who meet the eligibility requirements.
One of those questions is, “How important is it that you be able to resume your normal activities as soon as possible?” The response is, “In most cases, women who choose no reconstruction are able to resume their daily activities more quickly than women who choose reconstruction.” In my personal experience, that is false. I come from the same gene pool as two of my sisters. We were all in good health and roughly the same age at the time of our mastectomies. After Tram-flaps for both breasts, I was back at my magazine work within a week. Both of my sisters took far longer to recuperate after their mastectomies on only one breast without reconstruction.
“Everybody is different,” emphasizes Beegle. “The decision may depend on overall health, the stage of breast cancer, size of the natural breast, amount of tissue available, whether you want reconstruction surgery on one or both breasts, insurance coverage for the unaffected breast and related costs, the type of procedure you want, the size of the implant or reconstructed breast, and the desire to match the look of your other breast.”
Once you have decided on reconstruction, Dr. Beegle says, “A significant portion of the time, there is no reason not to do reconstruction at the time of the mastectomy. The advantage of not waiting is that the chest tissues are not damaged by radiation therapy or scarring, there is less surgery involved, and the final result looks better.
Most highly experienced plastic surgeons recommend skin-sparing mastectomies. “It’s a great option if you are planning to have reconstruction right away because there is less scar tissue and the reconstructed breast seems more natural,” Dr. Beegle states. “Most of the skin over the breast other than the nipple and areola are left intact. Since the skin is not breast tissue, there is no reason to remove it. The majority of the time, we are able to save the skin which makes reconstruction easier and aesthetically better.”
Once reconstruction is the choice, there is the question of whether to use implants or the patient’s own tissue. Women who do not want more surgery than what is required or who bleed or scar easily may want to steer clear of reconstruction or choose a saline implant. Of course, saline implants restore the shape but not the feeling in breasts.
“Implants are not for everybody,” Dr. Beegle says. “Saline-filled implants are silicone shells filled with saltwater and can actually be detrimental to your health. Leakage can cause immune system disease, so they are not used as often as they were in the past. They also may not last, causing a need for replacement and can rupture or cause infection or pain.”
“However, if done by a highly qualified and experienced plastic surgeon, reconstruction using your own tissue will usually leave your breast with almost the same sensation and feel as the breast it replaces,” according to Beegle. “The feel of the breast tissue will be much the same, but the skin will never have quite the same sensitivity, and the nipples will not regain any erotic sensations.”
Obviously, if the plastic surgeon is skilled in using the patient’s own tissue, that would be the first choice. The National Cancer Institute describes the process like this: “A piece of tissue containing skin, fat, blood vessels, and sometimes muscle is taken from elsewhere in a woman’s body and used to rebuild the breast. This piece of tissue is called a flap. Different sites in the woman’s body can provide flaps for breast reconstruction as follows:
- TRAM flap: Tissue, including muscle, that comes from the lower abdomen. This is the most common type of tissue used in breast reconstruction.
- DIEP flap: Tissue that comes from the abdomen as in a TRAM flap, but only contains skin and fat.
- Latissimus dorsi flap: Tissue that comes from the middle and side of the back.”
“The DIEP (deep inferior epigastric artery perforator) flap has pros and cons, but most of us who do lots of reconstruction do not {prefer} the DIEP flap because it has significant downsides.” states Beegle.
While Dr. Beegle does not favor the DIEP flap surgery, the renowned Brigham and Women’s Hospital describes it as a “cutting-edge breast reconstruction procedure that uses a flap of complete tissue—blood vessels (perforators), skin, and fat—from a woman’s lower abdomen as donor tissue.”
There are two types of ‘flaps’, the traditional TRAM flap and the free TRAM flap, or transverse rectus abdominis muscle flap. Beegle says that plastic surgeons prefer the free TRAM. One advantage is that only a small portion of the rectus muscle is used, which means there is less pain after surgery and decreased risk of complications like hernia.
According to Dr. Beegle, “The disadvantage of the free TRAM is that the amount of muscle used, though not a lot, is still greater than the amount used in DIEP. Patients are often weak afterwards as a result.” Still, the free TRAM flap uses less muscle tissue than the traditional TRAM flap.
Both free TRAM and DIEP involve the relocation not only of tissue but also of the tissue’s blood supply, which means that microvascular surgery techniques are required to complete them, says Peter Cordeiro, Chief of the Plastic and Reconstructive Surgical Service at MSK Cancer Center. He adds that one advantage of the flap is that it results in a softer, fuller breast {than the implant}.
The latest trend in reconstruction is the nipple-preserving mastectomy. Certain criteria must be met, such as the tumor cannot be in or near the nipple, and it cannot be done with certain types of tumors.
“Women feel satisfied with the results,” says Dr. Beegle. “If you can maintain your skin envelope, which is the skin on the breast, and maintain your nipple, a nipple-preserving mastectomy is less psychologically traumatic than the typical mastectomy.”
As you journey through breast cancer and possibly reconstruction, don’t hesitate to address any concerns with your surgeon so you feel comfortable. You may want to bring a list of questions with you, such as:
- What types of reconstruction are available?
- What is the average cost?
- How many such procedures have you done, and what was the success rate? 100 to 200 should be the base, with less than 1% failure rate.
- Will the reconstructed breast match the other? Ask to see several of the surgeon’s before and after pictures.
- How will it feel to touch? Will I have feeling?
- What possible problems may arise?
- How long will I be in the hospital?
- What is the recovery time?
- How do I care for the incisions?
- When can I start exercise?
- Can I talk to other women who had the same surgery with you?
- Will it interfere with chemo or radiation therapy?
- How long will the implant last? Will insurance pay for subsequent implants?
- Will there be any changes in my weight?
- Are there any new options of which I should be aware?
Breast reconstruction shows yet another advance in women’s health. It is important to never lose sight of your options and not be afraid to seek a second opinion when merited. #