Breast cancer. One out of nine women will hear these words over the course of their lives. Their mention evokes fears of death and concerns regarding disfiguring surgery. Fortunately for tens of thousands of women today, breast reconstruction has been able to address many of these issues.

Breast reconstruction has become a safe and accepted treatment, and the demands of the public have led to the passage of legislation making insurance compensation mandatory. Today, breast reconstruction is an option any woman having a mastectomy should discuss with her doctors and determine if it is right for her.

Womens Health and Cancer Rights Act of 1998 In October, 1998, federal legislation was signed into law requiring group health plans and health issuers that provide medical and surgical benefits with respect to mastectomy, to cover the cost of reconstructive breast surgery for women who have undergone a mastectomy. The coverage must include all stages of reconstruction of the diseased breast, procedures to restore and achieve symmetry on the opposite breast, and the cost of prostheses and complications of mastectomy.

The first goal in breast cancer is eliminating the disease. Surgery involves lumpectomy (removal of the cancerous lump) or mastectomy (removal of the breast tissue), usually with excision of axillary (armpit) lymph nodes. Other treatments such as radiation therapy and chemotherapy may be necessary.

Such treatments usually do not prevent a patient from undergoing breast reconstruction, but must be taken into account when coordinating a treatment plan.

When Should I Consider Breast Reconstruction?

You should consider breast reconstruction when discussing your surgical options with your doctor and especially if a mastectomy is planned. With a mastectomy, all of the breast tissue is removed, including the nipple and areola. There is always a skin deficit, even after skin-sparing mastectomies. These missing elements can all be reconstructed.

What Do I Need to Know?

Patients considering breast reconstruction need to explore their options and find an experienced plastic surgeon with whom they feel comfortable. The family doctor and breast surgeon can help recommend a plastic surgeon. Often a team treatment approach has already been established.

Patients can learn more by contacting the American Society of Plastic Surgeons, formerly known as the American Society of Plastic and Reconstructive Surgeons (www.plasticsurgery.org) or the American Cancer Society (www.cancer.org). Local breast cancer support groups can provide additional information and often have members who will share their own experiences.

Questions to Ask When Considering Breast Reconstruction Listed below are some questions to ask your plastic surgeon. You may have additional ones. What types of reconstruction are options for me? What type of reconstruction is best for me? Why? Will it interfere if I need radiation therapy or chemotherapy? What are the benefits to me? What are the risks? How much experience do you (the plastic surgeon) have performing this procedure? When can I have the reconstruction done? What will happen? How long will I be in the hospital? What is my recovery time? What will my reconstructed breast look like and feel like? What do I need to know about my reconstructed breast over time? Will it change shape? What happens as I get older? What happens if I lose (or gain) weight? Do you know anyone I can talk to who has had this same procedure?

When Can I Have the Reconstruction Performed?

You and your plastic surgeon will need to discuss when to have the reconstruction performed. It may be immediate, done on the same day as your mastectomy; or it may be delayed and performed on a later date. In general, the advantages of immediate reconstruction include easier surgical exposure, more pliable tissues during the operation, and reduction in the number of operations and hospitalizations.

When delayed reconstruction is done, the old scar is usually reopened, and additional release of contracted tissues may be necessary. Some surgeons prefer to delay reconstruction until after the period of radiation and chemotherapy.

What Are the Types of Reconstruction Procedures?

There are two categories of breast reconstruction: prosthetic reconstruction, which utilizes an implant, and autologous reconstruction, which utilizes your own tissues.

Prosthetic Breast Reconstruction

Prosthetic breast reconstruction is generally done in two stages. A tissue expander is placed under the chest muscle at the first operation, gradually inflated with saline injections, and then replaced by a permanent breast implant during a second operation.

For more information about prosthetic reconstruction, see part 2 of this series: Prosthetic Breast Reconstruction

Autologous Breast Reconstruction

There are several types of autologous breast reconstruction. Which method to use is determined by multiple factors, including the amount of tissue needed to match the opposite breast, the tissue availability in each possible donor site, and locations of scars from any prior surgeries you may have had. Underlying medical conditions may also affect the method to use or may even prevent this type of reconstruction altogether.

The transverse rectus abdominis myocutaneous (TRAM) flap is used most often. The TRAM flap procedure uses tissue and muscle from your lower abdomen. This flap transfers skin and fat of the lower abdomen to the chest using an abdominal muscle and its blood supply.

This procedure is usually done in a single stage. The feel of the tissue is natural, and a good contour match can be achieved, even with a fairly pendulous (or sagging) opposite breast.

Other types of autologous reconstruction can be used to meet individual needs. With a latissimus dorsi (LD) flap, the latissimus dorsi (back) muscle and overlying soft tissues are brought around from your back. This creates a pocket for an implant, which is usually used with this type of reconstruction.

Free flaps, which are portions of tissue completely detached from their original sites and reinserted into a new site with microscopic surgery, can also be used. The free TRAM flap is used most often, but tissue from other sites such as the buttocks, hips, and thighs are options in selected cases.

For more information on autologous reconstruction, see part 3 of this series: Autologous Breast Reconstruction.

Are There Other Considerations I Need to Know?

After the reconstructed breast has healed, the nipple and areola may be reconstructed. Nipple and areola reconstruction involves minor procedures usually done in the surgeons office. Flaps of tissue made with small incisions recreate the nipple, and skin grafting or tattooing recreate the areola. These can be done whether prosthetic or autologous reconstruction has been performed.

Another consideration is the shape of the non-affected breast. Some patients with large or pendulous breasts choose to have a reduction or mastopexy (lift) done to the opposite side for symptomatic reasons or to make contour matching easier. The timing of such procedures in relation to the mastectomy and reconstruction vary.

All patients with breast cancer need long-term follow-up. Undergoing reconstruction has not been shown to increase the rate of new or recurrent cancer, or to affect the ability to detect such cancers.

Breast reconstruction has evolved into a safe and effective treatment, and satisfaction has been very high, especially when you are well informed about the process preoperatively.

Part 2: Prosthetic Breast Reconstruction: Frequently Asked Questions
Part 3: Autologous Breast Reconstruction: Frequently Asked Questions

 

 

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