What is Breast Reconstruction?
If you have been told that you will need, or if you have already undergone a mastectomy, breast reconstruction may be an option for you. Breast reconstruction is a series of operations designed to recreate your breast to its original shape.
The initial step in breast reconstruction is to evaluate the proposed or existing changes to your breast due to a mastectomy. The types of changes that often occur are the loss of skin surface, breast volume, the nipple, symmetry and contour.
As you are already aware, being faced with the diagnosis of breast cancer forces you as a patient to make numerous difficult choices. Breast reconstruction is no different and is similar to an unfamiliar road with many different routes available. Although your physicians are there to help will guide you along the way by explaining the options, you must make the final decisions, which will direct you down the path best suited to your situation.
Your first choice is whether or not to proceed with ANY reconstruction. For hundreds of years, mastectomies were performed without any chance of reconstruction. In fact, for a number of reasons, most women in the United States who undergo mastectomy DO NOT undergo reconstruction. The breast is removed and the remaining skin is simply closed. For many women, this option remains the most expeditious, safe, and reasonable choice. The missing breast tissue can be disguised with clothing or by inserting foam pads into a special bra - - this is called a "bra prosthesis". This method can be looked at as the "full assault war approach": the object of the game is to eradicate the enemy (the cancer) quickly with maximal survival, fast recovery and minimal casualties (the ability to move on with ones life very quickly. The disadvantage of NOT undergoing reconstruction, however, is obvious...the mastectomy defect is quite deforming and oftentimes disturbing to some patients.
Our experience in counseling many patients over the years reveals that all patients have a different sense of body image and importance. The question of whether or not to proceed with reconstruction is a very personal one that must be answered by each patient individually.
For some patients, mastectomy without reconstruction is not a viable option as they are uncomfortable with the appearance of their body after the mastectomy and wish to pursue surgery as a means of regaining a more natural breast appearance.
When should you undergo breast construction?
There are two paths to choose from when deciding to have reconstructive surgery.
Breast reconstruction may begin at the time of the mastectomy, in which case is known as "immediate breast reconstruction" or weeks, months, or years thereafter, also known as "delayed" reconstruction.
What are the advantages of immediate reconstruction?
Reconstructing the breast immediately following the mastectomy avoids additional operations and general anesthesia at a later date. Furthermore, the reconstructive process is generally easier due to the absence of scar tissue from prior surgeries with the breast skin retaining the size and shape of the original breast.
In our experience, immediate reconstruction has had no impact on the timing of postoperative chemotherapy or radiation therapy. This is important, as it means that in general, undergoing immediate reconstruction does not delay the necessary therapy for treating the cancer. There are, however, select cases where immediate reconstruction is not recommend. An example would be "inflammatory carcinoma" or widely metastatic disease that is not controlled by chemotherapy. Additionally, delayed reconstruction may be advisable if you as a patient need more time to make the numerous critical decisions associated with your disease or your surgeon anticipates other problems with the control of the cancer, wound healing problems, personal preferences, etc. Here again, it is imperative that you work with doctor to understand the pros and cons for all the available options so that you can select the optimal path for your situation.
What are my reconstructive choices?
If you decide to pursue reconstructive surgery, you must then decide between a breast implant, known as a prosthesis, or autologous tissue flaps (the use of your own tissue from another part of your body).
What about breast implants?
A breast implant is a silicone shell and is similar to a balloon filled with either silicone gel or a salt-water solution known as "saline". Implant reconstruction is designed to recreate the original breast shape and contour. A component of the mastectomy is to remove the nipple and areola (the pigmented portion of the skin). The removal of this skin and tissue often times does not leave enough volume to accommodate the breast implants. Therefore, in order to allow for the placement of the implants, the skin and tissue must be expanded, or stretched. This is done by placing an expander, or a deflated silicone "balloon", under the remaining skin and chest wall muscle (the pec major). The skin is then closed without tension and allowed to heal for a few weeks. Once the incisions have healed, the expander is slowly inflated through a series of injections through a small port under the skin. This is done over a period of several months, using a small needle and syringe through the skin. After the expander has been completely filled, the expander can be replaced with the final implants. This requires an additional surgical procedure, usually under anesthesia, in an outpatient setting.
Although most patients are pleased with the improved appearance of their breasts due to the implants, this reconstructive method does present several fundamental limitations and problems. The implants, being placed so close to the skin, are almost palpable patients can feel the texture of the implants, the folds, rippling. In addition, sometimes, the implants become infected, exposed, or require replacement due to a sudden or gradual deflation due to normal wear and tear on the implant itself with a subsequent failure of the implant. Finally, all foreign bodies placed within the body will be associated with some time of scar tissue development. The degree of this scar tissue and its ability to contract will be different for each person and may cause "capsular contracture" or a distortion of the breast shape.
While implants have been used to successfully augment (or enlarge) breasts for greater than 20 years, the results for reconstruction are, in general, not as good. This is due to the differences in the amount of body tissue overlying the implant and your body's reaction to foreign material. In augmentation, the implant is placed under the breast, or oftentimes under the breast AND the chest wall muscle (pec major) to provide the increase in breast volume and projection. Once the implant is in place, the body will recognize the foreign material and develop a scar around the implant. The actual thickness of this scar (or capsule) will vary from person to person and will be more or less noticeable depending upon the thickness of the overlying breast tissue. Since the mastectomy will remove most of the tissue from the under-surface of the skin, the thin nature of this skin coverage may not be able to mask or hide any of the contour changes associated with implants. This means that the texture of the implant (envelope characteristics, ripples, folds) may be felt through the overlying breast tissue.
Despite these problems, breast implants remain the most common reconstructive technique performed in the world. They provide a reasonable facsimile of a breast with no other scars, minimal operative risks, and quick operating times.
What are the effects of radiation therapy on implants?
Problems and complications with breast implants are significantly increased with radiation therapy. In general, if one requires or has had radiation therapy, the use of breast implants should be discouraged unless there are no other options and both surgeon and patient understand the higher complication rates.
Autologous Tissue Breast Reconstruction (or "flap" reconstructions).
In contrast to the implants, autologous tissue (autologous = tissue from another part of your body) reconstruction methods require the transplantation of living skin, fat, and some muscle from a different part of the body to replace the breast tissue removed in the mastectomy. Once successfully transplanted to the breast area, the tissue can be sculpted to achieve optimal shape and size and fully restoring breast symmetry. A tremendous benefit of this method over the implants is that the tissue is from the patient's body so the reconstructed breast is not a foreign material. Another advantage to the flap procedure versus an implant is the long lasting result. Very often, implants will leak and require replacement; whereas, the autologous tissue will last the patient's entire life. The main disadvantages of autologous tissue breast reconstructions are the additional donor site scars (where the transplanted tissue was removed), the increased complexity and length of the surgery, longer recovery periods, etc.
If the autologous method is the selected option for reconstructive surgery, then the next choice is to decide where on the body to obtain the necessary tissue. There are five main areas that can be used, the abdomen (pedicled and free TRAM), the buttock (superior or inferior gluteal), the back (latissimus dorsi myocutaneous), the thigh (tensor fascia lata) and the hip region (iliac or Rubens flap). Each alternative should be discussed with your doctor and the most appropriate method should be selected to meet your specific requirements and personal preferences.
Pedicled and Free TRAM Flaps
The TRAM (which means Transverse Rectus Abdominus Myocutaneous) flap transplants the necessary skin and fat from the lower abdomen. The flap, or transported tissue, is surgically removed from the abdomen and moved to the breast where it is sculpted to match the original breast shape and size. In many patients the abdomen provides an excellent source of tissue for this type of procedure.
The TRAM flap can be transplanted or moved to the breast in two ways: a "pedicled flap" or a "free flap" technique. (A flap is simply a medical term to describe a piece of body tissue consisting of, for example, skin, fat, and muscle.) "Pedicled" flap means that the flap remains attached at all times during the surgery and is "tunnelled" from the abdomen into the breast.
"Free" flap means that the tissue is actually totally removed "free" from the body and then reattached by sewing the small artery and vein utilizing microsurgical techniques. The free flap transfers the same area as the pedicled flap, but utilizes the more dominant lower blood supply, called the "deep inferior epigastric artery and veins". In addition, only a portion of the muscle is taken with the flap preserving the upper part of the stomach muscles. The major benefit of the free TRAM flap is that it has an excellent blood supply within all areas of the transplanted flap tissue. Therefore, the flap is less prone to "fat necrosis", and allows for a much higher volume of healthy tissue. "Fat necrosis" is the end result of partially dead fat which has developed scar tissue, oftentimes with calcification, due to lack of blood supply to the transplanted tissue. The presence of fat necrosis can lead to firm nodular areas which may be confusing in terms of cancer detection and follow-up, although they can be removed over time. Given these factors, we believe the free TRAM is the preferred technique and in some cases, such as diabetes mellitus, severe obesity, and cigarette smoking, the incidence of peripheral fat necrosis is high enough that the free TRAM flap technique is the clear procedure of choice.
While the pedicied TRAM flap requires the transfer of the entire rectus abdominus muscle, the free TRAM flap only requires the transfer of a small segment of the lower aspect of the muscle. Therefore, in general, we have found that the postoperative recovery is shorter.
Are there any risks specific to the free TRAM flap technique?
Yes, clotting of the reattached blood vessels. If the microsurgically repaired blood vessels develop a thrombosis (or a blood clot), the flap (tissue) has no blood supply and will die if the blood supply is not restored. When a flap thromboses, this can usually be repaired if it is detected early. In general, the risk of thromboses is the greatest during the first 24 hours after surgery, and problems thereafter are quite rare - in general occuring in approximately 1-2 % of the patients (1-2 patients out of 100).s is the greatest during the first 24 hours after surgery, and problems thereafter are quite rare, and in general occurs in approximately 1-2 % of the patients (1-2 patients out of 100).
Microsurgical Skills and Medical Center
Given the microscopic nature of the free TRAM flap technique, the surgeon should be specially trained in this area or be experienced in microsurgery. In addition, the medical center performing these procedures should also have specialized nursing and postoperative care to allow for careful monitoring of the flaps.
Superior Gluteal Free Flap
The superior gluteal free flap transplants tissue from the upper buttock region, based on the superior gluteal artery and vein. This area can usually provide enough tissue to recreate the breast, even in very slender woman. This flap is technically more difficult to perform, with a significantly higher complication rate than the free TRAM flap and should only be completed by very experienced microsurgeons specifically trained in the execution of this type of flap.
Latissimus Dorsi Myocutaneous Flap
The latissirnus dorsi flap transplants tissue from the back. In a select number of patients, the back area has sufficient tissue (both skin and fat) to recreate the breast; however, in most patients, the use of this flap requires the use of an implant under the latissimus dorsi muscle to provide volume and projection.
Tensor fascia lata free flap.
This flap harvests the lateral area of the upper thigh, commonly known as the "saddlebag area". The major disadvantage of this type of flap is the resulting scar which extends down the outer aspect of the thigh region, which is not easily hidden. Nevertheless, this is a good alternative for some select patients.
Other Related Procedures
Nipple / Areola Reconstruction
Once the breast mound has been reconstructed, the nipple can then be created. This is done using tissue that was transplanted during the reconstructive surgery as part of the breast mound creation. The color of the areola (areola = the pigmented circle around the nipple) can be added with a tattoo to complete the reconstructive process and to provide a very natural look. The nipple reconstruction is generally done approximately 2-3 months after the first breast reconstructive surgery and is an out-patient procedure
Mastopexy (breast lift).
Oftentimes, the unaffected breast may need to be lifted in order to match the reconstructed breast. This can be done at the time of the initial reconstructive procedure, or at any stage thereafter.
Reduction or Augmentation Mammaplasty
Occasionally, the unaffected breast may be larger or smaller than the reconstructed breast. In order to achieve symmetry, one may be reduced or augmented for a better match. (see section on breast reduction for details of this procedure).
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