Reconstruction
The diagnosis of breast cancer brings with it tremendous emotional and physical distress. Concern about your future health coupled with the anticipation of a “disfiguring” operation may seem overwhelming. Fortunately, state of the art surgical procedures as well as a team of caring professionals can help alleviate some of your concerns and minimize the physical loss associated with a mastectomy.
Your consultation with a plastic surgeon has the potential to be quite complex and confusing. In some patients, there are many possible options for reconstruction, and it will be difficult to recall all of the specific details of your conversation. You will likely concentrate only on the recent diagnosis of breast cancer, and all else will be a blur. As a consequence, you may feel ill prepared to make any choices regarding your reconstructive procedure. This emotional state is certainly understandable and normal, and for that reason, a general review has been prepared in hopes of enabling you to make an informed decision regarding your reconstructive options.
After reviewing your pathology reports and diagnosis, your breast surgeon or general surgeon will make recommendations as to the proper surgical management of the breast cancer. Many variables will be taken into consideration: the type of cancer, the size of the tumor, the size of your breasts, the location of the tumor within the breast, and presence of known tumor cells in lymph nodes or other locations. In some cases, there will be no option other than mastectomy, whereas in others, you may have a choice between a mastectomy or lumpectomy with post-operative radiation therapy. Some physicians may even recommend initially treating the cancer with chemotherapy followed by surgical management.
Many patients may be candidates for breast conservation therapy, which usually involves lumpectomy and radiation therapy. Others may be advised to undergo a mastectomy. During a traditional mastectomy, the nipple and surrounding areola will be removed with the breast tissue. Previous biopsy sites as well as skin involved with tumor may also be removed. Most of the time, some degree of axillary (arm pit) surgery will take place as single or multiple lymph nodes will be removed for pathology review.
A careful and thorough discussion with your breast surgeon will help you weigh the risks and benefits should you be given a choice between the two procedures. Should you choose (or be advised) to undergo a mastectomy, there are several different methods of breast reconstruction available to the appropriate candidate.
During the reconstructive consultation, it is imperative to keep in mind the main objective: cure the breast cancer with appropriate treatment. It can be easy to lose sight of this goal while considering the complexities of a multi-stage reconstructive procedure. I will work closely with your breast surgeon and oncologist to develop the best possible reconstructive plan. Should chemotherapy or radiation therapy be recommended for you, the reconstructive procedures will be carefully coordinated to provide minimal interference with these additional treatment regimens. In general, chemotherapy will not prevent you from having reconstruction while the knowledge of future radiation treatments may compel me to delay reconstruction for at least 6 months to a year.
In the vast majority of cases, immediate breast reconstruction can be performed at the time of the mastectomy. All procedures are multi-staged and require a second surgery performed approximately 3-6 months later. This second surgery is necessary to adjust or revise the reconstructed breast, reconstruct the nipple, and possibly create an areola. Breast symmetry is part of the reconstructive goal, and modification of the opposite breast may also be recommended to improve shape and restore balance with the reconstructed breast. Procedures on the opposite breast are usually performed during the second stage operation. Typically, the second stage surgery is outpatient in nature. A third, very minor, office-based nipple and areola tattooing procedure typically completes the process.
Occasionally, the type and behavior of the cancer identified on the biopsy, your age, and/or your genetic predisposition to developing a future malignancy may lead your breast surgeon to recommend or consider a precautionary mastectomy in the other breast. Identical, immediate bilateral (double or both) reconstructive procedures can be performed in this setting.
There are two main categories of breast reconstruction: (1) techniques that incorporate the use of breast implants and (2) implant-free techniques that utilize the body’s own tissues to recreate a breast mound. Depending on your own personal wishes, your medical history, and your physical exam, a single operative plan or several options for reconstruction will be provided.
This two-stage reconstruction is characterized by the insertion of a temporary tissue expander (which will gradually be filled to expand skin and soft tissue over the breast) followed by exchange of the expander for a permanent breast implant. The expander is essentially a deflated breast implant that contains a metal port for injecting saline (salt water). The sole purpose of the expander is to stretch skin and make a space for the permanent implant; therefore, the expander should be expected to remain firm and relatively fixed to the chest wall.
Immediately following the mastectomy, an expander is placed beneath the available skin and muscle on the chest wall. Two to three weeks following the mastectomy and tissue expander insertion, the expansion process begins or resumes (if started at the time of the initial surgery). Using a magnet, the metal port can be located through the skin. The skin is locally numbed to allow the painless insertion of a needle into the expander. Sterile saline is then injected. As the implant fills, pressure can be felt beneath the skin as it begins to stretch. Sequential expansion is performed during weekly or biweekly visits until the desired expansion has been achieved. Usually, this can be accomplished between one and three visits. The expander is specifically designed to be a tough, firm, and immobile structure and in no way is meant to mimic a normally soft and supple breast. The filled tissue expander remains in the breast for 3-6months until the second operation is performed. During this second surgery, the expander is removed, and a soft, permanent breast implant is inserted. The implants chosen for permanent placement are filled with either saline or silicone gel. As the timing of the second stage reconstruction approaches, I will thoroughly discuss the best implant choice for you.
If, after mastectomy, a large amount of breast skin has been removed or the remaining breast skin is quite thin, supplementing the expander-implant reconstruction with additional tissue may be necessary. It will also improve the cosmetic outcome. In these cases, a muscle from the back (the latissimus dorsi), with some of its overlying skin, is moved to the chest and used to cover the expander. The expansion process and timing of the second procedure remains unchanged, though more initial (intra-operative) expansion can be expected. Patients who have this back/flank muscle rotated to the chest will have a scar on the back in addition to those placed on the breast, but again, the cosmetic outcome of the breast reconstruction is usually better and more natural than with a tissue expander alone.
The TRAM (Transverse Rectus Abdominus Myocutaneous) flap is the most frequently used technique to create a breast from one’s own tissue. It, too, is generally associated with two main operative stages. In this procedure, the skin and fat from the lower abdomen, along with a varying amount of one of the rectus abdominus muscles, is moved into the mastectomy defect. The abdominal tissue is then sculpted to closely match the opposite breast. A second operation, 3-6 months later, is still required to revise and improve the contour of the reconstructed breast, reconstruct the nipple, and address the opposite breast if necessary. This type of reconstruction has the potential to have the appearance, texture, and behavior of a natural breast. In addition, there should be no maintenance issues, like the future need to replace implants. The resultant scars resemble those associated with a tummy tuck and are located across the entire lower abdomen and around the umbilicus (belly button).
The TRAM flap must maintain its own blood supply after being delivered to the chest, and this can be accomplished in two possible ways: pedicled or free. The pedicled flap keeps the upper attachment of the rectus muscle to the rib cage, allowing it and its attached abdominal fat to be tunneled into the breast defect from below. The free flap is completely removed from the body, and its blood vessels are microsurgically reconnected to recipient vessels in the chest.
Compared to a pedicled TRAM flap, the free TRAM flap is a longer, more technically challenging procedure; however, it can reliably bring more abdominal tissue to the breast, and it generally results in a better cosmetic result than a pedicled TRAM . The disadvantages of a free TRAM flap include the small possibility of losing all or part of the transferred tissue due to problems with the microsurgically-attached blood vessels or inherent problems within the transferred tissue. The published failure rate for these procedures varies from 2-4%.
Recovery from any TRAM flap reconstruction is prolonged, usually requiring at least a 4-5 day hospital stay followed by a variable period of at-home recuperation (typically 3-6 weeks). Some abdominal weakness can be expected, and abdominal bulging and hernia formation are also quite possible.
If the TRAM flap could be performed without taking abdominal muscle, a patient could enjoy the benefits of the procedure without the prolonged recovery or the expected donor site problems (weakness or hernia). This is the sole basis for the development and perfection of perforator flap surgery, where skin and fat can be transferred from one part of the body to another, without the patient having to sacrifice a muscle. A completely natural breast mound can be created without the use of implants and with little or no possibility of abdominal weakness. These procedures include the DIEP (deep inferior epigastric artery perforator) flap and the SIEA (superficial inferior epigastric artery) flap Perforator flaps are exceptionally challenging procedures and require refined microsurgical skills and a comprehensive knowledge of anatomy.
The DIEP flap essentially uses the same blood vessels that are used in the TRAM flap and delivers the same section of the abdominal skin and fat to the chest; however, meticulous dissection is performed to preserve muscle fibers and the motor nerves supplying the muscle so that abdominal strength is preserved and recovery is hastened.
The SIEA flap takes advantage of an alternate blood vessel system, which supplies the abdominal skin and fat and is found more superficial to the location of the DIEP vessels. In fact, no abdominal wall or muscle dissection is needed, which completely preserves function and integrity of the abdominal wall. There is some limitation in the amount of tissue that can be reliably transferred and not every patient will have an intact, functional, or large enough SIEA system, so an intra-operative decision will be made to determine if this procedure can even be performed.
Both flaps are extremely difficult to successfully elevate and transfer to the chest and, for that reason, are relatively uncommon procedures in the United States. Dr. Krueger is among a handful of surgeons in the country possessing extensive experience with both the DIEP and the SIEA flap breast reconstruction, and he has performed them with high success rates since 2001.
One should note that TRAM / DIEP / SIEA flap reconstruction can only be performed once, and it is not a repeat option should you develop opposite breast cancer in the future. Some women may be counseled to consider or be advised to have a bilateral (both sides) mastectomy. In these special cases and in the appropriate surgical candidate, bilateral abdominal flap reconstruction is possible.
The other techniques that are used to reconstruct a breast from a patient’s own body involve the microsurgical transfer of tissue from the buttocks, back, or flank. These are quite complex operations with limited usefulness, and in Dr. Krueger’s practice are generally reserved for those patients in certain salvage reconstruction situations, where the traditional measures of reconstruction have failed.
The nipple and areola are typically reconstructed during the second breast operation, 3-6 months after the mastectomy and first stage reconstructive procedure. The nipple is created from the existing breast skin, from the skin brought with the latissimus flap or abdominal flap, or from a portion of the opposite nipple. The areola can simply be tattooed or it be physically reconstructed with a small skin graft taken from the abdomen, thigh, or from the opposite breast. Although healed skin grafts are usually different in color, their pigment can be further enhanced with tattooing.
Advances in microsurgery and implant technology have greatly improved outcomes in reconstructive breast surgery, but limitations may still exist when attempting to achieve perfect symmetry with the opposite breast. If ptosis (hang, sag, etc.) or volume cannot be easily matched, adjustments to the opposite breast (a reduction, lift, augmentation, etc.) may be recommended to improve symmetry with the reconstructed breast. These additional procedures are usually performed during the second stage surgery, 3-6 months following the initial operation.
Your initial visit to discuss the possible options for breast reconstruction will be comprehensive. I will review your current and past medical history, all previous surgical procedures, and your breast cancer pathology and treatment plan. Your goals for reconstruction are also important and will be discussed. A physical exam will be performed and will focus on the breasts as well as the quantity/quality of other tissue available for reconstruction. Digital images (necessary in planning, performing, and following your reconstruction) will also be taken and will become a part of your medical record.
Many variables are active when attempting to determine the most appropriate reconstructive plan for an individual. Your own goals, your thoughts on an implant versus a no-implant reconstruction, desired speed of recovery, preferred location of scars, hobbies, etc. are some of the many personal considerations that will play a role in developing your operative strategy. The need for and type of additional therapy, medical history, physical exam findings, etc. are factors that I will also consider. Using the information that you have provided as well as that which was gathered during the consultation, an individualized reconstruction plan will be created.
Although it is definitely more ideal to perform the first stage of breast reconstruction immediately following the mastectomy, some individuals may wish to delay their reconstruction until a later date. A desire to focus on the mastectomy and the recovery from any additional treatments may lead one to avoid compounding an already stressful situation with the need for multiple reconstructive procedures.
The need for chemotherapy does not interfere with the possibility of undergoing breast reconstruction. It will, however, affect the timing of tissue expansion, and it will delay additional staged procedures. Tissue expansion, if still required, will be performed a few days before or on the day of your chemotherapy infusions. Operative second stage surgeries will be postponed until you are at least one month out from your last round of chemotherapy.
Radiation therapy has a greater impact on your breast reconstruction. An implant-alone reconstruction in the setting of prior radiation administration carries with it an increased risk of both capsular contracture (hard, painful, unnatural appearing breast mounds) and the need for additional surgeries. Incorporating native tissue into an implant-based reconstruction, as in the latissimus flap, can help in this situation. Otherwise, an implant-free reconstruction using an abdominal flap (DIEP or SIEA) would be preferable.
In the setting of planned radiation therapy after the mastectomy, I typically will delay the definitive reconstructive procedure (latissimus with implant or abdominal flap) until after the additional therapy has been completed. To preserve skin surface area and provide some temporary breast shape while radiation therapy is being given, a tissue expander may be inserted at the time of the mastectomy. This will likely not eliminate the need for native tissue during the later operative stages.
Reconstructive procedures performed on the breast (following mastectomy for cancer) as well as surgical procedures on the opposite breast (to improve symmetry) are generally covered under your health insurance plan as mandated by Federal Law. We will assist you in determining the available benefits under your present coverage but encourage you to also notify your carrier before initiating any treatment plan. Even if I am not a participating provider in your insurance plan, you will likely be eligible for coverage for certain procedures, because there may be no physician in your network who can perform the procedure indicated for you for breast reconstruction. This is especially true for perforator flap breast reconstructions, which are only reliably performed by a few surgeons with extensive experience with this type of surgery. We will work with your insurance company to minimize your out-of-pocket expense for breast reconstruction.
Some procedures, especially perforator flaps, are only available at a limited number of centers nationwide. We frequently have patients who have traveled from outside of Texas, and we would be happy to assist you with your travel needs. We also work extensively with many of the leading surgical oncologists in North Texas, and we can assist you with timely referrals to one of these specialists, if necessary.
Advances in technology and surgical technique can make the possibility of achieving symmetrical breasts after mastectomy a reality for many patients. Breast reconstruction has the potential to reduce some of the emotional consequences of the initial diagnosis and surgical loss of the breast, but it can also be associated with unexpected complications and a poor cosmetic appearance. Taking part in the decision making process, having reasonable expectations, and possessing the motivation to get beyond the diagnosis of cancer will improve your chances of being satisfied with your reconstruction.
