> Breast Cancer Reconstruction

 

Helping You Become Whole Again

 

 

 


About 40% of breast cancer diagnosed women require a mastectomy.

Breast reconstruction is achieved through several plastic surgery procedures that attempt to restore a breast to near normal shape, appearance and size following mastectomy.

Incidence of breast cancer in India is expected to increase to about 2.5 lakh new cases by the year 2015. About 40% of breast cancer diagnosed women require a mastectomy.


The Breast is the foremost symbol of a woman’s feminity. Many women who are diagnosed with breast cancer may have to face the devastating prospect of losing a breast due to mastectomy. A mastectomy procedure wherein the affected breast is removed shatters the patient emotionally and lowers their self confidence. If mastectomy is your best treatment option, you will have to face the prospect of living without a breast. Until fairly recently, a flat chest was the only option, and for some women today, it is still the option of choice. A breast prosthesis was the only option to simulate the appearance of a natural breast.

However many women feel that their missing breast is an acknowledgement of their post-cancer persona. Recent advances in reconstructive techniques have given patients more choices when it comes to breast reconstruction, including the option to have breast reconstruction during the same operation in which the breast is removed, or secondarily after a few months/years. Breast reconstruction can be a physically and emotionally rewarding procedure and can improve a woman’s self image, self confidence and quality of life immensely. Not every woman facing the challenge of a mastectomy may feel the need for breast reconstruction, but for many women, it is an important part of their recovery. Women going in for breast conserving mastectomy rarely require reconstruction. There are many options available for women who decide that reconstruction is right for them.
 

What are the options available for Breast reconstruction?
The reconstruction method that is right for you will depend on the kind of mastectomy you have had, the size and ptosis of the contralateral breast that has to be matched and the availability of donor tissues. Most of the reconstructive methods are best done as staged procedures, where the first stage consists of creation of the breast mound and the second stage consist of nipple and areola reconstruction and equalisation procedure to match the contra-lateral breast.

The Primary Consultation
You will be given detailed informed choices regarding the reconstructive procedures. Remember, breast reconstruction can be done at the same time of the mastectomy (immediate or primary) or much later (delayed or secondary). This decision will be taken jointly by you, the Breast Oncosurgeon and Plastic surgeon. Reconstructive options will be discussed in detail including pros and cons of each procedure and the procedure most suitable for you.

General guidelines for patients to follow prior to Breast Reconstruction procedure

  • Detailed measurements

  • Pre-Operative Photographs

  • Obtain laboratory testing or a medical evaluation

  • Pre-operative Anaesthetic assessment for fitness for surgery

  • Sign an informed  Consent Form

  • Take certain medications or adjust your current medications

  • Stop smoking in advance of surgery

  • Avoid taking aspirin, anti-inflammatory drugs and herbal supplements as they increase risk of  bleeding.

  • Specific instructions relating to anaesthesia.


Implant only
This is only possible at the time of skin sparing mastectomy and only if the contralateral breast is small and without any ptosis. A silicone implant is placed under the chest wall muscle where the breast has been removed. The surgery is relatively simple and quick, using the patients own skin to cover the implant.  Disadvantages are that a permanent prosthesis is used with its accompanying risk of infection and implant extrusion. With Implants,  only small to medium sized reconstruction is possible, and  cannot give ptosis and hence cannot match a ptotic opposite breast. Implants are also not suitable after radiotherapy.

Expander plus implant
This can be done at the time of skin sparing mastectomies where the patients own tissues are used and a large ptotic (sagging) contra-lateral breast is to be matched. Initially a tissue expander is placed and inflated to the required size and then it is replaced with a permanent silicone implant to match. Contra-lateral reduction may or may not be necessary.

In this procedure no flaps are needed and patients own breast tissues are used to cover the implant. Disadvantages are that it is a two stage procedure and two prosthesis are needed. There is a slight risk of infection and capsular contracture and these patients are not suitable for radiotherapy.
 

LD muscle flap with implant/expander
This procedure is advocated both primarily or secondarily after mastectomy when there is skin deficit. This happens when a lot of skin is removed at the time of mastectomy and skin has to be imported from somewhere. In this procedure a paddle of skin and muscle (Latissimus Dorsi) of the back is swung around to add volume to the breast area. The volume of tissue is usually not enough and hence an implant/expander has to be used as well.

With expanders moderate sized breasts as well as moderately ptotic breasts can be better reconstructed. However this procedure entails an additional operative site is created on the back, where the LD muscle has to be partly sacrificed. Some weakness on forceful extension of the arm, such as climbing etc. may be experienced. There is also a higher incidence of capsular contracture if radiotherapy needs to be given.


Superior pedicle TRAM Flap
Here the skin and fat of the abdomen below the umbilicus is used. The  Rectus abdominis muscle(one of the vertical muscles of the tummy) is used as a carrier of the blood supply of the skin. The abdomen is closed like an abdominoplasty operation.

Advantages: No implant is necessary. Rarely surgery on the contralateral breast will be needed, if there is gross ptosis. Patient also gets a tummy tuck simultaneously. The look and feel of the reconstructed breast is quite natural. It is ideal for patients requiring Radiotherapy. Tummy scar is barely visible.

Disadvantages: After the abdominal Rectus muscle is used, there is an area of potential weakness, of the abdominal wall which has to be closed with a mesh. This can sometimes give rise to a hernia. A slight fullness in the upper part of the tummy may persist where the flap has been turned around. Small risk of partial flap loss exists.

Free TRAM flap
This is based on the inferior pedicle of the same muscle and the same amount of skin and fat is used, but the blood vessels have to be detached from the abdomen and re-attached to blood vessels around the breast. This involves microsurgery. It is a 5 - 8 hour procedure. A mesh may have to be used     to close the abdomen fascia.

Advantages: Patients own tissues are used. The blood supply to the flap is more reliable. The look and feel is more natural. Better positioning. There is no bulge in the upper abdomen. Can withstand radiotherapy well Tummy scar is barely visible.

Disadvantages:
Risk of hernia and risk of flap failure 5 - 10%. Operation time is longer and so is recovery time. There maybe potential weakness while sitting up.

Free DIEP Flap
This is a muscle sparing surgery wherein only the blood vessel which supplies the skin and fat of the lower abdomen is dissected out and the underlying Rectus abdominis muscle is spared. Microvascular surgery is used to join the vessels on the chest. With this flap, since no mesh is needed therefore there is less risk of hernia or weakness of abdominal wall. A simultaneous tummy tuck procedure is also achieved. Besides this flap withstands radiotherapy well. Overall the shape, position and appearance is good, and the Tummy scar is barely visible.

However it is important to note that this is a longer, more complex operation. There is risk of flap failure with longer recovery time along with risks of a longer operation.

Free Superior Gluteal Artery Flap / Free Anterolateral Thigh Flap
These are other microvascular flaps which can also be used in select cases and with special indications. The SGAP flap uses a vessel on your buttock and the ALT uses a vessel on the thigh to carry an island of skin for reconstruction purpose.

Secondary procedures

These are required 4 - 6 months after your first procedure to achieve symmetry in breasts and to reconstruct the nipple and areola. To achieve symmetry, you might be advised a reduction, augmentation or breast Lift of the other breast. The nipple can be reconstructed usually from the other breast, even under local anaesthetic if other procedures are not required . The areola is best matched by medical grade tattoing.

Post Operative period
After the surgery, you may find small tubes placed to drain out accumulated blood. Patient is discharged once all the tubes are removed ( 2-7 days). Swelling and bruising at the operation site is quite natural and usually takes about 3 - 6 weeks to clear.

It is important to understand that breast reconstruction can produce remarkable results, however it cannot exactly match a breast lost to mastectomy. Even with revision procedures on the opposite breast, sometimes symmetry between breasts may not be perfect. However, your appearance under most clothing and swimsuits can be natural and balanced. Sensation in breasts reconstructed with flaps may be reduced.

How are the Long term Results?
The final results of breast reconstruction following mastectomy can help you feel physically and emotionally fulfilled. Over time, some breast sensation may return and scar lines will improve, although never disappear completely. There are trade-offs, but most women feel these are small compared to large improvement in their quality of life and the ability to look and feel whole again. Careful monitoring of breast health through self- exam, mammography and other diagnostic techniques is essential to your long-term health.