This section is a reproduction of a full-Length Article written by Dr Zac Moaveni for PINK Magazine - A biannual lifestyle magazine dedicated to breast cancer.
Maybe your world has just turned upside down. You heard your surgeon say the words ‘breast cancer’ or ‘mastectomy’ and you’ve barely registered what else was said.
Or perhaps you are already a strong and sparkling breast cancer survivor. You have faced and endured not only this frightening disease, but also the loss of a breast, and along with it a sense of disfigurement or loss of sexuality.
The experience of breast cancer is highly individual and personal and a woman's response to the loss of a breast may surprise even herself. Needless to say no one method of restoring the missing breast(s), whether it be by prostheses or surgery, is suitable for all women.
What I hope this article achieves is an awareness of why women may choose reconstruction, what options are available, and most importantly a sense of empowerment and strength to hopefully diminish some of the fear that surrounds breast cancer.
Why consider breast reconstruction?
Breast reconstruction is not for everyone. For some women, surviving the disease is enough power and satisfaction in itself; their scars bearing testimony to what a determined mind and body can overcome. For a great number of women however, breast reconstruction can be an immensely physically and psychologically rewarding procedure. It can help bring closure to the cancer experience by improving her self-image, self-confidence and quality of life.
You must know at the outset that no reconstructed breast will ever be the same as the breast that was removed. A good reconstruction however can be relatively natural-looking, attractive and well-proportioned. Scientific studies show that the great majority of women who have breast reconstruction are glad they did and felt it very worthwhile.
The ultimate decision is of course up to the individual woman. What all New Zealand women do deserve is to be given the choice to opt for reconstruction if they wish. I would encourage you to ask for a referral to a plastic surgeon to discuss your options, even if you feel that surgery may ultimately not be right for you.
The initial step: choosing a plastic surgeon you can trust
Breast reconstruction involves a number of choices. The first is choosing your plastic surgeon.
It is essential that you feel comfortable with your surgeon and are able to have a mutually candid and respectful relationship. You have the right to seek a second opinion, whether you are seeing a plastic surgeon in the public hospital or private practice. As one patient memorably said to me “I feel like I’m commissioning a piece of art on my chest!”. You must feel that the artist understands what you want!
Plastic surgeons in New Zealand receive on average 10 years of postgraduate training in reconstructive surgery.
What decisions do I need to make?
Breast reconstruction surgery essentially involves creating a breast-shaped mound on the chest using an implant or tissue from your back, abdomen, or possibly buttocks. It may surprise you to hear that there is no such thing as a standard breast reconstruction. The process is highly tailored to your particular wishes and circumstances. As such, it makes sense for you to understand the options and some of the reasons why a particular procedure may be recommended to you. The ultimate decision of course, is always yours.
Immediate or Delayed?
Ideally you will have a chance to see your plastic surgeon prior to undergoing mastectomy. You may then decide to have the reconstructive surgery at the same time as the mastectomy (Immediate Reconstruction) OR after the breast cancer treatment, including any radiotherapy or chemotherapy, is completed (Delayed Reconstruction).
Which is better? This answer to this question depends on your desires, state of mind and health, as well as the cancer itself. Some women prefer the Immediate Reconstruction option as the treatment is completed in as few stages as possible. The downside is the amount of information that must be taken in and decisions that need to be made, at a time when the devastating diagnosis of breast cancer has just been made. Another important issue to consider is that you may need radiotherapy to the chest area after the mastectomy is completed. This always has a detrimental aesthetic effect on breast reconstruction, particularly if implant-based techniques have been used. Unfortunately sometimes the need for radiotherapy is only discovered after the breast cancer has been removed and looked at microscopically.
Other women prefer the idea of delayed reconstruction, choosing to concentrate their efforts on ‘fighting the fight’ against cancer, with the reconstruction being a journey of closure to be undertaken after the cancer is beaten.
What about the other breast?
Your breasts don’t need to be the same size or shape as prior to cancer and now is the time to be as candid as possible with your plastic surgeon about any thoughts you have in this regard. Usually we make every effort to match the newly reconstructed breast to the other side. However it may be a good idea to consider a breast lift, reduction or augmentation on the other (normal) breast. This usually helps in obtaining better symmetry between the two sides and consequently an ideal aesthetic result.
One step at a time
Whatever technique and timing for breast reconstruction is chosen, this will almost always involve several surgical stages. These steps include: creating a new (reconstructed) breast, adding a nipple and aereola, and possibly changing the size or shape of the opposite breast. This process may take around 12 months to complete.
What is a skin sparing mastectomy?
This is where the general surgeon who performs the mastectomy removes only the nipple / aereola and the existing biopsy scar, leaving the rest of the breast skin intact. The actual breast glandular tissue is then removed from under the breast skin. This gives the plastic surgeon more natural breast skin to use in the reconstruction, allowing for a better aesthetic result, as little or no skin needs to be imported from the back or abdomen. This applies to both immediate and delayed reconstruction.
What types of reconstruction are there?
You are probably aware that the most common methods of breast reconstruction are with an implant (with or without the Latissimus Dorsi muscle from the back), or with the use of your own natural tissue from the lower abdomen (TRAM flap). The following is a description of what each technique involves and its advantages and disadvantages. Please be aware that breast reconstruction is a constantly evolving field and hence what you may read in an older textbook, article, or even the web may be outdated.
Expander / Implant Reconstruction
In this method, an empty silicone bag (an expander) is surgically inserted under the skin and is then filled with saline weekly through a valve under the skin. This is done over the period of a few weeks to stretch the skin to the correct size. At a second surgery, the expander is removed and a permanent silicone implant is then inserted. ?
At times the latissimus dorsi muscle (a large fan-shaped muscle across the back) is also brought across at the first operation to provide extra soft tissue cover for the implant. This may be advised in certain circumstances to provide better cover for the implant.
There are some implants on the market that are designed to be left as a permanent implant once the expansion has achieved the correct size (expander impants). The filling valve is simply removed under local anaesthetic. Although this technique in theory reduces the need for a second operation, more recent studies show that the surgical revision rate for suboptimal results may by disappointingly high.
The advantage of an implant reconstruction is that the recovery is quicker than with a TRAM flap. Scars elsewhere on the body are also minimised. On the downside, implants are mechanical devices and are not designed to last forever. An implant may need revision after some years and is prone to certain problems such as infection and capsular contracture that are unique to this sort of reconstruction. Patients with implant reconstruction generally require a greater number of operations over their lifetime that those who choose to have a TRAM flap reconstruction.
Additionally if a patient requires radiotherapy the chances of a poor result with implant reconstruction are significantly increased.
Abdominal Flap (DIEP) Reconstruction
This technique essentially uses the ‘spare’ tissue from the lower abdomen for breast reconstruction – the same tissue that is removed in a cosmetic abdominoplasty (tummy tuck).
The Rectus abdominis muscle is one of the ‘six-pack’ muscles of the abdomen through which the blood supply reaches the skin and fat of the lower abdomen. In the original version of this operation, this muscle was sacrificed and pedicled (or tunneled) under the skin and up to the chest area to create the new breast mound. Because of concerns regarding residual abdominal weakness following this operation, most plastic surgeons now perform a FREE Muscle sparing TRAM flap or the more modern version, the DIEP (Deep Inferior Epigastric Perforator) flap. This procedure uses microsurgery techniques that are now a routine procedure in many different types of reconstructive surgery to transfer the abdominal tissue to the chest.
Many consider the gold standard of breast reconstruction to be the DIEP flap. Studies show that the impact of surgery on abdominal wall strength with this technique is negligible and most women experience little or no change in abdominal function following this procedure.
The advantage of the TRAM / DIEP flap for breast reconstruction is obvious. The lower abdominal tissue looks and feels almost exactly like normal breast tissue. Particularly when an immediate reconstruction is performed following a skin sparing mastectomy, the scars can at times be completely hidden within the new nipple / aereola reconstruction. Additionally the tissue is the woman’s own tissue and no implant is needed There is no leakage or need for replacement. Hence the flap will last a lifetime and will change with the body as it ages or with future weight gain or loss. It is also much more resistant to radiotherapy if this is required after surgery. Overall, TRAM/DIEP flaps probably require fewer operations than implant reconstructions. Moreover, if a woman has some excess skin and fat in the lower abdominal area, she will more than likely be happy with the flatter abdominal contour that results from having a TRAM / DIEP flap.
The main disadvantage of this technique is the need for a larger operation than an implant reconstruction. This means a longer initial hospital stay of 4-5 days along with a 6 week recovery period after surgery. Another consideration is that very rarely, some part or all of the flap may be lost if the microsurgery is unsuccessful. The risk of this is much higher if the patient has diabetes, smokes or is obese and in these patients a TRAM flap may be contraindicated.
The decision to have breast reconstruction following mastectomy can be a daunting one. It is essential that you are actively involved in making the decisions regarding the timing and technique of reconstruction. I strongly believe that in a well-informed and prepared patient, a reconstructed breast can be well-balanced and beautiful. It can significantly improve her quality of life and well-being as well as her perception of looking and feeling complete once more.