Filling the Void After Mastectomy
Twenty years ago the risk of breast cancer was quoted as one in twelve women. Now the figure is closer to one in eight. About one fifth of these tumors arise in women with a positive family history. In other words, four out of five women who develop breast cancer have no close relative with the disease.
Despite the apparent rise in cases of breast cancer, we are gaining ground in some respects. Educational programs stressing the importance of monthly self-exams, routine use of screening mammography, ultrasound, and a heightened public awareness of the disease and available treatments now allow for the identification of tumors at an earlier stage. By finding new and more accurate ways to identify smaller tumors, we can treat more breast cancers without mastectomy (removal of part or all of a breast through surgery) and improve overall cure rates.
The radical type of mastectomy, which included the breast, the muscles beneath the breast, and the entire contents of the armpit, is now all but forgotten. Studies have shown that the muscles can be preserved without compromising patient survival. The lymph nodes are now sampled more selectively to decrease associated swelling of the arm without increasing the risk of spreading of the cancer. Moreover, work is under way to reliably identify and remove only a few sentinel lymph nodes, without compromising either treatment or prognosis.
For now, modified radical mastectomy (MRM) is still the best treatment for many breast cancers. This involves removal of the tumor with the normal breast tissue and sampling of the lymph nodes in the armpit. Lymph node involvement affects prognosis and may indicate the need for additional treatment. So, although MRM may be the best way to cure breast cancer, it leaves a physical and emotional void.
Filling the Void
Fortunately, there are options available for breast reconstruction after mastectomy. I will preface this with the knowledge that reconstructed breasts look and feel different than the natural breast, and symmetry, which is rarely present in nature, is also extremely difficult to achieve through breast reconstruction.
There are many different ways to rebuild the breast, and no one way is perfect or works for everyone. Breast reconstruction usually requires several surgeries, but the seriousness decreases with each progressive stage. Moreover, the psychological and physical benefits outweigh the risks for the vast majority of breast cancer survivors.
Any of the options discussed below can be done immediately or can be delayed. Immediate reconstruction is done in the operating room right after MRM. With this approach, the breast mound is never absent. Delayed reconstruction can be performed any time after 3-6 months or after other treatments (chemotherapy or radiation therapy if indicated) are completed. The timing may be based on therapeutic reasons or personal preference.
Breast reconstruction should be discussed with your General or Oncological Surgeon and a Board Certified Plastic Surgeon before the mastectomy is performed. Your options can be reviewed in detail specific to your needs. The alternative ways to reconstruct the breast and make it match the uninvolved breast can be outlined, and the best option determined. Your surgeons can then work together to plan an operation that will give the greatest chance of cure with smallest feeling of loss.
Plastic surgeons have fought long and hard to protect a woman’s option for reconstruction. We do not view this as a purely cosmetic procedure or as a sign of vanity. The feeling of helplessness after the diagnosis of breast cancer can be overwhelming, and reconstructing the breast can restore a positive self-image and a sense of control. The federal government responded to lobbying efforts by plastic surgeons, their patients, and many others by requiring insurance companies to cover breast reconstruction. This specifically includes reconstructing the breast mound and the nipple on the affected side, and any surgery on the unaffected side necessary to improve symmetry.
I always begin my discussion with breast cancer patients by stating that there are many options, including the option of not having reconstruction. While the mastectomy may be life saving and necessary, the reconstructive part of the surgery is elective. Some women will not feel a sense of loss and have no desire for further surgery. It is a personal decision, but sometimes it is medically prudent to not perform reconstruction or at least to delay it. Examples include someone who is too frail to safely tolerate the procedure or someone with advanced disease where treatment may be compromised. These women may be better off waiting until the situation improves. An external prosthesis worn as an insert to the bra may be sufficient. In clothing, the result is quite good. Advantages of the external prosthesis include the elimination of additional surgery and the associated complications that could occur. Disadvantages include the absence of a breast without clothing, occasional rash or irritation of the chest wall, shifting of the prosthesis, poor fit, the need for maintenance and periodic replacement, and a limitation on clothing styles (especially bathing suits).
Breast Reconstruction: three main goals
If reconstruction is pursued, there are three main goals. The first is to reconstruct the breast mound. The second is to reconstruct the nipple and areola. The third is to provide symmetry. The procedures for these can be combined, but are usually staggered to obtain the best possible results.
Goal I — Breast mound reconstruction: There are two basic techniques for reconstructing the breast mound. The necessary volume may be provided with an implant or one’s own tissue (a flap) as described below. These techniques are usually used independently but occasionally it is desirable to use a combination of both.
Two problems must be corrected with breast mound reconstruction. First, the volume of the breast is lost after a mastectomy, and volume needs to be restored. Second, some of the skin covering the breast that is removed during mastectomy needs to be replaced. This problem is more subtle, and more difficult to fix. With flap surgery, extra skin can be brought directly to the breast as part of the flap. This is not possible with an implant, so the skin remaining on the breast is frequently stretched with a tissue expander before placing the final implant. In fact, an attempt is made to overstretch the skin so that the breast may sag a bit to match the opposite side.
The flap most commonly used for breast reconstruction is the TRAM flap. This takes the skin and fat from the lower abdomen and moves it to the breast. The fat on the flap restores the volume of the breast, while the skin deficiency is corrected by tailoring the skin on the flap. When this option exists, it provides very good results. A TRAM flap may be preferable if the breast skin cannot be stretched adequately with an expander for implant reconstruction. The TRAM breast is more likely to feel and move like a natural breast. The procedure, however, is a major operation and requires two to five days recovery in the hospital, and the overall recovery time is six to eight weeks. There may be permanent weakness of the abdominal muscles afterwards, and additional scars are left on the abdomen — and sometimes on the breast itself — that are not seen with implant reconstruction. Contraindications include obesity, cigarette smoking, some previous abdominal surgeries, and being very thin.
The next most common flap is the latissimus dorsi flap. This involves moving a muscle, skin, and fat from the back to the breast. Although the amount of skin is sufficient, the volume of fat in this flap is usually insufficient to provide enough volume for the breast mound. Frequently an implant is placed behind the flap to compensate. This procedure leaves scars on the back — and sometimes on the breast — that are not visible with implant reconstruction. It takes less time and usually has a shorter recovery time than the TRAM flap procedure. However, the latissimus dorsi flap does not obviate the need for an implant, and while it is not frequently performed as a primary reconstruction, it can be very useful to aid in restoring reconstructions that develop problems.
Implant reconstruction is usually performed in stages. If the breast is small and has little sag, sometimes the final implant can be placed at the time of MRM. Usually the results can be improved with the use of a tissue expander. By initially placing a tissue expander, the skin can be stretched to compensate for the skin lost from mastectomy. Additionally, the position of the implant can be fine tuned when the tissue expander is replaced with the implant. This second surgery is usually done in a surgery center, does not require hospitalization, and has a relatively quick recovery. Matching procedures, if necessary, may be performed on the unaffected breast at the same time. Advantages include no additional scar, shorter operating times, and quicker recovery. Problems unique to implants include deflation and leakage requiring replacement, tight scar formation leading to a hard breast, shifting, and an increased likelihood of additional surgery.
Another option in breast mound reconstruction is the initial placement of an adjustable implant. This can be over-expanded like a tissue expander, and then deflated to the appropriate volume after the skin has stretched. These devices usually have a remote filling port buried under the skin away from the implant, which eventually requires minor surgery for removal. Problems include those listed above for implants and superficial infection, discomfort at the port, separate scar to remove the port and occasional valve failure causing loss of volume and the need for replacement of the implant.
Goal II - Nipple reconstruction: Like breast mound reconstruction, nipple reconstruction has several options; however, the risks and benefits of each are similar.
The nipple can be reconstructed with local flaps or by grafting part of the uninvolved nipple. Local flaps involve rearrangement of the skin on the breast mound to form the nipple and a skin graft from the groin to reconstruct the areola.
‘Nipple sharing’ procedures take part of the uninvolved nipple and graft it onto the new breast mound. This can provide better symmetry if the opposite nipple is too large to match with local flap reconstruction.
No matter which technique is used, tattooing is frequently used to add color to the nipple and areola to match the opposite side.
Goal III - Matching procedures: Sometimes, due to limitations in breast mound reconstruction, it is necessary to modify the uninvolved breast to improve symmetry. This is most commonly done to correct sagging or to match volume. The procedures commonly used are the same as in routine breast lifts, breast augmentation, and breast reduction surgery. They allow the plastic surgeon to change the volume and shape of the breast to better match the reconstructed breast.
There are many different ways to reconstruct the breast, and it is important to discuss these options with a plastic surgeon as early as possible. Although these procedures can be started after a mastectomy has healed, the benefits of immediate reconstruction are lost. It is important to choose a plastic surgeon certified by the American Board of Plastic Surgery who is experienced in breast reconstruction. Most Board Certified Plastic Surgeons are members of the American Society of Plastic Surgeons (ASPS). For more information on breast reconstruction or breast implant removal please visit our breast reconstruction page. To find a board certified plastic surgeon near you, visit our directory.
Dr. Joseph A. Mele, III, M.D., F.A.C.S. is chairman of the Division of Plastic Surgery at John Muir Medical Center located in Walnut Creek, CA. He is certified by both the American Board of Plastic Surgery and the American Board of Surgery and is an active member of the American Society of Plastic Surgery.
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