Overview of Breast Reconstruction
Breast cancer is the most common type of cancer in women and the second main cause of cancer deaths in the United States. Over time, the treatment for breast cancer has become better because of improvements in hormonal treatments, earlier detection of the disease, and better surgical techniques that preserve as much of the breast as possible. However, for women who need to have their entire breast removed (a procedure called a mastectomy), the worry about disfigurement after surgery can seriously affect their wellness and recovery process.
The goal of the plastic surgeon, working with the patient and their breast surgeon, is to make a plan to restore the patient’s body image after successful cancer treatment. There are many ways to reconstruct the breast, and it’s important to discuss all options with the patient to achieve the best possible result. Before planning reconstruction, it’s necessary to consider all aspects of the cancer treatment. This would include the use of chemotherapy and radiation, the type of reconstruction procedure, the best timing for it, and the whole progression of cancer treatment.
Anatomy and Physiology of Breast Reconstruction
The type of breast removal surgery a person has undergone can affect the options available for their reconstruction. For instance, if a person has lost both the skin and nipple of their breast, replacement can be done using either tissue from other parts of the body, or an tissue expander. If they have lost the underlying breast muscle as well, it makes using implants for reconstruction tricky, as these implants are usually placed under the muscle layer.
There are certain things doctors need to check before deciding on the best way to reconstruct the breast. The size, shape, and pointiness of the other breast is extremely important, because the goal is to make a new breast that looks identical to it. Sometimes, the other breast could be reshaped as part of the rebuilding process to ensure this balance.
If the person’s own body tissue is going to be used in the reconstruction, the stomach region specifically must be examined keenly. Previous open surgeries on the stomach could result in cuts that affect blood flow to the skin flaps that might be used for the reconstruction. Also, the presence of hernias, which are bulges of organs through weak spots, could complicate this process. The fat content in the stomach region is also considered; moderate amount of fat is desirable. If there’s not enough fat, it might be difficult to achieve the needed volume in the new breast. If there’s too much fat, it could affect the survival of the skin flaps. In both cases, the doctors might have to resort to using skin flaps from the back or using implants instead.
Why do People Need Breast Reconstruction
One of the key factors when planning breast reconstruction surgery after cancer is deciding when the procedure should take place. This decision needs to be individualized for each patient, taking into account their specific situation with cancer. This is very important to ensure the surgery is safe, effective against the cancer, and provides the best final result in terms of looks and function.
Immediate reconstruction is when the breast is rebuilt at the same time as the surgery to remove the cancer. Though it does mean the patient is under anaesthesia for longer, a big benefit of this kind of reconstruction is that it can often provide a more natural-looking result. This is because the surgery can make use of the natural skin covering of the breast. However, there are factors that may influence this decision, such as the stage of the cancer and whether the patient has the BRCA gene mutation. Another key factor is whether the patient needs additional treatments after surgery, specifically radiation therapy. If radiation therapy is planned, it can increase the risk of complications if the reconstruction involves a breast implant. In these cases, using the patient’s own tissue may be a better approach for reconstruction.
On the other hand, delayed reconstruction is when the patient has the surgery to remove the cancer, but then comes back for a second surgery later on for the reconstruction. This option is often chosen by patients who are still deciding whether they even want breast reconstruction, or by patients who need radiation therapy after the surgery to remove the cancer.
Reconstruction using artificial implants is another option that can be used in both immediate and delayed reconstruction. This option will be discussed in more detail in a separate article.
When a Person Should Avoid Breast Reconstruction
There are certain conditions and situations where breast reconstruction surgery may not be recommended. These are referred to as contraindications. Some of these conditions include:
Severe lung or heart disease: These conditions can make any type of surgery, including breast reconstruction, more risky.
Collagen vascular disease: This is a disease that affects your connective tissue, which can complicate the healing process after surgery.
Obesity: Being significantly overweight can increase the risk of complications during and after surgery.
Age greater than 65 years: Older age can increase the risk of complications during and after surgery.
Current tobacco use with an unwillingness or inability to quit: Smoking can delay healing and increase the risk of complications.
Prior abdominal or chest surgery that has interrupted blood supply to potential flaps: Previous surgery in these areas can affect the blood supply that is needed for successful breast reconstruction.
Prior radiation therapy: Radiation can affect the condition of the skin and tissues, which can complicate breast reconstruction surgery.
Advanced breast cancer: This may mean that treatment of the cancer must take precedence over reconstruction surgery.
Equipment used for Breast Reconstruction
For performing breast surgery, certain specific tools are needed by the surgeon. These include a general set of surgical tools specific to breast surgery, a special microvascular tray with tools that can handle the small blood vessels, and a powerful microscope to help the surgeon see very tiny details.
Besides these, some other types of tools called lighted breast retractors can be used. These are specifically designed to gently pull the tissue aside and expose the surgical area, while also providing light at the same time. Names of some of these retractors include Ferriera and Tebbetts, among others. These tools help your surgeon to work more accurately and efficiently during the procedure.
Who is needed to perform Breast Reconstruction?
For any surgery that involves a microscope (known as microsurgery), it’s helpful to have a highly skilled assistant or a second surgeon. Their expertise can make the surgery go quicker and smoother, which can be important for your recovery. Just as important is a team of nurses and trained professionals who have experience with both breast surgery and microsurgery. This experienced team can offer better care during the surgery.
How is Breast Reconstruction performed
One common method for reconstructing breasts after surgery is the use of tissue expanders and implants. This approach is often chosen because it is straightforward, not too time-consuming, and has a relatively short recovery period. It also avoids possible problems from surgery at another site on the body to provide a flap of skin. However, tissue expanders can cause significant discomfort and need to be checked regularly as they are typically filled on a weekly basis. This method suits patients not requiring radiation therapy best. It’s also a good option for patients who had surgery on one breast with the other breast remaining fairly firm and lacking a lower layer of fat, as implants can reduce the natural sagging of the breast.
For this process, a variety of implants can be used, such as saline or silicone gel, round or anatomically shaped, and smooth or textured. You should discuss the advantages and disadvantages of each implant type with your doctor so you can make the best choice for your needs.
The breast reconstruction surgery can either be done immediately after the initial mastectomy, making use of the existing flap of skin left by the removing of the breast, or the procedure can be delayed and carried out later. Once the decision is made, a tissue expander is inserted either through the original scar, previous scars, or new ones created for access. The expander has an accessible port through the skin for weekly inflations in the clinic. After several weeks, when the skin has stretched properly, you’ll need to return to the operating room to swap the expander for a permanent implant. This is also the time when any asymmetry or tightness around the implant can be dealt with.
Another type of breast reconstruction is the Transverse Rectus Abdominis Musculocutaneous (TRAM) flap. If you are a healthy patient with adequate abdominal fat, this could be a good option for you. The surgery involves moving skin, fat, and a small piece of the rectus muscle from your abdomen to reconstruct the breast, creating a natural appearance to the new breast and also removing a bit of fat from your belly simultaneously. However, as with many surgeries, there are risks like blood flow problems to the flap that can result in failure. There is also an increased risk of future hernia formation due to the removal of the muscle from the abdominal wall.
The Latissimus Dorsi Flap is another reconstruction option where a muscle from your back is used. This is a good choice if you prefer using your own tissue for reconstruction but don’t have the right conditions for an abdominal flap procedure. However, an implant or fat grafting might be needed to ensure the right size and shape of the reconstructed breast.
Lastly, recreating the nipple-areolar complex (or NAC – the darkened skin around your nipple) can be an important psychological step in breast reconstruction. Medical tattooing is frequently used to recreate the color of the areola and nipple if the original cannot be used.
Possible Complications of Breast Reconstruction
Immediately after the surgery, some people may face issues including bleeding, swelling, dead tissue, moderate-to-severe pain or unevenness in the size or shape of the breasts. In the long run, some people may experience changes or loss in sensation, fat tissue dying, unevenness or undesirable scars. Also, there could be a hernia, which is an abnormal exit of tissue or an organ through the wall of the cavity, where the muscle flap was removed from. In rare cases, there’s a chance that the cancer could come back.
What Else Should I Know About Breast Reconstruction?
If you have had breast surgery, getting reconstructive surgery could help you to feel more comfortable and confident in your appearance. This can help you feel more at ease in clothes including swimsuits and bras. Furthermore, reconstructive surgery may prevent you from needing to wear prosthetics, which can sometimes be uncomfortable.
