Breast Cancer

Breast Reconstruction

What is breast reconstruction?
Advances in medical, surgical, and radiation therapy treatments for breast cancer have increased the number of breast-sparing procedures available to avoid removal of the entire breast. However, due to tumor size or other problems, nearly one-third of breast cancer patients require mastectomy, and many of these patients choose to have breast reconstruction.

Reconstruction of a breast is a surgical procedure that recreates a breast mound to replace a breast that has been removed due to cancer or other disease. It also can improve the defects that result from mastectomy. New medical procedures and devices have made it possible for surgeons to create a breast mound that can come close in form and appearance to matching a natural breast.

The goal of reconstructive surgery is to create a breast mound that matches the opposite breast and to achieve symmetry. If both breasts have been removed, the goal of breast reconstructive surgery is to create both breast mounds approximately the size of the patient's natural breasts.

What are criteria for breast reconstruction surgery?
In general, all women undergoing a mastectomy are candidates for immediate or delayed breast reconstruction. However, there are criteria for selecting the best candidates for the procedure:

The size and location of the cancer, which determines the amount of skin and tissue to be removed in the mastectomy, are primary consideration factors when making recommendations for reconstruction.

Whether tissue has been damaged by radiation therapy or aging, and is not sufficiently healthy to withstand surgery.

Other considerations include:
- potential for complications
- patient's desires
- the amount of tissue removed from the breast
- the health of the tissue at the planned operation site
- whether radiation therapy is part of treatment
- the patient's general health and body build
- overall health
- past medical history
- co-existing illnesses
- other risk factors such as cardiac disease, diabetes mellitus, smoking, and obesity

When is breast reconstruction surgery performed?
The patient is usually educated and counseled in breast reconstructive possibilities prior to mastectomy, so that she can make the decision for or against reconstruction before going into surgery. Based on the personal medical history of each patient, a recommendation will be made for either:

immediate reconstruction - surgery performed at the same time as mastectomy.

delayed reconstruction - a second operation performed after recovery from mastectomy is complete.

What are the risks or complications of having breast reconstructive surgery?
The general problems connected with any surgery are possible, such as:

bleeding
fluid collection
infection
excessive scar tissue
difficulties with anesthesia

Occasionally, these complications are severe enough to require a second operation.

The most common problem in breast reconstruction is capsular contracture, which occurs if the scar or capsule around the implant begins to tighten.

What are the types of breast reconstruction surgery?
The two most effective approaches available for both monolateral (one breast) and bilateral (both breasts) reconstruction are:

Expander/implant reconstruction - the use of an expander to create a breast mound followed by the placement with a permanent filled breast implant.

The silicone-implant controversy:
A controversy about the safety of silicone gel implants still exists. Many women prefer them to saline-filled implants because the silicone feels more like breast and shifts with body movement more naturally. If a leak occurs in a saline implant, the saline is absorbed into the body and is harmless. But, there is a question whether silicone leaks can trigger certain connective tissue and auto immune conditions.

In 1991, the Food and Drug Administration restricted the use of silicone implants in order to study the question. Studies completed thus far have failed to show an increased risk of auto immune disease among women with silicone implants, and several organizations, including the American Cancer Society, have petitioned the FDA, to ease the restrictions.

Implant surgery - surgery to insert an implant is a relatively simple procedure. Drains are put in place, and recovery time is longer due to the additional surgery, but the care afterward is the same as for mastectomy alone. In delayed reconstruction, drains are not routinely inserted. The recovery is much quicker than it is after immediate reconstruction because the mastectomy wound has already healed.

autologous tissue reconstruction - the use of the patient's own tissues to reconstruct a new breast mound.

transverse rectus abdominus myocutaneous (TRAM) flap is the most common procedure. The TRAM flap procedure removes skin, muscle and fat from the stomach leaving enough blood vessels intact to provide permanent circulation to the transferred tissue. The transferred tissue is molded to resemble the shape and size to the remaining breast instead of just the typical round shape of an implant. It also creates a breast with a natural texture.

Less-common procedures that may be used for either immediate or delayed reconstruction include:

latissimus dorsi myocutaneous transposition flap and implant - similar to the TRAM Flap technique in that it uses autologous tissue for breast reconstruction, but an implant may also be necessary.

free tissue transfer (also called free flap, or free TRAM) - an island of fat and skin is removed from the abdomen and stitched in place to the mastectomy wound requiring microsurgery to attach blood vessels supplying the flap to those in the chest wall. (A free flap graft can also be made from the soft tissue, muscle and skin of the buttock's gluteal free flap.