by Ram Kalus, M.D., F.A.C.S. F.A.A.P.
CONSUMER BRIEF: October is National Breast Cancer Awareness Month. A woman losing a breast to cancer must not only endure shocking medical news but the impact of losing one of the most intimate and defining characteristics of the female anatomy. The impact can be devastating.
A sense of self is an integral part of being human. A desire to look "normal" includes the desire to feel physically whole, symmetrical and attractive.
A woman losing a breast to cancer not only has to endure the shock associated with the diagnosis of the disease, but the physical, emotional and psychological impact of losing one of the most intimate and defining characteristics of the female anatomy. The impact can be devastating, both to the patient and those closest to her, and can have both short and long-term effects on her marriage and intimacy.
The reasons a woman might choose to proceed with breast reconstruction are fairly evident - a desire to feel whole, symmetrical or "restored" to her pre-cancer state. The reasons she might choose to avoid reconstruction are perhaps more troubling and complex. These may include guilt ("Am I being vain?"); fear of recurrence ("Will reconstruction in any way reduce my chance for cure or place me at greater risk of recurrence?"); and even biased physicians.
Believe it or not, some physicians who care for breast cancer patients still regard reconstruction as frivolous and unnecessary. This is truly unfortunate since the evidence is overwhelming that breast reconstruction does not in any way impact negatively on the prognosis or survival rate of women with breast cancer. In fact, the benefits of reconstruction clearly outweigh the risks. Furthermore, the majority of plastic surgeons performing breast reconstruction do so in close consultation with the oncologist, general surgeon, and radiation therapist to insure an optimal treatment for the patient.
Still, each patient must decide whether or not breast reconstruction is the right choice for her. Much of what goes into making the right decision is based on knowing all the options, once the recommendation for a mastectomy has been made. This article will, therefore, focus on those women who either lost one or both breasts to cancer. It will also include a brief discussion of those patients who face significant physical changes in their breasts following lumpectomy and radiation therapy.
While plastic surgeons continue to perfect breast reconstruction techniques, there are already many options available for women with some remarkably gratifying outcomes for many patients. Below is a summary or these options, from the simplest to most complex.
A 38-year-old woman seen immediately after being diagnosed with an invasive right breast carcinoma,
before surgery. She chose mastectomy with immediate reconstruction using a tissue expander for a larger
final breast size. The bandages on her right breast cover
a then recent needle biopsy performed by her radiologist.
In this procedure, referred to as a "Tissue Expander," the plastic surgeon temporarily places an expandable breast implant at the site of the mastectomy. This is done either at the same time as the mastectomy (it's known as "Immediate Reconstruction") or at some later date which is known as "Delayed Reconstruction". Over the course of four to twelve weeks, the patient makes weekly or bimonthly visits to the doctor's office for follow-up. During the office visits, the doctor uses injections with a tiny needle, to fill the expander with saline until the desired or slightly large breast size is achieved. This is followed with a fairly simple outpatient procedure to exchange the tissue expander for a permanent breast implant in which the outer shell is made of silicone; the filler substance may be either saline or silicone.
Same patient six months after undergoing reconstruction on her right breast and before her nipple has been reconstructed. The tissue expander has been removed while a silicone gel breast implant has been inserted. At the same time, her left breast was augmented. The scar on the right breast is from the mastectomy; those scars usually lighten over time.(Photos, courtesy of Ram Kalus, M.D.)
Despite the concern about silicone breast implants, both silicone gel and saline implants have been shown to be safe, with silicone filled implants showing some advantages in terms of softness and a more natural feel. Saline filled implants can sometimes feel firm or show ripples or creases. Although the FDA once limited the use of silicone gel prostheses primarily for women undergoing breast reconstruction, the overwhelming scientific evidence supports their safety.
A "Flap Reconstruction" involves a plastic surgeon using a suitable muscle near the breast along with the overlying skin and fatty tissue to mimic a female breast. This surgery is more complex and generally involves a slightly more prolonged recuperation. The most common muscle flaps used are the latissimus dorsi or LD, the large triangular muscle extending from the back and leading into the upper arm. The rectus abdominis muscle or TRAM flap can also be used. Other flaps that can be utilized include only skin fat without the use of a muscle, but these require microsurgical techniques.
The advantage of a flap procedure is the use of the patient's own tissue to mimic the breast, rather than an implant. With the LD flap, there is usually a requirement for a small implant since most women do not have enough volume in their latissimus dorsi to allow for an adequate size breast.
Alternatively, a TRAM flap almost always allows for avoiding an implant altogether. In general, a flap procedure is indicated in women who have had prior radiation, since a flap brings with it a new blood supply, which is critical to the skin and soft tissues that have been previously radiated.
Radiation can create difficulties for optimal wound healing by creating more hard scarring, swelling and pain.
Because a flap procedure is significantly more involved, particularly the TRAM flap, recovery is between four to 12 weeks, compared with an expander implant where recovery is usually between two to six weeks. In some cases, following lumpectomy and radiation therapy, both expander implants and flap procedures may be necessary to correct significant asymmetries. These patients may have particularly challenging reconstructive problems which more often require flap reconstructions.
The nipple is the final step in breast reconstruction. Most women elect to have it done however, some do not. Plastic surgeons use several methods, one of which elevates three small flaps, in the approximate shape of a cloverleaf, and then suturing them together. Other methods include using a graft of nipple tissue from the opposite nipple, if available. The least desirable option is using a portion of the patient's ear lobe to reconstruct a nipple. An areola is created by tattooing the area with naturally colored pigments.
All reconstructive procedures can be associated with potential complications which should certainly be discussed with the patient when she first consults with her plastic surgeon. But in general, in the hands of a skilled board certified plastic surgeon who is experienced in breast reconstruction techniques, complications should be rare and the vast majority of patients can expect a very apparent and significant enhancement in their appearance, self-esteem and quality of life after breast reconstruction.
Ram Kalus, M.D. is a board-certified plastic surgeon in Columbia, South Carolina and founder of Plastic Surgery of the Carolinas, PA. Much of his practice today is devoted to reconstructive and aesthetic surgery of the breast.
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