Studies have shown that most breast cancers can be treated with breast conservation: removal of the breast lump (lumpectomy) and postoperative radiation treatment. But 30% of women with breast cancer, require removal of the breast (mastectomy), which results in a significant chest wall deformity and psychological damage. It is important that women considering mastectomy or a large lumpectomy have a preoperative consultation with Dr. Park. Clearly, the primary goal in the management of breast cancer is cure of the disease, but treatment should consider the cosmetic outcome if the patient so wishes, as there are important psychological benefits to breast reconstruction for many. Dr. Park has extensive interest and experience in the full breadth of breast reconstruction options and is happy to provide advice and assist in decision making during this difficult time.
The Timing of Breast Reconstruction may be immediately after mastectomy or secondarily, once the wounds have healed and the chest wall swelling has resolved (typically 3 months after mastectomy or 6 months after radiation). With immediate reconstruction, the chest tissues are soft and pliable and easier to reshape and stretch, but Dr. Park feels that reconstruction should be delayed if there is any chance that additional tumor removal or radiation may be needed, especially with expander/implant reconstruction. Immediate breast reconstruction does not interfere with any plans for chemotherapy. Patients should be aware that intraoperative findings may alter the plans or lead to postponing reconstruction and erring on the side of safety, as reconstruction can be performed later and the result is better when the reconstruction is not radiated.
Reconstructive goals are to create a breast mound shape, size, and position to match the opposite breast without the need for an external prosthesis. Nipple reconstruction may be necessary at a later date after the breast mound has settled into position.
There are two general Reconstructive Options: using local tissue and a breast implant versus using autologous tissue from another area of the body. This decision is based upon patient preference, contralateral breast shape, medical condition, surgical history, radiation history and body characteristics. If the reconstruction cannot achieve symmetry with the opposite breast, surgery on the opposite side may be necessary, either reduction mammoplasty, augmentation mammoplasty, or lifting the opposite breast (mastopexy). These procedures are covered by most insurance plans and The Park Clinic can assist in determining your benefits. Certain patients especially those with genetic risk (BRCA), lobular carcinoma, or strong family history may receive the recommendation of removal of the opposite breast with reconstruction (prophylactic mastectomy). In these cases, this new variable must be accounted for and an experienced breast reconstruction surgeon such as Dr. Park is very helpful.
Breast Reconstruction with an Implant
After a mastectomy, tissues are usually deficient and in these cases, reconstruction must be done in stages. First, a tissue expander is placed under the muscles of the chest wall (pectoralis major and serratus anterior) and/or a biological mesh and the skin is closed. The muscle and skin are then closed over this empty silicone walled balloon. This straightforward operation takes 1 -1.5 hours per side and should not prolong the hospitalization or recuperation of a mastectomy. The expander is then inflated through the skin and into a valve every few weeks in clinic (approximately 5 minutes and only mildly uncomfortable) to stretch the muscle and skin beyond the desired size. The valves can be felt through the skin if the remaining soft tissue is thin but usually a magnet is necessary to identify the metal back wall of the valve. In the second operation, the expander is removed, the permanent breast implant is placed, the reconstructed breast can be revised, and the opposite breast can be modified. This second operation will usually take 1 to 2 hours in an outpatient setting. The permanent implant options and variables are the same as those for breast augmentation: either silicone gel or saline in a silicone shell. Rarely the expansion stage can be skipped with a skin sparing mastectomy or nipple sparing mastectomy and the use of biological mesh.
The primary advantages of implant reconstruction are shorter operations with less morbidity and scarring. The primary disadvantage is that the result is usually less natural unless the other breast is augmented, has certain characteristics, or is also reconstructed. Also, the delay to final reconstruction, the increased number of office visits, and the dependence on a man-made, mechanical implant subject to failure and complications, including capsular contracture, rupture, and leak, must be considered. Radiation therapy is a relative contraindication to implant breast reconstruction but successful breast reconstructions in this situation are possible.
Breast Reconstruction with Flap / Autologous Tissue
Breast reconstruction flaps create a breast by moving tissue from another part of one’s own body (autologous). The advantages are increased durability to radiation, more natural shape and feel, and the ability to add tissue where tissue is missing. In suitable patients, Dr. Park prefers flap reconstruction. Blood supply is critical for flap reconstruction and is impaired in patients who are smokers, diabetic, obese, or suffer from vascular disease, collagen vascular disease, and autoimmune diseases. The most common source for breast reconstruction flaps is the abdomen. The primary advantage of using abdominal tissue is that it provides the most cosmetic and natural breast reconstruction in women with the best skin and texture match to the breast. In addition, a modified version of an abdominoplasty or tummy tuck is performed at the same time, but this should not drive the decision. The potential complications of implants are also usually avoided.
The skin and fat of the lower abdominal wall, normally discarded in a tummy tuck operation, are elevated and moved to the chest using either the rectus muscle as a pedicle or hinge with blood supply (Pedicled Transverse Rectus Abdominis Myocutaneous /TRAM flap), disconnecting the tissues blood supply to the muscle and skin and moving it to the chest (Free Transverse Rectus Abdominis Myocutaneous / Free TRAM flap), a free TRAM with limited muscle (Muscle sparing free TRAM), or moving the tissue based only on a blood vessel, skin, and fat (Deep Inferior Epigastric Perforator / DIEP flap). The last 3 options mentioned are much more complicated and time intensive, requiring division of vessels and reconnection to blood vessels in the chest or armpit using a microscope, similar to a transplant. Once completed, the amount of blood flow is greater than the pedicled TRAM, but there is a risk of thrombosis (clotting) of the anastamoses, creating the need for urgent reoperation and the risk of complete loss of the flap. These procedures should only be performed by those experienced in their use and Dr. Park has learned the techniques of Dr. Bob Allen, the developer of the DIEP flap, and performed each of these procedures when he developed the microsurgical breast reconstruction program at Wake Forest University Baptist Medical Center prior to moving to Mobile.
The operation can take between 2-½ to 4 hours for a pedicled TRAM and 4 – 12 hours for a free TRAM/DIEP and usually requires a 3 to 5 day hospital stay. There will be tubes to drain fluid and blood from the breast as well as the abdomen for 1 to 2 weeks. This operation does require a prolonged convalescence. The removal of abdominal skin will leave the belly tight and the patient will not be able to stand or lay straight for at least a week in order to minimize pain and prevent tension on the abdominal closure. It will take at least 3 weeks before resuming light activity and 3 months to resume strenuous levels of activity. There will be a scar across the length of the lower abdomen as well as on the breast. The abdominal wall may be weakened and prone to bulge, which can be prevented or corrected with mesh reinforcement. Skin transferred from the abdomen may develop some sensation, but it will be quite different than sensation prior to mastectomy. Transfusions may occasionally be necessary.
If the lower abdominal wall is not available for reconstruction either because of one’s natural anatomy or previous operative procedures, then skin, fat, and muscle can be transferred from the back in what is called the pedicled latissimus dorsi myocutaneous flap. Skin and fat overlying the muscle are lifted up and transferred around to the chest wall. In most instances, a complementary breast tissue expander or implant is needed to achieve sufficient size and projection. This operation will leave a scar on the back. Dr. Park can design the scar with an orientation that permits easier concealment.
Reconstruction of the Nipple and Areola is completed several months after the final breast reconstruction, allowing the reconstructed breast to settle into its final shape and position before setting the location of the nipple reconstruction. The nipple can be reconstructed with skin flaps from the reconstructed breast and the areola (dark area) can be reconstructed with a skin graft or tattooing. If desired, this phase of reconstruction can be performed in the office awake. Otherwise, it will be done in the operating room. Skin grafts require some additional care, but usually only one treatment is necessary and activities are only limited for a week or so. Tattooing may require several rounds but each session has minimal downtime.