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Breast Reconstruction — After Breast Cancer?
It is the plastic surgeon’s unique opportunity to forge a strong, supportive partnership with women who have suffered the misfortune of breast cancer in the effort to restore by the best possible means for each woman those symbols of her femininity that nature has changed or taken from her. The type of breast reconstruction you choose depends on many factors: Your body, individual preferences and expectations, your breast size and shape, the type of breast cancer you have had and treatment required, how you feel about your body after mastectomy, and others. For the vast majority of women, breast reconstruction encompasses a series of procedures, not a single surgical operation. Reconstruction is part of your recovery, should never interfere with treatment of breast cancer, and is a process that occurs over time. Modern techniques, including skin sparing (and nipple sparing) mastectomy, microvascular reconstruction, and other advances have improved the possible result of breast reconstruction beyond what we’ve ever been able to achieve for women in the past. However, because of the complexity of natural breasts and surgical limitations we’ve still not overcome, most women can never be reconstructed to perfection, or even their ideal. For breast cancer patients, the original breast(s) was dangerous, so replacements, although not perfect, are an improvement. Dr. Laverson’s goal is to approach your desired shape and size with the minimum of risk, expense, and time away from your life. You will choose the new breast you want with Dr. Laverson’s help and guidance. A positive attitude, hope, and understanding what is realistically possible are important.
Types of Breast Reconstruction
There are two broad categories of breast reconstruction procedures:
Implant Based Breast Restoration
Most plastic surgeons perform implant reconstruction when a satisfactory result can be achieved by this method, because although serial surgical procedures may be involved, they are of less magnitude (usually outpatient day surgery) than tissue flap restoration, and there is no necessity for surgery elsewhere on your body to borrow tissue for transfer to the mastectomy site. Implant based reconstruction has some important limitations however. Thin scar your body forms around a breast implant may become thickened over time causing the reconstructed breast to become firm or hard, to reposition above its proper location, and to become more globular and un-natural in shape. This phenomenon, called “capsular contracture,” also occurs in women who have implants for augmentation, but less commonly. Capsular contracture is even more common among women who have had radiation therapy after mastectomy. Women who develop contracture are unhappy with their reconstructions. In these cases, surgery to remove the capsule is indicated. At that procedure, the implant may be replaced with another implant, replaced with a tissue expander type implant to enlarge available chest skin area for a better quality restoration, or replaced with a natural tissue flap.
Natural Tissue Flap Breast Restoration
(Autologous Tissue Breast Restoration)
Although transfer of skin and fat into the mastectomy defect involves a technically more complex surgical procedure, the final contours are often more natural, and the tissue usually remains softer over time. For many women, autologous restoration is a better choice than implant based procedures. These operations involve transfer of skin and fat to replace breast skin and breast volume removed at mastectomy. Sources of skin and fat for transfer are called “donor sites.” Dr. Laverson transfers skin and fat for breast reconstruction from either the lower abdomen or the back. Both of these donor sites are well established and widely used for post-mastectomy breast restoration. They often harbor enough extra skin and fat for breast restoration, and scars in these areas will be relatively hidden.
Natural tissue reconstruction has the advantage that it may be contoured to more precisely match the opposite breast. Still, sometimes a “symmetrizing” procedure on the non-mastectomy side to match both breasts is recommended. Secondary outpatient (day surgery) procedures are usually required to refine the natural tissue flap result over time and to fabricate a nipple and tattoo the areola. With either method of breast restoration, complications may develop that necessitate additional procedures and/or unanticipated choices. Generally however, problems are manageable, and reconstruction provides a satisfactory breast substitute.
Have your mastectomy, but keep your nipples!
Nipple skin removal is no longer mandatory in all mastectomies. The nipple-areola complex, because it contains terminal ducts, has traditionally been removed as part of every mastectomy procedure for breast cancer. A recently published study from Dr. V Suzanne Klimberg et al of 508 procedures in 293 selected patients compared skin-sparing mastectomy with and without preservation of nipple-areola skin. Comparable complication rates and local-regional tumor recurrence rates were demonstrated between the two groups. Women who had their nipple-areola preserved, not surprisingly, were more pleased with the outcome. Although not all breast cancer patients are eligible, for those with stage I and II breast cancer and for those downstaged with chemotherapy, the nipple skin-sparing mastectomy appears safe and offers a superior cosmetic result with the possibility of one-stage immediate breast reconstruction.
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