breast cancer - breast reconstruction
Reconstruction of a breast that has been either partially or totally removed due to cancer or other disease is one of the most rewarding surgical procedures available today. New medical techniques and devices have made it possible for surgeons to create a breast that can come close in form and appearance to a natural breast. Reconstruction can be performed at the same time as the mastectomy. This means that you will wake up with a breast mound already in place, rather than a flat chest. However, reconstruction is a complex procedure and there are often many options to consider as you and your doctor explore what's best for you. This section will give you a basic understanding of the procedures - when it's appropriate, how it's done, and what results you can expect. It can't answer all of your questions, since a lot depends on your individual circumstances. Please be sure to ask your surgeon if there is anything you don't understand about the procedure. Remember that a breast reconstruction aims to give you the appearance of a normal breast, but will never be the same as the breast you have lost.The Best Candidates for Breast Reconstruction
Most patients are suitable for reconstruction, many at the same time as the cancer surgery is performed. However immediate reconstruction is not essential and for some the option of a delayed procedure is important. Some women simply aren't comfortable assessing all the issues surrounding reconstruction whilst coping with a diagnosis of cancer. Others don't want to have any more surgery than is absolutely necessary at this time. With some types of cancer or if you have other health conditions, such as obesity, diabetes, high blood pressure, or smoking your surgeon may advise a delayed procedure.
In any case, being informed of your reconstruction options before surgery can help you prepare for mastectomy with a more positive outlook for the future.
Types of Reconstruction
In essence breast reconstruction is performed to restore symmetry and femininity, and there is good evidence that this type of surgery makes it easier for women to come to terms with the diagnosis and subsequent treatment of their cancer. These aims can be achieved by restoring the affected breast to match the normal side, by reducing the normal side to match the affected breast or by a combination of these techniques.
A new breast can be created using either implanted material or autogenous (one's own) tissue.
- Implanted materials consist of tissue expanders and prostheses. Tissue expanders are silicone shells, placed behind the muscles of the chest wall, that can be gradually inflated with saline over a period of a few weeks. Some of these are designed to be left in place whilst others are removed once fully inflated, and a silicone or saline prosthesis placed in the pocket thus created.
- Autogenous tissue reconstruction involves moving skin, fat and muscle from a distant site and moving it to form a breast mound. The two most common sites to harvest this tissue are either the back (latissimus dorsi or LD flap) or lower abdomen (transverse rectus abdominis muscle or TRAM flap).
- A combination of autogenous tissue and implants can also be used. An example is combining an LD flap with an implant.
At St Marks complications are minimised in two main ways:
- primarily by our extensive experience of performing reconstructions.
- secondly by using a minimum of two surgeons to reduce the operating time and hence duration of anaesthesia.
In general, the usual problems of surgery, such as bleeding, fluid collection, excessive scar tissue, or difficulties with anaesthesia, can occur although they're relatively uncommon. And, as with any surgery, smokers should be advised that nicotine can delay healing, resulting in conspicuous scars and prolonged recovery. Occasionally, these complications are severe enough to require a second operation.
If an implant is used, there is a remote possibility that an infection will develop, usually within the first two weeks following surgery. You will be given a course of antibiotics to reduce the chance of this. If you do get an infection, the implant may need to be removed for several months until the infection clears. A new implant can later be inserted.
The most common problem is capsular contracture. Whenever an implant, or any other foreign material, is placed in the body, the body responds by forming a layer of scar tissue around it. This is known as a capsule. Contracture occurs if the capsule around the implant begins to tighten. This squeezing of the soft implant can cause the breast to feel hard, and may change the appearance of the breast. Capsular contracture does not always need to be treated, but sometimes surgery is required to either remove or "score" the scar tissue. Occasionally removal and replacement of the implant is needed.
The most serious complication related to flap reconstruction is loss of part or all of the flap. This happens when the blood supply to the flap is impaired. Loss of all or most of the flap is very rare (<1% at St Marks). Loss of a little of the deep tissue, with resultant hardening or lumpiness of the reconstruction, is more common. This can be readily revised, often at the same time as a nipple reconstruction. This complication is much more common in smokers.
There is also the possibility of developing an abdominal hernia after TRAM flap harvest. This may require surgical repair.
Reconstruction has no known effect on the recurrence of cancer in the breast, nor does it generally interfere with chemotherapy or radiation treatment. If you have an implant reconstruction, especially if there is no autologous tissue, it may be affected by radiotherapy. It is normal for the implant to become a little harder after radiotherapy.
Your surgeon will recommend regular mammograms on both the reconstructed and the remaining normal breast. If your reconstruction involves an implant, be sure to go to a radiology centre where technicians are experienced in the special techniques required to obtain an optimal mammogram.
Women who have a delayed reconstruction may go through a period of emotional re-adjustment. Just as it took time to get used to the loss of a breast, a woman may feel anxious and confused as she begins to think of the reconstructed breast as her own.
Planning Your Surgery
You can begin talking about reconstruction as soon as you're diagnosed with cancer. After evaluating your health, your surgeon will explain which reconstructive options are most appropriate for your age, health, anatomy, tissues and goals. Be sure to discuss your expectations frankly with your surgeon. He or she should be equally frank with you, describing options and the risks and limitations of each. Post-mastectomy reconstruction can improve your appearance and renew your self confidence - but keep in mind that the desired result is improvement, not perfection.
Your surgeon should also explain the anaesthesia he or she will use, the facility where surgery will be performed, and the costs. In most cases, health insurance policies will cover most or all of the cost of post mastectomy reconstruction. Check your policy to make sure you're covered and to see if there are any limitations on what types of reconstructions are covered.
Types of Anaesthesia
The first stage of reconstruction, creation of the breast mound, is almost always performed using general anaesthesia, so you'll sleep through the entire operation.
Follow-up procedures may require only a local anaesthesia. This can be combined with a sedative to make you drowsy. You'll be awake but relaxed, and may feel some discomfort.
Issues Regarding Implants
If your surgeon recommends the use of an implant, you'll want to discuss what type of implant should be used. A breast implant is a silicone shell filled with either silicone gel or a salt-water solution known as saline.
You may have heard of concerns regarding the safety of breast implants. The most recent and comprehensive studies of these issues have shown that there is no link between implants and health problems. Please fell free to discuss any concerns you may have with your surgeon.
After Your Surgery
You are likely to feel tired and sore for a week or two after reconstruction. Most of your discomfort can be controlled by medication prescribed by your doctor.
Depending on the extent of your surgery, you'll probably be in hospital five to seven days. Most reconstructive options require several surgical drains to remove excess fluids from surgical sites immediately following the operation. These are usually removed within the first few days after surgery, but can also be removed after you go home.
Getting Back To Normal
You should avoid lifting or pushing anything heavy for three to four weeks. Most women can return to work (if it's not too strenuous) and social activities in about six weeks. You will have less stamina during this time and should limit your exercises to stretching, bending, and swimming until your energy level returns. If you feel you need a bra, you should use a good sports bra or lycra crop top for support. Do not wear an underwired bra for at least 4 - 6 weeks.
Although much of the swelling and bruising will disappear in the first few weeks, it may be six months to a year before your breasts settle into their new shape.
Your surgeon will make every effort to make your scars as inconspicuous as possible. Scars often remain lumpy and red for months, then gradually become less obvious, usually eventually fading to thin white lines.
Your New Look
Chances are your reconstructed breast may feel firmer and look more rounded or flatter than your natural breast. It may not have the same contour as your breast before mastectomy, nor will it exactly match your opposite breast. But these differences will be minor and are normally only apparent to you. For most mastectomy patients, breast reconstruction dramatically improves their appearance and quality of life following surgery.