Breast cancer has become one of the most common malignancies among women. Every year about 200,000 women are diagnosed with invasive breast cancer. About 40,000 women die of breast cancer every year. The lifetime risk of being diagnosed with breast cancer for women of all races is about 16%. This means one out of every 8 women will develop breast cancer at some point of their lives. Unfortunately, increasing numbers of women at very young ages are requiring surgery for breast cancer.
Recent advances in the treatment of breast cancer showing a trend toward less invasive procedures. However, a large number of women require mastectomies. There is a significant psychological trauma associated with the loss of one or both breasts. In one study it was noted, ?The breast, far more importantly than any other anatomical part, is an emotional symbol of a woman?s pride in her femininity, sexuality, and motherliness?.
Depression after mastectomy is very common and resembles mourning in the same way as responding to the loss of a loved one. Occasionally, even the breast preserving treatments may require removal of a portion of a breast which would create enough of a deformity to be the cause of significant psychological distress. Many studies have shown that negative psychological consequences of mastectomy can be reduced by breast reconstruction. There are data to show that immediate breast reconstruction at the time of the mastectomy is more effective in this regard. With advances in surgical techniques and postoperative care, nearly all patients are candidates for breast reconstruction.
There is a wide regional variation in the rate and type of breast reconstruction after mastectomy. Many factors play a role including patient’s choice, referring physicians’ biases, race, and availability of plastic surgeons. A recent study from Canada revealed that there is a great need for communication between the referring physicians and plastic surgeons to provide the women suffering from breast cancer with the most complete treatment plan. More than one-third of the referring physicians in the study indicated that breast reconstruction would delay the detection of local recurrence despite of evidence to the contrary. Within that study, women older than 49 years were not referred for reconstruction because they were considered too old for the procedure. Many women older than 49 years are indeed potential candidates for breast reconstruction.
A large group of women access the vast amount of information about breast reconstruction on the internet or through breast cancer support groups. Quite often, patients after being diagnosed with breast cancer initiate a consultation with a plastic surgeon specializing in breast reconstruction before finalizing their decision for the cancer treatment. The recent advances in surgical techniques make breast reconstruction available to women of all ages who do not have any severe underlying medical problems.
Major reasons for women who choose not to have breast reconstruction include the fact that they are afraid of complications, perceive themselves too old, and do not have enough information. The major reason most often cited by women who decided to have breast reconstruction was the desire to feel whole again.
There is evidence that women who were informed about their options for breast reconstruction before mastectomy suffered a lesser degree of psychological distress. It may be therapeutic to discuss the possibility of breast reconstruction with women because the treatment gives them a more hopeful outlook. The fact that the reconstructive options are available to them is a source of comfort and strength to many women who face mastectomy.
Several studies have reported that breast reconstruction after mastectomy for invasive cancer does not affect the detection of recurrent cancer. The prognostic factors for recurrence in patients after breast reconstruction remain similar to patients who did not have a reconstruction (i.e. tumor size, lymph node and hormone receptor status of the tumor cells). A study from M.D. Anderson Cancer Center showed that immediate breast reconstruction did not delay the detection of local recurrences. The placement of an implant under the chest muscle (pectoralis muscle) may bring the recurrent tumor nodules closer to the surface and therefore render them palpable earlier.
Breast ReconstructionBreast reconstruction consists of two parts. The first and, by far, more extensive, part is the reconstruction of the breast mound. The second part is the creation of the nipple and areola complex which is usually a minor procedure and can be performed under local anesthesia.
Breast reconstruction can be performed at the same time as the mastectomy (immediate reconstruction) or at a later time (delayed reconstruction). Immediate reconstruction is increasingly performed and accounts for approximately 40% of all breast reconstructions. It requires one less general anesthetic induction, is more convenient for the patients, and can provide better aesthetic results.
Breast reconstruction after cancer is generally covered by all insurances. Through hard work of the American Society of Plastic Surgeons (ASPS®) and many breast cancer support groups, health insurance companies are required by law to provide coverage for breast reconstruction and related procedures to adjust the opposite breast “Women’s Health and Cancer Rights Act of 1998”)
Different options for the creation of the breast mound vary in their level of complexity, potential morbidity and aesthetic result attainable.
1- Expander/Implant This method utilizes a specialized breast implant which is placed under the chest muscle at the time of mastectomy or later. Within a week after surgery, sterile saline solution is introduced into the implant which expands and stretches the surrounding tissue slowly. Over the following several weeks, the desired volume and shape are reached. Few months later, this expander is removed and replaced with the permanent implant which has a better shape and softer consistency. The second procedure takes about one hour and patients leave the hospital the same day.
This method is technically the least complicated method of breast reconstruction. Almost every patient could be a candidate for this procedure. The only exception is the patients who require radiation as part of their cancer treatment. Radiation renders the tissue more susceptible for scarring during the expansion process.
The expander/implant reconstruction is simple, does not require additional incisions, has a short recovery, and is often a great option for bilateral breast reconstruction.
2-Autogenous (Autologous) Tissue In a large group of patients, the tissue from other areas of the body can be used to reconstruct a breast which will have a more natural appearance and feel. If there is not adequate volume of tissue available, this can be combined with an implant.
Transverse Rectus Abdominis Myocutaneous (TRAM) Flap: This is the method of choice for autogenous reconstruction in suitable candidates. An ellipse of skin and fatty tissue from the lower abdomen is transferred to the chest based on one or both ?six-pack muscles? (rectus abdominis muscle). The donor site in the lower abdomen is closed directly. This creates a tighter abdomen similar to a tummy tuck procedure. During the free TRAM procedure, the same area of skin and fatty tissue is transferred to the breast area. Only a small portion of the abdominal muscle is removed.
This procedure requires special expertise in microsurgical technique to reattach the small blood vessels supplying the tissue.
DIEP Flap (Deep Inferior Epigastric Perforator) The latest advancements in microsurgical procedures enable the experienced surgeons to remove the skin and fatty tissue from the lower abdomen without sacrificing any or very minimal amount of the rectus muscle. This procedure maintains the abdominal wall integrity and does not cause any significant amount of postoperative weakness.
This is the ideal method for younger patients who continue to be active and participate in sports. A relatively small number of surgeons perform this procedure routinely.
3- Latissimus dorsi flap: The Latissimus dorsi muscle is a broad muscle over the back just below the shoulder blade. This muscle and a portion of the skin on the back can be rotated towards the front of the chest to reconstruct a breast. Depending on the thickness of the fatty tissue available, there may be the need for an implant under the muscle flap to create a larger breast mound. This method is also used for reconstruction of partial mastectomy defects. Removal of this muscle generally does not cause any functional deficit.
4- Other options:In addition to the free TRAM and DIEP flap, there are several other potential donor sites for tissue transfer. These methods are used less often.
The skin and fatty tissue on the upper and lower buttocks can be used for tissue transfer. The scars are generally well hidden. The donor site morbidity is relatively minor and excellent aesthetic results are possible.
The skin and subcutaneous tissue overlying the hip area can also be used for breast reconstruction. This method may leave a prominent donor defect requiring additional procedures to improve the appearance of the donor site.
Nipple and areola reconstruction: In the majority of the cases of breast reconstruction, the area of skin for the new nipple and areola is numb obviating the need for general anesthesia. There are several methods available for nipple reconstruction, varying from using the local skin and subcutaneous tissue on the breast mound to transferring a portion of the contralateral nipple (nipple sharing).
The procedures for the reconstruction of the areola include sharing some of the areolar skin from the contralateral breast, full-thickness skin graft, and tattooing.
In summary, every woman diagnosed with breast cancer should have the opportunity to discuss her options for breast reconstruction. The best source of information is a reconstructive surgeon who is capable of offering all modalities of breast reconstruction and works closely with the oncologic surgeons. This process can be of significant psychological help to the patients even if they decide against the immediate breast reconstruction. Post mastectomy breast reconstruction does not seem to change the rate of recurrent cancer and the time to its detection. A federal law mandates all insurances to cover the expenses for breast reconstructionl.