By Deniz F. Bastug, MD, FACS

​Breast Cancer continues to be one of the most prevalent forms of cancer for women. Currently, breast cancer will affect approximately one out of every 7 to 8 women, an increase from previous decades. There still remains no cure for breast cancer, but research is strong in that direction. Advances are made yearly in detection and diagnosis, in treatment protocols, as well as other factors and associated conditions affecting the discovery of breast cancer in a woman.

Treatment involves a multitude of factors including family history, genetic components, type of breast cancer, and individual personal preferences regarding treatment options. For all these reasons, treatment of this disease is heavily individualized and consists of a concerted effort by many different specialties, including the general surgeon, oncologist, geneticist, and radiation oncologist. The reconstructive portion of treatment is performed by a plastic surgeon, and this article will touch on the various reconstructive options.

When considering reconstruction after mastectomy, a woman must consider many factors. The first important question to ask should be „is reconstruction right for me?‟ Women choose breast reconstruction for many reasons, and the method of reconstruction chosen is very individualized. This depends on personal desire, physical attributes, type of breast cancer, lifestyle and psychological characteristics. No matter which method of reconstruction is chosen, it usually will entail multiple surgical procedures.

Breast reconstruction can be performed at the time of mastectomy, known as immediate reconstruction, or anytime later, typically months to years, which is known as delayed reconstruction. The timing of the reconstruction depends again on individual desire, but many times is more influenced by the disease itself, i.e. whether other adjuvant treatment such as radiation or chemotherapy will be needed. Once the timing is determined, the next step is in determining which type of reconstruction is best for the individual.

There are many types of reconstruction available, but all fall into one of two types. Either a portion of one‟s own body will be used, known as autologous reconstruction, or a breast implant will be used. Sometimes the two are combined. The procedures vary in complexity, recovery time and risks. Despite the method chosen, all can give a nice cosmetic result, and again choice is based on individual preference, anatomy, type of cancer and lifestyle.

Probably the gold standard in reconstruction these days is the ​autologous reconstruction, which is using a women‟s own tissue to create the breast. This is done with what is called a flap. This flap, which consists of skin, underlying fat, underlying muscle, and associated blood vessels can be taken from many different areas of the body. These are too numerous to go into detail here but these flaps can come from the abdomen (called a TRAM flap), from the back (a Latissimus Dorsi flap), or from other areas such as the buttocks region (Gluteal flaps). These flaps are either left attached to the underlying muscle, or can be completely disconnected from the muscle and placed into the chest to create the breast using microsurgical techniques. Flap or autologous reconstruction involves complex surgery, longer recovery time, affects other parts of the body and have the greatest risks. The benefits of these trade-offs are typically beautiful and very natural appearing breasts.

The alternative to the autologous reconstruction uses an implant to recreate the breast mound. In certain instances this can be performed as a one time procedure, but typically this will be at least a two stage process. Following a mastectomy, there is deficient skin. The various flaps provide for this skin, otherwise we need to place a special type of implant called an expander to stretch the skin and muscle slowly. This provides the room for the second procedure where the expander is removed and a permanent implant is placed.

Women have a choice of either saline implants or silicone implants as the permanent prosthesis. There has been a lot of press in the past regarding silicone implants, and unfortunately this has only confused and frightened women. Countless studies over the past 16 years have been performed, all verifying the safety of silicone implants. However there is still apprehension in some women. Talking to your plastic surgeon is the best way to get the information you need to make the proper informed choice.

As mentioned earlier, reconstruction usually involves more than one procedure, and many times one of these procedures needs to address the opposite breast. Often the non-reconstructed side needs something done to it in order to achieve symmetry with the reconstructed side. This can involve a breast lift (mastopexy), a breast reduction or a breast enlargement (augmentation). Once the reconstructions are done, symmetry has been achieved and the woman is well healed, one more decision needs to be made. This is whether or not to have a nipple and areola reconstructed. Several methods are also available for this, but fall into two categories, either tattooing or flap reconstruction if an actual protruding nipple is desired.

Breast reconstruction is a decision based on many factors involving many decisions and individual circumstances. In careful discussion with your plastic surgeon the best method for you can be determined. It is also very important to be aware that federal law requires insurance companies cover breast reconstruction for mastectomy following breast cancer, as well as cover procedures on the opposite breast to achieve symmetry. With the widely available options present, mastectomy alone need not be the endpoint for breast cancer. Through education and involvement in the decision making process, breast reconstruction can be a very fulfilling and satisfying option.

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by Deniz F. Batug, M.D., FACS

Breast Cancer affects one out of every eight or nine women and continues to be one of the most prevalent types of cancer among women. Although a cure for breast cancer has yet to be discovered, great advances have been made in recent years in both diagnosis as well as treatment, including possible preventative measures. Treatment of this disease involves a concerted effort by many specialists. The reconstructive aspect of care is performed by a plastic surgeon, and this article will present the various options available in breast reconstruction.

There are many factors to consider about breast reconstruction and many important questions a woman must ask. The first question should be “is reconstruction right for you?” Women choose to have breast reconstruction for many different reasons and the reconstruction option chosen depends on individual desire as well as one’s unique physical and mental characteristics. Any type of breast reconstruction will typically involve multiple procedures, with the exact number varying with individual circumstances.

Breast reconstruction can be performed as an immediate reconstruction, that is, at the time of the mastectomy or on a delayed basis, which is performed weeks to years after the initial mastectomy. After determining whether to go under immediate or delayed reconstruction, the next important decision is selecting the type of reconstruction one will undergo. Reconstruction is performed using a variety of methods including use of a prosthesis (a breast implant), use of a women’s own body tissue (a tissue flap), or by using a combination of the two. These procedures vary in complexity as well as recovery times and risks involved. Despite which reconstruction option is chosen, they all can give a very nice cosmetic result, and choice depends on many factors such as individual anatomy, type of cancer and life style.

The most common form of breast reconstruction procedure in the last ten to fifteen years is use of a breast implant to recreate the breast mound. Many times following a mastectomy there is deficient skin, and prior to placement of a permanent breast implant, a balloon like device called an expander may be placed as the first step in this type of reconstruction. The expander allows the surgeon to slowly stretch the skin and muscle creating sufficient space for placement of a permanent implant. At a second procedure the expander is removed and the permanent implant is placed. Both of these procedures can be performed on an outpatient basis with a fairly quick recovery time of one week to ten days. The time frame between procedures is determined by patient anatomy (how large a breast to reconstruct) as well as potential other factors such as need for additional therapy. The implant choice may either be a saline filled implant or a silicone filled implant. At this time, silicone implants are available for reconstruction purposes only if your surgeon is participating in ongoing clinical trials. Silicone implants have been shown in countless studies to be safe and not causative in any adjuvant diseases.

Flap reconstruction is a method of reconstruction that uses a women’s own tissue. This can be taken from either her back, abdomen, or buttocks to create a breast mound. If the tissue is left attached to the blood supply this is known as a pedicled flap, or it may be completely separated from its blood supply and reattached to a new blood supply using microsurgical technique. This is known as a free flap. There are a number of flap options that women can choose from. The latissimus dorsi flap utilizes the skin from the back attached to the latissimus muscle. This is then brought to the front of the chest to create the breast mound. Because this muscle is very thin, many times implants my be needed for creating the volume. This procedure typically takes approximately fours hours with a two to three day hospital stay. Recovery times are longer than implants alone and can range from three to four weeks. The advantage to this flap is its ability to provide needed missing skin in a reliable and consistent manner. Other available options for flaps include use of tissue from the upper hip or buttock region.

However, the most common type of flap in breast reconstruction is the TRAM flap. This stands for Transverse Rectus Abdominus Musculocutaneous flap. This option utilizes skin from the abdomen with its underlying rectus muscle to allow sufficient volume and replacement of missing skin. Implants are usually not needed with this type of reconstruction and surgery can last from six to eight hours. Hospital stays may be up to three to five days with recovery time of approximately six weeks or greater. Patient selection is very important with this type of reconstruction and not all women are candidates for this procedure. Because we are utilizing skin from the abdomen, previous abdominal surgery may preclude the use of this flap. In addition, medical conditions as well as individual anatomy and lifestyle (smoking history, etc) may determine whether the flap may be used.

As mentioned earlier, reconstruction is typically not a one procedure event. Many times addressing the opposite breast must be taken into consideration. This is done in order to achieve symmetry between the reconstructed and nonreconstructed breast. Procedures such as breast lifts (mastopexy), breast reduction (reduction mammoplasty), or breast enlargement (augmentation mammoplasty) may be required on the opposite breast in order to achieve the best symmetry and results. Another consideration is whether to proceed with reconstruction of a nipple areola. This is typically performed three to four months after the initial reconstruction and is usually done on an outpatient basis.

Breast reconstruction is a decision that is made based on many individual factors. By careful discussion with your plastic surgeon you determine the proper selection of reconstructive methods. With the current wide availability of reconstructive options mastectomy alone need not be the end point for breast cancer. It is now a federal law that all insurance companies must cover breast reconstruction following mastectomy for breast cancer, as well as covering procedures on the opposite breast to achieve symmetry. Through education and involvement in the decision making process, breast reconstruction can be a very fulfilling and satisfying option.

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