Expanded options for
breast reconstruction

Pablo BedanoThe incidence of breast cancer in women in the United States is approximately one in eight. It is critically important for women to perform regular breast self-examinations. Losing a breast can be both emotionally and physically overwhelming; luckily, most women who have mastectomies are favorable candidates for breast reconstruction.

Breast reconstruction lends an important physical and emotional support to women facing treatment for breast cancer. Fortunately, women's options for breast reconstruction have expanded dramatically in the last 20 years. There were 93,083 breast reconstructions done by board-certified plastic surgeons in 2010. Surgical procedures offer restoration after whole or partial breast removal, and newly applied techniques improve appearance after lumpectomies. A relatively natural appearance is usually created; however, a reconstructed breast cannot have the same feel, size or exact appearance of the breast before mastectomy.

Reconstruction is often done in a number of stages that can start at the time of mastectomy or tumor removal, or is sometimes delayed until other treatments for the cancer are completed. Coordination with other physician specialists treating the cancer can be paramount, and a team approach achieves this most effectively. The entire process may be completed in one stage or can extend over a year depending on adjunctive treatments or type of reconstruction. As with all physical changes, it takes time for a woman to accept and become accustomed to a reconstructed breast.

Oncoplastic reconstruction is a recent application of plastic surgical techniques offered to some women having lumpectomies. When the size of the cancer lump requiring removal is large in relation to the whole breast, a contour deformity can occur after lumpectomy. In consultation with the team oncologic breast surgeon, the plastic surgeon can, in select cases, reshape the breast tissues at the time of the lumpectomy to minimize deformity and improve breast shape. Coordinating these procedures at the initial treatment decreases risks of treatment after adjunct radiation.

Even when mastectomy is required, reconstruction is often done at the same time--a procedure called immediate reconstruction. During the mastectomy and reconstruction, members of the medical team work together to preserve as much breast skin as possible. For some women, even the nipple can be preserved. There are two main categories of reconstruction available. An implant-based reconstruction uses a stretching implant called an expander to recreate the breast mound. The expander is filled with saline solution during the first operation as much as is safely allowed and is constructed so that additional fluid can be added at subsequent office visits. Once this stretching implant is filled sufficiently, it is removed and replaced in outpatient surgery with a permanent gel or saline-filled implant. For some women, the initial expander can be retained as the permanent implant.

Using a woman's own tissue, known as autologous tissue reconstruction, is the other main type of reconstruction. Most often the fatty tissue from the abdominal area is used in various techniques known as the DIEP or TRAM flap. The DIEP flap is an acronym for Deep Inferior Epigastric Perforator flap. In this procedure the fat and skin from the lower abdomen are completely detached along with the blood vessels that supply their nourishment and transferred to the chest. The blood vessels are then micro surgically attached to reestablish the blood supply and the tissue is molded to recreate a breast. Another autologous method uses skin and muscle from the back to add tissue in the front of the chest for breast reconstruction. This is called the latissimus dorsi flap. Because there is less tissue volume on the back, an implant is usually used with this technique.

First and foremost, breast reconstruction must be tailored to the individual woman. In conjunction with other team members, the plastic surgeon will evaluate every woman regarding her age, medical condition, medical history and most importantly, her goals, and plan a reconstruction aligned with the patient's wishes and health. In some situations, medical conditions may contradict reconstruction or the woman may choose not to have a surgical reconstruction.

—Michael Stalnecker, M.D.