Breast Reconstruction: Exploring the Options

 
The loss of a woman’s breast to cancer can be an emotionally devastating experience. The breast is a symbol of ones femininity and its loss can leave a deep emotional scar. Current techniques in breast reconstruction can provide a breast that is natural in shape, feel and appearance. Further, breast reconstruction can help speed one's emotional recovery and improve self-confidence. Optimally, planning for reconstruction is begun at the time of diagnosis and should be done in conjunction with the breast surgeon, the oncologist and the plastic surgeon.

There are a variety of options available for breast reconstruction, all of which generally require a series of operations. The first and most complex step is the creation of a breast mound. This may be done using the patient’s own tissues or with a breast implant. Either of these techniques can be adapted to rebuild both breasts in the case of bilateral mastectomies. This is followed by a series of smaller operations to recreate the nipple-areolar complex and to improve symmetry with the other side. Deciding which technique to use is based on the stage of the cancer, the patient's general health, personal goals and expectations.

Breast reconstruction can be carried out at the time of mastectomy or delayed until some time in the future. In general, immediate reconstruction offers the best results. Tissues are softer and more pliable, the number of operations required is decreased and emotional recovery is enhanced. However, depending on the method of reconstruction chosen, immediate recreation of the breast can add hours to the initial operation, may increase the need for blood transfusion and increase hospital stay and recovery time. Additionally, immediate reconstruction may not be appropriate for more advanced tumors.

There are many techniques for recreating the breast mound that use only the patient's own tissues (autogenous reconstruction). The TRAM flap (an acronym for transverse rectus abdominis myocutaneous flap) is currently the most commonly used method for autogenous reconstruction. In this procedure, the skin and fat of the lower abdomen are transferred to the chest and shaped to recreate the missing breast. This lower abdominal donor site usually is able to supply ample tissue for the reconstruction, the incision is well hidden and the patient gets the equivalent of a “tummy tuck." Autogenous reconstruction techniques are considerably more complex, requiring a lengthy operation and an extended recovery time. However, they offer a very natural appearing and feeling breast without the use of foreign materials. Other areas that can supply tissue for autogenous reconstruction are the back, the buttocks and the upper hip area. These areas are less commonly used for primary breast reconstruction except under special circumstances.

A. The TRAM flap - lower abdominal tissue to be transferred to the chest is outlined by a dotted line.	B. Tissue transferred and shaped into breast mound.
Reproduced with the permission of the American Society of Plastic & Reconstructive Surgeons.

A series of smaller operations may follow primary reconstruction to add detail and create symmetry with the remaining natural breast. The nipple and areola are usually reconstructed three to six months following the initial surgery. Local tissue is rearranged to create the nipple projection. The slightly raised, pigmented areola that surrounds the nipple can be recreated by tattooing or skin grafting. Additionally, enlargement, reduction or lifting of the remaining natural breast may be needed to help create symmetry with the reconstructed breast. These are much shorter and simpler operations that are associated with minimal discomfort and a limited recovery period.

Dallas has many excellent reconstructive plastic surgeons and locating a qualified surgeon can be done through physician referral or by contacting the American Society for Plastic & Reconstructive Surgeons (800-635-0635 or www.plasticsurgery.org). One should not hesitate to obtain a second opinion as surgeons may differ in their philosophies and it allows the patient further insights to make a more informed decision. Most insurance policies will cover breast reconstruction but individual policies should be reviewed to determine coverage and limitations. Though concerns have existed in the past regarding reconstruction interfering with the diagnosis of cancer recurrence, studies have not shown this to be the case.

With the variety of options available today the majority of women who must undergo a mastectomy can have an attractive and natural appearing reconstructed breast. This can contribute to a more rapid emotional recovery, greater self-confidence and an improved quality of life.

 
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