Breast reconstruction involves the surgical recreation of a breast, most often in the setting of breast cancer when mastectomy is required. Plastic surgeons now have wide range of options to offer patients seeking breast reconstruction by using either prosthetic devices, or the body’s own tissues. There have been considerable advances in the management of patients with breast cancer over the past decade. These include the development of skin sparing techniques for mastectomy, acceptance of the oncologic safety of immediate reconstruction (i.e. at the same time as the mastectomy), and more recently – oncoplastic techniques (a fusion of plastic surgery and ablative techniques).
SKIN SPARING MASTECTOMY
A better understanding of the biology of breast cancer, has led to the development of this technique. Seminal work by the team at MD Anderson Cancer Center in the U.S., has shown quite conclusively, that in selected patients with early stage breast cancer, the breast can be removed through limited incisions, leaving most, if not all, of the breast skin for reconstructive purposes. In other words, the breast tissue can be “shelled out” of the skin envelope through small incisions. More recently, certain very select patients may find themselves suitable candidates for nipple sparing procedures.
The advantage is that the reconstructive surgeon can then fill this empty breast envelope at the same time as the mastectomy, with either a prosthesis, or the body’s own tissue, typically the excess tummy fat (TRAM flap or DIEP). The cosmetic implications are obvious: retaining the breast skin, allows for a better match of the opposite breast, better positioning of the scars, better return of sensation, and better preservation of the breast crease. The nipple and areola, however, are usually removed with the mastectomy specimen, but can be reconstructed – usually at a later date. What is important to note is that this procedure does not, in any way, negatively affect the prognosis or post operative course. The former belief that radical procedures are necessary to prevent recurrence has been shown to be untrue.
Traditionally, patients with breast cancer have the mastectomy soon after diagnosis. When all has settled, those who want reconstruction are referred to a plastic surgeon – usually several months after the mastectomy. Whilst this is a perfectly acceptable way of doing things, it does mean another operation, with all the trauma this entails.
We can now offer patients the choice of breast reconstruction at the same time as the mastectomy. This too has been shown to be quite safe in patients with early stage breast cancer, and does not affect the prognosis at all. Immediate reconstruction is usually done in combination with a skin sparing mastectomy for the best results. The breast, usually along with the nipple and areola, is removed, and the glands in the armpit may be sampled or resected as part of the cancer treatment. The breast envelope can be filled with either a tissue expander, silicone prosthesis, or a TRAM / DIEP flap – using the extra tummy fat to make a new breast. In my practice nowadays, I only perform one or 2 stage prosthetic breast reconstructions – the first stage is done at the time of mastectomy, and involves the placement of a tissue expander under the chest muscles. This is then serially inflated over a few weeks post operatively to allow for the second stage, done some months later, which involves placement of a permanent, form stable, gel prosthesis – I usually use Mentor CPG implants for this purpose. Nipple mound reconstruction completes the breast form, and is usually simply done under local anaesthetic. The areola is then tattooed.
This is the marriage of plastic surgery flap techniques with ablative surgery to facilitate a better cosmetic result. Certain patients who qualify for wide local resection of their disease (as opposed to a mastectomy) may be treated using breast reduction techniques to remove the tumour, or using local breast flaps to better contour the residual breast once the tumour has been removed. These procedures allow the breast mound to be better reconstituted than simple resection, but post operative radiation becomes mandatory. Breast reconstruction is usually covered by most medical aids, although it may occasionally require motivation and co-payments are the rule rather than the exception.