Breast Reconstruction Washington DC
In the treatment of malignant disease, the most important goal is the elimination of the cancer. Breast reconstruction is a different matter—a matter of patient preference. A motivated patient who desires the procedure is the best candidate for breast reconstruction. It can be a positive factor in a stressful situation: reconstruction has been found to improve self-image and self-esteem, as well as help a woman resume her normal routines without being constantly reminded of her cancer.
Breast reconstruction techniques have advanced dramatically over the past fifteen years; today many options are available, and the cosmetic results are impressive. Some reconstructions use breast implants and tissue expanders; others use the woman’s own tissues, in the form of muscle and skin flaps (called myocutaneous flaps), with implants; and still others use the patient’s own tissues without implants. This last form of breast reconstruction is called autologous reconstruction; the tissue for autologous reconstruction usually comes from the abdomen. The technique is customized to the patient’s needs and desires.
The vast majority of women who have had reconstruction surgery are pleased with their results, but there are limitations to what can be accomplished. For example, surgeons can not exactly match the other breast, even though the results of surgery today are coming close. To make the two breasts more closely resemble each other, some women choose to alter the unaffected breast with procedures such as reduction, augmentation (enlargement) and lift (mastopexy). Because a mastectomy interrupts the nerve supply to the skin, all reconstructed breasts will have less sensation in the skin; part of this sensory change will last forever. All reconstructed breasts have scars, though they usually fade over time. Reconstructed nipples look normal, but they do not change with stimulation and appear to be always erect.
The Envelope and the Contents
Two concepts in breast reconstruction are, first, that the skin is considered an envelope, and second, that the breast tissue is considered the contents. When a patient has a mastectomy, the general surgeon removes the nipple, the biopsy site, and the contents of the breast. The usual desired goal when a woman has chosen to have breast reconstruction is a skin sparing mastectomy. This technique involves removing the contents but attempting to limit the skin excision to the nipple.
All women having reconstructive surgery must have the contents restored after a mastectomy. A physical examination before the mastectomy determines whether there will be enough envelope remaining to hold the restored contents; if not, the patient will need additional skin for the reconstruction procedure. Measurements are taken during the examination to compare the normal breast to the breast with cancer. Because the nipple will be removed, the diameter of the nipple is subtracted from the vertical measurement. (If the cancer involves the skin, this skin—or envelope—is subtracted from the measurement as well; see Figure 12.1.)
Whether a patient will require additional skin (and how much) is determined by the difference between the size of the vertical skin envelope of the normal side and the anticipated vertical skin envelope after the mastectomy. The amount of skin required will play a major role in the choice of reconstruction procedure. Table 12.1 is an algorithm showing the options available to a woman needing between one and seven (or more) centimeters of additional envelope. (These procedures are described in this chapter.)
As noted earlier, for some women the best result is obtained when the opposite breast is modified, as well. If the cancer-free breast is noticeably larger than the reconstructed breast, then the reduction of the healthy breast may be desired. If the healthy breast droops in comparison to the reconstructed breast, than a breast lift may be a consideration. Both of these procedures reduce the skin envelope and may eliminate the need for additional skin on the mastectomy side to attain symmetry.
The next issue to be considered is timing. Breast reconstruction is classified as either immediate or delayed. In immediate reconstruction, the new breast is reconstructed at the time of the mastectomy. Once the general surgeon has completed the mastectomy, the plastic surgeon begins the reconstruction as part of the same operative experience. In delayed reconstruction, the operation may take place months or years after the mastectomy. Delayed reconstruction and immediate reconstruction use the same techniques and have similar cosmetic results. Timing, then, is an issue of personal preference with no wrong answer.
Stages in Breast Reconstruction
Breast reconstruction typically requires three steps or stages. The initial reconstruction with mastectomy (if immediate) or without mastectomy (if delayed) requires a general anesthetic and a oneto threeday hospital stay followed by a threeto four-week recovery. The other breast may be altered for symmetry at this time, or that may happen during the second stage. The second stage is a fine-tuning or adjustment and is an outpatient procedure with a weekend recovery in most cases. The second stage takes place when two criteria are met: first, the patient is back to her normal routine, and second, she has completed any adjuvant chemotherapy or radiation therapy. If chemotherapy is to be followed by radiation therapy, the second stage is delayed six months to a year to enable the tissues to recover from radiation. After radiation the blood supply to the tissues is diminished, and the actual texture of the skin may be affected. The tissues are evaluated, and the timing is set on an individual basis.
The second stage includes revision of the unaffected breast for symmetry. If one side is larger than the other or one breast sits lower than the other, the asymmetry can be corrected. If a tissue expander, a temporary implant, was placed at the initial procedure, it is exchanged for the more permanent implant at the second stage. Finally, if a patient elects to have a nipple reconstruction, it is started at this time. The nipple has two components, the raised part, or papule, and the pigmented area surrounding it, called the areola. The papule is created at the fine-tuning.
The third stage is the tattooing of the nipple to create the areola. This takes place eight to ten weeks after the second stage. The areola tattoo is an office procedure often requiring no anesthesia. In the past, grafts were harvested from the groin region to construct the areola, but today we use tattooing because it provides better symmetry and color match.
One form of breast reconstruction uses a breast implant. This implant is placed in a pocket that is developed under the muscles of the chest: the pectoralis major, the serratus anterior, and the rectus abdominis. These muscles make up the layer just beneath the breast tissue. A new addition to implant/expander reconstruction is Alloderm. This is a sheet of cadaveric dermis which is placed between the pectoralis major and the fold beneath the breast, eliminating the need to lift the serratus anterior and rectus abdominis muscles. This allows for easier expansion and in some cases the opportunity to place the actual implant at the time of the mastectomy. Alloderm is quite exciting as it allows for the ingrowth of blood vessels and actually becomes a part of the patient’s tissues. If the tissues are tight, an expander is placed. In smaller-breasted women, the pocket may be sufficient to accommodate the implant at the initial procedure, although this approach is less common. Moderateto large breasted women require a tissue expander to stretch the muscle and/or skin to make room for the actual implant.
The tissue expander is a deflated balloon made of silicone with a built in injection port. During the months following this reconstruction, the patient visits her plastic surgeon every one to two weeks, and the expander is inflated by injecting saline through the skin into the port, gradually inflating the expander. This process causes little or no discomfort. The expander is inflated for several months and then removed. The permanent implant is placed as part of the second stage, the fine-tuning. An alternative to this approach is an expander/implant referred to as a Becker implant. This implant has a remote valve and can be used as an expander; then, at the time of nipple reconstruction, the valve is removed and the implant is left in place (see Figure 12.2).
There are advantages of a tissue expander/implant approach over a flap approach (see below). The advantages include shorter operating time and a less involved procedure, limited to the breast area. This decreases the postoperative discomfort and recovery time. The limiting factor with tissue expansion is that only two to three centimeters of additional skin can be obtained through this technique. If more skin is required, the use of flaps must be considered.
There are some disadvantages associated with the tissue expander/implant option. These include infection, rupture, or leakage of the expander or implant; contour irregularities; frequent visits to the plastic surgeon in the postoperative period for expansion; formation of a capsule or scar tissue around the implant, which may cause discomfort or distortion; and lack of change of implant size with weight loss or gain. Whenever a foreign object is placed in the body (in this case, the expander or implant), the body perceives the object as foreign and forms a wall of scar tissue around it. This scar tissue is termed a capsule. In approximately 20 percent of patients with implants, this scar tissue may tighten around the implant, causing discomfort and possibly a change in shape, which is termed a capsular contracture. Additional surgery may be necessary to interrupt or remove this scar tissue and possibly replace the implant. Capsular contracture may develop at any time from several months to several years following implant placement.
Saline or Silicone?
As a reconstruction patient, women have the option of a silicone gel or saline implant. In the 1990s there was concern about a possible association between silicone implants and symptoms such as muscle aches, joint aches, and fatigue, as well as disease processes such as lupus and scleroderma. The studies to date show that these symptoms do not appear to be related to implants. These include studies from the Institute of Medicine (Safety of Breast Implants, 1999), Brinton study of 7,234 patients and a Danish study with nineteen-year patient follow-up. It is possible that there may be people with sensitivity to silicone, but they would be a rarity.
The silicone gel has the consistency of molasses, and saline has the consistency of water. The gel feels more natural to many, while others prefer the saline. Saline implants have a 3.7 percent deflation rate. This means that at some point, this implant will fail, and the patient will call and say she has a “flat tire.” Silicone gel implants can also fail. Cohesive gel implants are being studied as an alternative to currently used silicone gel implants. If an implant fails, the pocket is already in place, so only the contents have to be replaced. This can be done in a minimal outpatient procedure with no significant recovery time.
Another approach to breast reconstruction utilizes the patient’s own tissues, either with or without an implant. One surgical approach uses a latissimus dorsi myocutaneous flap. This is a muscle from the back which is taken, along with an overlying island of skin and fat, and rotated beneath the armpit to provide the necessary skin in women requiring as much as seven to nine centimeters of skin in a vertical dimension. Depending on the size of the breast to be reconstructed, an implant may or may not be required. There are at least two additional muscles that provide each of the functions provided by the latissimus dorsi, and therefore the woman usually does not notice any loss of function when this muscle is used in a flap (see Figure 12.3).
Another approach using a woman’s own tissues is the transverse rectus abdominis myocutaneous flap, or TRAM flap (see Figure 12.4). This flap employs the lower abdominal tissues that would normally be discarded if a tummy tuck were performed. These tissues are left attached to either one of both of the rectus abdominis muscles, which run from the center of the rib cage toward the pubic bone and are the width of a man’s tie. The tissues form an ellipse of skin, which includes fat and muscle. This ellipse is then rotated and placed into the mastectomy defect and the skin and fat are then contoured to match the opposite breast. The donor site is closed, leaving a scar that extends across the lower abdomen from one hip to the other with an additional scar around the navel as would be seen in a tummy tuck.
A variation of this procedure takes the same island of skin and part of one muscle, detaching it from the body and then reconnecting the artery and vein to other vessels in the armpit area using the operating microscope. This variation is called a TRAM free flap.
The TRAM approach has several advantages. First, the TRAM utilizes the patient’s own tissues and thus avoids the problems associated with breast implants. In addition, the breast mound is constructed at the initial surgery. This eliminates the need to make frequent trips to the doctor’s office. The TRAM flap will shrink approximately 10 percent after surgery. The flap will change somewhat in size with associated changes in body weight gain or loss. As one ages, the breast glandular tissue is replaced with fatty tissue. Thus, the consistency of the reconstructed breast is similar to the breast on the unoperated side.
The TRAM flap also has disadvantages. Approximately 5 to 10 percent of patients will lose a portion of their flap due to circulation problems, which the woman will notice as an area of firmness in the flap. This area is removed at the time of the fine-tuning. There are rare reports of the entire flap being lost due to the same circulatory problems. If this occurs, the flap has to be removed and an alternative method of reconstruction chosen. For women without significant heart, lung, or vascular disease, these procedures are routinely performed without difficulty.
Approximately 2 percent of TRAM flap patients develop a small area of abdominal wall weakness at their donor site. This is more common in cases in which both muscles are utilized. As a preventive measure, a layer of synthetic mesh may be utilized to reinforce the abdominal wall in cases where both muscles are used and in areas that may be exceptionally weak. If this weakness occurs and the woman is uncomfortable despite wearing supportive garments, a surgical procedure is required for repair. Rarely, and more commonly when parts of both muscles are used in a case of bilateral reconstruction, the woman may have difficulty sitting up from a lying-down position. The role of the rectus muscles is to initiate the process of sitting from a lying-down position. When both muscles are used, the abdominal wall may have a temporary or permanent weakness.
Another option may be to utilize the same abdominal tissues involved in the TRAM flap but leave the underlying muscle alone, avoiding the issues of abdominal wall weakness. This procedure is called a deep inferior epigastric flap or DIEP flap (see Figure 12.5). The blood vessels to the flap are dissected through the muscle and preserved, then attached to the island of skin and fat. This is a free flap. A free flap involves cutting the blood vessels to the island of skin and then transferring the island to the chest region and attaching the blood vessel with the assistance of a microscope to local blood vessels in the chest region.
Another form of free flap breast reconstruction, called the inferior gluteal free flap, employs tissues from the lower buttock (see Figure 12.6). This method fully removes an island of skin, fat, and muscle from the lower buttock, centered on the fold; the island is then transferred to the mastectomy site, where the artery and vein are connected to vessels in the armpit using the operating microscope. The advantage of this procedure is that it provides an alternative when the abdominal tissues are not available. The disadvantages include the creation of an asymmetry in the buttock area (unless the procedure is used for bilateral breast reconstruction). There is also the potential for parasthesias, which are abnormal sensations on the back of the thigh. This procedure takes longer, typically six to eight hours, and technically is more difficult. In rare cases, the entire flap or a portion of the flap does not survive the transfer, and further surgery is required.
Another variation is the superior gluteal free flap, which uses the upper portion of the buttock. Finally, some of the upper abdominal or lower chest wall skin may be moved upward to contribute one to two centimeters of skin to the lower portion of the breast. This procedure is called a lower thoracic advancement flap or Ryan flap.
Many patients choose to undergo nipple reconstruction, which is performed at the time of the fine-tuning (see Figure 12.7). As noted above, the nipple has two components: the raised part of the nipple, or papule, and the pigmented area surrounding this raised part, which is called the areola. The papule is developed from the local tissues of the reconstructed breast. It is intentionally made too large, as it will compress approximately 50 percent over the six to eight weeks following nipple reconstruction. A small skin graft may be required to fill the donor site for the papule. This is typically taken from an area of redundancy on the chest wall or the ends of an existing scar. In the past, skin grafts were taken from the groin or labial areas, but this is not done any longer. If a woman has a large papule on the other breast, a portion of that papule may be utilized to create the papule on the side of the reconstruction.
Six to eight weeks following creation of the papule, the areola is created by tattoo and the papule is also tattooed. In the majority of cases, no anesthesia is required for this office procedure. Nipple reconstruction is strictly a matter of patient preference. Although many patients choose to have a nipple reconstruction, some do not. Prior to a nipple reconstruction, women tend to pay attention to the other reconstruction scars. After the nipple reconstruction, her focus is on the nipple, and the scars become less of an issue.
The Other Breast
As noted previously, a woman may decide to alter the cancer-free breast for the purpose of greater symmetry between the two breasts. The alteration may involve prophylactic mastectomy, enlargement, reduction, or lift. For some women, these alternatives represent the most effective means of achieving symmetry. The surgery can be performed at the time of the initial reconstruction or at the fine-tuning. Alteration in the opposite side can help limit the amount of skin necessary to achieve symmetry in the reconstruction. A federal law states that for insurance purposes both breast reconstruction and alteration of the opposite side for symmetry purposes are covered procedures.
Lumpectomy and Radiation Therapy
Some patients with a localized small tumor may elect to have a lumpectomy followed by radiation therapy. A lumpectomy involves removal of the tumor and a component of normal breast tissue as well as some of the overlying skin. In most cases, nothing further is required to reconstruct the breast. If, due to the location of the cancer and subsequent skin resection, an asymmetry is created, alteration in the opposite breast may correct this.
A woman with a breast implant may develop a breast cancer and be a candidate for lumpectomy and radiation therapy. As there is a higher incidence of capsular contracture (scar tissue that forms around the implant creating firmness and distortion) associated with radiation, we need to consider removing the implant at the time of the lumpectomy and replacing it with a tissue expander. The expander is then immediately overexpanded until the affected breast is larger than the unaffected breast, prior to the initiation of radiation therapy. At approximately six months after radiation therapy is completed, the expander is removed and the implant is placed.
Sex and Well Being
Some women neither desire nor seek breast reconstruction after mastectomy. They resume their lives and adjust just fine. For some women, however, breast reconstruction provides them the opportunity to feel whole after mastectomy. The results are such that the woman is not reminded on a daily basis that she has had a mastectomy or cancer. She feels comfortable wearing any clothes as well as getting undressed in front of her spouse or others. She is able to resume a normal sex life without being self-conscious. (Because the reconstructed breast has less feeling than the other breast, or no feeling, she will need to communicate with her significant other to provide a satisfying sexual experience for both of them.)
BRACA Gene Positive
A woman with a strong family history of breast cancer may elect to undergo gene testing. If she has a positive BRACA gene, she may have up to an 80 percent lifetime chance of developing a breast cancer. Such a woman may feel as if she is walking around with a “time bomb” and may decide to undergo bilateral prophylactic mastectomies with immediate reconstruction. Depending on the amount of envelope, she may have either expander/implant reconstruction or bilateral latissimus dorsi myocutaneous flaps with implant placement.
Breast reconstruction can be an important component of breast cancer recovery for women who choose to pursue it. New surgical techniques have greatly improved the cosmetic results of breast reconstruction, and a woman’s decision to consult with a plastic surgeon at the time of her diagnosis makes her better informed when it comes to overall treatment planning. Whether a woman elects to have immediate reconstruction, delayed reconstruction, or no reconstruction at all, it is empowering for her to have options and to play an informed role in choosing the most comfortable path to full recovery.