Breast Reconstruction Options
Most women with breast cancer are treated with an excision of the breast cancer itself followed by radiation of the remaining breast. This treatment has remained a mainstay of treatment. It preserves the remaining breast with a typically good cosmetic result. The decision for mastectomy is also a complex one. Many factors are considered which include tumor type and size, patient genetics, breast appearance and size, and patient desires. After the preoperative educational and decision making process regarding the cancer treatment is completed, a consideration for breast reconstruction is undertaken.
Breast reconstruction can be performed at the time of mastectomy, or it can be delayed. Many women opt for an immediate reconstruction, but the ultimate result is cosmetically equal whether the reconstruction is immediate or delayed. I would advise against an immediate reconstruction if radiation therapy is anticipated after surgery. Good general and emotional health is also an important factor to consider with immediate reconstruction patients.
When considering types of breast reconstruction, a division would exist between tissue expansion (implant) and autologous (created from one’s own body) reconstructions. This may be oversimplified because sometimes the techniques are mixed. But, for the most part, it makes the techniques easier to separate.
It is my contention that most patients are very well served with implant reconstructions. This technique and the technology it requires have been greatly refined over the course of the last decade. The implants are an “off the shelf” product making tissue expansion the least physiologically challenging of the breast reconstructions. Particularly for bilateral reconstructions, the cosmetic result can be excellent. Remember that implants are the principle means by which plastic surgeons correct cosmetic breast deformities in non-cancer patients. Careful attention is always given to the unaffected breast using standard cosmetic surgery techniques to provide as close a match to the reconstructed breast as possible.
Debate continues among academic plastic surgeons as to the appropriate place of autologous reconstruction in technique selection. There are those who consider them first line interventions. Most would agree that if the chest wall has been radiated, then an autologous or mixed implant /autologous reconstruction is appropriate. The cosmetic results of these surgeries are more patient and surgeon dependent. They always carry with them more risk and longer periods of recovery. The most popular are the Lat. Dorsi which uses the back, and the TRAM flap which uses the muscles of the abdomen. There are now reconstructions in which the tissue needed for reconstruction is moved on a single blood vessel sewn into place with a microscope. These challenging surgeries are very surgeon dependent and are reserved for surgeons who have made the performance of these complex operations a specific subspecialty of their practice.
The final patient group for discussion is the woman who has undergone a lumpectomy and radiation only to have a poor cosmetic result. In most cases, I would recommend a completion mastectomy with autologous reconstruction in this population.
Breast reconstruction has matured to become a safe and reliable technique with a wide application to a great variety of patients.