Breast Cancer: Breast Reconstruction Following Mastectomy

The period of time following a diagnosis of breast cancer is a roller coaster ride of emotions as she is exposed to a magnitude of information requiring decisions to be made regarding not only her breasts, but her very survival. 

As the details of her breast cancer are examined and the most optimum treatment plan is chosen, one of the procedures necessary to eradicate the cancer may be a mastectomy, the removal of some or all breast tissue, and some or all of the lymph nodes in the arm pit and chest wall. 

With so many decisions to make, dealing with side-effects from chemotherapy treatments and the onslaught of emotions, it can be a very difficult time to make a decision regarding breast reconstruction.    Fortunately, it is not imperative that the decision be made at the time of the mastectomy, and, in some cases, it may be recommended that reconstruction be delayed for best results.

Reconstruction for breast cancer is performed by a plastic surgeon to replace skin, breast tissue and the nipple removed during the mastectomy.  Factors contributing to the amount of tissue removed, location of the original tumor and proximity to the axilla where the lymph nodes are removed are different for every woman.  Restoring symmetry between the two breasts is the ultimate goal of reconstruction. 

Breast reconstruction is a personal and difficult decision to make, and is not considered cosmetic surgery; restoring a woman's breast is giving back to her something that she was given by nature which was stolen by cancer.

Living with a partial breast or without a breast, or breasts, for the long term affects every woman  differently, and is a personal decision.  Following mastectomy, women may chose to wear external breast forms (prosthesis), breast pads or may not attempt to alter their appearance at all. 

Studies have shown that about 50% of women having radiation therapy after having had a mastectomy with immediate reconstruction using implants, develop complications requiring additional surgery.  Discussing immediate breast construction with your physician and surgical team will ensure a decision based on your particular diagnosis and treatment schedule.

Dr. Rodney Pommier, Professor of Surgery, Knight Cancer Institute, Oregon Health & Science University said, "the growing trend toward immediate reconstruction has turned into a runaway train; some women would be better off delaying it."

Whenever possible, women are encouraged to begin reconstruction  at the time of the mastectomy, as physicians believe the trauma of having a breast removed is reduced, as well as the cost of two major surgeries.

A variety of reconstructive techniques are available offering cosmetically appealing results.  Medical condition, previous surgery and patient's goals are considered when choosing to use breast implants or flaps of tissue removed from other parts of the body. 

Reconstructive procedures using the patient's own tissues provide superior and very natural results:
    *Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction - uses abdominal skin and fat, using blood vessels below and within the abdominal muscle.
    *Superficial Inferior Epigastric Artery (SIEA) Flap Breast Reconstruction - uses lower abdominal skin and fatty tissue, using blood vessels just below the skin.
    *Gluteal Artery Perforator (GAP) Flat Breast Reconstruction - uses excess skin and fat from the buttock region leaving all the gluteal muscle behind.
    *Transverse Upper Gracilis (TUG) Flap Breast Reconstruction - uses tissue from the inner portion of the upper thigh.
    *Latissimus Dorsi Flap Breast Reconstruction - uses muscle, skin and fat from the back of the shoulder blade.

Possible Complications for breast reconstruction with tissue flap procedures
    *Abdominal hernias and muscle damage or weakness at the tissue donor site
    *Weakness in back, shoulder or arm following Latissimus dorsi flap procedure
    *Poor wound healing
    *Infection

Flap procedures are not usually offered to women with diabetes, connective tissue or vascular disease, or to smokers due to the necessity of healthy blood vessels for the tissue's blood supply.

Another option, which is the most common method of breast reconstruction performed in the US, utilizes tissue expanders and implants. 

Possible Complications for breast reconstruction with implants:
    *Poor wound healing
    *Rupture or deflation of implant
    *Protrusion of implant through the skin
    *Infection
    *Bleeding
    *Scar tissue compressing implant and breast tissue into a hard, unnatural shape
    *Increased risk of future breast surgery to replace or remove implant

Breast reconstruction surgeries usually take from about 6-8 hours with the hospitalization after implant surgery for a couple of days, and Flap procedures requiring a five to six day stay.  Most daily activities at home and work can be resumed within six weeks.
   
Usually the nipple and areola is removed during a mastectomy because it is breast tissue and at risk for cancer recurrence.  Nipple reconstruction is a procedure to be considered, but usually is done after the reconstruction of the breast is complete allowing new breast tissue to heal and settle into place.

Similar to the numbness which occurred following mastectomy, there will be areas of numbness at the surgery sites for reconstruction.  The shape of your reconstructed breast(s) will gradually improve over time.

Breast reconstruction will not increase the risk of cancer recurrence, and it is important to remain diligent in breast self-exams and regular screening exams by your physician.  In the case of recurrence, chemotherapy, radiation and surgery are still treatment options.

Posted on the American Cancer Society's website, "Federal law requires most group insurance plans that cover mastectomies to also cover breast reconstruction."

The Women's Health and Cancer Rights Act (WHCRA) helps protect many women with breast cancer who choose to have their breast rebuilt (reconstructed) after a mastectomy. It was signed into law on October 21, 1998. The United States Departments of Labor and Health and Human Services oversee this law, which applies to group health plans, health insurance companies and HMOs, as long as the plan covers medical and surgical costs for mastectomy

Under the WHCRA, mastectomy benefits must cover:
    *  Reconstruction of the breast that was removed by mastectomy
    * Surgery and reconstruction of the other breast to make the breasts look symmetrical or balanced after mastectomy
    * Any external breast prostheses (breast forms that fit into your bra) that are needed before or during the reconstruction
    * Any physical complications at all stages of mastectomy, including lymphedema