Breast Cancer Reconstruction
Breast cancer is defined as cancer that originates from tissues in the breast. The most common type of cancer is ductal carcinoma, arising from the thin ducts that connect the milk glands to the nipple. Another common form of breast cancer is called lobular carcinoma, arising within the milk glands. Carcinoma in-situ (CIS) refers to an early, non-invasive form of breast cancer and it can be both ductal (DCIS) and lobular (LCIS). According to the National Cancer Institute, there were approximately 232,340 new cases of invasive and 62000 new cases of in-situ breast cancer diagnosed in American women in 2013. About 1 in 8 (12%) women in the US will develop invasive breast cancer during their lifetime. Despite the fact that most breast cancers develop in women with no significant family history or genetic mutation (BRCA), about 25% of cases are familial (inherited).
Surgery remains the cornerstone of treatment. There are a myriad of surgical options ranging from a lumpectomy to a modified radical mastectomy. A lumpectomy removes the tumor along with a small portion of surrounding normal breast tissue. This is often called breast-conserving therapy as it attempts to maintain the overall shape and aesthetics of the breast while not compromising the oncological treatment. Often times the lumpectomy is combined with radiation therapy to treat the areas of the breast not removed by the lumpectomy. In certain types of breast cancers, this treatment modality has been shown to be equivalent to a mastectomy in overall survival. When considering a lumpectomy, the surgical oncologist must evaluate the size of the tumor in relation to the overall volume of the breast. This balance is essential to provide a successful treatment, not only from an oncological standpoint but also cosmetically. For example, a large lumpectomy in an A-cup breast will create a different potential deformity as opposed to the same lumpectomy in a D-cup breast. In these situations it is imperative that the surgical oncologist consider the resulting deformity. Breast-conserving therapy is not for everyone, and in some cases a mastectomy can lead to a better cosmetic result when combined with the latest state-of-the-art techniques in breast reconstructive surgery. A mastectomy removes the whole breast along with a variable amount of lymph nodes in the axilla. Often times the skin of the breast is sparred in a mastectomy (skin-sparing mastectomy). The treatment of the nipple/areola complex (NAC) remains controversial with some surgical oncologists recommending its removal with the mastectomy in all invasive breast cancer cases, while other surgeons advocating the potential preservation of the NAC depending on the distance of the tumor from the NAC. In cases of prophylactic mastectomies (a mastectomy performed to decrease the future risk of breast cancer but whom currently does not have breast cancer), the preservation of the NAC has been more accepted.
Plastic surgeons are involved in restoring the natural shape and aesthetics of the breast that has been operated on for cancer. The role of the plastic and reconstructive surgeon is not solely to restore the breast that has been operated on by the surgical oncologist, but often times involves operating on the non-cancer breast to restore symmetry. There are many options available for breast reconstruction:
Reconstruction after Breast-conserving therapy (lumpectomy)
As mentioned earlier, a lumpectomy is often combined with radiation therapy. Depending on the techniques used by the surgical oncologist (e.g. neoplastic), this may or may not lead to specific localized contour abnormalities. Implant-based corrective measures are usually not advocated for restoring the natural shape of a breast after a lumpectomy/radiation therapy secondary to increased risk of implant-related complications (e.g. infection, wound complications, and capsular contracture). Regarding the specific contour deformities caused by the lumpectomy, fat grafting has been shown to be useful. This entails the harvest of adipose tissue (fat) from another part of the body (abdomen, flanks, thighs) and focally injecting the fat to the specific area of deformity. This has proven to be safe and effective even in the breast that has been radiated. The correction may be dramatic; however, the patient must understand that multiple sessions of fat grafting may be required. Another technique employed by plastic surgeons to obtain symmetry is to perform a breast lift (mastopexy) or breast reduction (reduction mammoplasty) on the contralateral (non-cancer) breast. The above techniques may be used alone or combined for any given patient to obtain balance. The procedures are performed on an outpatient setting and are usually covered by insurance.
Reconstruction after Mastectomy
Plastic surgeons are usually involved at the onset once a mastectomy is being considered by a surgical oncologist and the patient. It is beneficial to have a consultation with a plastic surgeon before the planned mastectomy in order to potentially perform the operation at the same time as the mastectomy (immediate breast reconstruction). This has been shown to be safe and not delay any potential further oncological treatments. The benefits are better cosmetically and usually less operative procedures. Most importantly, there is a significant psychological benefit if a woman does not have to experience the deformity of a mastectomy without reconstruction. However, there are situations where a mastectomy should be performed without the reconstruction; therefore it is imperative that the surgical oncologist and plastic surgeon communicate to formulate the best plan for the patient.
There are two general techniques used for post-mastectomy breast reconstruction: 1) Implant-based breast reconstruction or 2) tissue reconstruction. Implant-based breast reconstruction utilizes saline or silicone breast implants to restore the shape and volume of the breast. This is usually performed in two-stages or more recently has been performed as single-stage. In a two-stage reconstruction, a tissue expander is placed beneath the pectorals muscle after the mastectomy is complete. Over the course of the next several months, the tissue expander is inflated with saline in the surgeon’s office until it is the same shape and size as the contralateral breast. Once this volume is achieved, another outpatient procedure is performed to exchange the tissue expander for a permanent saline or silicone implant. This is often combined with a lift, reduction, or implant placement on the contralateral (non-cancer breast to restore symmetry. In a single-stage implant-based breast reconstruction, the permanent breast implant is placed immediately at the time of the mastectomy. Implant-based reconstruction remains the most common type of breast reconstruction in the United States.
For women who do not wish to have an implant-based reconstruction, who have had implant-related complications, or who have a history of radiation therapy to the breast, autologous tissue reconstruction is performed. This requires the use of a patient’s own tissue (skin and fat) to restore the volume of the breast without the use of an implant. The area of the body that is most commonly utilized is the abdominal tissue. Therefore these flaps are often referred to as “tummy-tuck flaps” as it is the same tissue removed in a tummy-tuck procedure, but instead of it being discarded, it is brought up the breast to form a breast. This technique is often referred to as a TRAM or DIEP flap. This procedure can be performed immediately at the time of the mastectomy or in a delayed fashion, months to years after a mastectomy. This can also be performed for women who have implant-related complications and wish to have the implant removed and the breast reconstructed with tissue. Tissue reconstruction is also covered by insurance for breast restoration.
Correction of Implant-related complications after a Mastectomy
For women who have had implant-based reconstruction after mastectomy and are having problems with the implants, there are also many options available. Common problems are implant rippling, harding (capsular contracture), bottoming-out, malposition, symmastia (implant too close to the sternum), and rupture. Many of these problems can be corrected with a combination of the procedures discussed above. Other techniques that can be employed to remedy these common problems include acellular dermal matrix or highly-cohesive form stable (“gummy bear”) silicone implants.