Breast Cancer Reconstruction Awareness

28 mai

General Overview

If you have just been diagnosed with breast cancer or are a survivor of breast cancer, this pamphlet is for you. Its purpose is to provide all the information on what we can do, as plastic surgeons, in matters of breast reconstruction, in order for you to make an educated choice in your battle plan.

Breast cancer reconstruction is widely accepted and performed. It has been proven to be oncologically safe and bring numerous psycho-social and even physical benefits.

Studies have shown that all postmastectomy patients have severe alteration in body image with adverse psychological consequences after being diagnosed with breast cancer 1.

In numerous countries, in an effort to raise awareness, the breast surgeon is mandated by law to inform patients about reconstruction. Breast cancer should not be considered a luxury such as aesthetic surgery. Unfortunately, to this day even private insurers refuse to cover breast reconstruction fees.

Plan early = Worry less

The reconstruction plan works best if you begin planning even before the mastectomy.

You should take notes, ask questions and expect answers, as well as decide on a plan A, B and C. After consulting your breast surgeon, you should consult a plastic surgeon.

An oncologist and a radiation therapy specialist will be needed later on. You should know that all breast cancer patients are presented to a tumor board including all of the specialists mentioned above where we discuss your case and decide on the next step in your therapy.

Before beginning your battle against cancer, you should be able to know about every step of the plan and anticipate every obstacle.

What type of mastectomy works best for you?

Basically, breast surgery is divided into breast conserving surgery (BCS) where part of the breast containing the tumor is removed with safety margins and total mastectomy where the whole breast is removed.

BCS is usually reconstructed with an oncoplastic reconstruction where the remaining breast tissues are mobilized to fill the defects left by the surgery. It is always followed by radiation therapy.

With the right indication, there is no survival difference between BCS + radiation and total mastectomy 2.

Total mastectomy can be further subdivided into Skin Sparing Mastectomy (SSM) where the nipple and areola are removed with the whole breast, and Nipple Sparing Mastectomy (NSM) where the nipple and areola are spared and only breast tissue is removed.

Obviously, when oncologically safe, the best reconstruction is accomplished with the breast’s native skin and areola. This is decided by your breast surgeon in accordance with the tumor board’s recommendations.

To reconstruct or not to reconstruct?

Extensive literature clearly supports the advantages and oncologic safety of reconstruction after mastectomy 3–5. It has been shown to be effective in restoring body image, improving quality of life, and reducing the psychological distress of mastectomy. Moreover, the quality of life in patients who receive any kind of breast reconstruction is significantly higher than that of patients who do not undergo breast reconstruction, and there is no significant difference in the overall survival rates of the two groups 6–9. Another study found the satisfaction of patients with the operated breast, reconstructed or not, is more important in quality of life than whether the breast was reconstructed or not 10.

Reconstruct now or later?

Immediate reconstruction helps immediately restore body image and self-confidence, without an intervening period of no breast mound. Several studies showed its oncologic safety, meaning that the risk of local recurrence or metastasis, as well as postoperative complications is the same as the general operated breast cancer population 3–5.

Delayed reconstruction is used when postoperatively, the patient only wants to worry about cancer treatment. Also, your plastic surgeon might deem immediate reconstruction non feasible when the breast skin left after mastectomy is too thin or fragile and could have a higher risk of wound complications or when there is a suspicion of incomplete resection.

Immediate reconstruction. What are your options?

Basically, immediate breast cancer reconstruction can be divided into three treatment options: Immediate implant reconstruction, Delayed immediate implant reconstruction and immediate autologous reconstruction.

Immediate implant reconstruction:

A breast implant can be inserted into the pocket created by the breast surgeon after mastectomy (sometimes under the pectoralis major muscle). It is tailored to the contralateral side in case of a unilateral reconstruction. In bilateral reconstructions, implant selection depends on patient wishes and surgical feasibility.

A breast tissue expander can also be used if there is insufficient breast skin to close over an implant. An expander is a deflated breast implant with a metallic valve through which it can be filled weekly. This acts as a progressive tissue stretcher/skin maker. The expander is exchanged for a permanent breast implant 6 weeks after the desired breast size is attained.

Implant reconstruction is best used in thin patients with a low volume requirement, in patients needing bilateral breast reconstruction, and in patients not willing or able to undergo lengthy surgery.

Delayed Immediate implant reconstruction:

This is a new concept, devised in order to keep the breast tissues from scarring into a block that would be difficult to operate on at a later stage, and preserve the breast tissue envelope. It is used when the risk of postmastectomy radiation therapy (PMRT) is high or uncertain (large tumors > 5 cm, locally advanced disease, postoperative positive margins, node positive disease, high risk features on pathology).

A breast tissue expander is inserted into the breast pocket under the pectoralis major and serratus anterior muscles and filled to a safe volume.

If no PMRT is required, the expander can be filled weekly or exchanged for an implant such as it is done in immediate implant reconstruction, or it is removed and exchanged for a flap (autologous reconstruction) 2 weeks after mastectomy to prevent a delay in the initiation of chemotherapy.

If PMRT is required, the expander is deflated 4-6 weeks after the completion of chemotherapy, PMRT is done for 6 weeks, the skin is left to rest for 2-4 weeks, and we begin to weekly reinflate the expander, and definitive breast reconstruction is done at 12 weeks (preferably autologous reconstruction)

Immediate Autologous reconstruction:

The most natural feel and volume can be achieved with your own tissues. Skin and fat can be taken from several locations from your body and transferred to your breast.

When it comes to radiated breasts, autologous flaps appear to have superior outcomes. Postoperative complications such as fibrosis, contracture, infection, fat necrosis, and reoperation were lower with autologous flap reconstruction than with implant reconstruction 11.

The DIEP flap (Deep Inferior Epigastric artery Perforator) is the most widely performed autologous breast reconstruction. Several small vessels called perforators are found around your umbilicus, they travel through your muscle and fat, nourishing the abdominal skin. This is called a free flap, which is a block of skin and fat that is taken around this perforator, cut freely from your body, and transferred to the breast by microscopically connected to vessels on your chest. The resulting scar is similar (although sometimes higher, depending on skin laxity) to a tummy tuck scar, and is usually well hidden under a bikini. It is indicated in motivated women with abdominal laxity without any significant scars on the abdominal walls, as well as a high volume requirement.

In women without abdominal skin laxity and lower volume requirements, the PAP flap (Profunda Artery Perforator) can be used. The skin and fat of the upper inner thigh are taken around a perforator and transferred to the chest as a free flap.

Finally, the Latissimus Dorsi flap can be used as a salvage option after a failed free flap or as a primary option in patients who do not wish to undergo lengthy surgery (free flaps take usually 6-8 hours in the operating room). This is a large back muscle that can be rotated in the breast pocket along with skin and fat from the back area. This will leave a horizontal scar that can be camouflaged in the bra area.

Delayed reconstruction: What are your options?

Delayed reconstruction was considered to be safer in high-risk disease but is nowadays widely replaced by delayed immediate reconstruction in this setting.

Delayed implant reconstruction is similar to immediate implant reconstruction. It almost always requires insertion of a breast tissue expander as the breast tissues are scarred together and cannot accommodate the volume of a permanent implant (especially after radiation therapy). Delayed autologous reconstruction is also similar to immediate autologous reconstruction.

It is only indicated in women with pressing medical comorbidities, obesity, smoking, inflammatory breast cancer, and for patients distressed regarding their breast cancer diagnosis who are not ready to make treatment decisions or do not wish to focus on breast reconstruction in addition to chemotherapy and radiation therapy 12,13.

Nipple-Areolar reconstruction: How do we do it?

A breast reconstruction is never complete without a nipple areolar reconstruction. It usually constitutes the final stage of reconstruction and transforms the breast mound to a natural appearing breast. Patient satisfaction highly correlates with the presence of a nipple and areola 14. This procedure is deferred after the completion of breast reconstruction steps as the breast mound settles down and its final shape is attained, as nipple position is the most important detail.

Nipple-areolar reconstruction is best accomplished using a local flap (rearrangement of skin) to achieve the three-dimensional structure of the nipple or by a contralateral nipple graft (if the other nipple is large enough). The areola can be created using medical tattooing 2 months after the nipple reconstruction and can require annual touch-ups, or a skin graft from the inner thigh can be used simultaneously with the nipple reconstruction.

Additional procedures: What can we do?

Any breast reconstruction includes a minimum of 2-3 procedures, this number can go as high as 6 depending on the case.

This can be done to achieve symmetry in the contralateral breast (breast implant or reduction), fat grafting to give more volume, cover up imperfections, or improve the skin quality and texture in the setting of radiation therapy, and nipple-areola reconstruction using a rearrangement of tissues (for volume) and medical tattoo (for color match).

For example, for an immediate implant or breast tissue expander reconstruction: