Breast Reconstruction
Breast cancer currently affects approximately one in eight women in the United States over the course of their lifetimes. In 2010, an estimated 207,090 new cases of invasive breast cancer are expected to be diagnosed in women in the U.S., along with 54,010 new cases of non-invasive (in situ) breast cancer.
The diagnosis of breast cancer can evoke significant psychological distress upon a woman. Concerns over the extent of the disease as well as the consequences of treatment can leave a patient overwhelmed.
At Lincoln Aesthetic Surgical Institute, we work with you and your other medical providers to help ease your concerns.
Treatment Options for Breast Cancer:
The treatment of breast cancer involves several variables and no one patient is the same. Factors including your age, co-morbid medical conditions, tumor size, involvement of lymph nodes, as well as certain pathologic features all play a role in determining your best treatment options.
Surgery is the main stay in treatment of breast cancer. Options generally involve either breast conservative therapy (i.e., a lumpectomy) or total mastectomy. With breast conservative therapy, a tumor along with a healthy rim of normal breast tissue is removed. This offers the advantage of a potential nonexistent or small breast deformity after the procedure, however in order to reduce the risk of developing recurrent or new cancer within the same breast, radiation therapy is usually needed to the remaining breast tissue. With a mastectomy, the entire breast tissue is removed. This usually includes the nipple/areola, as this tissue also harbors breast tissue. With a mastectomy, patients often eliminate the need for post-operative radiation therapy. The decision on whether a mastectomy versus breast conservative therapy is best for you is made in conjunction with the surgical oncologist. If a mastectomy is desired, consideration should be made on whether to perform bilateral mastectomies.
Whether or not you choose a lumpectomy or mastectomy, sampling of the lymph nodes within the armpit (axilla) may be needed at the time of your surgery. This is important to help to determine the extent or stage of disease, and helps guide further treatment including chemotherapy, radiation, and hormonal therapy.
Depending on the stage of your disease as well as your age and menopausal status, chemotherapy also may be recommended. This is usually performed following surgery, however, in some patients with more locally advanced cancer, chemotherapy may be needed prior to surgery.
Hormonal therapy is also commonly needed following surgery. Breast cancer often contains receptors for the hormones estrogen and progesterone. In some tumors, these hormones act as signals which tell the tumor to grow. Medications including tamoxifen as well as the newer class selective estrogen receptor modulators (SERMs) and aromatase inhibitors may also be recommended in order to reduce your chance of recurrent disease. In addition, depending on your specific tumor characteristics, your medical oncologist may also recommend certain targeted therapies such as the medication Herceptin to combat your cancer.
Radiation therapy is routinely used as an adjunct to breast conservative therapy in order to lessen the likelihood of recurrent cancer within the same breast following a lumpectomy. For a patient who undergoes a mastectomy, radiation is usually not necessary as all of the breast tissue is removed. Nevertheless, as the treatment of breast cancer evolves, there are certain instances where radiation therapy may be necessary following mastectomy. Radiation may be recommended if the tumor size is large (greater than four to five cm in diameter) or if four or more lymph nodes within the axilla are found to have cancer within them at the time of surgery.
Breast Reconstruction
For women with breast cancer, the result or expected effects of surgery can lead to a severely altered self body image. A woman’s breasts are central to her femininity, and the loss of one or both breasts due to surgery can be profound.
At Lincoln Aesthetic Surgical Institute, we understand your concerns. For women who have undergone a prior mastectomy, or are scheduled to have the procedure, we can help you restore your self-confidence and body image. For women who have undergone a prior lumpectomy and are left with a distorted breast, we can help shape the breast back to a more aesthetically pleasing form.
Breast reconstruction may be performed either at the time of a mastectomy (i.e., immediate reconstruction) or later after the completion of your treatment of breast cancer (i.e., delayed reconstruction). The timing of the reconstruction varies. In general, candidates for immediate reconstruction are those with clinically early stage disease. This includes patients with smaller tumors and no evidence of palpably enlarged lymph nodes within the armpit or axilla. There are advantages and disadvantages to both techniques. With immediate reconstruction of the breast(s), the reconstructive process begins at the time of the mastectomy, avoiding the potential need for an additional surgical procedure. Further, with immediate reconstruction following a mastectomy, the majority of the natural skin of the breast is preserved, decreasing the need to obtain from other parts of the body as is commonly needed with delayed reconstruction. In those patients who do not undergo immediate reconstruction, the remaining skin over the breast will often contract down to lie flush with the chest wall. Finally, immediate reconstruction allows the woman to feel more “whole” sooner after the mastectomy. Disadvantages of immediate reconstruction include the possibility of finding more extended disease at the time of mastectomy than was anticipated pre-operatively resulting in the need for potential adjuvant therapies including radiation. Advantages of delayed reconstruction include allowing full treatment of the cancer without potential interruptions.
In general, there are two main types of breast reconstruction – implant-based reconstruction and reconstruction using your own body tissue (i.e., autologous reconstruction).
Implant Based Breast Reconstruction
Implant based reconstruction involves placement of an initial breast tissue expander at the time of the mastectomy. After the breast surgeon has removed the entire breast tissue underneath the skin overlying the breast, Dr. Mitchell then places a temporary tissue expander device within a space created below the pectoralis major muscle within the chest. Placement underneath the muscle helps to reduce the potential of rippling after the permanent implant is placed by providing more soft tissue coverage over the implant. The purpose of the tissue expander is to create a space for the eventual placement of a permanent implant. A tissue expander is basically a balloon with a small port located within it. Some may ask why this step is necessary. The reason for the initial placement of the temporary expander is that the skin overlying the breast is usually supplied with blood vessels that run through the breast tissue itself. When the entire breast tissue is removed, so are the main blood vessels supplying the remaining skin. Blood supplying the remaining skin over the breasts now comes from a network of vessels located within the dermis of the remaining skin. If a large permanent implant were inserted at the time of the mastectomy, this may produce internal pressure of the skin, disrupting the flow of blood and potentially leading to necrosis of the skin overlying the breast. The tissue expander allows Dr. Mitchell to place some fluid within it to keep the skin from contracting down at the time of the mastectomy. Then, in the office setting, Dr. Mitchell can add more fluid slowly to the tissue expander to gradually stretch the remaining skin over the breast without compromising its blood supply.
At the time of the placement of the tissue expander, Dr. Mitchell often uses a product called Alloderm. Alloderm is a biological product made of human skin processed to remove all living cells and antigens within it. In essence, it leaves all of the good products of the skin such as collagen and elastin. With Alloderm, the product acts as a scaffold, and the patient’s own living cells grow into the product and revascularize it. The purpose of the Alloderm is three-fold: 1) The pectoralis muscle helps to provide coverage over the upper and medial portion of the tissue expander, however it is not large enough to cover the entire expander. Alloderm is generally sewn in along the fold below the breast and attached to the muscle above to provide complete coverage over the implant. It acts as a sling in order to help keep the initial tissue expander in the proper place within the breast. 2) The Alloderm provides an extra layer of tissue between the implant and the thin skin in order to help reduce palpability and rippling that can occur. 3) Because Alloderm is revascularized, it provides an extra layer of protection if problems arise with healing of the incision over the breast. Before Alloderm, if the incision broke down and the implant was visible within the wound, then bacteria were present on the implant and the implant had to be removed in order to completely clear the infection. With Alloderm, many implants can now be potentially salvaged should wound healing problems arise.
At the time of the mastectomy, one or two drains may be needed in order to remove fluid that may build up between the remaining breast skin and the underlying muscle and Alloderm. The drains are necessary and remain in place until tyeh have are having less than 30 ccs or milliliters output per day. This typically takes between one to two weeks.
After the drains are removed and the incision has healed appropriately, in-office expansion of the tissue expander occurs. Using a magnet, Dr. Mitchell localizes the port to the tissue expand below the breast skin. A needle is inserted into the tissue expander through the skin overlying the expander and fluid is added to stretch the breast skin. The procedure causes minimal discomfort, as the skin overlying the breast is generally numb due to loss of sensory input following the removal of the breast tissue. Patients often feel some pressure from the expanded implant which generally eases as the skin relaxes and stretches. Patients typically receive the expansion every one to two weeks until the desired volume has been obtained. Once the desired breast volume is acheived, usually about one month, arrangements are made to place the final permanent breast implant. This is performed as an outpatient procedure.
Options regarding the type of permanent implant include either a silicone or saline breast implant. Both implants consist of a thin shell made of a silicone elastamer. These come in a variety of shapes and sizes. Dr. Mitchell will help choose the implant most appropriate for you. With all breast implants, there are certain long-term risks associated with the devices. The first is the risk of potential rupture of the shell. In general, the older the implant, the increased risk of rupture with time. Diagnosing a ruptured saline breast implant is relatively straight forward. The saline used to fill the implant is the same saline used as intravenous fluid at the time of your operation. If a saline implant leaks, the breast may suddenly decrease in size as the saline leaks out of the implant and is absorbed by your body. With silicone breast implants, detecting a leak is more difficult. First, the silicone used in the current generation of breast implants is a gel. It has certain cohesive properties to it which make the silicone molecules stick together. Also, silicone is non-absorbable. As such, the breast does not usually change in size. Symptoms of a potential leak are subtle and may be as mild as a slight irregularity in the way the implants feel over time. Often, even on physical examination, it is difficult to discern if an implant is ruptured. At present, if a silicone implant is suspected of being ruptured, a MRI of the breast may be needed. This currently is the most sensitive test for detecting a leakage within a silicone implant. It is approximately eighty to ninety percent effective for detecting a leakage. At present, the current FDA recommendations for assessing a leakage for silicone breast implants includes a MRI three years after placement, then every two years. If a leakage is diagnosed within either a silicone or saline breast implant, surgery is recommended to remove the leaking implant and replace it with a new implant.
Another risk inherent to all breast implants is the development of a capsular contracture. With all foreign objects placed with the human body, the body reacts by forming scar tissue around the object. We refer to a capsule as the scar tissue that surrounds all breast implants, whether placed as part of breast reconstruction or for augmentation purposes only. In some patients, this capsule may cause problems over time – a condition we refer to as a capsular contracture. The first sign of a capsular contracture is that the implant begins to feel firmer than normal. In some women with breast implants, the capsular contracture can progress, causing the implant to shift locations from where it was initially placed. Finally, some women can develop pain in the breast due to the capsule. The development of a capsular contracture is best treated with surgery to release either part or all of the offending capsule. The implant also may need to be exchanged for a newer one at that time.
There are advantages and disadvantages to both silicone and saline implants, and the choice for final implant is ultimately yours. Silicone implants offer the most natural feel. Current evidence regarding silicone implants has shown a decreased risk of rupture as compared to saline implants. Unfortunately, leakage is difficult to detect and may require a MRI to diagnose. With saline implantsa leak is easy to deteck and the saline is harmless. With past silicone implants, there was a concern over a potential link between the silicone used to fill the implants and the development of potential connective tissue disorders (CTD). At present, no link has ever been shown between silicone breast implants and connective tissue disorders in the United States or worldwide. Nevertheless, some patients still harbor reservations over the silicone implants and choose saline.
Autologous Based Breast Reconstruction
Autologous based breast reconstruction refers to using the patient’s own tissue to help reconstruct the breast. This generally involves transferring from another part of the body to reconstruct the breast. The abdomen is most common site of excess tissue used to reconstruct the breast.
With all flaps of tissue taken from other parts of the body and used to reconstruct a breast, one key is universal. Each flap consists of tissue supplied by a certain blood source. Successful flaps involve transferring the tissue in a way that the blood supply to that living tissue is preserved so that the flap will thrive.
The Transverse Rectus Abdominus Myocutaneous Flap (TRAM flap)
The Transverse Rectus Abdominus Myocutaneous Flap or TRAM flap is the most commonly used autologous method of reconstructing a breast following mastectomy. It has a proven track record and is generally extremely reliable. There are several variations of the flap, however, in essence, excess abdominal skin and fat are transferred from the lower abdomen to reconstruct the breast mound. The skin and fat that are transferred are identical to the skin and fat typically removed during an abdominoplasty or tummy tuck procedure. This offers the patient a smoother, flatter mid-section while at the same time reconstructing the breast. The skin and fat overlying the lower abdomen is supplied by a blood vessel called the epigastric artery. This artery passes below the rib cage and underneath the rectus abdominus muscles within our abdominal wall. The vessel joins an artery called the iliac artery inferiorly. Beneath the muscle, little branches of the vessel called perforators pierce the overlying muscle and supply the blood to the skin and fat of the lower abdomen. There are several techniques for transferring this tissue with its blood supply. The most common technique involves dividing the most lower portion of the vessel before it joins the iliac artery. From here, the skin, fat, rectus abdominus muscle, and underlying epigastric artery are lifted up and passed through a tunnel under the skin up into the breast area created by the mastectomy. The blood supply to this skin and fat is now based upon the upper portion of the epigastric artery. This is referred to as a “pedicled” TRAM flap.
Other techniques to transfer the excess lower abdominal tissue generally involve a process called “free tissue transfer” (i.e., free flap). These techniques have were developed in order to help eliminate or reduce potential side effects associated with the traditional pedicled TRAM flap. One concern with all potential flaps is blood supply. We know through anatomical dissections that the epigastric artery is simply not a straight pipe carrying blood uniformly beneath the muscle. The upper or superior portion of the blood vessel has a smaller diameter than the lower or inferior portion of the artery. With all flaps, the better its blood supply, the less risk of problems. Because the diameter of the blood vessel is larger in the inferior portion of the vessel, more blood is supplied to the overlying skin and fat from the vessel. Unfortunately, if the upper portion of the blood vessel is divided, then the skin and fat cannot be rotated into the breast area without first completely dividing the lower epigastric artery and using this end to supply the flap. With a free TRAM, the blood vessel is divided in both the upper portion of the vessel as well as where it joins the iliac artery. Next, a recipient blood vessel is identified in the chest near the breast area and the larger diameter lower portion of the blood vessel is sewn into the recipient vessel in order to restore blood flow to the flap. This in theory improves blood supply to the flap. Further variations of the free TRAM including the muscle-sparing approach as well as the Deep Inferior Epigastric Perforator (DIEP) flap all seek to limit the potential loss of natural muscle within the abdominal wall while preserving blood supply to the transferred skin and fat. In essence, these procedures add to the complexity of the case and increase time in surgery.
In general, there are several factors which are important in determining if use of the abdominal tissue is appropriate for breast reconstruction. First, previous abdominal surgeries may affect or influence the safety of these procedures. Upper abdominal incisions such as incisions resulting from an open removal of the gallbladder may affect potential healing of the abdominal skin after closure. In addition, prior lower abdominal surgeries influence its safety. For those with a prior abdominoplasty procedure, the normal perforators supplying the overlying skin and fat to the abdominal tissue have been divided and these patients are not candidates for a TRAM. Second, ability to restore adequate symmetry between the native normal breast and reconstructed breast depends upon the amount of available tissue in your lower abdomen. Some women simply do not have enough excess abdominal tissue to match the size needed to approximate the normal breast. Conversely, some women have too much excess abdominal tissue which raises concerns over maintaining a good blood supply to the flap. In overweight patients who are not candidates for implant based reconstruction, the more invasive free TRAM procedures are generally more indicated.
There are many factors in deciding whether implant based versus autologous reconstruction is best for you. With implant based reconstruction, the additional procedure typically takes an additional two to three hours to complete following the mastectomy, depending on whether it is unilateral or bilateral. With the use of the TRAM flap, additional operative time can be from up to six to twelve hours depending on whether or not it is performed as a pedicled flap versus free flap. With the use of implants, pain is limited post-operatively to the chest. The use of the abdominal tissue adds a second site at the abdomen. In general, it may take up to two weeks to recover from placement of initial tissue expanders. The TRAM flap procedures take approximately six weeks of recovery. With the TRAM flap procedures, the need for a second operative procedure and anesthetic is avoided to exchange out the temporary tissue expanders for permanent breast implants. Thus, restoration of the breast occurs sooner. Autologous reconstruction offers the most natural feel, as it is your own skin and fat that you are using to replace the breast tissue. Further, long-term risks such as implant leakage as well as capsular contractures necessitating further surgeries are avoided with the use of autologous tissue. With implant based reconstruction, scars are limited to your breast only. With the use of a TRAM flap, you will have scar that runs low on the abdominal wall from hip bone to hip bone, albeit with an improved abdominal contour. Wound healing problems can occur with either procedure. In both procedures, potential necrosis of the breast skin flaps can occur with over thinning of the mastectomy skin flaps during removal. Bleeding and infections are also possible. With a TRAM flap procedure, additional wound healing concerns are possible. Potential necrosis of the abdominal skin after closure is possible, as well as potential disruption in the blood supply to the umbilicus or belly button. Furthermore, patients who undergo a TRAM flap procedure can also develop potential abdominal wall hernias or weaknesses in the abdominal wall that may produce a bulge. Potential concerns with them include disruption in the blood flow causing part or potentially all of the tissue to die.
Other Autologous Based Flaps for Breast Reconstruction
Although the use of the excess abdominal tissue remains the mainstay in autologous reconstruction, other flaps of tissue are available. This includes the use of the gluteal tissue (i.e., the Superior or Inferior Gluteal Artery Free Flaps) as well as the latissimus dorsi muscle from the back. In general, these are used as secondary flaps in cases in which autologous reconstruction is indicated or preferred, however the abdominal tissue is not available. The latissimus dorsi muscle deserves special consideration in cases of prior radiation to a breast from previous breast cancer. Most often, this occurs when women present with a history of recurrent cancer within a breast treated with lumpectomy and radiation or in women who underwent a prior lumpectomy and radiation and developed a cancer within the previous non-affected side. Often times, these women may elect to undergo bilateral mastectomies and desire implant based reconstruction. For these patients, the effects of prior radiation to a breast inhibits wound healing. Using the latissumus dorsi muscle with its reliant blood supply assists in avoiding wound healing problems which can occur if a tissue expander or implant is used alone.
Symmetry in Breast Reconstruction
Whether a unilateral or bilateral procedure is desired, Dr. Mitchell’s ultimate goal is to produce a breast(s) with an aesthetically pleasing form that matches the best between the two sides. In unilateral cases, this may often necessitate the need for a procedure on the contralateral side in order to restore symmetry. In bilateral cases, symmetry between the reconstructed breasts is often easier to achieve. Dr. Mitchell will discuss this with you in detail during your evaluation and subsequent visits.
Final Touches
Ssome women are happy to have a breast mound that in a bra gives them adequate shape and form. Some, however, also desire to undergo reconstruction of both the nipple and areola which was removed during the mastectomy. Nipple reconstruction is typically performed within the office. The procedure takes approximately one hour. In this procedure, Dr. Mitchell rearranges the skin on the breast in order to recreate a three-dimensional nipple that sticks up off the breast. This is typically performed one month following the placement of the permanent silicone implants or after reconstruction using autologous tissue. After the nipple reconstruction has healed properly, a tattoo is applied within the office to create the areola. This is typically one month after the nipple is recreated.