Overview By Jeffrey S. Rosenthal, M.D.
Written BACUP (England)
Breast Cancer Awareness
Although the major incidence of breast cancer is found in women, there are also a significant number of males who are afflicted with this life-altering problem. We have made enormous strides in the detection and treatment of breast cancer but have yet to offer freedom from this physical and emotional malady.
Self-examination, followed by routine physician evaluation and mammography allow timely recognition, treatment and cure. Your active participation in your own health care is of paramount importance. Therapies have become more effective and easier to tolerate. Deforming surgeries, performed many years ago, have been replaced by simpler yet effective modalities for removing the cancer cells. And for those women who choose a mastectomy there are a host of reconstructive procedures available to reshape this very vital area of the body. Hope is the common thread that weaves us together, as we fight against and treat breast cancer. The Norma F. Pfriem Breast Care Center, whose symbol is the rose of hope, at Bridgeport Hospital and in Fairfield, is an organization dedicated to quality of life. It may be ironic to celebrate this month with the enthusiasm normally given to a holiday, but the progress that has been made and will continue to be made in the detection and cure of breast cancer not only gives us all hope for the future, but tears of joy for those women and men who will be able to live normal, productive lives. Wishing health and happiness for the years ahead!
Common Reconstructive Procedures
Your suitability for breast reconstruction will be influenced by a host of factors. The type of tumor, position of the tumor in the breast, and the extent of the cancer will all be important factors in determining the amount of breast tissue left behind after the mastectomy. Operations that spare the chest (pectoralis) muscle, such as simple or modified mastectomies, usually leave behind ample amounts of skin and fat. This allows for an easier reconstruction than those operations that remove this muscle, such as a radical mastectomy. One of the main decisions to be made about breast reconstruction is whether to start the reconstruction simultaneously with the mastectomy (immediate reconstruction) or to delay the process for days, months, or even years (delayed breast reconstruction). In attempting to restore the breast to a shape and size compatible with your wishes and to match the opposite breast, surgeons start by considering the simplest procedure and progress to the more complicated ones as necessary. The controlling factors in this decision will be the amount and quality of the tissue left behind and the position and shape of the opposite breast.
Immediate Breast Reconstruction
With immediate reconstruction, the breast is removed and simultaneously reconstructed, or at least the beginnings of reconstruction will be carried out. This is done with either an inflatable medical balloon, which stretches the remaining available tissues, an internal permanent prosthesis (silicone gel or saline-filled implant) or with tissue transfer, which will be discussed later on. The main advantages of this technique, if available for you, are in the economy of time due to the reduction in the overall number of operations and its positive effect on your psychological outlook. The period of mourning and depression often experienced with mastectomy is markedly diminished once the breast restoration has begun. Likewise, the sense of loss associated with the mastectomy is shortened, and in many cases not experienced, as the substitute breast has already taken its place. The ability to get on with your life and potentially reduce the overall number of operations also makes this an attractive alternative. Additional procedures may follow to refine the breast shape, exchange implants, alter the opposite breast to give better symmetry, or to build a nipple and areola. Immediate reconstruction allows the plastic surgeon to work with the general surgeon in designing the best and most appropriately shaped breast at the time of the mastectomy.
As the reconstruction starts immediately after the mastectomy, this adds to the overall operating and anesthesia time. However, it does reduce the total number of operations. At the conclusion of these procedures your surgeons will be concerned not only with the healing of the mastectomy site, but also with the progress of the newly restored breast. Despite being a valuable option, not all women are good candidates for immediate reconstruction. Factors such as the size and extent of your breast cancer as well as your overall general health may make immediate reconstruction impractical.
Delayed Breast Reconstruction
The vast majority of breast reconstruction operations are performed months or even years after the mastectomy. This allows the skin and scar tissue to soften and become more malleable. During this time, a foam rubber external prosthesis may be worn inside your bra, if desired, to simulate the lost breast. Some women start to focus on other areas of life, no longer worrying about the removed breast or its significance and becoming quite comfortable with the external breast prosthesis. Others still do not feel whole, find the external prosthesis bothersome, and wish their breast to be restored. Unlike immediate reconstruction, a separate operation is planned to restore the breast mound. The procedure chosen will depend upon the quality of remaining chest tissues (skin, fat and muscle). The reconstructive choices are similar to that discussed for immediate reconstruction. Frequently this, too, will be staged, necessitating more than one operation to complete the total process. An advantage of the delay is that is allows the unsure woman time to think about her desire for reconstruction and focus on one procedure, rather than two. The disadvantages lie in having an additional operation apart from the mastectomy and waiting a number of months for the chest tissues to heal prior to the commencement of the restoration. With reconstruction, these women now pass through another stage in their overall treatment. The sense of bodily loss experienced with the mastectomy is diminished. This change is not just a physical alteration, as the new breast can bring psychological benefits by improving self-esteem body image. Women have reported that within months the reconstructed breast is accepted by the mind as being a natural, integral part of the body. If you have opted for a delayed breast reconstruction, now is the time to meet with your plastic surgeon to discuss which procedures will give you the best results. Many of these decisions will be based upon your physical examination which will determine the tissues that are available to enhance your new breast. Your expectations and wishes will be discussed and the major complications identified. The probable number of operations needed, recovery time, and the aspects of healing are also important parts of this discussion. This meeting should aim to prepare you for the surgery, both physically and mentally.
Submuscular Permanent Implant
Recreating the breast mound with a prosthesis (implant) is done by using a silicone envelope or bag. This contains gel or saline to give it shape, form and consistency. Implants come in a great many sizes and shapes, from the very small to the very large, to simulate the shape and weight of the removed breast. A specific type is chosen for each individual to produce a new breast and to match the opposite breast, when possible. During surgery, usually under a general anesthetic, the implant is placed beneath the chest muscles through the old mastectomy scar. This is done to protect the implant by providing additional soft tissue coverage. Quite often there is sufficient skin, fat and muscle left behind after the mastectomy to allow for this. The operation may take a few hours, but the hospital stay is brief, not usually requiring an overnight stay. A moderate amount of swelling and discoloration of the chest skin may be present for a few weeks. The final shape of the new mound will take some time – up to a year – before it becomes established. Some women have moderate discomfort from the operation for a few days which is usually relieved by pain medication. Generally, daily regimes can be quickly resumed (three weeks), except for the most vigorous athletic, work or household-related activities. Despite the best intentions of your doctors, complications cannot always be prevented. The most common complications include infection, bleeding, and scarring (capsule formation) around the newly-implanted prosthesis. This latter problem is not really a complication, but actually a natural means by which the body isolates man-made materials from body tissues. All implants cause some capsule formation, but only those that become very hard or pull on the implant and deform it require further surgery. Your doctor’s knowledge and awareness of these potential complications will help to prevent or control them, should they occur. In situations when there are inadequate amounts of skin and/or muscle to cover the implant, or when the surgeon attempts to match the opposite breast without operating upon it, another technique known as tissue expansion is utilized.
Through an incision in the skin, with delayed reconstruction or at the time of the mastectomy, an empty medical balloon is inserted beneath the chest muscles. A separate valve is attached to this balloon, which is placed beneath the chest skin and left undisturbed for a few weeks. The balloon is gradually inflated on a weekly or bi-weekly basis by passing a thin needle into the valve through which a sterile solution is injected. A mild pressure sensation may be felt during this process but the discomfort is brief and most women find it bearable. The gradual inflation of the balloon continues until it is over-inflated. This ensures that sufficient skin and muscle are available to match the larger, opposite breast, or allows the placement of a permanent implant in situations that might require the addition of other tissues, as in tissue transfer. Usually, this over-inflated state lasts from four to six months to allow for stretching of the tissues making up the mound before the second stage is attempted. Difficulty in wearing some clothing and certain physical limitations may be experienced during the expansion. Stage two involves the exchange of the expanded balloon for a permanent prosthesis similar to that described above for a simple submuscular reconstruction. This may be done under either local or general anesthetic. When necessary, the shape of the breast can be altered during this stage or the crease under the breast can be moved or reestablished. As with submuscular reconstruction, the hospital stay is limited. Activity levels are similar, and post-operative discomfort is usually not severe. The final shape of the breast mound will take many months to finish healing. In some cases, a permanent tissue expander is placed under the chest muscles. This type of implant requires that only the valve is removed (under local or general anesthetic) when the breast has achieved its desired shape and size. The drawbacks in using this prosthesis include the inability of the doctor to further refine the breast after the expansion has taken place either by altering the position of the prosthesis, repositioning the lower breast crease, or by substituting another implant. For those women who lack sufficient quantities of tissue despite tissue expansion, or those with poor quality tissues left after the mastectomy, healthy and plentiful skin, fat and muscle from other areas of the body can be transferred to the chest (tissue transfer).
Areas of the breast that could not be rebuilt by the previous methods can be filled in and/or recontoured using tissues from the upper back, abdomen or buttocks (tissue transfer). One of the tissue transfer procedures rotates the back (latissimus dorsi) muscle to the mastectomy site. The muscle carries the overlying fat and skin which is maneuvered into its new position on the upper chest. Still attached to its original blood supply, this blend of tissues can build up the hollows created by some radical mastectomy operations. This enables a prosthesis to be inserted, thus reconstructing the breast mound. The transferred portion of muscle and skin does not leave behind a significant deformity or weakness of the back. It does, however, add a scar to the upper back which some women may object to. The Transverse Rectus Abdominalflap (TRAM) is a blend of tissues taken from the abdomen or lower portion of the belly. This, too, relies on a blood supply still attached to the muscle. Portions of fat, muscle and skin are transferred to the upper chest leaving behind a long lower abdominal scar. Unlike the other procedures, a prosthesis is not always needed if this tissue transfer method is used, as the lower abdomen usually has more than ample amounts of fat and skin to build the breast mound. But do not be misled–more is not always better, and the fat in this region must be firm. Illnesses such as diabetes or vascular disease, and even having had prior operations on the abdomen, can prevent you from being a suitable candidate for this type of reconstruction. A third tissue transfer method uses portions of tissue from the buttocks. This tissue is reconnected to the chest blood supply using specialized microvascular techniques. This operation is chosen in only a few selected cases and is by no means the usual method for most reconstructions needing tissue transfer. All tissue transfer procedures are extensive operations and have a potentially higher complication risk. They are, however, extremely valuable, offering alternative methods of reconstruction, especially when simpler operations cannot be performed.
The Opposite Breast
Even though the breast mound is now restored, the reconstruction is not complete until it resembles the opposite breast. In well-endowed women who have a large or pendulous (droopy) opposite breast, obtaining breast symmetry is more difficult. To achieve a better match with the newly reconstructed breast, the surgeon may reduce the size of the opposite breast, elevate and reshape it (mastopexy), or in some cases insert a prosthesis to enlarge it (augmentation) Frequently, these operations can be performed in conjunction with either the nipple/areola reconstruction or during further refinements of the breast mound. After these procedures most women have a breast mound of appropriate size and shape and one which matches the opposite breast. Finally, the breast mound is transformed into a breast with the addition of a nipple and surrounding areola (darkened skin).
Nipple and Areola Reconstruction
Nipple and areola complex reconstruction is begun some months after the breast mound swelling has diminished and the shape of the breast has settled in. Premature placement of the nipple and areola will cause it to be either too high or too low. Under either general or local anesthetic, the new nipple is outlined on the peak of the breast mound. Using tissues from this area, the nipple is raised and fashioned. A skin graft is then taken from the upper, inner part of the thigh to form the surrounding doughnut, or areola, leaving behind a fairly inconspicuous thigh scar. The operation is usually performed on an out-patient basis and is accompanied by some tenderness in the thigh donor site for a week or two. The shape and projection of the new nipple and size of the areola are approximated to that of the opposite breast. However, the color of these structures may not be identical to the original. When this is a problem, tattooing of both the nipple and areola may produce more acceptable results. Sometimes simply tattooing the shape of a nipple and areola on the mound will give the illusion of having a completed reconstruction, although authentic projection is lacking. Alternatively, the nipple is rebuilt and the surrounding areola is tattooed without the use of a skin graft. A less frequently used method is taking part of the nipple from the opposite breast to fashion a nipple for the new breast. However, the other nipple may be too small to be used, and there is a risk that sensation in the existing nipple will be diminished. The nipple from the original breast containing the tumor can rarely be used on the reconstructed breast. There is concern that some cancer cells will be transferred to the newly formed breast. Besides, with the available technology, nipple and areola formation has been elevated to a refined art. Often, two operations can be combined so that the nipple and areola are fashioned simultaneously with the remolding of the opposite breast. The newly fashioned nipple and areola transforms the reconstructed breast to appear more like the original. Unfortunately, though, the new nipple and areola will not have the original nipple’s unique sensitivities. Sometimes a false nipple can be used. These are made of soft plastic and simply adhere to the peak of the new breast. The false nipple will give an authentic projection under your clothes but, again, will not have the original nipple’s sensitivity nor will it be a permanent part of the breast. Nipple and areola formation is usually regarded as the final step which completes the reconstruction. Many women see this step as an ending to the struggles, physically and psychologically, which began with the initial diagnosis of breast cancer.
Questions For You and Your Plastic Surgeon
- 1. Does breast reconstruction interfere with other treatments (for example, chemotherapy or radiotherapy)? Both treatments can start fairly soon after the reconstruction; however, a slight delay may be necessary to allow the surgical wounds to start healing. Neither therapy is made less effective by the breast reconstruction. Radiotherapy for cancer prior to the breast reconstruction can affect the quality of the remaining skin. This may mean you will need a tissue transfer or tissue expansion operation. 2. Does the breast implant cause cancer? No. Medical research to date does not indicate that the implant causes cancer. 3. Will a recurrence of breast cancer be hidden after the breast is reconstructed? Normally, a local recurrence is first seen in the skin of the chest or the scar tissue left behind after the operation. Both of these areas can usually be seen or felt by your doctor during your follow-up examinations. Tissue transfer techniques may be a slight hindrance to physical examinations, as new skin and muscle are brought to the chest. Continued follow-up examinations by your physician will help to detect any changes. 4. Will my reconstructed breast feel normal? The gel or saline-filled implant matches the breast tissue that has been removed in weight, size, and consistency. The breast may remain soft or become firmer than the day it was restored due to capsule formation. Fat within tissues transferred may atrophy or become thinner causing a change in breast consistency. Keep in mind that breasts normally feel slightly different from side to side and from woman to woman. The new breast skin will feel normal to the touch, but some areas may feel numb. This is due to the mastectomy which removed or cut many of the nerves leading to the breast. Likewise, the new nipple and areola will look and feel normal to touch, but lack in most sensitivities. 5. Will the new breast look exactly like the one which was removed? No, it would be almost impossible to exactly copy the removed breast, but in many cases a close match can be obtained. 6. Is the recovery period lengthy or painful after reconstructive surgery? Depending upon the method used, various physical restrictions may be placed upon you. In general, no strenuous activities can be performed for at least three weeks from the time of the reconstruction to allow for initial healing to take place. Most women notice some stiffness and soreness in the operated areas, which is short-lived and usually relived by mild painkillers and local therapy (e.g., stretching). When combined with the mastectomy, the sub-muscular implant or tissue expansion reconstruction does not cause additional discomfort. Tissue transfer may cause additional discomfort in the donor site. Any further limitations, as well as individual information on what to expect after the operation, should be fully discussed with your surgeon before the reconstruction. 7. Do I need nipple and areola reconstruction? The final stages or finishing touches are entirely up to you. Many women are very satisfied to have just the breast mound, while others feel that the nipple/areola transforms the mound into a visual breast. There is no need to make this decision until the breast has settled in. 8. Is it always necessary to alter the opposite breast? Once again, you are an active participant in the decision to operate upon the other breast. In many instances uplifting, reducing, or enlarging this breast will allow for better symmetry between the two breasts. 9. With immediate reconstruction, is the hospital stay prolonged over that of the mastectomy alone? The recovery time is usually about the same; however, this will depend upon the type of reconstruction and if there are any associated complications. 10. Is the breast implant easily broken or damaged? Both the gel and saline-filled implants are surrounded by a strong silicone envelope. Under normal conditions they do not break. In the rare case of the implant leaking, rupturing or deflating, it may be substituted for a new one, usually without affecting the previous results. 11. Does capsule formation around the implant or expander have any effect on the reconstruction? Every man-made prosthesis is surrounded by scar tissue. This is the body’s way of isolating it. In some cases the scar tissue becomes overabundant causing the implant to feel harder than normal. If firmness or distortion of the breast becomes a problem, then the capsule can be surgically broken. 12. What is the most common type of breast reconstruction? The placement of an implant below the chest muscles after the mastectomy can give very pleasing results if there are adequate healthy tissues present. Individual selection for this and every other type of restoration procedure is critical. The options available for your particular situation should be thoroughly discussed before the reconstruction takes place. 13. Will I ever view the reconstructed breast as my own? Studies show that within months of the surgery women begin to assimilate their new breast into their own body image and soon thereafter feel it is their own. 14. Do my expectations about the breast reconstruction play a role in my satisfaction level? Definitely. Having a realistic idea of what to expect and knowing that the new breast will never be an exact duplicate of the one removed will assist in your satisfaction. 15. Are most women pleased with their results and if given the opportunity would they do it again? The vast majority say that they would undergo either immediate or delayed reconstruction again. Having the ability to wear normal clothing and not constantly being reminded of the cancer, by a flattened chest, has helped them adjust to the mastectomy. 16. Will I still be able to have a breast reconstruction if I did not consult a plastic surgeon before my mastectomy? The availability of breast reconstruction does not depend on the length of the interval between the mastectomy and your decision to have reconstruction. It is determined by your health and the quality and amount of tissues remaining after the mastectomy. A discussion with your surgeon beforehand, however, will enable planning of the breast reconstruction and possibly allow for immediate reconstruction. 17. Is breast reconstruction available from the National Health Service? Yes. If you have had or are going to have a mastectomy as cancer treatment, you are entitled to a free breast reconstruction from the National Health Service. Alternatively, if you prefer, there are surgeons who will do reconstructive surgery privately. One must be responsible for one’s own well being. I hope that I have assisted you in your quest and that you will continue to seek out those answers that will benefit your recovery.
Jeffrey S. Rosenthal, M.D.
Emeritus, Chief Section Plastic Surgery Bridgeport Hospital
Private Practice-Cosmetic Surgery
Diplomate, American Board of Plastic Surgery
Copyright© 1986 Written BACUP (England)
Modified 2008 Norma F. Pfriem B