The Female Breast plays an important role in a woman's life. Not only as an organ that helps sustain and nourish a newborn, it is also an organ of sexual identity, a major component of a woman's self image. A normal breast gives a woman psychological sense of femininity and sexuality. Abnormal breast structure from a congenital deformity or acquired due to cancer, burn, or trauma may have a negative impact on self esteem, adversely affects the sense of well-being, and generally decrease the quality of life.
Breast Cancer is the 2nd most frequently occurring cancer in the US. Women have a 12.5% lifetime risk of developing breast cancer and a 3.5% lifetime risk of dying from it. It is the most common reason for reconstructive breast surgery, which is an essential component in physical and psychological recovery.
High risk for development of breast cancer include:
- a family history in 1st and 2nd degree relatives
- BRCA 1 or BRCA 2 gene (Lifetime risk 60-90%),
- two or more relatives with breast or ovarian cancer,
- breast cancer before age 50 in a relative
- Both breast and ovarian cancer in a relative
Increased Risk for development of breast cancer is found in:
- Patients first diagnosed younger than age 40 will have an increased risk in the opposite breast
- Family History of Breast or ovarian cancer and Ashkenazi Jewish heritage
- Male relatives with breast cancer
- Atypical hyperplasia
- Fibrocystic breast disease
- invasive lobular Ca
- diffuse microcalcifications on mammogram
Breast Cancer Surgery
Types of treatments available for patients with breast cancer depend on the stage and the type of cancer. Lumpectomy, Simple Mastectomy, Modified Radical Mastectomy, or a Radical Mastecomy may be indicated for removal of all cancerous tissue from the breast. Additional lymph node procedures may be required to evaluate and treat lymph node involvement.
Most early breast cancers may be treated with a lumpectomy, also called breast conservation therapy. This approach to cancer treatment removes the cancerous growth and a margin of normal breast tissue. The remaining breast tissue may be treated with radiation therapy and lymph nodes may be sampled. Upon completion of the cancer treatment, 20-30 % of patients will have residual breast deformities which are a direct result of the type of resection, radiation, breast size and shape, and location of the tumor.
Mastectomies may be partial (removing a large part of the breast), simple (all breast tissue removed), Modified Radical Mastecomy (all breast tissue and most of the lymph nodes in the axilla), or Radical Mastectomy (all breast tissue, pectoral muscles, and all lymph nodes). The extent of Mastectomy is determined by the extent of the tumor. Most patients who require a mastectomy have either a simple or a modified radical mastectomy. These may be indicated for malignant disease (cancer), premalignant, benign disease (non cancerous tumors), prophylactic (to decrease the likelihood of breast cancer for high risk patients). A skin sparing mastectomy may be performed to improve the reconstructive results, some surgeons also perform nipple sparing mastectomies.
Some patients may elect to have a prophylactic mastectomy even without a cancer diagnosis. The results of prophylacticly reconstructed breast are usually superior to breasts that are treated for cancer.
Patients who are candidates for prophylactic mastectomy are
- those with BRCA 1 or BRCA2 gene mutations,
- family history of breast cancer (family cancer syndrome)
- multiple first-degree relatives and/or
- multiple successive generations of family members with breast and/or ovarian cancer,
- bilateral and/or pre-menopausal and/or male breast cancer
- Atypical ductal or lobular hyperplasia, or lobular carcinoma in situ confirmed on biopsy
Reconstruction plans are usually discussed between the plastic surgeon and the patient prior to the planned cancer treatment. The reconstructive options are discussed and the patient chooses an appropriate reconstruction method. The goal of reconstruction is to correct underlying deficiencies and recreated an aesthetically pleasing breast shape. Achieve bilateral symmetry with breast reduction, a lift (mastopexy), or augmentation (enlargement) of the other breast. The reconstruction is usually performed with the use of a tissue expander, an implant, or an autologous reconstruction with a flap of skin and muscle from the abdomen, back, or buttocks.
Techniques of reconstruction
Tissue Expander/Implant reconstruction involves the placement of a silicone shell anatomically shaped tissue expander which is filled over time to the desired breast volume. When the adequate pocket is created it is replaced with a soft silicone gel or a saline filled breast implant. A nipple is then created and tattooed to match the color of a normal areola. This process begins immediately after the mastectomy or after completion of breast cancer treatment. The process of reconstruction may take up to a year. Weekly office visits may be necessary while the expander is filled. The Benefits of an expander/implant reconstruction are shorter initial procedure, faster recovery, no additional surgical incisions. The disadvantages are that the breast "looks like an implant", which may be a desirable look in some women. A lift or an implant may be needed on the opposite breast for symmetry. Weekly visits for expansion may be required. Foreign body complications are possible as with any implant, such as infection, rupture, etc.
Latissimus Dorsi flap w/implant type of reconstruction uses the back muscle and skin brought to the front to create breast shape with breast volume added with an implant. This is a one stage operation with additional surgery required to create the nipple. The patient benefits from a natural appearing breast with incisions hidden around the back. The disadvantages are a longer surgical procedure, a longer recovery, additional scar on the back, implant related complications.
TRAM flap reconstruction is performed using abdominal skin, fat, muscle transplanted to the breast. No implant is used and the tissue may be performed to reconstruct both breasts. The benefits are a single stage procedure with a natural feeling and a normal appearing breast, no need for a breast implant, and an added tummy tuck. The disadvantages are a longer surgery, a longer recovery, abdominal weakness, high risk of complications in obese (BMI>35) and smokers
Pedicle TRAM is attached to the muscle and a blood vessel. The muscle is lifted and tunneled into the chest. Free TRAM or DIEP flaps involve no tunneling, a microscopic connection of the vessels of the transferred tissue to the chest. It is a long procedure that requires several days of hospitalization. The success of the procedure depends on the ability to provide blood flow into the transferred tissue.
Radiation and Reconstruction
Radiation after reconstruction damages the reconstructed breast so definitive reconstruction is usually delayed until the end of radiation therapy. Radiation therapy reduces risk of recurrence and improves survival. Radiation is indicated after Mastectomy for a large tumor (>5 cm) or skin involvement (T3, T4), or 4 or more axillary lymph nodes involved. It is also indicated after Breast Conserving Therapy (Lumpectomy).
Patients who may need radiation after their surgical treatment are usually patients
- over the age of 50,
- have lymphovascular invasion of the tumor,
- have tumor larger than 2 cm (T2)
- have a positive Sentinel node,
- have close or involved margins of tumor excision
- received preoperative chemotherapy
- Immediate vs. Delayed Reconstruction
When considering the timing of cancer reconstruction, some patients may elect to have the reconstruction at the same time as the cancer surgery (immediate), or after completion of their cancer treatment (delayed). Immediate reconstruction is associated with improved aesthetic outcomes, has not been shown to increase local recurrence or mask recurrent tumor detection. It does require additional time during the cancer surgery and may not be an option for some patients.
Immediate Reconstruction may be recommended for patients who have a clinical Stage I or Stage II with a low risk for Radiation. These patients can benefit from better aesthetic outcome and a psychological benefit of awakening with a reconstructed breast. They have an easier time adjusting to their daily routine and are able to Exercise, swim, and wear regular clothes soon after surgery.
Delayed Reconstruction is performed in cases where the cancer treatment may require additional therapy or radiation. After the mastectomy is completed and skin closed, the patient may wear an external prosthesis while she continues her treatment. After radiation patient's own tissues are used for reconstruction. Sometimes a delayed-immediate reconstruction may be performed by inserting a tissue expander immediately after the mastectomy, waiting until completion of cancer treatment, then starting the reconstructive process by slowly expanding the breast to the appropriate size.
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