22 Jun Breast Reconstruction
BY Dr Terrence Scamp
For many women the fear of deformity after treatment for breast cancer is almost as great as the fear for their life. Significant advances in breast reconstruction have been made in both techniques using implants and techniques using the tissues of the body.
But before you do anything, ask why? (Even if the answer is only ‘Why not!”).
If you ask a woman why one should reconstruct the breast she will probably look at you like you’ve got two heads. Aristotle was once asked if beauty was significant. His reply was “No one with eyes should have to ask such a question”. So one can ramble on about the breast being a symbol of womanhood and of its sexual significance but the reason I hear most commonly given to me by patients who’ve actually undergone breast reconstruction is that they simply don’t want to have to go through a major production every time they pull on a T-shirt. And if you live in our lovely warm climate and you’re forced to dress in heavy loose clothing then you do have a significant impediment. So really it’s all about making life easier.
One of the improvements in breast reconstruction has been a change in the mindset with regards to timing of breast reconstruction. In many cases reconstruction can be performed at the same time as the mastectomy itself. This of course saves an anaesthetic and means that the woman is able to leave the hospital with some degree of shape there which greatly facilitates dressing and helps remove some of the dread of the deformity. Not all cases are suitable for this however and each case must be assessed on the basis of the characteristics of the tumour and the wishes of the patient herself.
Tissue expanders are commonly used to reconstruct the breast and can often be placed at the time of the mastectomy. These expanding prostheses are inserted partially-filled at the time of the initial surgery and the overlying tissues are allowed to heal. When this has been achieved the expander is inflated further step by step until an adequate size is achieved. The expander is then left for some months whilst the internal scar matures and then can be replaced with a permanent prosthesis. Nipple reconstruction can also be performed at this stage if needs be and some quite lifelike reconstructions are now possible.
Along with changes in the shape and design of tissue expanders, breast implants for reconstruction have also improved in their shape and design. Flattening of the reconstructed breast has always been a problem when compared with the opposite normal breast. Recent developments in implant design have been aimed to overcome this by enhancing the projection of the implant. Breast implants in particular for reconstruction employ a more natural tear-drop shape, with an appropriate height and width and projection of implant chosen to match the breast outline. Many more variations in shape and size are now available than were seen 15 years ago.
Where reconstruction is performed from the body’s own tissues, the TRAM flap using the spare tyre from the abdomen and the Latissimus Dorsi flap (using skin and muscle from the back) are the most common choices. The Latissimus Dorsi often requires an implant to be placed below it to give sufficient size and an appropriate shape. Focus with this operation includes placing the scar on the back appropriately to make it easy to conceal and minimizing the length of the scar so it does not create an excessive inconvenience. A Latissimus Dorsi flap may be recommended to cover an implant where the patient has previously undergone radiation as implants alone after radiotherapy are associated with a higher complication rate in breast reconstruction.
The TRAM flap has been around for about 30 years now. The idea came from taking the “spare tyre” of skin and fat from the abdomen commonly discarded after a tummy tuck procedure and using that tissue to reconstruct a lifelike breast. In most cases with the TRAM flap an implant is not required at all.
Improvements in TRAM flap techniques have minimized the weakening of the muscle wall of the abdomen and enabled a faster recovery. The scar of the TRAM flap is much like the scar of a tummy tuck and as such is usually quite long but placed discreetly at the lower edge of the abdomen above the hairline. Improvement in abdominal contour can be significant and the TRAM flap can often enable the most lifelike of breast reconstruction.
More and more these days, patients are receiving lumpectomy or partial excision of the breast rather than the full mastectomy. The choice between these two procedures is made on the basis of the tumour characteristics and its location and size as well as the desires of the patient and their body build. In some cases the tumour can be removed in a breast reduction style pattern and the opposite breast altered to match. Where radiation is performed or a significant portion of the breast has to be removed in a smaller breast a “patch” repair with a flap such as the Latissimus Dorsi can restore good breast shape and size. The smaller flaps usually permit a more discreetly placed and shorter scar.
The aim of breast reconstruction of course is always to end up with two breasts that look good and match, so attention to the opposite healthy breast is always considered. In fact, the first question in a consultation may well be “What do you think of your normal breast?”. If the woman feels that her normal breast is too big, too small or sags too much then an appropriate plan can be formulated to alter that breast and arrive at a situation where the patient now has a breast that she likes and a breast reconstruction that matches well.
One of the most enjoyable things for the Reconstructive Plastic Surgeon is to hear the patient say that “My breasts look better than they did before I had breast cancer!”. Naturally this is not always possible but it remains the aim of every breast reconstruction.
Through developments in implants, expanders and flap techniques breast reconstruction surgery has become more precise and with shorter recovery times. Some procedures are even possible as a day patient.
Plastic Surgeons continue to strive to improve these techniques in the hope that the availability of a lifelike and aesthetically-pleasing reconstruction will take away some of the fear felt about breast cancer.