Your breast Surgeon would have informed you of the treatment options available to you in terms of your breasts. If you have been referred to me, a surgical option involving reconstruction has been advised.
Breast cancer surgery consists of either lumpectomy, partial mastectomy or mastectomy, with in all cases some surgical attention being directed to the draining glands in the armpit (lymph nodes).
In order to obtain optimal results and to leave you with the best cosmetic result, we believe that a team approach is vital. We try to deliver a service to you that is in keeping with international standards and protocols.
I wish to present you with a brief summary of treatment options, which will be discussed with you.
LUMPECTOMY OR PARTIAL MASTECTOMY
Lumpectomy or partial mastectomy involves removing the tumour with a margin of normal tissue under the guidance of an intra-operative pathologist. In many instances this would be sufficient, however on occasion it is necessary, due to the size of the defect or the position of it on the breast (eg the area of décolletage and around the nipple), to reconstruct this defect by either cosmetic surgery techniques or reconstruction techniques which may or may not involve the opposite breast in order to leave you with a pair of similar sized and shaped breasts after the surgery.
Techniques could include:
- Breast reduction approaches to the breast tissue through a keyhole type incision. The tumour is removed along with surrounding normal breast tissue. Subsequent to the report of clear margins reconstruction of the breast mound is commenced. The aim of this is to achieve a normal looking breast mound and nipple areolar complex. The opposite breast then undergoes a similar process to obtain symmetry. The ideal result is obtained in women who have slightly larger breasts. In these cases we would hope to attain a pleasing breast mound with the nipple above the fold below the breast and sited at between 18 to 24 cm from the notch of the breastbone. The main disadvantage of this approach is scarring around the nipple of the lower part of the breast and in the fold. This scar resembles an anchor and may be initially angry and red and take up to a year to mature to a white flat scar.
- In cases where the breasts are not large enough to allow the above approach, tissue from elsewhere would need to be imported into the defect. The most common donor site for these cases is the skin fat and muscle from the back. This process involves taking an island of skin and fat from the back and basing it on the latissimus dorsi muscle (the fan shaped muscle which extends from the armpit to the top 12 vertebrae), using the blood supply which enters the muscle in the armpit. The entire block of tissue is raised and brought around to the front of the chest and inserted into the defect left by the surgery. As this tissue has its own blood supply, which is retained, during surgery it is known as a flap and not a graft. The advantage of this flap is that it has very little problems in dealing with the radiotherapy, which would follow. All flaps add some risk to the procedure, as anything which compromises the flow of blood to the transported tissue, may increase the risk of complications. Smoking, arterial disease, obesity, low blood pressure and conditions with abnormal clotting can all increase the potential for complications. The final result of the latissimus dorsi flap may involve some back skin the on chest wall as well as a scar on the back, which should be able to be concealed by the bra or costume strap.
COMPLETE MASTECTOMY WITH RECONSTRUCTION
Mastectomy is an operation used to treat breast cancer and other breast diseases in which the nipple plus an amount of skin and virtually all the breast tissue is removed. In some cases the underlying pectoralis muscle may also need to be removed.
Breast reconstruction following mastectomy is a complex field involving many choices based on some of the following criteria or risks/benefits as well as integration with the rest of the treatment plan:
- Type and extent of mastectomy
- Previous surgery/radiation to breast
- Size and shape of opposite breast
- The need for post operative radio of chemotherapy
- Potential donor sites for tissue transfer or patient’s own body
- Age, medical conditions and anaesthetic risk of the patient
- Preferences and/or fears with regards silicone and certain procedures.
Having read the above you will see that certain options may not have been made available to yourself. This is due to the fact that they have been deemed as technically not viable due to either the nature of your mastectomy, underlying conditions you might have or an inability to integrate those options in a realistic post operative plan.
The other reason may be that either previous surgery or the current mastectomy may damage the blood supply to the tissue needed to be transferred during the reconstruction. I will shortly explain briefly what the options are to re-cap on the consultation.
MASTECTOMY WITH SILICONE PROSTHESIS RECONSTRUCTION
Just after the mastectomy a silicone prosthesis can be inserted into a pocket created under the pectoralis muscle into which is inserted a bag containing silicone gel. This is similar to normal cosmetic breast enhancement surgery.
This option is ideal for patients with smallish non droopy breasts. It is however not a good option in primary breast reconstruction which will need radiation therapy to complete the therapy for the breast cancer. Please see the attached information sheet with regards the history of silicone prosthesis and current thinking.
The advent of Acellular Dermal Matrices ( ADM's) has made primary implant based reconstruction a more viable option, addressing many of the problems associated with inadequate coverage of the implant in the lower pole of the breast. ADM's are structural scaffolds that are inserted at the time of the reconstruction and are sutured to the remnant of the divided pectoral is muscle as well as the inframammary fold, hereby achieving complete coverage of the implant, with no disruption of the serrated anterior muscle. They are however very expensive, and negotiation with health care finders is an ongoing process.
TISSUE EXPANSION FOLLOWED BY PROSTHETIC RECONSTRUCTION
Tissue expansion is a process whereby existing tissue, which is insufficient for breast reconstruction, can be altered by a slow stretching by a balloon type device to create sufficient tissue with which we can create a breast. This is similar to the stretching of the abdominal skin during pregnancy. After mastectomy the device is placed under the pectoral muscle, with an integrated access port , through which fluid can be injected later to fill the device as the skin expands. The expander isn’t in the final position, as it requires complete muscle cover to allow expansion. After three months (no other treatment required) six months (if chemotherapy if administered) the expander is removed and replaced with a permanent silicone prosthesis. At the same time the opposite breast can undergo a matching procedure i.e. augmentation, breast lift or breast reduction.
Problems specifically associated with expanders are deflation, extrusion and pain of expansion (rare) as well as rotation and malposition of the expander. It is wise to remember that we are merely creating space with the expander in order to accommodate the permanent prosthesis later and whilst the initial shape with expansion may appear odd, we address these issues at a second and third stage.
FLAP RECONSTRUCTION OF BREASTS
LATISSIMUS DORSI FLAP
This flap is ideal for patients who require post operative radiotherapy, for patients who have had the pectoral muscle removed during mastectomy and patients who require more skin than can be reliably achieved with tissue expansion.
Whilst quick and easy to perform, and relatively robust, the Latissimus dorsi flap is not without its problems. These include a large donor site scar on the back, a contour deformity on the back as well as going problems with pain, shoulder instability and neck pain. it is therefore utilized under duress in our practice and usually as a backup option in salvage reconstructions.
This flap can be used as a total reconstruction or in some cases may have a prosthesis added to achieve significant size of the breast mound.
This total reconstruction is a method by which excess skin and fat of the lower abdomen can be transferred using the blood supply from the rectus abdominus muscle. The paired rectus abdominis muscles for the “six pack” muscles. One of these is raised with the fat and skin attached and passed through a tunnel between the abdomen and the hole created by a mastectomy.
This operation cannot be performed on people with the following conditions: Obesity, previous abdominal surgery, diabetes, smokers and major heart/lung problems.
In spite of the above this flap is a very nice form of reconstruction as it utilizes excess tissue in one region to reconstruct a defect in another, the tissue used is similar, the skin type of breast and lower abdomen are also the same and finally the scar can often be hidden in the panty line (like the scar of a tummy tuck)
Special problems with this procedure are herniation caused by loss of the muscle in the abdomen (5 – 10% of cases), the length of the procedure and transient loss of sensation to the lower abdominal skin.
COMPLICATIONS OF BREAST RECONSTRUCTION
- Blood loss: With simultaneous reconstruction especially if a flap is used this can be somewhat higher. In this practice all reasonable attempts are made to minimize the usage of blood transfusions including cell saving and post operative auto transfusion. Sometimes it is necessary to surgically drain collections of this blood after the operation.
- Infection: All surgical procedures are association with infection particularly with prosthesis. The average rate worldwide is between 2 – 5%. I have 2.9% of my own patients in the last ten years. However this means liberal use of antibiotics to prevent this potential problem. This however may necessitate the removal of the prosthesis and replacement after an appropriate time delay.
- Wound healing problems: All surgical wounds can experience wound healing problems such as break down. This is more common amongst smokers, people who are overweight, people who have had previous chemotherapy and radiotherapy or other forms of immuno suppression
- Flap loss: In all cases as with wound healing, the same conditions could affect blood flow through the tissue that has been transported resulting in the flap not getting enough oxygen and failing, fortunately this is a rare but serious problem.
- Donor site problems: All the above problems cannot only occur in the reconstructed breast mound but in the donor site should a flap reconstruction be used.
- Silicone related problems: Please read the attached article on silicone prosthesis related problems to further your knowledge should we have decided that a silicone prosthesis is appropriate for your reconstruction.
- Anaesthetic related problems: These as you have probably heard can vary from minor (nausea, discomfort) to major (drug interactions etc.) but fortunately common but extremely rare.