Breast Reconstruction After Mastectomy
The day Laura Tiller, 32, discovered that the small lump in her breast was cancerous, she knew she was living every woman's worst nightmare.
She was familiar with the numbers: every year, more than 180,000 women in the United States discover cancerous lumps in their breasts. But like most of us, those staggering numbers did not truly speak to her until the diagnosis became her own.
That day, as she and her oncologist discussed her treatment options, her focus was on surviving. She knew losing her breasts would change the way she looked, but that day, her first priority was to rid her body of the cancer.
"I wasn't worried so much about my physical appearance at that time. I just wanted to get better," she said. "But my oncologist suggested I talk to a plastic surgeon. He talked about cosmetic procedures that extended months into the future. He helped me realize that there was a reason to have hope for the future, and that I'd be able to look like a woman again after the surgery."
According to Dr. Alexander Digenis, a plastic surgeon who specializes in breast reconstruction after mastectomy, Tiller's reaction is common.
"This is a very emotionally charged time," said Digenis. "Understandably, when a woman hears she has breast cancer, all she is concerned about is getting cured. It turns out that finding out about the possibility of reconstruction is one of the few bright spots. Many women don't even know breast reconstruction is available. They generally assume they will have to wear a prosthesis of some kind."
Today, breast reconstruction after a mastectomy is considered an integral part of treating breast cancer. Surgical techniques are now available that offer a woman many options that include using implants, her own tissue, or a combination of both.
Immediate or Delayed Reconstruction
One of the first decisions a woman must make is whether to have immediate reconstruction (performed at the same time as the mastectomy) or delayed reconstruction (the reconstruction is performed after the woman has recovered from her mastectomy).
Digenis generally recommends immediate reconstruction, depending on each patient's case. Immediate reconstruction saves the patient from having to undergo an additional surgery, offers significant psychological and emotional benefits, and produces better aesthetic results.
"We prefer to do it at the time of mastectomy, but there are caveats to that," Digenis explained. "For example, for patients who have advanced stages of cancer, reconstruction immediately following mastectomy might complicate her care."
Ultimately, each woman and her doctor must decide which option is best.
Implant-based reconstruction uses a temporary expandable implant to stretch the skin where the implant will be placed. "After a mastectomy, usually the nipple and a big piece of skin from the breast are removed and what's left is a tight closure," Digenis explained. "You can't immediately put an expanded implant there because it could harm the dissected tissue."
To make room for the permanent implant, the deflated expander is gradually filled with saline over several weeks. A special "one-way port," which is located under the skin, allows the doctor to inject the saline into the expander and inflate the implant. After the skin is sufficiently stretched and the mastectomy is healed, the expander is removed and the permanent implant is put in its place.
With implant-based reconstruction, no extra time is added to the mastectomy. "The incision is already made," said Digenis. "I just go in and make a pocket under the muscle at the time of the mastectomy. Then I give a nice plastic surgery closure. In terms of recovery, it takes the same time as the mastectomy."
Digenis said that in general, implant-based reconstruction works best with younger patients with breasts that are less ptotic (Ptotic refers to the sag or droop that naturally occurs as breasts mature). "About 25 percent of patients need contouring surgery on the other side to match the more youthful looking reconstructed breast. But many patients focus on that as a benefit. A lot of times, after reconstruction, women feel their breasts look better than they did prior to the mastectomy. That is hugely important in terms of their esteem and recovery."
Autologous Reconstruction, commonly called flap reconstruction, involves using the woman's own tissue from her back, abdomen, or buttocks to create a breast mound. The relocated tissue used in the reconstruction is called a flap. Reconstruction typically involves one of three methods: the latissimum dorsi flap, the TRAM flap, or the buttocks flap.
The lastissimus dorsi is a broad, fan-like muscle of the back. A wedge of skin and muscle are tunneled below the skin to the breast area to create a breast mound. The surgeon swings the tissue underneath the armpit keeping the blood supply connected.
According to Digenis, the scars that result from this procedure tend to be unsightly. Often, an implant must be used because the muscle is so thin. "This procedure is sort of a hybrid of using implants and the patient's tissue. In most cases, I don't choose to use this procedure unless I don't have other options."
Two muscles of the abdomen, called the rectus abdominis muscles, are used in the transverse rectus abdominis myocutaneous (TRAM) flap procedure. One of the two muscles, including its blood supply and fat, are tunneled up into the mastectomy cavity and shaped into a mound. This procedure takes advantage of the fat pad found in the lower abdomen of most women. In addition, the underlying muscle covering the abdomen is tightened, and the end result is a "tummy tuck" operation.
"Recovery time for this procedure is much longer," Digenis admitted. "I tell my patients they are getting three operations instead of one. Most women tend to focus on the tummy tuck as much as they do their mastectomies."
While TRAM flaps result in the most natural looking breasts, require no implants, and offers a tummy tuck operation in addition to reconstruction, they are technically more challenging operations. After the mastectomy is complete, an additional four hours is needed to complete the surgery. Recovery time can take up to six weeks.
In the buttock flap procedure, tissue is taken from the buttocks and attached at the site of mastectomy. Microsurgery is required to reattach the tissue to a blood supply, which makes this the most time-consuming procedure to perform.
Areola and Nipple Reconstruction The final phase of the reconstruction process, which is usually done up to six months later, is the formation of the nipple and areola. "The nipple is produced by making a 'skate' flap and rolling the tissue to form a nipple," said Digenis. "Tattooing the site allows us to match the color of the existing areola, and eliminates the need for skin grafting."
Nipple reconstruction can be performed as an outpatient procedure.
The art of breast reconstruction has come a long way. Tiller recently recalled the differences between her mother's mastectomy from several years ago, and her own.
"Back when my mom had her mastectomy, they didn't do reconstruction until months or years later. She never had the opportunity to have reconstruction. She had a large, empty place on her chest where her breast used to be. And she was left with a large scar on her back.
"But my reconstruction began immediately following my surgery. I came out of surgery with two small mounds on my chest, and we began filling them with saline about two weeks later. In about six months, I'll have the nipple reconstruction done, and I'm very excited about that. It really makes a difference in the way you feel."
Digenis said the techniques continue to improve, and the standards are extremely high. "When reconstruction was evolving, we just worried about making a mound so the patient looked good in a bra. Today, we are not satisfied until we get as close as we can to the look of a natural breast."