Radiation Therapy And Natural Tissue Reconstruction
With both natural tissue and implant reconstruction, radiation therapy can cause:
- Changes in skin color and skin quality
- Changes in the shape and contour of the breast
- Tissue shrinkage
- Scars that get worse over time
For women who will need radiation therapy after mastectomy, it may be better to delay the flap reconstruction until after radiation therapy.
This greatly lowers the chances the look, feel and size of the reconstructed breast will be harmed by the radiation therapy .
Delayed reconstruction using flaps after radiation therapy generally requires using a larger patch of the donor site skin . Most of the chest skin damaged by the radiation therapy is removed during surgery. So, theres less chest skin available after radiation therapy and the larger patch helps cover the reconstructed breast.
Women may also consider having immediate reconstruction with a tissue expander to preserve the breast skin envelope. Then, once radiation therapy is over, the expander can be removed and a flap reconstruction can be done as a delayed reconstruction. This may help to preserve the breast skin as much as possible so less skin from the abdominal donor site will be needed. However, complications related to the tissue expander can still occur, especially with radiation therapy.
Breast Reconstruction Surgery After Cancer Treatment
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If youve had or are about to have a mastectomy or lumpectomy to treat breast cancer, you may be considering whether to undergo reconstruction after your treatment. Not everyone chooses to reshape one or both breasts following surgery, but having reliable information about the possibilities is important.
In 2017, the American Society of Plastic Surgeons reported that just 23 percent of those facing breast reconstruction surgery understood the range of options available to them. This article provides an overview of the different procedures to help in your decision-making process.
You have several options to restore the shape of your breasts after mastectomy for breast cancer. The option you choose may depend on:
- the amount of breast tissue removed
- the shape of your breasts
- whether your treatment plan includes radiation therapy
- other health factors that could complicate your healing
Below, well discuss some of the many options available for breast reconstruction after mastectomy.
Things You Might Not Know About Delayed Breast Reconstruction
Whether its been 20 days or 20 years since your lumpectomy or mastectomy,youre likely a candidate for reconstruction.
More than 70 percent of women who forgo reconstruction at the time of theirbreast surgery dont know its an option,dont have access to a plastic surgeon, or are focused and worried about managing their diagnosis, saysGedge Rosson, director of breast reconstruction at Johns Hopkins.
Rosson and his colleagueMichele Manahanshed some light on what most people may not know about delayed breastreconstruction:
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How Do Surgeons Use Tissue From A Woman’s Own Body To Reconstruct The Breast
In autologous tissue reconstruction, a piece of tissue containing skin, fat, blood vessels, and sometimes muscle is taken from elsewhere in a womans body and used to rebuild the breast. This piece of tissue is called a flap.
Different sites in the body can provide flaps for breast reconstruction. Flaps used for breast reconstruction most often come from the abdomen or back. However, they can also be taken from the thigh or buttocks.
Depending on their source, flaps can be pedicled or free.
- With a pedicled flap, the tissue and attached blood vessels are moved together through the body to the breast area. Because the blood supply to the tissue used for reconstruction is left intact, blood vessels do not need to be reconnected once the tissue is moved.
- With free flaps, the tissue is cut free from its blood supply. It must be attached to new blood vessels in the breast area, using a technique called microsurgery. This gives the reconstructed breast a blood supply.
Abdominal and back flaps include:
Flaps taken from the thigh or buttocks are used for women who have had previous major abdominal surgery or who dont have enough abdominal tissue to reconstruct a breast. These types of flaps are free flaps. With these flaps an implant is often used as well to provide sufficient breast volume.
Nipple Inflammation Is A Red Flag
If one or both of your nipples become red, painful, and hot to the touch, see a doctor right away. These are signs of inflammation, and could signal an infection called mastitis, which is often caused by a blockage plugging a milk gland. This is very frequently seen in women who are breastfeeding, and its easily treatable with antibiotics, says Dr. Tung.
Those symptoms could also be signs of inflammatory breast cancer , an aggressive form of cancer that can be easily misdiagnosed because it rarely presents with the traditional breast lump that is the hallmark sign of so many other types of breast cancer. In IBC, the skin on the nipple or breast can also becomes pitted and thick like an orange peela symptom known as peau dorange.
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What Does The Mourning Process Look Like
While grief will look different for everyone, and the stages dont progress one after the other at specified intervals, most will begin with denial and disbelief followed by protest. The disorientation and detachment stages may be even more difficult. Disorientation might include feeling like a stranger in your own body, being overwhelmed at the prospect of getting dressed, or not recognizing yourself in the mirroror not wanting to look. Detachment may involve us drawing away from family and friends, feeling listless or resigned, and wanting some time to just sit with our loss.
The acceptance stage is ongoing, and a person who has reached acceptance may still feel times of grief. Acceptance is a lifestyle, and a time when a woman gains wisdom from her experience and can help other women going through the same thing.
After A Mastectomy Do Women Still Have Nipples
Dr. Harness explains if women retain their nipples after a mastectomy.
Dr. Harness, M.D.:If you are doing mastectomy without reconstruction, there is no point in leaving the nipple or areolar complex behind. You want to try and maximize the amount of skin you take off so that, again, the skin is down flat against the chest wall so that a prosthesis, either inside the bra or stuck on the chest wall, can fit properly. So no, there is no point in leaving the nipple-areolar area behind.
About Dr. Harness, M.D.:
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Womens Health And Cancer Rights Act
The Womens Health and Cancer Rights Act of 1998 requires group health plans, insurance companies and health maintenance organizations that pay for mastectomy to also pay for :
- Reconstruction of the breast removed with mastectomy
- Surgery and reconstruction of the opposite breast to get a symmetrical look
- Breast prostheses
- Treatment of any complications of surgery, including lymphedema
The Womens Health and Cancer Rights Act doesnt apply to some church and government insurance plans.
Other Free Flap Reconstructions
There are some other reconstruction techniques using flaps from other areas of the body. The following types of free flap reconstruction use tissue from the buttocks or thighs.
These techniques are mainly used when other types of reconstruction arent suitable. They may be appropriate for women who are too slim for tissue to be taken from their abdomen or who have scarring from previous surgery to their abdominal or back area. Only a few surgeons in the UK offer these techniques and you may need to travel to another centre if you need this type of surgery.
As with all types of flap reconstruction, these techniques are generally not suitable for women who have diabetes, are heavy smokers or are very overweight.
SGAP flap and IGAP flap
SGAP and IGAP use only fat and skin taken from the upper or lower buttock to create a new breast . This involves microvascular surgery, which is the process of joining blood vessels together. Where tissue has been removed from the buttocks, there will be a scar and an indentation.
TMG flap or TUG flap
The tissue removed in this procedure is taken from the upper inner thigh and consists of skin, fat and a small strip of muscle .
The procedure may be suitable for women with small- or medium-sized breasts. The inner thigh fat feels soft and is therefore similar in texture to the breast fat. Microvascular surgery is needed to join the blood vessels.
This film shows the SGAP and IGAP, TMG and TUG techniques.
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Body Tissue Reconstruction Surgery
With this operation, your surgeon takes skin, fat, and sometimes muscle from another part of your body and makes it into a breast shape.
- Body tissue reconstruction can usually be done in one or two operations, but you may need minor adjustments to the new or opposite breast.
- The reconstructed breast is warm and gives a more natural shape and feel compared to an implant .
- Women with small or large breasts can have this type of surgery.
- It is a much bigger and longer operation than implant reconstruction.
- The operation leaves you with two wound sites and two sets of scars.
- There is the risk of arm weakness if you have tissue taken from your back .
- There is a risk of tummy weakness if you have tissue taken from your tummy .
The reconstructed breast tends to match the other breast well at first but may droop after some time. So then the breasts may be out of alignment.
What Is A Radical Mastectomy
A radical mastectomy is the complete removal of the breast. The surgeon also removes the overlying skin, the muscles beneath the breast, and the lymph nodes. But doctors rarely do radical mastectomy today because it isn’t usually more effective than other types. Itâs recommended only when cancer has spread to the chest muscle.
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‘i Have Sensation In My Breasts Again’
When Sarafina Nance found out she had a very strong chance of getting breast cancer, she decided to have a preventative double mastectomy followed by reconstruction. The surgery would dramatically reduce the risk, but she would likely lose feeling in her chest. The 26-year-old was “fully prepared” to be numb, until pioneering surgery changed her life.
The first time Sarafina was screened for breast cancer, doctors found something worrying.
She already knew she had inherited the BRCA2 gene from her father, after he was diagnosed with advanced prostate cancer and she had genetic testing.
The gene increases the risk of developing a number of cancers – including breast cancer Sarafina, who lives in California, was told she’d need twice-yearly screening.
But after her first MRI scan, doctors ordered a biopsy.
“Waiting for the results, I was completely debilitated,” Sarafina says.
“I remember calling my dad, asking him what happens if we both have cancer. What if I die?”
The mass was benign, but Sarafina realised she didn’t want to go through repeated scans.
Still in her mid-20s, she decided to have a preventative double mastectomy with reconstruction. She would have all her breast tissue removed and implants would create new breasts.
Typically, mastectomy with reconstruction is offered to two groups: those with a cancer diagnosis, and those who have a high genetic tendency to developing breast cancer who choose to undergo preventative operations.
How This Study Was Done
This South Korean study focused on breast cancer recurrence rates in the nipple/areola area after nipple-sparing mastectomy, as well as the risk factors linked to recurrence in that area.
The study included 944 women who had nipple-sparing mastectomy and immediate reconstruction on 962 breasts. All the women were diagnosed with early-stage breast cancer between March 2003 and December 2015. None of the women had chemotherapy or hormonal therapy after surgery. About 80% of the women were younger than 50 and 20% were 50 or older.
The characteristics of the breast cancers:
- 52.9% were multifocal or multicentric
- 68.3% had zero positive lymph nodes, 24.3% had one to three positive lymph nodes, and 7.4% had four or more positive lymph nodes
- 60.7% of the cancers were more than 1 cm away from the nipple/areola tissue, and 37.8% were 1 cm or closer to the nipple/areola tissue
- 63.0% were hormone-receptor-positive and HER2-negative, 15.8% were hormone-receptor-negative and HER2-positive, 12.8% were hormone-receptor-positive and HER2-positive, and 8.4% were triple-negative
- 60.2% had large areas of DCIS in addition to the invasive cancer
After surgery, the women had follow-up visits with their doctors every 3 to 6 months for the first 5 years, then every year after that. Follow-up time ranged from 14 months to 15.4 years. Half the women were followed for more than 7 years and half were followed for shorter periods of time.
- large areas of DCIS in addition to the invasive cancer
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Tips For Mastectomy Recovery
Once youâre home, make sure you follow the plan your doctor gave you. Also make sure that you:
- Rest. Get plenty of it the first few weeks after surgery. It takes a lot out of you.
- Take your meds. Donât tough it out. Take the medication as prescribed. Youâll probably feel a mix of pain and numbness.
- Keep the site dry. Take sponge baths only until your drains and stitches are out.
- Do your exercises. Theyâll keep your arm from getting stiff.
- Ask for help. Donât be shy. It takes time to get better. Get all the help you can with meal prep, shopping, housework, child care, pet care, rides to doctorsâ appointments, and whatever else you arenât ready to take on by yourself.
American Cancer Society: “Surgery for Breast Cancer.” âMastectomy,â “Surgery for Breast Cancer in Men,” “Treatment of Breast Cancer in Men, by Stage.“
National Comprehensive Cancer Network: “Breast Cancer: Treatment Guidelines for Patients.”
Cancer Net: “Guide to Breast Cancer.”
BreastCancer.org: “What is Mastectomy?” âMastectomy: What to Expect,â “Rates of Preventive Double Mastectomy in Men Nearly Doubles.“
John Hopkins Medicine: âMastectomy.â
Manouras, A. Archives of Surgery, June 2008.
Mayo Clinic: “Modified Radical Mastectomy,â “Male breast cancer: Definition,” “Male breast cancer: Treatment and drugs.“
Townsend, C. Sabiston Textbook of Surgery, Saunders Elsevier, 2007.
Brunicardi, F. Schwartz’s Manual of Surgery, McGraw-Hill, 2006.
American Cancer Society:
Preparing For A Mastectomy
Before having a mastectomy, you will have the opportunity to discuss the operation with a specialist breast care nurse or surgeon. You can discuss how the procedure might affect you physically and emotionally.
You’ll get practical advice about bras and bra inserts, if you need them.
Your surgeon will discuss the type of mastectomy you’ll have, the possible complications and the option of breast reconstruction. You may need to have chemotherapy or hormone therapy before the operation to reduce the size of any tumours.
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The Long Road To Regaining Sensation
Ten years after Daltons mastectomy and reconstructive surgery, her left implant ruptured.
In her search for a surgeon who could perform natural tissue breast reconstruction, she found Dr. Chen, who suggested she undergo autologous flap reconstruction surgery with the technique Resensation.
Resensation uses a processed nerve allograft as a bridge to reconnect nerves in the chest to the reconstructed breast tissue. The processed nerve allograft is believed to guide regrowth of nerve fibers and help regain sensation over time.
The procedure uses skin and fat from one of part of the body and transfers it to the chest wall. Then an artery, vein, and nerve in the chest wall are secured to a nerve connecter, which reconnects the nerve from the flap and chest wall to restore sensation.
Chen explains the procedure may add 30 to 60 minutes depending on the anatomy of the patient.
Resensation minimizes donor site numbness by using a nerve graft to optimize restoration of sensation, Chen said. For many women especially young women or women undergoing prophylactic mastectomies restoring sensation after mastectomy is life-changing.
However, she says regaining sensation is gradual, because nerves grow a millimeter a day.
Dalton underwent the surgery in 2018.
After healing for a few weeks, Id feel a little pain or pinch and initially I thought, Ouch, that hurts, and then I thought, Thats awesome I can feel pain, I can feel something, Dalton said.
Making Decisions About Breast Reconstruction
After having a complete mastectomy, there are various choices available. Reactions to the loss of a breast or breasts vary from woman to woman, and only you can choose what feels best for you.It is important that you know the advantages and disadvantages of having a reconstruction. Breast reconstruction is a specialised form of surgery and you should talk it over with your breast surgeon first.
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Nipple And Areola Reconstruction
The nipple and areola are usually the final phase of breast reconstruction. This is a separate surgery done to make the reconstructed breast look more like the original breast. It can be done as an outpatient surgery or sometimes as an office procedure. Its usually done about 3 to 4 months after surgery after the new breast has had time to heal.
Ideally, nipple and areola reconstruction tries to match the position, size, shape, texture, color, and projection of the new nipple to the natural one . Tissue used to rebuild the nipple and areola comes from the newly created breast or, less often, from skin from another part of your body . If a woman wants to match the color of the nipple and areola of the other breast, tattooing may be done a few months after the surgery.
Some women opt to have just the tattoo, without nipple and areola tissue reconstruction. A skilled plastic surgeon or other professional may be able to use pigment in shades that make the flat tattoo look 3-dimensional.