Immediate Breast Reconstruction After Mastectomy For Cancer

Comparison Of Immediate And Delayed Breast Reconstruction121011

Immediate breast reconstruction

• Indicated for patients with early stage breast cancer who are not expected to require radiation therapy after mastectomy

• Preserves key anatomic landmarks

• Preserves the quality and quantity of the native mastectomy skin flap when a skin-sparing mastectomy is performed

• Single operation for mastectomy and first stage of reconstruction

• Increased postoperative complications compared with delayed reconstruction

• Clinically nonsignificant delay in the delivery of chemotherapy

Delayed breast reconstruction

• Indicated for patients with locally advanced breast cancer who are expected to require radiation therapy after mastectomy. Reconstruction usually takes place a minimum of six months following completion of radiation.

• Results in the loss of important anatomic landmarks

• At least two operations for mastectomy and initial stage of reconstruction

Smoking And Body Weight

Smokers and women who are overweight have an increased risk of complications for all types of breast reconstructive surgery .

If you smoke or are overweight, talk with your plastic surgeon about problems that may occur after surgery with implant or flap procedures, such as delayed wound healing, infection and reconstruction failure.

Sometimes, its best to delay breast reconstruction until after quitting smoking or losing weight to lower these risks.

Your plastic surgeon or health care provider may discuss ways to quit smoking and/or lose weight before you have reconstruction.

Alternatives To Breast Reconstruction

For women who are not good candidates due to health reasons, or who simply choose not to have the additional surgery, mastectomy will be performed without reconstruction. The surgery leaves the chest flat on that side.

In these cases, women can request an external breast prosthesis once their incisions are healed. It can fill the brassiere on the affected side and provide the external appearance of a breast under clothing.

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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 a 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.

Choosing Breast Cancer Treatment

Choosing breast cancer treatment is a personal decision you should make with a healthcare provider. Treatment options can include a combination of surgery, radiation, chemotherapy, and more. Research indicates differences in breast cancer treatments that vary by racial/ethnic lines.

Studies have shown that Black women are more likely than White women to choose breast conservation over breast removal , even with aggressive subtypes of breast cancer.

Several factors influence this disparity in breast cancer treatment, including:

• Systemic factors:Where a person lives, their income, and if they have any physical or financial barriers to accessing health care services
• Provider factors:Historic mistrust of the medical system combined with healthcare provider bias
• Patient factors: Personal, family, cultural beliefs and preferences, and a person’s perceived risk

Some studies have noted that Black breast cancer patients have reported feeling less worried than White ones about cancer recurrence and are less likely to believe that mastectomy would have better success rates than other, less-aggressive treatment options.

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How Do Surgeons Reconstruct The Nipple And Areola

After the chest heals from reconstruction surgery and the position of the breast mound on the chest wall has had time to stabilize, a surgeon can reconstruct the nipple and areola. Usually, the new nipple is created by cutting and moving small pieces of skin from the reconstructed breast to the nipple site and shaping them into a new nipple. A few months after nipple reconstruction, the surgeon can re-create the areola. This is usually done using tattoo ink. However, in some cases, skin grafts may be taken from the groin or abdomen and attached to the breast to create an areola at the time of the nipple reconstruction .

Some women who do not have surgical nipple reconstruction may consider getting a realistic picture of a nipple created on the reconstructed breast from a tattoo artist who specializes in 3-D nipple tattooing.

A mastectomy that preserves a woman’s own nipple and areola, called nipple-sparing mastectomy, may be an option for some women, depending on the size and location of the breast cancer and the shape and size of the breasts .

What Is The Role Of Immediate Breast Reconstruction In The Treatment Of Early Stage Breast Cancer

Immediate reconstruction offers the benefits of breast reconstruction on body image and quality of life with little interruption.41,42 In the past, immediate breast reconstruction was an unpopular concept because of concerns that the surgical resection or detection of local recurrence could be compromised.43 This has not been found in practice, and these concerns are no longer barriers to immediate reconstruction.7,8,41,42Box 1 presents a comparison of immediate and delayed reconstruction in terms of clinical and psychosocial advantages and disadvantages.

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Final Look Of The Breast

It will take some time to see the final results of your reconstructed breast.

How you feel about the final results may depend on your expectations. A reconstructed breast will never look or feel the same as a natural breast.

Most of the scarring will fade and improve over time, but it doesnt go away completely.

As you age and the opposite breast changes shape, the reconstructed breast may look and feel less natural.

Other Breast Cancer Treatment Options

Depending on your situation, healthcare providers may also recommend one or more of the following:

• Chemotherapy: A more aggressive treatment used to attack quick-growing cancer cells
• Immunotherapy: A treatment type that mimics the body’s immune system to fight cancer cells
• Radiation: Use of high-dose energy waves to shrink tumors
• Targeted drug therapy: Medications that directly target cancer cells for specific subtypes of breast cancer
• Surgery : Surgical removal of a smaller, cancerous portion of the breast
• Hormone therapy: A treatment type that blocks hormones from encouraging breast cancer cells to grow

Researchers are also looking into the role that complementary and alternative medicine may be able to play within the breast cancer treatment plan. This includes:

• Mind-body therapies
• Biologically based practices
• Body-based techniques
• Whole medicine systems

This field of research is still underway, and there are still many unknowns regarding the effectiveness of these integrative cancer therapies.

Experts have highlighted persistent socioeconomic gaps along with delayed treatment start times compared to White patients as issues that have pervaded Black patients’ breast cancer treatment experience.

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Choosing The Type Of Breast Reconstruction Thats Right For You

Breast reconstruction can be done with:

• Breast implants
• Natural tissue flaps
• A combination of these methods

Theres no one breast reconstruction method that works best for everyone. You may be a good candidate for one reconstruction method, but not another. There are pros and cons to each method.

For example, breast implants require less invasive surgery than procedures using your own body tissues, but the results may look and feel less natural .

Having A Partial Reconstruction

Some women will need to have a larger amount of breast tissue removed, for example, a quadrantectomy. This means that the surgeon removes about a quarter of the breast tissue. This type of surgery leaves a dent in the breast and means the treated breast ends up smaller than the other breast. But it is sometimes possible to get back the shape with a partial reconstruction of the breast by filling the dent with a small area of living tissue.

The surgeon may use tissue from your back to fill in the dent. This is called a latissimus dorsi flap . There are other ways to do this. Your surgeon will explain these to you. You will need radiotherapy to the remaining breast tissue to reduce the risk of the cancer coming back.

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Things To Think About Before Getting Implants

Most women will do well with implants. But there are some important factors to keep in mind if you are thinking about having implants to reconstruct the breast and/or to make the other breast match the reconstructed one:

• The longer you have breast implants, the greater the chance you might need more surgery to remove and/or replace your implant later.
• You might have problems with breast implants. They can break or cause infection or pain. Scar tissue may form around the implant , which can make the breast hard or change shape, so that it no longer looks or feels like it did just after surgery. Most of these problems can be fixed with surgery, but others might not.
• Breast MRIs may be recommended every few years to make sure silicone gel implants have not broken. Your health insurance might not cover this. Talk to your plastic surgeon if you have any questions regarding the indication for breast MRIs.

What Happens During Immediate Reconstruction

You will be under general anesthesia during your mastectomy and immediate reconstruction.

Your breast surgeon will usually make an oval-shaped incision over the nipple area. In some people with certain early breast cancers, the nipple can be preserved on the breast. This is done by using incisions at the bottom of the breast or near the nipple.

From the incision, your surgeon will remove all of the breast tissue of that breast. They may also remove some or all lymph nodes from under your arm, depending on your stage of cancer and your surgical plan.

The plastic surgeon will then reconstruct the breast or breasts. In general, a breast may be reconstructed with an implant or with your own tissue from another part of the body.

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What Types Of Implants Are Used For Breast Reconstruction

Several types of breast implants can be used to rebuild the breast. Most implants in the US are made of a flexible silicone outer shell, and they can contain saline or silicone gel. Other types of implants that have different shells and are filled with different materials are being studied, but these are only available if you are taking part in a clinical trial.

It’s important to discuss the benefits and risks of the different types of implants with your doctor.

Making An Informed Choice

Each person is unique. Your breast cancer treatment, your body, your breast shape and your lifestyle affect not only your reconstruction options, but also the pros and cons of your options.

Your plastic surgeon will help you choose the type of reconstruction that will give you the best results and fit your lifestyle, while minimizing the risk of complications.

Study your options and make a thoughtful, informed choice after carefully considering the pros and cons of each option.

Although this decision may seem overwhelming, it may help to know most women whove had breast reconstruction dont regret the method they chose .

If youre a good candidate for a procedure, there are fairly few complications with any of the current methods .

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What Can You Expect During Recovery

Plan to be in the hospital for several days, depending on the type of reconstruction. You may be in the hospital overnight for an implant reconstruction, or up to a week or longer for a reconstruction with your own tissue. Your doctor will prescribe pain medication during the healing process.

For some time, you may be instructed not to sleep on your side or stomach. Visible scarring on your breasts, even after reconstruction, is normal. Over time, the visibility of the scars will go down. Massage techniques and scar removal creams can decrease their appearance, as well.

You wont need to be on bedrest once you are released from the hospital. The sooner you can get up and walk around, the better. However, until the drains in your breast tissue are removed, you will be restricted from driving and other tasks that require the use of the upper body.

Driving under the influence of some pain medications, such as Vicodin, is also restricted.

There are no special dietary concerns, but you should focus on eating foods that are high in protein. These will promote cell growth and healing. Your doctor will give you safe exercises to help you regain sensation and strength in your chest and upper body.

Besides immediate reconstruction and tissue flap reconstruction, there are other options for recreating the look of your breasts from before the mastectomy. These include having reconstructive surgery as a separate procedure and not getting reconstructive surgery at all.

What Happens After Breast Reconstruction Surgery

After surgery, you may need to stay in the hospital for up to a week. Your team of providers will watch you to ensure youre healing. You may wear a surgical bra. As your breasts heal, the bra supports your breasts and reduces swelling. When its time to go home, your provider will give you instructions detailing how to care for yourself.

Your provider will help you manage pain after surgery. They may recommend prescription or over-the-counter pain medication. Follow your providers instructions carefully when taking medication.

If you had reconstruction on one breast, you may need more surgery to make your breasts match. This may include breast reduction surgery or breast augmentation.

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Limitations Of Breast Reconstruction

A lot of women who have reconstruction are satisfied with the result. However, not everyones experience is positive and some women feel unsure about their new shape or self-conscious about their new breast.

• Reconstructed breasts will not feel, look or move exactly the same as before. They tend to be less sensitive and sometimes very numb.
• If you lose or gain weight, this will affect the natural breast but not the reconstructed breast, causing a difference in shape and size.
• Several visits to the hospital for appointments and further operations are often needed to get the best cosmetic result.
• Recovery after breast reconstruction will take longer than if you have a mastectomy without reconstruction.
• You may have scars on other parts of your body depending on the type of reconstruction.
• Compared with a mastectomy without reconstruction, there is a higher risk of complications, and this may delay further treatment.
• If you need radiotherapy after your reconstruction, this can affect the appearance of your reconstructed breast.
• Reconstructed breasts dont usually have a nipple, but one can be created with surgery, or a nipple tattoo, often at a later date .

Where a muscle has been used to cover an implant or is part of the reconstruction you may see movement of the reconstructed breast as that muscle contracts.

Despite these limitations, most women say the results after reconstruction surgery are acceptable and that they feel confident about the way they look.

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Factors Influencing The Decision To Pursue Immediate Breast Reconstruction After Mastectomy For Breast Cancer

1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands Department of Plastic Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands

Contributions: Conception and design: All authors Administrative support: M Weenk, LJ Strobbe Provision of study materials or patients: E Heine, LJ Strobbe Collection and assembly of data: M Weenk, P Wunschel Data analysis and interpretation: All authors Manuscript writing: All authors Final approval of manuscript: All authors.

Correspondence to:

Background: Immediate breast reconstruction after mastectomy has shown to be oncologically safe and to improve quality of life in breast cancer patients. However, most women undergoing mastectomy do not undergo IBR. In this study, we aim to identify breast surgeon-related factors in considering IBR and factors affecting patients decision to choose for IBR.

Methods: Retrospective analysis of the records of breast cancer patients who underwent mastectomy with or without IBR between 2010 and 2013. We documented all information whether or not a patient underwent IBR after mastectomy.

Anticipated radiation therapy, higher age and higher BMI were important breast surgeon-related factors in refraining from IBR. Almost one third of all patients declined IBR. In almost 10% of all patients, IBR was not discussed.

Keywords: Breast neoplasms breast reconstruction decision making mammaplasty mastectomy

Submitted Aug 11, 2016. Accepted for publication Oct 27, 2016.

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Applying The Results Of This Review In Clinical Practice

A 60-year-old woman has a 2-cm invasive ductal carcinoma in the upper lateral quadrant of her right breast diagnosed by means of ultrasound-guided needle biopsy. There are no abnormalities in the other breast. She has no family history of breast cancer and is otherwise in good health. On physical examination, she has relatively symmetric B-cup breasts with minimal ptosis and a moderate amount of redundant lower abdominal tissue with a scar from a cesarean section.

Based on this clinical picture, this woman is a candidate for breast-conservation therapy, mastectomy alone or skin-sparing mastectomy with immediate breast reconstruction. Her age is not a contraindication for breast reconstruction.

When discussing the surgical approach, her general surgeon points out that all three treatment options have equivalent survival rates. Because the decision will need to incorporate the patients personal values, priorities and expectations, the surgeon spends some time discussing these with the patient. In addition, the surgeon offers an urgent referral to a reconstructive surgeon and a radiation oncologist to discuss the details of these treatment options.

After speaking with the reconstructive surgeon, the patient chooses to undergo skin-sparing mastectomy with immediate breast reconstruction using an autologous tissue flap.

Pain And Discomfort After Surgery

You will likely have some pain after surgery. For most people, this pain is temporary.

The bruising and swelling from the surgery may take up to 8 weeks to go away .

Starting after the mastectomy, you will be numb across your chest, from your collarbone to the top of your rib cage. Unfortunately, this numbness usually doesnt go away. You may get some feeling back over time, but it will never be the same as before surgery.

Learn about managing pain after surgery.

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