Breast Reconstruction

Living a long, cancer free life is the most important goal for our patients. Simultaneously, we understand that wanting to hold on to your femininity may also be essential to your well-being. If your surgeon recommends a mastectomy, in most cases you will have the option to choose whether to have immediate or delayed reconstruction. There is no absolute right or wrong choice, just which option best suits your needs.

Based on your risk factors and on information from your biopsy, your surgeon will have a general idea of the extent of your tumor. However, your cancer care team won’t be able to determine the full extent of the cancer until they have removed the entire tumor and evaluated the lymph nodes. In some patients prior to surgery, there may already be signs of advanced disease, or a doctor may determine that radiation will be required as part of the treatment plan. If this is the case, it may be in your best interest to delay reconstruction until after all treatments have been completed.

Immediate and delayed breast reconstruction each have their own advantages and disadvantages. While delaying reconstruction gives you time to focus on treatments and research the type of reconstruction that best suits your needs, being without a breast can be emotionally devastating for some. Immediate breast reconstruction, which begins at the time of the mastectomy, has become the standard of care for most patients when it can be done safely. The obvious benefit to immediate post-mastectomy reconstruction is the psychological and aesthetic advantage of waking up after the mastectomy with a lesser deformity and a reconstruction well underway. Also, immediate reconstruction can spare the patient additional stages of surgery. The primary drawback of immediate reconstruction is that it requires a longer surgery and recovery than just having mastectomies alone. Also, if radiation treatments are needed following surgery, the reconstruction may become compromised.

Regardless of whether an immediate or delayed approach is utilized, several procedures may be needed to achieve the final aesthetic result a patient desires. The approach to reconstruction should be tailored to the individual needs of the patient.

Radiation therapy has long been part of breast cancer treatment plans, particularly for patients who choose breast conserving surgery, have multiple positive lymph nodes, or have a local recurrence.

Radiation acts by damaging cancerous cells and preventing their growth. However, radiation also damages normal, healthy cells by disrupting the blood supply to normal skin. This creates a greater risk of complications following surgery like infection, delayed healing, wound breakdown, and fat necrosis. When reconstruction is included in breast surgery, implant related problems such as extrusion and capsular contracture are also possible.

Since radiation can introduce additional complexities pertaining to reconstruction despite its benefits, be sure to discuss all aspects of your treatment plan with your comprehensive care team. If radiation therapy is part of your treatment plan, your breast team can work with you to coordinate the timing and approach to reconstruction to give you the best aesthetic result.

Whether a patient is a good candidate for immediate breast reconstruction is partially determined by the need for radiation therapy as part of treatment. Patients with combinations of advanced disease, multiple positive lymph nodes, or large tumors may have radiation as a part of their treatment. Since radiation can have adverse effects on reconstructed breasts, in these cases immediate reconstruction may not be ideal, and your provider may instead recommend a delayed reconstruction.

Sometimes, predicting who will need radiation before a mastectomy is completed isn’t possible because the mastectomy specimen can help inform providers as to whether radiation is necessary. If the patient has already begun the process of reconstruction and radiation is required, your providers will work together and with you to manage the negative effects of radiation therapy on the reconstructed breast.

Radiation therapy will also impact the quality of breast skin overlying a tissue expander, if one is in place. Following radiation, the skin may recover enough to allow exchange of the expander for a final implant. However, if the skin remains too damaged, reconstruction can also be completed with the use of a flap while retaining the implant as part of the reconstruction. The other alternative is to forgo an implant reconstruction and instead proceed with an autogenous flap alone, such as a DIEP flap.

In cases where an autogenous flap reconstruction is radiated, the quality of the skin will be impacted and fat necrosis may develop within the flap, possibly causing an area of the reconstructed breast to become firm. An ultrasound, MRI, or possibly biopsy may be done to evaluate and confirm the fat necrosis diagnosis. Over time, the firmness usually softens.

Women considering delayed reconstruction following radiation should be aware that even following treatment, radiation therapy can leave lingering effects like poor wound healing, a greater risk of wound infection, and increased likelihood of capsular contracture. These risks may make the use of an implant a suboptimal choice for those with a prior history of radiation.

Patients who choose breast conserving surgery and undergo radiation therapy often have noticeable breast deformities after the swelling subsides, such as indentation of the breast, breast asymmetry, firmness, and changes in skin pigmentation. Correction of such deformities must be individualized for each patient. Occasionally, implants can be used to improve symmetry. More commonly, lumpectomy deformities are corrected with fat grafting.

Mastectomy techniques have evolved considerably along with the development of breast reconstruction. A traditional mastectomy removes the central breast skin including the nipple and areola with the underlying gland and leaves a scar across the central breast. The introduction of immediate breast reconstruction has changed the paradigm in favor of a skin-sparing approach.

A skin-sparing mastectomy preserves most of the normal breast skin and allows for a reconstruction with more natural contour and less visible scars. The nipple and areola are removed for oncologic reasons as they are intimately associated with the underlying breast tissue. Large studies about the oncologic outcomes of skin-sparing mastectomies suggest that they are equally effective as traditional mastectomies in clearing breast cancer. The reconstruction after skin-sparing mastectomy can be based on implants or autologous (the patient’s own) tissue.

More recently, the concept of skin-sparing mastectomy was extended to preserve the nipple and areola (the pigmented skin around the nipple) in select patients. This technique is best suited for patients with favorable breast skin (no excessive drooping or skin redundancy), and offers the most naturally appearing reconstructed breast. However, as the nipple is intimately associated with the underlying glandular breast tissue, nipple preservation is associated with potential oncologic concerns.

Recent studies have defined criteria that allow the appropriate selection of patients in whom occult cancer in the nipple is highly unlikely and who may be candidates for a nipple-sparing mastectomy. Breast surgeons may consider a nipple-sparing mastectomy in patients in whom the tumor is sufficiently small (typically less than 3-4 cm) and distant (at least 2-4 cm) from the nipple, or in patients undergoing prophylactic mastectomy. The reconstruction after nipple-sparing mastectomy can be based on implants or autologous (the patient’s own) tissue.

In patients with significant breast ptosis and skin excess, the mastectomy can be designed utilizing a skin-reduction pattern as typically used in a breast reduction or breast lift procedure. This allows the removal of any excess skin in a manner that results in a more favorable shape of the reconstructed breast. Also, this approach may result in a less conspicuous scar as compared to a standard mastectomy approach.

In the mid 1990's, scientists identified two genetic mutations, known as BRCA1 and BRCA2, that harbor an increased risk for developing breast and ovarian cancer. Both men and women can carry these mutations. For people that carry a BRCA gene mutation, the increased lifetime risk for developing breast cancer can be up to 8 in 10. The increased risk for ovarian cancer is estimated to be around 40 percent. In both cases, people assigned female at birth have a higher risk of developing breast or ovarian cancer. A blood test is used to determine whether or not a patient carries one of these mutations and can be useful for preventative and/or post-diagnosis decision making.

Risk factors for having a gene mutation include:

• Having another family member that has tested positive for a BRCA gene mutation
• Having had early onset breast cancer (diagnosed before age 45)
• A family history of early onset breast cancer
• A family history of ovarian cancer
• Being of Eastern European or Ashkenazi Jewish heritage

Your breast surgeon can help you determine if you are considered high risk and if you could benefit from genetic testing. Some patients find the decisions surrounding genetic testing to be emotionally overwhelming, so your doctor or genetic counselor should inform you of the risks associated with testing either positive or negative for a BRCA gene mutation. For example, a negative test result does not entirely eliminate the chance of developing breast cancer. Also, in some cases, patients may have a strong family history of breast or ovarian cancer but may still test negative for both BRCA gene mutations; it is likely that scientists have yet to identify some mutations that may increase your risk for breast or ovarian cancer.

There are certain potential non-medical implications of testing positive for a BRCA gene mutation. While U.S. health insurance carriers cannot discriminate against patients with a BRCA gene mutation, life insurance carriers have no such restrictions. For those already diagnosed with breast cancer, this may have less of an impact, but it may be worth knowing for family members who want to get tested.

High risk patients who have not been diagnosed with breast cancer may find genetic testing to be helpful in choosing a preventative course of action, especially because for those with a BRCA gene mutation, a bilateral prophylactic mastectomy can reduce a person’s risk of getting breast cancer by more than 90%.

Genetic testing can also help inform patients already diagnosed with breast cancer who are considering treatment options, particularly between lumpectomy and mastectomy. For these patients, a risk-reducing contralateral mastectomy can help reduce the risk of recurrence or the development of cancer in the healthy breast.

Those who choose to not pursue preventative surgery will likely need MRI, ultrasound, and mammography screening every three to six months to monitor for any changes.

Because the risk of developing cancer is so significant with a BRCA mutation, many women find peace of mind in having preventative surgery. Now, with the option to have immediate reconstruction, patients can wake up from surgery with a breast shape and can usually finish staged reconstruction within several months.

The decision on how to manage a BRCA gene mutation is personal, and there is no one size fits all option. Having quality breast reconstruction available to patients considering prophylactic or risk reducing mastectomies can help make a difficult decision easier.

Breast cancer has held a place in women’s lives for thousands and thousands of years, and for most of that time, treatments for the disease were limited. Rather than undergoing painful and questionably effective treatments, many decided to live with their disease as it progressed.

Though mastectomies have been performed routinely to treat breast cancer since the Byzantine Empire, Dr. William Halsted revolutionized breast cancer surgery in western medicine in the 19th century when he popularized the “radical mastectomy” as the treatment of choice for breast cancer. He removed not only the breast, but also the lymph nodes and the chest muscles. The procedure took out an extreme amount of tissue, but women were surviving the operation and their breast cancers. The most significant revision to radical mastectomy methodology was developed by John Madden in 1972. His “modified radical mastectomy” preserved the pectoral muscles.

Soon after that, research began showing that breast conservation therapy (local tumor removal, lymph node biopsy and radiation) had outcomes equal to mastectomy, and throughout the last couple of decades BCT has become a more popular option for people with stage I and stage II breast cancer. As advancements in breast cancer treatment continued, the emergence of breast cancer reconstruction took off.

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The first silicone breast implant occurred in the United States in 1962 using a prosthesis developed by plastic surgeons Frank Gerow and Thomas Cronin and supplied by Dow Corning. Dow Corning would go on to become the predominant manufacturer of silicone breast implants in the country. These implants were used both for cosmetic augmentation and reconstruction after mastectomies. Around that time, a French company also developed saline filled breast implants, but women found that silicone implants looked and felt better than the saline alternative.

Over the next couple of decades, improvements were made to the implants to address issues like silicone leakage. In the 1980s, some alleged that breast implants could cause cancer or autoimmune diseases, fueling mass litigation. With a dearth of data on the safety risks of silicone implants up to that time, in 1992, the Food and Drug Administration prohibited the use of silicone implants in elective cosmetic surgeries and required those who received them for special conditions to enroll in clinical studies. David Kessler, the head of the FDA stated, “We want surgeons to stop using these implants in patients until this new evidence can be thoroughly evaluated, I’m asking patients to understand that the Food and Drug Administration commissioner cannot assure the safety of these devices at the present time.” Facing hundreds of thousands of lawsuits, Dow Corning filed for bankruptcy in 1995.

Until 2006, saline filled breast implants were the only fully-approved type of implant on the market in the U.S. In this interim period, many studies were done on the health effects of silicone implants, all finding no causal relationship between breast implants and illnesses like autoimmune disorders or cancer. Eventually, in 2006, after exhaustively reviewing the now robust information available on the risks of silicone implants, the Food and Drug Administration reversed its ban and licensed two companies to manufacture them.

Today, both saline and silicone implants are popular choices for augmentation and reconstruction. Newer generation silicone devices are the safest, softest and most natural implants to date.

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Autogenous tissue reconstruction, also sometimes referred to autologous or “Flap” reconstruction, uses tissues from other parts of the body rather than an artificial implant to reform a breast.

This tissue often comes from the belly, buttocks, back or inner thighs and can include a combination of skin, fat and muscle. In cases where additional volume is needed to reconstruct the breast, flap procedures can also be paired with a breast implant.

There are two main categorizations for flap procedures: pedicle flaps and free flaps.

Pedicle flaps retain a tissue’s original blood supply when it is moved from its initial position to the chest wall or breast. The most common version of this procedure is the latissimus dorsi flap, which takes skin, fat and muscle from the back and rotates the tissue to the front to create a breast.

Free flaps involve completely removing tissue including fat, skin and some or no muscle from one area of the body to the breast area. Microsurgery is then used to reconnect the blood vessel to the chest wall vessel, which enables the relocated tissue to survive in its new position. Because this version of a flap preserves the muscle at the donor site, the procedure limits the loss of strength and retains the original look of the donor site.

There are a variety of flap procedures that relocate tissue from various parts of the body. Learn more about these procedures here.

Surgical treatment for breast cancer has undergone a long history of evolution. However, the advancements in tissue removal, whether through mastectomy or lumpectomy, paired with continuously improving reconstructive techniques, present a bright future for patients.