One of the most important decisions a newly diagnosed patient with breast cancer must make is to choose between breast preservation (i.e. lumpectomy and radiation) and mastectomy. Although breast preservation is generally considered the procedure of choice for women with early stage breast cancers, for various reason many women are either not candidates for breast preservation, or choose mastectomy for personal peace of mind.
If a woman is considering mastectomy, it is important that she be given the option of immediate breast reconstruction. One problem facing such women is that it is difficult to coordinate the reconstructive surgery with the mastectomy on a timely basis. Some of the more common options include:
Our most common reconstruction option is the placement of a tissue expander under the muscle at the time of the mastectomy. After the wounds have healed, the expander is slowly filled with saline over a period of several weeks. Once the skin is adequately stretched, the expander is exchanged for permanent implant. Nipple reconstruction can be performed within a few months following the placement of the permanent prosthesis.
Tissue transfer techniques
Not all women are candidates for tissue expanders and some women prefer the advantages of all natural tissue. For these women, the option of tissue transfer is a logical alternative. The two standard options for tissue transfer are:
- Transverse rectus abdominus muscle flap (TRAM): In this procedure tissue from the lower abdomen is transferred to the chest and a breast mound is reconstructed that matches the opposite breast. This procedure is often done at the time of the initial mastectomy. The patient leaves the hospital with remarkable breast symmetry (also, with a tummy tuck).
- Latissimus dorsi flap: This flap comes from the back and is usually used in situations where extra skin is needed to close the mastectomy incision. It is often used when the breast has been previously radiated or when patients are not candidates for the TRAM flap.
Tram flap (tranverse rectus abdominal muscle flap)
The Tram flap has several advantages. In this procedure skin and fatty tissue for the lower abdomen are transferred under the skin to the mastectomy incision. A new breast is fashioned with the tissue. The tissue transferred to the chest has its own blood supply and feels much like normal breast tissue. Thus, immediately after the breast has been removed a new breast can be reconstructed (nipple reconstruction typically takes place a few months latter at which time the shape of the newly reconstructed breast is often revised. Not only does this reconstructed breast look and feel like a normal breast, but the woman also gets a tummy tuck in addition.
Latissimus dorsi flap
The latissimus dorsi flap is a remarkably well tolerated by the patient and is associated with very few complications. It is our flap of choice for older patients and for patients with medical problems. In this procedure skin, fatty tissue, and muscle is taken for the back and transferred under the skin to the mastectomy cavity following the removal of the breast (it can also be done as a delayed procedure following mastectomy). In many cases an implant is placed under the latissimus flap in order to create a breast that is symmetrical with the other breast. The following are examples of latissimus flap reconstruction:
- Placement of a tissue expander under the muscle at the time of mastectomy is the least traumatic and most popular of our reconstruction options. The tissue expander is nothing more than an empty sack made of silicone that is placed under the muscle after the breast has been removed. Most patients go home on the first or second day after surgery, and in general the post-operative pain is easily controlled with oral medication.
- The surgical wounds are usually given a few months to heal before the process of expansion is started. Over a period of several weeks saline is injected into the implant (simple in office procedure done with a local anesthetic) until it enlarges to a size that is slightly larger than the original breast. Following the completion of the expansion process the expander is exchanged for a permanent implant which is filled with either saline or silicone. This procedure is done as an out-patient, usually under local anesthesia.
- After another few weeks of healing, a woman may choose to have nipple reconstruction. This again is done as an outpatient, and is a well tolerated procedure. After the reconstructed nipple heals, it is tattooed so that the color matches the other side.
- In some cases there is the need to modify the opposite breast to produce a more cosmetic result. In cases where the opposite breast is small, an implant can be added. If the opposite breast is large, it can be reduced.
Reconstruction following lumpectomy and radiation
Most patients that are have lumpectomy and radiation for the treatment of their breast cancer have a good to excellent cosmetic result. However, in some cases the breast is distorted following completion of radiation therapy and reconstruction is an option for selected patients. Our standard approach to reconstructing the irradiated breast is to place an implant under the breast. Other approaches to reconstruction include the transfer a latissimus flap to fill in the surgical defect or mastectomy with tram flap reconstruction.