Valley Health Magazine

By Kaye M. Riolo M.D., and John F. Burnett M.D.

Breast reconstruction is usually thought of in conjunction with mastectomy, or removal of the breast, for breast cancer. While this is by far the most common underlying reason for reconstruction, there are also partial defects, deformities and imbalances caused by cancer treatment, as well as  congenital asymmetry (breasts of different shapes/sizes), underdevelopment or even absence of the breast that can be improved or corrected by breast reconstruction.

The reasons women seek out breast reconstruction are as unique as the individuals themselves. For some, it is the simple convenience of not having to locate and situate a breast prosthesis in their bra and clothing every day. Breast prostheses, while providing a very reasonable external appearance in clothing, tend to shift, pull heavily on the shoulder strap of the bra (like carrying a heavy shoulder bag), and can be very hot in the summer months. They have been known to fall out while golfing and float away while swimming, causing obvious embarrassment and discomfort!

For others, the reasons are more internal. Some women feel less feminine or attractive without a breast. Others feel that reconstruction helps close the door on that chapter of their lives, helping them to move forward into "life after cancer." Some women can be so traumatized by the absence of their breast that they will shower in the dark and avoid looking in the mirror for years. Breast reconstruction can help them feel whole again. One of the most beneficial recent trends has been the coupling of  Immediate Breast Reconstruction with the actual mastectomy, allowing the woman afflicted with cancer to begin the restorative process immediately.

While it takes additional coordination between the breast and plastic surgeons' offices, it is definitely the standard of care here in Fresno. The options for immediate reconstruction are essentially the same as those for delayed reconstruction, but with the obvious advantage of being able to preserve and utilize the skin that is unaffected by the cancer. In a traditional mastectomy, not only is the nipple removed (there is breast tissue within the skin of the nipple), but also enough additional skin to allow for a smooth closure similar to the appearance of a young boy's chest. When reconstruction is performed simultaneously, an additional skin excision of the biopsy site and any skin directly attached to the tumor will also be taken. In this case, a Skin Sparing Mastectomy is designed by the plastic surgeon, allowing the additional, unaffected skin to be utilized in the reconstruction of the new breast. Compared to the description of a traditional mastectomy in which the Nipple-Areola Complex (NAC) is removed along with as much skin as it takes to make a flat chest, in a Skin Sparing Mastectomy with immediate reconstruction, the NAC is removed, as well as the scar used to biopsy the cancer; and then if the tumor sticks to the skin (rare) the skin overlying the cancer can be used in order to have an adequate superficial margin. This is true regardless of which reconstructive option is selected by the patient.

The reconstructive options to replace an entire breast generally fall into two categories: the use of implants or the use of autologous (a woman's own) tissue. Implant Reconstruction is done in two stages. The first stage involves the insertion of a temporary stretching device known as a tissue expander. If the implant were placed right where the breast tissue came from, it would touch the undersurface of the skin and cause a very unfavorable reaction and appearance. So the implant is hidden, so to speak, from the underside of the skin by placing it under the upper half of the pectoralis muscle, and a product known as acellular dermal replacement, akin to interfacing in sewing, is placed in the lower half. This pocket is not large enough to accommodate the entire volume needed on day one.

The expander is then further filled in the plastic surgeon's office for several weeks after surgery until a pocket of adequate volume has been achieved. A second surgery is subsequently scheduled, to exchange the tissue expander for an actual breast implant. This can be either saline or silicone, and the pros and cons of each should be discussed in detail with each woman. Every woman needs to be fully informed and comfortable with her choice. Don't hesitate to take as much time as you need deciding and ask as many questions as possible.

The appearance that is achieved once the implant is finished is usually very good  in clothing, especially with the right bra, although at times a symmetry procedure (optional, of course) may be advised for the other breast to maximize the result. Naked, the reconstructed breast has the appearance of a breast that is a bit too perky, and somewhat flattened across the front such as that seen in a sports bra. One of the biggest drawbacks of the implant reconstruction is that the implants do not last forever. It is  expected that there will be"maintenance surgery" to replace the implants after 10 years or so, or to make other adjustments that become necessary over time.

Autologous Breast Reconstruction typically involves the use of the abdominal tissues. While there are other more remote sources of tissue for reconstruction they are seldom utilized due to significantly higher problems associated with the surgery and the donor sites. Breast reconstruction using the abdominal tissues is based on the fact that the skin and subcutaneous fat that sits in the lower abdomen, from the umbilicus (belly button), to the pubic area, (the tissue that is discarded in a tummy tuck), receives its circulation through the rectus muscles (sit-up muscles, six-pack, etc). The most commonly utilized technique, a pedicled TRAM (Transverse Rectus Abdominus Myocutaneous) flap, leaves the muscles attached to the lower edge of the ribs, but detaches them at the pubic bone. The fat, skin and muscle are then passed under the skin of the upper abdomen and into the chest area where the breast has been removed.

The results are a breast very similar in consistency to the natural breast, which also has a high fat composition. It is the most reliable way to match a large or a "sagging" breast. The trade off is in the abdomen. While it has some similarities to a tummy tuck in terms of the tissue removed and the resulting smiley-face scar in the lower abdomen, the fact that it borrows one or both of the abdominal muscles makes it quite different. There is loss of some of the so-called "internal girdle" support, there is fullness in the area below the bra where the muscle turns the corner into the breast, and there is an ironing out of the fold beneath the breast that sometimes allows the bra to continually ride up onto the breast.

More complicated versions of this surgery either tease the feeding vessels from the stomach out of the muscle, (DIEP flap) or in fact completely disconnect the vessels, reattaching them to blood vessels in the  underarm (Free TRAM flap). The trade-offs in the abdomen are less with these techniques, but the chance of losing some or all of the tissue rises commensurately.

Sometimes a woman will require the use of radiation to the chest wall after a mastectomy. This complicates the reconstructive options because radiation gives the tissues a more leathery quality, preventing sufficient stretching to allow for a comfortable and  attractive implant reconstruction. Autologous tissue can still be used, but a simple two-stage implant reconstruction cannot. If the abdomen is not an option for one reason or another, a Latissimus Flap is added to the staged implant reconstruction scenario. This brings non-irradiated skin and muscle around from the back, beneath the skin of the armpit, to the breast area. The tissue expander is then placed beneath the pectoralis muscle at the top and the latissimus muscle at the bottom to accomplish complete implant coverage. The stages then proceed as afore mentioned.

Symmetry Procedures on the Opposite Breast are certainly optional for those who prefer to avoid surgery on the opposite breast, but are sometimes employed to “meet in the middle when the limitations of what can be done on the reconstructed side have been reached. These include breast lift, breast augmentation, and/or breast reduction. There are also times when a larger breasted woman will not want to reconstruct her absent breast but will elect to reduce the remaining breast so that she can wear a lighter, smaller breast prosthesis. Insurance covers not only the reconstruction of the lost breast, but the necessary symmetry procedures as well, recognizing that a successful reconstruction creates a "pair" of breasts that are similar in size and shape, and at times a bilateral approach is needed to achieve this result.

Partial Mastectomy Defects are frequently more challenging to address than the complete absence of the breast. After a lumpectomy and radiation, the affected breast may simply be smaller, or it can have a localized tissue deficit. While there is not an implant to just "fill in a dent," implants can be utilized to restore overall volume loss or to address asymmetries. The latissimus flap can be used to fill in a localized defect, although there are long term consequences if the cancer should return that must be discussed before proceeding in this direction.

Congenital Breast Abnormalities fall into two categories, volume and shape and volume alone. In the typical volume discrepancy setting, the affected breast is smaller, sits higher on the chest, and has a smaller nipple areola complex than the opposite side. If there is an associated absence of the pectoralis muscle, the condition is known as Poland's Syndrome. A tubular breast deformity is a condition in which the lower portion of the breast is significantly underdeveloped or absent, leaving the nipple at the lowest portion of the breast (a question of shape). It is usually associated with herniation of breast tissue into the nipple areolar complex, which causes a protruding areola. Breast implants and manipulation of the breast from within can improve the appearance tremendously.

Revision of Previous Reconstruction is expected over the years, although more so with  implant reconstruction than with autologous tissue. Breast implants do not last forever, and there can be changes in the breast shape, constriction of the scar tissue around an implant, sagging of the reconstructed tissues, the opposite breast, or both, all of which can be addressed with secondary surgery as the need arises.
While we sometimes think of breast augmentation as simply "implants", or a luxury for women who can afford it, the truth is there are myriad reasons why a woman might seek out information on her surgery options. For all women, including those seeking reconstruction after cancer, it is vital to know that there are top-quality doctors and choices here in the Central Valley. Most importantly, women undergoing mastectomy may want to start thinking about or doing some research on breast reconstruction as early as pre-biopsy. As with anything else, the more proactive you are and the more information you obtain, the better informed your choice will be.