Tough Questions about Reconstruction after Breast Cancer
By Dr. Emily Clarke-Pearson and Dr. Kelly Sullivan
One Out of Eight Women Are Diagnosed with Breast Cancer
A breast cancer diagnosis can be overwhelming and can lead to fear, confusion and feelings of despair. Sadly, because approximately one out of every eight women gets breast cancer, most of us have at least one friend or family member either battling with or recovering from this disease.
With the obvious emphasis on curing the cancer, it is often hard in the initial stages of diagnosis and treatment planning to think about breast reconstruction after the cancer is removed. Some women are not interested in any reconstruction and prefer to undergo a mastectomy and then wear a bra with a prosthetic breast. This is a perfectly acceptable option. However, expectations for breast reconstruction have evolved over the past several decades, and there are now many options to create a new breast, helping to restore a woman’s sense of self.
If I am getting a lumpectomy or partial mastectomy, will I need breast reconstruction?
In some cases, a woman and her breast surgeon may decide that a lumpectomy, or removal of only a part of the breast, is the best surgical treatment. Some lumpectomy surgeries, however, require removal of enough breast tissue to create a mismatch with the normal side. In larger breasted women who desire to be smaller, this creates an opportunity to do an oncoplastic reduction. What this means is that the breast surgeon performs the lumpectomy, and in the same surgery, a plastic surgeon then comes in and does a breast reduction on the normal side. The plastic surgeon can also rearrange or remove more tissue from the cancer side to achieve the smaller size desired by the patient.
What are the options for breast reconstruction after mastectomy?
If a mastectomy, or removal of the entire breast, is the treatment plan, several reconstructive options are available. These options fit into two main categories: implant-based reconstruction and autologous (using the patient’s own tissue) reconstruction. The type of reconstruction chosen depends on many factors: a woman’s breast and body size, what cancer treatment (such as radiation) is required, and, of course, what the patient prefers.
Are breast implants safe to use for breast reconstruction after cancer?
Breast implants are safe to use in all settings, both for cosmetic enhancement and also for cancer reconstruction. Despite rumors and bad press two decades ago implicating silicone implants as potential culprits of cancer and other problems, no scientific evidence ever supported these claims. Currently, the majority of implant reconstructions after breast cancer are done with silicone implants, not saline water–filled implants. The new models of silicone implants are softer and more natural feeling, and have very low rates of rupture or leaking.
Can my breast cancer surgery and implant breast reconstruction be done in only one operation?
In many cases, this is possible. If the breast surgeon is able to keep most of the breast skin and potentially even the nipple, an implant can be placed at the time of the mastectomy. This means the cancer surgery and reconstruction can be done in one surgery, allowing the patient to begin the healing process immediately.
If a patient requires radiation treatment after mastectomy, desires to be a larger size, or has more breast skin or the nipple removed, the implant reconstruction is done in two stages. Stage one is at the time of mastectomy, when a deflated prosthetic breast called a tissue expander is placed. This surgery requires at least an overnight stay in the hospital.
The tissue expander has a port that is injected with saline water in the plastic surgeon’s office over the course of six to eight weeks. While the patient looks relatively “flat” after the first surgery, as the expander is inflated, the new breast mound forms. When the patient is happy with the expanded size, the tissue expander is removed and a permanent implant is placed. This is stage two. The surgery is usually much shorter than stage one and can be done as an outpatient.
What if I don’t want an implant? Can I use my own tissue for breast reconstruction?
Recreating a breast with a patient’s own tissue is also an excellent option for the right patient. Usually, the tissue used for this reconstruction comes from the belly, so a “tummy-tuck” procedure is performed, and instead of discarding the tissue, the surgeon uses it to create a new breast. If a bilateral mastectomy is performed, which is when two breasts are removed, both can be made from the belly tissue. There are many advantages to autologous reconstruction. The tissue is softer and more natural feeling than an implant, and long-term satisfaction tends to be overall higher. The reconstruction can be done at the same time as the mastectomy, which means only one hospitalization and recovery process.
Traditionally, one drawback to using the belly tissue was that the abdominal wall musculature must be cut to do the tissue transfer. However, the standard of care in these reconstructions has now evolved to use microsurgery. The surgeon dissects tiny vessels that feed the fat and skin of the belly and plugs them in to tiny blood vessels in the chest. In this way tissue is transferred without hurting any abdominal muscle. Not all plastic surgeons are trained to perform microsurgical breast reconstruction, so it is important to ask you surgeon about this option.
I do not have a lot of extra belly tissue, can tissue from my thighs or back be used?
If a woman does not have enough belly tissue for reconstruction, or has had abdominal surgeries that interfere with using the belly, autologous tissue can be transferred from the back, buttocks or thighs to recreate a breast. This is often done with the help of microsurgery to provide good blood flow to the transferred tissue.
I had a mastectomy a decade ago and never got reconstructed. Is it possible to go back and get a breast reconstruction now?
Absolutely. A plastic surgeon that specializes in breast reconstruction can advise you on what the best choice is for you. Implant reconstruction and reconstruction with your own tissue are both potential options.
Where can I find support for dealing with my cancer diagnosis?
Wellness House is a nonprofit organization in Annapolis that provides free support services to those affected by cancer and their loved ones. Wellness House operates out of a bucolic farmhouse on Mas Que Farm Road and has services such as Reiki, Healing Touch, massage, art therapy, book club, children’s support programs, and group and individual counseling sessions. All of the services are free of charge and are designed to help cancer patients and their loved ones receive the emotional support and strength they need to fight their cancer. For more information, visit annapoliswellnesshouse.org.
Dr. Kelly Sullivan is certified by the American Board of Plastic Surgery and is a fellow in the American College of Surgeons. She received her Bachelor of Science degree in mechanical engineering from M.I.T., her medical doctorate from Harvard Medical School, and completed her general surgery residency and plastic surgery fellowships
at Emory University.
Dr. Emily Clarke-Pearson is a plastic and reconstructive surgeon specializing in complex reconstruction and cosmetic surgery. She graduated Phi Beta Kappa from the University of North Carolina and then received her medical doctorate from Brown University Medical School. Dr. Clarke-Pearson completed her general surgery residency at Mount Sinai Beth Israel in New York and her plastic surgery fellowship at Harvard University. Dr. Clarke-Pearson has just completed an additional year of fellowship at Johns Hopkins Hospital focusing on microsurgical reconstruction of cancer and trauma patients.