Breast reconstruction is now a well established and integral part of the treatment pathway for women with breast cancer. Indeed, women are ever more informed about the possibilities that are available to them. Breast reconstruction is now part of the process of recovery from breast cancer for many women, and is a very positive step.
The two surgeons (the cancer consultant and the plastic surgeon) work closely together throughout the process - the treatment of cancer being the first priority. The breast reconstruction may take a little time, but for many women the benefits outweigh other considerations.
Breast reconstruction can be carried out at the same time as mastectomy or some time afterwards. Many factors influence this decision - patient choice being one factor - but if radiotherapy is prescribed for use after the mastectomy, reconstruction will have to be delayed, as radiotherapy can affect reconstructed breasts.
Reconstructions principally group into three surgical categories
- Implant based reconstruction
- Autologous reconstruction (using areas of the body) such as the abdomen (TRAM/DIEP Flap) or the back (latissimus dorsi muscle) without the need for an implant
- A combination of 1 and 2 where usually some body tissue is combined to form a breast with an implant (usually the latissimus dorsi - a back muscle).
It should be stressed that each of these methods has its own advantages and disadvantages and that no one method is necessarily the "correct" method. It is also important to know that not necessarily all of these options are available to everyone. The choice of reconstruction depends on overall body shape and also the shape, size and dimensions of the opposite breast.
Some reconstructions are better suited to some breast forms than others.
Choosing the right option
Briefly, implant based reconstruction using fixed volume or expandable prostheses has the advantage of being technically less complex to carry out. It has a relatively short operative time and hospital stay, and a quick post-operative recovery. The disadvantage is that perhaps aesthetically the results are not always as good as in the autologous group - an implanted breast feels different to a natural breast. Also an implant potentially needs maintenance over time, for reasons such as hardening, malposition, infection or rupture.
A reconstruction using one's own body tissue (most commonly the abdomen), on the other hand, is often technically highly complex, requires prolonged operative time and inpatient stay. Recovery time is slower and has a greater impact on daily activities in the initial period. The advantages, however, lie in that fact that the breast produced is as close to the real thing as possible and it feels, moves and flows very similarly to a normal breast. Once symmetry is achieved it needs no further maintenance throughout life.
Implant based reconstruction may be suitable for those who have busy schedules, want little downtime or simply do not want to go through major surgery with slower recovery. Very good results can be achieved. On the other hand, for women who feel they want to invest time and energy into achieving the most natural breast they can get, then the autologous route may well be the choice for them.
Somewhere in between lies the combination of a latissimus dorsi myocutaneous flap (back muscle) and an implant. The skin and muscle from the back draped over the implant will afford more protection and also allow for a slightly more natural look than with just an implant. A more natural droop can be produced using the skin paddle from the back.
As with all fields of medicine and surgery, continual refinement is constantly being undertaken. In the field of breast reconstruction,the old abdominal flaps known as TRAM flaps are slowly being superseded by the DIEP flaps (Deep Inferior Epigastric Perforator flap) and other related alternatives designed to maximize use of the tissue.
At the time of breast cancer diagnosis it is very difficult to take in detailed explanations about complex procedures for breast reconstruction and often it takes several visits before being able to make an informed decision.
It is important that the decision is made as a joint one between the consultant and patient. Breast reconstruction is part of a process, it is rarely a one-off event. Once the main operation to make the breast has been completed, small adjustments may be required to perfect the outcome.