Post Mastectomy Reconstruction
Although the elusive goal of a cure for breast cancer has not yet been achieved, we are fortunate to have a much wider array of options for breast cancer therapy than were available even five years ago.
Rush has long been a leader in the field of medical oncology and we are grateful that our colleagues are able to provide therapies that in many cases can hold even advanced disease at bay. From a surgical perspective, many patients are able to take advantage of various techniques of breast conservation therapy, which may eliminate the need for mastectomy. There remains, however, a significant group of patients for whom mastectomy is the best treatment option, and for many of these patients immediate breast reconstruction at the time of mastectomy (post mastectomy reconstruction) can lessen the stress of the treatment experience. For many patients who have undergone or who are about to undergo mastectomy there is a sense of a double threat.
There is the potential threat to longevity that the breast cancer itself imposes- with the associated concerns of family responsibility and the ability to accomplish life’s major goals. There is also the threat to a woman’s sense of beauty, physical harmony and sexuality. This second threat is sometimes neglected by the doctors who seek to cure the patient of her disease. The plastic surgeon can step into this void and help to complete her cure in the truest sense of the word through breast reconstruction surgery. A person is not “cured” until her sense of physical integrity and well-being is restored. Several techniques are available for immediate reconstruction after mastectomy. These techniques can be divided into two general categories, those which make use of silicone gel or saline implants to provide the volume of the reconstructed breast and those techniques which require the movement of tissue from other parts of the body (so-called autologous techniques of reconstruction). If autologous tissue is part of the treatment plan, most plastic surgeons make use of either tissue from the abdomen or the back.
When abdominal tissue is used for breast reconstruction, the fat that surrounds the umbilicus and a portion of the overlying skin is transferred to the chest in order to provide the volume and contour of the reconstructed breast. In order for this tissue to survive it must have a blood supply. There are three main ways that blood supply can be provided. In the TRAM (transverse rectus abdominis myocutaneous) flap, the rectus muscle (the main sit-up muscle) is released from its attachments in the lower abdomen and kept attached near the ribs, so that it can be brought up as a life line to the abdominal flap. There are arteries and veins that run the length of this muscle and provide the actual blood supply to the abdominal flap. In the free TRAM a set of arteries and veins that run into the rectus muscle near its lower end in the pelvis are disconnected from their source vessels. These vessels, a segment of the rectus muscle, and the overlying abdominal skin and fat are brought to the breast area and the blood vessels are reconnected to vessels in the vicinity of the breast so that a blood supply is established. The DIEP (deep inferior epigastic perforator) flap is conceptually similar to the free TRAM flap, but involves the dissection of small blood vessels which run through the rectus muscle and serve as a blood supply to the flap. When one of these abdominal flaps is used for immediate breast reconstruction, there are both disadvantages and advantages.
Potential advantages include the natural fatty consistency of the flap and the avoidance of the possibility of implant related complications. There is also the possibility of a single stage reconstruction, as opposed to a reconstruction that requires several steps. As a practical matter it is often necessary to go back and do “touch up” operations if one desires a good balance between the reconstructed and the natural breast. Although some surgeons suggest an additional advantage to the abdominal flaps, that of providing a “tummy tuck,” this is not really so. In a well-performed tummy tuck (abdominoplasty) the scar should be hidden low, so that it runs along the line of a bikini or a French-cut swim suit, according to patient preference. The deep support of the abdominal wall is strengthened by sutures that bring the rectus muscles back near the midline, where they existed before being displaced by the stretching forces of pregnancy. After a tummy tuck of this nature, patients often experience a significant improvement in lower back pain due to an improvement in core muscle dynamics.
Unfortunately with the abdominal flaps for breast reconstruction the scar in most cases runs across the mid portion of the abdomen, since the key tissue for the flap surrounds the umbilicus. Also in order to obtain the blood supply for the flap some degree of abdominal wall compromise is often involved. With the TRAM flap most or all of one of the sit up muscles is taken. With the two free flaps, less muscle is sacrificed, but there are still consequences. In recent years an increasing number of people have discovered the critical importance of balancing and strengthening the function of the core muscles through such techniques as yoga and Pilates. A patient contemplating the use of an abdominal flap for breast reconstruction should discuss the issue of core muscle function with her surgeon.
The other main technique of autologous reconstruction is the back flap (latisiums flap). With this method a portion of the latisimus dorsi muscle (a very wide muscle from the upper and mid back) and often part of the overlying skin is moved from the back to the chest area to help reconstruct the breast. For most patients a saline or silicone gel implant is placed beneath this flap in order to provide sufficient volume for the reconstructed breast. The skin that is carried with the muscle is used to replace the missing skin that was taken with the mastectomy. This flap can be useful in very thin patients where there is concern about providing sufficient protection of the implant in the lower pole of the breast. In some cases just the muscle is taken, so that a second scar on the back is avoided. Even in this version of the flap, there are functional considerations. The latisimus muscle has important functions, particularly for athletes. The muscle plays an important role in certain motions, such as pushing off with a ski pole.
There are also considerations of long term body balance when all or part of a functionally important muscle is sacrificed. Tissue expander and implant reconstruction is well-suited to the patient who desires immediate breast reconstruction after mastectomy, because the initial procedure, the placement of the tissue expander, can be accomplished more quickly than either the back flap or the abdominal flap. Also, the recovery from the surgery tends to be easier, since the tissue expander method does not require the plastic surgeon to create scars in or remove tissue from other parts of the body. With tissue expander reconstruction, the plastic surgeon places a tissue expander beneath the pectoral muscle (the main muscle involved in push-ups) after the general surgeon has completed the mastectomy. Think of the tissue expander as a saline implant with a valve embedded in its surface. This allows the plastic surgeon to inject a small amount of saline solution into the expander at the end of the procedure. The valve will also allow the plastic surgeon to add additional amounts of salt water into the device, usually at weekly intervals; with the weekly addition of the saline solution to the device, the skin and underlying muscle will be stretched to create a breast of the appropriate size.
In our practice tissue expansion is carried out in a series of office visits which start either two or three weeks after the surgery. Most patients identify a particular day and time that is most convenient, and this becomes the regular expansion visit. Depending on the day, either Dr. Cook or one of his highly-skilled team of clinicians will carry out the expansions. We typically inject about 60 cc’s or 2 ounces of sterile salt water solution into the expander during each visit. Our goal is to move the expansion process forward at a good pace without causing unnecessary discomfort to the patient. If a patient needs either chemotherapy or radiation therapy after her mastectomy the treatments usually begin several weeks after the initial surgery to allow sufficient time for healing. This typically allows for between one and three expansions before the patient begins radiation or chemotherapy.
Once radiation or chemotherapy is underway, we will hold off on further expansion until the therapy is completed. Chemotherapy rarely impacts the result of tissue expansion in a negative way; the only disadvantage is that the expansion occurs over a longer time period, due to the pause during chemotherapy. Radiation therapy can be more problematic. Radiation can cause a production of extra scar tissue in the treated area. This means that the skin usually is stiffer than in someone who has not received radiation.
In some patients this stiffer tissue may resist the forces of tissue expansion and make it difficult for the surgeon to create an ideal breast shape with the expansion process. With tissue expansion the patient is an active participant in the decision as to when the optimum volume has been reached. There will typically come a point where the patient feels that the breast has achieved its proper size. If both breasts are undergoing reconstruction, both expanders are brought to the same volume. If one breast is reconstructed, the patient has a number of choices regarding the management of the opposite breast when the second stage of the reconstruction is carried out. If the opposite breast is large and heavy, it may be best to carry out a breast reduction. If the opposite breast is lacking in volume, particularly in its upper portions, it may be helpful for us to place an implant behind the breast in order to optimize the balance between the two breasts.
For some patients with a settled opposite breast, a mastopexy or breast lift may be helpful. There are also many patients who do not require any surgery of the opposite breast. Our goal is to provide each patient with a good background of information, so that she can select the proper combination of procedures for the second stage of surgery. Once the expander is brought to its optimum volume we carry out several more expansions to create extra space for the breast implant. The patient will then go through a resting period during which no further expansions are carried out. This period lasts from one to several months and allows the expanded tissue to relax.
During this period in which the reconstructed breast is over expanded, the patient can compensate by padding the brassiere on the side of the natural breast, so that balance will be maintained in clothing. The patient is now ready for the second stage of breast reconstruction. This stage is where the artistry occurs, since it is the stage that determines the form of the reconstructed breast and also brings the opposite breast into balance if that is desired by the patient. The second stage operation is carried out on an outpatient basis. A small portion of the mastectomy incision is opened and the tissue expander is removed. A number of techniques are used to create the fold under the breast, so that a natural curve in the lower pole of the breast is obtained.
Dr. Cook may also make use of fat transfer at this stage in order to add structure to particular areas of the reconstructed breast. According to the patient’s preference, Dr. Cook will use either a silicone gel or a saline breast implant to provide the main volume of the reconstructed breast. It is at this second stage outpatient procedure that Dr. Cook will modify the form and structure of the opposite breast in order to obtain optimum balance, if this is the patient’s desire. Options include breast reduction, breast lift (mastopexy), breast augmentation, and augmentation-mastopexy. Most patients are pleasantly surprised by the relatively quick recovery after the second stage of breast reconstruction. Light activity is permitted after the first postoperative visit, which usually occurs 3 or 4 days after surgery. Patients who work can return to their occupations in approximately 1 week, as long as the job does not involve heavy physical activity.
At our Winnetka and Chicago centers, we encourage our breast reconstruction patients to return to gentle exercise, such as walking, as soon as comfort permits. Soon after surgery we instruct our patients on a series of exercises designed to keep the space around the implant from becoming too restricted. This is particularly important in patients who have undergone radiation. We long for the day when this wonderful surgery will no longer be necessary!