Breast Reconstruction

Overview :

Breast reconstruction is done in two stages, with the ultimate goal of creating a breast which looks and feels as natural as possible. It is important to remember that while a good result may mimic a normal breast closely, there will inevitably be scars and loss of sensation. The reconstructed breast cannot be exactly like the original.

The first step is to form a structure called a breast mound. This can be accomplished using artificial materials called breast implants, or by using tissues from other parts of the woman's body. The second step involves creating a balance between the newly constructed breast and the breast on the opposite side. The nipple and areolar complex (darker area around the nipple) are recreated. This is usually done several months after the mound is created, to allow swelling to go down. Other procedures may be necessary, such as lifting the opposite breast (mastopexy), or making it larger or smaller to match the reconstructed breast.

Timing, immediate or delayed reconstruction

While immediate reconstruction (IR) is not recommended for women with breast cancer who need to undergo other, more important treatments, breast reconstruction can be done almost anytime. It even can be done during the same procedure as the mastectomy, or it can be delayed. There are psychological benefits to IR. The ability to return to normal activities and routines is often enhanced when reconstruction follows immediately after mastectomy. A better appearance may result from IR. There is less skin removal, often resulting in a shorter scar. The surgeon is better able to preserve the normal boundaries of the breast, so it is easier to match the opposite breast more closely.

The cost of IR is generally lower than the cost of delayed reconstruction (DR). There is one fewer operation and hospital stay. Surgeon's fees may be lower for a combined procedure than for two separate surgeries.

There are disadvantages of IR as well. The surgery itself is longer, causing more time under anesthesia. Post-operative pain and recovery time will be greater than for mastectomy alone.

Other authorities contend that delayed reconstruction (DR) offers different physical and psychological advantages. The initial mastectomy procedure alone takes less time, and has a shorter recovery period and less pain than mastectomy and IR. The patient has more time to adjust to her diagnosis and recover from additional therapy. She is better able to research her options, and to formulate realistic goals for reconstruction. Some reconstructive surgery requires blood transfusions. With DR, the patient can donate her own blood ahead of time (autologous transfusion), and/or arrange to have family and friends donate blood for her use (directed donation).

The psychological stress of living without a breast is a disadvantage of DR. The extra procedure DR entails results in higher costs. Although initial recovery is faster, an additional recuperation period is required after the delayed operation.

Type of reconstruction

There are two basic choices for breast reconstruction. The breast tissue can be replaced with an implant or the breast is created using some of the woman's own tissues (autologous reconstruction).

ARTIFICIAL IMPLANTS. In general, implant procedures take less time, and are less expensive than autologous ones. Implants are breast shaped pouches. They are made of silicone outer shells, which may be smooth or textured. The inside may contain silicone gel, saline (salt water), or a combination of both.

An implant may be a fixed volume type, which cannot change its size. Implants that have the capacity to be filled after insertion are called tissue expanders. These may be temporary or permanent.

The initial procedure for any implant insertion uses the mastectomy incision to make a pocket of tissue, usually underneath the chest wall muscle. In DR, the mastectomy scar may be re opened and used for this purpose, or a more cosmetic incision may be made. The implant is inserted into the pocket, the skin is stretched as needed and stitched closed.

If there is inadequate tissue to achieve the desired size, or a naturally sagging breast is desired, a tissue expander is used. It resembles a partially deflated balloon, with an attached valve or port through which saline can be injected. After the initial surgical incision is healed, the woman returns to the doctor's office, on a weekly or bi-weekly basis, to have small amounts of saline injected. Injections can continue for about six to eight weeks, until the preferred size is obtained. In some cases it may be overfilled, and later partially deflated to allow for a more pliable, natural result. A temporary tissue expander will be removed after several months and replaced with a permanent implant.

IR surgery using an implant takes approximately two to three hours, and usually requires up to a three day hospital stay. Implant insertion surgery, as part of DR, takes one to two hours and can sometimes be done as an outpatient, or it or it may entail overnight hospitalization.

AUTOLOGUS RECONSTRUCTION. Attached flap and free flap are two types of surgery where a woman's tissue is used in reconstruction. An attached flap uses skin, muscle, and fat, leaving blood vessels attached to their original source of blood. The flap is maneuvered to the reconstruction site, keeping its original blood supply for nourishment. This may also be known as a pedicle flap. The second kind of surgery is called a free flap. This also uses skin, muscle, and fat, but severs the blood vessels, and attaches them to other vessels where the new breast is to be created. The surgeon uses a microscope to accomplish this delicate task of sewing blood vessels together. Sometimes the term microsurgery is used to refer to free flap procedures. Either type of surgery may also be called a myocutaneous flap, referring to the skin and muscle used.

The skin and muscle used in autologous reconstruction can come from one of several possible places on the body, including the abdomen (TRAM flap or "tummy tuck"), the back (latissimus dorsi flap), or the buttocks (gluteus maximus free flap).

Finishing the reconstruction

Other procedures may be necessary to achieve the goal of symmetrical breasts. It may be necessary to make the opposite breast larger (augmentation), smaller (reduction), or higher (mastopexy). These, or any other refinements should be completed before the creation of a nipple and areola. Tissue to form the new nipple may come from the reconstructed breast itself, the opposite breast, or a more distant donor site, such as the inner thigh or behind the ear. The nipple and areolar construction is usually an outpatient procedure. A final step, often done in the doctor's office, is tattooing the new nipple and areola, to match the color of the opposite nipple and areola as closely as possible.

Insurance

Insurance coverage for breast reconstruction varies widely. Some policies will allow procedures on the affected breast, but refuse to pay for alterations to the opposite breast. Other plans may cover the cost of an external prosthesis, or reconstructive surgery, but not both. As of January 1998, 25 states had different laws regarding required insurance coverage for post mastectomy reconstruction.

Implants may pose additional insurance concerns. Some companies will withdraw coverage for women with implants, or add a disclaimer for future implant-related problems. Careful reading of insurance policies, including checking on the need for pre-approval and/or a second opinion, is strongly recommended.