Treatment
There are two types of breast reconstruction available for women today: implant reconstruction, in which silicone or saline implants are inserted into the breast area, and autologous reconstruction, in which a surgeon creates a new breast using fat, tissue and, usually, muscle from another part of your body.
Which procedure is right for you depends on several factors, including your overall health and any other medical conditions, whether or not you smoke, your size (autologous reconstruction often can't be performed on thin women), the size and shape of the other breast and your past surgical history.
Breast Reconstructive Surgery with Breast Implants
Breast reconstructive surgery involves inserting a breast-shaped, silicone shell filled with either silicone gel or a salt water (saline) solution behind the pectoral muscle. About 60 to 75 percent of breast reconstructions are performed with an implant.
Breast reconstruction with breast implants has several advantages, including a shorter surgery and quicker recuperation than autologous breast reconstruction. Disadvantages include a greater risk of future complications that include infection, rupture, extrusion (in which the implant comes through the skin) or capsular contracture, in which scar tissue builds up around the implant, sometimes causing pain and distortion of the tissue.
One study published in The New England Journal of Medicine found that one in three women using breast implants for reconstruction required another operation within five years. Similar to other medical devices, breast implants—saline or silicone—are not lifetime devices. It is likely, that at some point in your lifetime they may need to be removed or replaced and you should talk to your surgeon about this prior to surgery. Also, check with your insurance company to see if it covers subsequent surgeries.
Breast implants also may require a two-stage surgical process, depending on how much skin is left in the breast area after mastectomy. The first stage involves placing a balloon-like tissue expander under the skin in the breast area, then adding saline every week or so for a month to several months to stretch the skin. This isn't painful but may be uncomfortable.
After the skin is stretched enough, the expander is removed and the permanent breast implant is inserted in a second surgery, usually in an outpatient setting under general anesthesia. In some instances, however, the expander can be left in place as the permanent breast implant although this is not usually recommended. The advantage of a permanent implant is that the position, contour, and symmetry of the breast is usually improved.
When reconstructive surgery with an implant is only performed on one breast, the difference between the new and old breast may be quite noticeable. In many cases, surgeons may recommend breast implant surgery on the unaffected breast as well to achieve a similar, balanced look. Even though this procedure is considered cosmetic, it is covered by health insurance under the 1998 Federal Breast Reconstruction Law.
If you choose breast implants, you need to decide whether you want a silicone gel-filled implant or a saline implant. You and your surgeon should work together to decide which breast implant will better fit your needs and expectations.
In 1992, due to reports of leaking silicone and possible health implications, the U.S. Food and Drug Administration (FDA) called for a voluntary moratorium (delay) on the use of silicone gel-filled breast implants until new safety information could be thoroughly reviewed by the FDA's advisory panel. Within three months, the FDA allowed silicone breast implants to be used again but only for reconstructive surgery and revision (implant replacement) surgery under clinical study protocols. At this time, silicone gel-filled breast implants were not approved for women seeking cosmetic breast augmentation.
Silicone gel-filled breast implants are among the most extensively studied medical devices in existence, according to the FDA. In the past 15 years, more than 100 studies have been conducted on the safety of silicone gel-filled breast implants in the United States and around the world. These studies find no increased risk of autoimmune disorders (lupus and rheumatoid arthritis) or connective tissue diseases (like scleroderma) or related disorders, breast or other cancers or neurological disorders in women who use silicone gel-filled breast implants. These findings were clearly outlined in a 400-page, 1999 Institute of Medicine report on the Safety of Silicone Breast Implants. One study published in the journal Breast Cancer Research in early 2005 found that women who received breast implants after mastectomy lived longer and had a lower risk of death from breast cancer compared to women with breast cancer who didn't have implants, regardless of the type of implant used.
As a result, the FDA is now allowing silicone gel-filled breast implants to be used again. Silicone gel-filled breast implants are approved for breast reconstruction in women of all ages and for breast augmentation in women age 22 and over. Silicone gel-filled breast implants are manufactured and sold by Allergan, Inc., and Mentor Corp.
Today's silicone gel-filled breast implants benefit from more than 15 years of improved manufacturing technology and more stringent tolerance specifications, resulting in a more consistent manufacturing process that significantly reduces manufacturing errors. Major changes include thicker shells and more cohesive gel to reduce the risk of rupture and the likelihood that gel will leak into the body if the breast implants do rupture.
Questions remain, however, about silicone gel-filled breast implant rupture rates. To better understand the long-term safety of breast implants, the FDA has required that Allergan and Mentor each conduct a 10-year study of 40,000 women with breast implants to assess potential safety issues. The FDA requires post-market surveillance for all medical devices and drugs as a standard condition of approval.
Similar to other medical devices, breast implants—saline or silicone—are not lifetime devices. It is likely, that at some point in your lifetime they may need to be removed or replaced and you should talk to your surgeon about this prior to surgery. Additionally, an estimated 58 percent of women who undergo breast reconstructive surgery with breast implants experience some type of complication, such as infection or rupture, which may require additional medical treatment or surgery.
Autologous Breast Reconstruction
Autologous breast reconstruction, also called tissue flap reconstruction, is used in about 30 percent of breast cancer reconstructive surgeries. It involves taking fat, blood supply and, usually, muscle from other parts of your body to create a breast. Most flap procedures use tissue from your back or abdomen, although some use tissue from your thigh or buttocks.
While this procedure tends to provide a more natural looking breast, it is much more difficult to perform than breast reconstructive surgery with breast implants, requiring a very experienced surgeon. As with breast implants, this surgery can usually be performed immediately after mastectomy unless you need radiation or there are other medical reasons to delay breast reconstructive surgery.
In general, women who smoke, or who have diabetes, connective tissue or blood vessel diseases are not good candidates for this procedure because these conditions can affect blood circulation. A healthy blood supply to the new breast is critical to the success of the surgery.
Also, women who are overweight or who have had previous surgery at the site from which the tissue will be taken may not be good candidates. A consultation with a plastic surgeon is necessary to assess eligibility.
All flap reconstructions carry certain risks, including the loss of blood supply to the new breast, which could lead to infection and/or the loss of some or all of the breast tissue. Procedures that use abdominal muscle to create the breast carry a slight risk of abdominal hernia, a hole or weakness in a muscle wall that allows whatever lies behind the muscle to push through. Additionally, recovery from all autologous procedures is much more extensive than from implants, requiring up to a week in the hospital and several weeks recovery at home.
Several types of flap reconstruction may be performed to create the breast or a pocket for an implant.
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Latissimus dorsi flap (LDF). In this operation, the surgeon transplants a section of tissue from your back to your chest to reconstruct the breast. This procedure is most appropriate for women with small breasts and heavy women in whom use of the TRAM or DIEP flaps (described below) is not possible. Downsides include the possibility of weakness in your upper back and chest, a noticeable scar on your back and a seroma or fluid collection
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TRAM (Transverse Rectus Abdominis Muscle) flap. This is the most commonly performed autologous breast reconstruction. The surgeon uses sections of artery and vein, as well as fat, skin and muscle from the lower abdomen to shape a new breast. An added bonus is that you get a tummy tuck. This procedure takes about three to six hours and requires several days of hospitalization. But it provides a very natural looking breast, similar to the unaffected breast. Disadvantages include the possibility of a hernia or bulging in the abdominal wall and some loss of abdominal function, particularly if two abdominal muscles are used.
There are two main types of TRAM flaps:
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Pedicle flap. In this procedure, the surgeon leaves the flap attached to its original blood supply and tunnels under the skin to bring it to the breast area.
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Free flaps. In this procedure, the surgeon cuts a portion of the abdominal muscle along with its blood supply out of the abdomen, and then reattaches it to the breast area using microsurgery to connect the blood supply. This procedure is more complex than the pedicle flap and requires a longer operating time and admission to a ward that specializes in the monitoring of flaps to ensure that the new breast's blood supply works properly. It is particularly useful when tissues are damaged such as following radiation therapy and cannot be used for tissue expansion. The free flap procedure is not performed as often as the pedicle flap, but it has a high satisfaction rate. There's also less risk of abdominal bulges, or hernia, because only part of the muscle is used, and there may be less postoperative pain and discomfort, because there's no "tunneling."
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Gluteal free flap. This procedure is similar to the free flap already described, but uses muscle and other tissue from the buttock instead of the abdomen. This is a good option for women who do not have enough abdominal tissue for breast reconstruction. The two types of flaps from the gluteal region are the SGAP (superior gluteal artery perforator) and the IGAP (inferior gluteal artery perforator).
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DIEP (Deep Inferior Epigastric Artery Perforator) flap procedures. Like the free flap, this procedure transfers tissue from the abdomen to the breast. However, instead of transplanting the muscle, the surgeon carefully teases the blood supply away from the muscle, sparing the muscle. This is a very delicate procedure requiring microsurgery and a specially trained surgeon to ensure a healthy blood supply in the new breast, but it leaves you with full function in your abdomen.
Reconstruction of the Nipple and Areola
Once your breast has been reconstructed, you can choose to have a nipple and areola (the surrounding dark tissue) created. This is done as a separate, outpatient procedure after the reconstruction heals, usually under local anesthesia. The nipple is usually reconstructed with a tattooed skin flap, with skin taken from your own body, such as from your opposite nipple, ear, eyelid, groin, upper inner thigh, buttocks or the newly created breast. The areola is created with tattooing a few weeks later.
Realistic Expectations
It's important that you have realistic expectations about your breast reconstructive surgery. Among the issues to consider are:
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Scarring. There will be some scarring. How much depends on your individual situation. All scars will be pink to red for six to 12 months before they fade to a normal skin tone.
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Mismatched breasts. Your new breast may not match your old breast entirely, and you may need surgery on the unaffected breast to make the two look the same.
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Lack of sensation. Depending on how much skin was left after the mastectomy, you may not have much sensation in the reconstructed breast. Over time, the skin may become more sensitive but may never return to the level of sensitivity it had before the surgery.
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Repeat surgeries. In some instances, particularly with breast implants, you may need additional surgeries in the years ahead to correct any problems. Also, similar to other medical devices, breast implants—saline or silicone—are not lifetime devices. It is likely, that at some point in your lifetime they may need to be, removed or replaced.
After Breast Reconstructive Surgery
After breast reconstructive surgery, you may not need mammograms on the reconstructed breast, although you should still continue breast self exams on the healthy breast to feel for any abnormalities. Make sure you continue following up with your surgeon and oncologist for signs of any recurrence. If the cancer recurs, your treatment will be the same whether or not you've had breast reconstruction. If breast imaging is advised, an MRI is usually recommended.
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Create Date: 10/21/05
Date Last Updated: 9/19/07
Review Date: 9/1/07
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