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Breast Reconstruction After Mastectomy


July 28, 2008 — In this edition of Siteman Cancer Center’s Cancer Connection podcast series, plastic and reconstructive surgeon Keith Brandt, MD, discusses breast reconstruction after mastectomy and the latest developments in the field.

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On this edition of Cancer Connection, we’ll talk about breast reconstruction after mastectomy, find out what a woman should know before surgery and discuss the latest approaches surgeons are using.

Host: Thanks for downloading this podcast from the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine in St. Louis. I’m Jason Merrill. If a patient is going to have a mastectomy, breast reconstruction – which is surgery to rebuild the breast shape after mastectomy – may be considered. To talk with us about it is Keith Brandt. Dr. Brandt is a breast reconstruction specialist with the Siteman Cancer Center. Dr. Brandt, thank you for joining us.

Brandt: Thank you. It’s a pleasure being here.

Host: How many patients go on to reconstruction after mastectomy?

Brandt: It’s a little bit different depending on where you’re at. Here in a major metropolitan area that has a unique center like the Siteman Cancer Center, we’re probably in the 25 to 30 percent range. Nationally, however, the figure is down around 8 to 10 percent.

Host: Why do you think that number is so low nationally?

Brandt: Outside of the major metropolitan areas, we do not have the well-oiled teams like we do here at Siteman, where you have surgical oncologists working day to day with reconstructive surgeons devoted to breast reconstruction. So the number drops outside of the major metropolitan areas.

Host: So you work hand in hand with breast surgeons after they remove tumors, correct?

Brandt: We actually start working with them prior to any procedure and make a combined decision with the surgical oncologist. And then yes, we work with them on the day of the mastectomy.

Host: How does it work, typically, for a breast cancer patient? Everyone is different, obviously, but as a rule, how do things usually work out?

Brandt: It is surprising how many women have a little bit of twist to their history or their story that requires there be a decision made between the surgical oncologist and the reconstructive surgeon prior to surgery. But typically our goal is to preserve all the lady’s options, and that means to preserve her breast skin. The surgical oncologists here at Siteman do a skin-sparing mastectomy, and they leave everything behind that’s healthy. And then our goal is to preserve that through any other treatment that they may require – chemo or radiation. Then after all that’s done, then to rebuild the breast based on what the lady desires and what is possible for her and her particular situation.

Host: Now if someone were to Google your name, Keith Brandt, and breast reconstruction, a procedure called TRAM flap comes up. You were saying to me that things have changed over the past few years about the approach with that procedure, correct?

Brandt: Correct. We used to try to do the TRAM flap at the time of the mastectomy, but the treatment of breast cancer itself has changed in that the indications for radiation therapy have risen. And if they irradiate the TRAM flap, they can potentially distort it. So what we want to do is, again, preserve the lady’s options, preserve her breast skin, give her a temporary reconstruction – usually with a tissue expander – through any treatment that she needs. And then when she’s done with everything else, then reconstruct her either with an implant or with the TRAM flap based on, again, the lady’s desires and the options that are available to her.

Host: Technically, what do you do in the OR?

Brandt: At the time of the mastectomy, the volume of the breast is removed when they remove the breast tissue, so we put in an expander, which is sort of a temporary balloon, if you will, that fills up the breast skin pocket. And then after the procedure, we can expand it even a bit more to match the lady’s breast size on the opposite side.

Host: What’s the latest you’re doing with breast reconstruction?

Brandt: More and more women are opting for bilateral mastectomies if they have a high risk on the opposite breast once disease has been found in one of the breasts. They will electively plan for a prophylactic mastectomy on the uninvolved side. So now we have to rebuild two breasts. And if the lady elects to do a TRAM flap, which takes the tissues from the lower abdomen to rebuild the breasts, it requires some involvement of the rectus muscles, which are the ones that help you sit up if you’re lying flat. If we take both of them, the lady might be a little bit functionally inhibited, so there’s a new variation of the TRAM flap called the DIEP flap – D  I  E  P – and what it does is it tries to preserve as much of the rectus muscle as possible, taking only the artery and vein that are necessary to transfer the flap and leaving almost all the muscle behind. It’s technically a little bit more challenging and takes a bit more time in the OR, but if we can preserve at least one of the lady’s muscles, she’ll be 100 percent functional.

Host: How many women are you doing this with now?

Brandt: There really has been a significant shift from one-sided mastectomies to bilaterals. You know, it was pretty rare to begin with, so we’re probably only sneaking up on 20 percent of the women presenting for flap reconstruction, but I expect it’ll increase in the future as the testing for the gene identifies more patients at higher risk and, therefore, more patients opt for bilateral treatment and bilateral reconstruction.

Host: Psychologically, do you think it’s important for a patient to have reconstruction at the time of the mastectomy?

Brandt: Absolutely. I mean it’s bad enough to have to go through cancer to begin with. But then to also start losing body parts can really affect the patient. So we want to get the lady back to her physical health and to her full potential and everything that she had prior to surgery.

Host: Not everyone performs reconstruction. What advice do you give to listeners who face surgery and are interested in reconstruction?

Brandt: They should at least talk with a reconstructive plastic surgeon, somebody who does it on a regular basis, about what are their options and why they might want to consider working with a team because there are some options that are lost if you don’t do it starting at the beginning. And then it’s their decision. Once they’re fully educated, it’s their choice if they want to proceed with reconstruction or not.

Host: And this is covered by insurance?

Brandt: Absolutely. In 1998, there was actually a federal law passed – the Women’s Health Act – that said that insurance companies are required to pay for reconstruction as well as procedures on the opposite breast for symmetry. Because oftentimes in the older patient, there are things that we need to do to the opposite breast in order to make the two more symmetric.

Host: Dr. Brandt, thank you for joining us.

Brandt: It was my pleasure. Thank you.

Host: For more information about breast reconstruction, you can visit the Siteman Cancer Center online at or call 800-600-3606. Thanks for downloading. Until next time, I’m Jason Merrill.