Know Your Options: A Guide to Breast Reconstruction

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Terence Myckatyn, MD

From the February 2013 issue of YWBCP magazine
By Terence Myckatyn, MD
Plastic and Reconstructive Surgeon
Washington University School of Medicine

During their lifetime, one in eight women will develop breast cancer and will require removal of at least a portion of their breast tissue. Fortunately, breast reconstruction following removal of either all or part of the breast is available for most women being treated for breast cancer. Importantly, numerous studies show that breast reconstruction neither impacts the treatment of breast cancer nor affects doctors' ability to detect recurrent cancers. Breast reconstruction is more commonly performed for removal of the entire breast after mastectomy but is also an option in women who undergo removal of part of the breast for lumpectomy. Breast reconstruction can be initiated at the time of mastectomy or lumpectomy, in which case it is referred to as an immediate reconstruction, a couple of weeks later, which is referred to as a delayed immediate reconstruction, or months (even years) after mastectomy or lumpectomy, in which case it is called a delayed reconstruction.

The vast majority of women who undergo mastectomy – and many who undergo lumpectomy – are candidates for breast reconstruction. Unfortunately, according to the Surveillance, Epidemiology and End Results (SEER) database, only 17 percent of eligible women received postmastectomy breast reconstruction between 1998 and 2002. The likelihood that a woman undergoes reconstruction after mastectomy appears to be influenced by several factors. Geography is a key predictor, ranging from only 4.5 percent of eligible women reconstructed in the state of Alaska to 34.7 percent in Atlanta. Women treated at large centers that specialize in breast cancer care are the most likely to receive breast reconstruction. For example, 42 percent of women treated at National Comprehensive Cancer Network (NCCN) centers are reconstructed. At the Siteman Cancer Center, which is one of these NCCN centers, 69 percent of eligible women receive post-mastectomy breast reconstruction, which represents one of the highest reported reconstruction rates in the United States. Women insured by managed-care payers rather than Medicare or Medicaid, those with post-high school education and those employed outside of the home are more likely to undergo breast reconstruction. Studies evaluating the influence of race and ethnicity on the likelihood that a woman receives breast reconstruction have yielded conflicting results. Some studies found a relationship whereas others did not.

Perhaps more disturbing than the low percentage of women who receive breast reconstruction is that less than 30 percent of eligible women are even offered breast reconstruction. To address this, several federal and state laws are in place to protect a woman’s right to receive breast reconstruction. Acknowledging several quality-of-life studies that clearly demonstrate the psychological benefits of breast reconstruction, the 1998 Women’s Health and Cancer Rights Act was established. This act mandates that health insurance payers provide coverage for breast and nipple reconstruction, procedures on the healthy breast to improve balance and management of any complications arising from mastectomy or reconstruction. To ensure insurance coverage, additional legislation was passed in 2001 to impose penalties for noncompliance. While providing insurance coverage for breast reconstruction is a critical piece in improving access to breast reconstruction for all eligible women, it is equally important for women to be informed that breast reconstruction exists in the first place. Fortunately, progress has recently been made on this front as well. On Aug. 17, 2010, a new bill was passed in New York (A10094B/S6993-B) mandating that all women are informed, prior to undergoing mastectomy, about their right to reconstruction and the types of reconstruction that are available, even if this means referring women to another facility or hospital system.
This bill went into effect Jan. 1, 2011, and may encourage similar legislation in other states.

While breast reconstruction is an option for most women, a particular woman may not be a candidate for every form of breast reconstruction. Typically, women are eligible to receive breast reconstruction if they are healthy enough for surgery and are undergoing a mastectomy to prevent cancer (prophylactic mastectomy), an in situ cancer like DCIS or a Stage I-III breast cancer. Women who were born without a breast – a congenital condition known as Poland’s syndrome – or those who have had traumatic injuries or burns to the breast are also often candidates for breast reconstruction.

Many factors go into deciding which forms of reconstruction are appropriate for each individual. These factors can be generally categorized as patient factors and cancer-management factors. Important patient factors include patient wishes, body mass index (BMI), overall health and previous surgical history. Without a doubt, patient wishes are an extremely important component of the decisionmaking process, but unfortunately there are instances where patient expectations in terms of cosmetics or the desired type of reconstruction are not consistent with a sound medical decision. In these cases, other forms of reconstruction are recommended. BMI, which is a measure of a woman’s relative weight, is a critical factor for choosing the type of reconstruction and predicting the risk for complication. A BMI of greater than 30 is associated with a higher rate of complications with any form of reconstruction. Still, some forms of reconstruction are better than others in heavier women, and even women who are morbidly obese are usually candidates for a form of reconstruction. Overall health will also guide a plastic surgeon toward specific forms of reconstruction, as healthier women are more tolerant of longer operations and have a lower risk of wound healing problems compared to women with medical conditions like heart, lung or connective tissue disease. Further, previous abdominal, back, buttock or thigh surgery can limit some types of reconstruction with a woman’s own tissues.

Cancer-management factors will influence the timeline and type of reconstruction. The type of mastectomy that is performed can influence the type of reconstruction as well as the overall cosmetic quality of the reconstruction. Nipple-sparing mastectomies in small- to moderate-sized breasts typically render the best cosmetic outcomes but are not always possible due to the location or the nature of the breast cancer. While both are important, adequate surgical management of a breast cancer will always take priority over the cosmetic outcome. Breast reconstruction is usually staged, whereby the breast mound is created at the time of mastectomy and is later refined and balanced with the other breast. Nipple and areola reconstruction are performed later. Chemotherapy, which is often a critical component of breast cancer treatment, often takes three to four months to complete and will extend the duration between creation of the breast mound and subsequent refinement of the reconstruction. Radiation therapy, when required in women undergoing mastectomy, is usually administered after chemotherapy and further prolongs the timeline between the first and second phases of reconstruction. In addition to extending the reconstructive timeline, radiation will often influence which form of reconstruction is selected. Most breast reconstruction research has concluded that in patients who require radiation, reconstruction with a woman’s own tissues is favored over reconstruction with breast implants alone.

Breast reconstruction can be done with implants, your own tissues or a combination of the two. Implant-based breast reconstruction starts with placement of a tissue expander in the majority of cases. A tissue expander is a temporary breast implant that can be filled in the plastic surgeon’s office over several weeks to months to stretch the chest muscle and remaining skin in preparation for placement of a more permanent silicone or saline implant at a later stage. In certain cases, like when a nipple-sparing mastectomy can be performed, there is often enough remaining breast skin that an immediate breast implant can be placed. When possible, this technique, known as a direct-to-implant breast reconstruction, in conjunction with a nipple-sparing mastectomy may provide a woman with a mastectomy and the entire reconstruction in a single operation.

A woman’s own tissues can also be used for breast reconstruction. The pedicle TRAM (transverse rectus abdominis myocutaneous) flap is probably the best known of these options and utilizes tissue normally removed during a tummy tuck to reconstruct the breast. However, this operation requires the transfer of a substantial component of abdominal wall musculature and can lead to bulges and weakness of the abdominal wall. Fortunately, advances in microsurgery – where blood vessels are reattached under a microscope – have enabled modern plastic surgery to offer procedures such as the DIEP (deep inferior epigastric artery perforator) flap. In this operation, the abdominal fat is still used to reconstruct the breast, but the muscle tissue is left in the abdominal wall, leading to less pain and better strength after surgery overall. Other tissues can be transferred for breast reconstruction as well and may be better options than the DIEP flap in specific cases. These include the latissimus dorsi myocutaneous flap, which transfers back fat and muscle tissue, the TUG (transverse upper gracilis) or PAP (profunda artery perforator) flaps, which use tissue from the inner thigh, or the SGAP (superior gluteal artery perforator) flap that uses upper buttock skin and fat tissue for breast reconstruction.

For physicians and patients alike, breast reconstruction is typically associated with restoring a breast following mastectomy. However, breast reconstruction is also available to treat breast deformities following lumpectomy. Breast conservation therapy – which includes lumpectomy with radiation therapy – is used to treat approximately 60 percent of all breast cancers, while mastectomy is used to treat the remaining 40 percent. While acceptable cosmetic results are often achieved with breast conservation therapy, studies show that up to 46 percent of women who undergo breast conservation therapy are not satisfied with the cosmetic appearance of their breasts. Reconstruction following lumpectomy is often referred to as oncoplastic reconstruction and is usually performed with tissue rearrangement similar to a breast reduction or unique, small, customized flaps comprised of skin and fat known as perforator flaps. Reconstruction of lumpectomy defects can be performed at the time of lumpectomy, or a couple weeks after lumpectomy but before radiation therapy begins. This ensures that the entire breast cancer is adequately removed at the time of lumpectomy and before the reconstruction is performed. Oncoplastic reconstructions can be performed after radiation therapy as well, but usually reconstruction is delayed for one year or longer in an attempt to limit wound healing issues that can occur when performing surgery in a previously radiated area. Reconstruction following lumpectomy is also covered by insurance payers and is customized for each woman’s unique circumstances.

Appropriate cancer management always takes precedence over breast reconstruction. Still, in the majority of cases, women requiring mastectomy or lumpectomy are eligible for reconstruction and should consult with a board-certified plastic surgeon experienced in all forms of breast reconstruction to understand their options.