By Dr Rajeev Venugopal, ContributorTHE BREASTS of a woman symbolise femininity, maternity and sexuality; so it is not unexpected that a mastectomy (surgical removal of the breast) will have a negative psychological impact on that individual. The absence of the breast and the residual scar are constant reminders of the disease.
The aim of breast reconstruction is to achieve a balance with the opposite breast in clothes, allowing the woman to feel more confident. When the diagnosis of breast cancer is presented to the patient it is a devastating experience. A variety of emotions are experienced, these include denial, anger, guilt and finally acceptance.
During this time, large volumes of information have to be processed about the cancer and treatment options. A relative short time is given to assimilate this information and make informed decisions about management. The options of reconstruction may be introduced at this time depending on the stage of the disease.
EARLY BREAST CANCER
Breast reconstruction is offered to patients who present with early breast cancer, many women now present themselves early due to increased screening and patient education. The details of the reconstruction will be discussed by a plastic surgeon and the most appropriate technique is decided based on the medical history, physical examination and patient's desires.
Generally, there are two main techniques of reconstruction, the use of autologous tissue (using the patients own body parts) or the use of a prosthesis (artificial materials).
The reconstruction process may require more than one operation; the first operation is the longest and requires general anaesthesia (going to sleep). Minor adjustments and creation of the nipple can be done under sedation with local anaesthesia ('freezing the skin') at a later date.
PERSONAL REASONS
Some patients do not want reconstruction done for personal reasons. Persons with serious medical problems or who are not able to tolerate long operations may be better suited with use of prosthesis. Autologous reconstructions may not be suited in extremely obese women, persons with certain abdominal surgeries or bleeding disorders.
Smokers have an increased risk of complications, due to reduced blood flow to tissues and poor lung function. The most common methods of autologous reconstruction include the Transverse Rectus Abdominis Myocutaneous flap (TRAM) and latissimus-dorsi myocutaneous flap. The TRAM flap utilises the extra skin and fat which is normally removed in abdominal lipectomy ('tummy tuck') to recreate the breast mound. The rectus ('six-pack') muscle which contains the blood supply to the skin and fat is detached from its lower attachment and tunnelled under the abdominal skin to the chest.
SCULPTED TO MATCH
The abdominal wall is then closed in a similar manner to an abdominal lipectomy. The skin and fat, which is relocated, are sculpted to match the opposite breast in shape and volume. This entire procedure takes at least five hours, the hospitalisation period is a minimum of four days and recovery period is at least four weeks. (Fig. 1, Pg. 18)
The ability to do sit-ups is reduced due to the detachment of the rectus muscle. This recovers after a few months. There is a risk for abdominal hernia formation and in certain cases an artificial mesh is placed to reduce the risk.
The latissimus dorsi is a muscle of the back which aids in moving the shoulder. It can be sacrificed without any interference in regular activities, as other muscles can perform the same actions. The muscle along with the overlying fat and skin of the back is taken to recreate the breast mound. There is difficulty in creating a breast larger than a B cup as there is less volume of fat located on the back. If larger volumes are needed, then the prosthesis has to be placed underneath the muscle flap. The surgical scars are located on the back and can be hidden under most clothing. The surgical time is at least three hours with a shorter recovery period than for the TRAM. (Fig. 2, Pg. 18).
TEMPORARY PROSTHESIS
Prosthesis are constructed from a silicone elasatomer which is filled with saline (salt water of the same concentration as blood). A temporary prosthesis (expander) is classically placed beneath the chest muscle. The expander is then inflated, by the weekly injection of saline through a tiny valve under the skin. This is done until the
volume matches with that of the opposite breasts. The expander is then exchanged for a 'permanent' implant.
The implant operations are shorter and less recovery is needed and, hence, is the most popular reconstruction option. The implant is foreign, hence a slightly higher risk of becoming infected than autologous tissue. It may also become enclosed in heavy scar tissue (capsular contracture) which makes the breasts appear and feel hard. (Fig. 3)
SILICONE GELS
Silicone gels are used as fillers in permanent implants as it gives it a closer feel to the normal breast consistency. In 1992, the United States Food and Drug administration called a moratorium on silicone gel implants. There are ongoing studies to assess the safety of these gel implants for reconstruction.
In the past the reconstructions were done after the mastectomy and completion of chemotherapy and radiotherapy. The delayed reconstruction was done due to concerns that reconstruction may delay the detection of recurrent disease and to ensure that patients would be more appreciative of the reconstructed breasts. Both these views have changed and immediate reconstruction (at the time of mastectomy) is safe in appropriate candidates. The advantages to this are that the number of operations is reduced and the woman will not have to suffer the psychological loss of the breast.
A new technique, known as a skin sparing mastectomy (SSM), has enhanced the quality of immediate reconstruction. The SSM is done through an incision around the areola (the dark skin surrounding the nipple). The native envelope of the breast skin aids naturally in the contouring, leading to a superior appearing reconstructed breast with less surgical scars.
LIMITED INCISION
This technique is more difficult as the operation is done through a limited incision and increases operative time by 45 minutes. This technique is, however, not suitable for all candidates as certain criteria have to be met. The oncological safety (cancer survival and local recurrence of the tumour) of this operation is comparable to the standard modified radical mastectomy. (Fig. 4)
The reconstructed breasts will naturally have asymmetry to the natural breast. So, in order to recreate the balance between the breasts, additional procedures such as breast reduction or lift may be necessary. These are usually done months after the initial procedure, allowing time for the new breast to settle. The nipple-areola can be created from using tissue from different parts of the body or by
tattooing.
Breast reconstruction is a safe option available for women who are undergoing a mastectomy for early breast cancer. It is not an essential procedure and should only be done after appropriate counselling and thought.
