Breast Cancer is the second most common cancer in women and was diagnosed in 231,840 patients in 2015 in the United States. It is treated either with breast conserving surgery (lumpectomy and radiation) or mastectomy (removal of the entire breast gland with various degree of skin, areola and nipple preservation, usually without radiation). If mastectomy is the chosen treatment option, reconstruction of the breast is often desirable and is an integral part of the breast cancer treatment plan.
The reconstruction can either be done at the time of the mastectomy (immediate) or at some other time (delayed). In either case a new breast can be created using prosthesis (expander/ implant) or the patient’s own tissue- from the abdomen or the back, for example (autologous).
In the United States, 57,000 expander/ implants based reconstructions are performed annually, which represents 2/3 of all mastectomy reconstructions.
In our practice, 90% of mastectomies are done using this technique as it is simpler and requires less recovery. Invariably, it requires a staged approach with 2-3 trips to the operating room over the course of 6-9 months. This is well illustrated in our video series with “Mickey” undergoing the process of delayed reconstruction from beginning to end. An expander is placed under the chest muscle and a dermal graft. The expander is essentially a breast implant to which saline is added sequentially in the office to stretch the mastectomy skin. Once the desired contour is obtained (3-6 months), the expander is exchanged for a permanent gel prosthesis, modifying the implant pocket as needed and reconstructing a new nipple/areola usually during the same operation (stage II mastectomy reconstruction).
The last phase, 3 months after stage III, is the tattooing of the nipple/areola reconstruction under local in the office. Occasionally, the expander process can be skipped and an immediate permanent prosthesis can be placed if a sufficient amount of skin is preserved as in “Maureen’s” video of left prophylactic mastectomy.
If significant skin deficit exists, if the patient has failed expander reconstruction or if the mastectomy flaps are severely damaged by radiation, an autologous procedure may be preferable. This involves transferring tissue from another part of the patient’s body to the chest wall and sculpting it into a new breast. This can be done as a “pedicle” flap, where a small attachment containing the blood vessels is preserved, most commonly the T.R.A.M. flap (see “Tammy’s” video) or the Latissimus Dorsi flap (back tissue). Alternatively, the autologous reconstruction can be done as a “Free Tissue Transfer”, where the blood flow must be reconnected through microsurgery. ( Free TRAM, DIEP flap, Free gluteal flap etc…)
Whether the breast cancer reconstruction is done using expanders/implants or autologous flaps, it is highly advisable that patients stop smoking as this significantly increases the chance of skin necrosis (inadequate blood flow to the tissues, leading to skin death and, often, failure of the reconstruction).
Other factors increasing complications include obesity, advanced age and co-morbid diseases such as diabetes, vascular disease and autoimmune ailments.
Surgical complications include bleeding, infection, seroma (fluid accumulation), skin necrosis malposition (in adequate pocket shape leading to asymmetry) capsular contracture (hardening and pain of the breast from tightening of the scar around the implant or expander) as well as poor scarring on the chest or donor sites (in the case of autologous reconstruction).
Fortunately, most of our reconstructions (86% ) are completed without having these complications, as we are careful in selecting patients that are lower risk.