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Advances in breast reconstruction

Author: Mia James

If you have been diagnosed with breast cancer and are facing treatment, the prospect of breast reconstruction may be daunting. It is, after all, another procedure to evaluate and prepare for at a time when you may be overwhelmed by the impact of the diagnosis. With recent innovations in reconstruction techniques, however, the process is becoming less invasive and producing improved, more natural results.

Options for reconstruction

Aaron Pelletier, MD, a plastic and reconstructive surgeon at Cancer Treatment Centers of America® (CTCA) in Zion, Illinois, says that women considering reconstruction should be aware that there are two basic categories of reconstruction: procedures that use implants and procedures that use the patient’s own body tissue. Innovation in both areas is expanding options and improving outcomes.

Implants

According to Dr. Pelletier, significant improvements have been made to the actual implants used during reconstruction. Implants are filled with silicone gels, which, he says, are “much improved” compared with previous generations. “The theory is that the quality and the cohesiveness of the gel are ultimately more likely to give the implants increased longevity and reduce the risk of damage and failure, such as rupture,” Dr. Pelletier explains. The current gel is not a liquid as it was previously, when people feared that silicone might leak.

During implant reconstruction a balloonlike device called an “expander” is implanted into the chest area, either at the time of mastectomy (immediate reconstruction) or during a later procedure (delayed reconstruction). The expander is filled with fluid periodically over a span of several weeks, which gradually stretches the skin over time and makes space for the eventual implant. Then, during implant surgery, the expander is removed and replaced with a permanent implant. In unique situations, it is possible to place the gel implant at the time of mastectomy, avoiding the need for expansion and a second surgery.

Using your own tissue

Breast reconstruction that uses one’s own tissue, instead of implants, is known as “autologous” reconstruction, or “flap” reconstruction. During flap reconstruction a plastic surgeon removes tissue (a flap) from somewhere on the body and uses the tissue to reconstruct the breast. “A flap may be composed of skin, fat, muscle or any combination thereof,” Dr. Pelletier explains. The area on the body from which tissue is taken is called a “donor site.” This location can vary, depending on physical factors and patient preference. “An example,” he says, “is using the skin and the fat from the lower abdomen.” Other potential donor sites include the inner thighs, back and buttocks. Depending on individual factors, autologous reconstruction can also be performed in an immediate or delayed fashion. But regardless of timing, it usually takes more than one surgery to complete the reconstruction.

Dr. Pelletier says that autologous reconstruction has improved with advances in microsurgery. “Microsurgery” refers to procedures using a microscope and extremely small instruments that allow the surgeon to work on small structures in the body (blood vessels, for example). “We can take tissue much more precisely and carefully and avoid having to take muscles and other parts of the body that might cause more damage to the donor site,” Dr. Pelletier explains. This translates into a less invasive procedure with easier recovery, lower rates of complication and potential for improved aesthetic outcomes.

Advances in surgical treatment affect your choices

Advances in mastectomy techniques also allow for more options in reconstruction. Breast cancer surgeons are now able to spare more of the breast than was previously possible.

Dr. Pelletier says that current research has demonstrated the oncologic safety of preserving breast skin and, in some instances, the nipple and the areola. “The ability to spare more breast skin, and potentially the nipple and the areola, has dramatic effects on the reconstruction capabilities,” he says. Your surgical oncologist will consider individual factors to determine whether you are a candidate for these advanced types of mastectomy.

Your needs are unique

It is exciting to learn about the innovations in breast reconstruction and the potential options, but Dr. Pelletier says that it is important for patients to remember that each case is unique. What may work for others may not work for you. “Not all women are candidates for every reconstruction technique or mastectomy type,” he says. Timing of reconstruction (immediate versus delayed) will also vary for each individual. “Understand that you need to have a very comprehensive evaluation by the reconstructive surgeon so that he or she can figure out what is appropriate and what is possible,” Dr. Pelletier says. It is also important that your reconstructive surgeon have a close working relationship with your surgical oncologist, medical oncologist and any other members of the multidisciplinary treatment team.

One factor that will affect your reconstruction plan is the type of treatment you undergo. Radiation, for example, is a concern with implant-based reconstruction because it can cause tissue damage and scarring. “One of the biggest factors that affect reconstruction, in terms of type and timing of reconstruction, is whether radiation is needed,” Dr. Pelletier says. “The risk of complications, such as wound healing, potential implant infection and ultimate failure of the reconstruction, increases dramatically with radiation.” Typically, women who require radiation therapy are recommended autologous reconstruction in a delayed fashion.

Risks and benefits, pros and cons

As you consider which reconstruction plan best fits your situation, you will want to weigh all of the potential risks and benefits. One of the major considerations for many women is recovery time, which varies considerably among different types of reconstruction.

Dr. Pelletier explains that flap reconstruction, for example, requires moreinvolved surgery and longer recovery compared with implants. You can expect a three- to four-day hospital stay and a four- to six-week recovery following flap reconstruction. The surgery can take about six to eight hours for one breast and 10 to 14 for both, and you will be healing from both the breast reconstruction and the incision at the donor site. This is much more extensive compared with tissue expanders and implants, which require about 90 minutes of surgery per side, one or two days in the hospital and a three- to four-week recovery.

With new microsurgical techniques, however, concerns about flap reconstruction have lessened, allowing patients and physicians to focus more on the advantages. “In the long run, it’s your own tissue,” Dr. Pelletier explains. “It is durable, and women do recover fairly quickly relative to how the surgeries used to be done.” For some women, he says, the trade-off of the more involved initial process (compared with implants) may be worthwhile.

Other considerations related to implant reconstruction include the multiple doctor visits required in advance of the implant surgery to gradually fill the expanders with fluid, as well as the lifespan of the implants (which isn’t guaranteed) and the fact that they may require maintenance. As well, Dr. Pelletier says, implants can be at risk of infection and a complication known as “capsular contracture,” where a scar forms around the implant; the scar can be painful, and surgery may be required. Though Dr. Pelletier says that you won’t necessarily have a high risk of complications with implants, the possibility exists.

When to have the reconstruction

With both implant-based and autologous techniques, timing of reconstruction is currently an important topic. For some patients the option of having reconstruction done at the time of mastectomy is appealing, though not everyone is a candidate. Timing is a complex decision, Dr. Pelletier explains, and “requires a lot of careful interaction among the reconstructive surgeon and all other treating physicians.” Immediate reconstruction may be an option for women who have earlier-stage cancers, who are otherwise healthy and who do not have many other health concerns, he says.

It is never too early to plan

According to Dr. Pelletier, it is never too early in the breast cancer treatment process to begin discussing your reconstruction options—in other words, as soon as surgery for breast cancer is recommended. “A lot of the decisions that are made about reconstruction depend on what happens at the time of mastectomy,” he says. Furthermore, this way you can bring your reconstructive surgeon into the decisionmaking process from the start. “Breast reconstruction requires a lot of communication,” he explains, and by getting involved early, “I can get on the same page as my patients and understand what their expectations and goals are.”

Making the choice that is right for you

To choose the reconstruction technique that is best for you, Dr. Pelletier recommends that you and your health-care team consider the following questions.

  • How much time can I take off from work or be away from home? If time constraints are a concern, find out which procedures work best with your schedule.
  • Does my treatment for breast cancer affect my reconstruction choices? As explained previously, radiation to the chest wall can cause complications with implant reconstruction. Discuss how radiation and other treatment may affect your options.
  • How important to me is it to know that my breasts are reconstructed with my own tissue? For some women knowing that their breasts are as natural as possible—that they are made of their own tissue—is very important.
  • What are the benefits and the longterm risks of all techniques I am considering? Weigh the benefits and risks and the pros and cons of all of your options to decide what is best for you.

Even though there is a lot of exciting progress in breast reconstruction, your best choice will be the one that is right for you. “Never make assumptions or get your mind set on what you want,” Dr. Pelletier says. It is possible that an approach that sounds great won’t work in your individual case. On the other hand, learning about your options can help you and your surgeon make appropriate choices. “I love it when patients have done some research and ask good questions,” he says.

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