Breast Reconstruction after Mastectomy

Breast cancer is always personal. As a physician who counsels women at different steps during the healing process, I am acutely aware of this undeniable fact. Every decision she makes from the point at which she is diagnosed with breast cancer will require her focused engagement and a physician who is central to understanding her need for clarity of options. It is an intimate relationship where trust is a requirement and every woman faced with the many unknowns ahead will rely on that trust again and again to empower her to make the best decisions on her road back to good health.

A major part of the process of a cancer diagnosis may involve reconstruction of the breast after mastectomy. Breast reconstruction after cancer isn’t always for everyone, and that choice is personal but legislation protects a person’s right to make that choice. The law sees an important distinction between reconstructive and cosmetic surgery, as well it should and insurance providers must include reconstruction as part of treatment.

So, for options in breast reconstruction. I’ll share a personal motto I have written on my office wall which has become a go-to maxim to my many hundreds of patients over the years. Fear leaves when Education joins the party. In short, learn all you can about the options presented to you and know that each person will have different choices available to them based on the type of cancer they have, the stage, the treatment and the overall health of the patient.

Breast reconstruction can be performed as an immediate construction or Single Stage procedure or as a delayed construction or Multi-Step Procedure. Immediate reconstruction of the breast has been introduced successfully in more recent years and is becoming a viable option with patients who are not facing additional health complications, months in Radiation or Chemotherapy treatments. Generally speaking, immediate reconstruction with saline implants provides good cosmetic results usually with less scarring as the saline implant is inserted behind the already stretched muscle at the end of the mastectomy procedure.

In addition, there is often a reduced risk factor when immediate construction is employed because the patient will often require only one surgery and will not have to endure nipple or areola reconstruction at a later date.

If both options of immediate construction and delayed construction of the breast are available, Flap Reconstructive Surgery (DIEP Reconstruction or TRAM Flap) may be an option presented. DIEP and TRAM (Deep Inferior Epigastric Perforators and Transverse Rectus Abdominus Myocutaneous, respectively) is the moving of blood vessels from tissue elsewhere in the body to construct a new breast. Both procedures can happen during the immediate construction of the breast after the mastectomy procedure or weeks or even months down the road.

The upside to using live tissue to reconstruct the breast is that often times the patient will describe the reconstruction feels more like her original breast and that the skin is warm to the touch. Also, saline implants currently have no more than a ten year expiration date which means a women will most always need to have the original implants updated at least once in her life time, depending on her age when the implant is placed.

The downside to tissue flap procedures include increased risk of infections, extended surgical times and increased number of surgeries that many interrupted the patient’s healing process. Healing itself can often be prolonged as infection after surgery is more likely and scaring is usually more visible.

The Multi-Step Procedure includes delaying reconstruction for different reasons. These can include a diagnosis of advanced breast cancer (stage III or IV), inflammatory breast cancer, radiation or chemotherapy treatment, or personal preference. Lacking a feasible surgical option in your area also plays a significant role.

It is vital to understand that delayed reconstruction of the breast in no way limits your ability to have your breast reconstructed in the future. I have found women will choose to wait to reconstruct for many reasons, if at all and I support ever one of them. Breast Cancer is a harrowing event in a woman’s life and often times people need to finish the work of one healing before they can find it in them to go on to the next. My advice to my patients has always been that you will know when the time is right for you.

When that time does come, however, it is important to remember that although the muscles have healed, (in the case of saline implants) the muscle walls will need to be stretched again to accommodate the implant. This will include some weeks of muscle ‘adjustment’ involving the insertion of tissue expanders. These are inserted behind the muscle wall; a few trips to your doctor will be required Once the implant is in place a follow-up appointment often follows a few months down the road for any additional modifications you and your doctor may feel is necessary.

Areola and nipple reconstruction is usually discussed at the onset of any breast reconstruction path you take and this includes using tissue from elsewhere in the body. Another choice is creating a realistic nipple area is 3D tattooing. In fact, tattooing is gaining in popularity among my patients and they usually present with excellent results!

Whichever path to breast reconstruction you may choose, if any, make it your choice and your choice alone. As a physician I find myself too often present at times of crisis in a woman’s life but I am honored to be there and I am always inspired by the strength she finds in herself.

Dr. Elizabeth Hall Findley. M.D., FACS, PRMA Plastic Surgery is a board-certified plastic surgeon, breast reconstruction surgeon, and microsurgeon at University College Hospital Macmillan Cancer Centre, Huntley Street , London, WC1E 6AG. A principle authority and teacher in post mastectomy reconstructive surgery, Dr. Hall Findley is a vigorous patient advocate and believes that equal input between physician and patient throughout the reconstructive process is central to healing.

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