The diagnosis of breast cancer comes as a big shock even to the most stoic woman;then follows the agonising period of further staging tests and treatment options. The most important concern is of course effective treatment with the aim of cure. Although the treatment has evolved considerably over the past three decades and more breast conservation is practised now, the fear of losing one’s breast always looms large. With the global focus on early detection, more women are now cured of the disease and many even get to keep the breast almost intact. But for a significant number of women, removal of the breast [mastectomy] is an essential part of the treatment protocol. It helps such women to know that an aesthetically pleasing breast can be reconstructed by plastic surgery techniques later on.
Loss of an essential symbol of feminity affects the woman in various ways. While some adapt well, for others it is a major loss which affects their physical and emotional well being as well as their inter-personal relationships. An external breast prosthesis worn inside the bra is an excellent adjunct in the short term but for women many it constantly reminds them of their loss.
The entire breast can be reconstructed by plastic surgery. It is imperative that every woman dealing with breast cancer knows that she has the option of breast reconstruction at a suitable time if she so wishes. There is light at the end of the tunnel ! To know more, read on:
The breast is basically an organ made up of fat and gland with a skin envelope and surmounted by the nipple-areola complex [NAC]. In breast reconstruction, the surgeon first tries to create a mound of pleasing shape and size, in the correct location and covered with supple skin. This may be achieved either by using an implant under the patients muscle or by using patient’s own [native] tissues or by a combination of both. The nipple and areola are reconstructed 6 months later after the tissues have had time to settle down. The opposite normal breast may need some adjustment as well for good symmetry. A surprisingly normal appearing breast can be recreated.
Various methods may be used alone or in combination to create a breast mound. One may use a silicone implant under the chest muscles or move patient’s own body tissues into the area. Sometimes a combination is used to achieve optimum results. Choice depends on the patient’s body shape, amount and location of excess tissue available, amount and quality of locally available skin and the preference of the patient. This is one surgery where the lady is encouraged to participate in the decision process after she is given enough information about options.
Option: 1. IMPLANT-EXPANDER. A silicone implant is implanted usually beneath the muscle of the chest to give the desired mound. The silicone implant is basically a silicone envelope filled with either saline water or with silicone gel. It comes in different volumes and sizes. Often the skin is tight and enough volume cannot be restored in one go. Surgeons get around this problem by either using a tissue expander to expand the skin first or by using an adjustable implant. An expander is a sterile silicone balloon which can be gradually inflated till the desired volume is reached. This is done by injecting saline into the implant every week in the clinic. It is usual to over-inflate the balloon more than the desired size and then to remove some fluid which makes the new breast hang a bit to appear more natural. Although rather simple, this option can have late problems especially with gradual hardening of implant capsule and some distortion. Not all women are suitable for this procedure.
Option: 2. Latissimus Dorsi (LD) flap. Here tissue is moved from upper back to the breast area carrying muscle, fat and skin to recreate the mound. If the woman has enough fatty fold in the back and if the opposite breast is not big then this is a good option. Often this can be combined with an implant to give more volume. The disadvantage is a scar on the back – this can however be kept along the bra strap with careful planning.
Option 3. TRAM flap. Here native tissue is moved from the lower belly to the breast area to recreate the mound and bring more skin envelope. This is excellent for women who have borne children and thus have some excess loose tissue in lower abdomen. The woman gets a bonus of a tummy tuck as well since the excess is removed and the abdomen is tightened. The major disadvantage is a higher risk of complications and that the surgery is long and so is the recovery. Many women who have undergone the trauma of a mastectomy are not emotionally ready for another big surgery. This is an excellent method when option 1 gives problems later on and the lady wants native tissue reconstruction.
Other options: there are variations on the theme basically with the way the tissue is moved and also with alternative donor sites such as the buttocks. In order for the tissue to survive, its route of blood supply must be kept intact [the connecting bridge is called a pedicle] or its blood vessels must be reconnected to new blood vessels close to the breast area so as to restore blood supply – this is done by a microsurgical process and the flap is termed a “free flap”.
Newer Advances: Scientists are experimenting with fat grafting to see if an entire breast can be rebuilt by fat grafting. There is encouraging response. Briefly, in this technique, an external bell is fitted on the flat chest and external vacuum is applied by a microprocessor controlled unit [called BRAVA]. The skin expands as it is drawn out to fill the transparent bell. New tissue and blood vessels are made by the body in response to this. After some time, fat grafting is done using thin cannulae, there are no cuts and it is a simple procedure. The newly grated fat can grow further thereby giving volume. A modest breast volume can be produced. This method may soon be made available here.
[P.S: The BRAVA method is now available for select cases]
The opposite breast: If the opposite breast is large or pendulous it has to be reduced or lifted surgically. This of course involves additional surgery and scars in the “normal” breast. Symmetry cannot be restored otherwise since it is difficult to reconstruct a pendulous breast.
The recovery: Depending on the method chosen the recovery varies. It is generally quicker in option 1 and slowest in option 3. A breast support garment is usually worn in the first month and helps in shaping and in patient comfort. Women often take several months to integrate the new body image and the new breast also needs time to mature.
Points to ponder: If a woman decides to undergo reconstruction, she must get as much reliable information as possible, her plastic surgeon and the internet can be good resources. She must assimilate this information and be emotionally ready for the slightly difficult road ahead. What is done to the opposite breast by way of a lifting operation or reduction and the resultant scars must be understood. A clear visualization and looking at representative before/after pictures of both average results and poor results is important. Depending on her tissues and the option chosen, she must be aware that there could be complications along the way – but these can be overcome. The financial arrangement and the time off work must be sorted out. She will need support at home during the recovery period.