A good place to start when discussing breast reconstruction is with the nature of your breast cancer surgery. Your breast cancer surgeon has a variety of options available to them depending on the type of cancer, how extensive it is, and a range of other features. So, lets discuss a few commons scenarios: we will consider how the breast is affected by different types of surgery and what it means for reconstruction.
The first scenario to consider is a “lumpectomy” or Breast Conserving surgery. In this scenario, a tumour is removed from the breast with perhaps a small amount of surrounding breast tissue and skin overlying the tumour. This means that the rest of the breast remains intact. However, it does not mean that the remaining breast is unaffected. The problem with this type of surgery is that it will often leave a scar across the breast. This scar is visible on the skin, but I think more importantly, the scar tissue extends deep into the breast also and this creates distortion of the breast gland and a contour deformity (particularly noticeable to women when they lean forward, as the scar is adherent to the underlying pec major muscle). The scar can result in the nipple being displaced, and the operated breast will lose some volume compared to the un-operated side. Additionally, when this option is chosen, the patient will often require radiotherapy which can exacerbate the effect of the scarring.
So, whilst this may seem like a less significant type of surgery, it can still leave you with a reconstructive challenge, in order to address the problems of loss of volume, scarring and distortion of the breast. Furthermore, in a small breasted woman, the loss of even a minor amount of breast tissue can create a significant problem. This type of surgery tends to give better results in larger breasted women in whom the loss of small amount of breast tissue is less noticeable.
Many patients who have lumpectomy will be treated by a breast surgeon alone. A plastic surgeon may only be involved with large breasted women, who can have a procedure referred to as a "therapeutic mammaplasty", which is essentially a breast reduction performed with the reduction being derived from the removal of the tumour. This can offer large breast women a very satisfactory outcome, and the opposite breast can be similarly reduced for symmetry.
The benefits of a therapeutic mammaplasty are that the recovery is much quicker than after a mastectomy (it is really no different to having an ordinary breast reduction), and for large breasted women whose BMI is too high to allow for DIEP flap or implant reconstruction, this may be the perfect technique.
The biggest challenges after breast conservation come from ladies who have a simple lumpectomy, where amount of tissue removed, as a proportion of the whole breast volume, is too large. This results distortion and asymmetry which can be incredibly challenging to reconstruct without actually removing the remaining breast tissue. This is often compounded by the radiotherapy that most ladies who have breast conservation would require.
Whilst it may seem counterintuitive, reconstructing the breast after a lumpectomy can be very challenging….even more so than reconstructing the breast after mastectomy.
The conventional, or so-called simple mastectomy, which involves the removal of the breast gland with an ellipse of overlying skin including the nipple, is the type of mastectomy that many patients are familiar with and the type of mastectomy that many patients are fearful of. The loss of the breast and the overlying skin, leaving a long transverse scar across the chest, results in a far more dramatic change to a woman’s appearance than a lumpectomy or other forms of mastectomy. The chest is left totally flat. The loss of the skin overlying the breast (and the nipple) create the distinct (and quite obvious) reconstructive requirements for this type of breast cancer surgery. It is worth noting that patients who undergo simple mastectomy present in a delayed fashion for their breast reconstruction.
When skin has been removed with the breast, the reconstructive priority is to introduce new skin to allow the creation of a breast with as much skin as the removed breast. Performing “flap” surgery (more about this in a future article) allows for the introduction of new skin (from the abdomen for example) and fat which can then be shaped into the new breast. This new skin can also then form the basis for a nipple reconstruction.
When flap surgery is performed in this context (and certainly, this is the preference in most cases), there will always be a large “paddle” or island of skin with a scar around the entire perimeter of this island, indicating where the skin of the flap has been sutured to the remaining skin of the breast. It is possible to create a pleasingly shaped breast using flap surgery after simple mastectomy, and when clothed, the reconstructed breast may be indistinguishable from the other breast. Obviously, the same cannot be said when a patient is naked. Whilst the breast shape may be very similar, the large skin island from elsewhere in the body will always be apparent.
An increasingly common operation, the skin-sparing mastectomy involves the removal of the nipple and the breast via an incision made circumferentially around the nipple. This type of mastectomy is hugely beneficial for the reconstructive surgeon as the skin of the breast is preserved (including, vitally, the crease under the breast or “inframammary fold”). This means that using either a breast implant or a tissue flap the breast can be reconstructed in a far more natural way than is possible after a conventional mastectomy.
“The preservation of breast skin at the time of mastectomy allows for the most natural-appearing breast reconstruction.”
If an implant is used to reconstruct the breast, then a short scar will result where the incision around the nipple is closed as a straight line. On the other hand, where a flap has been used, a small disc of skin can be introduced where the nipple and areola were previously. This skin can then be used for the nipple reconstruction, and once tattooing is performed to colour the nipple and the areola, the scar is often very well disguised.
The reconstruction of the breast after skin sparing mastectomy is performed immediately. This is the ideal scenario from my perspective, even if a patient requires additional treatment such as radiotherapy.
This last type of mastectomy, is increasingly common as we better understand the behaviour and recurrence risks of certain breast cancers.
In recent years, more women have been offered preservation of the nipple for the less aggressive forms of breast cancer, and for tumours that are a sufficient distance from the nipple. The obvious benefit of this operation is the fact that the nipple is a very obvious aesthetic focal point of the breast, and when the nipple can be spared, it is possible to reconstruct a breast in a way that is far less obvious. For some women, the post-operative appearance may be almost indistinguishable from their pre-operatve appearance.
Nipple sparing surgery is also typically performed as a bilateral mastectomy for risk reduction, in younger women who have a very high chance of having breast cancer in their lives (either due to genetic tendencies eg. BRCA1 & 2; or in some women with a very strong family history of cancer). Risk reducing surgery requires a slightly different philosophy. In these cases, the mastectomy is being performed where there is no cancer. As such, the tolerance for complications after surgery may be significantly lower than when a cancer is being treated. Well publicised celebrity cases recently have increased community awareness of these scenarios.
In risk reducing cases, we may take a flexible approach to reconstruction, given the relative youth of the patients and the cosmetic benefit of keeping the nipple. It is possible to perform a tissue flap immediately, although the scarring may be greater in this instance. It is also possible for the mastectomy to be performed via an incision under the breast (similar in location to the incision used for cosmetic breast enlargement) and then to place a breast implant via this same incision. In some cases, young women choose to have an implant reconstruction initially after risk-reducing mastectomy, for several reasons: 1) because they are undergoing bilateral mastectomy, it is much simpler to create a symmetrical breast reconstruction using implants for both breasts, 2) these younger women may not have sufficient abdominal tissue to allow for the most common type of flap reconstruction, and 3) it is possible for these ladies to have the implants removed and converted to a free-flap reconstruction in 10, 15 or 20 years, by which time an abdominally based flap such as a DIEP (we will discuss DIEP flaps in the next post) may be possible for them.
Well, it should be apparent that there are many different factors to consider when contemplating breast reconstruction. Whilst some of these factors relate to the nature of your breast cancer and what surgery you require, there is a degree of choice for every patient. Your surgeon will advise you if certain procedures are likely to have greater risk. Be open with your surgeon when having this discussion. It is worth remembering as well that for many women, work, family and life in general have to be considered when making a decision about breast reconstruction. An operation, like a flap reconstruction, that requires 6 weeks of down-time, whilst ideal, may not be practical or realistic. Certainly though, that is a discussion worth having.