What is breast cancer?
Few things hold greater fear over women than the diagnosis of breast cancer. Even if you have been told that the cancer is curable and that you are going to live, the realisation of losing one or both of your breasts can be as devastating as the diagnosis itself. You are not alone - breast cancer is the most common form of cancer affecting women in the UK, with 40000 new cases diagnosed every year; and most women diagnosed with breast cancer are cured.
To better understand how breast cancer is treated, let us look at the disease itself. Cancer occurs when normal cells stop responding to the control systems used to co-ordinate the function of cells. These 'rogue' cells start to multiply abnormally forming cancerous tumours. The reason why these cells stop functioning normally is the subject of a great deal of research, but is a combination of environmental, lifestyle and genetic factors. The treatment of breast cancer is directed at eliminating all of these 'rogue' cells, whether by cutting them out at an operation, or by killing them with radiotherapy and chemotherapy. Which type of treatment you require depends on the type of breast cancer, whether the cells have spread outside their normal position within the breast, and whether they have spread outside the breast. Your breast surgeon will discuss the options available for you and help guide your decision.
What is mastectomy and is it really necessary?
About 40% of women diagnosed with breast cancer require or choose to undergo mastectomy, the surgical removal of the entire breast. The breast is positioned between the skin of the chest and the 'pec' muscles, and consists of milk ducts, glands, fat and some connective tissue holding all of these together. The glands produce milk, which runs via the ducts to the nipple. As the nipple is connected to the entire breast and the cancer can involve the ducts, the nipple must be removed as part of the mastectomy.
Mastectomy is recommended for women with certain types of breast cancer. The details should be discussed with your breast surgeon, but generally if cancer is present in 2 or more areas of the breast, if the breast has been previously irradiated, if a large tumour is found in a small breast or if the tumour is likely to recur, mastectomy is recommended. In addition, on discovering cancer within one breast, many women prefer to have that entire breast, or even both breasts, removed to minimise the chance of breast cancer in the future.
Why breast reconstruction?
If mastectomy is your best treatment option, you will have do decide what to do about your missing breast. Until fairly recently, a flat chest was the only option. and for some women today, it is still the option of choice. Many women feel radically changed by their cancer experience, and some feel that their flat chest is an acknowledgement of their post-cancer persona. An additional option is to wear a breast prosthesis. This provides the appearance of a natural breast and provides a better fit in clothing. It can help to minimise the un-balanced or lop-sided feeling that the missing breast creates. This option can also be used temporarily if you are undecided about breast reconstruction, or if your reconstruction needs to be delayed for radiation treatment.
Breast reconstruction is the process of recreating a breast mound aiming to match the remaining natural breast. It has been shown to improve mental health, emotional well-being, energy level and satisfaction with breast appearance after mastectomy. Reconstruction is performed by a reconstructive plastic surgeon. The main procedure is the creation of the breast shape and volume, either at the same time as the mastectomy, or at a later date. It may be necessary to undergo one or two subsequent smaller procedures, aimed at slightly altering the shape of the breast or creating a nipple and areola (the darker skin around the nipple).
Timing of Reconstruction
One of the first choices you will have is whether to undergo immediate or delayed reconstruction. Immediate reconstruction is performed during the same operation as the mastectomy. Delayed reconstruction involves only performing the mastectomy at the first operation. After you have fully recovered and any additional necessary treatment has been completed, a second operation is performed to reconstruct the breast. These are generally a few months apart.
Here are some advantages and disadvantages of each type of procedure :
| Immediate Reconstruction | |
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Advantages
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Disadvantages
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| Delayed Reconstruction | |
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Advantages
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Disadvantages
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Any type of mastectomy and reconstruction will result in scarring of the breast. The shape and size of the scars, however, vary between immediate and delayed reconstruction. For immediate reconstruction, it is often possible to perform a 'skin-sparing mastectomy'. This involves removing the nipple and the entire breast contents, but leaving most of the breast skin behind. As scars are inevitable whenever one area of skin is joined to another, being able to keep the natural breast skin results in smaller scars after reconstruction and the best skin-colour match between the two breasts. The scars after immediate reconstruction are either a circular scar around the nipple and areola (darker skin around the nipple) or a relatively small straight line scar. For delayed reconstruction, the skin must be stitched up after the mastectomy part of the procedure. It is not possible to use as much breast skin for reconstruction as, during the months between the two procedures, any loose skin shrinks and scars to the muscle underneath. By the time the reconstruction is performed, this skin is hard and non-malleable, and using it for the reconstruction would lead to a very poor cosmetic result of the breast surface. More skin is, therefore, removed at the time of mastectomy, resulting in a long scar across the chest wall. Although this scar will fade in time, it will always be present, even after reconstruction.
Types of Reconstruction
There are 2 main types of reconstruction: prosthetic and autogenous. Prosthetic reconstruction uses an artificial implant to recreate the breast mound whereas autogenous reconstruction uses your own alive tissue from elsewhere in the body to recreate the breast. Which option is most suitable for you depends on the shape and size of your breasts, the level of reconstruction required and the types of surgery you are prepared to undergo to achieve your reconstruction.
Prosthetic reconstructions involve making a space between your ribcage and 'pec' muscles and inserting an implant into this space. The overlying skin is then sutured together to close the wound. Expandable implants are often used for this technique, which are slowly enlarged over 3 to 6 months to give the desired shape and size. These are covered in more detail in the Implants chapter of this disk.
Autogenous reconstructions involve moving tissue from your back, buttocks or abdomen to the site of your breast and reshaping the tissue to form the new breast mound. As the tissue is alive, these techniques provide the most natural shape and feel to the reconstructed breast at the expense of undergoing surgery to and creating scars in healthy parts of your body. In contrast to prosthetic reconstructions, there is a full-size breast mound immediately after the operation, although it is likely to change shape and size slightly over first few months following reconstruction.
Nipple reconstruction is performed as a final stage of breast reconstruction, after the breast has reached its final shape and size, and when you are happy with your reconstruction. As changes inevitably occur in the breast during the first few months after reconstruction, creating a nipple too early would result in a poor match between the two sides.
Comparing reconstructive techniques :
| Prosthetic Reconstruction | |
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Advantages
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Disadvantages
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Autogenous Reconstruction | |
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Advantages
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Disadvantages
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Surgery to the Remaining Natural Breast
Although a good match can often be achieved by reconstructing the affected breast alone, the best symmetry is obtained by also considering surgery to the unaffected breast. For some women, reconstruction gives an opportunity to address any concerns with shape or size of breasts, and it is possible to complete reconstruction with bigger, smaller or less drooping breasts than before.
What is a Flap?
All of the autogenous reconstructive options involve the use of a 'flap', so you will hear this term used during your discussions. A 'flap' is a term to describe a group of different types of tissue together with a blood supply keeping all of the tissue alive. For breast reconstruction, the 'flap' is the living tissue including skin, fat and muscle that can be moved from one site in the body to form the new breast mound. As it is living tissue, it requires a blood supply and this can be provided using two main techniques.
The first is known as a 'pedicled flap'. This involves detaching the tissue within the flap from the surrounding tissues but keeping the blood vessels attached to the body. The tissue can then be rotated around the blood vessels to a new position. The main advantage of this technique is that the blood supply is not disrupted so microsurgery is not necessary. The main disadvantage is that the tissue needs to stay attached to the body where the blood vessels enter the flap, and so only tissue relatively close to the breast can be used.
The second is known as a 'free flap'. Free flap surgery involves completely detaching the flap from the surrounding tissues, moving the whole block of tissue to a new site and re-connecting the blood vessels to vessels close to the breast using microsurgical techniques. Using this method, tissue further from the breast can be used, but requiring microsurgery means a longer operation. Also for the first few days after the operation, you will need to be in a heated room, avoiding smoking and caffeine.
Reconstructive Options Presented
The reconstructive options and other associated topics discussed on this disk are the following :
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Name |
Type of Reconstruction |
Type of Flap |
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Implants |
Prosthetic |
No flap |
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Latissimus Dorsi (LD) |
Autogenous / Mixed |
Pedicled |
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Pedicled Transverse Rectus Abdominis Myocutaneous (TRAM) Flap |
Autogenous |
Pedicled |
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Free Transverse Rectus Abdominis Myocutaneous (TRAM) Flap |
Autogenous |
Free |
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Deep Inferior Epigastric Artery Perforator (DIEP) and Superficial Inferior Epigastric Artery (SIEA) Flaps |
Autogenous |
Free |
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Superior Gluteal Artery Perforator (SGAP) and Inferior Gluteal Artery Perforator (IGAP) Flaps |
Autogenous |
Free |