The need for radiation therapy largely determines the type of breast reconstruction that can be performed. Dr Marisse Venter clarifies why this is so.
The indications for radiation have increased over the past few years, as studies have shown a definite survival benefit in patients, especially young patients who receive radiation. But radiation therapy poses a particular reconstructive dilemma.
In the majority of patients, the need for radiation would be evident before the breast reconstructive surgery. Your surgeon and oncologist would be able to provide information with regards to the need for radiation.
Types of breast reconstruction
Reconstruction is broadly divided into immediate reconstruction – done at the time of the cancer removal surgery – or delayed reconstruction – done a year or so after the cancer has been removed and all treatments, including radiation, are completed. Both these options are correct and merely depend on the strength of character, personality, personal and interpersonal relationships, work, age, comorbid disorders and time availability of the particular individual.
In delayed reconstruction, a tissue expander (balloon) is placed in the same way you would place an implant. A month after the placement of the balloon, expansion with saline (water) may commence. The expansion is done in the consulting room and is not painful – a small pinprick. Expansion may occur at weekly, bi-weekly or monthly intervals, and can take up to six months to obtain the desired size.
Once that is reached, the tissue expander has to remain for a period of three to six months before it can be replaced with either your own tissue or a silicone prosthesis. This waiting period allows the skin to soften, and the balloon to experience the effects of gravity and move down a little. In total, the delayed reconstruction may take up to two years.
The radiation previously applied to the chest wall provides difficulty in terms of the tissue expansion and, even, in cases where a prosthesis is placed in a previously radiated field. The radiation causes the prosthesis or balloon to move upward and outward and makes it, at times, impossible to make the breasts look the same, which may lead to additional procedures in order to achieve symmetry. None the less, this is a good reconstruction option, and patient satisfaction is generally good.
Breast reconstruction is a process;
even in immediate reconstruction you would still have to have multiple procedures in order to achieve an acceptable cosmetic result. Unfortunately, there is no such thing as having one operation and that is the end of the breast cancer experience. The number of reconstructive procedures will depend on how fussy both you and your reconstructive surgeon are.
In immediate reconstruction, it may be far quicker to get to the end goal as the anatomical envelope of the breast or blueprint has been maintained.
Delayed reconstruction makes it more difficult as the shape of the breast and the fold under the breast have been lost; these two factors are very difficult to reconstruct symmetrically.
The application of radiation makes the area difficult to move, and tight, thus making it even more difficult to achieve the desired shape. This holds true for both immediate and delayed reconstruction. But, let’s not forget that is why we (reconstructive surgeons) are here!
How does radiation work?
Radiation is a type of energy – think the atomic bomb in Hiroshima – which is used on a much smaller and less potent scale to make the treatment area unfavourable for growth, preventing the cancer bed from spreading or, at least, make it hard to do so.
Various technological advances have drastically improved the quality of radiation machines. Thus, these days we see less of skin burning as seen many years ago; the newer machines penetrate the depth of tissue just deep enough to hit the treatment area, while concentrating less on the skin. Machines used at bigger treatment centres seem to yield better cosmetic results, this could be due to improved quality of these machines.
Nevertheless, radiation is a type of heat applied not dissimilar to a ‘braai’. But, you can’t braai plastic, can you? Therefore, inserting a prosthesis then radiating it, is not a good idea. Having said that, there are some cases where a prosthesis may be radiated at risk of hardness, contracture formation, chronic pain and poor cosmetic result.
But fat also doesn’t braai nicely. Thus, taking large amounts of your tummy fat and muscle may also not take radiation well, as it may cause hard clumps of fat in your reconstruction. This is called fat necrosis. The tummy operation takes long and may need two procedures to elevate the initial reconstruction, and has a higher failure rate. Exposing a cancer patient to many hours of anaesthetic may not have a favourable outcome. Long anaesthetic increases the risk of deep vein thrombosis (DVT) in a patient already at an increased risk, as a cancer diagnosis increases the risk of DVT at a baseline level. Thus, this type of reconstruction is far better tolerated as a delayed procedure.
Lat flap breast reconstruction
The increased indications and the need for radiation brings us to…what braais the best? Meat and muscle braai the best (using your own body). This brings you to the use of your latissimus dorsi muscle as a reconstructive choice – this is known as lat flap breast reconstruction.
The latissimus dorsi muscle is a large muscle in the side of your chest that extends all the way to the back. In men, this muscle is far greater developed than in women. The operation will affect patients who are rock climbers or gymnasts and require the use of this muscle to pull themselves upwards. For the rest of us, this muscle is a dispensable muscle. Meaning that our other muscles will take over the role of it. But the onus is on the patient to strengthen the other muscles, including the core abdominal muscles and back muscles, after the completion of the surgery.
But like all other reconstructions, the lat flap is not without problems and complications. In order to take something big from one area, you’ll have to sacrifice in another area. The area where the muscle is taken from, including the newly formed breast, will always have a numb feeling as is the case of all other operations where you had a surgical cut. Some patients report return of feeling up to 18 months after the operation, but unfortunately it is not possible to predict the extent of the recovery.
There may be some bulkiness under the arm where the muscle was brought forward. Although this improves with time, you may need additional surgery later to correct this deformity. The muscle may also always contract in the breast, giving the appearance of a moving breast, which occurs in some breast augmentations. I tend to not divide the nerve that causes the contraction in patients who have received taxotere-based chemotherapeutic regimes, as the tissue is friable, and there is a risk of tearing the main blood supply to the muscle.
In addition, I can’t guarantee the size of the newly formed breast as it depends on the size of your muscles. Patients that participated in sport in their younger years tend to have thicker muscles, especially swimmers and netball players, allowing for bigger breasts. The larger your body weight is, better reconstruction is more likely, as large amount of fat allows me to reconstruct a beautiful breast.
You may experience fluid collection at the back; this may last for a period of three to six months and will require removal in the consulting room. You may also experience pain and tightness at a later stage. These two symptoms are common in all types of operations. But, it may perhaps be slightly worse in operations involving the chest wall. None the less, some patients may need prolonged physiotherapy after the procedure. Young patients, physically active patients and those with a good support system seem to recover far quicker. Most patients report full function after a year – being able to swim, play golf and even play lawn bowls.
No breast reconstructive procedure is ideal and final, just like no Venus statue glued together after been broken, would be quite the same as before. But let’s not focus on by whom and why it was broken, but rather remember, you are still a Venus statue.
Written by Dr Marisse Venter.