To be confronted with the finding of a breast ‘lump’, and worse still, a ‘cancer’ is a difficult and often unexpected situation for a woman to find herself in.
Many questions come to mind and what follows will hopefully offer a guide to what options are available. All the choices to be made are very personal.
What should be done about a breast lump?
Investigate it and get as much information as possible: Ultrasound, mammography, core biopsy etc. Also formulate a treatment plan with a good multi-disciplinary team.
When can breast reconstruction be considered?
Any time! Breast reconstruction should be part of the management plan of every breast cancer patient. The timing is either ‘Immediate’ or ‘Delayed’:
An immediate reconstruction is started at the time of tumour excision. It requires accurate histological confirmation of the tumour (usually earlier stages 1-2cm, and smaller, <5cm tumours, are more suitable for this type of reconstruction) as well as assessment of the axillary lymph nodes (glands within the armpit). This intraoperative decision-making allows the intraoperative commencement of breast reconstruction immediately after the mastectomy is completed.
A delayed reconstruction, by comparison, takes place months to years after removal of the breast cancer, once all adjuvant chemotherapy and radiotherapy has been concluded. This time delay allows for healing of the tissues and widens the reconstructive options available. It has the disadvantage that a woman has to live without her breast for the duration of the ‘delay’.
What is an implant based reconstruction?
This is a reconstructive plan that involves the use of silicone implants. The usual sequence of events starts with the insertion of a tissue expander (most often anatomical in shape) that is inflated with saline over a period until it is an appropriate volume, after which it is replaced with an implant (usually an anatomical one).
What effect does radiation therapy have?
Radiation therapy is a very useful adjunct in breast cancer management, Its major role is in ‘breast conserving surgery’, for dealing with the lymph nodes of the axilla (armpit), the residual breast tissue and the tumour bed after the removal of large tumours (>5cm).
The use of alloplastic material (particularly silicone implants) was historically contra-indicated during or after radiation due to the increased incidence of complications such as ‘capsular contracture’. However, protocols involving the use of silicone expanders and implants in the context of radiation are becoming more common and show promising results.
What autologous reconstructive options are available?
Autologous options use the tissue and anatomy of the patient to reconstruct the breast without any alloplastic (synthetic) material such as silicone. These types of procedures are the options of choice when radiation has been necessary and when alloplastic options aren’t available.
A woman’s autologous options can be summarised as follows:
- If less than 20% of the breast volume is removed, it can be remodeled by means of parenchymal breast flaps.
- Pedicled flap options (remain connected to their blood supply and are ‘carried’ on muscle or fascia):
– The latissimus dorsi flap from the back.
– The TRAM (Tranverse rectus abdominus muscle) flap from the abdomen.
- Free flap options (where the tissue is separated from it’s native blood supply and is connected to new vessels in the recipient bed):
– Free TRAM flap (with all variants).
– SGAP flap from the gluteal area.
– TUG flap from the inner thigh.
What about surgery to the opposite (unaffected) breast?
This is an important question. A woman who accepts surgery to her opposite breast can have a ‘matching’ procedure such as a lift or an augmentation to match the reconstructed breast. What needs to be remembered is that follow up screening (by means of ultrasound and mammography) of both breasts is a major priority in the years following a cancer diagnosis and reconstruction.
What other breast reconstructive procedures are available?
The final touches to a reconstruction involve the nuances of symmetry, shape, size and natural landmarks. These are most often addressed once the major reconstructive procedures have been done. Techniques of nipple reconstruction using breast skin along with full thickness skin grafts, fat filling for shape and contour, along with tattooing to camouflage scars and duplicate contralateral pigmentation, all offer valuable ways of completing a breast reconstruction.