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Breast reconstruction options following mastectomy

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ABSTRACT

Breast reconstruction can help to address the disfigurement and sense of loss that often follow mastectomy. The decision whether to pursue reconstruction and the choice of reconstructive strategy are individualized decisions that must take into account the patient's body characteristics, overall health, breast cancer treatment plan, and personal preferences. Options for reconstruction broadly include placement of breast implants or use of the patient's own tissue (autologous reconstruction). Both saline-filled and silicone gel-filled implants are safe and effective options for implant-based reconstruction. Autologous reconstruction usually involves transfer of tissue from the abdomen, with recent advances allowing preservation of the abdominal muscles. Both implant-based and autologous procedures have advantages and drawbacks, and both types of reconstruction may be compromised by subsequent radiation therapy. For this and other reasons, consultation with a plastic surgeon early in treatment planning is important for women considering postmastectomy reconstruction.


 

References

Patients recently diagnosed with breast cancer are distraught with concerns not only about surviving their disease but also about how its treatment will affect their body image and self-image. Although the risk of breast cancer increases with age, it is not a disease limited to the elderly. With advances in screening and awareness, breast cancers are now detected at earlier stages and in younger women. Approximately 5% of breast cancer patients are age 40 years or younger, which explains the recommendation that women be told about the benefits (and limits) of regular breast self-examinations beginning in their 20s.1 Additionally, breast cancer is the most common cancer in pregnant and postpartum women, occurring in about 1 in 3,000 pregnant women.2 Although breast conservation therapy is an attractive option, for many patients mastectomy is still the recommended surgical treatment. When mastectomy is required, it is understandable that many women are very concerned about losing their breast.

REASONS FOR RECONSTRUCTION

Mastectomies are commonly performed for women with ductal carcinoma in situ or with early or locally advanced invasive breast cancer (infiltrating ductal carcinoma) and sometimes for recurrent disease or for prophylaxis in high-risk women such as those with BRCA gene mutations or lobular carcinoma in situ. As reviewed in the preceding article in this supplement, mastectomy can be performed in various ways, using modified radical, skin-sparing, or nipple-sparing mastectomy techniques.

An emotional ‘double hit’

Following mastectomy, women are often left with what may be regarded as an emotional “double hit.” First, of course, is the anxiety from having a cancer diagnosis. Second, and perhaps equally devastating for some, is the emotional impact of losing a breast and the accompanying perception of disfigurement or loss of femininity and sexuality. These latter feelings often lead women who have undergone or will undergo mastectomy to explore the possibility of breast reconstruction.3–5

Both a medical and an emotional decision

While the reasons that women may seek breast reconstruction are many and varied (eg, to restore their self-esteem and social functioning, to help put their cancer experience behind them), it is important for primary care providers and other referring physicians to recognize that this decision is both a medical and an emotional one. Most women healthy enough to undergo extirpative surgical procedures are, in fact, healthy enough to undergo breast reconstruction if desired. Since choosing a reconstructive strategy is a complex process that takes into account many therapeutic and individual patient factors, plastic surgery consultation plays a major role in the comprehensive treatment of breast cancer.

TIMING AND TYPE OF RECONSTRUCTION

The timing of breast reconstruction can vary. In cases where the patient knows she will want reconstruction and the cancer surgery is performed at a site where a reconstructive surgery team is available, reconstruction can be performed immediately following mastectomy during a single trip to the operating room. When a reconstructive surgeon is not available locally or when systemic or local cancer therapies need to be completed first, reconstruction may need to be delayed.

Immediate reconstruction has the advantage of improved aesthetics while mitigating the sense of loss that can accompany mastectomy. Delayed reconstruction will give the patient more time for her decisions. An additional option, called “delayed-immediate” reconstruction, involves placing a tissue expander at the time of mastectomy (to preserve the breast skin envelope) and awaiting pathology results to determine whether radiation therapy is needed. If radiation is not needed, the patient undergoes reconstruction right away; if radiation is needed, the patient undergoes delayed reconstruction after radiation therapy is completed, with the breast skin envelope preserved for better aesthetic results. (The timing of reconstruction and these various timing options are discussed in detail in the final article in this supplement.) Selecting the correct timing and method of reconstruction requires good communication and coordination between the patient, her oncologist, and her multidisciplinary surgical team comprising both breast and plastic surgery specialists.

The patient and her surgeon will also discuss which reconstructive technique is best for her. Choosing a reconstructive strategy is a highly individualized process that takes into account the patient’s body characteristics, overall health, breast cancer treatment plan, and personal preferences. Consequently, a strategy offered to one patient is not necessarily valid for another. In general, options for reconstruction include use of the patient’s own tissue (autologous tissue), use of implant material (nonautologous), or a combination of an implant and autologous tissue.

IMPLANT-BASED RECONSTRUCTION

What the procedure involves

Nonautologous breast reconstruction usually involves a two-step procedure: placement of a tissue expander followed by later placement of a permanent implant.

Figure 1. The process of expander placement and inflation in preparation for implant-based reconstruction.
Figure 1. The process of expander placement and inflation in preparation for implant-based reconstruction.
At the time of mastectomy, a tissue expander type of implant is placed under the pectoralis major muscle, the main muscle under the breast. The tissue expander is then inflated at weekly intervals by percutaneous injection of saline solution, allowing expansion of the tissues over the expander, including the muscle and breast skin. These injections are administered in an outpatient clinic beginning about 2 to 3 weeks after expander placement. Once the expander is filled to the desired volume and the tissue has been expanded sufficiently, which typically takes 3 to 6 months, a second procedure is performed to remove the expander and place a permanent implant. This latter procedure is done through the previous scars and usually is much less involved than the first operation. Figure 1 illustrates the various stages of expander placement and inflation.

Choice of permanent implant

Permanent implants vary by shape, texture of the implant shell, and filler material. They are typically filled with either silicone gel or saline.

Breast implants have been available for many years for use in both reconstructive breast surgery and cosmetic augmentation. A great deal of bad press and misinformation had surrounded the use of silicone gel-filled implants, with the result that they ceased to be marketed in the United States beginning in the early 1990s while the US Food and Drug Administration (FDA) reviewed additional safety information on their use. During this period when the use of silicone implants was limited, saline-filled implants became the preferred choice until the FDA approved the reintroduction of silicone implants to the market in November 2006, after what the agency described as years of rigorous scientific review of multiple clinical studies and other data.6 The FDA concluded that silicone implants are safe and effective for general use in breast reconstruction, correction of congenital breast anomalies, and breast augmentation.6 There is no evidence that silicone implants pose a significant systemic risk to women undergoing breast reconstruction.

Figure 2. Preoperative (left) and post­operative (right) photos of a patient who underwent mastectomy of the right breast followed by silicone implant placement and nipple reconstruction
Figure 2. Preoperative (left) and post­operative (right) photos of a patient who underwent mastectomy of the right breast followed by silicone implant placement and nipple reconstruction. She had matching vertical mastopexy of the left breast. The postoperative photo was taken 20 months after reconstruction.
The silicone implant offers a softer, more natural feel to the reconstructed breast than the saline implant. As a result, increasing numbers of women are opting for silicone implants (Figures 2, 3). However, saline implants remain a sound, proven alternative for women who are not comfortable with receiving a silicone implant.

Potential complications

Figure 3. Preoperative (left) and postoperative (right) photos of a patient who underwent reconstruction with silicone implants after bilateral nipple-sparing mastectomy.
Figure 3. Preoperative (left) and postoperative (right) photos of a patient who underwent reconstruction with silicone implants after bilateral nipple-sparing mastectomy. The postoperative photo was taken at 9-month follow-up.
Implant extrusion. One of the potential complications of implant-based reconstruction is extrusion of the tissue expander or implant through the skin. If the implant becomes exposed, it will likely need to be removed. The risk of implant extrusion is, in part, why the implant is placed under the chest wall muscle, since the muscle provides protective cover. Because the breast skin often is very thin after mastectomy, placement of the implant directly under the skin alone does not provide adequate protective cov­erage and is therefore no longer an acceptable recon­structive technique.

Capsular contracture is another potential and more frequent complication of implant-based reconstruction. In all cases, the body forms a protective coverage, or fibrous capsule, around the implant. This process is called encapsulation. Most of the time, the capsule is relatively thin and pliable. Infrequently, however, the capsule can become thickened, hardened, and contracted, which constitutes capsular con-tracture. Although rare, severe contractures cause deformation of the reconstructed breast as well as pain. Severe contractures often require an operation to replace or remove the implant and treat the excessively thickened capsule. This can be done by exchanging the implant and either opening the capsule (capsulotomy) or removing the capsule (capsulectomy). If the contracture is significant enough or if the contracture recurs, then reconstruction using autologous tissue might be needed.

Next Article:

Reconstruction options following breast conservation therapy

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