Breast reconstruction options following mastectomy
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.
COMPLETING THE RECONSTRUCTION
Nipple reconstruction
Reconstruction of the nipple and areola is important in that many patients feel that the nipple is what makes a breast. With the increased use of nipple-sparing mastectomy and improved reconstructive techniques, the aesthetic outcomes of reconstruction are often regarded as superior to many breast conservation procedures. A recent study by Cocquyt et al suggests that skin-sparing mastectomy with immediate DIEP flap reconstruction or TRAM flap reconstruction appears to yield a better cosmetic outcome than breast conservation therapy.9
Reconstruction of the nipple and areola restores the shape of the nipple, the shape of the areola, and the color of both with tattoos. Closing the autologous flap in a circular manner creates the shape of the areola, and the nipple is formed by local bilobed or trilobed skin flaps wrapped around each other to create a cone. Although nipple reconstruction can be performed at the time of immediate reconstruction, it is usually performed at a later time in the outpatient setting when the shape of the reconstructed breast is more definite after healing has occurred.
Revisional procedures
In many cases reconstructive breast surgery is not able to provide a breast that is shaped or sized exactly as desired or that perfectly matches the contralateral breast. Revisional procedures are sometimes performed to improve breast appearance and symmetry. Most revisional breast surgeries are performed on an outpatient basis and at times can be completed at the time of nipple reconstruction.
Modifying the contralateral breast
Modification of the contralateral breast is often necessary, and either a mastopexy (breast lift), reduction, or augmentation of the contralateral side may be needed for symmetry.
Mastopexy and reduction mammaplasty. Mastopexy, a skin-tightening and nipple-repositioning procedure, is performed to correct soft tissue descent without removing much breast tissue (see Figure 2), while reduction mammaplasty involves removing 400 to 2,000 grams of breast tissue (see Figure 4). A patient who has had a unilateral mastectomy without reconstruction may be a candidate for reduction mammaplasty of the contralateral breast. A unilateral large breast can cause marked neck and back pain due to the asymmetry of the weight on the chest.
Augmentation. Patients with smaller breasts often will undergo a matching augmentation procedure on the contralateral breast following completion of mastectomy and reconstruction on the other side.
Prophylactic mastectomy. For some women with a very high lifetime risk of breast cancer, such as those with BRCA1 or BRCA2 gene mutations, prophylactic mastectomy of the contralateral breast or even bilateral prophylactic mastectomy may be recommended by the oncologic surgeon. In some of these selected patients with sufficient abdominal tissue, bilateral DIEP flaps may be suitable; otherwise, the reconstruction can be completed with tissue expanders and implants.
WHAT ABOUT INSURANCE COVERAGE?
As the result of a federal law enacted 10 years ago, insurance coverage should not be a concern for women who are considering breast reconstruction following mastectomy. The Women’s Health and Cancer Rights Act of 1998 requires all medical insurers that provide coverage for mastectomy to also cover all stages of reconstruction of the affected breast as well as surgery and reconstruction of the contralateral breast to produce a symmetrical appearance.10
CONCLUSION
Although breast cancer remains a significant health risk to women and can result in significant disfigurement, breast reconstruction strategies continue to improve. These strategies offer women who have undergone mastectomy some excellent options for creating a near-normal-appearing breast. Women interested in pursuing reconstruction should meet with a plastic surgeon early in the course of their breast cancer treatment planning in order to better understand the options available and make an informed and individualized choice.
