Breast Reconstruction after Breast Cancer Treatment: All You Wanted to Know

Breast Reconstruction after Breast Cancer Treatment: All You Wanted to Know

Cancer and its treatment can change the body in several ways. This change could be a physical change, mental change of both. Some changes are easy to cope up with, while others may be difficult. One such change, that any woman may find difficult to make peace with, is the partial or complete loss of their breast after breast cancer treatment.

Mastectomy is a surgical procedure that involves the removal of the whole breast tissue with an intent to treat breast cancer. Most women feel difficult to cope with this biggest change, as the loss adversely impacts their body image. Some women may even develop depression or anxiety, as they find themselves less attractive or desirable. However, with the biotechnological advancements, now there are solutions available to reconstruct the breast, and restore its appearance. Before making a decision to opt for breast reconstruction, it is always important to know about the available options, and their pros and cons.

Breast reconstruction

Breast reconstruction is a surgical procedure done to rebuild or reshape one or both the breast after mastectomy. Breast reconstruction can be done in several ways, but the most common ways are by using saline or silicone implants, or by using autologous tissue (person’s own body tissue obtained from other regions of the body). In some cases, both implants and autologous tissue are used for breast reconstruction.

Breast reconstruction can be done or can be started at any time depending on the condition of the woman. It can be done:

• At the same time of mastectomy, which is referred to as immediate breast reconstruction.
• After the mastectomy when the incisions are completely healed and breast cancer therapy is completed, it is referred to as delayed breast reconstruction.
• Some years later if desired.

Why choose breast reconstruction?

Most women choose breast reconstruction due to several reasons and the following are some frequently reported reasons:

• To regain a feeling of femininity
• To create a balanced look of the chest when wearing a bra or swimsuit
• To feel better and confident about their body
• To wear all forms of clothes with better fitting
• To regain their breast shape permanently
• To avoid the use of an artificial breast form that fits inside the bra
• To improve their marital and sexual relationship

Candidates for breast reconstruction

Not all women who undergo mastectomy may need breast reconstruction. But in some cases, when there is an obvious breast deformity due to removal of a large tumour from a small breast during cancer surgery, the doctor may combine the cancer surgery and plastic surgery techniques to address this problem. This procedure is referred to as oncoplastic surgery. This procedure usually involves reshaping the breast during the initial surgery, through partial breast reconstruction after breast-conserving surgery or by a full reconstruction after mastectomy. These women could be the best candidates for the following types of breast reconstruction:

• Local flaps using your own tissue
• Fat grafting
• Breast lift
• Breast reduction
• Smaller tissue flap
• Implants
• Smaller autologous flap reconstruction

Although there are several techniques for breast reconstruction, the specialist would  decide the best technique for a woman based on the following factors:

• Age
• Overall health
• Medical history
• Lifestyle
• Body type and BMI (body mass index)
• Size and location of the breast tumour
• Breast density
• Extent of breast tissue removal
• Requirement of cancer therapies other than surgery
• Patient preferences

Types of breast reconstruction procedures

The common types of breast reconstruction procedures include the following:

1. Implant breast reconstruction: In this type of breast reconstruction, a silicone or saline implant is inserted underneath the skin of the chest. These implants are inserted either in a single stage or two-staged procedure. When it is a two staged procedure,
   
   • First stage: In this stage, a tissue expander is placed under the skin or chest muscle. This expander serves as a temporary saline implant, which are periodically refilled with saline or air during hospital visits after the procedure.
   • Second stage: Once the patient is completely recovered after the surgery, the tissue expander is removed and replaced with a silicone or saline implant. This implant is usually placed two to six months after the mastectomy.
   • Alternatively, surgeons prefer inserting the implant immediately using a silicone implant, without using a tissue expander.  

2. Autologous breast reconstruction: In this procedure, a piece of tissue that contains skin, fat, blood vessels, and sometimes muscle is obtained from another part of the body to rebuild the breast shape. This piece of tissue is referred to as a flap and is usually obtained from the abdomen, back, buttocks, or inner thigh region.

   Sometimes, the tissue is completely separated from its original site and placed in a new place near the chest to rebuild the breast shape. This procedure is known as a free flap. In some cases, the tissue partly remained attached to the original site and transposed to the chest region to reconstruct the breast. This procedure is known as a pedicled flap.

3. Nipple and areola (pigmented area around the nipple) reconstruction: This is the final phase of breast reconstruction surgery, and is recommended when nipple and areola are not preserved during the mastectomy. This procedure involves the re-creation of the nipple and areola on the reconstructed breast to give it a more natural look. Nipple and areola reconstruction is usually done a few months after the breast reconstruction surgery.

   In this procedure, a small piece of tissue is removed from the newly created breast and placed on the nipple site to recreate a nipple on the reconstructed breast. A few months after the nipple reconstruction, the areola can be recreated by tattooing, especially in women who do not want further surgery. However, sometimes areola is recreated during nipple reconstruction by taking a skin graft from the abdomen or groin region and placing it near the areola region.

    

Factors that may affect the choice of the breast reconstruction method

In addition to the woman’s age, overall health, and past medical history, the woman must consider the following factors before making the decision about any type of breast reconstruction.

Reconstruction with implants	Reconstruction with autologous tissue
Advantages Shorter procedure duration Quicker recovery Close follow-up required for the first few weeks	Advantages Initially, the recovery period may be longer than the reconstruction with implants Close follow-up not needed Clear fluid may build-up at the donor site occasionally
Disadvantages Clear fluid may build-up within the reconstructed breast Hematoma (abnormal pooling of blood) formation within the reconstructed breast Blood clots may form Implant extrusion and rupture may happen Development of hard scar tissue around the implant High complication rate in obese, diabetic, and smokers	Disadvantages Longer procedure duration Hematoma formation at the chest or abdominal region Blood clots are more frequent Pain and weakness at the site of donor tissue Death of the transferred tissue High complication rate in obese, diabetic, and smokers

 

Recovery after breast reconstruction

 

Tiredness and soreness for a week or two with implants is common; it may be longer with a flap procedure.  During this period, certain medicines are prescribed to manage pain and discomfort. The duration of hospital stay depends upon the type of breast reconstruction and overall health of the patient.  Before discharge, the patient may receive instructions about wound care, and the schedule for follow-up.

Breast reconstruction and the risk of cancer recurrence

Breast reconstruction does not increase the risk of cancer recurrence; neither does it hide the cancer if it recurs, as believed by many. Hence, recurrence should not be factored in while deciding about breast reconstruction.

References:

1. org. when is breast reconstruction done? https://www.breastcancer.org/treatment/surgery/reconstruction/when. Accessed on 22 December, 2020.
2. Breast reconstruction after mastectomy. https://www.cancer.gov/types/breast/reconstruction-fact-sheet. Accessed on 22 December, 2020.
3. American cancer society. What to expect after breast reconstruction surgery? https://www.cancer.org/cancer/breast-cancer/reconstruction-surgery/what-to-expect-after-breast-reconstruction-surgery.html . Accessed on 22 December, 2020.
4. Reaby LL. Reasons why women who have mastectomy decide to have or not to have breast reconstruction. Plast Reconstr Surg. 1998 Jun;101(7):1810-8.

https://pubmed.ncbi.nlm.nih.gov/9623821/

5. American cancer society. Should I get breast reconstruction surgery? https://www.cancer.org/cancer/breast-cancer/reconstruction-surgery/should-i-get-breast-reconstruction-surgery.html . Accessed on 22 December, 2020.
6. org. Autologous or flap reconstruction. https://www.breastcancer.org/treatment/surgery/reconstruction/types/autologous . Accessed on 22 December, 2020.
7. What are the possible complications from TRAM breast reconstruction? https://www.medscape.com/answers/1273752-165979/what-are-possible-complications-from-tram-breast-reconstruction . Accessed on 22 December, 2020.
8. Regan JP, Casaubon JT. Breast Reconstruction. [Updated 2020 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470317/