Breast reconstruction following cancer is now an integral part of the treatment process for women diagnosed with breast cancer. The diagnosis of breast cancer is devastating and decisions about investigation, treatment and reconstruction are made within a multidisciplinary team of specialists in the best interests of the patient. Women are now extremely well informed about the options that have become available and breast reconstruction is part of the process of recovery from breast cancer for many women. It is a very positive step.
Breast reconstruction involves two surgeons (a Cancer Consultant and a Plastic Surgeon) who work closely together throughout the process – the most important priority however is the treatment of the cancer. Breast reconstruction may take a little time, but for many patients the benefits outweigh the other considerations.
Breast reconstruction may be carried out at the same time as a mastectomy or some time afterwards. Many factors influence this decision – patient choice being one factor – and if radiotherapy or chemotherapy is needed after the mastectomy, reconstruction may need to be delayed, as radiotherapy can affect reconstructed breasts.
Breast Reconstructions can be grouped into three surgical categories
- Implant based reconstruction.
- Autologous reconstruction (reconstruction using the patient’s own body tissue) such as the abdomen deep inferior epigastric artery perforator flap (DIEP Flap) or the back latissimus dorsi muscle (LD Flap) without the need for an implant to create a small breast.
- A combination of an implant and latissimus dorsi flap is combined to form a breast with an implant.
Each of these methods has its own advantages and disadvantages and that no one method is necessarily the correct method. It should be noted that not all of these options are available to everyone. The choice of reconstruction depends on overall body shape as well as the shape, size and dimension of the opposite breast.
Some reconstructions are better suited to some breast forms than others.
Choosing the right option
Briefly, implant based reconstruction using fixed volume or expandable prosthesis, has the advantage of being technically less complex to carry out. It has a relatively short operative time and hospital stay, and a quick post-operative recovery. The disadvantage is that perhaps aesthetically the results are not always as good as in reconstructions using the patient’s own body tissue (autologus reconstruction) explained above – an implanted breast feels different from a natural breast. An implant also potentially needs maintenance over time for reasons such as hardening, malposition, infection or rupture.
An autolougous reconstruction using patient’s own body tissue (most commonly the abdomen) i.e. DIEP flap on the other hand, is often technically highly complex, requires longer operative time and inpatient stay of approx one week. The advantages lie in the fact that the breast produced is as close to the real breast as possible and it feels and moves very similarly to a normal breast. Once symmetry is achieved it needs no further treatment throughout life. This reconstruction also involves having an abdominoplasty (“tummy tuck”) in the process
Somewhere in between lies the combination of latissimus dorsi myocutaneous flap (back muscle) and an implant. The skin and muscle from the back draped over the implant will afford more protection and also allow for a slightly more natural look than with just an implant. A more natural droop can be produced using the skin paddle from the back. This is a choice for women with little abdominal tissue.
As with all fields of medicine and surgery, continual refinement is constantly being undertaken. In the field of breast reconstruction, the old abdominal flaps known as TRAM flaps are slowly being superseded by the DIEP flaps and other related alternatives designed to maximize use of the tissue.
At the time of breast cancer diagnosis it is very difficult to take in detailed explanations about complex procedures for breast reconstruction and it often takes several visits before being able to make an informed decision.
It is important that the decision be made as a joint one between the Consultant and patient. Breast reconstruction is part of a process; it is rarely a one off event. Once the main operation to make the breast has been completed, small adjustments may be required to perfect the outcome.
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