Options Of Breast Reconstruction
January 6th, 2013
Options of Breast Reconstruction After Mastectomy For Breast Cancer
Being diagnosed with breast cancer is an extremely traumatic and difficult time for any woman.
Initial discussion after conveying the diagnosis revolves around breast cancer management in general and specifically around breast surgery. These discussions can be quite confusing and hard to understand for the patient who is already trying to cope with this traumatic news. Some of the discussions, especially around reconstruction, are very technical and require lengthy explanations around each procedure.
I am writing this blog to make it easier for these patients to understand breast cancer management when they are ready, especially surgical aspects of mastectomy and reconstruction, and have the opportunity to obtain a clearer understanding of reconstructive surgery.
General issues in breast cancer management
The majority of diagnosed breast cancers will have 3 to 4 components to their management: surgery, radiotherapy, chemotherapy and hormonal therapy. The order of delivering these treatment modalities will depend on the clinical presentation, age of the patient and patient choice but in majority of the cases, surgery is done as a primary treatment. Subsequent treatments are again dependent on several above-mentioned factors but can either be combination of radiotherapy, chemotherapy and hormonal therapy or just one or two of the above.
- Simple lumpectomy/wide local excision
- Therapeutic mammoplasty
Please see the respective sections in oncoplastic surgery on breast conservation surgery
In this blog I will discuss the indications, manners of mastectomy and different techniques of immediate breast reconstruction.
Simple mastectomy with standard approach
This is the most common approach used to remove the breast via an elliptical incision. This is an effective way of carrying out the procedure but it has its limitations. It’s not ideal for patients in whom there is a plan to either perform immediate or delayed breast reconstruction but is a very effective oncological way of removing the breast.
Skin-sparing mastectomy through peri-areolar incision with or without lateral extension
In this technique, the breast is removed along with the nipple and areola through an incision around the areola (sometimes with lateral extension). This allows for preservation of the breast skin envelope, a very useful technique used while doing immediate breast reconstruction. This is suitable for small to medium size breasts with minimal ptosis (drooping of breast and nipple).
Skin-sacrificing mastectomy/ Wise-pattern mastectomy
An oncoplastic technique for performing mastectomy through inverted T incision. The nipple areola complex and a wedge of skin is removed along with the mastectomy specimen, sacrificing a portion of breast skin envelope, thus the name skin-sacrificing mastectomy. This technique of mastectomy is indicated in moderate to large volume breasts with grade 2 or above ptosis. Immediate reconstruction can be done with all the available options, including autologous and implant/ADM-based reconstruction. The end result is an uplift of the reconstructive breast. The contra-lateral breast usually requires some adjustment at a later date.
Ultra skin-sparing mastectomy
This is a relatively new oncoplastic mastectomy technique, which is indicated in the medium to small volume breast. Mastectomy is performed through an inferior mammary crease incision, sparing the nipple areola complex as well as all of the breast skin envelope. It is indicated when the tumour is small and remotely placed with reference to the nipple areola complex. Immediate reconstruction can be undertaken with a variety of techniques, including autologous or implant/ADM based surgery. This technique gives by far the most superior cosmetic outcome when compared to other mastectomy techniques.
In the majority of breast cancer patients, axillary surgery is an essential component. Breast cancer, just like any other cancer, has the potential of spreading and the most common site for the breast cancer spread is axillary lymph nodes (lymph nodes in the armpit). Of all breast cancers, only 30% of the cancer would have spread to the axillary nodes and if axillary nodes are involved, their removal is advised (this is known as axillary node clearance).
In order to find out if the cancer has spread to the axillary nodes, one or two nodes are selectively removed with a single or dual targeting technique. Targeting is achieved by injecting radioisotope and/or patent V blue dye in the peri-areolar area. They in turn travel to the first axillary nodes draining the breast tissue. These nodes (average number of nodes retrieved 2.4) are then removed through a small incision in the axilla.
Intra-operative node analysis
Traditionally these removed nodes are analysed along with the breast specimen to find out if there are any cancer cells involving these nodes or not. This can take seven to ten days.
Fortunately locally in the RCHT NHS trust we have the facility to perform intra-operative node analysis (OSNA). Once the nodes have been harvested from the axilla, they are sent to an adjacent lab to theatre. It takes 30-45 minutes to analyse these nodes and results are made immediately available to the surgeon, who then will perform surgery accordingly. If:
- One or more big cancer cells are found in the node (macro mets): Total axillary clearance is advised.
- Two or more small cancer cells are found (micro mets): Total axillary clearance is advised.
- One or no small cancer cells are found (micro mets): No further surgery is recommended.
Immediate Breast Reconstruction
NICE guidelines are to offer breast reconstruction to anyone who is undergoing mastectomy in immediate or delayed settings.
Breast reconstruction is discussed in full detail with the patient at the time of diagnosis and in most instances a second appointment is made to go through the details once again in the reconstruction clinic.
Options of Breast Reconstruction
Autologous breast reconstruction
- Latissimus Dorsi breast reconstruction with or without implant
- Pedicle TRAM reconstruction
- DIEP (free flap)
Please see the respective sections in ‘Oncoplastic Breast Surgery’ for details of the above procedures.
Latissimus Dorsi reconstruction when done on its own is termed as Extended Autologous LD (EALD) reconstruction and it is my preferred way of doing reconstruction. If there is any volume deficiency, I tend to correct it with a lipo-filling technique. In my experience, implant-aided LD reconstruction in most instances will require removal/exchange of the implant, whereas there are less chances of revision surgery in EALD reconstructions.
Using lower abdominal tissue (TRAM, DIEP) to reconstruct the breast is extremely useful, especially in women in whom there is substantial volume of lower abdominal tissue. Some women favour this over LD reconstruction due to its ability to give them a flat tummy.
This is a relatively new technique and is rapidly gaining popularity as a method of choice for breast reconstruction for both patients and surgeons alike. ADM stands for Acellular Dermal Matrix and involves the use of Strattice, Surgimed and Parmacol, etc. This technique has an advantage of a relatively quicker recovery time.