BREAST RECONSTRUCTION AFTER MASTECTOMY
SHOULD I HAVE BREAST RECONSTRUCTION SURGERY BREAST RECONSTRUCTION OPTIONS BREAST RECONSTRUCTION USING IMPLANTS BREAST RECONSTRUCTION USING YOUR OWN TISSUE (flap procedures) RECONSTRUCTING THE NIPPLE AND AREOLA GENERAL INFORMATION RISKS AND SAFETY
BENEFITS OF BREAST RECONSTRUCTION IMPORTANT THINGS TO CONSIDER CAN RECONSTRUCTION MASK CANCER OR CAUSE IT TO REOCCUR?
Breast reconstruction surgery is performed on women who have had their breast (or breasts) partially or completely removed. The surgery rebuilds the breast to achieve symmetry and help women feel more comfortable with their bodies. The nipple and areola can also be reconstructed.
Having a breast removed to treat cancer can be a shock and breast reconstruction helps you to adapt to this change more easily. Breast reconstruction can either be done immediately (immediate reconstruction) with the mastectomy(delayed reconstruction) or at a later stage.
Women choose breast reconstruction for many reasons:
- To make their chest look balanced when they are wearing a bra or swimsuit
- To permanently regain their breast shape
- So they don’t have to use a form that fits inside the bra (an external prosthesis)
- To be happier with their bodies and how they feel about themselves
Breast reconstruction often leaves scars that can be seen when you’re naked, but they should fade over time. Newer techniques have also reduced the amount of scarring. When you’re wearing a bra, the breasts should be alike enough in size and shape to let you feel comfortable about how you look in most types of clothes. Breast reconstruction after a mastectomy can make you feel better about how you look and renew your self-confidence.
Keep in mind that the reconstructed breast will not be a perfect match or substitute for your natural breast. If tissue from your tummy, shoulder, or buttocks will be used as part of the reconstruction, those areas will also look different after surgery.
- You might not want to have any more surgery than is absolutely required.
- Not all reconstructive surgery is a total success, and the result might not look like you’d hoped.
- The cancer surgery and reconstruction surgery will leave scars on the breast and any areas where tissue was moved to create the new breast mound.
- A rebuilt breast will not have the same sensation and feeling as the natural breast, and any flap donor sites might also lose some sensation. With time, the skin can become more sensitive, but it won’t feel the same as it did before the surgery.
- You may have extra concerns if you tend to bleed or scar more than most people.
- Breast skin or flaps might not survive reconstructive surgery. This tissue death is called necrosis. If it happens, healing is delayed and more surgery is often needed to fix the problem.
- Healing could be affected by previous surgery, chemotherapy, or radiation therapy. It can also be affected by smoking, diabetes, some medicines, and other factors.
- You might have a choice between having breast reconstruction at the same time as the mastectomy (immediate reconstruction) or at a later time (delayed reconstruction).
- Dr van Rooyen may suggest surgery to reshape the other breast to match the reconstructed breast. This could include reducing or enlarging its size, or even surgically lifting the breast.
- Knowing your reconstruction options before surgery can help you prepare with a more realistic outlook for the outcomes.
Studies show that reconstruction does not make breast cancer come back. If the cancer does come back, reconstructed breasts should not cause problems with chemotherapy or radiation treatment. If you are thinking about breast reconstruction, either with an implant or flap, you need to know that reconstruction rarely, if ever, hides a return of breast cancer. You should not consider this a big risk when deciding to have breast reconstruction.
Some early research has found that breast implants may be linked to a rare kind of cancer, known as anaplastic large cell lymphoma (ALCL). This is mainly based on a few small studies, but other studies so far have not shown any significant link. ALCL has been noted between 1 and 23 years after implants, and usually responds well to treatment. It can show up as a lump or as a collection of fluid near the implant. More careful studies are needed to find out what link, if any, there is between this rare cancer and breast implants.
Several types of breast reconstruction surgeries are possible for women who have had surgery to treat their breast cancer. When deciding what type is best for you, you and Dr van Rooyen should discuss factors including your health and your personal preferences. Take the time to learn about what options are available to you before you make a decision.
If you’ve decided to have breast reconstruction, you’ll still have many things to think about as you and Dr van Rooyen talk about what type of reconstruction might be best for you. Some of the factors you and Dr van Rooyen will need to take into account when considering your options include:
- The size and location of your breast cancer
- Your overall health (including issues that might affect your healing, such as smoking or certain health conditions)
- Your breast size
- Whether you will need treatments other than surgery for your cancer
- The amount of tissue available (for example, very thin women may not have enough extra tummy tissue to use this area for breast reconstruction)
- Whether you want reconstructive surgery on one or both breasts
- Your desire to match the look of the other breast
- Your insurance coverage and related costs for the unaffected breast
- How quickly you want to be able to recover from surgery
- The effects that different types of reconstructive surgery might have on other parts of your body
We will review your medical history and overall health, and will explain which reconstructive options might be best for you based on your age, health, body type, lifestyle, goals, and other factors. Talk with Dr van Rooyen openly about what you expect. Be sure to voice any concerns and priorities you have for the reconstruction, and make sure that you feel comfortable.
You may have a choice between having breast reconstruction at the same time as the surgery to treat the cancer (immediate reconstruction) or at a later time (delayed reconstruction).
Immediate breast reconstruction is done, or at least started, at the same time as the surgery to treat the cancer. The benefit of this is that breast skin is often preserved, which can produce better looking results. Women also do not have to go without the shape of a breast.
While the first step in reconstruction is often the major one, many steps are often needed to get the final shape. If you’re planning to have immediate reconstruction, be sure to ask what will need to be done afterward and how long it will take.
- You don’t want to think about reconstruction while coping with cancer. If this is the case, you might choose to wait until after your breast cancer surgery to decide about reconstruction.
- You have other health problems. We may suggest you wait for one reason or another, especially if you smoke or have other health problems. It’s best to quit smoking at least 2 months before reconstructive surgery to allow for better healing.
- You need radiation therapy. Many doctors recommend that women not have immediate reconstruction if they will need radiation treatments after surgery. Radiation can cause problems after surgery such as delayed healing and scarring, and can lower the chances of success. Flap reconstruction surgeries (using other body tissues to create the new breast) are often delayed until after radiation.
There are several types of reconstructive surgery available, and the reconstruction process sometimes means more than one operation. Give yourself plenty of time to make the best decision for you. You should make your decision about breast reconstruction only after you are fully informed.
Two main types of operations can be done to reconstruct the shape of your breast or breasts:
- Breast implants (using silicone or saline inserts)
- Tissue flap procedures (using your own body tissues)
- Sometimes a combination of an implant and flap procedure is used to get the best result. In addition, nipple and areola reconstruction procedures can be done to help make the reconstructed breast look more like the original breast.
Using a breast implant is one option to reconstruct the shape of your breast after surgery to remove the cancer. Several types of implants can be used. This type of breast reconstruction can be done in one step at the same time as the cancer surgery. Or it can be started when you have your cancer surgery and then completed during another surgery later on. You should understand the benefits and risks of implants for breast reconstruction and discuss them with Dr van Rooyen.
Several different types of breast implants can be used for breast reconstruction surgery. Implants are made of a flexible silicone outer shell, which can contain:
- Saline: These implants are filled with sterile salt water. These types of implants have been in use the longest.
- Silicone gel: Gel implants tend to feel a bit more like natural breast tissue. Cohesive gel implants are a newer, thicker type of silicone implant. They are more accurately called form-stable implants, meaning that they keep their shape even if the shell is cut or broken. They are firmer than regular implants and might be less likely to rupture (break), although this is still possible. Any type of implant might need to be replaced at some point if it leaks or ruptures.
Breast reconstruction surgery using implants can be done in different ways:
- One-stage immediate breast reconstruction (also called direct-to-implant reconstruction): The implant is put in at the same time as the mastectomy is done. After the general surgeon removes the breast tissue, Dr van Rooyen puts in a breast implant. The implant is usually put beneath the muscle on your chest. A special type of graft (made from skin) or an absorbable mesh is used to hold the implant in place, much like a hammock or sling.
- Two-stage reconstruction: For this type of reconstruction, a short-term tissue expander is put in during the mastectomy to help prepare for reconstructive surgery later. The expander is a balloon-like sac that’s slowly expanded to the desired size to allow the skin to stretch. It’s used when Dr van Rooyen believes that the mastectomy skin flaps are not healthy enough to support a full-sized implant right away. Through a tiny valve under the skin, Dr van Rooyen injects a saltwater solution at regular intervals to fill the expander over a period of about 2 to 3 months. Once the skin over the breast area has stretched enough, a second surgery is done to remove the expander and put in the permanent implant. This method is sometimes called delayed-immediate reconstruction because it allows time for other treatment options. If radiation therapy is needed, the filling of the expander and the final placement of the implant is put off until radiation treatment is complete.
Tissue support is needed in breast reconstruction using implants. This support helps to keep the prosthesis in place, add coverage and/or position the muscle where it needs to be.
We generally have two types of tissue support options that we offer:
- Natural = LATS (Latissimus Dorsi Flap)
- Synthetic = ADM (Acellular Dermal Matrix)
Tissue support is sometimes needed for breast reconstruction, especially when implants are used. This tissue can provide added coverage, support the implant, or position the muscle where it needs to be. One way to do this is to use a woman’s own body tissues as part of a flap procedure. Tissue from another part of the body, such as the tummy or back, is used to create a kind of pocket to hold the implant in place or to provide added skin coverage over the implant.
Keep these important factors in mind if you are thinking about having implants to reconstruct the breast and/or to make the other breast match the reconstructed one:
- You may need more surgery to remove and/or replace your implant later.
- You might have problems with breast implants. They can break (rupture) or cause infection or pain. Scar tissue may form around the implant (called capsular contracture), which can make the breast harden or change shape, so that it no longer looks or feels like it did just after surgery. Most of these problems can be fixed with surgery, but others might not be reversible.
- MRIs may be needed every few years to make sure silicone gel implants have not broken. Your health insurance may not cover this.
- Routine mammograms to check your remaining breast for cancer will be harder if you have a breast implant there – you’ll need more x-rays of the breast, and the compression may be more uncomfortable.
- An implant in the remaining breast could affect your ability to breastfeed, either by reducing the amount of milk or stopping your body from making milk.
A tissue flap procedure is one option to reconstruct the shape of your breast after surgery to remove the cancer. The tissue used for a flap procedure comes from somewhere else on your body, such as your tummy or back. As with any surgery, you should learn as much as possible about the benefits and risks, and discuss them with your doctor, before having the surgery.
In general, flaps require more surgery and a longer recovery than breast implant procedures. But when they work well, they look more natural and behave more like the rest of your body. For instance, they may enlarge or shrink as you gain or lose weight.
While tissue flaps are often used by themselves to reconstruct the breast, some tissue flap procedures can be used along with a breast implant.
Tissue flap operations leave 2 surgical sites and scars – one where the tissue was taken (the donor site) and one on the reconstructed breast. The scars fade over time, but never go away completely. There can be donor site problems such as abdominal hernias and muscle damage or weakness. There can also be differences in the size and shape of the breasts. Because healthy blood vessels are needed for the tissue’s blood supply, flap procedures can cause more problems in smokers, and in women who have uncontrolled diabetes, vascular disease (poor circulation), or connective tissue diseases.
We most common use 2 types of tissue flap procedures:
- DIEP (deep inferior epigastric perforator) flaps, which use tissue from the abdomen (tummy)
- Latissimus dorsi flaps, which use tissue from the upper back.
When treating breast cancer with a mastectomy, the nipple is typically removed along with the rest of the breast. (Some women might be able to have a nipple-sparing mastectomy, where the nipple is left in place.) If you’re having breast reconstruction after your mastectomy, you can decide if you want to have the nipple and the dark area around the nipple (areola) reconstruction.
Nipple and areola reconstructions are usually the final phase of breast reconstruction. This is a separate surgery done to make the reconstructed breast look more like the original breast. It can be done as an outpatient procedure. It’s usually done after the new breast has had time to heal (about 3 to 4 months after surgery).
Ideally, nipple and areola reconstruction matches the position, size, shape, texture, color, and projection of the new nipple to the natural one (or to the other one, if both nipples are being reconstructed). Tissue used to rebuild the nipple and areola comes from the newly created breast or, less often, from another part of your body. If a woman wants to match the color of the nipple and areola of the other breast, tattooing may be done a few months after the surgery.
Some women opt to have just the tattoo, without nipple and areola reconstruction.
- Breast reconstruction procedures are generally performed in the Kloof Mediclinic Hospital.
- You may experience an uncomfortable pressing feeling on your chest as well as pain and a burning sensation for a week or more.
You’ll want to keep the following in mind:
- It’s safe to have mammograms with breast implant , so be sure to maintain regular screening as prescribed by your doctor.
- It is important to have frequent mammogram check ups.
- Future pregnancies or weight fluctuations may affect your results, and a secondary surgery may be needed to correct any changes you are unhappy with over time.
- Nothing can stop the normal aging process; over time, breast tissue will change. You can help prevent unnecessary sagging by wearing a bra with adequate support for your activity level.
- Dr van Rooyen may prescribe some pain medication and in certain instances antibiotics.
- You will have bandages and drainage tubes when you wake up. Once you leave the Day Clinic you will be required to empty these drains and measure the contents thereof. Please empty the drain on the day that you go home at 8PM. Thereafter you should empty the drains and measure the contents every 12 Hours (8AM-8PM). Once you are home, you are required to phone us daily after you have taken your 8AM reading and give us the evening and morning reading.
- Generally this surgery only has dissolvable stitches.
- Most of your bandages should be removed once Dr van Rooyen removes the drains. After these have been removed you will be allowed to bathe and shower normally. Before the drains have been removed you will not be allowed to get them wet and should take caution when washing yourself.
- We suggest that you purchase a (sold at our practice) compression bra which you should sleep in for 2 weeks. It should be worn during the day for 6 weeks. You are not allowed to wear a bra with underwire for 3 months. This garment helps to alleviate swelling and pain and offers support.
- You are not allowed to exercise for 6 weeks.
- You may scar. please note that scarring may take up to a year to heal and in some patients it will always leave some mark
The decision to have reconstructive surgery is extremely personal, and you’ll have to decide if the benefits will achieve your goals and if the risks and potential complications of surgery are acceptable.
You will be asked to sign consent forms to ensure that you fully understand the procedure and any risks.
Surgery risks include:
- Anesthesia risks
- Fluid accumulation (seroma)
- Poor wound healing
- Skin loss
- Numbness or other changes in skin sensation
- Skin discoloration and/or prolonged swelling
- Unfavorable scarring
- Recurrent looseness of skin
- Fatty tissue found deep in the skin might die (fat necrosis)
- Deep vein thrombosis, cardiac and pulmonary complications
- Suboptimal aesthetic result
- Possibility of revisional surgery
- Persistent pain
These risks and others will be fully discussed prior to your consent. It’s important that you address all your questions directly with Dr van Rooyen.
Your surgeon can help you know what to expect from your breast reconstruction surgery and be as prepared as possible. You should have realistic expectations of how your body will look and feel after surgery, and understand the benefits and risks of the type of reconstruction you are having. Increase your chances for a successful outcome by following your surgeon’s instructions carefully.
[Unattributed]: Citing Sources: [http://www.cancer.org/acs/groups/cid/documents/webcontent/002992-pdf.pdf]:[Jan 03, 2017]
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