Categorized | Health

Reconstructing the Reconstruction

By Jason J. Hall, MD, FACS

In the past few years, we have seen a quantum shift in the treatment of breast cancer.  Medical treatments for breast cancer – chemotherapy, hormone treatments, and genetic treatments – have changed significantly, and although no cancer treatment is “easy,” newer therapies are much more effective and patient-friendly than in the past.  Likewise, radiation treatments have become more targeted, meaning less “normal” tissue is affected.

Surgical treatments for breast cancer have also undergone significant changes.  Here are just a few:

» Mastectomy techniques have changed for the better.  Gone is the “breastbone to armpit” scar of the “old” mastectomy; a modern mastectomy respects the anatomy and shape of the breast instead of destroying it.  Contemporary mastectomy incisions are designed like breast reduction or breast lift incisions with the assistance of the plastic surgeon responsible for reconstruction.

» Nipple-sparing mastectomy techniques have been proven safe and effective.  In the right patients, a mastectomy that spares the nipple can result in a reconstruction that is difficult to differentiate from a normal breast.

» The “lumpectomy,” or partial mastectomy, is becoming more common.  In women who are able, removal of the tumor itself, sparing the rest of the breast, is becoming a more common form of surgical treatment.  The lumpectomy must be combined with radiation treatment but with newer forms of radiation (such as implantable radiation treatments or “partial breast” irradiation).  This is quickly gaining favor among breast cancer patients.

» Lymph node removal is rarely performed anymore.  With the advent of targeted “sentinel” lymph node biopsies, removal of the lymph nodes of the armpit are no longer routinely performed.  Removing the lymph nodes can cause severe arm swelling, which is difficult to treat without sophisticated surgery.

» Breast reconstruction is being planned as part of the cancer treatment process.  The most important aspect of a cosmetic breast reconstruction is that as much normal tissue (skin and the fat immediately under the skin) is left behind as possible.  Collaboration between the general surgeon and plastic surgeon BEFORE surgery is essential for this to occur.   

The benefit of breast reconstruction for a woman’s psychological and physical well-being has been well documented.  Proper tumor removal is the most important factor in a successful reconstruction, and “newer” techniques that respect the anatomy of the breast are the best first steps to achieving a satisfying reconstructive result.  Once we, as plastic surgeons, are left with a healthy skin “envelope,” any number of techniques can be used to recreate the breast itself.   A few of the newer techniques include shaped silicone implants, fat grafting, and perforator flaps.

Shaped silicone implants.  Newer, breast-shaped implants allow us to recreate the normal shape of the breast and avoid the “stuck-on” look that was common in older reconstructions.  When combined with nipple-sparing mastectomy techniques, these newer implants can allow us to reconstruct a breast in a single stage instead of the three stages that were common in the past.

Fat grafting, where fat is harvested from one area of the body with liposuction and re-injected somewhere else, has allowed plastic surgeons to further recreate the natural shapes and curves of a beautiful breast.

Perforator flap techniques, such as the DIEP flap, allow for reconstruction of the breast without the need for implants.  A DIEP flap is a lengthy, complex operation that requires a few days in the hospital to recover.  Every year more plastic surgeons are adding it to the list of techniques they use for breast reconstruction.

If you are a woman (or know a woman) who had breast reconstruction already, you may have a reconstruction that isn’t satisfying or that you feel you have to “live with” for the rest of your life. This is not the case.  Fortunately, asymmetric, unnatural breast reconstructions can be salvaged or, in some instances, completely transformed using newer reconstructive techniques.

» Hollowness in the upper part of the breast can be eliminated.  A hallmark of older breast reconstruction techniques, this can be eliminated using fat grafting, shaped implants, or a combination of both.

» Breast crease asymmetries can be fixed.  Using newer, shaped implants or acellular dermal matrix, the crease below the breast can be recreated in an even position.

» Old transverse scars can be corrected, either surgically or with the use of laser treatments or fat grafting (which, in addition to adding shape, can significantly improve the quality and texture of overlying skin).

Leave a Reply