Amid the emotional turmoil of a breast cancer diagnosis, a woman faces critical decisions about her treatment writes Dr Brigid Corrigan, Australasian Society of Aesthetic Plastic Surgeons (ASAPS) member and Specialist Plastic Surgeon at the Western Australian Plastic Surgery Centre.
Being told you must undergo mastectomy is further complicated by the array of options available and the decision about whether, when and how to have breast reconstruction.
There are two types of breast reconstruction and multiple options for each: using implants or a reconstruction that uses the body’s tissue, known as autologous tissue reconstruction. Either type can be performed immediately, or months or even years later.
Radiation Treatment Will Affect Breast Reconstruction Timing
A crucial factor that will affect the timing of reconstruction is whether a patient will need radiation therapy after her mastectomy.
In some cases, it is preferable to delay reconstruction until after radiotherapy. However, it is also still possible to have an immediate reconstruction, even when post-operative radiotherapy is planned or likely. This may influence what type of reconstruction is recommended. It is generally not recommended to have a permanent implant placed before radiotherapy as there is a higher rate of capsular contracture, implant exposure and implant malposition. Usually, it would be recommended to have some form of autologous (using your tissue) reconstruction if radiotherapy is planned. In this situation, it may also be an option to undergo a ‘delayed immediate reconstruction’, in which a tissue expander is placed at the time of mastectomy to preserve the breast skin. A tissue expander is an implant that’s more like a balloon. It stretches the skin to make room for the final implant.
A Specialist Plastic Surgeon can place a tissue expander between the skin and chest muscle after the Breast Surgeon has removed the breast tissue. Then the autologous reconstruction can be performed after the radiation is completed.
Women who know they need radiation treatment or who are at high risk of post-surgery pathology should work with their Oncologist and Specialist Plastic Surgeon to determine the best time to perform the final reconstruction.
Immediate Breast Reconstruction Advantages
Often the best aesthetic result and the most sustained level of patient satisfaction is with immediate autologous tissue reconstruction performed at the same time as the mastectomy. This is because the breast skin can be kept, and the aim of reconstruction is to fill the skin envelope with either autologous tissue or an implant. Autologous tissue reconstruction produces a soft, natural result that looks and feels most like a breast. Sometimes the nipple and areola can also be preserved, although this depends on where the tumour is located and is more common when the mastectomy is being performed prophylactically rather than when breast cancer is present. You should discuss with your breast surgeon and plastic surgeon whether it is possible to keep the nipple.
The most significant advantage of immediate reconstruction is a superior aesthetic outcome and minimising the emotional trauma from losing a breast. Psychologically, for a woman to wake up from a mastectomy and look down to see that she still has breasts, is very beneficial.
Immediate Breast Reconstruction Disadvantages
One disadvantage of immediate reconstruction is that the hospitalisation and recovery period may be more extended than with mastectomy alone. For patients who need radiation therapy and/or chemotherapy, it may delay treatment until healing is complete. It also means that you may have to make a lot of decisions in a short space of time. For women who are diagnosed with breast cancer, they can suddenly find themselves bombarded with information and decisions to make regarding their treatment. Some women find it easier to deal with treating breast cancer first and then to have more time to consider the reconstructive options after they have had their cancer treatment.
Delayed Breast Reconstruction Advantages
Delaying reconstruction reduces the recovery time after mastectomy. If a patient has a high-grade tumour or advanced disease, she may want to delay reconstruction so that she does not delay her chemotherapy or radiation therapy. Either type of reconstruction – implants or with the woman’s tissue – can be performed at any time after healing from a mastectomy is complete and after chemotherapy and radiation therapies, if those are required.
Delayed Breast Reconstruction Disadvantages
The disadvantage of a delayed reconstruction is potentially an inferior aesthetic result and the need for additional surgery. The reconstruction itself may be more difficult because the breast skin has already been resected, so it will be necessary to make up for the lost skin as well as restoring the volume of the breast. There will likely be a need for follow-up procedures to improve the cosmetic result. However the satisfaction from delayed reconstruction is still high, and some women find it very helpful to be able to take the extra time and recover from their breast cancer treatment, both physically and emotionally, before embarking on reconstructive surgery.
Whatever the decision is, a woman must feel she is somewhat in control. There is no right or wrong for the best time for reconstruction or the best type of reconstruction. The option of reconstruction should be discussed with all women having mastectomies, and an individual treatment plan should then be planned in discussion with your Breast Surgeon and Specialist Plastic Surgeon.