Options for Breast Reconstruction

April 19, 2017

BREAST cancer is the number one killer among women in Malaysia.

The brutal truth is losing one or both breasts can be really devastating as the bosom is an important physical asset that makes a woman feel whole.

Indeed, the option of reconstructing the removed breast(s) is a big plus for the breast cancer survivor to restore her self-confidence and rebuild her life.

According to plastic and reconstructive surgeon Dr Ng Siew Weng, there are two main considerations for single or double mastectomy patients wishing to have their breast(s) restored — timing and method of reconstruction.

Immediate vs Delayed Breast Reconstruction

“When the reconstruction is done on the same day as the mastectomy, it’s called immediate reconstruction. Whereas if it’s done months or years later, it’s known as delayed reconstruction,” he said.

Dr Ng said when breast reconstruction was first introduced (before the 1990s), there were fears over how safe the immediate reconstruction option would be as it was believed at that time the procedure could delay the detection of cancer recurrence.

However, he pointed out that several studies showed immediate reconstruction offered many advantages and “is just as safe as delayed reconstruction for early stage breast cancer”.

In immediate breast reconstruction, skin-sparing mastectomy is performed to remove the interior breast tissue and nipple areolar complex while keeping the external skin, explained Dr Ng.

“In this type of reconstructive surgery, the surgeon will restore the breast volume within this breast skin envelop. The ability to preserve the native breast skin envelop is extremely important in producing natural looking result.”

Delayed breast reconstruction, on the other hand, involves the removal of the breast tissue and overlying skin.

“The result will be less than desired because it tends to incur more scars and be less natural in appearance.

“Conversely, immediate breast reconstructive has a huge positive psychological benefit for the patient who wakes up from the surgery without the feeling the loss of body form. Besides, it’s more cost-effective as a single stage procedure,” Dr Ng noted.

As for advanced breast cancer, he suggested that delayed reconstruction was recommended since advanced cancer has higher risk of recurrence.

Various Methods of Breast Reconstruction

Reconstruction surgery can be done using the patient’s own tissue from another part of the body (autologous reconstruction) or with a breast implant (alloplastic reconstruction).

“It is ideal to perform reconstruction, using the principle of ‘replacing like with like’. Autologous breast reconstruction applies this principle to use the patient’s own tissue as much as possible.

“The result is long-lasting and the reconstructed breasts tend to appear more natural in appearance and consistency,” Dr Ng explained.

According to him, transverse rectus abdominis myocutaneous (TRAM) flap is the most common autologous breast reconstruction procedure.

It is said to be similar to a tummy tuck, which removes excessive lower abdominal skin and fat together with a portion of the abdominal muscle, transferring it to the breast for reconstruction.

The end result — a flatter tummy and a reconstructed breast. Patients who had previous Caesarean deliveries may also undergo this procedure.

However, Dr Ng pointed out TRAM flap reconstruction surgery is ‘strictly unsuitable’ for patients wishing to get pregnant after cancer treatment.

“In this instance, the Latissimus Dorsi (LD) flap is more suitable. The LD muscle is a fan-shaped muscle from the back and does not provide much volume and thus, a breast implant may be added,” he advised.

Hence, autologous breast reconstruction will be recommended if the patient’s priority is a reconstructed breast with soft consistency, natural appearance matching the contralateral breast with long-lasting result.

The downside of this option is that the patient must be willing to accept a higher initial cost, longer surgery and additional scar from the tissue donor site.

Simpler, faster and cheaper

Dr Ng said another method which uses implants is much simpler and faster. This option, he added, is suitable for the patient who prefers a simpler shorter surgery with lower initial cost.

“The recovery process is usually less complicated because there are fewer wounds involved. A tissue expander can be added to serially stretch the skin before placing the definitive breast implant.

“In the long run, implant replacement may be required in event of implant rupture or capsular contracture (scarring around the implant).”

The downside is that even though the initial cost of the implant procedure may be lower, the long-term cost may be higher.

“The patient must bear in mind the possibility of further revision surgery for change of implant. She also has to accept less than ideal match of breast shape with the contralateral side if such condition occurs.”

Post initial reconstruction

After the initial reconstruction surgery, the patient may have to undergo ancillary procedure like nipple reconstruction which is planned four to six months after the first stage of breast reconstruction surgery.

“In nipple reconstruction, local tissue is used to reconstruct a new nipple, followed by nipple areolar tattooing one to two months later. “Fat transfer can be introduced at a later stage if there is any contour imperfections in the reconstructed breast,” Dr Ng said.

The entire reconstructive process from mastectomy to nipple areolar tattooing, will typically take between six and 12 months.

He suggested the time frame would be lengthened with protracted adjuvant chemotherapy or radiotherapy.

“Throughout the entire period, the patient’s condition will be reviewed regularly by her breast surgeon and plastic surgeon,” he said, adding that the vast majority of patients were often glad they chose immediate breast reconstruction surgery over other options.