Breast cancer reconstruction

Breast cancer is the most common form of cancer in women and the second leading cause of cancer deaths in American women.  In 2009, approximately 194,280 patients are estimated to be diagnosed with invasive breast cancer, and 62,280 with carcinoma in situ.  According to the American Society of Plastic Surgeons, nearly 79,500 women underwent breast reconstruction surgery post-mastectomy in 2008.  Approximately 70% of these women had their breast(s) reconstructed with expander/implant(s), whereas the other 30% had autologous breast(s) reconstructed by one of the various flap procedures. 

Expander/implant procedures are relatively safe and simpler to perform, and take approximately two hours of operative time per breast.  During the first surgery, often done at the same time as the mastectomy, an expander is inserted underneath the pectoralis (chest) muscle.  Patients usually stay overnight in the hospital for strong pain medications (narcotics) given in the intravenous line.  The next day or the following day, when the pain can be controlled with pain medications by mouth, then the patient may go home.  Over the next few months, the expander is inflated gradually in the plastic/reconstructive surgeon’s office.  Eventually, when the desired size is achieved, the patient returns to the operating room to have the expander(s) removed and replaced with implant(s).  Complications in breast reconstruction are approximately three-fold higher than in breast augmentation (implant done for cosmetic purpose).  Reconstruction patients, especially those undergoing radiation therapy, experience numerous problems, with capsular contracture being the most common.   In 2008, more than 14,000 procedures were performed in reconstruction patients to remove the original implants.  Even in successful cases, implants do need to be replaced (by surgery) periodically. 

In contrast to implants, autologous breast(s) reconstructed by one of the various flap procedures are meant to last “forever”.  Flap procedures generally require lengthy, more complex and costly operations, 4-5 day hospital stays, and 4-6 weeks of outpatient rehabilitation.  The patient’s own tissue from the donor site (abdomen, back or buttock) is brought in to fill the void left by the mastectomy, above the pectoralis chest muscle.  The choices are: 1) free TRAM (transverse rectus abdominis musculocutaneous) flaps from the abdomen, 2) pedicled TRAM, 3) free DIEP (deep inferior epigastric perforator) flaps from the abdomen, 4) pedicled latissimus dorsi myocutaneous flaps (from the back), and 5) free gluteal flaps (from the buttock).  “Free” flaps mean that the flap blood vessels have to be re-connected with blood vessels in the chest using microsurgical techniques, and the plastic/reconstructive surgeon needs to have this special training.  “Pedicled” means that the flap tissue retains its original blood supply, and no microsurgical reconnection is needed.   The patient then has one or more permanent large scar(s) at the donor site(s) and depending on the type of procedure performed, some experience physical impairment. 

The decision for reconstruction is complex, and highly individualized.  The patient should be well informed and think carefully about her priorities.  Sometimes, the patient may be better served by dealing with the cancer first, and delaying the reconstruction surgery until all cancer treatments are finished.  Other times, it may be most efficacious to combine mastectomy with immediate reconstruction in one operation.