What are the options for breast reconstruction after cancer?


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Patient meeting with her physician to discuss reconstruction options.

We all take great pride in our personal appearance – it’s human nature. We choose our clothes and style our hair to fit our personalities and accentuate our favorite features.

But breast cancer can drastically change a woman’s appearance. Understandably, having part or all of a breast removed can have a major effect on body image and sense of self. That’s why many women choose breast reconstruction to make their breasts appear as they did prior to cancer – or even better, in many instances.

We always emphasize to patients that breast reconstruction is a process and an ongoing journey, both physically and artistically. Our end goal always is an excellent result and a happy patient, even though we cannot restore all that is missing following a mastectomy and treatment of breast cancer.

UT Southwestern’s Department of Plastic Surgery specializes in breast reconstruction for patients in the Dallas-Fort Worth area and beyond. We emphasize a team approach tied to a multidisciplinary clinic composed of breast-only oncologic surgeons, plastic surgeons, medical oncologists, radiologists, geneticists, physical therapists, and psychologists.

Both Dr. Haddock and myself have predominantly focused our practice in breast reconstruction, performing more than 200 breast microsurgery procedures a year as a team, and over 500 other breast reconstructive procedures yearly. None of the surgeries are the same and, in each one, the patient remains at the center of the decision-making process and involved in their journey.

We work and operate as a cohesive breast reconstruction team, making crucial decisions geared toward achieving a goal the patient desires. When you are treated for breast cancer, some or all of your breast tissue might need to be removed by your surgical oncologist. This tissue can then be replaced, or reconstructed, by a plastic reconstructive surgeon. Various options are available, depending on your age and medical condition.

It’s important to understand all your options and to have your questions answered before you make your decision.

Here are some of the questions we hear most frequently from our patients:

Do I need an expert in breast reconstruction for my surgery?

Many good plastic surgeons are well trained in breast reconstruction, but may not be able to offer a wide variety of expertise in reconstructive surgery. Many procedures, especially involving microvascular surgery, require highly specialized teams in order to have a predictable, efficient, and successful result with low complications. We’re fortunate that both of us dedicate nearly our entire practice to breast reconstruction, emphasizing the latest techniques in reconstruction and frequently publishing our work in peer-reviewed medical journals.

We continue to remain creative and make decisions that individualize reconstruction, a strength we possess by working together in an academic environment that supports our breast-only clinical practice, research, and education. As a result, we’ve been able to help pioneer and add to technical and creative aspects of breast microvascular surgery procedures that are uncommonly performed yet suitable and applicable to many patients with different types of physiques.

What types of uncommonly performed procedures are available in your practice?

We see and evaluate patients who previously have experienced failure in breast microvascular surgery. In many of these patients, we look for other areas of the body where tissue can be taken and be useful for a second microvascular surgery procedure. Although these situations are uncommon, our team approach and creativity have yielded new approaches to breast reconstruction.

We also are one of the few breast-only centers in the U.S. with extensive experience in Profunda Artery Perforator Flap (PAP flap), using tissue from the back of the thigh. For some very selective and healthy patients, we also offer another higher level of microvascular surgery called the 4-flap procedure (using tissues simultaneously from various parts of the body). In addition, a large part of our practice consists of performing stacked-flaps (multiple tissues joined together under a microscope).

Should I have breast reconstruction right away?

It’s your decision whether to have breast reconstruction immediately after cancer surgery, to wait for a period of time, or to not have reconstruction at all. You may not be prepared for another surgical procedure right after surgery for cancer. Treating your cancer comes first and should be your top priority.

If patients are undecided about which type of reconstruction to proceed with at the time of their cancer diagnosis or if there is radiation involved, we can place a temporary expandable device to prepare for future reconstruction. This is commonly known as Tissue Expander reconstruction, which involves a saline-filled device. Using such a device has many advantages even for patients who choose a reconstructive procedure that uses their own tissue.

An option that doesn’t involve reconstruction is an external prosthesis. A prosthesis – a breast form you wear inside a bra – can look great, and it requires no surgery. Some patients are happy with this option. Before we ever proceed with reconstructive surgery, we make sure our patients are physically and emotionally prepared to make important decisions about reconstruction.

What do I need to know about breast reconstruction?

One of the most common misconceptions about breast reconstruction is that it’s completed in one procedure only. It can be in some circumstances, but ultimately it’s a process of a few procedures. If patients need additional treatment for their cancer, such as chemotherapy and/or radiation therapy, the breast reconstruction process can take longer than 1-2 years, which includes completion of all parts of reconstruction.

A great deal of artistic measure is tied to a successful outcome in breast reconstruction. In addition, scarring is part of the surgeries and generally we try to place scars in areas that are hidden or at least minimized by natural shadows and curves of the patient.

Procedures that involve using a patient’s own tissue can take up to 4-6 hours per operation, and sometimes more, depending on the patient’s anatomy, but many can be performed in a few hours or less. We’re fortunate that we work in a highly specialized environment that supports breast reconstruction and emphasizes successful outcomes while reducing complications – an attitude that extends all the way from the anesthesia team to the OR team, nursing care, hospital staff, and clinic support. Various levels of care are provided to ensure that patients going through breast cancer and reconstruction have a comfortable and predictable experience.

Anatomical and biological issues also dictate the type of breast reconstruction that can be performed. For example, heavy smokers often have complications because their skin heals more slowly. Heart and lung problems also may play a role in eligibility. Additionally, severely obese patients and patients with clotting disorders usually are not good candidates for breast reconstruction. Every patient’s anatomy is different, and every procedure has to be individualized.

Another misconception is that older patients cannot have breast reconstruction surgery. Age is not the primary factor. More important is the patient’s overall health and physiology, and whether she can tolerate or desire the stages of surgery.

Should I get implants or use body tissue?

Most implants used in breast reconstruction are made of silicone. The FDA has approved many different implant shapes and sizes, and the results have the potential to look wonderful.

Implants are used in more than two-thirds of the 100,000+ breast reconstruction operations performed each year in the U.S., according to the American Society of Plastic Surgeons. Implants also can use saline; however, silicone is softer than saline and has a better shape and feel after mastectomy.

About one-third or fewer of breast reconstruction surgeries use the patient’s own tissue. That tissue can come from the abdomen, back, thighs, or buttocks. Essentially, we transplant tissue and link it to blood vessels in the chest or armpit area. This advanced surgery calls for an experienced and multidisciplinary microsurgical breast reconstruction team and can involve using a microscope and, often, sutures as thin as a hair. Our team approach has yielded high success when it comes to microvascular surgery, with tissue survival rate in the range of 98-99 percent.

We think of breast reconstruction as an art form involving surgery. The ultimate goal is to create the look you want, whether it’s an implant or using your own tissue. And it’s a process toward an artistic and balanced result.

Are there drawbacks to breast implants?

Most patients who opt for implants are generally happy with the results. But it’s important to note that artificial objects inserted in the body will not last forever.

Implants can change shape, leak, rupture, or scar, and they don’t age as your body does. Sometimes, they can stretch the skin and feel heavy. In instances where radiation is involved in treating breast cancer, an implant can adversely affect the result and may not last long without additional surgeries.

Though an implant doesn’t really ‘age’, the tissues around it will. Some women – often five to 10 years after breast reconstruction – opt for additional surgery. Some patients, later in life, choose to have their implants removed and either replace them, opt for surgery using their own tissue, or have no reconstruction.

Is breast reconstruction available for high-risk or late-stage cancer?

Almost all relatively healthy cancer patients can be candidates for breast reconstruction. However, we have operated on many high-risk patients during our career. Patients who are on medications to suppress cancer also may have the surgery performed if they are willing to undergo the process of reconstruction and understand the risks. The decision to undergo reconstruction is an important one and must be individualized to a particular medical challenge a patient faces.

Even stage 4 patients can have breast reconstruction as long as they are under medical supervision. If a patient can physically and emotionally handle the surgery, we can go ahead with it.

Ultimately, it’s your decision whether to have breast reconstruction, use a prosthesis, or do neither. Again, your cancer treatment should be your top priority. You can make decisions about reconstructive surgery when you’re ready.

We invite you to visit our breast reconstruction page for additional information and to learn more about the types of breast reconstructive surgeries.