Breast cancer is the most common cancer among women in the United States and the second leading cause of cancer death among women behind lung cancer. One in 8 women will develop breast cancer in their lifetime. Today there are over 2.6 million breast cancer survivors in the United States. Public awareness of the disease and greater efforts for early detection with screening mammography have increased early detection of the disease, treatment and long-term survival. Early stage localized breast disease is associated with a 98% 5-year survival rate.
Treatment of breast cancer has evolved dramatically. Patients typically have an option for mastectomy or breast conserving therapy (lumpectomy and radiation). In addition, a sentinel lymph node biopsy is performed to see if the cancer has spread beyond the breast. Final determination of your treatment plan will be determined by your surgical and medical oncologist.
Your general surgeon may refer you to a plastic surgeon to discuss options for breast reconstruction. You also have the choice to discuss options for breast reconstruction regardless of the treatment plan. If you are a breast cancer survivor and now wish to have a reconstruction, you have the option to seek options for breast reconstruction after mastectomy.
Why Women Choose Breast Reconstruction
The diagnosis of any type of cancer can be overwhelming and scary. Patients often experience fear for their life and an urge to have the cancer removed immediately. Patients can be overwhelmed as they meet a team of doctors including medical oncologists, surgeons, and radiation oncologists. When confronted with information and decisions, patients may not feel ready to discuss breast reconstruction. One study showed only 40% of patients who have mastectomy go on to have breast reconstruction. The decision to have breast reconstruction is a personal one and there are multiple factors as to why women choose not to reconstruct their breast. Some women feel it is not a priority. Others don’t want to go through the additional surgery. Some women are afraid of the cost and think their insurance will not cover such a “cosmetic” procedure.
In 1998, Congress passed the Women’s Health and Cancer Rights Act which mandates that all insurance companies cover post-mastectomy reconstruction and symmetry operations to make both breasts look proportioned. Although the option for reconstruction is a personal one, the fact that more and more women choose to have reconstruction is a testament to the importance, safety and satisfaction of breast reconstruction. Ideally, the first stage of reconstruction can be performed at the time of the mastectomy to minimize the number of procedures and improve the cosmetic result. There are numerous studies validating the safety and patient satisfaction of breast reconstruction.
Patient Choices and Operative Technique: Implant vs. Autologous
There are multiple options for breast reconstruction with evolving techniques that have improved the cosmetic outcomes. Reconstruction done at the time of the mastectomy is called “immediate” reconstruction whereas reconstruction done after mastectomy is called “delayed.” There are essentially two methods of reconstructing the breast: using an implant (alloplastic) or using a patient’s own tissue (autologous). The breast reconstruction procedure of choice will depend on the patient’s preference, the stage of the breast cancer, and the patient’s anatomy. All things being equal, it will be up to the patient to decide if they wish to use an implant to reconstruct their breast or their own living tissue. Each method has advantages and disadvantages and is described in detail below.
Dr. Jerome Liu or Dr. Tom Liu. are fellowship-trained and utilize the latest techniques and technologies for alloplastic (implant) and autologous (flap) reconstruction. Dr. Liu incorporates the principles of “onco-plastics” for all the breast reconstruction patients to maximize oncologic care and aesthetic results. Dr. Liu will discuss the surgical options thoroughly to help you make an informed decision.
Your initial consultation will take approximately one hour. During this time, Dr. Liu will take a thorough medical and breast history, help you with the decision making process, and answer all of your questions. Dr. Liu understands the importance of your oncologic treatment plan as the centerpiece in planning the appropriate reconstruction. The goal of the consultation is for you to obtain all the information you need to make an informed decision regarding the different types of breast reconstruction (implant vs. autologous) and to determine which method is best for you.
Types of Reconstruction
Patients who are getting mastectomies are not the only ones who could benefit from a plastic surgeon. The term “Onco-Plastics” represents a growing new field highlighting the collaboration between the general surgeon and plastic surgeon in delivering the best oncologic and aesthetic surgical care for the patient. It is a principle that Dr. Jerome Liu and Dr. Tom Liu use for all their breast reconstruction patients. In patients with a large or hanging breast (also known as a “ptotic” breast), special incisions can be used to remove the tumor while reshaping and rejuvenating the breast. Working closely with your general surgeon or breast surgeon, Dr. Jerome Liu and Dr. Tom Liu will design skin excision patterns for ease of tumor access while maximizing healing and hiding the scar.
Implant reconstruction can be performed as a two-staged or one-stage operation. In the two-stage reconstruction, a tissue expander (temporary saline implant) is placed underneath the pectoralis major muscle (Stage 1). Additional coverage and support is provided by using a piece of acellular dermal matrix, one of the new cutting edge techniques in breast reconstruction. Patients usually spend one day in the hospital overnight for pain control. During your follow-up, the plastic surgeon will begin expansion of the implant in the office until the final volume is reached. When the breast size is finalized, you will schedule the next stage of your reconstruction (Stage 2), which is typically 3 months after the first stage. The second stage is an outpatient procedure where the tissue expander will be removed and final silicone implant will be placed. After the final size and shape of the implant is set, the reconstruction culminates with the reconstruction of the nipple followed by tattooing of the areola (office procedures). In certain unique cases, a tissue expander is not necessary and the final silicone implant is placed at the time of the first operation. Dr. Liu will help you determine which method is best for you.
There are many reasons why patients seek autologous reconstruction. Some patients do not like the notion of having a prosthetic silicone implant in their body. Others wish to have their breast reconstructed with their own tissue. The advantages of autologous reconstruction include the longevity of the procedure and the lack of implant related complications. In theory, an autologus reconstruction can last an entire lifetime. In other situations, anatomic or medical indications may dictate that a patient receive one type of reconstruction over another type. Examples of this are use of radiation therapy, other co-existing medical problems, or anatomy (presence or absence of sufficient “donor” tissue). During your consultation, Dr. Liu will present the risks, benefits, and alternatives and help you decide on a method of breast reconstruction.
Abdominal-based flaps are the ideal type of autologous reconstruction with many advantages. The skin and fat quality of the abdomen makes a very good substitute for creating a new breast. The location allows for preparation of the tissue while the mastectomy is being performed. This reduces the amount of time a patient is under general anesthesia. Many women are pleased to donate their excess abdominal tissue to reconstruct the breast. For all of these reasons, the transverse rectus abdominus myocutaneous (TRAM) flap is the workhorse flap for autologous breast reconstruction. All abdominal-based flaps use the same standard elliptical skin and subcutaneous fat excision resulting in what resembles a “tummy tuck” scar. However, it is what happens at the muscle and blood vessel level that differentiates the different types of TRAM-flap variants.
One of the early and still commonly performed abdominal-based flaps is the pedicle TRAM flap. Although the skin excision is the same, the main difference between this flap and other abdominal-based “free flaps” is the underlying blood supply of the flap. The abdomen has a pair of rectus abdominus muscles which provides the blood supply to the skin and fat of the abdomen. The blood supply also comes from two directions: one above (the superior epigastric vessels) and one below (the deep inferior epigastric vessels). A pedicle TRAM derives its blood supply from the superior epigastric vessels and remains connected to the muscle during a breast reconstruction. The inferior blood supply is divided at the time of surgery when the tissue is moved into the chest to recreate the breast. During a pedicle TRAM, the entire rectus abdominus muscle is sacrificed on one side. The flap is then “pedicled” by the superior blood supply and then tunneled into breast cavity to recreate the breast. The abdomen is closed similar to a “tummy tuck.”
The main advantage of the pedicled-TRAM is the ease of harvest of the surgical procedure and the avoidance of a technically more challenging microsurgical dissection. Although the majority of patients do very well from a pedicle TRAM operation for breast reconstruction, the major disadvantages is that the entire rectus abdominus muscle is sacrificed resulting in mild weakness of the abdominal wall. Furthermore, it is believed that the inferior blood supply (deep inferior epigastric artery) is the dominant blood supply to the abdominal flap. Therefore, the blood supply to a pedicle TRAM is less robust than a free TRAM flap. In a patient who wishes to have a bilateral autologous reconstruction, the bilateral pedicle-TRAM is NOT an option due to the resulting sacrifice of both rectus abdominus muscles.
The advent of microsurgery brought a new paradigm to flap reconstruction as composite blocks of tissues (“flaps”) could be kept attached to its blood supply (vascular pedicle = artery and vein). The tissue could then be completely disconnected from the body (thus the term “free”), transported to any part of the body, and reattached using a microscope. Microsurgery significantly increased the plastic surgeons reconstructive capabilities and decreased the donor site morbidity of many flaps. Microsurgery brought a new level of refinement of the pedicle TRAM flap design with the advent of the free TRAM flap.
Unlike the pedicle TRAM, the free TRAM requires careful surgical dissection to find and preserve the dominant deep inferior epigastric vessels. The flap is completely disconnected from the patient, thus making it a “free flap.” Once liberated the flap vessels are then connected to blood vessels in the chest or armpit using refined microsurgical techniques and a surgical microscope. A technically more difficult operation, the free TRAM can be safely performed with a team of dedicated and skilled plastic surgeons. The advantages of the free TRAM over the pedicle TRAM are numerous. Whereas the pedicle TRAM sacrifices the entire rectus abdominus muscle, a free TRAM only removes a portion of the rectus abdominus muscle and leaves the remaining majority of muscle intact. Saving the majority of the rectus muscle preserves the abdominal wall integrity and improves recovery. Preservation of the muscle, allows for the ability to perform a bilateral autologous reconstruction using the free TRAM flap.
Further advancements in microsurgery have transformed the traditional free TRAM even more by further reducing (“sparing”) the amount of rectus abdominus muscle sacrificed for the flap. The next generation muscle sparing free TRAM flaps continue to evolve as less and less muscle is removed preserving more of the abdominal muscle and integrity of the abdominal wall. The continued advancement to preserve more and more muscle has evolved into perforator flaps such as the deep inferior epigastric perforator flap (DIEP), the ultimate iteration of the free TRAM.
Deep Inferior Epigastric Perforator (DIEP)
Just as muscle sparing free TRAM flaps have evolved to spare more and more rectus abdominus muscle, the deep inferior epigastric perforator (DIEP) flap is the culmination of this evolution. The DIEP flap represents a new class of “perforator flaps” which means that the entire rectus abdominus muscle is spared. This is the most technically challenging of the TRAM-flaps as the blood vessels (“perforators”) are dissected completely free of the muscle. This is completely opposite of the pedicle-TRAM. Whereas the pedicle-TRAM sacrifices the entire rectus abdominus muscle, the DIEP sacrifices none. As a result, the abdominal morbidity is the least and the abdominal integrity is the best with the DIEP.
Other Types of Autologous Reconstruction
There are unique cases where patients wish to have autologous reconstruction but are unable to have a TRAM flap. Examples such as this include patients who have already had a tummy tuck, a TRAM flap, or simply do not have enough abdominal tissue to reconstruct a breast. Other situations may make a TRAM flap more difficult, such as prior abdominal surgery scars or underlying medical problems. When a TRAM-flap is not available, secondary autologous breast reconstructions are considered including using the soft tissue and muscle of your inner thigh (transverse upper gracilis free flap or TUG-flap), the soft tissue and muscle of your back (latissimus dorsi muscle flap) or your buttock (gluteal flap).
About the Operation
Breast reconstruction typically takes 3 stages (operations) to complete. Whether you choose implant or autologous reconstruction your initial breast reconstruction (Stage 1) will be performed at one of the hospitals we are credentialed at. For immediate reconstructions, the plastic surgeon(s) will work closely with the surgical oncologist for optimal safety and aesthetic results. The reconstruction can be performed immediately after or at the same time as the breast surgery. For delayed reconstructions, the surgery is performed entirely by the plastic surgeon(s). After your recovery (typically 3 months) you will proceed with the second stage of your reconstruction (Stage 2).
The goal of the second stage is to shape and size the breast to it final form. In the case of a unilateral reconstruction, the reconstructed breast is made to replicate your native breast. Sometimes, the uninvolved breast will need to be lifted, reduced, or augmented to match the size and shape of the reconstructed breast, also known as the symmetry operation. For implant reconstructions, the tissue expander is exchanged for a final silicone implant at the second stage. Unfavorable scars are also revised at this time and excess subcutaneous tissue can be liposuctioned. Although these procedures are “cosmetic” in nature, these symmetry procedures are an integral part of the reconstruction and are fully covered by insurance as mandated by the Women’s Health and Cancer Rights Act of 1998. These procedures are done in an outpatient surgery facility and you will be discharged home after the procedure.
Once the breast shape and size are finalized, the nipple is reconstructed (Stage 3). The nipple-areola complex (NAC) reconstruction (Stage 3 and 4) are the final steps of the reconstruction and are not performed until the final breast shape and size is achieved. The NAC is considered the crown or peak of the breast and is reserved until the final breast shape and size is achieved. This procedure is performed as an outpatient and can usually be done under local anesthesia. Once the nipple reconstruction fully heals the areola is tattooed.
Breast reconstruction is done in stages. In most cases, the reconstruction will take 3 stages to complete. The first stage is always the biggest procedure with the longest recovery, while subsequent surgeries are shorter with much easier recoveries. Dr. Liu will be an integral part of your post-operative care and will be available at all times during your recovery. While you are in the hospital, we will see you daily until you are medically safe and ready to be discharged to home. During subsequent stages, most patients do not need to stay in the hospital. Stages 2 and 3 may be safely performed as an outpatient and have easier recoveries.
Time off of work varies by the patient and by the method of reconstruction. In general, patients will need 1 to 2 weeks off of work for the first stage to focus on their recovery. Patients recover much faster during the subsequent operations (Stages 2 and 3) and may require 5 to 10 days off of work. From start to finish, breast reconstruction takes approximately 6 months to complete. We will provide you with individualized post operative care instructions following each operation to ensure a smooth and speedy recovery.
Dr. Jerome Liu or Dr. Tom Liu, along with our patient coordinator and office staff, will be an integral part of your care team and will work hard to make sure that you have a safe surgical experience and the proper post-operative care.
Breast reconstruction following mastectomy for the treatment of breast cancer is an option available to all women. Research publications continue to demonstrate that breast reconstruction is an integral part of breast cancer treatment with obvious psychological benefits without jeopardizing disease free survival. Advances in breast reconstruction surgery continue to provide women with multiple surgical options, whether it is with newer generation silicone implants or the latest refinements in microsurgery free flap breast reconstruction. The Women’s Health and Cancer Rights Act of 1998 mandates insurance coverage for not only the reconstruction but also the ensuing symmetry operations. Although the decision to reconstruct the breast is a personal one, we encourage you to seek a consultation with a plastic surgeon trained and dedicated to breast cancer reconstruction to discuss your surgical options along with your breast oncology surgeon.
Contact Liu Plastic Surgery
Dr. Jerome Liu or Dr. Tom Liu are fellowship trained plastic surgeons and perform all aspects of breast reconstruction from implants to microvascular free flaps. Liu Plastic Surgery is dedicated to advancing the reconstructive care of the breast cancer patient through research and community outreach. To discuss your options for breast reconstruction, please make an appointment with Dr. Jerome Liu or Dr. Tom Liu.