Breast Reconstruction: ‘We have come a long way’

Breast Reconstruction Awareness Day on Oct. 15 is soon approaching us.

Plastic surgeon Melissa Johnson feels the event, during National Breast Cancer Awareness Month, is important to highlight the surgical options available today, based on diagnosis, for women facing mastectomies, and wanting breast reconstruction.

A mastectomy is the surgical removal of the breast, traditionally involving breast tissue, the nipple and areola, and the lining of chest muscle. Rather than leave the area flat, breast reconstruction involves the rebuilding of the breast mound.

“Times are changing,” said Johnson, in terms of options for reconstruction, based on what type of mastectomy is being done. She sees “several patients a week” for such reconstruction.

“We have come a long way. Our game is better and better. Surgery is better. Recovery is better. Anesthesia and pain medication are better.”

Today, Johnson noted some women may have “skin-sparing” mastectomies, in which the surgeon preserves as much breast skin as possible, after the removal of the tumor and any malignant skin, along with the nipple, areola, fat and and tissues.

Some women, who are having a prophylactic mastectomy, or whose tumors are a certain distance from the nipple, may have the option of nipple sparing surgery, as well, during their mastectomy.

Reconstruction can be done immediately, in which case Johnson teams with a breast surgeon, during the mastectomy, or it may be delayed until other treatment is completed.

Johnson added she is “definitely seeing more patients,” who have tested positive for BRCA gene mutations, as “education has improved, and counseling has improved.” These mutations put a woman at higher risk, for both breast and ovarian cancer, and prompt some women to have a double mastectomy, removal of both breasts to lower their risk, a choice actress Angelina Jolie made, and wrote about, in 2013.

“They probably tend to be younger patients. Some are quite young, in their early 20s. They range into their 70s, and there are a lot in between, with a pretty impressive family history (of related cancers),” said Johnson of these patients.

Johnson noted there are basically three main ways of reconstructing the breast mound. These include the use of implants, done in one or two stages, the use of the woman’s tissue only for what is called “autologous” reconstruction, or a combination of these two.

“Women with stage 1, or stage 2, breast cancer are good candidates for the two-stage tissue expander-implant reconstruction,” Johnson said.

In this procedure, a temporary implant, called a tissue expander, is used and gradually inflated over several weeks, before the permanent implant. The temporary implant helps to gradually expand what skin and chest muscle was not removed during the mastectomy, so there is room to insert the permanent implant.

Johnson sometimes uses what is called acellular dermal matrix, material made from donor skin, to help support the implant and improve volume.

“Our shapes have gotten better, and this is all in step one,” Johnson said. “Step 2, we take the tissue expander out for the permanent implant, and there are more options for these implants.”

Johnson added that women may also have surgery done on the opposite breast to make it similar in appearance, if they are not having a double mastectomy.

While infection rates are not “zero,” from such shaped implants, which may need to be replaced during the course of a lifetime, rates are “low,” Johnson said.

In autologous reconstruction, muscle tissue is taken from the buttock, or abdomen, to create shape.

“Whether someone does an implant-based or autologous reconstruction depends on the individual,” Johnson said.

Factors considered include the patient’s diagnosis, health, body weight, and lifestyle.

A recent study found less than half of women elect to have breast reconstruction after a mastectomy. The study, published in JAMA Surgery, was led by researchers at Memorial Sloan Kettering Cancer Center in New York, and involved 485 women who had been diagnosed with breast cancer, between 2005 and 2007.

Reasons varied, from the women not wanting more surgery, to fear of implants, to reconstruction not being important. The results have also been interpreted as a need for more education.

“Everybody has different reasons,” Johnson said. “The breast is very important to some women (in terms of appearance), and less important to others. Women are counseled on what the options are and whether they want to do something or not. Knowing what is involved, they many not want to go there.”

Johnson said a total mastectomy requires a hospital stay, with recovery time of four weeks. Implant surgery can be done at the time, but followup saline injections are needed, along with recovery time until the permanent implant can be inserted, a number of weeks later.

“It is a commitment,” Johnson said of breast reconstruction. “It comes at a really difficult time in a woman’s life, when they have this profound diagnosis and, all of a sudden, the clocking is ticking and they have to make a decision. When you counsel them, as to what their options are (in terms of reconstruction), there is usually a No. 1 choice, with a secondary option.”

Johnson said the fact that breast reconstruction can improve “their self esteem” is an important element.

“There are studies that show a 70 to 75 percent depression rate among women who undergo mastectomies with no reconstruction,” Johnson said. “It is a big deal to have a mastectomy, and breast reconstruction contributes to quality of life, and helps answer the question, ‘I have survived breast cancer, now what.””

A 1998 federal law, the Women’s Health Care and Cancer Rights Act, requires most group insurance plans that cover mastectomies to also cover reconstructive surgery.

This article was originally published by masslive