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8 October, 2008

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Breast reconstruction and mastectomy

Breast cancer is treated with surgery. The aim of the operation is to remove the cancer so it is less likely to grow or return. The two types of surgery are breast conserving treatment and mastectomy. Some women choose to have breast reconstruction surgery to give a similar appearance to the look of their original breast in normal clothes.

Breast conserving treatment
The tumour, some of the surrounding breast tissue and possibly nearby lymph nodes in the armpit are removed during breast conserving treatment. Most of the breast remains, although it will be smaller than (and a different shape to) the remaining breast. A subsequent operation is sometimes needed to make sure the margins of breast tissue surrounding the excised tumour are free of cancer. Breast conserving treatment (lumpectomy) includes radiotherapy, which is the use of x-rays to kill any remaining cancer cells. Research shows that women have fewer body image and sexuality concerns following breast conserving treatment than after mastectomy.

Mastectomy
Mastectomy is an operation that removes the entire breast. Lymph nodes from the armpit will also be taken out. Breast conserving treatment with radiotherapy is just as effective as a mastectomy, and you might have the choice between the two. Sometimes, the size and location of the cancer means that mastectomy is the better option; for example, the tumour may be spread across the bulk of the breast. Your hospital stay will be between two and seven days. After the operation, your chest will be flat with a scar across it. Usually, the underlying chest muscles are still intact. In some cases, radiotherapy might be used after the operation.

Common side effects of surgery
Some of the side effects that happen in the first few months after surgery include:

Pins and needles across the chest
Numbness of the armpit and arm
Difficulties moving the shoulder
Swelling of the arm, if the lymph nodes in the armpit have been removed
Breast pain
Changes in balance because the weight of one breast is missing
Depression and anxiety.

Possible complications
Some of the possible complications of surgery include:

Infection
Death of tissue along the edges of the incision
Post-mastectomy pain syndrome (sharp pain on the chest wall).

'Breast forms'
After the operation, you may be given a temporary 'breast form'. This is a soft breast-shaped cushion that you pin inside your bra. After around two months, when you are no longer sore, and your surgical wound has healed, you can be fitted for a permanent 'breast form', or 'external prosthesis'. This breast form is weighted to restore your balance. It also moves and looks like your other breast when worn under normal clothes.

Breast reconstruction surgery
Surgeons can build you a new breast, either at the same time as your mastectomy or later on. A reconstructed breast will not look or feel the same as your original breast but, in normal clothes, you will look like you did before the mastectomy. The different types of breast reconstruction surgery include:

Prosthetic implant
TRAM flap
Skin flaps taken from other areas of the body.

Prosthetic implant
The prosthetic implant reconstruction is suitable for women with smaller breasts. A tissue expander is inserted under the skin and is gradually filled with saline (over weeks or months) to promote a 'pocket' of skin. Once the pocket is large enough, the tissue expander is removed and a silicone or saline breast implant is inserted. Saline implants are more susceptible to deflation than silicone, and a subsequent operation to replace the implant may be necessary. The main drawback of using implants is that they don't look or feel like natural breasts.

TRAM flap
Transcutaneous rectus abdominus myocutaneous muscle (TRAM) flap reconstruction is particularly suitable for women who have lax abdominal skin. A section of skin and fat from the tummy is removed (similar to the 'tummy tuck' cosmetic operation) and transferred, along with a tag of abdominal muscle and two blood vessels, to the chest. The flap's blood vessels are connected to blood vessels of the armpit or beneath the ribs. The flap is then formed into the shape of a breast and sewn together. TRAM flap reconstruction offers a more natural looking breast (with normal 'hang') than prosthetic implant reconstruction. It does, however, leave a large scar across the abdomen where the muscle was removed.

Skin flaps from other areas of the body
Other skin flaps used for breast reconstruction include:

Breast - this is known as breast-sharing reconstruction. Tissue from the remaining breast contributes to the reconstruction. Women with large breasts are candidates for this option.
Back - this operation may be preferred if the chest muscles were removed during the mastectomy. Muscle from the back (latissimus dorsi) and the overlying skin are taken and used to form a breast shape. In many cases, the reconstructed breast has to be filled out with an implant. The back is left with a visible scar and a slight hollowing near the shoulder blade where the muscle was removed.
Buttock - a small flap from the buttock (gluteus muscle) is sometimes taken if the abdominal skin isn't sufficient. A vein needs to be taken from one leg in order to secure a blood supply to the tissue in its new location on the chest wall.
Hip - a flap of skin from the hip may be used if the abdomen and buttock are unsuitable.

Possible complications of breast reconstruction
Possible complications depend on individual factors, such as the type of surgery performed, but may include:

Haemorrhage
Infection
Scarring
Loss of blood circulation to the transplanted flap
Loss of sensation in the arm
Adverse reactions to anaesthesia or drugs
Abdominal hernia
Hard lumps forming within the reconstructed breast (fat necrosis)
Breast asymmetry
Clots forming in leg veins
Capsular contracture (scar tissue squeezes and distorts the implant)
Implant rupture or deflation
Loss of sensation in the abdomen where the skin and muscle were removed
Body image concerns.

Nipple reconstruction
It is best to wait at least three months after breast reconstruction surgery before having a nipple reconstruction. This is to allow the new breast sufficient time to
'drop' into its position. The new nipple is fashioned using skin flaps from either the abdominal scars or the reconstructed breast. It is then medically tattooed to colour-match it to the existing nipple and areola.

Where to get help

Your doctor
Your specialists
Your breast care nurse
Plastic surgeon
Women's health clinic
Cancer Council of Victoria, Cancer Information and Support Service Tel. 131 120

Things to remember

After mastectomy, some women choose to have breast reconstruction surgery to mimic the look of their original breast in normal clothes.
Breast reconstruction surgery can be performed at the same time as the mastectomy, or later on.
The different types of breast reconstruction surgery include the insertion of prosthetic implants, and the transfer of skin flaps from other areas of the body to the chest.