Nervous about Breast Reconstruction with Mastectomy

Hello,

The results of immediate reconstruction are usually better than those of delayed reconstruction, but you can opt to wait if it seems "too much to bear" at this time.  Starting reconstruction immediately allows the plastic surgeon to work with the general surgeon to limit the extent of tissue removal to only that which is needed to clear the cancer. The removal can also be done in a way that does not limit options for later reconstruction and placing even an empty expander in the pocket created limits scarring that can limit later reconstructive efforts. 

Best Regards,

John Di Saia MD

Having been instrumental as a founding member of a breast clinic in a major urban hospital treating breast cancer with a multidisciplinary approach I have a few points to make.

First of all, the fact that your oncologist, and hopefully your general surgeon, has offered immediate reconstruction as a possibility is a step forward. Many doctors, especially in the "old days," wouldn't allow any reconstruction, thus condeming a lot of patients to many months, if not years, of emotional trauma and physical deformity of living without a breast. Having this option is your first vistory.

Second, since there are many variables to breast reconstruction, including type of reconstruction (i.e. implants vs. your own tissues), available anatomy at the beginning of treatment (i.e large breast vs. smaller breast), goal of breast reconstruction (i.e. desired size and shape), and requirement for skin excision by the general surgeon, there can be no one formula for the reconstructive process. However, if immediate reconstruction is a viable option, my recommendation is that if you know you don't want to live without a breast (i.e. that you know you will undergo reconstruction but not know when to undertake it), you should at the very least have the plastic surgeon insert a tissue expander or a spacer that is often just a small implant that holds the space open, preserves tissue, and gets the reconstructive process off the ground thus giving most patients an emotional boost of seeing the potential future take shape. The expander or spacer can be left in indefinitely until you are ready to tackle the bigger questions of what type of reconstruction to choose. If you think about it, a cosmetic augmentation in a very small breast is almost the same as an implant reconstruction after mastectomy.

Third, it might be important to view the plastic surgeon as the overall lead architect in the whole process of treating breast cancer. While this sounds a little strange, it is what really works well since the goal is a long term goal of having a certain result 6, 12, or 24 months down the road when you are hopefully disease-free with the body and breasts you are happy with. In many situation, a plastic surgeon who has this long term vision can often produce a result that is even better than what you began with. The assumption is that the general surgeon, oncologist, and radiation therapist will be working as a team to "cure" you so that it is the end result down the road that is the target.

Fourth, it is always more difficult to reconstruct a flat breast with shortage of skin and existing scar , the length, orientation and position of which the plastic surgeon has no say in, than a breast with more skin and less scar in the advantageous position for optimal reconstruction. The only difference is the possible increased risk of complications that you should discuss fully with your plastic surgeon. Best wishes for a successful treatment.

It is certainly overwhelming to be presented not only with the diagnosis of breast cancer, but also the variety of possible treatments that follow from the breast cancer diagnosis, including possible chemotherapy or radiation therapy.  The thought of reconstructive breast surgery may seem like one additional complicating factor to consider.

There are excellent reasons to consider immediate  breast reconstruction, which is initiated at the time of the mastectomy.  Your plastic surgeon works with the general surgeon performing the mastectomy, helping to design the most appropriate pattern for the mastectomy incision, and then performing the breast reconstruction either with your own living tissue (TRAM or other skin/muscle flap, pedicled or "free"), or by inserting a tissue expander beneath the pectoral muscle of the chest, which is later exchanged for a permanent breast implant prosthesis.  The advantage of immediate reconstruction is that the process begins simultaneously with the mastectomy, so patients embark on the restorative procedure right away, combining the healing process of the reconstructive procedure with that of the mastectomy.

For patients unable to cope with this decision, or those who wish to wait until all issues related to the breast cancer diagnosis, mastectomy, and subsequent related medical treatments are completed, delayed breast reconstruction remains a viable option.  The same menu of choices are available to the patient and to the reconstructive surgeon, but the patient must live with the absence of the breast and possibly an external prosthesis in the interim.  Some women choose never to have breast reconstruction, which is also an option.

Your oncologist, general surgeon, and plastic surgeon can provide you with the options best suited to your particular situation.  When in doubt, however, patients should listen to their own best instincts.

The only time you lose an opportunity for your best result is when you could have had a "skin sparing mastectomy" with an immediate reconstruction using your own tissues such as from the lower abdomen. I these cases, less breast skin is removed and the crease under the breast is preserved and the tissue removed is replaced with new tissue. This is the Cadilac of breast reconstruction but can't always be offered for a wide variety of reasons.

Otherwise, all reconstructions can be done on a delayed basis. This has the advantage of allowing the tissues to heal, the dust to settle, and any pathology issues to be reviewed and discussed especially when it comes to the possible need for radiation treatments or chemotherapy. So don't feel rushed into anything you're not ready for!

Make sure the plastic surgeon you see can do all forms of reconstruction including the microsurgical tissue transfers so that the very best option for your body can be selected. And avoid implants if you have had any radiation treatments because they are fraught with problems from excessive scar tissue.