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Q&A on breast reconstruction - Answers from plastic and reconstructive surgeon Dr. Ben Schalet

October 06, 2015
Dr. Ben Schalet in surgery

By Dr. Ben Schalet, Gazette Contributing Writer

(Published in print in The Daily Hampshire Gazette: Tuesday, Oct. 6, 2015)

A new study from Austria published on Sept. 28 in the journal Cancer reports that Angelina Jolie Pitt’s breast surgery raised women’s awareness of reconstructive breast surgery options.

Conducted on the heels of a previous study done a month before Jolie Pitt’s announcement of her double mastectomy, it found that 92.6 percent of women in the survey of 1,000 Austrian women knew that breast reconstruction was an option after mastectomy. That figure was up from 88.9 percent in the earlier poll.

The most common cancer among women, breast cancer will strike about one out of eight women in their lifetimes. Researchers today report that most women with breast cancer are now opting for breast reconstruction after undergoing a mastectomy, which can have a major impact on their quality of life.

I am a plastic and reconstructive surgery specialist at Baystate who works in tandem with doctors from the Baystate Regional Cancer Program based in Springfield. Following is a look at what is involved in breast reconstruction presented in a question and answer format.

Q. Where does breast reconstruction fit in among women who require mastectomy after a cancer diagnosis?

A. Breast reconstruction can influence a woman’s overall quality of life after cancer treatment, including improving her self-esteem and interactions with family, friends and co-workers. For this reason, it is important that each patient has the opportunity to decide for herself whether or not to pursue it.

The standard of care is to provide each patient with information regarding the types of breast reconstruction and offer a consultation with a plastic surgeon. It is important to remember that breast reconstruction is not a cosmetic surgery, and that the right choice for one woman may not be the right choice for another.

Sometimes the best option is not to do it.

For women with a highly aggressive cancer that has a strong chance of recurring, reconstruction surgery could complicate treatment. Therefore, it would not be recommended although it may be possible to do it at a much later time.

For others, depending on age or pre-existing medical conditions other than cancer, such as heart disease, the surgery may not be a good option.

Q. How has breast reconstruction advanced?

A. In 1998, the U.S. Congress passed the Women’s Health and Cancer Rights Act (WHCRA) that requires insurance companies to cover breast reconstruction services if they cover mastectomy to treat breast cancer. This legal requirement has expanded access to reconstruction and has spurred continued improvement in techniques.

We are now better able to begin the reconstructive process at the same time as the mastectomy for most women. We can also address symmetry with the breast not affected by cancer as a part of the reconstruction, with our end goal being a natural appearance.

Q. What are the different types of breast reconstruction surgery?

A. There are many techniques for breast reconstruction and no one approach is perfect. Some breast reconstructions use a silicone or saline-filled implant to create breast volume. In some cases, the implant can be placed on the same day as the mastectomy.

In other cases, it is better to use a temporary implant, referred to as a tissue expander, to stretch the healthy skin and muscle, then replace it with an implant a few months to a year later.

Other types of reconstruction use a woman’s own tissue including skin, fat and sometimes muscle from the abdomen, thigh or buttocks to create breast volume. This can involve removing tissue from an area of excess and connecting an artery and vein using a microscope to ensure the tissue can survive.

Sometimes using both an implant and a woman’s own tissue is necessary. One of the newest of these methods is called DIEP.

Q. What differentiates DIEP from other procedures?

A. DIEP uses a woman’s own tissue to create a new breast. This surgery, which is only performed in western Massachusetts at Baystate Medical Center, is the closest we have now to being able to combine the benefits of a tummy tuck with breast reconstruction and not cause problems for the patient’s abdomen in the future, because the abdominal muscles are disturbed as little as possible.

DIEP is an acronym for the artery that is used in the surgery called the deep inferior epigastric perforator artery. The idea of the surgery is to spread the abdominal muscle fibers rather than cut them to free the main artery that supplies blood to skin and fat that doctors move to the chest to create a breast shape.

Q. Is it for anyone?

A. It is a great choice for healthy, active people who do not wish to have the limitations of an implant.

We also need to make sure that a patient has the appropriate anatomy for the procedure by conducting a physical exam and sometimes following up with a CT scan or MRI. Those tests can tell us whether there is likely to be one large artery needed for the DIEP procedure.

Some women have multiple smaller arteries that supply the skin. In those cases, we need to cut a small portion of the muscle to move with the skin and fat.

Q. Are there benefits to having reconstructive surgery done immediately?

A. One important part of breast reconstruction is the timing of surgery: immediately after mastectomy or after a waiting period. The first thing to remember is that reconstruction can never interfere with the appropriate treatment for breast cancer.

Sometimes surgeons can perform a complete reconstruction on the same day as the mastectomy, giving a woman one operation and one recovery period.

Other patients, such as those with more advanced cancer who will require radiation after surgery, can get started with reconstruction with a tissue expander on the same day as the mastectomy, but their reconstructions won’t be completed until after their chemotherapy or radiation therapy has ended. It is possible to do reconstruction even years later.

This choice can be a good one if a patient wants more time or has an aggressive form of cancer.

Q. What is the recovery like?

A. Reconstruction with an implant or tissue expander is typically four to six weeks and tissue reconstruction is somewhat longer at six to 12 weeks. The hospital stay is one to two nights with an implant/tissue expander and four to five nights with a tissue reconstruction.

All patients require drains after surgery for one to three weeks. Time out of work will vary with a patient’s occupation, but may be as short as three weeks for those with sedentary jobs and as long as 12 weeks for some who must do a lot of lifting on the job.

Women should expect to return to all the activities they did prior to surgery, although there can be some period of adjustment to the reconstruction.

Q. What does a reconstructed breast feel like?

A. A woman will see the final shape and feel of her breast reconstruction generally three months after surgery. After mastectomy, the skin of the breast does not have feeling and a reconstructed nipple will not respond to temperature changes.

Q. Does breast reconstruction increase your risk of developing cancer again or hide new cancers?

A. Breast reconstruction does not increase the risk of developing cancer again. Studies have not shown that cancer recurrence is harder to detect after reconstruction.

After a mastectomy with reconstruction, routine screening mammograms are not performed on the reconstructed breast, although a patient may still get a mammogram on the other breast. The reconstruction is monitored with physical exam by the patient and her doctors.

Cancer Q&A, which appears monthly, is written by doctors from Baystate Regional Cancer Program, based in Springfield.