Reconstructive Breast Surgery after a Mastectomy or Lumpectomy
Reproduced with Breast Cancer Network Australia’s permission
Mr Mark Ashton, Head of the Plastic Surgery Unit at The Royal Melbourne Hospital, is a leader in the field of breast reconstructive surgery. We asked him some key questions about breast reconstruction.
When is the best time to have a reconstruction?
It depends on each woman’s circumstances. If timelines for the surgery to remove the cancer are short (e.g. two weeks) a temporary tissue expander can be inserted at the time of the mastectomy. That allows the woman time to consider all the options and to decide on the best course of action. A tissue expander can stay in place for two to five years. However, this may not be suitable for women with a high-grade tumour or a high risk of recurrence, as it can limit the ability to feel any new lumps and make fine needle biopsy difficult in the future.
A reconstruction is still possible, but may need to be delayed a year or two. Women diagnosed with dCIS, or those with a strong family history who choose to have a preventive mastectomy, are more likely to have had time to consider the options available, and may be able to undergo a reconstruction at the same time as the mastectomy.
Women undergoing a large lumpectomy may also be able to have a reconstruction at the same time as the lumpectomy, although this may be delayed if a woman is undergoing radiation treatment.
What if I need radiotherapy?
Radiotherapy may scar tissue, so women undergoing a Breast Cancer Network Australia reconstruction using their own tissue are usually advised to wait until after radiotherapy is completed.
Women undergoing reconstructions using breast implants are advised to have the implants inserted before radiotherapy. Recent research has shown that women who have implants inserted after radiotherapy have a 56% chance of requiring further surgery relating to the reconstruction, whereas women who have implants inserted before radiotherapy have only a 19% chance of needing further surgery after radiotherapy.
If there is a possibility that radiotherapy may be delayed as a result of the reconstruction, inserting a tissue expander before treatment is usually recommended. That allows the permanent implant to be inserted after treatment is finished.
Is body type an issue?
Small-breasted women (A or B cup) usually have an implant reconstruction, as they may not have enough extra body tissue to be used in a tissue flap reconstruction. Women with a C cup or larger usually use their own tissue in the reconstruction, as a larger breast mound can be created. Women with larger breasts sometimes have the other breast reduced in size at the same time, to better match the newly constructed breast.
Do choices vary depending on a woman’s age?
Generally age is not a factor when considering a reconstruction, as long as a woman is fit and healthy. Reconstruction using a woman’s own tissue is a much longer operation, with a longer recovery time.
Therefore, women who have other health issues, such as a heart condition, may choose a surgically simpler procedure, such as implants. Younger women who are considering future pregnancies may not find a TRAM flap suitable, as it can result in weakened muscles in the abdomen.
Can my breast surgeon perform a reconstruction?
Breast surgeons can insert tissue expanders at the time of mastectomy and can perform implant reconstructions. In the case of TRAM flap or other tissue reconstructions, which involve microsurgery, a plastic surgeon is required.
General surgeons are also not always aware of the full range of options available, so that is why it is advisable to consult a plastic surgeon when considering a reconstruction.
How does a reconstruction affect follow-up treatment or cancer detection?
A reconstruction should not affect follow-up treatment or cancer detection, as long as the breast surgeon has identified that there is not a high risk of recurrence. Mammograms would not usually be needed on the side that has had the mastectomy. MRI would be recommended for future screening of the new breast.
What are the future directions for reconstructive surgery?
The new perforator flap surgeries, which just take skin and fat, leaving the underlying muscles from the ‘donor’ site intact, are the future direction for reconstructive surgery. There has been a lot of research into using different parts of the body as donor sites to provide the skin and fat for the reconstructed breast.
These procedures are technically difficult and require extensive microsurgery. At present, not all surgeons are trained to perform these types of procedures. It is also expected that implants will continue to develop to provide more natural and realistic reconstructions.
How do women find a good plastic surgeon?
They can visit the Australian Society of Plastic Surgeons’ website at www.plasticsurgery.org.au > Surgeon Search or call 1300 367 446 for a list of surgeons in each state and territory who specialise in breast reconstruction. They can also speak to other women who have had reconstructive surgery.