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Diagnosis: Breast Cancer – But What About My Breasts?

The odds are that one in nine women will get breast cancer in their lifetime. Those are staggering numbers.

Once a diagnosis of breast cancer is made a whole team of specialists get involved to guide the patient through the treatment choices. What essentially determines your prognosis and treatment is your staging of the disease – the worse (of higher) the staging, the more aggressive the treatment.

There are essentially a combination of treatments ranging from chemotherapy (including hormone blockers), radiation and surgery that can be used. The best determination will depend on age, stage, certain hormone receptors of the disease and family history.

A majority of women will probably not need plastic surgery because the disease, if caught at an early stage, can be treated with lumpectomy and possible radiation and/or chemotherapy. If these treatments are done then a woman preserves her own breasts and the cosmetic result is excellent.

For those whose treatment regimen may include a total mastectomy the question is, “What about my breasts???”

For women who have more advanced disease, the best treatment may be a mastectomy with or without lymph node sampling. At this stage a thorough consultation with a plastic surgeon is required prior to the mastectomy so that reconstruction can be done simultaneously while in the operating room.

The first meeting should include a thorough history and physical exam. A plastic surgeon will consult with his or her colleagues regarding the type of mastectomy, the staging of the disease and whether post operative radiation or chemotherapy may be used. Most importantly, the patient is examined for the risk of surgery and reconstruction. Is she healthy, does she smoke, are there comorbidities? During the interview, the plastic surgeon will ask whether the patient wants to do reconstruction at all or does she want reconstruction with her own tissue or using implants and other materials.

Some patients that get mastectomies at an older age or have severe comorbidities may not be candidates for aggressive reconstruction. If a patient has aggressive disease and requires radiation, then reconstruction may be delayed for a while until her disease is better controlled.

So what are the options?

OPTION 1: Bypass reconstruction and possibly be fitted for an external prosthesis.

OPTION 2: Reconstruction using your own tissue.

This may require we use the muscle and skin from your back, tummy or buttocks. It may be done as a flap with an artery supply that is intact and simply moved or the blood supply is interrupted and reanastomosed under a microscope (free flap). Sometimes an implant may be needed to get proper size.

Reconstruction using your own tissue (autologous) gives the most natural feel and look to the breast but the trade off is another site of surgery including a scar, longer surgery, more prolonged recovery and possible revisions in both the donor site and the mastectomy site. The transferred tissue may need to be trimmed and revised. Once the proper look is achieved a nipple will have to be reconstructed and tattooed. Also the other breast may have to be augmented and/or lifted or reduced to achieve symmetry. If radiation is used post-operatively then autologous reconstruction is delayed for a while.

OPTION 3: Reconstruct with implants.

Usually a tissue expander is placed at the same time as the mastectomy and expanded post operatively to a desired result. Then the patient is brought back in after a couple of months or after chemotherapy and/or radiation and a permanent implant is inserted. The implant may be saline or silicone. The risks and benefits of both implants can be discussed with your doctor. As with any reconstruction the other breast may be augmented and/or lifted or reduced. Finally, a nipple on the reconstructed breast will have to be made and tattooed. In some instances a muscle may be harvested to add to the reconstruction. Lately to reduce the morbidities, Alloderm (cadever dermis) can be used to substitute for the muscle.

Every patient, regardless of staging, age or comorbidities has to make wise and educated decisions both for their treatment as well as their reconstruction. Whether the reconstruction is done during the initial mastectomy or delayed for a time can be dependent on the disease and subsequent treatment. It may be wiser to treat the disease and then reconstruct once the patient has had chemotherapy and/or radiation. The resultant reconstruction will not be affected by these modalities as much.

All surgeries carry risk and a qualified board certified plastic surgeon can discuss the risks, treatments and possible choices in a simple yet thorough matter.

Dr. Ayoub Sayeg is a Board Certified Diplomate, American Board of Plastic Surgery, Cosmetic and Breast Fellowship Trained. He received his medical degree from the University of Toronto and served his general surgery residency at Washington Hospital Center, Washington, D. C. Dr. Sayeg served his plastic surgery residency at Wayne State University in Detroit from 1998 to 2000.