breast reconstruction

changes in reconstruction

Breast reconstruction has changed in the last 10 years, with the reconstruction rate of patients with early breast cancers being 30-50% in many areas. As well as the increase in reconstruction there have been 2 other changes:

1) Skin-sparing mastectomy is being performed with earlier cancers/DCIS. This type of mastectomy removes less skin with the breast tissue, and combined with immediate reconstruction with a flap gives the best possible cosmetic result. It may also reduce the need for surgery on the other breast to achieve a symmetrical result. There have been 2 large studies (now with 10 year follow-up following surgery) which have shown that skin-sparing mastectomy does not affect the treatment of early breast cancer. This technique, however, is only suitable for patients with very early breast cancer.

2) Immediate reconstruction (at the time of mastectomy) is being used more because it has better results (and because of the increasing number of patients with earlier cancers). Immediate reconstruction may decrease the number of operations involved, but depending on the type of reconstruction often increases the recovery time after the operation. Again immediate reconstruction has been shown not to affect treatment of early breast cancer. Immediate reconstruction can also decrease some of the psychological impact of mastectomy, allows a quicker emotional adjustment to the diagnosis of breast cancer and a quicker return to normal life - it avoids wearing external prostheses, and allows a quick return to wearing normal clothes, normal activities eg swimming.

There have been a number of studies looking at the benefits of breast reconstruction, which have shown that these patients have significant increases in emotional well-being, vitality, general mental health, functional well-being, and body image compared to those patients without reconstruction.

decisions in reconstruction

The major decisions in breast reconstruction are:

1) What type of mastectomy is needed? - this depends on the individual patient's situation. However, these days many mastectomies are performed for very early cancers or precancerous changes (eg DCIS), and in this situation a "skin-sparing mastectomy" can sometimes be performed, which minimises the scar and often allows a better reconstruction to be achieved. If used with an immediate flap reconstruction (see below) nearly all plastic surgeons would consider this the gold-standard technique for treating early disease - the patient wakes up after the operation with a breast almost exactly the same as the one they went into the operation with.

2) When can the reconstruction be done? - it used to be said that a women should live without a breast for at least 1 year before a reconstruction was done, because of worries of reconstruction delaying detection of local cancer recurrence. There are now studies in large numbers of patients with early breast cancer showing no increase in local recurrence with skin-sparing mastectomy and immediate reconstruction. In general immediate reconstructions have better results compared to delayed reconstructions.
Delayed reconstruction can be performed any time after mastectomy, and reconstruction should be delayed it is known that radiotherapy will be given after the mastectomy, or if the patient needs more time to make a decision about the options.

3) What technique would be used for the reconstruction? - here there are 3 main choices, which all have advantages and disadvantages. Most types of reconstruction usually take at least 2 operations to complete.

These decisions are made on an individual basis, depending on many factors, including the position and particular type of cancer, the patient's general medical health, the size and shape of the patient's breasts, and the patient's lifestyle and wishes.