A diagnosis of breast cancer can be daunting. Suddenly you're faced with a potentially life-threatening disease that will very likely involve months of medical care. Removing the tumor surgically is generally the first step in treating breast cancer. Inevitably concerns arise: Will I lose my breast, or will it be misshapen? How will treatment affect my relationships and quality of life? What will it do to my sex life? If you're still in the childbearing years you may have additional worries about the effect of breast cancer treatment on fertility. (It can, in some cases, bring on premature menopause.)
While you're weighing your treatment options, it should comfort you to know that surgeons today are well aware of those concerns. Most give careful consideration to the cosmetic results of breast cancer surgery, without compromising the oncological outcome in any way. In fact, for the past decade there's been a movement away from performing radical mastectomies, in which the entire breast is removed along with the pectoral (chest) muscles and lymph nodes in the armpit. Now, in all but the most serious cases, surgeons can achieve the same survival rates using more conservative techniques that keep the breast intact. In breast-conserving surgery--you probably know it as a "lumpectomy"--only the tumor and a surrounding margin of healthy breast tissue are removed, followed by radiation therapy.
Even when the breast is preserved, studies show that up to forty per cent of patients are left with changes in the appearance of the breast that they find aesthetically unacceptable. (If the tumor is large or very deep, or is located in the center or lower portion of the breast, the chance of some disfigurement is even greater.) The best time to deal with these deformities is during the initial surgery. Once t he breast is irradiated, the results of corrective surgery are less predictable. Radiation leaves scar tissue that is inelastic, limiting the breast's ability to conform to reshaping or reconstruction.
Oncoplastic breast surgery is directed specifically at reducing deformities that result from removing a significant amount of breast tissue. It combines cancer surgery techniques for excising tumors with reconstructive plastic surgery techniques for reshaping the remaining healthy tissue to give the breast a natural contour.
In one procedure, simple volume displacement, normal breast tissue near the incision is separated from the chest wall to form a flap. ("Flap" simply means a piece of tissue that can be moved). The flap is then used to fill the cavity left after the tumor is removed. If the resultant breast is smaller than it was before the operation, the surgeon can reduce the opposite breast to restore symmetry.
When more tissue is lost in excising the tumor, the plastic surgeon may use a breast-reduction technique to reshape the breast, making longer incisions on the breast surface to create larger skin flaps. If necessary, a reduction of the opposite breast will create a balanced appearance.
Most women today opt for breast-conserving surgery whenever possible, but there are situations in which a mastectomy is the recommended treatment--for example, when the tumor is very large or there are multiple tumors, or when radiation therapy is not advised. Some women opt for a mastectomy because they don't want to have radiation treatments, or they feel more comfortable having the breast removed as an extra safety measure.
For women who require or chose a mastectomy, there are several reconstruction options. The choice may be based on a number of factors--age, lifestyle, body build, body image, as well as prognosis and the need for future treatment. Often the surgeon initiates reconstruction during the operation to remove the cancer, but in most cases more steps will follow later on. It is important to view reconstruction as an ongoing process rather than a one-time procedure.
The two most common options for breast reconstruction are implants and autologous tissue transfers. ("Autologous" refers to tissue from the patient's own body). Of the two procedures, the implant route usually involves less extensive additional surgery. At the time of the mastectomy, the surgeon places a tissue expander behind the pectoral muscle. Then once or twice a week over the next few months, saline (salt-water) solution is infused into the expander to stretch the muscle and skin. When the skin and muscle are adequately stretched, there is a second surgery to remove the expander and replace it with a permanent implant--either saline- or silicone-filled. Separate surgeries may be needed later to make minor adjustments to the implant, or to create a nipple and areola.
Autologous tissue transfer allows the surgeon to create a breast made of the patient's own tissue. The most common procedure is the TRAM (transverse rectus abdominis musculocutaneous) flap, in which extra tissue from the abdomen is used to fill a skin envelope and form a breast. There are two ways of performing this surgery. One method, called the pedical flap, moves the skin flap to the chest but leaves it hooked up to the blood supply at its original site in the abdomen. In the free flap method--lengthier and more complex--the blood vessels are detached and moved with the flap, then reattached in the chest using microsurgery. With either method, additional procedures are generally needed to contour the reconstructed breast and create a nipple and areola. In most cases, autologous tissue transfer results in a reconstructed breast that closely approximates the pre-surgery form. The extent of scarring in both the abdomen and the breast will depend on the amount of skin removed.
Another type of reconstruction combines elements of both the implant and tissue-transfer techniques. Tissue from the latissimus dorsi muscle of the upper back is rotated to the front of the chest and placed over an implant to give volume to the reconstruction. This creates a very natural-looking breast.
If you smoke, or are overweight, or have heart disease, diabetic vascular disease, or another significant illness, you are at high risk for complications with the TRAM flap procedure--in large part because of the extensive blood vessel involvement. Before you decide on the TRAM flap or any other reconstructive procedure, you should discuss the risks and contradictions with your surgeon. If you have doubts, get a second opinion. Don't let someone sell you an operation that carries unnecessary risk when a simpler one might be the better choice.
With any type of breast surgery, scarring is often a concern. Though it's impossible to predict exactly how your reconstruction will look, these procedures are designed to maximize your chances of a complete cure with a minimal amount of scarring that is easy to hide under most clothing. Reconstruction surgery follows the original mastectomy or lumpectomy incision. Since in many cases your reconstruction will be done by a surgeon other than the one removing the tumor, whoever is performing the reconstruction will very likely participate in pre-op decisions about where and how much to cut.
Physically and emotionally, dealing with breast cancer is difficult, no question. But the many advances in reconstructive surgery, particularly oncoplastic techniques, can help make the experience easier. The medical teams involved in breast cancer care today are working continually to improve not only the survival rates but also the cosmetic outcomes of breast cancer surgery.
Contact Dr. Stephanie F. Bernik at:
The Saint Vincent's Comprehensive Cancer Center
325 West 15th Street
New York NY 10011
Phone 212-604-6006
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