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General Surgery

Breast Reconstruction including Timing and Reconstruction Rates

Breast reconstruction is a surgical procedure performed to restore the shape and size of the breast after the cancerous tissue is removed during mastectomy. This is a cosmetic procedure conducted by a plastic surgeon. The surgery aims to match the removed breast with the existing one or create both breasts to be symmetrical and look as natural as possible.

Breast reconstruction has been found to greatly enhance the patient’s self-image and quality-of-life after mastectomy. Once your surgeon has decided on the removal of your breast, the options for the reconstruction will be discussed with you. After considering the pros and cons of the surgery, you could opt for or against reconstruction.

NO RECONSTRUCTION

The decision not to reconstruct your breast is a personal choice. One of the main reason women choose not to undergo breast reconstruction is to avoid any more surgical procedures, and associated complications and further treatments. They are comfortable wearing a prosthetic breast in their bra. Many others find themselves renewed and profoundly changed after the experience of cancer treatment, and choose to retain their flat chest after mastectomy.

RECONSTRUCTION

If you decide to reconstruct your breast, you should bear in mind

  • It is optional and not a part of treatment
  • Desired results may be achieved in one or more procedures – the first being more complex and lengthy
  • Frequent visits may be necessary over a couple of months
  • Complications may occur, which could require unplanned procedures
  • Results may not be obvious immediately
  • Results will depend on the technique used
  • Original appearance and shape may not be precisely restored
  • Sensations will not be the same in the restored breast
  • Lactation is not possible in the restored breast
  • Does not interfere with future detection of breast cancer
  • Does not increase the risk of recurrence
  • Not all are suitable for reconstruction

TIMING OF RECONSTRUCTION

When you have made the choice to have your breast reconstructed, you will have to decide on whether you want to undergo the surgery immediately after mastectomy or at a later stage. Reconstruction at the time of mastectomy is currently the mainstream option. The advantages include:

  • Optimal aesthetic value
  • Preserves more of the original skin (even the nipple and areola)
  • Less scarring of breast tissue

The ideal candidates for immediate reconstruction are women who are in good health and have early-stage cancer. Those who smoke and with health issues like high blood pressure, diabetes or obesity will not be suitable and may be advised to wait.

Delayed reconstruction has its own benefits:

  • Cancer treatment will not be delayed
  • You have more time to consider reconstruction
  • You have far less to deal with at one instance

Radiation therapy post-surgery is a deciding factor for the timing of reconstruction as it can cause disfigurement, tissue damage and other complications when performed on a reconstructed breast. Radiation therapy is considered for the following cases:

  • High risk of recurrence
  • 4 or more nodes involved
  • Tumors of more than 5 cm
  • Involvement of skin and chest wall
  • 1-3 positive axillary nodes

Delayed reconstruction, 6-12 months after radiation therapy is therefore the most suitable option, where ample time is given for the tissues to heal. With delayed reconstruction, it is important for patients to remember that they are still candidates for reconstruction even if their breasts were removed a long time back. However, radiotherapy candidates persistent about immediate reconstruction can undergo the procedure by providing a larger margin to account for the probable tissue loss due to radiotherapy. Another option, considered a ‘‘delayed-immediate’’ method, temporarily places a tissue expander in the breast pocket to preserve the skin until the time of reconstruction.

WAITING PERIOD

It is important for patients to understand that while all efforts are made to keep their best interests at heart, an immediate reconstruction may be associated with short delays that will not affect cancer outcomes. Studies (2009 UK and 2011 American study) have shown that a mean delay of 29 days may occur as the different surgeons and operating theater are arranged for. This delay could also be because reconstruction is classified as a cosmetic procedure that is clinically non-urgent.

RECONSTRUCTION RATES

The rates of breast reconstruction are seen to vary across countries. It’s been found to be low in England (16.5%; 2006–2009), Denmark (14%; 1999–2006) and Australia (9%; 1982–2000). Immediate reconstruction has seen a steady increase, but is still fairly low. Factors like age, insurance, income, limited knowledge, inapt referrals to reconstructive surgeons and racial/ethnical disparities, and sociodemographic issues account for the low use and the inconsistency across nations.

The rates of breast reconstructions across countries as per different studies:

  • US
    • National Cancer Database: 8.3% (1994 to 1995)
    • SEER Program of the National Cancer Institute: 16.2% (1998 to 2002)
    • Nationwide Inpatient Sample: 23.6% (1999 to 2003)
  • UK
    • First National Mastectomy and Breast Reconstruction Audit: 11% immediate reconstructions (1997 to 2006)
    • 4th National Mastectomy and Breast Reconstruction Audit: 21% immediate and 11% delayed reconstruction (2008 to 2009)
  • Australia
    • 6% (1999)
    • National Breast Cancer Centre: 8% (2003)
    • RACS National Breast Cancer Audit: 9.4% (2007)
    • National Breast & Ovarian Cancer Centre and Royal Australasian College of Surgeons National Breast Cancer Audit: immediate reconstruction for 13% private and 6% public patients (2008)

Rates of breast reconstruction based on age of patient

Age of patient Percentage receiving reconstruction
<40 20%
40-49 19%
50-59 11%
60-69 4%
70-79 2%
80< 0%

Rates of breast reconstruction based on location

Location Percentage receiving reconstruction
City 13%
Inner regional 5%
Remote 2%

FACTORS DETERMINING BREAST RECONSTRUCTION

Factors influencing the choice of reconstruction are governed by the surgeon and patient.

Surgeon

It is the responsibility of the surgeon to explain and confirm any clarifications you may have about the procedure in a clear and concise manner. Along with providing information about the details of surgery, including probable complications and other options, the surgeons must also help the patient have a clear idea about her goals and priorities.

The surgeon also plays a pivotal role in the decision-making for immediate reconstructive surgery. Many understand the afflictions that cancer therapy can inflict on you, both physically and emotionally, and may advise you to wait until strong enough for another surgery. Unbiased counseling by the surgeon is extremely important. You need to be told that there is no difference in survival, outcome or recurrence with immediate, delayed or no reconstruction.

Surgeons also act as gatekeepers to reconstruction. It has been seen that a surgeon’s referral to a plastic surgeon determines whether or not the patient opts for reconstruction. Without a referral, a patient is not likely to independently consider reconstruction. Therefore, a close collaboration between breast surgeon and plastic surgeon is imperative for success through a team approach.

Patient

  • Age: Younger patients are more concerned about aesthetic value. Increasing number of comorbidities as age increases could limit the procedure in older age groups.
  • Socioeconomic factors: According to a 2001 US study, women earning over $40,000 were more willing to undergo reconstruction, while those with lower incomes may not even be aware of the option.
  • Smoking: Cigarette smoking is considered a contraindication in many centers, in view of respiratory and cardiovascular comorbidities, post-op complications, and effects on wound healing.
  • Urban setting: Presence of plastic surgeons and better connectivity in urban settings have contributed to higher rates of reconstruction, in both Australia and US.

MAKING THE RIGHT CHOICE

The decision to undergo breast reconstruction may not be of much importance in the light of the more grave issue of cancer diagnosis and the surgical treatment. In such a state of mind, you may not be able to make a judicious decision on reconstruction. Taking one thing at a time would be the best option, where you could first address the treatment and then gradually understand the procedure and requirements for reconstruction. It is important for you to remember that an immediate decision is not required. You can take your time to understand the pros and cons of the procedure, clarify doubts, and even get first-hand experience from other patients who have undergone the procedure.

Despite this, if you are unable to make up your mind, you can keep it on hold until a later date when you have returned to normalcy after mastectomy. Don’t hesitate to ask your surgeon for more time as it is in no way going to affect the outcome of the surgery.

Conclusion

Reconstructive surgery is thought to be performed only for aesthetic value. However, it is an important part of recovering and returning to a normal life for many women, and should not be thought of as trivial or a luxury. It is a personal choice that you make for yourself and not to please someone else.

If you decide to get a new breast, all your efforts should be focused towards ensuring the best option, conducted by a skilled and experienced surgeon in the procedure.