[ PRINT ] [ Printing FAQ ] About OncoLink Editorial Board Sponsors Help See Today's OncoTip Usage Statistics Virtual Classroom Abramson Family Cancer Research Institute "Confronting Cancer Through Art" is an exhibition by people whose lives have been touched by cancer. This week we are featuring artwork by: Jacqueline Kniewasser Pontypool, Ontario Visit the Children's Art Gallery This week's artwork was donated by a pediatric cancer patient who received treatment for cancer at The Children's Hospital of Philadelphia.

Breast Reconstruction After Mastectomy Authors: Coni Ellis, MS, RNC, OCN Affiliations: Clinical Instructor for General Surgery, Nursing Staff Development, M.D. Anderson Cancer Center, Houston, TX, USA reprinted with permission from the publisher Innovations in Oncology Nursing Vol 10, No. 1, 1994 Copyright © 1994, Meniscus Health Care Communications DESPITE ADVANCES IN BOTH early detection and treatment, the incidence of breast cancer is increasing. This disease strikes one in nine women in the United States during their lifetime. The American Cancer Society estimated that 182,000 new cases of breast cancer would be diagnosed in 1993 and that 46,000 women would die from this disease. [1] Women for whom surgery is the recommended treatment for their breast cancer will undergo either a lumpectomy or a mastectomy. [2] These women are faced with both a potentially lethal disease and the loss of a socially prized organ. [3] Breast reconstruction can help women cope with the resulting anxieties and adjust to their new lifestyle. This article reviews the decision-making process, timing considerations, and breast reconstruction options available today. Decision-Making Process Five critical factors interact to influence a woman's decision regarding breast reconstruction: access to information, economic concerns, medical condition(s), intrapsychic perspective, and interpersonal/transitional impact [4] (Table 1). In the final analysis, the extent of consideration given each factor depends on the woman's age, stage of disease, psychological profile, interactions with significant others, information level, and socioeconomic status. Timing Considerations In the initial discussions with a woman diagnosed with breast cancer for whom surgery is recommended, the breast surgeon should make the patient aware that reconstruction may be possible. This information can minimize the psychological trauma a woman may experience upon realizing that her breast is at risk of deformity. [5] If the patient expresses interest, she should be encouraged to consult with a plastic or reconstructive surgeon, prior to her mastectomy, regarding her breast reconstruction options. The breast surgeon should always reassure the patient that her mastectomy will be done with reconstruction in mind. Schwartz noted that knowledge about breast reconstruction may not only minimize post-mastectomy morbidity but may also minimize the patient's tendency to delay seeking treatment because of the fear that a mastectomy causes an irreversible physical defect. [6] It has also been suggested that the availability of information about breast reconstruction may prompt symptomatic women to seek early detection. [4] There is no standard period of time between mastectomy and reconstruction that can be considered ideal for all patients. Central to all decisions concerning the timing, type, and extent of breast reconstruction is the goal of providing the best-possible management of the cancer itself. [7] With respect to time, there are two categories of reconstruction: immediate and delayed. Immediate Reconstruction Immediate reconstruction occurs during the same operative procedure as does the mastectomy. This option is especially appropriate for patients with stage I breast cancer. The advantages of immediate reconstruction are that the patient experiences only one operation, one anesthesia application, and one hospital stay, as reconstruction of the nipple and areola can be done on an outpatient basis. Women with stage II and III breast cancer are also candidates for immediate reconstruction, since evidence has shown that reconstruction does not prolong healing, does not delay or postpone initiation of chemotherapy or radiation, does not alter recurrence or survival rates, and does not affect the frequency of recurrent disease. [3,8- 11] Studies have also shown that patients who have undergone immediate breast reconstruction experience less anxiety, depression, sexual dysfunction, and body image problems. [12-15] TABLE 1: Critical Factors That Influence Decision Making Regarding Breast Reconstruction FACTOR RESULT RESOURCES ACCESS TO INFORMATION Inhibits decision - Photographs of - Lack of widespread, finished results quality-controlled - Volunteer patients information - ACS, NCI pamphlets - ACS slide program on breast reconstruction ECONOMIC CONCERNS - High variability/expense Inhibits decision - Letter from physician - Question of - Written agreement from cost-effectiveness insurance company preoperatively - Research hospital MEDICAL CONDITION(S) - Stage of disease Inhibits decision - Delay in scheduling - Obesity reconstruction until - Diabetes condition(s) under - Hypertension control - Smoking - Irradiation INTRAPSYCHIC PERSPECTIVES - Against reconstruction Inhibits decision - Professional counseling * Fear of additional surgery and support * Fear of cancer recurrence - Discussion of * Belief it is "not necessary" reconstruction options * Martyred syndrome with significant others * Superfunctioning - Information on breast - For reconstruction reconstruction * Elimination of external - Consultations prior prosthesis to mastectomy * Need to feel whole again * Restoration of symmetry * Increase in self-confidence * Maintenanc of feelings of feminine attractiveness INTERPERSONAL/TRANSITIONAL IMPACT - Spouse or lover Inhibits or promotes - Information on breast - Mother, daughter decision reconstruction prior - Breast surgeon to mastectomy - Plastic surgeon - Consultations prior to mastectomy Delayed Reconstruction Delayed reconstruction is performed after the mastectomy wound heals. In the 1980s, breast reconstruction was usually performed after mastectomy 2 to 3 months after adjuvant therapy ended, which resulted in a 6 to 9-month delay. [7] Reconstruction was also delayed when women were not emotionally prepared to make the decision at the time of the mastectomy, they were not fully informed of their options, or there was inadequate time to prepare properly (eg, autogenous blood donation). [2] These reasons remain true today. Reconstruction Options Women seek breast reconstruction with hopes of creating a symmetrical, natural-looking breast mound. Thanks to the urgings of breast cancer patients, general surgeons have developed less ablative surgical treatments for breast cancer, and plastic and reconstructive surgeons have developed new techniques for breast reconstruction. [7,16] Breast reconstruction can be accomplished as a prosthetic implant, tissue expansion, or flap procedure. Together, surgeon and patient select the method that meets the patient's needs with minimum complications. Although the woman who seeks breast reconstruction may theoretically be eligible for a variety of procedures, many factors must be considered in determining which method is most appropriate. A discussion of some of these factors, including the patient's medical history, surgical techniques, complications, and the advantages and disadvantages of each reconstruction option follows. Figure 1 Silicone Breast Implant Under Muscle and Skin Adapted from Knobf et al, [18] with permission. Implant-Dependent Techniques These techniques are especially appropriate for women whose opposite breast is small to moderate in size and has minimal ptosis. The most common method of breast reconstruction-breast implants-involves the use of available tissue and the placement of a silicone or saline prosthesis after a total mastectomy. [15-17] The prosthesis is implanted under the musculofascial layer of the chest wall (Fig 1). Because the tight tissues of the mastectomy site are gradually stretched by the implant, the final result is not achieved until several months after implant placement. [7] The incidence of capsular contracture has decreased since surgeons began placing the silicone implant beneath the musculofascial layer rather than under the subcutaneous tissues.[17] Also, the polyurethane-covered (textured) silicone implants are less likely to cause contracture. [2,6,16,19,20] The following complications, which are being investigated by the FDA, can occur with silicone implants: capsular contracture gel bleed implant breakage, rupture, and retrieval allergies and rare forms of autoimmune diseases (such as lupus erythematosus and scleroderma) asymmetry dislocation With the exception of capsular contracture, which occurs with an average of 35% of silicone implants, quantification of these alleged complications has not been well established. [3] However, patients should be alerted to the possibility of problems such as infection, leakage, or rupture of the implant; persistent or prolonged joint pain; extreme asymmetry or dislodging of the prosthesis; and hardness or discoloration around the implant. If any of these problems are observed, the patient should consult her reconstructive surgeon, who should make the necessary report to the Product Problem Reporting Program (PPRP: 1-800-638-6725). [3] Tissue Expansion Breast reconstruction utilizing a tissue expander is best suited to women with a larger, more ptotic opposite breast. It is also indicated for women who have medical problems that prohibit reconstruction with autogenous tissue. [2] Contraindications for using a tissue expander are radical mastectomy, extremely tight chest wall skin, and an irradiated chest wall. [2,21,22] After most modified radical mastectomies, the remaining skin flaps are soft and supple and have no skin excess. Tissue expansion is often performed at this point. Tissue expansion applies the principle of gradual stretching of the chest wall to obtain enough cover for a silicone breast implant that is larger than one that could be positioned during the initial operation, and that reduces tightness and subsequent firmness of the chest wall against the implant. Figure 2 Round 700cm^3 Tissue Expander With Remote Port-a Design Commonly Used for Breast Reconstruction. In this procedure, an empty silicone bag or "balloon" (Fig 2) is placed either subcutaneously or submuscularly. About 1 to 2 weeks postoperatively, after the mastectomy wound has healed, the tissue expander is slowly inflated with saline solution during weekly outpatient visits. In order to achieve ptosis of a normal breast, the expander is filled about 200 mL beyond the volume of the opposite breast and kept overfilled for several months until the tissues can accommodate their expanded condition (Fig 3). Figure 3 Immediate Breast Reconstruction Patient Undergoing Temporary Overexpansion Figure 4 Same Patient as in Figure 3, After Completion of Reconstruction During a second operation, the tissue expander is replaced with a permanent silicone breast implant that is symmetrical with the opposite breast. If necessary for symmetry, mastopexy or other surgical alteration of the opposite breast can also be performed at that time [19] (Fig 4). Recently, a permanent tissue expander and implant that eliminates the need for a second operation has been developed. After the desired size and position of the breast are achieved, the fill valve is removed, and the device becomes a permanent, double-lumen silicone breast implant. [7,23] The great advantage of tissue expansion is that it permits breast reconstruction without the need for distant flaps, which simplifies reconstruction and minimizes scarring. Disadvantages, though slight, do exist. One is the amount of time the procedure involves. The entire process, from tissue expansion to nipple/areola reconstruction, can take 4 to 6 months to complete. Patients often require ongoing emotional support during this time. The possibility of complications poses another disadvantage. [24,25] Capsular contraction, implant rupture, and periprosthetic infection may necessitate the removal or replacement of the implant. [2,7,19] Flap Procedures Flap procedures offer breast cancer patients a third reconstruction option. Three methods are available: the transverse rectus abdominis myocutaneous (TRAM) method, the latissimus dorsi method (LDM), and the gluteal free flap method. Each method has distinct indications and contraindications, as discussed below. TRAM FLAP.--The TRAM flap, an autogenous tissue reconstruction, can be offered to most women who request it. The only significant contraindications are uncontrolled cancer, diabetes, extreme obesity, or other severe medical problems that would make elective surgery unwise. [19] The TRAM flap is especially indicated in the following instances: salvage of the breast and chest wall reconstruction after modified radical mastectomy reconstruction after bilateral mastectomy reconstruction after subcutaneous mastectomy for patients with silicone intolerance [2] Candidates for the TRAM flap must be selected carefully and critically, however, to avoid serious complications. Cigarette smokers should abstain from smoking 3 to 4 weeks preoperatively and 1 to 2 weeks postoperatively to decrease the risk of necrosis in the newly transferred tissue. [7,16] Known as the "rummy tuck," this procedure involves the removal of skin and fat from the lower abdomen in a transverse dimension. The donor site is then closed primarily, with a resulting low- transverse abdominal scar (Figs 5, 6). Figure 5 Preoperative Plan Showing Location of Donor site for TRAM Flap. Figure 6 Result of TRAM Flap Reconstruction There are two types of TRAM flaps: the conventional TRAM and the free TRAM. With the conventional TRAM procedure, the superior epigastric artery and vein and the entire length of one (sometimes two) rectus abdominis muscle(s) are used to transfer abdominal tissues as a myocutaneous pedicled flap to form a breast mound via an epigastric tunnel. In the free TRAM procedure, the larger vessels of the inferior epigastric artery and vein are used. With the free TRAM flap, the blood supply does not need to travel the entire length of the rectus abdominis muscle. [26] The tissue is completely detached from the abdomen and reattached to the chest with the blood supply reconnected to the blood vessels in the axilla. [19] One advantage to the TRAM flap is that it does not require a silicone implant. Another advantage is that the result is a naturally soft breast in a shape and size adjusted for ptosis and symmetry. Also, the scar is easily hidden. Disadvantages of the TRAM include the fact that it involves a highly technical procedure that requires 3 to 4 hours of surgery, a 4 to 5- day hospital stay, and an average of 2 to 3 months for recovery. The TRAM procedure is also very expensive. Complications include necrosis of a significant part of the flap and the risk of flap ischemia, which is higher in patients who smoke and in obese patients. Use of the double-pedicle flap (procedure utilizing two rectus muscles instead of one) and free flap techniques has improved the survival of the TRAM flap. Fortunately, the most significant abdominal complications, bulging and hernia, can usually be corrected with further surgery. [19] LDM FLAP.--The LDM flap is selected when there is a skin deficit that can be corrected with the transportation of large amounts of skin, fat, and muscle to the chest wall area. The LDM procedure transports a segment of skin from the upper back to the anterior chest (Fig 7)i. Figure 7 Donor Site Plan for LDM Reconstruction Women who are not candidates for the TRAM flap are the most frequent candidates for the LDM flap. Tight or irradiated skin, marked obesity, and smoking history are other indications for this procedure. [7,19] When this procedure was initially done, it corrected for the shortage of skin created by the mastectomy but did not provide enough tissue volume to simulate a breast mound, which had to be achieved later with a silicone implant [19] (Fig 8). Figure 8 Result of Breast Reconstruction with LDM Flap. A recent study described a process that involved the recruitment of overlying fat transferred with the latissimus dorsi muscle, such that the new breast can be reconstructed without an implant. [2] The LDM flap is planned on the back to include the appropriate amounts of skin and muscle to replace missing tissues and permit the introduction of a silicone implant beneath it to give the proper size and shape to the reconstructed breast. Although a complex operation, this procedure is reliable, with only a 2% rate of partial loss of the flap. [7] Some complications have occurred, however. The implant itself has developed firmness or distortion from capsule contracture in 25% to 30% of the patients. [19] Also, patients may complain about having a scar on their back or report that the loss of muscle from the side causes tightness. GLUTEAL FREE FLAP.--When other flap techniques are not appropriate, the breast can be reconstructed with fat and skin from the buttocks. [2,7,9,24] This option is known as the gluteal free flap. The appropriate tissue needed for this breast reconstruction, along with a segment of the gluteus maximus muscle, is elevated on the vascular pedicle. The internal mammary artery or axillary vessels are prepared, and the buttocks tissue is then transferred via a microvascular technique and anastomosed to the internal mammary artery. [27] Figure 9 Donor Site Plan for Superior Gluteal Free Flap Breast Reconstruction Figure 10 Result of a Superior Free Flap Breast Reconstruction The advantages of the superior gluteal free flap (Figs 9, 10) procedure are that a breast implant is not required, and the donor scar can be hidden at the fold of the buttocks area. Also, the procedure is less painful and recovery is less prolonged than with the TRAM flap procedure. [7] However, the gluteal free flap procedure is technically difficult, expensive, time-consuming, and has a significantly higher failure rate than does the TRAM flap. [19] Nipple-Areola Reconstruction Although not mandatory, reconstruction of the nipple-areola complex puts the finishing touch on the breast mound, leaving women with more natural looking breasts. [24] Regardless of which breast reconstruction is used, nipple- areola reconstruction (Fig 11) has been successfully accomplished with a wide variety of techniques. Earlier nipple reconstruction often used tissue taken from an opposite large nipple. [7] New procedures enable the reconstruction of the nipple with tissues available at the skin site of the new nipple. [28,29] The pigmentation match for the nipple-areola is achieved by selecting a darker skin color from the color chart to allow for fading, and using an intradermal tattoo technique that is performed by nurses in an outpatient setting. [30] Conclusions Breast reconstruction is a valuable option in the total treatment and management of breast cancer. It is imperative that physicians and nurses be well informed of the reconstruction methods available. Taking into account each woman's physical and psychological profile, as well as other interpersonal factors, is also essential. Once assessed, the patient and family can be educated and resources can be mobilized in order that a timely and appropriate decision regarding breast reconstruction options can be made. References 1. Cancer Facts and Figures--1993. Atlanta, Ga: American Cancer Society; 1993. 2. Elliott LF, Beegle PH, Hartrampf CR, et al. Breast Reconstruction following mastectomy: an update. J Med Assoc Ga. 1991;80:607-615. 3. Schain WS, Jacobs E, Wellisch DK. Psychosocial issues in breast reconstruction. In: Symposium on Advances in Breast Reconstruction. Bethesda, Md: 1991:237-251. 4. Schain WS. Breast reconstruction: update on psychosocial and pragmatic concerns. Cancer. 1991;68:1170-1175 5. National Survey on Breast Cancer: Measure of Progress in Public Understanding. Washington, DC: The National Cancer Institute, Dept of Health and Human Services; 1980. 6. Schwartz GF. Breast reconstruction following mastectomy for malignant disease: surgical oncologist's point of view. Clin Plast Surg. 1979;6(1):5- 13. 7. Bostwick J. Breast reconstruction after mastectomy: recent advances. Cancer. 1990;6:1402-1411. 8. Noone RB, Murphy JB, Spear SL, et al. A 6-year experience with immediate reconstruction after mastectomy for cancer. Plast Reconstr Surg. 1985;76:258-262. 9. Goldwyn RM. Breast reconstruction after mastectomy. N Engl J Med. 1987;317:1711-1714. 10. Ward J, Cohen K,. Knaysei GA, et al. Immediate breast reconstruction with tissue expansion. Plast Reconst Surg. 1987;8:559-566. 11. Johanson CH, VanHeerdan JA, Donahue JH, et al. Oncological aspects of immediate reconstruction following mastectomy for malignancy. Arch Surg. 1989;124:819-824. 12. Wellisch DK, Schain WS, Noone RB, et al. Psychosocial correlates of immediate versus delayed reconstruction of the breast. Plast Reconstr Surg. 1985;76:713-718. 13. Goin MK, Goin JM, Midlife reactions to mastectomy and subsequent breast reconstruction. Arch Gen Psychol. 1981;38:225227. 14. Schain WS, Wellisch DK, Pasnau RO, et al. The sooner the better: A study of psychosocial factors in women undergoing immediate versus delayed breast reconstruction. Am J Psychol. 1985;142:40-46. 15. Frazier TG, Noone Rb. An objective analysis of immediate simultaneous reconstruction in the treatment of primary carcinoma of the breast. CA Cancer J Clin. 1985;55:1202-1205. 16. Riley WB. Breast reconstruction after mastectomy: What are today's options? Postgrad Med. 1991;89:205-212. 17. Gruber RP, Kahn RA, Lash H, et al. Breast reconstruction following mastectomy: comparison of sub-muscular and sub-cutaneous techniques. Plast Reconstr. Surg. 1981;67:312-317. 18. Knobf T, Stahl R. Reconstructive surgery in primary breast cancer treatment. Semin Oncol Nurs. 1991;7;200-206. 19. Kroll SS. Breast reconstruction after mastectomy. Cancer Bull, 1990;42:34-38. 20. Burkhardt BR. Breast implants: Brief history of their development characteristics and problems. In: Grant T, Vasconex C, eds. Post Mastectomy Reconstruction. Baltimore, Md: Williams and Wilkins Co; 1988;18-28. 21. Dickson MG, Sharpe DT. The complications of tissue expansion in breast reconstruction: review of 75 cases. Br J Plast Surg 1987;40;629- 632. 22. Gibbons WP. Caution in expanding radiated tissue. Plast Reconstr Surg. 1987;80:871-874. 23. Becker H. Breast reconstruction using an inflatable breast implant with detachable reservoir. Plast Reconstr Surg. 1984;73:678-683. 24. Knobf MT, Stahl R. Reconstructive surgery in primary breast cancer treatment. Semin Oncol Nurs. 1991;7:200-206. 25. d'Angelo T, Gorrel CR. Breast reconstruction using tissue expanders. Oncol Nurs Forum. 1989;16:23-27. 26. Ellis C. Nursing care for the mastectomy patient who has immediate TRAM flap breast reconstruction. In: Nursing Interventions in Oncology. M.D. Anderson case reports & Review. 1993;5:10-13. 27. Shaw WW. Breast reconstruction by superior gluteal microvascular free flaps without silicone implants. Plast Reconst Surg. 1983;72:490- 499. 28. Little JW III, Munasifi T, McCullough DT. One-stage reconstruction of a projecting nipple: the quadrapod flap. Plast Reconstr Surg. 1983;71:126-132. 29. Kroll SS. Nipple reconstruction with the double- opposing-tab flap. Plast Reconstr Surg. 1989;84:520-525. 30. Spear SL, Convit R, Little JW. Intradermal tattoo as an adjunct to nipple-areola reconstruction. Plast Reconstr Surg. 1989;83:907-911. Acknowledgement.--The author would like to thank Stephen S. Kroll, MD, for the use of Figures 2-10.

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