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Patients with breast cancer face many heart-wrenching decisions about their course of treatment, perhaps the greatest of which is whether to undergo mastectomy. Some young women find themselves facing this choice due to their genetic makeup, before even being diagnosed with cancer. Lucikly, options abound for breast reconstruction, which helps to ease the blow of mastectomy.
Regardless of the choices you have made or you face in the future, it's important to select a team of qualified medical professionals who can walk you through the process and offer the latest in techniques and procedures. Involving everyone from your primary care physician, general surgeon, pathologist to your radiologist, oncologist, gynecologist and plastic surgeon from treatment onset ensures the best outcomes, according to Matthew Kilgo, MD, FACS, plastic surgeon, Long Island Plastic Surgical Group. The optimal reconstruction procedure should be matched to a woman's body type, cancer treatment, recovery considerations and desired goals, Dr. Kilgo says.
Most physicians recommend immediate reconstruction for those who choose the surgery, but women with relatively advanced cancers may require chest wall radiation after mastectomy. "This can negatively impact on the appearance of the reconstruction, and sometimes in these cases, I may suggest delaying the final reconstruction until after chemotherapy and radiation is completed," says Lisa Jablon, MD, director of the Breast Program at Albert Einstein Medical Center, Philadelphia. In addiiton, other factors come into play, including the patients' age, other co-morbidities, prior surgery and prior radiation.
Reconstruction Techniques
New techniques are constantly emerging, so patients can realistically expect natural looking breasts. In fact, one patient describes waking up after she got a mastectomy and reconstruction and being amazed at seeing two breasts. "I thought they didn't do the mastectomy," she recalls. Hear more of Donna's story in an interactive slideshow. This decision is a personal one for each patient. Some may choose to forgo reconstruction. Advances in clothing and specialized mastectomy fitters have made it possible for these women to appear natural in everything from swimwear to camisoles and sleepwear.
For those who undergo reconstruction, the type of mastectomy performed and the incisions made can have a tremendous impact on the cosmetic results, notes Thomas Sterry, a New York City based plastic surgeon. Dr. Sterry divides breast reconstruction into two basic categories: autologous (those performed with the patients own tissue) and those using a prosthesis (breast implant) to form the breast.
Patients who use their own tissue as donor sites are experiencing less pain and fewer complications due to some surgical innovations. For example, the traditional procedure, known as a TRAM flap (transposition of the rectus abdominus muscle), is giving way to a new procedure that uses the same tissue, without moving the muscle, Dr. Sterry revealed. The new technique, called a DIEP flap (deep inferior epigastric perforator), means less pain, more functionality, and theoretically, fewer complications, he says. Other options include the TDAP flap, which harvests tissue from the back, and the SGAP flap, which uses tissue from the buttock.
Dr. Sterry described another new technique using human cadaver or pig skin to create a tissue matrix, or scaffolding that acts as a spacer in the reconstructed breast and improves contour, while shortening the patient's downtime. Matthew D. Goodwin, MD, Plastic Reconstructive and Cosmetic Surgery, West Palm Beach, FL, says the matrix works almost like an internal brassiere, supporting the implant under the skin for an improved cosmetic result.
The alternative to using the patient's own tissue is a prosthetic implant-an option which saves the patient the pain of the harvested tissue site, and can shorten recovery time, Dr. Goodwin says. While typically, prosthetic implant reconstruction is performed in several stages and requires a tissue expander that is injected with saline, this process is increasingly being forgone in favor of a permanent implant, Dr. Goodwin noted.
Plastic surgeons have also made progress in incision techniques, which cut down on scarring. At Long Island Plastic Surgical Group, Dr. Kilgo's team uses the Oncoplastic technique, making incisions similar to those used for breast-reduction surgery. This method can be used in reconstruction with implants or flap reconstruction.
Steps to Recovery
Recovery time varies from patient to patient and with what type of surgery is performed. Because flap techniques require a more intensive surgery, they require a longer recovery period than implant reconstruction (after which patients can return to work within a few weeks), Dr. Kilgo said.
However, patients undergoing implant reconstruction may face more trips back to the physician's office for gradual expansion, according to Barbara Cunningham, MSN, CRNP, an advanced practice nurse in the Surgical Oncology Abramson Cancer Center of the University of Pennsylvania in Philadelphia
Additionally, patients may return within the first few months for nipple reconstruction or tattooing to resemble the areola. For others, the process can be delayed if the patient needs to undergo additional chemotherapy or radiation treatment.
Regardless of the technique used, patients will likely spend a couple days in the hospital after surgery. The major post-operative concerns are infection, blood supply problems, fluid collection or wound breakdown. Patients may experience a tight sensation across the chest wall, which can be managed with subcutaneous catheters administering local anesthesia, and patient controlled pain pumps, Dr. Jablon notes.
Additionally, patients will have two to four drains for up to two weeks. Patients are advised not to shower while these drains are in place, so sponge baths will be necessary early in your recovery, Dr. Kilgo explains. While reconstructed breasts will initially appear extremely swollen (or, in contrast, deflated with expander-style reconstruction), in time, they will gradually assume a more natural appearance, Dr. Kilgo reassured. "A successful surgery will result in healthy, natural looking breasts."
Dr, Jablon says full recovery can generally be expected in about six weeks, though many patients ease back into parts of their routines earlier. It's important to ask your medical team about what level of activity you should expect and how far to push yourself.
Julie Goodale, a personal trainer and cancer exercise specialist who underwent a mastectomy, says breast cancer surgery can be more invasive than other cancer surgeries, and can leave patients with tightness across the chest, shoulder stiffness and a tendency to roll the shoulder forward, as though to protect the area. "Left unaddressed, this can result in serious problems over time, including poor posture, lack of mobility, weakness and pain."
Implementing a stretching routine as soon as your physician gives you the all clear is crucial to regaining range of motion. Start slowly, Goodale cautions. "Always stretch only to the point of a slight pull. A slight pull is OK; sharp pain is not! Never stretch to the point of pain. If you feel a sharp pain, stop immediately and talk to your doctor about it." She tells patients to be patient, but diligent. Once you are comfortable with stretching, move on to strengthening your back muscles. "If it's not addressed, poor range of motion and weakness can prevent you from doing important things in the future: enjoying sports, gardening, or simply holding your child," Goodale points out.
Emotional Support
Facing a cancer diagnosis and a mastectomy is undoubtedly one of the most frightening experiences you will endure. Making sure you have not just proper medical, but also emotional support in place is crucial to helping you survive, cope and recuperate. Fortunately, today there are a plethora of resources for patients with breast cancer, from support groups, to fundraising foundations, internet forums and help lines.
According to Christina Koenig, director of communications and media relations, Breast Cancer Network of Strength, knowing where to turn to for support and information can help patients regain a sense of hope and control. Also, speaking to someone who has gone through the same experiences and procedures is comforting. Peer support is the foundation for Breast Cancer Network of Strength's YourShoes Breast Cancer Support Center, a 24/7 help line staffed by breast cancer survivors who coach callers on effective communication with physicians and dealing with the complicated emotions they are feeling.
Cunningham noted many hospitals have psychosocial teams in place or can connect patients with others who have undergone similar procedures, or can recommend outside resources for patients.
Kerri Penno is managing editor at ADVANCE, the parent company responsible for this patient resource center.
To hear patients' experiences with breast cancer, please view our interactive slideshow.
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