Whenever we talk of female beauty, breast is considered as one of the attributes of femininity. As much as it is ornamental to a female physique, it forms the first bondage between mother and the child.
When a lady has to loose that epitome of femininity as a result of cancer, it feels as if her psychological identity of a female is put at risk.
With modern advancement of reconstructive surgery, we are capable of reconstructing the breast after mastectomy by different methods.
First and foremost is, deciding on the timing of surgery. Reconstruction can be carried out immediately at the time of mastectomy or later as an elective procedure. Those who opt for immediate reconstruction do not have to go through the stressful experience of losing a breast. However, the recurrence of cancer can be missed clinically as it is covered by the reconstructed breast.
I personally prefer delayed reconstruction:
- The patient can be monitored for signs of recurrence
- If necessary radiotherapy can be given before
- The patient can choose between different types of procedures available
During this period of delay, the patient can use an external prosthesis. There are very good external prostheses available in Kolkata.
When considering breast reconstruction, first and foremost issue is what type of material we use to reconstruct the breast and secondly to balance the other breast and finally the different methods of nipple reconstruction.
Breast Reconstruction can be by:
- Artificial Materials
- Natural Tissue
ARTICIAL MATERIALS (IMPLANTS)
One of the issues to remember is with mastectomy (simple, radical or modified radical) the skin of breast is also sacrificed. To get that extra skin we have to expand the available skin. This can be done by inserting a silicone balloon underneath the skin and muscle and expanding this weekly. When we have enough skin, the reconstruction can be completed.
There are two ways in which this can be achieved:
- One is to insert a silicone balloon called “tissue expander”, underneath the skin. Then expansion is carried out on a weekly basis, until sufficient skin is obtained. Then we remove the expander and insert the definitive prosthesis, which can be made of silicone, saline or a hydrocolloid. Here the patient gets to choose the type of the material she can have as her final implant. The only disadvantage is the patient has to undergo two operations.
- The other is to insert a special type of prosthesis called “Becker” implant, which acts as the expander as well as the final prosthesis. This “Becker” implant is inserted underneath the skin and muscle and expanded weekly until final size is obtained. Here we do not have the choice of filling material, as only saline can be injected and kept to give the final prosthesis. So this is in reality it is a ‘saline filled implant’.
One of the key issues in reconstruction with a prosthesis is to insert it underneath the muscle.
The natural tissues used for breast reconstruction are called flaps. Either a flap can be used individually, or can be combined with a prosthesis.
Lattisimus Dorsi Flap
This age old method of breast reconstruction is to take a muscle from the upper back and turn it over to make a breast mound. Here the shape is less than perfect and sometimes needs an implant to be placed underneath the muscle to give the requisite shape and volume.
TRAM (Transverse Rectus Abdominis ) Flap
Transverse Rectus Abdominis Flap, as it is called, is a piece of skin and fat with an underlying muscle taken from lower abdomen (below the belly button) and turned over to make one or two breasts. This can be moved with a muscle in abdomen, called rectus abdominis, which provides the blood supply. To take less amount of muscle, or to increase the blood supply of this flap, the blood supply of this flap can be established by microvascular techniques – hence it is called a ‘free flap’. Sometimes this flap is totally detached with its blood supply and re-attached to vessels in the armpit or chest wall by microvascular techniques.
Here the shape of breast is aesthetically acceptable. The only disadvantage is the donor area, where sometimes a hernia can result, especially around belly-button.
DIEP (Deep Inferior Epigatric Perforator) Flap
This is a variation of TRAM flap. Here the abdominal muscle is left behind, taking only the blood vessels. These blood vessels are joined by microvascular technique with an operating microscope. Since these blood vessels are small, considerable expertise in microvascular surgery is essential.
Here the main advantage is there is no chance of a hernia.
Gluteal Free Flap
Here buttock skin, fat and muscle are used to make a breast mound by microvascular technique.
I personally do not prefer this technique, as there is an inequality of the buttocks.
In all cases of breast reconstruction to give a correct aesthetic match, the other breast has to be lifted by a technique known as ‘mastopexy’.
RECONSTRUCTION OF NIPPLE-AREOLA
The main issue here is that the nipple-areola is darker than rest of breast tissue.
- To make the areola, darker skin as skin of inner thigh or female genital (labia) or the other breast is used.
- A much simpler procedure called cosmetic tattooing (micropigmentation) can also be done to darken the areola.
- If the patient is not keen on surgery, even stick-on nipples can be used.
In those cases of breast cancer, where only a lump is removed under ultrasound localisation, often called a lumpectomy, the lattisimus dorsi muscle can be used as filler.
Each procedure has its own merits and demerits. There is no alternative to a detailed consultation with the plastic surgeon, who will brief you on these and a combined decision as what option of reconstruction the patient has, is taken depending on the social, economic, medical and psychological issues.
Breast is an organ of femininity to the lady, and in the unfortunate circumstance of having to loose this organ due to cancer, plastic surgeons can remake this breast to an aesthetically, socially and psychologically acceptable level.