Breast reconstruction after a mastectomy should be available to every woman who is diagnosed with breast cancer and undergoes breast removal surgery. Breast reconstruction is an option for women who have preventive breast removal surgery on their remaining breast or on both healthy breasts. Treatments and technical advances on two fronts are opening up more choices to women who have breast cancer or fear getting it at some point in time.
The gold standard in preventative breast cancer treatment is breast removal surgery. Some women who have one breast removed also opt to remove the healthy breast as a preventive measure. Women who are at a high risk of breast cancer, but have not yet been diagnosed with it, are also opting in large numbers to remove their healthy breasts as a way to reduce the risk of breast cancer in the future. Such risk reducing procedures are referred to as prophylactic mastectomies.
In both cases, a mastectomy can be a life changing procedure. The good news is that the options open to women—both those diagnosed with breast cancer and those who live with high levels of risk—are increasing on two fronts.
We are finding more and better ways of treating breast cancer that avoid or minimise the need for breast removal. Cryotherapy (freezing cancerous tissue) and techniques that try to preserve the natural breast are already in use. Further advances in treatment may one day eliminate the need for radical mastectomy.
There is also a wide range of breast reconstruction techniques that lead to a natural look and feel in the treated breast. Muscle-sparing breast reconstruction, nipple-sparing mastectomy, immediate reconstruction following breast removal, and the use of tissue expanders are some of the options in this category.
Oncoplastic surgery
Oncoplastic surgery combines the latest surgery techniques with surgical breast oncology in treating breast cancer. It can be used in a number of situations, including mastectomy with immediate breast reconstruction; partial mastectomy and reconstruction; in conjunction with breast reduction surgery; and for removal that is followed by remodelling mammoplasty.[1]
Conventional breast removal surgery or lumpectomy can result in a deformed breast or no breast, especially in cases where more than one fifth of the breast mass has to be removed. In oncoplastic surgery, even though more breast tissue is removed than in a conventional lumpectomy, it is done in a way that allows the remaining tissue to be reshaped into a more pleasing contour. The end result looks as if the patient has had a breast lift or breast reduction, especially after the other breast has been treated to improve symmetry.
Here’s how Johns Hopkins Medicine Breast Centre web explains the benefits of oncoplastic surgery:
“When a large lumpectomy is required that will leave the breast distorted, the remaining tissue is sculpted to realign the nipple and areola and restore a natural appearance to the breast shape. The opposing breast will also be modified to create symmetry.
“This is a good option for patients who are candidates for breast conservation therapy or lumpectomy, and are also candidates for breast reduction or mastopexy (breast lift).”
In the same way, careful preoperative planning, an essential part of any breast-sparing procedure, is imperative for oncoplastic surgery. The possibilities for positive outcomes dramatically increase when cancer surgeons work closely with cosmetic plastic surgeons. Ideally, such cooperation should come before breast removal surgery is planned.
Oncoplastic surgery is still in its infancy. While many scientific studies have been performed on the procedure’s safety, efficacy and cosmetic outcomes, the jury is still out on its finer points, including its long-term safety and benefits.
Does that mean oncoplastic surgery may not be a viable option for you? Despite being a relatively new procedure, oncoplastic surgery has produced positive outcomes for many women undergoing breast surgery and breast reconstruction. According to a recent paper in the Annals of Plastic Surgery (March 2013) comparing breast conservation therapy alone and in combination with the oncoplastic technique, patients are more satisfied with outcomes when the oncoplastic approach is used.[2]
[1] Menke-Plugmers MB, Wai RT, van Geel AN, Eggermont AM. [Oncoplastic surgery of the breast: a combination of oncological and plastic surgery].[Article in Dutch]. Ned Tijdschr Geneeskd. 2007 Jul 21;151(29):1623-7. Abstract accessed on 31 May 2012 at http://www.ncbi.nlm.nih.gov/pubmed/17727183
[2] Losken A, Dugal CS, Styblo TM, Carlson GW. A Meta-Analysis Comparing Breast Conservation Therapy Alone to the Oncoplastic Technique. Ann Plast Surg. 2013 Mar 13. [Epub ahead of print]. Accessed on 30 May 2013 at http://www.ncbi.nlm.nih.gov/pubmed/23503430
Minimally invasive breast surgery
Minimally invasive breast surgery is an umbrella concept that covers a range of new developments. Breast-conserving techniques are increasingly popular among both doctors and patients because they can achieve the same or better results than standard surgery, with fewer implications for health.
The goal of breast-conserving surgery is to remove the cancer and surrounding tissue, but leaving the breast looking as normal as possible afterwards. Enough surrounding tissue needs to be removed to reduce the chance of the cancer returning.
Lumpectomy and partial mastectomy are two common breast-conserving procedures. In lumpectomy, the breast lump is surgically removed in one piece, together with some surrounding tissue. The lump is then sent for examination.
Partial mastectomy is a more extensive procedure. It removes the cancer-containing area of the breast together with some extra breast tissue over the chest muscles that lie below the tumour. Partial mastectomy also removes some of the underarm lymph nodes.
A sentinel lymph node biopsy is a procedure which removes lymph nodes most likely to be affected by cancer and checking them for cancer cells. More lymph nodes will be removed only where cancer is found in the removed nodes. If tests show that there is cancer in the lymph nodes close to the breast, several nodes will be removed at the same time in a procedure called an axillary lymph node dissection.
Other areas with potential for less invasive procedures include percutaneous excision of tumours and mammary gland ductoscopy.
Percutaneous excision techniques are those that do not require breaking the skin to remove or destroy the cancer cells. Percutaneous techniques are typically used on patients who have been diagnosed using a percutaneous biopsy instead of surgical biopsy. The biopsy itself is performed with ultrasound imaging and other technology, including an MRI. The breast cancer cells are destroyed using lasers, freezing (cryotherapy) or radiofrequency devices.
Mammary ductoscopy uses a mircro-endoscope with a video camera to investigate the duct linings of the breast. It is a minimally invasive procedure that helps doctors look at and assess early changes taking place within the breast. Mammary ductoscopy is a very important area of development in early cancer diagnosis and treatment, because most changes in the breast, both benign and malignant, originate in the cells that line the mammary ducts. During a mammary ductoscopy, doctors can also collect sample cells for testing.
New breast cancer drugs
New breast cancer drugs are also producing promising results for future treatments. A cancer drug for the treatment of HER-2 breast cancer, which represents 20 percent of all invasive breast cancers, has been called the “first smart bomb for breast cancer”. According to the Duke Cancer Institute where it’s being tested, the drug “links standard chemotherapy with a second drug that targets and is aimed at destroying breast cancer cells. Because it leaves healthy cells alone, side effects typically associated with chemotherapy like nausea and hair loss are significantly reduced. The therapy also extends survival time.”
Advances in breast reconstruction
Breast reconstruction refers to any surgical procedure that attempts to restore a breast to its previous shape, size and appearance after mastectomy or the partial removal of a breast.
Nipple sparing mastectomy and muscle sparing breast reconstruction widen women’s options, because they allow for better and more natural looking breasts at the end of the process. Muscle sparing mastectomies ensure that the abdominal wall is not weakened, as only a small amount of tissue is taken, together with skin for reconstructing the new breast. Tissue expanders are used in breast reconstruction to stretch the skin of the breast to the size needed to fit a breast implant.
You can read more about the process of breast reconstruction in the procedure section of this website. Our article, “Which Type of Breast Reconstruction Is Right For You?”, explains the many options that are open to you and the timeframe for making your decisions.