Breast Reconstruction
with Alyson Wells, MD
When does reconstruction take place?
Today’s breast cancer surgery, combined with breast reconstruction, removes disease but leaves a woman’s self-esteem intact. “Women literally can wake up from breast cancer surgery and have what looks like a breast,” says Alyson Wells, MD, Plastic Surgeon at GBMC. “It does so much for a woman’s psyche to have that part of her restored.”
Thanks to early detection through mammography and other image-guided diagnostics, only about one- third of breast cancer cases require mastectomy. About one-third of those women opt to have breast reconstruction. According to Dr. Wells, breast reconstruction is most often done at the same time as mastectomy. “In the majority of cases, we are able to immediately reconstruct the breast. We work very closely with the oncology surgeons and are in the room at the same time,” she says. Even when immediate reconstruction is not an option, delayed breast reconstructive surgery may restore a woman’s breast.
Surgeons at GBMC take a team approach to performing mastectomy plus breast reconstruction. In fact, Dr. Wells attends a weekly multidisciplinary tumor conference to discuss specific cases. “It’s really important for the general surgeon, plastic surgeon, radiation oncologist and medical oncologist to be on the same page,” she says. “It helps me in the reconstruction because I know about all the patient’s particular issues.”
In cases where the skin is not affected by the disease, a surgical oncologist is able to remove the cancerous breast tissue underneath the skin through a four-centimeter incision. A plastic surgeon is then able to fill the breast flap during the reconstruction phase of surgery.
“There are two main ways to perform a beast reconstruction,” says Dr. Wells. “One is to use the patient’s own tissue; the other is to use implants.” The TRAM flap (transverse rectus abdominis muscle) procedure uses the patient’s own tissue (called autologous tissue) and is the most natural. The procedure is done by taking fat, skin, and muscle from the patient’s abdomen and transferring it to the chest. In recent years, this procedure has been refined so that preservation of the abdominal muscle is now possible.
Although technical and cosmetic improvements are constantly being made to this procedure, the TRAM flap currently requires a longer operation, hospitalization and recovery time than implants. Sometimes, the decision comes down to lifestyle. “For many women, it’s important to get back to being a mother, or a wife, or to go back to work. For them, a longer hospital stay and another incision in their abdomen just isn’t an option, so they may choose implants,” says Dr. Wells.
With advances in plastic surgery, implants can look and feel as good as the natural breast. The main types of implant materials are saline implants, which are filled with salt water and silicone implants, which are made from soft gel.
Once a controversy, silicone implants are now considered the gold standard by many beast reconstruction surgeons. In the early 1990s, the U.S. Food and Drug Administration put restrictions on silicone implants to study whether they were increasing a women’s risk of autoimmune disease. “Although there was some controversy and skepticism surrounding it, we have proven that silicone is safe to use,” says Dr. Wells. “And many surgeons prefer it because it most closely mimics a woman’s own breast tissue.”
Traditionally, there have been two choices for implant procedures: a permanent implant or a tissue expander. When a tissue expander is first inserted into the breast, it is flat. Later, it is filled with saline injections over the course of three to four months. In addition to several office visits, a second surgical procedure to convert the expander to a permanent implant is required.
There is another newer option. “We now have hybrid implants, which serve as a tissue expanderand a permanent implant,” says Dr. Wells. “Instead of being flat, they have a certain amount of volume to them because they are already loaded with silicone gel when they are implanted.” Saline can then be added to expand the breast to the preferred size. A second minor procedure to remove the saline tubing and re-build the nipple is then performed, thus avoiding a more invasive surgical procedure to remove the tissue expander and replace it with the permanent implant.
Thanks to early detection of breast cancer and recent advancements in breast reconstruction, women often face a hopeful future. “As surgeons, we have a larger variety of techniques than we had twenty, or even ten, years ago to help make a woman feel emotionally and physically whole again after breast cancer,” says Dr. Wells.
