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02 December 2008

When should reconstruction be performed?

It is important that any woman who has been diagnosed with breast cancer should have time to come to terms with the diagnosis and make a decision about the type of surgery.

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It is very important that any woman who has just been diagnosed with breast cancer should have time to come to terms with the diagnosis and make a decision about the type of surgery that is appropiate for them. This means that first, the decision about the surgery for the breast cancer is made. Is breast conservation possible or should a mastectomy be considered?

The timing of the reconstruction depends on:

  • The woman’s general health
  • The stage of the cancer
  • Personal preference

When making the decision, it should always be remembered that the long-term appearance is the most important and this should not be compromised for short-term gain.

1. Immediate reconstruction
Ideally, reconstruction is performed at the time of the original breast cancer surgery. This is not always appropiate or the option that will give the best long-term result. Immediate reconstruction means that as much breast skin as possible is left at the time of surgery.

A mastectomy performed in this way is known as a skin sparing mastectomy. Generally the skin over the breast cancer and areola/nipple will have to be removed as part of the cancer surgery. All the rest of the skin of the breast can be left. The breast is then reformed using either a prosthesis or a woman’s own tissue.

To get a good result, there has to be excellent healing at the time of surgery. Patients who may have poor wound healing would include those who have had prior radiotherapy, smokers, those with impaired immune systems (eg. diabetes) or patients with hypertension. Each of these factors would have to be weighed up against the woman’s general health.

2. Delayed reconstruction
This may be done in two ways. If a woman knows she will want a reconstruction but does not have enough skin to allow for an immediate reconstruction, a tissue expander may be placed at the time of surgery.

A tissue expander is a silicone envelope that is flat on initial insertion. This means a woman intially has a flat chest but the space either under the muscle/skin is gradually stretched with saline to allow the placement of either muscle/fat or prosthesis as a second precedure. This may be done at the same time as chemotherapy/radiotherapy is being given.

The expansion takes place every week or two for a few months. Saline is injected through a valve until the expander is inflated to a size slightly larger than the implant. This stretches the skin until the surgeon can replace the expander with a permanent implant. (Some implants combine the expander and the permanent implant. After the skin expansion is complete, the filling valve is sealed and the expander remains as a permanent implant.)

Some women will need radiotherapy after the mastectomy. Radiotherapy impairs wound healing and will cause some tissue to die (eg. fat used for a reconstruction). At the time of presentation, it may be clear that it will be needed post-operatively. Generally, an immediate reconstruction is best avoided in these circumstances. Either a delayed reconstruction could be considered or insertion of an expander.

There are many decisions to be made at the time of diagnosis and some women prefer to wait until the initial stages of management of the breast cancer are over. If this is the case, a delayed reconstruction should be considered. If a woman is undecided, she should not embark on an immediate reconstruction. She can always decide to have a delayed reconstruction later. It is not sensible to go backwards after an immediate reconstruction.

 
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