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Reconstructive Surgery: What are Your Options After Breast Cancer?

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One out of eight women will be diagnosed with breast cancer during their lifetime. Over 40,000 American women will die this year from the disease, but many more will survive thanks to early detection and treatment. Those women who are diagnosed with breast cancer must understand their options with regard to reconstruction of the involved breast. Federal laws mandate health insurance coverage for reconstruction of both the involved breast and the opposite uninvolved breast to achieve symmetry. Breast reconstruction after cancer is considered to be an integral part of the treatment of the disease, and thus requires coverage by your health insurer.

In the past, breast cancer survivors were counseled to accept their deformity and simply be happy to be alive. A combination of the advancement of surgical techniques and the realization that reconstruction of the lost breast significantly improves the psychological outcome of the survivor has changed this out-of-date concept.

The following is a basic guide regarding surgical options for breast reconstruction. It is meant to provide an overview to help people understand what can be done for them and what it involves. After receiving a diagnosis of breast cancer, the horror and shock often clouds the minds of individuals and their family. This guide is presented to assist in the decision-making process. The links provided outline more detailed descriptions of the operations described and will further enhance your understanding.

The first decision required is whether to undergo breast reconstruction at the time of mastectomy (immediate reconstruction), or wait and have the reconstruction done at a later date (delayed reconstruction). The advantages of immediate reconstruction include: decreased number of operations, psychological benefit of being without a breast for the shortest possible time, and shortened overall recovery period. The advantage of delayed reconstruction is increased time to consider reconstructive options or alternatives. Most patients opt for immediate reconstruction when the diagnosis supports it.

Breast reconstruction is a team approach involving the general surgeon who performs the mastectomy or partial mastectomy, and the plastic surgeon who performs the reconstruction. They should both be board certified in their respective specialties. Your plastic surgeon should describe all options with careful detail and include your input regarding the decision for the choice of breast reconstruction operation. The surgeon should be able to tailor the operation to your needs, desires and physical characteristics.

The first and simplest option is placement of a saline or silicone breast implant at the time of the mastectomy. There must be adequate muscle and skin coverage for the implant, and this is rarely feasible after a mastectomy, but quite feasible after a lumpectomy (removal of the breast cancer and some breast tissue, but not the entire breast). The advantage of this option is that no other immediate surgery is required. The disadvantage is the need to replace the implant every 10 years or so.

Another choice involves placement of a tissue expander, followed after expansion at a later date, with a silicone or saline implant. A tissue expander is a type of balloon with a valve that will expand the chest skin slowly with placement of salt water over approximately three months. It is necessary to visit the plastic surgeon's office every two or three weeks for injections into the valve to allow the skin to expand. Once expanded to the appropriate size, a second shorter operation involves removal of the tissue expander and placement of a saline or silicone implant. Reconstruction of the nipple may be done at that time or a later date.

Silicone implants received a bad reputation in the early 90s because of the manufacturers' lack of data ensuring the safety of the implants. They were briefly removed from the market by the FDA, but have been proven to be safe in numerous well-documented studies. The FDA reinstated them years ago. In my opinion, they are a better choice for breast reconstruction because of their texture and characteristics. They simply feel and look more like a human breast than saline implants because of the thinner coverage remaining after the mastectomy.

The advantage of this technique is that it is a fairly simple procedure and adds only 30 to 60 minutes to the operative time after the mastectomy, and the second operation is also short and can be done as an outpatient. Disadvantages include the need to change the implant every 10 years and the possibility of infection, rejection or hardening of tissue around the implant over time.

Another option is transferring muscle and sometimes skin from the back to the chest region to reconstruct the breast. In most instances a tissue expander and subsequent implant is required. This technique is often used when there is an inadequate amount of skin remaining after the mastectomy or radiation therapy was or will be needed.

A very popular technique involves movement of lower abdominal muscle, fat and skin to the chest and this tissue is molded into the shape of a breast. The abdominal tissue is tunneled underneath the skin to the chest (pedicle flap), or surgically transplanted there utilizing a microscope (free flap). The advantage of this technique is that no implant is required, your natural tissue is used to form a new breast and a tummy tuck is included. The disadvantages are significantly longer operating room time, possible flap failure, requiring reconstruction using other options and longer postoperative recovery time.

It is often necessary to modify the opposite breast to match the reconstructed side. A breast reduction, breast lift (mastopexy), or implant placement is often needed to achieve symmetry. This is considered part of the reconstruction after cancer and is covered by your insurance.

While all this surgery sounds scary and overwhelming, the final result is worth the effort for many people. Studies demonstrate that breast cancer patients who have opted for reconstruction are pleased with the results and satisfied with their decision.

There is no reason why breast cancer survivors need to look in the mirror and be reminded of their fate. The most important ally and clinical partner of the surgeon are the patient's husband or significant other and family. Their persistent love and support are the best medicine for this terrible disease.

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