Today, October 17th is Breast Reconstruction Awareness Day. Or “BRA DAY.” This day to raise awareness for breast reconstruction was initially started in Canada in 2011. Over the past past 7 years this day has blossomed into a wonderful campaign to inform women with breast cancer of the many options that they have for breast reconstruction that they may not know about.
Thanks to events such a BRA Day and other initiatives to increase awareness for breast reconstruction, the number of breast reconstructions that have been performed in the United States has been increasing every year.
An important aspect of breast reconstruction that many people even in the medical field may not be aware of is that it is a federal mandate that private insurance companies MUST Cover Breast Reconstruction. This is a direct result of the Women’s Health and Cancer Rights Act of 1998 (WHCRA). According to this law, group health plans and individual health insurance policies must cover:
* All stages of reconstruction of the breast on which the mastectomy is performed
* Surgery and reconstruction of the other breast to produce a symmetrical appearance
* Prostheses and physical complications of of all stages of the mastectomy
When I see patients in the office in consultation for breast reconstruction, it is not uncommon for my patients to be surprised to learn that all aspects of reconstruction is covered by insurance.
The first step in the reconstructive process is to have the involvement of a reconstructive surgeon early after the diagnosis of breast cancer. Early involvement of a plastic surgeon streamlines the reconstructive process and may lead to better outcomes and improved aesthetics of reconstruction. In Monmouth County, we are very fortunate to have skilled and world class breast surgeons who understand this process and provide plastic surgery referrals to their patients who will be undergoing breast cancer surgery. It is important to seek out consultation with a plastic surgeon experienced in all aspects of breast reconstruction and who is board certified by the American Board of Plastic Surgery.
When I am seeing a patient in my office for a breast reconstruction, my patients can expect an environment that is comfortable and and a consultation that is never rushed. Many of my initial consultations take at least an hour or longer as adequate time is needed to explain all aspects of breasts reconstruction as well as the many options that are available. In addition I also coordinate care very closely with all other members of them patient’s cancer care team such as the breast oncologic surgeon, oncologist and radiation oncologist to ensure a safe and successful process.
As we approach breast reconstruction awareness day this year, I am amazed at the multitude of options and reconstructive modalities that are available to women undergoing treatment for breast cancer. There have been significant advancements in reconstructive breast surgery over the past several decades. Technological advances and improvement in surgical technique have made breast reconstruction safe. We have come a long way from the first ever documented breast reconstruction that took place in 1895. Weather a patient is undergoing a mastectomy or a lumpectomy, options exist to reconstruct and restore the breast.
The two main options that exist for breast reconstruction are prosthetic reconstruction which is the use of breast implants and autologous reconstruction which is the use of one’s own natural tissue. A consultation with a plastic surgeon that is familiar with all aspects of breast reconstruction will help a patient choose which option is the right for them.
Prosthetic reconstruction involves the use of breast implants which are usually filled with silicone gel or saline ( salt water) solution. This is normally done in a two stage process. The first stage involves the placement of a temporary device called a tissue expander at the time of undergoing a mastectomy. The tissue expander is a deflated implant which is slowly filled with saline solution over the several weeks following the initial operation. Once the expander is fully expanded to a size that the patient desires, then a second operation is done to remove the tissue expander and place the final implant. The advantages of this is that a patient starts reconstruction at the same time of the mastectomy and only adds about 1.5 to 2 hours to the operation. The tissue expander is safe as it does not put much tension on the skin and is slowly filled to allow the skin to stretch.
Sometimes, if the patient’s tissues allow, the final implant may able to be placed at the time of mastectomy and this is called a “direct to implant” reconstruction. Not all patients are candidates fo this operation and it potentially has increased complications. If a direct to implant reconstruction can be done, it has the advantage of avoiding a second operation to remove a tissue expander and place an implant.
Regardless of weather a tissue expander or the final implant is being placed, a very important adjunct that many reconstructive surgeons such as myself use is an acellular dermal matrix or “ADM.” The ADM is a piece of donated human skin which as been processed by tissue banks. This is implanted at the time of the initial reconstruction to provide additional structural support for the tissue expander or implant.
Some patients are deemed candidates for autologous reconstruction. This involves using the patient’s own tissue to perform a reconstruction. A very popular method of autologous reconstruction is the deep inferior epigastric artery perforator (DIEP) flap. This is a method of breast reconstruction which was popularized by one of my mentors, Dr. Robert Allen Sr, in New Orleans in the early 1990’s. Since its first introduction for breast reconstruction it as become the the standard of care for breast reconstruction.
A DIEP flap involves using the skin and fat of the lower abdomen to reconstruct the breast. The tissue is harvested along with its blood vessels. The tissue is then “transplanted” to the chest using highly specialized techniques called microsurgery. Microsurgical breast reconstruction involves the stitching of blood vessels that are 2 mm in diameter with stitches that are the width of an eyelash. A DIEP flap uses the same tissue that is normally discarded during an abdominoplasty or “tummy tuck” to reconstruct the breast. Using a DIEP flap uses a woman’s own tissue and can avoid the use of an implant. It has the benefits of feeling more natural and can have the potentially lead to less revisions in the future. If a woman has had a previous tummy tuck procedure, a flap reconstruction can still be done using other parts of the body such as the thigh or buttocks to reconstruct a breast. When this is taken from the inner part of the thigh this is called a profunda artery perfor
ator flap or “PAP” flap. If the thighs do not have adequate tissue, the buttocks can also be used as a source of tissue to reconstruct the breasts. This is called a gluteal artery perforator flap or “GAP” flap.
Another method of autologous reconstruction is fat grafting. Fat grafting involves liposuction of fat from areas that are less desirable such as the love handles, abdomen, thighs, and back. This liposuctioned fat is then processed and reinjected into the breast. This method is normally used as an adjunct to improve the appearance of the breast following either implant based or flap based reconstruction. Fat is injected into areas to give more fullness and projection to the breast as well as provide correction of any irregularities that may be present. In some cases, an entire breast may be reconstructed using only fat grafting. However, this method often involves at least 3 operations.
The final stage of breast reconstruction that occurs after all of the other stages are finished is the nipple reconstruction. The nipples are reconstructed using the skin on the breast. Incisions are made and rotated and nipple is made from these rotations. Following this, the areola is tattooed.
In certain cases, a woman with breast cancer and her breast surgeon may decide that the best course of action is to preserve the breast and not perform a mastectomy. This is called breast conservation surgery. In women with large pendulous breasts, a certain type of reconstruction can be performed called and oncoplastic reconstruction to improve the appearance of the breast at the same time as the cancer operation. This usually involves perform a breast reduction. An oncoplastic reconstruction involves close coordination between the breast surgeon and the plastic surgeon. The plastic surgeon usually designs the incisions for the breast and the cancer is removed by the breast surgeon through these incisions. Following the removal of the breast cancer, the plastic surgeon then re-shapes the breast to leave an aesthetically pleasing result.
Some women elect not to undergo reconstruction and that is completely okay. The decision undergo or forgo reconstruction is a very personal choice. It is however important for all women diagnosed with breast cancer to be given the opportunity to meet with a plastic surgeon to make an informed decision.
Given the multitude of options that are available to women today for breast reconstruction, it is very important to involve the plastic surgeon early in the process to improve clinical outcomes and patient satisfaction.
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