Ask the Expert

Archives

Southern Ocean County Hospital would like to thank everyone who e-mailed questions for this edition of Ask-The-Expert and would like to especially thank Dr. Stephen E. Small for taking part in the program.

October : Breast Reconstruction Surgery & Breast Reduction Surgery

Question 1
I was just diagnosed with breast cancer and I might need to have a mastectomy. When you perform reconstruction after mastectomy, do you perform the surgery immediately, at the same time the mastectomy is performed. Or, do you prefer that the patient wait a while before having the reconstruction.

Breast cancer is the most common malignancy affecting women. Fortunately, with advances in breast cancer treatment mortality has been declining and women are benefited by more choices and less invasive surgical procedures for treatment with an improved quality of life. In fact, the five year survival for women who are diagnosed in the early stage of the disease is nearly 100%.

Many women benefit from non-surgical options such as chemotherapy and radiation combined with surgery. Surgery can entail breast preservation called a lumpectomy where only the tumor is removed or mastectomy which removes the entire breast.

While mastectomy is sometimes the best treatment and life-saving many women undergoing this procedure often experience difficulty with the loss of their breast(s). As a result, breast reconstruction has become an integral aspect of management for the patient with breast cancer. Before having a mastectomy a woman should discuss this option with her oncologist, general surgeon and plastic surgeon to discuss the risks, benefits, and options of reconstruction.

The goal of breast reconstruction is to recreate a natural appearing breast that is soft, symmetric with the opposite breast, and has a similar texture and color to the native breast that was removed. There are many options in breast reconstruction and this needs to be individualized to achieve the best result for each patient. One of the first decisions to make is whether to have the reconstruction done at the time of mastectomy called immediate reconstruction or at a later time, called delayed reconstruction. Emotionally, immediate reconstruction might be better for some since it enables the women to have her reconstruction without having to live with the absence of a breast as well as it avoids a second surgery since the two procedures are combined. However, some women would like to only deal with their cancer and the cancer surgery and consider reconstruction later which is just as acceptable. Other considerations for delayed breast reconstruction are those with larger tumors, lymph node involvement and those with close surgical margins. These patients often need radiation which can create problems with the reconstruction.

There are many types of breast reconstructive surgery. Some procedures involve an implant and others use muscle and tissue from other parts of the body to reconstruct the breast or a combination of the two techniques. What determines the type of reconstruction depends on many factors such as the patient’s health, size of her natural breasts, whether or not the patient is a smoker, obese, needs radiation as well as the patient’s overall desires. Generally, implants are chosen for women who have smaller breasts who do not need radiation and would rather not have a prolonged surgery or the risk of complications from tissue taken from another part of the body. Autogenous reconstruction often takes tissue from the abdomen in a procedure call a TRAM. This type of reconstruction is usually chosen when a patient needs radiation or has slightly larger breasts since it can provide for a more natural appearing breast than an implant in these circumstances. However, this procedure requires a longer operation with additional recovery needed because tissue was taken from the abdomen to reconstruct the breast. The decision to have breast reconstruction as well as the timing and the type of surgery is very personal and after discussing the patient’s desires I can help them make the best informed decision as to which reconstruction best fits their needs and is most appropriate based on these many factors.

Breast reconstruction should be considered, offered and discussed with any women undergoing a mastectomy. It is not merely the creation of an illusion of a breast mound. The benefits can be tremendous and positive in many ways. For some women reconstruction makes them less self conscious, restores self esteem as well as social and personal relationships that were impaired after mastectomy. While others just want a more natural, balanced look while wearing a brassiere without the need to wear a prosthesis.

Question 2
I am considering breast reduction and I have a few questions. Will I be able to breast feed after breast reduction surgery. Also, how long will I have to stay in the hospital after the surgery ? And, will insurance cover this type of surgery, or is it strictly considered cosmetic.

Breast reduction surgery is a reconstructive procedure that is performed to decrease the size of the breasts to relieve symptoms related to the weight of the breasts. Although, repositioning and reshaping the breast for aesthetic reasons are often sought and accomplished with the procedure as well. Insurance carriers typically will cover this type of surgery if it can be demonstrated that the patient is experiencing problems attributed to excessively large breasts which include neck, back and shoulder pain, shoulder grooving from the brassiere, breast pain or infections under the breast. In addition, excessively large breasts called macromastia can also affect a women’s lifestyle preventing them from certain work related and social activities. Not to mention this condition can be psychologically stressful causing embarrassment and unwanted attention and might be further indications for having the procedure. Most insurance carriers will need to review the indications for the procedure and ask for preoperative photographs before granting approval. The insurance carrier’s will also request your height and weight measurements to determine your body mass index (BMI). Using this figure based on your body’s weight and height an amount of breast tissue that will need to be removed from each breast is given to the plastic surgeon. What this means in terms of your final breast size would be explained by the plastic surgeon. My staff and I do everything possible to make this process a positive experience but it does require patience while waiting for approval.

Breast reduction surgery offers many benefits however there are several risks and potential complications that need to be understood. Typically, the surgery lasts approximately 3-3 1/2 hours. I like to keep my patients in the hospital overnight and discharge them home in the morning the next day. However, there are some surgeons who may elect to send you home the same day of the procedure. The recuperation period is usually 2 to 2 1⁄2 weeks.

In the office I would demonstrate to you where the incisions go, the types of scars and where they occur. Some people have a propensity to form thickened scars which is beyond the patient’s or my control. We would discuss interventions to make these scars smoother and softer. One of the more serious complications is total or partial skin loss of the nipple and areola area of the breast or the skin just below the nipple. This problem is more common in diabetics and smokers who share the problem of diminished circulation. If this were to occur the patient would require further reconstruction. Bleeding and infection are also possible risks and some patients might need a drain post operatively and all my patients go home on antibiotics after this surgery. Decreased nipple and areola sensation can occur but this usually returns in 3-6 months. Asymmetry of the breasts might be present before surgery and may be present after the procedure as well. Depending on the size of the breasts the nipple and areola may need to be removed and replaced as a skin graft. If this was done the patient would not be able to breast feed and the nipple areola would not be sensate. Most patients do not need to have a free nipple graft and most can breast feed after this surgery. However, it can not be guaranteed.

In conclusion, of all the reconstructive procedures patients who have had a reduction are some of the most satisfied and can appreciate the benefits of having had the surgery just a few days after the procedure. Most are very happy and satisfied by having their breasts reduced to a size that is more proportionate to their body.

Question 3
I had breast reduction surgery when I was 19, over 20 years ago. Is there any link between breast reduction surgery and breast cancer ? Thank you.

There is no link between breast reduction surgery and breast cancer. In fact. there are several studies that suggest there is a reduction in breast cancer risk for those who have had a breast reduction. This is most likely due to the fact that breast tissue is removed during these procedures with the exception of breast reduction by liposuction. More specifically, it is thought by removing breast tissue during the procedure pre-malignant tissue or breast tissue that is susceptible to cancerous change is removed thereby reducing your risk. The overall decrease in risk is difficult to predict due to the unique characteristics of each patient based on their initial breast size and the amount of reduction performed. As a result, different amounts of breast tissue are removed in any given procedure. Studies do suggest women who have had larger reductions, more breast tissue removed, might have a greater reduction in risk of breast cancer than those who have had smaller reductions, less breast tissue removed.

While there may be a slight decrease in risk after having had a breast reduction a significant amount of breast tissue still remains and you should still have screening mammography and clinical breast exams as indicated by your doctor.

Dr. Small's answers are informational only and should not be used as a diagnosis or for treatment. Please talk to your physician about official diagnosis of your condition and treatment.