Although breast cancer is the most common form of cancer, finding accurate information and guidance, particularly about the options you have for breast reconstruction, can be more difficult than expected. Dr. Tanna has provided answers to many of the most common questions about breast surgery and reconstruction to assist you to make an educated decision.
Breast cancer continues to be the most common type of cancer in the United States, with over 300,000 cases of breast cancer diagnosed yearly. About one in eight women will be diagnosed with the disease. While a breast cancer diagnosis is a frightening situation, treatment is very effective. The American Cancer Society reports the estimated five-year survival rate for women with stage 0 or stage 1 breast cancer is almost 100 percent. For women with stage II breast cancer, the five-year survival rate is about 92 percent, and for women with stage III breast cancer have a five-year survival rate of about 72 percent.
A lumpectomy is a breast-conserving surgery that removes abnormal or cancerous tissue from the breast. Unlike a mastectomy, which removes the entire breast, a lumpectomy is designed to only remove a smaller portion of the breast. Normal tissue is also extracted around the lump to ensure that all the cancerous tissue is removed. A lumpectomy is usually performed to verify a diagnosis of cancer or to treat the early stages of cancer. Most commonly, if a woman chooses a lumpectomy, radiation therapy will be required to decrease the chances of the cancer returning.
A lumpectomy preserves a portion of the native breast. However, the radiation treatment, often required after a lumpectomy procedure, may deform the shape and appearance of the remaining breast. In addition, radiation can permanently damage the skin of the breast. It can decrease the blood supply to the skin and subsequently cause it to contract.
Women who have a history of breast radiation who later undergo a mastectomy are at a higher likelihood of having healing problems at the radiated site. In addition, women who choose to pursue a lumpectomy will have to continue breast cancer surveillance (i.e. sonograms, mammograms, MRI). Reconstructive surgery, performed at the time of the lumpectomy (preferable) or after, can help improve the aesthetic appearance of the breast treated with a lumpectomy.
It is overwhelming, intimidating, and frightening to be diagnosed with breast cancer. There is an abundance of information available, but the sheer magnitude of data can be a source of confusion. The first step is to understand that a mastectomy is a safe and reliable procedure, and that time and time again the procedure has been proven to be one of the best treatments for breast cancer. In many cases, it is either the recommended procedure, or one of the choices. And with modern breast reconstruction surgery techniques, undergoing a mastectomy does not mean having to lose a feminine, natural breast appearance.
A mastectomy is a surgery that removes the entire breast. A mastectomy is a treatment option for women who have breast cancer or those who do not wish to have a lumpectomy. In addition, many women who are in a high-risk group elect to have a prophylactic mastectomy, which is a preventive surgery that removes a normal breast to prevent the occurrence of breast cancer.
It is important to remember that after a mastectomy, women no longer require imaging (i.e. sonograms, mammograms, MRI), as the breast tissue has been removed. There are different types of mastectomy surgeries, and your surgeon will consult with you about your options.
With a nipple-sparing mastectomy, a woman’s existing, natural nipple and areola are preserved. The obvious advantage is the aesthetic benefit, as no further surgery is required to reconstruct the nipple-areola complex. A common misconception is that leaving the nipple-areola complex increases the chance of cancer recurrence, but this is false. Research reveals, in the appropriately selected patient, there is no increase in cancer recurrence in patients who have had nipple-sparing mastectomy compared to patients who have undergone a traditional mastectomy.
There are some limitations to a nipple-sparing mastectomy, the first of which is that not all women are candidates. It may not be the right surgical option for large cancers or those occurring near the nipple. Since all the ducts terminate at the nipple, the nipple is considered part of the breast and therefore is usually removed when the cancer is it near that structure. Women with very large or ptotic (sagging) breasts may not be ideal candidates. When considering this treatment, you should be aware that there may be a loss of sensation or altered appearance of the nipple areola complex.
During a nipple-sparing mastectomy, the breast tissue at the base of the nipple is removed. This can affect the projection, position, sensation, and healing of the nipple after surgery. This procedure should only be done if the primary cancer is distant from the nipple areola complex, and when your breast surgeon is experienced in this technique. Finally, it may be a possible treatment option if your nipple is in a relatively good position for breast reconstruction. Otherwise, a skin sparing mastectomy is the better choice.
A skin-sparing mastectomy is a technique to save the breast skin while removing all the underlying breast tissue and nipple. The preserved skin structure provides a good shape and form for implant or flap (autologous) reconstruction. This type of mastectomy is one of the more favorable options due to the natural look, feel, and aesthetic results in immediate breast reconstruction – performed in the same surgery as the mastectomy.
Women often have a misconception that a mastectomy is synonymous with amputation of the breast. In fact, this is quite the opposite from the truth, as almost all the breast skin is preserved in a skin-sparing mastectomy. As most of the breast skin (called the pocket) is preserved during a skin-sparing mastectomy, this option is by far the best for cases in which the breast reconstruction is performed at same time of the mastectomy (immediate reconstruction).
The pocket that the reconstruction is to be placed in already exists and does not have to be created. This is your normal breast skin and it is basically draped over the reconstruction. When breast reconstruction is not performed at the same time as the mastectomy (delayed reconstruction), the pocket of skin will contract and not be useable in the future. Instead, a new pocket will need to be created.
The goal of breast reconstruction is to restore one or both breasts to near normal shape, appearance, symmetry and size following a mastectomy or lumpectomy. Most women undergoing mastectomy choose breast reconstruction, as it is a realistic option for restoring their breast and body image.
The breast reconstruction process takes several weeks to months to complete and may encompass more than one procedure. These treatments can be performed in several stages, starting at the time of mastectomy and continuing thereafter.
The different reconstruction options available can be overwhelming to patients when considering treatment. Although plastic surgeons are rapidly advancing and developing new breast reconstruction techniques, about 70 percent of women who are eligible for breast reconstruction have not been fully informed about their options.
This problem led to the passage of a law in New York State in 2014 that requires physicians to inform their patients about the options of breast reconstruction at the time of mastectomy consultation. For detailed information on each type of breast reconstruction, go to our breast reconstruction page.
There are many emotional, psychological, and physical benefits of reconstructive breast surgery. Studies have shown that women who have breast reconstruction after cancer experience an increase in feelings of self-worth and confidence. Women who have had breast reconstruction surgery report they have restored feelings of femininity and self-esteem.
Breast reconstruction restores the appearance and symmetry of both breasts. This allows women to regain the ability to wear some clothing that they would not have been able to before such as swimsuits, gowns, tank tops, and other revealing clothing.
Breast reconstruction has become well-integrated into the treatment of breast cancer. Some women consider foregoing breast reconstruction, choosing to use an external prosthesis (worn within a bra) instead. Even a well-fitted breast prosthesis can end up being a source of frustration and dissatisfaction.
Some women find the breast prostheses to be uncomfortable, hot, and heavy. The false breast may shift with movement and will restrict clothing choices. Aside from the physical discomfort associated with wearing a prosthesis, many women will only wear it when outside the home, resulting in less confidence in appearance while in the home environment. Some patients eventually choose to undergo breast reconstruction after using a prothesis for a period of time (delayed reconstruction).
Studies have demonstrated the immense benefit of breast reconstruction for your overall health and wellbeing. Women who have had breast reconstruction report feeling comfortable in and out of the home. This helps women when getting out of the shower, during intimacy, when looking in the mirror, wearing certain clothing, and when sharing time with loved ones. The choice to pursue breast reconstruction is personal -- one that is yours and yours alone.
Choosing to have a mastectomy can be a very emotional and difficult decision for many women. For women considering mastectomy of a breast affected by cancer, the question often comes up as to what should be done with the other breast. You may elect to have one breast (unilateral mastectomy) or both breasts removed (bilateral mastectomy). Some women with breast cancer in one breast will choose to have the opposite healthy breast removed in what is called a “contralateral prophylactic mastectomy” (CPM).
There are many arguments that can be made for either having or not having the other breast removed. Many women choose to have the opposite breast removed. This may reduce their risk of breast cancer recurrence and may allow you to achieve better symmetry in reconstruction.
Some women choose a bilateral mastectomy if they feel that the healthy breast will require extensive adjustment to achieve a symmetrical look in reconstruction. Others choose to undergo prophylactic or preventative mastectomy of the opposite breast to avoid the ongoing testing required when the other breast is not removed. After a mastectomy you will no longer need to undergo sonograms, MRIs, or ultrasound testing.
For women who decide not to have a double mastectomy, with only the one breast removed (unilateral mastectomy), it may be important to alter the unaffected breast to match the newly reconstructed breast. Options to match the healthy breast to the reconstructed breast include a breast lift (mastopexy), breast reduction, or adding an implant (breast augmentation).
These symmetry (matching) procedures on the healthy breast are covered by insurance. Alternatively, if a woman chooses to have a double or bilateral mastectomy, reconstruction surgery is then performed on both breasts. Insurance also covers the reconstructive surgery of both breasts.
There is no data to suggest that undergoing breast reconstruction places a woman at higher chance of breast cancer recurrence than those who have mastectomy alone (without reconstruction).
Reconstruction can be performed either immediately (at the same time of mastectomy) or delayed until a later date (after the mastectomy). Prior to your mastectomy, your surgeon and your healthcare team will help decide whether to have immediate or delayed breast reconstruction. Your decision will be based on your cancer treatment plan, personal preferences, risk factors and medical information.
An immediate breast reconstruction will take place in the same surgery as the mastectomy. Both the breast surgeon and plastic surgeon will operate during your surgery to remove the breast and reconstruct the breast with either an implant or a flap (created from your own tissue).
The benefit of having immediate reconstruction is the psychological and emotional advantage of having a breast structure restored immediately after the breast is removed. This is also appealing because reconstruction starts right away, often resulting in fewer surgeries. While immediate reconstruction has become increasingly popular, not all women are candidates for an immediate reconstruction. Your team of physicians will consult and make the decision about whether you will be a successful candidate.
Patients may delay a breast reconstruction procedure for months – or even years – after undergoing a mastectomy. Some patients need more time to think about the decision, while others may have extensive risk factors making immediate reconstruction impractical.
In other cases, patients have extensive cancers that require chemotherapy and/or radiation therapy delivered immediately after the mastectomy. By delaying reconstruction, the treatment team is ensuring that the patient will receive the chemotherapy or radiation therapy in a timely fashion.
Considering the timing of your breast reconstruction is important. While delayed breast reconstruction (after mastectomy) is almost always possible, the best reconstructions are usually performed at the same time as the mastectomy. There are very few patients who have cancer that is so advanced that immediate reconstruction at the time of the mastectomy is contraindicated.
Even if you do not have a cancer diagnosis, you may consider having a mastectomy if you are at high risk of developing breast cancer. Bilateral prophylactic (preventative double) mastectomy involves removing both breasts to reduce breast cancer risk. Most women who consider this option have a family history of breast cancer or a strong genetic predisposition for mutations that increase the risk of breast cancer.
Bilateral prophylactic mastectomy can be a wise choice for a woman who has an extensive family history of breast cancer, or a woman who has a gene mutation that makes them more susceptible to breast cancer. The more common gene mutations include BRCA1, BRCA2, CHEK2, NF1, ATM, CDH1, PALB2, PTEN, STK11, and p53. Women who with a family history of breast cancer are encouraged to undergo genetic testing to determine if one of these genetic mutations exists.
Individuals with a strong family history of breast cancer may have genetic testing for the BRCA 1 and BRCA 2 gene. Mutations (abnormalities) in the BRCA1 and BRCA2 genes are linked to breast cancer. These women are genetically predisposed to developing breast cancer, and the genetic mutation can occur in women with any cultural background.
Women with the BRCA1 mutation have a 55-65 percent chance of developing breast cancer by age 70. Those with BRCA2 have about a 45 percent chance of developing breast cancer by age 70. In comparison, women without the gene (general population) carry about a 7 percent chance of getting breast cancer by age 70.
The recommendation for a woman who carries this gene is to have a preventative double mastectomy with breast reconstruction. A woman who presents with breast cancer and who is BRCA positive would have a curative mastectomy on one side and a prophylactic mastectomy on the other side.
Despite the increased risk of breast cancer in patients with BRCA gene mutations, it is important to remember, that most women diagnosed with breast cancer have no family history or genetic mutation.
One of the most important and personal decisions during your consultation with your plastic surgeon is choosing the type of breast reconstruction to undergo. Once you have opted to have a mastectomy, the discussion of breast cancer reconstruction naturally follows. There is no one option that is the “right” choice for every woman. Instead, women are encouraged to understand the advantages and limitations of each option.
In general, breast reconstruction falls into two categories – implant reconstruction or reconstruction using a patient’s own tissue, which is referred to as a “flap” or microsurgical breast reconstruction. A plastic surgeon will consider factors such as the type of mastectomy, indication for mastectomy, patient preference, and patient’s body type when considering which reconstructive option is best for the patient.
It is important that your plastic surgeon is very open with you and clearly answers all your questions – but what are the questions you should ask? These are a list of important questions to get answered by a plastic surgeon you are considering for your procedure:
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