Is breast reconstruction always necessary?
Breast reconstruction is not always necessary since considerable improvements have been made in the ablative procedures. In contrast to the highly aggressive methods at the beginning and middle of the last century, when large portions of the breast and chest wall were removed (fig. 1, Halsted procedure), in recent years, there has been a trend towards less aggressive mastectomies (fig. 2, modified radical mastectomy) and more limited resections.
These more limited resections are referred to as “breast-conserving surgery” or “breast conservative therapy”: only a small segment of the breast is removed and the remaining breast is irradiated (tumorectomy ** segmentectomy). In some cases an acceptable aesthetic result can be achieved (fig. 3), but if patients are very sensitive to irradiation, the scarring and fibrosis of the remaining gland and overlying skin can cause a significant breast deformity (fig. 4). In addition, breast conserving surgery cannot be performed in all patients. In individuals with a small breast, or those who have a large tumor, a mastectomy remains the gold standard and frequently better results can be achieved when a mastectomy is combined with an immediate breast reconstruction.
Assuming there are no contraindications, the decision on whether to undergo breast reconstruction should be entirely up to the individual. Outcomes of patients who undergo reconstruction, are similar in patients who choose not to. In addition, breast reconstruction patients do not have an increased risk of developing recurrence or metastases and will live just as long as non-reconstructed patients.
In our experience, patients dealing with the initial shock and fear of a breast cancer diagnosis, tend not to consider the aesthetic implications of treatment. They only realize the full impact of this with the passage of time, as the shock and fear subsides. Receiving information about breast reconstruction before undergoing surgery and having a simultaneous cancer resection and breast reconstruction, can give a superior aesthetic result, without reducing the effectiveness of the oncological treatment.
Every patient has a choice:
- Yes, I would like to have breast reconstruction
- No, breast reconstruction is not for me, but I would like to know the other options available
A significant number of women with breast cancer decide not to have reconstruction. This can be for a variety of reasons; the patient is comfortable with the idea of living without her breast(s), or her partner or family are convinced that reconstruction is unnecessary. Unfortunately though, we frequently notice that this decision is based on inaccurate or incomplete information. Obtaining the correct information from peers, patient support groups, academic publications, relevant websites and medical personnel that are involved in breast cancer treatment, can help you make the right decision.
In breast cancer, complete oncological treatment always takes priority over the reconstructive procedure. This includes a swift and professional diagnosis, correct ablative surgery, adequate adjuvant therapy (radiotherapy, chemotherapy and hormonal therapy) and finally good out-patient follow-up. However, once the cancer treatment has been completed, you will be faced with the consequences of your oncological treatments and over time, the aesthetic aspects assume an increasing level of importance. Obtaining the correct information about breast reconstruction before starting treatment, and simultaneously addressing the oncological and aesthetic aspects, will result in a superior cosmetic outcome without influencing the quality of the oncological treatment or long-term prognosis.
An external breast prosthesis is one option (fig.1). This is a teardrop shaped silicone device that can be added to a bra to imitate the breast shape. It can be worn either loosely, in a specially designed bra, or attached to the chest skin by an adhesive support. Different sizes and shapes are available. The external prosthesis can be a temporary solution whilst awaiting surgery or be a permanent device. The main advantage of an external prosthesis is that no additional surgery is required. The major drawback is that an external prosthesis has to be replaced every day and is sometimes difficult to combine with certain clothing. For many patients an external prosthesis remains a stigma, constantly reminding them of their breast cancer.
Benefits of an external prosthesis:
- Artificially restores the natural shape of the breast.
- Avoids further surgery.
- The external prosthesis can easily be exchanged, if the volume of the other breast changes.
- An external prosthesis is often reimbursed by public health care systems or private insurance companies.
Disadvantages of an external prosthesis:
- Wearing low cut dresses or blouses can be more difficult than following surgical breast reconstruction.
- The prosthesis may feel heavy, cold, or warm and sweaty, leading to skin irritation.
- A loose prosthesis can move and sometimes slip out of a bra. It may be necessary to wear a special bra or adapted clothing to prevent this from happening.
- Certain sports or hobbies can become more difficult, unless a specific support garment is worn, for example, a specially adapted swimsuit.
- The volume of the prosthesis does not change with fluctuations in weight, although a different prosthesis can be bought.
An external prosthesis can be purchased in specialty lingerie stores or orthopedic shops. Get advice from personnel who specialize in measuring and modifying such prostheses.
The main goal of reconstruction is resumption of normal social and professional activities as quickly as possible after treatment for breast cancer. This primarily means being able to wear different styles of clothes without having to worry about the look or appearance of her breasts and in particular the décolleté area.
Following a mastectomy, breast reconstruction can significantly improve a woman’s self-image and self-esteem. She can again feel feminine, facilitating a return to normal sexual activity. The changing emotions of fear, dismay and depression may be dampened or even overcome.
Especially after a delayed reconstruction, a patient may also feel more attractive, helping her as a woman, wife and mother fulfill her different social roles and professional activities. In addition, with the passage of time, hopefully she will be reminded less and less about the initial treatment for cancer as a result of the improved appearance of her breast(s).
Some points worth considering about surgical breast reconstruction include:
- Regardless of the type of reconstruction, you will have to undergo more surgery. This means more discomfort, with additional risks and possible complications.
- You will be off work for longer and unable to attend to your family.
- If you are unlucky enough to have a complication, it will take more time for you to recover.
- There may be more scars.
- With additional surgery, higher expenses may be incurred, depending on your personal insurance plan.
- You need to have realistic expectations about the surgical results that can be achieved.
- The reconstruction, no matter how good it is, will never replace your natural breast.
- For implant based breast reconstruction, one should be aware that the longer the implant is in place, the more likely it is that complications may arise.
Finally, if you decide to proceed with surgical breast reconstruction, two more important issues have to be considered:
- The timing of your breast reconstruction and the number of operations required
Number of procedures
- The surgical technique that suits you best
Techniques of surgical breast reconstruction