For many women who undergo mastectomy, their thoughts after surviving cancer turn to breast reconstruction.
If a patient goes to a breast center of excellence that has specific subspecialties involved in a comprehensive breast cancer therapy program, she will see everybody she needs to see before the mastectomy. “A lot of times the center will actually require the patient to see a plastic surgeon as part of the evaluation,” said Dr. Therese-Anne LeVan with Bluegrass Plastic Surgery.
LeVan said she sometimes works with surgeons as they are performing mastectomies if the surgeon plans to do immediate reconstruction. This depends on the patient, the type of cancer she has and where it is located.
“A lot of times they can do mastectomies through an incision we might prefer,” LeVan said. “I might say to the surgeon, ‘For this patient, this might work a little better; what do you think about making the incision this way?’ And the surgeon might say, ‘No, I really need to get this [tissue] out, so therefore I can’t do that.’ Most of the time we will have a conversation about it and plan together what we’re going to do.” If the patient is to have a delayed reconstruction in order to finish her treatments, LeVan said she will sometimes ask the surgeon to leave extra skin behind to make the reconstruction a little easier.
LeVan says delayed reconstruction is better from a plastic surgery standpoint because the patients usually do better. “They do not have to heal from two different surgeries at once,” she said. “And from a mental standpoint, they’ve already dealt with their cancer, so that’s all done. It is a real challenge when patients are still thinking about their cancer and worried about their survival.”
For patients seeking breast augmentation surgery, expectations play a central role in the procedure they choose.
“What someone’s expectations are determine whether or not they’re going to be happy with their surgery,” LeVan said. “Some women need more than just a breast augmentation to get what they’re wanting. Sometimes they need a breast lift in addition to augmentation.”
One surgery may not be enough to achieve the desired result. “You have to evaluate to see what the patient is wanting and whether or not it’s reasonable to achieve and whether or not it can be achieved,” LeVan said. “Some women are better candidates for one procedure than another, based on what they start with and what their goals are. Sometimes one or a couple of procedures may be better than others for them.”
The most common type of reconstruction LeVan performs is implant reconstruction. “We start with tissue expanders and eventually put in implants,” she said. There are also flap reconstructions. The two most common flap reconstructions are the TRAM flap, usually performed in conjunction with an abdominoplasty, and the muscle flap. “With the TRAM flap, instead of throwing away the tissue from a tummy tuck, you bring it up to the breast area and reconstruct the breast,” LeVan said. The muscle flap involves removing a muscle from the back and transplanting it to the breast area.
LeVan also performs a relatively new, multi-stage procedure called fat grafting. “I do liposuction to harvest fat, and then I inject the fat into the breast area or the area where the breast was to be able to reconstruct the breast,” LeVan said. The fat must be injected into areas of the chest wall with adequate vascularity in order to take. “If you try to inject it into an empty space, you’re just going to have a big bunch of dead fat,” she said.
Patients undergoing this procedure must wear an external expander device for 10 hours a day for about four weeks before and two and a half weeks after surgery. The device helps stretch the skin and enhance the blood supply to the breast.
“It is a very nice procedure with very little chance of rejection,” LeVan said. “The hardest part of it is that it’s not always easy to wear the device.”
By Tanya J. Tyler, Associate Editor