domingo, 24 de febrero de 2013

Breast Reconstruction After Mastectomy - National Cancer Institute

Breast Reconstruction After Mastectomy - National Cancer Institute

National Cancer Institute at the National Institutes of Health

Breast Reconstruction After Mastectomy

Key Points

  • Breast reconstruction can be done using either breast implants or tissue taken from elsewhere in a woman’s body.

  • Each breast reconstruction method has advantages and disadvantages. The choice of method depends largely on a woman’s individual preference and her cancer treatment plan, but other factors can influence the type of reconstructive surgery a woman chooses.

  • Studies have shown that breast reconstruction does not increase the likelihood of cancer recurrence or make it harder to check for recurrence with mammography.

  1. What is breast reconstruction?

    Many women who have a mastectomy—surgery to remove an entire breast to treat or prevent breast cancer—have the option of having more surgery to rebuild the shape of the removed breast.
    Breast reconstruction surgery can be either immediate or delayed. With immediate reconstruction, a surgeon performs the first stage to rebuild the breast during the same operation as the mastectomy. A method called skin-sparing mastectomy may be used to save enough breast skin to cover the reconstruction.
    With delayed reconstruction, the surgeon performs the first stage to rebuild the breast after the chest has healed from the mastectomy and after the woman has completed adjuvant therapy.
    A third option is immediate-delayed reconstruction. With this method, a tissue expander is placed under the skin during the mastectomy to preserve space for an implant while the tissue that was removed is examined. If the surgical team decides that the woman does not need radiation therapy, an implant can be placed where the tissue expander was without further delay. However, if the woman will need to have radiation therapy after mastectomy, her breast reconstruction can be delayed until after radiation therapy is complete (1).
    Breasts can be rebuilt using implants (saline or silicone) or autologous tissue (that is, tissue from elsewhere in the body). Most breast reconstructions performed today are immediate reconstructions with implants (2).

  2. How do surgeons use implants to reconstruct a woman’s breast?

    Implants can be inserted underneath the skin and chest muscle that remain after a mastectomy, usually as part of a two-stage procedure.
    In the first stage, the surgeon places a device called an expander under the chest muscle (2,3). The expander is slowly filled with saline during visits to the doctor after surgery. In the second stage, after the chest tissue has relaxed and healed enough, the expander is removed and replaced with an implant. The chest tissue is usually ready for the implant 6 weeks to 6 months after mastectomy.
    Expanders can be placed as part of either immediate or delayed reconstructions (2). An optional third stage of breast reconstruction involves recreating a nipple on the reconstructed breast (see Question 4).

  3. How do surgeons use tissue from a woman’s own body to reconstruct the breast?

    In autologous tissue reconstruction, a piece of tissue containing skin, fat, blood vessels, and sometimes muscle is taken from elsewhere in a woman’s body and used to rebuild the breast. This piece of tissue is called a flap. Different sites in the body can provide flaps for breast reconstruction.

    • TRAM flap: Tissue, including muscle, that comes from the lower abdomen. This is the most common type of tissue used in breast reconstruction.

    • DIEP flap: Tissue that comes from the abdomen as in a TRAM flap, but only contains skin and fat.

    • Latissimus dorsi flap: Tissue that comes from the middle and side of the back.

    More rarely, flaps are taken from the thigh or buttocks (2).
    Wherever the flaps come from, they can either be pedicled or free. With a pedicled flap, the tissue and attached blood vessels are moved together through the body to the breast area. With a free flap, the tissue is cut free from its blood supply and attached to new blood vessels in the breast area.
    Rarely, an implant and autologous tissue will be used together. They might be used together when there isn’t enough skin and muscle left after mastectomy to allow for expansion and use of an implant (3). In these cases, the autologous tissue is used to cover the implant.

  4. How do surgeons reconstruct the nipple and areola?

    After the chest heals from reconstruction surgery and the woman has completed adjuvant therapy, a surgeon can reconstruct the nipple and areola. Usually, the new nipple is created by cutting and moving small pieces of skin from the reconstructed breast to the nipple site and shaping them into a new nipple. A few months after nipple reconstruction, the surgeon can recreate the areola. This is usually done using tattoo ink. However, in some cases, skin grafts may be taken from the groin or abdomen and attached to the breast to create an areola (2).
    Skin-sparing mastectomy that preserves a woman’s own nipple and areola (called nipple-sparing mastectomy) is performed by some surgeons on select women who are at low risk of cancer recurrence (4,5).

  5. What factors can affect the choice of breast reconstruction method?

    Most women can choose their type of breast reconstruction method based on what is important to them. However, some treatment issues are important to think about. For example, radiation therapy can damage a reconstructed breast, especially if it contains an implant (6-8). Therefore, if a woman knows she needs radiation therapy after mastectomy, that information may affect her decision.
    Sometimes, a woman may not know whether she needs radiation therapy until after her mastectomy. This can make planning ahead for an immediate reconstruction difficult. In this case, it may be helpful for the woman to talk with a reconstructive surgeon in addition to her breast surgeon or oncologist before choosing the type of reconstructive surgery.
    Other factors that can influence the type of reconstructive surgery a woman chooses include the size and shape of the breast that is being replaced, the woman’s age and health, the availability of autologous tissue, and the location of the breast tumor (3).
    Each type of reconstruction has factors that a woman should think about before making a decision. Some of the more common concerns are listed below.
    Reconstruction with Implants
    Surgery and recovery

    • Enough skin and muscle must remain after mastectomy to cover the implant

    • Shorter surgical procedure than for reconstruction with autologous tissue; little blood loss

    • Recovery period may be shorter

    • Many follow-up visits may be needed to inflate the expander and insert the implant

    Possible complications

    • Infection

    • Pooling of blood (hematoma) within the reconstructed breast

    • Extrusion of the implant (the implant breaks through the skin)

    • Implant rupture (the implant breaks open and saline or silicone leaks into the surrounding tissue)

    • Formation of hard scar tissue around the implant (known as a contracture)

    Other considerations

    • Can be damaged by radiation therapy

    • May not be adequate for women with very large breasts

    • Will not last a lifetime; the longer a woman has implants, the more likely she is to have complications and to need to have her implants removed or replaced

    • Silicone implants may provide a more natural-looking breast shape than saline

    • The Food and Drug Administration (FDA) recommends that women with silicone implants undergo periodic MRI screenings to detect possible “silent” rupture of the implants

    More information about implants can be found on FDA’s Breast Implants page.
    Reconstruction with Autologous Tissue
    Surgery and recovery

    • Longer surgical procedure than for implants; more blood loss

    • Recovery period may be longer

    • Pedicled flap reconstruction is a shorter operation than free flap but requires more donor tissue

    • Free flap reconstruction uses less donor tissue than pedicled flap reconstruction but is a longer, highly technical operation requiring a surgeon with experience re-attaching blood vessels

    Possible complications

    • Necrosis (death) of the transferred tissue

    • Blood clots

    • Pain and weakness at the site from which the donor tissue was taken

    • Obesity, diabetes, and smoking may increase the rate of complications

    Other considerations

    • May provide a more natural breast shape than implants

    • Less likely to be damaged by radiation therapy than implants

    • Leaves a scar at the site from which the donor tissue was taken

    Any type of breast reconstruction can fail if healing does not occur properly. In these cases, the implant or flap will have to be removed. If an implant reconstruction fails, a woman can sometimes have a second reconstruction using autologous tissue. If an autologous tissue reconstruction fails, a second flap cannot be moved to the breast area, and an implant cannot be used for another reconstruction attempt due to the lack of chest tissue available to cover the implant (2).

  6. What type of follow-up care and rehabilitation is needed after breast reconstruction?

    Any type of reconstruction increases the number of side effects a woman may experience compared with those after a mastectomy alone. A woman’s medical team will watch her closely after surgery for complications, some of which can occur months or even years later (2, 3, 6).
    Women who have autologous tissue reconstruction may need physical therapy to help them make up for weakness experienced at the site from which the donor tissue was taken, such as abdominal weakness (9, 10). A physical therapist can help a woman use exercises to regain strength, adjust to new physical limitations, and figure out the safest ways to perform everyday activities.

  7. Will health insurance pay for breast reconstruction?

    Since 1999, the Women’s Health and Cancer Rights Act (WHCRA) has required group health plans, insurance companies, and HMOs that offer mastectomy coverage to also pay for reconstructive surgery after mastectomy. This coverage must include reconstruction of the other breast to give a more balanced look, breast prostheses, and treatment of all physical complications of the mastectomy, including lymphedema.
    WHCRA does not apply to Medicare and Medicaid recipients. Some health plans sponsored by religious organizations and some government health plans may also be exempt from WHCRA. More information about WHCRA can be found through the Department of Labor.
    A woman considering breast reconstruction may want to discuss costs and health insurance coverage with her doctor and insurance company before choosing to have the surgery. Some insurance companies require a second opinion before they will agree to pay for a surgery.

  8. Does breast reconstruction affect the ability to check for breast cancer recurrence?

    Studies have shown that breast reconstruction does not increase the chances of breast cancer coming back or make it harder to check for recurrence with mammography (11).
    Women who have one breast removed by mastectomy will still have mammograms of the other breast. Women who have had a skin-sparing mastectomy or who are at high risk of breast cancer recurrence may have mammograms of the reconstructed breast if it was reconstructed using autologous tissue. However, mammograms are generally not performed on breasts that are reconstructed with an implant after mastectomy.
    A woman with a breast implant should tell the radiology technician about her implant before she has a mammogram. Special procedures may be necessary to improve the accuracy of the mammogram and to avoid damaging the implant.
    More information about mammograms can be found in the NCI fact sheet Mammograms.

Selected References

  1. Ananthakrishnan P, Lucas A. Options and considerations in the timing of breast reconstruction after mastectomy. Cleveland Clinic Journal of Medicine 2008;75 Suppl 1:S30–33.
    [PubMed Abstract]

  2. Patel SA, Topham NS. Breast Reconstruction. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2009.

  3. Cordeiro PG. Breast reconstruction after surgery for breast cancer. New England Journal of Medicine 2008;359(15):1590–1601.
    [PubMed Abstract]

  4. Petit JY, Veronesi U, Lohsiriwat V, et al. Nipple-sparing mastectomy—is it worth the risk? Nature Reviews Clinical Oncology 2011;8(12):742–747.
    [PubMed Abstract]

  5. Gupta A, Borgen PI. Total skin sparing (nipple sparing) mastectomy: what is the evidence? Surgical Oncology Clinics of North America. 2010;19(3):555–566.
    [PubMed Abstract]

  6. D'Souza N, Darmanin G, Fedorowicz Z. Immediate versus delayed reconstruction following surgery for breast cancer. Cochrane Database of Systematic Reviews 2011(7):CD008674.
    [PubMed Abstract]

  7. Roostaeian J, Crisera C. Current options in breast reconstruction with or without radiotherapy. Current Opinion in Obstetrics and Gynecology 2011;23(1):44–50.
    [PubMed Abstract]

  8. Barry M, Kell MR. Radiotherapy and breast reconstruction: a meta-analysis. Breast Cancer Research and Treatment. 2011;127(1):15–22.
    [PubMed Abstract]

  9. Monteiro M. Physical therapy implications following the TRAM procedure. Physical Therapy. 1997;77(7):765–770.
    [PubMed Abstract]

  10. McAnaw MB, Harris KW. The role of physical therapy in the rehabilitation of patients with mastectomy and breast reconstruction. Breast Disease. 2002;16:163–174.
    [PubMed Abstract]

  11. Agarwal T, Hultman CS. Impact of radiotherapy and chemotherapy on planning and outcome of breast reconstruction. Breast Disease. 2002;16:37–42.
    [PubMed Abstract]

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