MASTECTOMY BREAST RECONSTRUCTION

Breast reconstruction - mastectomy : Breast reconstruction, especially if it is begun at the same time as the simple mastectomy, can minimize the sense of loss that women feel when having a breast removed. Although there may be other smaller surgeries later to complete the breast reconstruction, there will not be a second major operation nor an additional scar. If there is not enough skin left after the mastectomy, a balloon-type expander is put in place. In subsequent weeks, the expander is filled with larger amounts of saline (salt water) solution. When it has reached the appropriate size, the expander is removed and a permanent breast implant is installed. If there is enough skin, an implant is installed immediately. In other instances, skin, fat, and muscle are removed from the patient’s back or abdomen and repositioned on the chest wall to form a breast. None of these reconstructions have nipples at first. Later, nipples are reconstructed in a separate surgery. Finally, the areola is tattooed in to make the reconstructed breast look natural. Breast reconstruction does not prevent a potential recurrence of breast cancer.

Diagnosis / Preparation
If a mammogram has not been performed, it is usually ordered to verify the size of the lump the patient has reported. A biopsy of the suspicious lump and/or lymph nodes is usually ordered and sent to the pathology lab before surgery is discussed. When a simple mastectomy has been determined, such preoperative tests as blood work, a chest x ray, and an electrocardiogram may be ordered. Blood-thinning medications such as aspirin should be stopped several days before the surgery date. The patient is also asked to refrain from eating or drinking the night before the operation. At the hospital, the patient will sign a consent form, verifying that the surgeon has explained what the surgery is and what it is for. The patient will also meet with the anesthesiologist to discuss the patient’s medical history and determine the choice of anesthesia.

Aftercare
If the procedure is performed as an outpatient surgery, the patient may go home the same day of the surgery. The length of the hospital stay for inpatient mastectomies ranges from one to two days. If breast reconstruction has taken place, the hospital stay may be longer. The surgical drains will remain in place for five to seven days. Sponge baths will be necessary until the stitches are removed, usually in a week to 10 days. It is important to avoid overhead lifting, strenuous sports, and sexual intercourse for three to six weeks. After the surgical drains are removed, stretching exercises may be begun, though some physical therapists may start a patient on shoulder and arm mobility exercises while in the hospital. Since breast removal is often emotionally traumatic for women, seeking out a support group is often helpful. Women in these groups offer practical advice about such matters as finding well-fitting bras and swimwear, and emotional support because they have been through the same experience.

Finally, for women who chose not to have breast reconstruction, it will be necessary to find the proper fitting breast prosthesis. Some are made of cloth, and others are made of silicone, which are created from a mold from the patient’s other breast. In some case, the patient may be required to undergo additional treatments such as radiation, chemotheraphy, or hormone therapy.

Risks
The risks involved with simple mastectomy are the same for any major surgery. There may, however, be a need for more extensive surgery once the surgeon examines the tumor, the tissues surrounding it, and the lymph nodes nearby. A biopsy of the lymph nodes is usually performed during surgery and a determination is made whether to remove them. Simple mastectomy usually has limited impact on range of motion of the arm nearest the breast that is removed, but physical therapy may still be necessary to restore complete movement.

There is also the risk of infection around the incision. When the lymph nodes are removed, lymphedema may also occur. This condition is a result of damage to the lymph system. The arm on the side nearest the affected breast may become swollen. It can either resolve itself or worsen. As in any surgery, the risk of developing a blood clot after a mastectomy is a serious matter. All hospitals use a variety of techniques to prevent blood clots from forming. It is important for the patient to walk daily when at home.

Finally, there is the risk that not all cancer cells were removed. Further treatment may be necessary.

Normal results
The breast area will fully heal in three to four weeks. If the patient had breast reconstruction, it may take up to six weeks to recover fully. The patient should be able to participate in all of the activities she has engaged in before surgery. If breast reconstruction is done, the patient should realize that the new breast will not have the sensitivity of a normal breast. In addition, dealing with cancer emotionally may take time, especially if additional treatment is necessary.

Morbidity and mortality rates
Deaths due to breast cancer have declined by 1.4% each year between 1989 and 1995, and by 3.2% each year thereafter. The largest decreases have been among younger women, as a result of cancer education campaigns and early screening, which encourages more women to go to their physicians to be checked. The five-year survival rate for cancers that were confined to the breast was 97% in 2003. For cancers that had spread to areas within the chest region, the rate was 78%, and it is only 23% for cancers occurring in other parts of the body after breast cancer treatment. The best survival rates were for early-stage tumors.

Two 20-year longitudinal studies concluded in 2002 indicated that the survival rate for patients with modified radical mastectomy (the removal of the entire breast and all lymph nodes) was no different from that of breastconserving lumpectomy (the removal of the tumor alone).

Implications of these studies suggest that the removal of the entire breast may not afford greater protection against future cancer than breast-conserving techniques. However, it should be noted that the majority of cancer recurrences occurred within the first five years for both those with mastectomies and those with lumpectomies.

Alternatives
Skin-sparing mastectomy, also called nipple-sparing mastectomy, is becoming a treatment of choice for women undergoing simple mastectomy. In this procedure, the skin of the breast, the areola, and the nipple are peeled back to remove the breast and its inherent tumor. Biopsies of the skin and nipple areas are performed immediately to assure that they do not have cancer cells in them. Then, a cosmetic surgeon performs a breast reconstruction at the same time as the mastectomy. The breast regains its normal contours once prostheses are inserted. Unfortunately, the nipple will lose its sensitivity and, of course, its function, since all underlying tissue has been removed. If cancer is found near the nipple, this procedure cannot be done.