Breast Reconstruction - Breast Cancer Patients Denied Right To Choose

Despite the increase of breast reconstruction procedures performed in 2008, nearly 70 percent of women who are eligible for the procedure are not informed of the reconstructive options available to them, according to a recently published report. Newly released statistics by the American Society of Plastic Surgeons (ASPS) shows there were more than 79,000 breast reconstruction procedures performed in 2008 - a 39 percent increase over 2007. But in spite of this, current research suggests that many breast cancer patients are missing out on a key conversation that should take place at the time of diagnosis.

"Women need to understand all of their options to make an informed decision," said ASPS President John Canady, MD. "Those who are diagnosed should be immediately referred to a full team of physicians that can provide breast care, and plastic surgeons need to be included as part of that treatment team."

Taking the position that every woman deserves the right to choose which, if any reconstruction option is best for her, the ASPS is launching an ongoing effort to bring public awareness to breast reconstruction issues, including education, access, and a team approach. Because early involvement by plastic surgeons and other physicians can allow development of an optimum treatment plan for each individual patient, collaboration amongst specialties is essential. As such, ASPS suggests that primary care, general surgery, radiology, pathology, oncology, gynecology, and plastic surgery be available from the onset of treatment to ensure the greatest possible outcome for the patient.."

It is also important that patients actively participate in their treatment. Though a common misconception, eligible patients should not assume that anyone other than a board-certified plastic surgeon affiliated with an accredited facility is qualified to perform breast reconstruction. While technology has made breast cancer diagnosis, treatment, and reconstruction better than ever, it does not negate the need for medical expertise within each specific area of care.

Among the factors contributing to patient awareness and understanding, specific education regarding the options for breast reconstruction is often lacking. Therefore, in the coming months, ASPS will reach out to women through a variety of materials, ranging from information cards and online videos, to an ad campaign featured online and in the waiting-room publication produced by the American College of Obstetricians and Gynecologists.

"We know that there are many issues surrounding breast reconstruction and that addressing them all will take time, but this is a very important first step," said Dr. Canady. "Our goal is to make sure that those women who are not getting breast reconstruction are doing so of their own accord and not because they are uneducated or uninformed about their options."."

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient's own tissue. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction at The Breast Cancer Reconstruction Blog. Please also Follow Dr C on Twitter.

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Mammograms after Mastectomy and Breast Reconstruction - Are They Really Needed?

"Do I still need to have mammograms after my mastectomy and breast reconstruction?"

I'm asked this question quite often.

The truth is there's a lot of ongoing debate about this.

Some doctors feel that since there is no "natural" breast tissue left, there is no need to continue monitoring patients. I disagree with this strongly.

Breast cancer can come back after mastectomy - there's a 6.7% chance in fact. Breast reconstruction does not increase or decrease the risk of recurrence at all - the recurrence rate is the same whether women have reconstruction or not.

Since the risk of breast cancer recurrence is a real one, surely we need to continue some sort of monitoring?

Self breast exam is a no-brainer. It's relatively easy to perform and it's dirt-cheap (free). The issue of mammograms is less clear-cut.

The appearance of the mammogram changes completely after breast reconstruction. Even if the breast looks very natural and similar to the way it did before the mastectomy on the outside, the inside of the breast is completely different.

Let's take the following example: a woman who undergoes a skin-sparing mastectomy and tissue (flap) reconstruction like a DIEP flap may look like she has natural breasts that have merely been "lifted". In reality her breast tissue has been completely replaced by tummy fat. Fat and breast tissue look completely different on mammograms so the post-reconstruction mammograms cannot be compared to any taken before the mastectomy. You're essentially starting from scratch as far as the mammograms go.

Some surgeons feel that patients should have 1 mammogram after the reconstruction has been completed just to get a new "baseline". If the regular self breast exams reveal anything new of concern then the mammogram can be repeated. At least now the new mammogram can be compared to the baseline mammogram.

Other breast surgeons take it a step further and recommend a baseline MRI once the reconstruction is completed instead of a mammogram. MRIs are much more sensitive and the information they provide is also more specific. Again, if self breast exam reveals a new area of concern in the future the MRI can be repeated to see if anything has changed. The only issue with MRIs is the additional cost compared to a mammogram.

Yet one more viewpoint is that any new breast lumps that appear in the future are going to require a biopsy anyway so what is the point of getting a "baseline" MRI or mammogram at all?

I understand this point of view but don't agree with it. Tissue (flap) breast reconstructions can occasionally develop something called "fat necrosis". These are areas of fat in the new breast that become hard and create "lumps". While a biopsy may indeed be planned anyway, there is a lot to be said for the physician and patient knowing this "lump" has been there all along (on the MRI) and the chance of this representing a new cancer is extremely low. The additional peace of mind and information a baseline MRI provides in this situation alone warrants it in my opinion.

What do I recommend? At least a mammogram 6 months after the breast reconstruction is completed and regular self breast exams. If it was my wife she'd get a baseline MRI after the breast reconstruction and continue monitoring herself with monthly self breast exams.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient's own tissue. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction at The Breast Cancer Reconstruction Blog. Please also Follow Dr C on Twitter.

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Breast Reconstruction in Metastatic Breast Cancer Patients

Traditional medical opinion states that women with metastatic breast cancer are not candidates for breast reconstruction. Once metastases are diagnosed (stage 4 breast cancer), attention turns solely to aggressive medical treatment to prolong life. Breast reconstruction is no longer discussed as an option.

At least that was the consensus up until fairly recently.

Opinions have started to change over the last few years. 

While we are still losing the battle with stage 4 breast cancer and most women will die from their disease, who are we to decide that these women should not be made "whole"? Why should any women interested in breast reconstruction die breastless?

As long as patients interested in reconstruction  are medically stable and passed "fit for surgery", the psycho-social and quality of life benefits that breast reconstruction can provide should not be ignored. While the priority must always remain "life over breast", breast reconstruction should be discussed with patients regardless of the stage of the disease.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient's own tissue. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

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Impact of Radiation on Breast Reconstruction

Radiation therapy is often recommended as part of breast cancer treatment. Patients undergoing lumpectomy receive radiation routinely once they've healed from surgery. Some mastectomy patients also need radiation after surgery depending on the characteristics of the tumor.

I think it is fair to say that most reconstructive breast surgeons, myself included, are not particularly fond of radiation because of the way it impacts the patient's tissues (and breast reconstruction in general.) Nonetheless, it is important to remember that "life comes before breast" and in certain situations there is a definite benefit for the patient in having radiation therapy.

So what's the problem with radiation therapy (from a plastic surgeon's perspective)? For starters it can cause toughening (fibrosis) and shrinking (contracture) of the patient's tissue which makes the tissue lose its elasticity and become more tough and rigid. Skin color changes are common, red at first turning more brown over time. Radiation can also cause burn injuries as well as damage to underlying organs such as the lungs and heart. Anyone who is facing radiation therapy must discuss all the potential risks with their their radiation oncologist beforehand.

Women undergoing lumpectomy are often told that most of their breast will be preserved and that radiation is given "as insurance" to decrease the risk of cancer recurrence. What many women don't appreciate is that the breast can end up looking vastly different once the treatment is done because of radiation changes, even though they underwent "breast conservation". Many women end up going to see a plastic surgeon anyway to fix this unforeseen problem, which ironically can include the same reconstructive procedures as for mastectomy.

Radiation after a tissue reconstruction (eg tram flap, diep flap) can cause the reconstructed breast to shrink and harden. Unfortunately, this is a fairly common scenario. Less frequently (with heavy radiation doses), new wounds can develop in the reconstructed breast which need wound care. Patients facing radiation after flap breast reconstruction should know that there is a risk of needing further reconstructive surgery to correct changes caused by the radiation therapy. One study found a re-operation rate of almost 30% in patients receiving radiation after TRAM flap reconstruction.

Tissue expander / implant reconstructions fair even worse with radiation. The complication rates in this setting are much higher than with tissue reconstructions, including complete failure of the reconstruction altogether (and removal of the implant). Some surgeons routinely offer implant reconstructions to patients that are either facing or have already had radiation therapy. There are even articles published in the plastic surgery literature supporting it. I have to respectfully disagree (strongly). In my experience mixing implants with radiation typically ends badly. I will only do this in the very rare instance that there is absolutely no other option.

So what's the take-home message?
1) "Breast conservation" can fall short of the patient's cosmetic expectations.
2) breast implants and radiation do not mix well.
3) If you're facing radiation after mastectomy think twice about insisting on immediate reconstruction. You may be lucky and things may work out just fine. However, there's also a good chance you'll be signing up for more surgery than you bargained for.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient's own tissue. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

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Texas Plastic Surgeons Offer Innovative New TUG Flap Procedure to Recreate Natural Breasts After Mastectomy

San Antonio, TX (PRWEB) February 23, 2009 -- Plastic, Reconstructive & Microsurgical Associates (PRMA) of South Texas, a leading breast reconstruction surgery practice in San Antonio, is now offering women the Transverse Upper Gracilis (TUG) flap procedure to restore their breasts after mastectomy. PRMA plastic surgeons specialize in breast reconstruction after breast cancer, with particular expertise in advanced microsurgical techniques using the patient's own living tissue.

"Increasingly, women facing mastectomy prefer new breasts sculpted from their own skin and fat, thereby avoiding the problems that often occur with implants," says Dr Chrysopoulo. Breasts shaped from living tissue have a natural look and feel that can't be achieved using implants or temporary prostheses. "While most patients prefer the Deep Inferior Epigastric Perforator (DIEP) flap technique which uses a woman's lower abdominal tissue, it is a technique that may not be an option for those who have had previous tummy tucks, who don't have adequate abdominal fat, or who prefer not to scar their abdomens. TUG flap surgery is a viable option for these women; a way to restore their natural breasts with excellent results."

Both the TUG and DIEP flap procedures are complex, technically demanding microsurgical procedures requiring special skill and experience. During the TUG procedure, surgeons transplant a flap of skin, tissue and muscle from a woman's upper thigh to her chest. The process has distinct advantages compared to other types of natural tissue breast reconstruction: thigh tissue has superior contour, shape and projection; loss of the muscle does not inhibit an individual's mobility or function; scarring is not easily visible, and the procedure produces a cosmetic thigh lift as well as a new breast.

"TUG flap surgery allows a woman to come out of the operating room the same way she went in," says Chrysopoulo. "With nice-sized natural breasts in place." The TUG flap is an excellent post-mastectomy option for women who have mastectomy to either treat or prevent breast cancer.

Candidates for the TUG are women who:
• have small to medium-sized breasts.
• want to avoid an abdominal scar.
• lack sufficient abdominal tissue for DIEP breast reconstruction.
• have had a previous tummy tuck or other abdominal surgery.

PRMA board-certified surgeons routinely offer both reconstructive and cosmetic breast procedures, and perform more than 400 microsurgical breast reconstructions annually for patients from Texas and across the U.S. PRMA surgeons are in-network for most U.S. insurance plans. Visit www.prma-Enhance.com or contact 800-692-5565 to schedule a consultation or for more information about the TUG flap or any other reconstructive breast procedure.

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