THINKING AHEAD – BEING PROACTIVE ABOUT BREAST RECONSTRUCTION
Discussing breast reconstruction at the time of breast cancer surgery – rather than afterwards – can bring many benefits to patients.
Mastectomy and breast reconstruction have, generally, been considered as two separate procedures – each following their own separate discussion, often with different surgeons. But the rise in oncoplastic breast surgery as a sub-specialty has been drawing attention to the benefits of considering these two procedures as closely related, and of the advantages if they can be done as a single procedure.
Dr Deborah Cheung – specialist oncoplastic breast surgeon, who works from the Macquarie University Breast Centre – says that planning the two surgeries together and combining them into one procedure can bring functional, cosmetic and psychological benefits to patients.
“Breast removal and reconstruction should be tailored to each individual woman, with a patient offered all the options – including explanations around benefits and potential complications,” said Dr Cheung, who is also a clinical lecturer at the Australian School of Advanced Medicine. “Only by approaching both procedures this way, can the whole process bring the best patient outcomes.
“All patients who choose to have a mastectomy should also have a discussion with their surgeon about immediate breast reconstruction at the time. This allows for the possibility of preserving skin and, if suitable, the nipple – to provide the best possible cosmetic result. Such an approach has become increasingly important as women survive breast cancer better and longer than ever before.”
Knowing that a breast reconstruction is to be part of a mastectomy will affect the placement of incisions, for example, and call on techniques to preserve all the skin of a breast. These approaches improve greatly on delayed breast reconstruction where the skin may have been sacrificed and a surgeon has to essentially ‘start all over again’ by borrowing skin from another part of the body or stretching the remaining skin with tissue expanders.
Ultimately, a single operation means fewer scars, more effective skin use and, importantly, nipple sparing. So, psychologically, because of the single operation and the better aesthetic result, a patient’s wellbeing is inevitably enhanced.
“Often patients think that a breast reconstruction may mask breast cancer recurrence or delay breast cancer treatment,” explained Dr Cheung. “Many studies now show, however, that breast reconstruction does not impact negatively on breast cancer survival, addressing a very important misconception by many.”
Single surgeon, staged procedures
Often breast reconstruction after a mastectomy can be a very complex process requiring a stepwise approach to improve safety and optimise cosmetic outcomes. Even if a mastectomy and reconstruction need to be done as two separate surgeries, patients can still benefit from selecting one surgeon to see them through the process.
In cases where a patient undergoes post-operative radiation therapy, other considerations come into play for an oncoplastic surgeon. If a patient undergoing mastectomy and requiring radiation treatment is also considering breast reduction, then the reduction is best done at the time of mastectomy, given that it is not always possible following radiation treatment due to the strong possibility of fibrosis developing.
In addition, radiation therapy has a higher complication rate for larger breasts and so combining reduction with a lumpectomy or partial mastectomy can decrease fibrosis, and help to make the dosing of radiotherapy more even when a breast is reduced.
Incorporating neoadjuvant therapy
Neoadjuvant therapy is a new approach to breast cancer treatment and can play an important role in oncoplastic surgery. Certain patients are eligible for this approach, which, when given to the right patient, has the ability to downsize the cancer and allow for less breast tissue to be removed, thus helping to reduce deformity.
ABOUT DR CHEUNG AND THE MACQUARIE UNIVERSITY BREAST CENTRE
Dr Cheung is a pioneering oncoplastic surgeon in Sydney who has performed oncoplastic surgery for more than 12 years. She works as part of multidisciplinary team at the Macquarie Cancer Institute, which includes oncologists, radiologists, mammographers, lymphoedema specialists, physiotherapists, psychologists and social workers.
Macquarie University Breast Centre prides itself on being able to provide a multidisciplinary opinion for all patients and offer them a plan of management to best suit their condition and their preferences.