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Physicians Update

 
Fall 2006: Plastic Surgery

New Procedures Offer Safer, More Natural Breast Reconstruction

For women undergoing mastectomy, breast reconstruction can now be offered safely in conjunction with the surgery, with less morbidity and better cosmetic outcomes than in the past, according to plastic surgeons at the Revlon/UCLA Breast Center.

“Previously, when breast reconstruction was done at the same time as the mastectomy, many patients experienced complications that could delay chemotherapy or radiation, which made many physicians reluctant to recommend immediate reconstruction,” says James Watson, M.D., UCLA plastic surgeon. “Today, we have more options and we can tailor the reconstruction to the individual patient, thereby avoiding a lot of the complications that we had previously.” Primary-care physicians should refer their breast cancer patients to a plastic surgeon at the same time that they are referring to an oncologist so that the two can coordinate their treatment plans and, preferably, perform the surgeries at the same time, adds UCLA plastic surgeon Jaco Festekjian, M.D. “It’s very rare now that we would recommend delaying reconstruction,” he says. “Too often, women unnecessarily have to live without a breast for a period of time before the reconstruction.”

Immediate reconstruction not only prevents the negative psychological consequences many women experience through their changed body image, it also provides the plastic surgeon with tissue that is softer and easier to work with, making a better result more likely, Dr. Festekjian explains. The most significant advance facilitating immediate reconstruction has been the use of new microsurgical techniques that enable specially trained plastic surgeons to employ autologous-tissues without the need to transfer muscle, which weakens patients. At UCLA, the most common procedures use excess skin and fat from the patient’s lower abdomen to replace the breast tissue. Two new techniques are employed: deep inferior epigastric artery perforator flaps (DIEP) and superficial inferior epigastric artery flaps. Another option utilizes skin and fat from the buttocks.

“We used to transfer muscle with the tissue during these procedures to protect the blood supply to the flap,” says Dr. Festekjian. “Now that we’re able to do it without using muscle, patients have less pain and a much faster recovery.” This option is particularly important for women undergoing radiation. “Complication rates are very high when placing implants in radiated breasts,” Dr. Festekjian notes. “Most plastic surgeons are still using tissue expanders and implants to reconstruct the breast, but at UCLA we have a philosophical bias toward autologous tissues,” says Christopher Crisera, M.D., UCLA plastic surgeon. “Although it requires a longer recovery, an autologous-tissue reconstruction yields a more durable and natural result.” Delayed autologous reconstruction is still sometimes indicated in cases where post-operative radiotherapy is anticipated, says Brian Boyd, M.D., chief of plastic surgery at Harbor-UCLA Medical Center.

Immediate placement of a temporary implant or tissue expander maintains body image and skin tone while protecting the eventual reconstruction from the harmful effects of radiation. Implants still represent an attractive option for many patients, notes UCLA plastic surgeon Andrew Da Lio, M.D. “Our results are getting better not only with the use of flaps in autologous-tissue transfers, but also with the use of implants,” he says. Dr. Da Lio explains that there are now multiple types of implants, using both saline and silicone, with a variety of shapes and textures. After a large study on the safety of silicone gel implants, a Food and Drug Administration (FDA) advisory panel concluded that they are not causally related to autoimmune syndromes and recommended that the material, which tends to produce a softer breast than saline implants, be made more widely available.

In addition to the newer autologoustissue reconstruction technique, refinements have occurred in previous approaches to expander implant reconstructions, notes Dr. Watson. The improvement involves use of an acellular dermal graft to cover the lower half of the implant. “This has allowed us to give the breast a much better cosmetic shape,” he explains. Dr. Da Lio notes that as genetic testing is made more widely available and women with a strong family history of breast cancer become more aware of their risk, more are opting for prophylactic mastectomies, often with immediate reconstruction. “Certainly it’s an individual decision but in some cases, if patients and their physicians saw what we can now do, they would probably be more accepting of the idea,” says Dr. Da Lio. “For women who do elect to go through with prophylactic mastectomies, this no longer has to be looked at as a mutilating type of experience.”

Prophylactic mastectomies are also becoming more common among high-risk breast cancer patients, many of whom choose to have both breasts removed at the time of diagnosis on one side. “We’re gaining insight into genetic mutations that predispose patients to cancer, and we can test for some of those now,” Dr. Crisera says. “In addition, the Society of Surgical Oncologists has defined the patients who are at high risk and may benefit from having prophylactic mastectomy. As a result, a growing number of women are coming to us needing both breasts reconstructed at once.” In some cases, Dr. Crisera explains, this can limit the available options. “If we want to do a bilateral reconstruction using autologous tissue, the best aesthetic outcome would be to start the process at the time of the mastectomy,” he says. “That means the patient’s body has to be able to provide twice as much tissue as when we are reconstructing one side.” Certain autologous options lend themselves better than others to bilateral reconstructions, Dr. Crisera explains, the deep inferior epigastric artery perforator flap being one of them. For patients who don’t have enough tissue on their abdomen, it is not always feasible to reconstruct both sides at once. Indeed, although immediate reconstruction typically provides the best result, it is important to tailor the approach to the individual patient, says Dr. Watson. “For patients who are actively smoking, have diabetes, have late-stage breast cancer, or are obese, it is safer in some cases to wait and do delayed breast reconstruction after chemotherapy and radiation,” he says. “Even in these cases, we can offer an excellent cosmetic result.”

When patients are receiving chemotherapy and radiation along with the mastectomy, oncologists should work closely with the plastic surgeon so that the procedures are properly coordinated to ensure the best cosmetic outcome, says Dr. Festekjian. Whether reconstruction is immediate or delayed, Revlon/UCLA Breast Center plastic surgeons agree that close collaboration among the services is a key to successful outcomes. The Revlon center offers the advantage of all breast cancer services—including surgical, medical and radiation oncologists; plastic surgeons; psychiatrists; and social services—working together in a single facility. “It’s a one-stop shop for the patient to get an understanding of what is going to be involved in her oncologic management, including reconstructive options,” says Dr. Crisera. “It also helps plastic surgeons to be able to see patients in that environment because we’re better able to tailor the reconstruction to the individual patient.”

“It is very helpful to be able to provide patients with a complete treatment plan in one visit,” says Helena Chang, M.D., Ph.D., director of the Revlon/UCLA Breast Center. “Patients appreciate being able to see everyone on the same day. We also offer free surgical education classes every week with a nurse practitioner, a psychosocial team member, and a volunteer survivor who come together to make sure patients are happy with their choice and that they understand what is involved. Our center’s multidisciplinary approach ensures that we are covering all of the bases and providing patients with all of the options, including immediate reconstruction.”





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