Joining FORCES is the FORCE newsletter with news, views and supportive information for individuals concerned about hereditary breast and ovarian cancer.
by Kathy Steligo
Presented at the 2006 Joining FORCEs Conference by Andrew Salzberg, MD; Jeffrey Friedman, MD; and Frank DellaCroce, MD.
Breast reconstruction is an issue of interest to many BRCA women, whether they’re considering mastectomy as a prophylactic measure or as a breast cancer treatment. Many women came to the conference looking for answers about reconstruction: What procedure is best? What is recovery like? Is it practical or possible to spare their nipples?
Conferees came to the right place. Plastic surgeons introduced different reconstructive methods, while women in various stages of reconstruction happily answered questions, shared personal perspectives, and displayed their results (impromptu show-and-tell sessions occurred at any given moment in the ladies room).
The Breast Reconstruction Options session began as three FORCE members told why the procedure they chose was right for them. Elaine described having hybrid saline/ silicone implants for 24 years before replacing them. Sharon explained how pleased she was to have an AlloDerm® implant reconstruction that didn’t require the discomfort and awkwardness of traditional expansion. Joan talked about her satisfaction with delayed bilateral GAP reconstruction and later revision surgery.
Three plastic surgeons then spoke about various reconstructive techniques. Dr. Andrew Salzberg elaborated on the AlloDerm implant procedure, which uses patches of acellular tissue (donated human tissue that has been stripped of its epidermis and genetic material) to support and hold an implant in place. This helps define the shape and contour of the new breasts and provides a cushion between the breast skin and the implant. More importantly for the patient, it often eliminates the need for expansion (gradual stretching of the chest muscle and breast skin to accommodate an implant). Dr. Salzberg also clarified subcutaneous prophylactic mastectomy, a procedure that spares a woman’s nipple and areola.
Dr. Jeffrey Friedman discussed the difference between attached (pedicled) transverse rectus abdominis myocutaneous (TRAM) flaps, which sacrifice all of a woman’s abdominal muscle, compared to a free TRAM, which produces similar cosmetic results but preserves most of the muscle. Dr. Friedman explained how abdominal flaps can rebuild breasts to be smaller or larger than a woman’s natural breasts, but the size of the new breasts are limited by the amount of excess skin and fat in a woman’s tummy.
“You can’t make a D-cup breast with an A-cup abdomen,” he said.
Dr. Frank DellaCroce spoke about the cosmetic advantages of immediate reconstruction, and presented two microsurgical muscle-sparing flap procedures: the deep inferior epigastric perforator (DIEP) and, for women who don’t have sufficient abdominal tissue or who can’t have abdominal surgery, the gluteal arterial perforator (GAP). Dr. DellaCroce explained that perforator flap surgeries are labor intensive and lengthy, but they produce superior cosmetic results and require a shorter hospital stay and recovery than older flap methods. He also described how breast improvements and new nipples are accomplished with revision surgery.
Later roundtable discussions set the stage for personal question-and-answer sessions, as women directed their individual concerns and questions about reconstruction to the surgeons. At the end of the day, the women, some with spouses or partners, felt better equipped to make their own decisions about reconstruction.
Prophylactic mastectomy is the most extreme action a woman can take to minimize her risk of breast cancer. It’s also the most effective, reducing the risk in BRCA carriers by 90 percent. When immediate reconstruction is performed with prophylactic mastectomy, skin-sparing surgical techniques can provide emotional and cosmetic advantages. Implants or tissue from a woman’s own back, abdomen, or buttocks can be used to rebuild new breasts through her mastectomy incisions. FORCE recommends women who believe they are at high risk consult with a genetics specialist before pursuing prophylactic mastectomy. Know your personal risk for breast and ovarian cancer, and understand your risk management options before you decide prophylactic mastectomy is right for you.
Sentinel node biopsy is a procedure to determine whether invasive breast cancer cells have spread beyond the breast into the lymph system. By injecting a blue dye or radioactive material into the breast, the surgeon can fi nd the underarm node most likely to contain cancer cells. If this sentinel node is found to be free of cancer, a more extensive “axillary dissection” surgery can be avoided. Prophylactic mastectomy does not always include either sentinel node biopsy or axillary dissection because the woman is assumed to be free of breast cancer. However, because breast cancer is occasionally found in high-risk women during prophylactic mastectomy, some breast surgeons perform sentinel node biopsy as a precautionary measure. Women considering prophylactic mastectomy should discuss the benefits, risks and limitations of sentinel node biopsy with their surgical team.