Modern Techniques Refining the Process of Breast Reconstruction

A study published last year in Socio-Demographic Factors and Cancer Research found that about 30 percent of women nationwide have breast reconstruction after a mastectomy, or breast removal. The study noted that breast reconstruction offers a range of psychosocial, physical and quality-of-life benefits.

 

“One of the more important aspects is the mental, the emotional or psychological impacts that having no breast or having a deformed breast or having severely discrepant breasts have on the patient’s self-confidence, the way they view themselves, and their emotional and psychological well-being,” said Dr. Zachary Young, plastic surgeon at Arkansas Plastic Surgery in Little Rock.

 

 

“There are plenty of women out there that are totally fine with that, but a lot of women, that’s part of their identity, so restoring their physical form also restores mental health and psychological well-being.”

 

The good news is that breast reconstruction has become more efficient and effective over the years, although the process can take various routes depending on the patient. Young likened breast reconstruction to a game of Plinko on the TV series The Price is Right.

 

“We’re trying to navigate you through the ups and downs and the twists and turns that can come with [cancer],” he said. “Every patient, that journey is different. That’s why when we see patients in consultation for breast reconstruction, those are usually pretty extensive discussions because there’s no right path for anybody. There’s usually multiple paths for patients and physicians.”

 

 

He said the majority of his reconstructions utilize direct implant reconstruction, in which the mastectomy and reconstruction are done at the same time. One of the benefits of the technique is that it only necessitates one surgery. The concept has been around since reconstruction began, Young said, but needed to be refined before becoming commonplace.

 

“The first reconstruction that was done was basically just a plastic surgeon putting in an implant underneath the skin,” he said. “That had some issues with it, so it fell out of favor for quite a long time, but I would say at least for the past, probably, 15, 20 years, this style of reconstruction has become more and more popular with advancements in technology and the way we can support the implant and support the breast skin.”

 

One of the most impactful developments has been using a mesh made of cadaver tissue or synthetic bioabsorptive material to hold the implant in place while the breast heals, said Dr. Eric Wright, owner of Wright Plastic Surgery & Med Spa in Little Rock. Previously, most patients had to have delayed reconstruction using tissue expanders, empty devices that were gradually filled with fluid to create a space for the implant.

 

 

“An implant and a breast are not the same size, meaning breast tissue is not just a round object, but that’s what an implant is,” he said. “You can’t just put a round object where the breast used to be, so you have to control and kind of support things, but now, when we use the mesh, we’re able to use direct implant reconstruction with greater consistency, which allows us to get the end result at the same surgery.”

 

Avoiding manipulating the muscle and using nerve blocks to control pain has resulted in another positive trend for patients, he added — many only stay at the hospital overnight or do not spend time in the hospital at all.

 

“We’re doing these procedures as an outpatient basis, which, again, has changed over the past 15, 20 years that I’ve been doing it,” Wright said. “We used to just keep patients in the hospital for days, not just overnight. Instead of the days they would stay in the hospital after a mastectomy, now patients go home the same day and do fine, which is great.”

 

 

Another advancement, Young said, is the use of dye to check for perfusion, meaning sufficient blood flow to the affected tissues.

 

“It’s a dye called ICG or indocyanine green, and we have special cameras with lasers on them. We can watch the blood flow through the tissue and see if it’s perfused,” he said. “With direct implant reconstruction, it allows us to look at the skin in a very detailed way and see what, if any, parts of the skin after the mastectomy are or are not perfused because we require good perfusion in order to perform a direct implant reconstruction.”

 

The implants themselves have changed, as well. Young said more cohesive “gummy bear” implants are becoming the standard for breast cancer patients.

 

“We use a firmer implant in reconstruction because it minimizes the implant visibility or what we call ‘rippling’ or just the way an implant looks,” Wright added. “[Traditional implants] are too soft of an implant because for reconstruction purposes, there is no breast tissue. You’re covering it with skin, and so you see more of an implant.”

 

Fat grafting, in which fat is liposuctioned from one part of the body and injected into another, can also be used to camouflage the appearance of an implant, he said, as well as counteract scarring and implant changes from postsurgical radiation. Understanding whether the patient will receive radiation after surgery also affects implant positioning and could necessitate delayed reconstruction in some instances, he added.

 

Young said fat grafting has been a great addition to the available reconstruction options.

 

“We’re able to add volume into the breast in order to either simply enhance volume and/or improve contour,” he said. “Sometimes people feel like they don’t have enough fullness in certain areas. We can add that in, or, like I said, we can simply add volume in that way, and you don’t have to use a bigger implant or use other kinds of measures.”

 

Another option is autologous breast reconstruction, although Wright said he did not know of any surgeons offering the procedure in Arkansas. During autologous reconstruction, tissue from another part of the body, such as the abdomen, inner thighs or buttocks, is moved to the chest to create a breast using microvascular surgery without the need for an implant. Young said the procedure has improved significantly over the years.

 

“People who do a lot of microvascular surgery have honed those techniques to where they can take less and less and disturb the body’s natural shape and physical structures as little as possible so there’s as little morbidity as possible,” he said. “Those techniques continue to be advanced, and now microvascular surgery is a popular form of reconstruction for patients that choose it.”

 

One of the latest advancements in breast reconstruction is nerve grafting, in which donor nerves are used to connect existing nerves to areas where nerves are removed during a mastectomy, allowing sensation to return to the nipple and areola complex.

 

Wright said that he, along with surgical oncologist Dr. Yara Robertson, recently performed the first successful nerve-grafting surgery in Arkansas at CARTI Cancer Center in Little Rock.

 

 

“That’s what we consider sort of the final evolution of breast reconstruction because now not only can we get a great aesthetic outcome; now we’re able to do procedures that have restoration or repair of the sensory deficit that was lacking,” he said.

 

 

Other milestones for breast cancer patients have taken place in the legislative sphere. Last year, the Arkansas General Assembly passed a law that requires health insurance companies to cover all aspects of breast reconstruction.

 

 

“For us, it’s great,” Wright said. “It was always frustrating when certain procedures would be denied just based on some policy somewhere that if they had a different insurance, they would be able to have that procedure.”

 

One key to ensuring patient satisfaction, he added, is to provide realistic expectations about what to expect from reconstruction — which, these days, is pretty good.

 

“Showing them realistic pictures and having realistic expectations of the process is important, but our realistic expectations are really good these days, even compared to when I started,” he said. “The techniques and equipment and technologies continue to get better, so I just tell them that there’s a process, and there’s always a potential for tweaks and tune-ups, but the goal is to help them feel as much as themselves after this whole process.”

 

Young said he sees more patients opting for breast reconstruction, and he expects that upward trend to continue, along with scientific advancements that help refine the procedure.

 

“A lot of people in the past didn’t know that that was an option for them. Nowadays, most women know that that is an option,” he said. “I think that as we continue to do more and more, we’ll continue to make advancements both through the surgical side and the materials side.”

 

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