There are a few layers to peel back when answering this question. It goes without saying I am referring to those affected by breast cancer and are facing a mastectomy. Whether you are a surgeon, patient, family member, or friend, should you be telling someone what kind of reconstruction to have?
Understanding the Overwhelming Shock
I see some differences but more similarities when I speak to women who are at high risk of getting breast cancer than those with an active diagnosis.
Those who are at high risk of getting breast cancer are a those who have a genetic mutation. The first step is knowing your family history. This will be followed by a visit to a genetic counselor or oncologist to begin formulating a plan that might include:
- Increased Screening (mammography and MRI).
- A type of risk reducing hormonal therapy.
- Options for risk-reducing surgery.
People who have just received the news they have a breast cancer diagnosis have considerations for planning their treatment that can include:
- Further testing to determine tumor biology (biopsy and other lab work).
- Considerations of hormonal treatment depending on breast cancer type.
- Chemotherapy is used to destroy breast cancer cells.
- Reducing breast cancer cells with chemotherapy prior to having surgery.
- Options for surgery when facing a mastectomy.
These are a few considerations but imagine living your life one day not knowing any of this would be something you are going to face? Most people I speak to are overwhelmed and feel shocked about all they must learn and understand regarding treatment, surgery, surveillance, and recovery. This is important to consider if we are going to answer the question of should we be telling someone what kind of reconstruction to have.
Appointments with Surgical Specialists
This is when information for patients becomes key to successful outcomes. When you consider someone is going to be taking surgical instruments to your body, it is important to understand the latest techniques and find a highly skilled surgeon, breast surgeon or plastic surgeon. All professions in life have varying degrees of experience, skill level, and compassion. It is a rare find to hit on all three, but it happened in my case for my double mastectomy and DIEP flap breast reconstruction. I can only guide others facing these decisions through a process I feel will honor them, their preferences, while providing information to have a shared decision-making conversation with each member of their healthcare team.
What Kind of Information for Which Surgical Specialist?
Breast tumors are in various parts of the breast. They are different sizes. Depending on the size and location of the breast tumor we know numbness can occur because of nerves being cut during surgery. However, with advancements in breast surgery, new research and studies being conducted, it is now possible to preserve nerves at the time of mastectomy. Thanks to pioneering surgeons, Anne and Ziz Peled, more and more breast surgeons are giving this technique consideration and adding it to their armamentarium.
Patients can also consider oncoplastic breast surgery. This is when a lumpectomy is performed, and the surrounding tissue is used to fill in areas where the tumor was taken. Another way of understanding it is breast conserving surgery that combines oncological principles with plastic surgery techniques. I heard great, robust conversations on oncoplastic surgery at the most recent ASBrS (American Society of Breast Surgeons) conference in April of 2024. Here is information I feel patients should have regarding breast surgery with the links to the information.
- Oncoplastic Breast Surgery after a Breast Cancer Diagnosis with Dr. Lashan Peiris
- New Possibilities for Maintaining Sensation after Mastectomy with Anne and Ziv Peled
Unfortunately, not all breast surgeons have adopted this technique, nor do they feel it works. I will continue to push the envelope encouraging both breast surgeons to try it and patients to ask for it. Otherwise, change will be slow to take place. I believe through our combined interest in optimal patient care and outcomes, patients and surgeons can work together to ensure this technique is adopted in breast surgery.
Understanding Plastic Surgery and Options in Reconstruction
Plastic Surgery in Breast Reconstruction
The world of plastic surgery is vast, complex, and often difficult to navigate for someone affected by breast cancer and facing loss of breasts. Most plastic surgeons who work with breast cancer patients are familiar with and able to place an implant. Many patients still choose this option for breast reconstruction. Many get very pleasing results.
Microsurgery in Breast Reconstruction
However, increasingly more patients are learning about the option to use their own tissue to reconstruct breasts after mastectomy. This is called autologous (using your own tissue) breast reconstruction. This requires more training after completing a plastic surgery program. It will either be a fellowship program or focused training program specifically centered on breast reconstruction. Why? Because it requires anastomosis or tying together of blood vessels under high powered surgical loupes and microscopes. The technique to learn this takes more specialized training than a plastic surgery medical degree.
The gold standard in microsurgical breast reconstruction is using the tummy tissue called DIEP flap. However, for those who are not a candidate, there are other options to use. It is important to understand that nerves not preserved at the time of mastectomy can also be reconstructed at the time of DIEP flap. Patients often ask me if I am pleased with my aesthetic outcomes? They also want to know what recovery is like because many desire to get back to work after their reconstruction. Studies have shown using the co-surgeon model in autologous breast reconstruction improves patient outcomes. And of course, insurance coverage is often a concern. Education is vitally important to ease the mind of patients. Here are some important links to share and consider if you know someone going through this process.
- What Accreditation Should your Breast Reconstruction Surgeon Have with Dr. Daniel A. Liu.
- Microsurgery in Breast Reconstruction after Mastectomy: A look at the Intricacy of Training
- DIEP Flap Breast Reconstruction: From PRMA Plastic Surgery
- Options for Breast Reconstruction after Mastectomy with Dr. Steven Pisano
- Sensory Nerve Reconstruction: Restoring Sensation During DIEP Flap after Mastectomy with Dr. Minas Chrysopoulo.
- DIEP Flap Breast Reconstruction: Aesthetic Questions to Ask Your Plastic Surgeon.
- ERAS (Enhanced Recovery after Surgery) Protocol in Breast Reconstruction
- The Value of the Co-Surgeon Model in Breast Reconstruction and Insurance Coverage Concerns.
Should You be Telling Someone What Kind of Reconstruction to Have?
My answer will always be, NO! Should you be giving them all the information needed to understand what treatment and surgical options are available when facing a mastectomy? My answer is and always will be YES! It is then that patients can begin to feel ownership in their decision when facing mastectomy.
There are many great resources available across the internet these days and this where many patients go to find their information. I share a small footprint in that internet space. This is what I do every day because when I hear a voice on the other end of the phone, or see a comment on my private Facebook group, this is what I can offer as one who has walked this walk. If I can minimize someone’s time and give them some sort of lifeline at a time when they are overwhelmed and shocked with the news they are affected by breast cancer, then I feel empathy for them and am happy to help.
I would like to acknowledge the surgical community, both breast surgeons, plastic surgeons, and microsurgeons who I have established a trusted relationship with on behalf of patients. You generously give your time to this community to empower patients with information in the DiepCJourney podcast and the DiepCFoundation educational channel. I am a better patient advocate because of your dedication. Thank you for all you do for the breast cancer community. The Journey continues.