Thursday, October 1, 2009
The collaborative art and science of breast reconstruction at Memorial Sloan Kettering.
To receive a diagnosis of cancer can be terrifying. Then to learn that the surgery required to remove the cancer will result in a life-altering physical disfigurement or a functional impairment, or both, can compound the devastation. However, in recent decades, with the increasing sophistication of microsurgical techniques, plastic and reconstructive surgeons have helped the majority of patients facing such crises to return to normal or near-normal lives, with often-remarkable cosmetic and functional results.
Memorial Sloan Kettering’s plastic and reconstructive surgeons, leaders in their field, performed nearly 1,300 reconstruction procedures in 2008. The lion’s share of these — 1,069 — were reconstructions after surgery for breast cancer, followed by head and neck reconstructions (140). But reconstructions are not limited to these areas of the body. Memorial Sloan Kettering plastic surgeons do procedures that range from small reconstructions on the face following the removal of skin cancers, to reconstructions after operations to remove advanced pelvic malignancies, and reconstructive surgery of the lower and upper extremities to help in salvaging limbs after large tumors have been removed.
“When trying to reconstruct anything with a patient’s own tissues — a breast, a tongue, a jaw — we need to take tissue from another part of the body to replace the tissue that has been removed,” explained Peter G. Cordeiro, Chief of Memorial Sloan Kettering’s Plastic and Reconstructive Surgical Service. “And microsurgery has revolutionized reconstruction. It allows us to take what we need — skin, muscle, fat, bone, or any combination — and connect the very small blood vessels that supply the transferred tissue to the vessels in the area we’re reconstructing.” At Memorial Sloan Kettering the success rate for such procedures is extremely high, approximately 98 to 99 percent.
Reconstruction After Mastectomy
The goal of breast reconstruction after mastectomy (the removal of a breast) is to restore anatomy and symmetry, either with artificial implants or by using a woman’s own tissue. (Of the 1,069 breast reconstructions performed in 2008, 936 were with implants while 133 were autologous tissue reconstructions, meaning that the patient’s own tissue was used.) Breast surgeons, who perform the mastectomies, and plastic surgeons, who reconstruct breasts, work closely with medical oncologists, radiation oncologists, and with patients themselves to develop the optimal surgical treatment and a reconstruction strategy. The type of breast cancer a patient has — including its location within the breast and the stage of the cancer — her body type, general health status, what adjuvant therapy she may need either before or after surgery, as well as her own wishes regarding the type of surgery she may want, are all factors in determining surgical approaches and choices.
Once a woman has made the decision to have reconstruction after a unilateral or bilateral mastectomy, “the pros and cons of the different techniques are not simple to sort through,” noted Memorial Sloan Kettering plastic surgeon Babak J. Mehrara.
“You absolutely must individualize the decision for each patient — in close consultation with that patient.”
Reconstruction with Implants
Today, the most common form of breast reconstruction remains the implant, which uses either a silicone or saline implant to rebuild the breast. At Memorial Sloan Kettering, silicone implants are most frequently used. “The newest silicone implants — called ’cohesive’ because the gel is more viscous and less of a liquid than in earlier implants — are powerful tools in performing breast reconstructions,” explained Memorial Sloan Kettering plastic surgeon Joseph J. Disa. “They come in a great variety of shapes and sizes, and our ability to match the natural breast has been significantly improved over the traditional round silicone or saline implant.”
Implant reconstruction is usually a two-stage process. First, a tissue expander (a balloon-like plastic bag) is inserted into a pocket under the skin and muscle of the chest. Over the course of several months, fluid is introduced by needle into the expander to gradually expand the muscle and skin of the chest. The expander is replaced with an implant in a separate surgical procedure. Once the implant is in place, if a woman has had a unilateral mastectomy and reconstruction, the contralateral (opposite) breast may be altered to achieve symmetry, either with a breast reduction, breast lift, or even another implant.
The last step in the process — as is the case with most breast reconstruction procedures — is the re-creation of the nipple and areola. The nipple is usually made from the skin and fat of the reconstructed breast and the areola by taking a skin graft from the upper inner thigh or lower abdomen. The final nipple color is created by a tattoo technique.
Implant surgery is a less extensive operation, requiring about two to three hours in the operating room under general anesthesia, while reconstructing a breast from a patient’s own tissue may require as many as six to ten hours or more of surgery. “There are also oncologic reasons not to use the patient’s own tissue for reconstruction at the time of mastectomy,” said Dr. Mehrara. “For example, a woman who will be getting radiation after mastectomy probably should defer autologous reconstruction. In this case, we can put in an implant and do reconstruction with her own tissue later.”Back to top
Reconstruction with a Patient’s Own Tissue
Autologous tissue reconstruction — in which a plastic surgeon transfers tissue from elsewhere in a patient’s body — usually results in a breast that feels softer and more natural to the touch than an implant and provides the best match to the contralateral breast.
The most common method of breast reconstruction using a patient’s own tissues is a procedure called a TRAM flap. TRAM (transverse rectus abdominus myocutaneous) is the medical term for the piece of tissue, or flap, that is being transferred. (The rectus abdominus is what is colloquially known as the “six-pack” muscle in the abdomen, and the area below the belly button is the donor site most often used.)
In the TRAM flap procedure known as a pedicle flap, the skin, fat, and at least one abdominal muscle are tunneled underneath the skin to the breast area but remain attached to their blood vessels in the abdomen. This allows the transferred tissue to continue to get its blood supply from its site of origin. However, removing the abdominal muscle results in a certain amount of abdominal weakness and may increase the risk of a bulge, or hernia.
From the TRAM flap, two additional procedures have been developed. One is called the muscle-sparing free TRAM flap, and the other the DIEP (deep inferior epigastric perforator) flap. Both are known as free flaps because the surgeon detaches an entire section of tissue along with its blood supply and reattaches it, using microsurgery, at the recipient site. Muscle-sparing means that the surgeon is able to spare most if not all of a patient’s abdominal muscle. In a DIEP flap no muscle is used to form the breast mound.
In both surgeries, the transferred tissue includes an artery, vein, and tiny vessels called perforators. “The deep inferior epigastric artery is the vessel that supplies blood to the abdominal muscle,” explained Dr. Disa. “It also gives off side branches, which travel through — or perforate — the muscle to the overlying fat and skin. Sometimes these perforator vessels are large enough that we can tease them out of the muscle without removing any muscle at all — that’s a DIEP flap.”
But when the perforators cannot be entirely separated from the muscle, a surgeon will take a very small piece of muscle along with these vessels in a muscle-sparing free TRAM flap. In either procedure, the artery, vein, and perforators are reattached to recipient vessels in the chest. (For illustrations of these procedures, see page 10.) Other sources of free flaps for breast reconstruction include the gluteal (buttock) and latissismus dorsi (back) muscles. Whatever free tissue transfer technique is used, only highly trained microvascular surgeons are properly equipped to perform these operations. “My colleagues and I do nothing but reconstructive surgeries,” said Dr. Cordeiro, “and are active in investigating new modalities to continually improve outcomes.”Back to top
Choices and Decision Making
For many women diagnosed with early-stage breast cancer, breast-conserving surgery — more commonly known as a lumpectomy — is an important option. However, increasing numbers of women are choosing mastectomy. Memorial Sloan Kettering breast surgeon Kimberly J. Van Zee observed, “We are seeing more women coming in with early-stage breast cancer who want bilateral mastectomies and reconstruction. And it’s our role as breast surgeons — as we are usually the first physicians a newly diagnosed patient will meet with — to take the time to educate patients about all their options.”
In an editorial published on September 1 in the Journal of Clinical Oncology, Monica Morrow, Chief of Memorial Sloan Kettering’s Breast Service, wrote, “We know very clearly from the literature that breast-conserving surgery and mastectomy do not vary in terms of survival.” She noted that many women choose bilateral mastectomy because they greatly overestimate the risk of developing cancer in the opposite breast “and do not understand that many of the drugs used to treat breast cancer have the added benefit of reducing the risk of future cancers in the other breast.” In addition, Dr. Morrow said, “Women are often unaware that a bilateral mastectomy is not a 100 percent guarantee that the breast cancer will not develop at the surgical site.” She emphasized the need for more research on how to effectively communicate complex treatment choices to women facing the stress of a new cancer diagnosis.
“These are not easy or simple decisions,” concurred Memorial Sloan Kettering breast surgeon Alexandra S. Heerdt. “Part of my discussion with patients is going through the data about contralateral mastectomy [if breast cancer is only diagnosed in one breast] and the fact that there’s not a single study that shows that bilateral mastectomy increases longevity. One of things I listen for is ’It’s not about longevity. It’s about my quality of life. I will be terribly anxious.’”Back to top
Specialized Knowledge, Specialized Techniques
For women who choose mastectomy and reconstruction, Memorial Sloan Kettering plastic and reconstructive surgeons and their colleagues have been leaders in advancing specialized knowledge and techniques that allow more patients to have the option of such surgery.
“There are two types of patients who historically have not been candidates for reconstruction,” said Dr. Van Zee. “These are women who have already had breast cancer and radiation therapy and who have a recurrence years later, and women who present with a more advanced cancer that will require chemotherapy and radiation.” However, over the past decade, she and her colleagues have collaborated in doing reconstructions in both these patient populations with good results.
“Women with stage II or III breast cancer who will require chest wall radiation and chemotherapy as part of their treatment will now often receive their chemotherapy before surgery — and in consultation with their medical oncologist, plastic surgeon, and radiation oncologist, we are able to schedule a mastectomy for three weeks after they finish their chemo, so very little time is wasted,” said Dr. Van Zee. (Chemotherapy is more traditionally delivered after breast cancer surgery.) Following mastectomy, Memorial Sloan Kettering plastic surgeons put in a tissue expander that is filled with fluid on an accelerated schedule of three to four weeks — rather than the more conventional several-month schedule — after which the implant is put in, and a woman then embarks on radiation therapy. “So patients haven’t really delayed any aspect of their cancer care,” explained Dr. Van Zee, “but are able to end up with a reconstruction. We’ve had a good experience with it, and this is very much due to the wonderful breast cancer system-wide collaborations here.”
In patients who have undergone previous chest irradiation and whose skin may not expand as easily as nonirradiated skin, the option of a tissue expander and an implant — still the type of reconstruction preferred by most women — wasn’t thought to be an option. But Memorial Sloan Kettering plastic surgeons have shown that this surgery can be successful. “If the skin is normal to the touch and doesn’t appear to be damaged by the radiation, you can do an implant reconstruction,” said Dr. Disa. “The outcomes tend to be not quite as good as if the skin has never been radiated. When you put the implant in, it’s always a little firmer and tighter than with nonirradiated skin. But it is acceptable in the majority of patients.”
During the past ten years, success with skin-sparing mastectomy — in which the entire breast skin envelope is preserved — has led to increased interest in nipple-sparing mastectomy (NSM), a procedure that combines skin-sparing mastectomy with preservation of the nipple and areola. Memorial Sloan Kettering breast surgeon Virgilio Sacchini has led research efforts in this area. “As the rate of contralateral prophylactic mastectomy has increased, we have wanted to improve the cosmetic results of reconstructive surgery,” explained Dr. Sacchini, “and in certain patients, preserving the nipple and areola is a possibility.” Patients may be candidates for NSM if they are undergoing prophylactic mastectomy because of genetic mutations or a strong family history that predisposes them to the development of breast cancer, or if the cancer “is at least two centimeters away from the nipple,” said Dr. Sacchini. (Removal of the nipple in mastectomies has routinely been performed based on the presumed risk of occult cancers in the nipple; and, of course, a nipple must be removed if pathology identifies any cancer.) A study published this year in The Breast Journal, on which Dr. Sacchini was the senior author, included a comprehensive review of the literature as well as a report on the short- and midterm postoperative outcomes of NSM at Memorial Sloan Kettering. It concluded that while more research is needed to definitively determine the oncologic safety of NSM, the data indicate that the procedure can be safely performed in carefully selected cases.
“Memorial’s plastic and reconstructive surgeons are absolutely crucial to what we do here,” said Peter T. Scardino, Chair of the Department of Surgery. “They do a beautiful job, and they’re the ultimate collaborators. They spend at least as much time helping us, the ablative surgeons, with our operations as they do doing their own surgery. Today, it’s not enough to treat and cure a cancer. You want to leave a person as functionally and aesthetically whole as possible. The medical application of plastic surgery in oncology is highly related to quality of life and getting patients back to as normal a life as we can.”
This is the first in a series on plastic and reconstructive surgery at Memorial Sloan Kettering. Following articles will focus on research into the prevention of lymphedema after breast cancer surgery, complex head and neck reconstructions, research into quality of life after reconstruction, and the contribution of Memorial Sloan Kettering’s nurses in post-reconstruction care.