Breast Reconstruction: New Video Discusses Latest Breast Reconstruction Options

Breast reconstruction surgery restores something that nature has provided but cancer has taken away.

Unfortunately, most American women with breast cancer do not even realize they have the option of breast reconstruction after mastectomy or lumpectomy.

Breast reconstruction is not a cosmetic procedure.... it is every woman's right: it restores something that nature has provided but cancer has taken away. It is also covered by insurance thanks to a Federal Mandate passed in 1998.

Despite this mandate, studies alarmingly show that only 30% of women facing mastectomy are even offered the option of breast reconstruction.

Women have many reconstructive options after mastectomy or lumpectomy. These range from breast implants to "autologous" techniques which use the patient's own tissue to recreate a more "natural", warm, soft breast. The nipple and areola (the darker area surrounding the nipple) can also be recreated.

Impact of Radiation on Breast Reconstruction

Radiation therapy is often recommended as part of breast cancer treatment. Patients undergoing lumpectomy receive radiation routinely once they've healed from surgery. Some mastectomy patients also need radiation after surgery depending on the characteristics of the tumor.

I think it is fair to say that most reconstructive breast surgeons, myself included, are not particularly fond of radiation because of the way it impacts the patient's tissues (and breast reconstruction in general.) Nonetheless, it is important to remember that "life comes before breast" and in certain situations there is a definite benefit for the patient in having radiation therapy.

So what's the problem with radiation therapy (from a plastic surgeon's perspective)? For starters it can cause toughening (fibrosis) and shrinking (contracture) of the patient's tissue which makes the tissue lose its elasticity and become more tough and rigid. Skin color changes are common, red at first turning more brown over time. Radiation can also cause burn injuries as well as damage to underlying organs such as the lungs and heart. Anyone who is facing radiation therapy must discuss all the potential risks with their their radiation oncologist beforehand.

Women undergoing lumpectomy are often told that most of their breast will be preserved and that radiation is given "as insurance" to decrease the risk of cancer recurrence. What many women don't appreciate is that the breast can end up looking vastly different once the treatment is done because of radiation changes, even though they underwent "breast conservation". Many women end up going to see a plastic surgeon anyway to fix this unforeseen problem, which ironically can include the same reconstructive procedures as for mastectomy.

Radiation after a tissue reconstruction (eg tram flap, diep flap) can cause the reconstructed breast to shrink and harden. Unfortunately, this is a fairly common scenario. Less frequently (with heavy radiation doses), new wounds can develop in the reconstructed breast which need wound care. Patients facing radiation after flap breast reconstruction should know that there is a risk of needing further reconstructive surgery to correct changes caused by the radiation therapy. One study found a re-operation rate of almost 30% in patients receiving radiation after TRAM flap reconstruction.

Tissue expander / implant reconstructions fair even worse with radiation. The complication rates in this setting are much higher than with tissue reconstructions, including complete failure of the reconstruction altogether (and removal of the implant). Some surgeons routinely offer implant reconstructions to patients that are either facing or have already had radiation therapy. There are even articles published in the plastic surgery literature supporting it. I have to respectfully disagree (strongly). In my experience mixing implants with radiation typically ends badly. I will only do this in the very rare instance that there is absolutely no other option.

So what's the take-home message?
1) "Breast conservation" can fall short of the patient's cosmetic expectations.
2) breast implants and radiation do not mix well.
3) If you're facing radiation after mastectomy think twice about insisting on immediate reconstruction. You may be lucky and things may work out just fine. However, there's also a good chance you'll be signing up for more surgery than you bargained for.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient's own tissue. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

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Fat-Derived Stem Cell Enhanced Breast Reconstruction for Lumpectomy Repair

Article by Pam Stephan

Cytori Celution Improves Soft Tissue Transplantation
A lumpectomy is less drastic than having a mastectomy, but it leaves you with a scar and a dimple where a smooth, full curve used to be. The breast can also end up much smaller causing significant breast asymmetry in some women. This asymmetry is often exacerbated by the contraction (shrinkage) caused by the radiation therapy that usually follows lumpectomy. An investigational breast reconstruction technique is being studied that uses your own fat and stem cells to repair the shape of your breast. This technique is called Cell-Enhanced Reconstruction, and was presented at the 2007 San Antonio Breast Cancer Symposium.

A Technique for Partial Breast Reconstruction
Women who have had breast-conserving surgery (lumpectomy, partial mastectomy) currently do not have any options for breast reconstruction. Mastectomy patients can choose from implants and tissue flap procedures for recreating a lost breast, but lumpectomy patients have been left behind - until now.

Japanese Investigational Study
Dr. Keizo Sugimachi, of Kyushu Central Hospital in Fukuoka, Japan, has used this new fat graft procedure on 21 patients, 79% of which said they were pleased with the results. His colleague, Dr. Kitamura, who led the Japanese study, said, "The investigational procedure offers hope to partial-mastectomy patients who have limited options," said Dr. Kitamura. "Unfortunately the concept of 'breast conserving therapy' can often times be misleading, as even minimally invasive resections can result in defects that leave patients dissatisfied with the cosmetic outcome."

Stem Cell Enhanced Breast Reconstruction
Cell-enhanced reconstruction uses your own fat tissue (adipose) that is a rich source of stem and regenerative cells. These stem cells are not the controversial embryonic stem cells. Soft tissue transplants have been done for many years, but this new procedure uses a special process to ensure that the transplanted cells will live and adapt to the transplantation site. The process was developed by Cytori, and uses a machine called CelutionTM System EU.

Stem and Fat Cell Liposuction and Injection
Cytori Celution System is used to remove fat and stem cells. These cells are processed to create a mixture of concentrated stem cells combined with fat cells. This concentrated mixture is injected into your lumpectomy area in 3 places, to fill out the missing tissue. Your breast won't immediately look like it has been repaired; it will need about a month for the transplanted cells to settle into position and fill out the lumpectomy cavity.

The Reconstruction Technique:
1: Standard liposuction removes fat, regenerative, and stem cells from abdomen.
2: Cells go into the Cytori Celution processing system
3: Celution system separates regenerative and stem cells from fat cells. The regenerative and stem cells are then washed and concentrated.
4: The concentrated stem cell mixture is combined with the fat cells.
5: The final mixture is injected into the lumpectomy area, where it fills in and replaces tissue volume.

One Surgical Procedure
Fat cells (adipose tissue) can be extracted from your abdomen, thighs, hips, or lower back. Only one surgical procedure is required for this breast reconstruction technique. In the Japanese study, patients were followed for up to 18 months after the procedure, with no loss of tissue volume and no recurrence of breast cancer.

Planned Clinical Studies
Women who participate in a clinical trial of cell-enhanced reconstruction must be recovered from their breast conservation surgery and any follow-up treatments, and must be recurrence-free for at least two years. There will be two clinical trials in Europe during 2008, which will involve about 90 patients. If approved, clinical studies will begin in the United States after 2008.

Sources:
1) Kitamura K, et al "Stem cell augmented reconstruction: a new hope for reconstruction after breast conservation therapy" Breast Cancer Res Treat 2007; 106 (Supp1): Abstract 4071.
2) Medpage Today. Medical News from SABCS: San Antonio Breast Cancer Symposium Meeting. Fat-Derived Stem Cells Used for Breast Reconstruction. Published: December 17, 2007.
3) Cytori Therapeutics. Cytori Therapeutics Receives FDA 510(k) Clearance for the Cytori Fat Transfer System. Published: December 12, 2007.

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One-Third of Breast Cancer Patients Unhappy with Outcome of Lumpectomy

Women with breast cancer often undergo a lumpectomy and radiation to save their breasts and avoid the need for additional reconstructive surgery. However, approximately one-third of all patients are unhappy with how their breasts look after undergoing breast conservation therapy and many would consider reconstruction, according to a study presented today at the American Society of Plastic Surgeons (ASPS) Plastic Surgery 2006 conference in San Francisco.

“I have patients walking into my office saying lumpectomy was supposed to save their breast but what’s left doesn’t look like a breast to them,” said Howard Wang, ASPS Member Surgeon and co-author of the study. “Conservation is believed to be an acceptable way of saving a woman’s breast. But many of these women are coming to plastic surgeons for help, saying it isn’t so.”

In the study, 28 percent of the breast cancer patients stated they were dissatisfied with the cosmetic result of their lumpectomy. Of those patients, 46 percent stated their physical appearance was worse or much worse after the surgery and were considering reconstruction. Only nine percent of patients who were satisfied with the outcome, however, would consider reconstruction if it were offered.

Approximately 26 percent of patients were unhappy with their physical appearance after the lumpectomy but had an improved sense of body image. Plastic surgeons believe this disparity occurred because many patients felt relieved to be free of the cancer, leading them to feel better about their bodies even though they were not happy with how their breasts looked.

According to the American Cancer Society, almost 213,000 women will be diagnosed with breast cancer this year. Almost 58,000 women underwent breast reconstruction surgery in 2005, according to ASPS.

“Patients should know their options and understand that just because they undergo a lumpectomy to save their breast does not mean they will be happy with the cosmetic outcome,” said Dr. Wang. “Oncologists need to work with patients to help them understand the potential physical outcomes and refer them to a board-certified plastic surgeon to consider all of their choices.”

For referrals to ASPS Member Surgeons certified by the American Board of Plastic Surgery, call 888-4-PLASTIC (475-2784) or visit www.plasticsurgery.org where you can also learn more about cosmetic and reconstructive plastic surgery.

The American Society of Plastic Surgeons is the largest organization of board-certified plastic surgeons in the world. With more than 6,000 members, the society is recognized as a leading authority and information source on cosmetic and reconstructive plastic surgery. ASPS comprises 94 percent of all board-certified plastic surgeons in the United States. Founded in 1931, the society represents physicians certified by The American Board of Plastic Surgery or The Royal College of Physicians and Surgeons of Canada.

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Dr Chrysopoulo is board certified in Plastic and Reconstructive Surgery and specializes in breast reconstruction surgery after mastectomy for breast cancer. He and his partners perform hundreds of microsurgical breast reconstructions with perforator flaps each year including the DIEP flap procedure. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Reconstruction Blog.

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