“Burn No Bridges” Specialty Care for Breast Cancer Patients
Patients recently diagnosed with breast cancer are overwhelmed with information regarding surgical treatment options and medical healthcare to include chemotherapy and radiation.
For small breast cancers, the discussion is focused on the use of breast conservation (lumpectomy and total breast irradiation) as the start point for moving forward.
For larger cancers, typically > 5 cm or with multiple cancers within the same breast, the discussion is focused on the possible use of neoadjuvant chemotherapy (chemotherapy before surgery) as a means to shrink the cancer therefore making the patient a candidate for breast conservation and avoiding mastectomy if possible.
For patients with evidence of cancer spread to the regional lymph nodes under the arm, neoadjuvant chemotherapy is a common starting point with the assumption that adjuvant radiation will occur after surgery to remove the original cancer in the breast either by lumpectomy or mastectomy and lymph node removal.
Patients often are confused as to the use of total breast irradiation in the setting of breast conservation (after lumpectomy) versus that of adjuvant radiation to treat a large or locally advanced breast cancer (after mastectomy) as both forms of irradiation occur after surgery whether that be lumpectomy or mastectomy. Each form of radiation is distinct in dose and delivery and have been associated with post-treatment complications to include soft tissue fibrosis, progressive breast and chest wall deformity and lymphedema.
It may seem strange or uncomfortable to discuss the aesthetic outcomes of cancer treatment choices when you and the team are focused on your survival. But, the final aesthetics are an important survival-ship issue as more than 90% of all patients diagnosed with breast cancer today will be living with the long-term consequences of surgery and radiation at 5 years.
A key component to the best aesthetic outcome from breast cancer surgical treatment and radiation is the involvement of a board-certified Plastic Surgeon with additional training and focused clinical expertise in breast cancer care. Few ABPS Board-Certified Plastic Surgeons focus solely on breast cancer reconstruction as their practice most often includes cosmetic surgery of the face, botox/filler injections, laser treatments and liposuction. Plastic surgeons with specialized and focused training in oncologic breast reconstruction are better able to provide patients with an overview of the long-term consequences of radiation to the retained breast without an oncoplastic intervention at the time of lumpectomy. Further, early expert-directed education provides patients with information regarding ALL forms of breast reconstruction including simpler breast implants or more sophisticated natural breast reconstruction using microsurgical fat flaps in the setting of a total mastectomy.
Most patients have concern as to the long-term side effects of radiation to include soft tissue scarring and contracture, wound healing and arm, chest wall and breast lymphedema. Only a Board-Certified Plastic Surgeon with expertise in oncoplastic surgical procedures and lymphedema care may appropriately educate a patient as to their personal risk and benefit to an oncoplastic lumpectomy prior to the start of breast conserving radiation versus total mastectomy without a radiation requirement.
Some patients have aversion to the idea of using silicone breast implants for cancer reconstruction and prefer a more natural solution. Only a Board-Certified Plastic Surgeon with additional post graduate training and clinical expertise in microsurgery may appropriately educate a patient as to their personal risk and benefit of a natural fat flap breast reconstruction.
Some patients diagnosed with a new breast cancer have cosmetic breast implants already in place at the time of diagnosis. Best to be evaluated by a Board-Certified Plastic Surgeon with expertise not only in breast implants but microsurgical breast reconstruction fat flaps as most surgeons agree that using radiation atop cosmetic breast implants is associated with higher rates of capsular contracture, asymmetry, pain and infection requiring permanent removal of the implant.
All patients with advanced disease where radiation to the chest wall and axilla is required due to cancer spread outside of the breast are best served by a consultation with a Board-Certified Plastic Surgeon with additional training and expertise in microsurgical breast reconstruction. It is well accepted that breast implant reconstruction in an irradiated field suffers many long-term complications to include higher rates of infection, breast implant extrusion, capsular contracture, asymmetry and pain. Should a patient elect to proceed with implant reconstruction in an irradiated field, they may suffer a complication whereby the implant must be removed. Most patients want to know that their treating Plastic Surgeon has the ability to correct this issue with a muscle and nerve sparing natural fat flap. They proactively would avoid the need to be referred to another surgeon to secure such care to address these well described complications.
Many patients lean towards keeping things simple – fewer incisions and fewer initial operations. It’s a challenge to focus on what may be in 10 years after diagnosis when focusing on cancer today… In that light, we focus on “Burning No Bridges” breast care at the Dr. Marga Practice Group.
All possible breast and lymphatic reconstructive options are introduced to all patients such that initial diagnostic and treatment decisions will not limit future reconstructive solutions:
- Diagnostic lumpectomy incisions are designed to be included in possible breast lifts, breast reductions or mastectomy incisions.
- Oncoplastic procedures are considered for all diagnostic and treatment lumpectomies.
- Bilateral breast lifts or reductions are considered prior to breast conservation to affect the best post-treatment symmetry and youthful appearance.
- Air-filled, pre-pectoral tissue expanders with and without the inclusion of an Acellular Dermal Matrix are offered as an initial Stage of reconstruction for many patients unsure of the use of final implants or natural fat flaps. Patients are allowed the opportunity to “test drive” the implant means of reconstruction before final reconstructive procedures are completed.
- The oncologic safety and aesthetic outcome of nipple sparing mastectomy is discussed with all patients. Intra-operative frozen section and staged nipple bud excision are addressed.
- Incision placement for mastectomy relative to breast size is discussed with each patient to include hidden infra-mammary fold incisions vs. radial incisions.
- Surgical correction of acquired natural fat flap donor site deformities are addressed to include personal aesthetic expectations and need for staged interventions.
- Lymphedema Pro-Active Care is provided cost-free for all breast cancer patients evaluated at our center. The staged nature of lymphatic reconstruction of the axilla using cervical Vascularized Lymph Node Transfers (VLNTx) and possible liposuction-assisted limb debulking are addressed on an as-needed basis for each patient.
- The historic use of muscle flaps as the LD (Latissiums Dorsi) or TRAM (Transverse Rectus Abdominus) are reviewed with all patients to include long-term consequences as irreversible muscle loss, functional weakness, pain syndromes, and possible hernia and abdominal wall disfunction. Patients receive education as to why these forms of reconstruction have been abandoned as more safe and sophisticated forms of breast reconstruction have been introduced and accepted as the standard of care for most breast cancer patients to date.
All forms of muscle and motor nerve sparing breast reconstructions are offered from the simplest of implant modalities to the most sophisticated microsurgical free fat transfers.