NEW YORK, SUNDAY, SEPTEMBER 9, 2001

Breast Reconstruction: Weighing the Options

In an era of medical breakthroughs, it is reassuring to learn that breast cancers are being diagnosed in there earliest stages so that, according to the American Cancer Society (ACS), 96 percent of women with such cancers are alive after five years. Another promising trend: advances in reconstructive techniques have made it possible for plastic surgeons to create a breast that more resembles a natural one.

"One of the most frequent questions among women facing breast surgery is 'how will I look afterwards'?" said Dr. Frank J. Ferraro Jr., an attending plastic surgeon at Pascack Valley Hospital in Westwood. "They worry about whether their clothes will fit and if they will still feel attractive. "In the past, the majority of women who had mastectomy surgery wore a prosthesis - a breast form made from materials that have the weight and feel of a natural breast - in their bras and bathing suits after surgery. Many women found such a prosthesis inconvenient or uncomfortable and wanted to feel "whole" again; plastic/reconstructive surgeons began to develop techniques to restore the shape and contour of the original breast. According to NIH, today about 75 percent of women who have mastectomies choose postsurgical reconstruction.

Choices in Breast Reconstruction

"Advances in breast reconstructive surgery mean that almost all women are candidates for the procedure," Dr. Ferraro observed. Cosmetic results also have improved. Although a reconstructed breast isn't a perfect copy of the original, many women - especially those with stage one tumors, the smallest - find that their breast may look almost unchanged.

If you are planning to have breast reconstruction surgery, you must find a plastic surgeon skilled in the procedure before the mastectomy surgery so that the plastic surgeon can work with the general surgeon to develop a plan that lends itself to reconstruction. Since this is a demanding technique, it is important to choose a plastic surgeon who is bored certified in this specialty and experienced in breast reconstruction. Women can choose to have the procedure at the same time as the mastectomy operation or return to the hospital for reconstruction several weeks or months later. The women and her surgeons will discuss what type of procedure is best for her: an artificial implant or a muscle-flap procedure in which the breast is reconstructed with skin, muscle and fat taken from another part of her body. Factors to be considered include the woman's medical history, height, weight and amount of body fat as well as other medical conditions.

Choosing a Muscle Flap

Although implants require less extensive surgery and shorter hospital stays, many women now choose muscle flap procedure. Dr. Ferraro, who learned the techniques at Duke University Medical Center in Durham, North Carolina, is a leader in the procedures. "Muscle-flap procedures use tissue from the back or abdomen to either form a breast or create a pocket for an implant. As a result, the breast looks more natural." The flap is made in several ways. In the latissimus dorsi technique, tissue is transferred from the area on the back below the shoulder blade by way of tunnel made under the skin in the underarm area. The blood supply to the muscle is left intact. The muscle and skin create a pocket that an implant fills out to provide a breast shape.

The TRAM flap is another variation. The flap comes from the transverse rectus abdominus just below the waistline. The reconstructive surgeon detaches a small piece of skin, muscle and fat and pulls it through a tunnel under the skin between the abdomen and chest. Some women have enough extra fat in the abdomen to create a breast shape without an implant.

One advantage of the TRAM techniques is that some women find that their abdomens look flatter - as though they have had a tummy tuck. Women who have chronic lower back problems often choose other techniques since they may develop weakened abdominal muscle after the procedure and can increase back strain.

A third technique, the free flap, eliminates the tunneling step. A portion of skin, fat and blood vessels is removed from the buttock, thigh or abdomen and move to the breast area. The blood vessels in the flap are sewed to the vessels under the arm at the mastectomy site. Because extensive microsurgery is required to reattach the blood vessels, the free flap is the most technically demanding of the muscle flap procedures. This technique, however, gives superb results.

"Women who smoke or have diabetes may be poor candidates for muscle flap procedures because their blood vessels may have narrowed enough to prevent healing of the flap," Dr. Ferraro noted. "That's why we advise patients to quit smoking and keep their blood sugar as close to normal as possible so that they can benefit from these procedures and have a natural looking breast."