Breast reconstruction is surgical intervention to restore the physical appearance of a breast resulting most often from acquired deformities. Acquired deformities are those where a breast has been completely lost or disfigured as the result of breast surgery to treat breast cancer, or trauma. The origins of breast reconstruction date back to the 1890s and documentation of attempts to use early surgical techniques to rebuild a breast from a flap (where skin, fat, and other tissue is transplanted from one part of the body to another). It was not until the later part of the 1900s, however, that breast reconstruction became a very specific focus of plastic surgical intervention. Advancements in surgery resulted in the advent of flaps to cover and support a breast implant in the 1970s. Then, in 1982, the first completely reconstructed breast using a woman’s own tissue taken from her abdomen, called a TRAM (transverse rectus abdominus musculocutaneous) flap, was performed.
Currently, through the use of microsurgery (the reattachment of nerves and vessels in surgery performed via microscope and microsurgical techniques), breast reconstruction can be accomplished with a woman’s own tissue while minimizing functional problems from the site of the donor tissue. The use of breast implants and microsurgery and flap techniques remain the basis for all breast reconstructions today. Refinements are continuously evolving and allow for reconstructed breasts that are remarkably natural looking and feel very natural to the touch as well. However, much like nature is not always perfect, surgery to mimic nature does not result in the perfect replacement of a woman’s natural breast. All cases of breast reconstruction will leave some visible scarring on or near the breast. Reconstruction of the nipple and areola can look highly natural; however, it will not have the same sensation of a natural nipple. No woman with a completely reconstructed breast can breast-feed naturally, as the mammary glands have been removed. And, a reconstructed breast may not match the shape and slope of the breast it replaces. Breast reconstruction allows a woman to have a positive self-image, feeling confident of her body and herself in her most public and intimate encounters in life. The National Institutes of Health reported that nearly 165,000 women were diagnosed with breast cancer in 2000.
That same year, over 80,000 breast reconstruction procedures were performed. The assumption is that somewhat less than half of all women who are diagnosed with breast cancer will undergo reconstruction. However, of those diagnosed, there are missing data, including the number of those with mastectomy versus lumpectomy (also called breast conserving surgery [BCR]). At present we do not have statistics that define how many women diagnosed with breast cancer received information about breast reconstruction. Some studies estimate that as many as one third to one half of women who undergo some form of surgical intervention to remove a portion of or a complete breast due to disease do not receive any information about reconstruction. Who is a good candidate for breast reconstruction? Good candidates for surgical breast reconstruction are determined by four factors:
• Individual desire: You want to look and feel whole with a breast that is part of your own body.
• Physician recommendations: Your doctor or plastic surgeon recommends or prescribes breast reconstruction to address your individual circumstances and your desire.
• Timing: When reconstruction is medically appropriate and when you feel ready to invest the time necessary for surgery and to heal.
• General health:When the state of your overall health does not put you at added risk for complications.
Nearly all women with acquired deformities of the breast are good candidates for breast reconstruction. The exception is any health condition that can greatly impair a woman’s ability to heal or increase her risk of very serious complications during or following surgery. In addition, timing can define good candidates for breast reconstruction. In some cases, a woman undergoing or who will undergo certain medical treatments in the future (such as chemotherapy or radiation therapy) may not be a good candidate to have breast reconstruction until those treatments are completed. Additionally, a woman who is uncertain of her personal goals, has unrealistic expectations for breast reconstruction, or who is unable to confidently make a decision about breast reconstruction, may be not be a good candidate.Women who are having emotional difficulty dealing with a diagnosis of breast cancer and ablative surgery may be advised to get emotional support before making a decision about breast reconstruction. According to the American Society of Cosmetic Surgeons, breast reconstruction procedures numbered nearly 62,930 in 2004, and show a slow and steady decline over recent years. The likely cause is an increase in the number of lumpectomies for small tumors and a decrease in the number of mastectomies.
Breast reconstruction is performed by board-certified cosmetic surgeons. Breast reconstruction is a plastic surgical intervention procedure, with plastic surgery being the defined specialty of medicine that includes training specific to the techniques and procedures that rebuild a woman’s breast. Breast reconstruction may also be defined as a reconstructive procedure among cosmetic surgery procedures. However, there is no defined specialty of reconstructive surgery, nor is there a defined subspecialty of reconstructive surgery. There is nothing that prevents other medical or surgical specialists from performing breast reconstruction; however, the only specialty with defined training in breast reconstruction is plastic surgery.
The process of breast reconstruction can sometimes begin at the time of mastectomy or lumpectomy. Reconstruction may be delayed depending on additional prescribed medical treatments (chemotherapy or radiation therapy) based on the recommendation of your oncologist. It may also be delayed if that is your preference. Dealing with breast cancer or tumor removal is a very difficult process. The ability to awaken from any ablative breast surgery (which is surgery that removes all or a portion of the breast) with the beginnings of a new breast mound already in place can be immensely important to a woman. But you cannot pursue immediate reconstruction if you don’t discuss your options for reconstruction with your doctor and with a plastic surgeon before ablative breast surgery. Immediate reconstruction offers a woman the advantage of sparing her from the experience of completely losing a breast or seeing herself severely disfigured. It also spares a woman subsequent major surgery. As well, the outcomes of breast reconstruction can be somewhat enhanced when the surgeon performing your ablative breast surgery and your cosmetic surgeon can work together through such things as skin-sparing techniques and optimal incision placement.
The greatest benefit of immediate reconstruction is that it may allow you to feel whole again and return to your normal life more quickly. As a result, your emotional and physical health will benefit greatly. But if you cannot undergo immediate reconstruction, knowing your options will give you some encouragement for your future ability to feel whole. Therefore, it is important to consider breast reconstruction and all of your options before undergoing ablative breast surgery. Discuss this with your doctor, and consult with a plastic surgeon as soon as possible.
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1. Appropriate surgical interventions for breast reconstruction
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