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Course: Decoding Breast Reconstruction Return to Course Outline

Decoding Breast Reconstruction

What you need to know in primary care

Learning Objectives:

1.      Understand the mechanisms of different reconstruction options available.
2.      Understand potential complications of different reconstruction methods.
3.      Understand and apply the role of primary care provider in post-reconstruction care.

Given the high incidence of breast cancer in the United States today, primary care providers are increasingly likely to encounter patients who have undergone breast reconstruction after cancer treatment. Breast reconstruction surgeries include implants, autologous tissue with implants, autologous tissue pedicle flaps, and autologous tissue free flaps. These reconstructive procedures are complicated and result in unique risks and complications, as well as alterations in the approach to clinical breast exams and guidelines for recurrence screenings and mammograms.

Women affected by breast cancer today are not limited to those who have been diagnosed with cancer; this population can include women with genetic predisposition to breast cancer as well as those with precancerous ductal carcinoma in situ.1 Surviving breast cancer-and thriving despite it-is a multifaceted and personal experience. Every woman facing breast cancer needs to feel secure in her healthcare environment. Breast reconstruction is a complicated, confusing area of post-breast cancer care. It is also one of the more common aspects of the breast cancer journey that will be assessed by primary care clinicians. Understanding the mechanism of reconstruction, complications that could be associated with the reconstructed breast, and the role of the primary care provider in continuing care are vital in order to provide appropriate management and support.

Background                                       

In 2014, the most recent year for which comprehensive data are available, more than 3 million women in the United States were living with breast cancer.2 The general population has a 12% chance of developing breast cancer at some point in their lifetime. From 1975 to 2007, the 5-year survival rate for breast cancer increased from 75% to 91%, with new cases steadily climbing over the same time period.3 This means that more women are being diagnosed with breast cancer, and that more are surviving and moving beyond breast cancer.

Since surgical removal of the tumor is the first-line treatment for breast cancer, more women are undergoing surgical procedures that create the possibility of reconstruction. Of the average 200,000 women diagnosed with breast cancer each year, 60,000 have surgical removal of the tumor by way of mastectomy.4 Reconstruction of the removed breast can be a key element in maximizing quality of life and restoration of body image, regardless of age.4-6

A multitude of options for breast reconstruction exist. These options can be offered and completed at many different stages of the breast cancer treatment continuum. Reconstruction can be immediate, at the time of mastectomy, or delayed, after treatment is complete.7-9 It can be following nipple-sparing or skin-sparing mastectomy, in which all or part of the nipple complex and breast skin are preserved.7-9 Reconstruction can also be a single-sided, bilateral with prophylactic reconstruction of the unaffected breast, or performed to correct asymmetry following lumpectomy.9,10

The majority of patients see a primary care provider concurrently with the rest of their cancer care team, ultimately transitioning completely into the primary care office with remission of disease. The role of the primary care clinician is to ascertain the type of reconstruction the patient has undergone and understand how best to assess and care for her. As an important member of the healthcare team, the primary care provider needs to be familiar with the mechanics and possible complications of breast reconstruction, as well as guidelines for follow-up surveillance, support needs, and changes in the physical examination of the reconstructed breast.

 Types of Reconstruction

Most women face three choices after mastectomy. They may choose not to undergo reconstruction of the breast, they may choose reconstruction with implants, or they may choose reconstruction with autologous tissue. Each course is outlined below.

No reconstruction. The choice to forego reconstruction is made by women for many reasons. These include a desire to minimize surgery, viewing reconstruction as unnecessary or impractical, and a fear of pain, cancer recurrence or complications.11 Women who elect not to have reconstruction do not report feeling that reconstruction was essential or even beneficial to their well-being or self-image, citing a desire to minimize surgery and focus on being rid of the disease.11,12

Some women choose not to reconstruct due to the perception that advanced disease precludes reconstructive surgery.12 Despite 3-year life expectancies around 40% among patients with metastatic disease, many do not want to spend the additional time recovering from surgery.13

Breast Implants. Implants are by far the most popular form of reconstruction.14 A two-stage approach is generally used. In the first stage, a pocket is created using the pectoralis muscle or a combination of muscle and acellular dermal matrix or other synthetic mesh. This pocket is filled with a tissue expander.9,10 After the surgical site heals, the expander is gradually filled to create a pocket of appropriate size for the intended implant.9,14

After the pocket is stable, a second procedure exchanges the expander for a silicone or saline implant. Silicone implants are generally preferred because they are available in shaped forms, allowing for more natural height, width and projection.14 Silicone also provides a softer, more natural feeling.14

Implant reconstruction is frequently selected because the breast is the only surgical site and thus has diminished risks for surgical complications compared to other reconstruction methods.9,15 This single surgical site also affords much less time in surgery and quicker recovery.10 The implant-based reconstruction is, however, the most revised of all reconstructive surgeries. On average, half of implant reconstructions require revisionary surgery within the first 6 years.9,10

Capsular contraction, a complication unique to implant reconstruction, occurs when the scar tissue around the implant shrinks and distorts the shape of the breast.14 This contracture may be asymptomatic, but if it causes severe distortion or is painful, surgical revision of the implant may be necessary. Continuing surveillance is recommended to evaluate for implant rupture.

The rupture of a saline implant would be noticed by the woman due to loss of volume, however, silicone implant rupture may go unnoticed.14 Even in the absence of complications, the general life expectancy of any implant is 10 years, meaning that women who surpass the 10-year mark would require additional surgery to replace the implants.10

Autologous Tissue

In autologous tissue reconstruction, the woman's own fat and skin are used to recreate the breast. This allows for the creation of soft, ptotic, natural feeling breasts.10 Since they are made from the patient's own tissue, these reconstructed breasts will age with her, increasing or decreasing as body weight fluctuates and falling subject to time and gravity as a natural breast would.9 For these reasons, autologous tissue reconstruction is becoming the preferred option for the most natural outcome.16

Two broad categories of autologous tissue reconstruction are common. Pedicle flaps derive their blood supply from donor site muscle, which is interrupted and transferred with the new breast mound. These include the transverse rectus abdomini myocutaneous (TRAM) and the latissimus dorsi (LD).17,18 Free flaps are created by microvascular dissection and anastomosis of key blood vessels without muscle involvement.10,19-21 Since the free flap is not limited by musculature, a number of donor sites can be utilized. The abdomen is the most common donor site, using the deep inferior epigastric perforator (DIEP) as the dissected blood supply or the superficial inferior epigastric artery (SIEA) based upon the patient's anatomy.22 Donor sites can also be found on the buttocks in either the superior gluteal artery perforator (SGAP), which is taken from the superior area of the buttocks, or the inferior gluteal artery perforator (IGAP), taken from under the gluteal fold.23 Another free flap donor location is the transverse upper gracilis (TUG), using donor tissue from the upper inner thigh.10,20,24 Illustrations representing all of these reconstruction methods can be found at the associated links in the reference list.17,18,21-24

This type of reconstruction is by far the most durable and does not carry the risks of capsular contraction or displacement associated with implant reconstruction.17 A minimum of two surgical sites are used, which increases the risk for surgical complications, delayed wound healing and infections.21 All flap reconstructions carry a small risk for flap failure and tissue necrosis, in which all or a portion of the reconstruction dies from lack of blood supply, necessitating emergent revision.20 Unique to pedicle flaps, the relocation and subsequent loss of use of abdominal or back muscles places the patient at risk for weakness and herniation.21

Implications for Primary Care       

Current national guidelines for follow-up care recommend mammography every 6 months after breast conserving surgery (i.e., lumpectomy or nipple-sparing mastectomy).25 Women with one remaining natural breast should receive a mammogram every 6 months following primary treatment.25 A complete history and physical, including clinical breast examination, should be conducted every 3 to 6 months for the first 3 years, then every 6 to 12 months for 2 years. After 2 years of normal results, annual examination is appropriate.25 Mammography is not indicated in bilateral mastectomy with reconstruction. Routine lab work and radiologic tests are not recommended for any patients based on breast cancer history alone. 

Support         

While support needs are as unique as the women themselves, several areas are top priorities in primary care. Breast reconstruction creates a long-term replacement of the missing breast, which can improve quality of life.25,26 Reconstruction does not, however, eradicate the possibility of depression, body image issues, fear of recurrence, or anxiety about intimate partner acceptance and intimacy.1,26 Patients need to be screened for depression regularly and counseled about support resources to aid in psychological healing from the disease.

Clinical Breast Exams          

The breast exam, which can be completed by any trained member of the care team, is moderately different when examining the reconstructed breast. Clinical breast exams should follow normal patterns, with particular attention paid to the axilla and the site of the original tumor. Lack of breast reconstruction alters the clinical breast exam only in that there may be excess skin and prominent scar tissue to examine around.

In implant reconstruction, the patient needs to be screened regularly for implant rupture as well as local recurrence around the edges of the implant.14 Autologous tissue reconstruction carries the possibility of increased scar tissue and fat necrosis formation, which can cause the breast to feel lumpy and irregular upon exam. Care should be taken to know the patients' normal reconstruction contours and irregularities and any areas of concern should be screened using ultrasound.25

It is worth noting that the reconstructed breast is generally numb to the patient. In flap reconstructions, it is common to see variations in skin tone, hair distribution and temperature between native skin and the transplanted flap.

Integral Care

Nurses and other clinicians in the primary care setting are an integral part of a breast cancer care team. Competent understanding of the various reconstruction modalities allows clinicians to appropriately care for patients throughout the cancer journey. Knowledge of guidelines, support needs and exam considerations that are unique to the reconstructed breast enables nurses to effectively care for and support women through breast cancer.

References

1. Salani R, Andersen BL. Gynecologic care for breast cancer survivors: Assisting in the transition to wellness. Am J Obstet Gynecol. 2012;206(5):390-397.

2. American Cancer Society. Breast cancer facts and figures 2015-2016. http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-046381.pdf

3. Cancer of the breast (female) - SEER stat fact sheets. http://seer.cancer.gov/statfacts/html/breast.html

4. Hernandez-Boussard T, et al. Breast reconstruction national trends and healthcare implications. Breast J. 2013;19(5):463-469.

5. Pusic AL, et al. Measuring and managing patient expectations for breast reconstruction: Impact on quality of life and patient satisfaction. Expert Rev Pharmacoecon Outcomes Res. 2012;12(2):149-158.

6. Sisco M, et al. The quality-of-life benefits of breast reconstruction do not diminish with age. J Surg Oncol. 2015;111(6):663-668.

7. Dobke MK, et al. Issues related to advances and controversies in breast cancer management: A multicultural experience. Int J Surg. 2012;10(9):429-435.

8. Atiyeh B, et al. Original research: Skin sparing/skin reducing mastectomy (SSM/SRM) and the concept of oncoplastic breast surgery. Int J Surg. 2014;12(10):1115-1122.

9. Critchley AC, et al. Overview: Current controversies in breast cancer surgery. Clin Oncol. 2013;25(2):101-108.

10. Caterson SA, et al. Evolving options for breast reconstruction. Curr Probl Surg. 2015;52(5):192-224.

11. Flitcroft K, et al. An evaluation of factors affecting preference for immediate, delayed or no breast reconstruction in women with high-risk breast cancer. Psychooncology. 2016. Doi 10.1002/pon.4087

12. Somogyi RB, et al. Understanding the factors that influence breast reconstruction decision making in Australian women. Breast. 2015;24(2):124-130.

13. Durrant CAT, et al. Original article: Mastectomy and reconstruction in stage IV breast cancer: a survey of UK breast and plastic surgeons. Breast. 2011;20(4):373-379.

14. Lamp S, Lester JL. Reconstruction of the breast following mastectomy. Semin Oncol Nurs. 2015;31(2):134-145.

15. Hanwright PJ, et al. The differential effect of BMI on prosthetic versus autogenous breast reconstruction: a multivariate analysis of 12,986 patients. Breast. 2013;22(5):938-945.

16. Harmer V. Reconstruction for breast cancer in a nutshell. Br J Nurs. 2012;21(15):904-909.

17. University of Wisconsin. Transverse rectus abdominus myocutaneous (TRAM) flap reconstruction. http://www.uwhealth.org/uw-carbone-cancer-center/breast-cancer/transverse-rectus-abdominus-myocutaneous-tram-flap-reconstruction/46816

18. University of Wisconsin. Latissimus dorsi flap reconstruction. http://www.uwhealth.org/uw-carbone-cancer-center/breast-cancer/latissimus-dorsi-flap-reconstruction/46812

19. Critchley AC, Cain HJ. Breast: Surgical techniques in breast cancer: An overview. Surgery. 2016;34(1):32-42.

20. Adamthwaite J, et al. A safe approach to sparing the rectus muscle in abdominal-based microvascular breast reconstruction-TRAM, MS-TRAM, DIEP or SIEA? Eur J Plastic Surg. 2012;35(9):653-661.

21. University of Wisconsin. Deep inferior epigastric perforator (DIEP) flap reconstruction. http://www.uwhealth.org/uw-carbone-cancer-center/breast-cancer/deep-inferior-epigastric-perforator-diep-flap-reconstruction/46807

22. University of Wisconsin. Superior gluteal artery perforator (SGAP) flap reconstruction. http://www.uwhealth.org/uw-carbone-cancer-center/breast-cancer/superior-gluteal-artery-perforator-sgap-flap-reconstruction/46815

23. University of Wisconsin. Transverse upper gracilis (TUG) flap reconstruction. http://www.uwhealth.org/uw-carbone-cancer-center/breast-cancer/transverse-upper-gracilis-tug-flap-reconstruction/46817

24. National Guideline Clearinghouse. Breast cancer follow-up and management after primary treatment: American Society of Clinical Oncology clinical practice guideline update. http://www.guideline.gov/content.aspx?id=38701

25. Pauwels EE, et al. Care needs after primary breast cancer treatment. survivors' associated sociodemographic and medical characteristics. Psychooncology. 2013;22(1):125-132.

26. Kenyon M, et al. Late and long-term effects of breast cancer treatment and surveillance management for the general practitioner. J Obstet Gyncol Neonat Nurs. 2014;43(3):382-398.


Ashley Harris is doctor of nursing practice family nurse practitioner student at the University of North Florida in Jacksonville. She has completed a disclosure statement and reports no relationships related to this article.




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