Healing Hands

Created on 15th May 2009

Reconstructive surgery following breast cancer can be a devastating experience and often the results are not satisfactory. Oncoplastic surgery has changed the face of this delicate procedure and given hope of better cosmetic outcomes

Oncoplastic surgery for the breast is a welcome concept. It is the combination of the best and latest techniques in plastic surgery with surgery for breast cancer. Plastic surgical techniques that were originally used for cosmetic surgery of the breast are combined to enable women with breast cancer to have better cosmetic outcomes.

As many as 1 in 9 women in the UK will be diagnosed with breast cancer by the age of 85 years. Most will need surgery as part of their treatment and about 40 per cent will need to have a mastectomy. While the remaining women will be offered breast conservation surgery in the form of a wide local excision of the tumour (lumpectomy), as many as 4 in 10 of these women will have an unsatisfactory cosmetic result despite saving their breast.

This may be because the nipple ends up pointing in a different direction, the breast becomes misshapen or there is a contour defect (dent) in the breast where the tissue is removed. These deformities are best corrected using oncoplastic surgical techniques at the same operation as when the cancer is removed.

This is because it is more difficult to correct a deformity after the scar has formed following radiotherapy to the breast, and because the results of secondary corrective surgery are often not as good.

The aims of oncoplastic surgery are to minimize scars and to obtain the best breast shape and the most favourable cosmetic outcome with optimal control in the treatment of breast cancer. It involves careful preoperative planning by a surgeon who is experienced both in breast cancer surgery and cosmetic surgery of the breast.

Oncoplastic techniques are used to reshape the remaining breast tissue or reconstruct the breast after removal of the breast cancer. Plastic surgical techniques can also be used to adjust the opposite breast to obtain the best cosmetic result.

Case Study
Angela, a nurse had just celebrated her fiftieth birthday when she attended her first screening mammogram on the NHS breast screening programme. This is her story.

"I knew that breast cancer was more common in older women but never for the life of me imagined that I would be one of the ‘ones' to get it."

She was diagnosed with an invasive ductal cancer in her right breast and surgery was planned in the first instance. It would be necessary to remove the cancer in her right breast and to remove some of the lymph glands from her right armpit.

"I mentioned to my surgeon that I had been thinking of having a breast uplift operation as my breasts had become droopy after breastfeeding both my children. I never imagined that anything could be done now that I had breast cancer. However, to my surprise, she said that it would be possible to remove the cancer and move my nipple upwards to give my breast an uplifted appearance. She did warn me that a further operation might be necessary if the cancer was not completely removed."

A right breast wide local excision and mammoplasty (also called ‘therapeutic' breast reduction) operation was carried out.

"Unfortunately, two cancers were found in the breast tissue that was removed (only one cancer was visible on the original mammogram) and that the cancer had not been completely removed.

I felt devastated all over again. After the first operation, I was really pleased with the uplifted appearance of my right breast and now my surgeon told me that I needed to have the dreaded mastectomy. She did however ask me if I wanted a breast reconstruction.

"I thought about it and all the options for breast reconstruction she said were possible in my case. She talked about using implants or the LD (latissimus dorsi) muscle flap from my back or the fatty tissue from my ‘tummy'. Again, the stretched skin on my ‘tummy' was something that I hadn't been so happy with after having had two babies. I liked the idea of using my own tissue. I decided to go for the ‘tummy' flap."

A right mastectomy and immediate breast reconstruction with a free DIEP (Deep inferior Epigastric artery Perforator) flap was performed. Once Angela had recovered from her right mastectomy and immediate reconstruction, she had a left mastopexy (breast uplift) procedure in order to match her breasts.

"The final stage was to have my right nipple reconstructed. My surgeon made the nipple out of the ‘tummy' skin that had been transferred to my new right breast and used tattoo pigment for the surrounding dark skin of my areola.

"I feel like a new person and am delighted with my uplifted breasts. I am glad that I decided to have the reconstruction at the same time as my mastectomy. It has really helped me move on from my breast cancer diagnosis."

Summary
With breast conservation surgery for breast cancer, there is always a conflict between removing a wide enough margin of tissue around the cancer in order to remove it completely and leaving behind sufficient normal tissue that can be reshaped into a cosmetically acceptable breast.

When planning surgery for breast cancer, the surgeon will decide on whether or not it will be possible to offer breast conservation surgery. He or she will take into consideration whether it is possible to use the remaining breast tissue to move into the defect, whether it will be necessary to import nearby tissue into the breast, whether the nipple will need to be moved or whether it would be better to do a mastectomy.

An oncoplastic breast surgeon can perform both the cancer excision surgery and breast reconstruction and can discuss any necessary procedures to the opposite breast in order to give the best overall cosmetic result. These may include breast reduction, augmentation (enlargement), mastopexy (breast uplift) or a combination of these.

Conclusion
Oncoplastic surgical techniques for breast cancer are a welcome innovation and provide a breakthrough for women who not only have to deal with the diagnosis and life changing implications of breast cancer, but also the effect of possible disfiguring surgery to their breast.
CS&AM