By: Tal Barak and Dr. Ronnie Moscona, Rambam Health Care Center
If there is one thing that bothers Dr. Ronnie Moscona, it's the voices calling for the women to refrain from immediate breast reconstruction following mastectomy. "What's the alternative?" he asks angrily. "Walking around without a breast and with a terrible ugly scar? Ask the women what they prefer – I have no doubt that the majority would prefer to wake up with a reconstructed breast that looks exactly like a natural breast, even taking into account the low risk of infection and complications." Even the statements in favor of delayed surgery of breast reconstruction, to be performed several months or years following the mastectomy, succeed in enraging Dr. Moscona. "This is a statement that I would politely describe as 'Not very smart.' There are absolutely no advantages in delayed reconstruction, only disadvantages," he says.
It wouldn't be a mistake to describe Dr. Moscona as a warm, open and ever smiling person. The fact that his CV includes a period of working as a general surgeon gives him quite a rare advantage, enabling him to examine the treatment of breast cancer through two sets of spectacles: those of a surgeon who performs mastectomy surgeries and those of a plastic surgeon, who performs breast reconstruct.
Breast reconstruction was introduced in the early 1980's. Until then, the common practice was radical mastectomy, where the oncologists and the surgeons concentrated on saving the woman's life, without giving much consideration to her quality of life following mastectomy. The involvement of plastic surgeons was negligible.
"The change in attitude was caused by the patients' demand for quality of life, as well as by the fact that the average age of breast cancer patients has dramatically decreased in recent years," says Dr. Moscona. "I remember that, at the beginning of my career, most of the patients were around the age of 60-65. Unfortunately, today most of them are in the age range of 30-50. They are young women not willing to walk around without a breast or with an external prosthesis instead of a breast.
In addition, two major studies published in the early 1980's also contributed to the change in attitude. The first study demonstrated that the average time to the appearance of a first metastasis in women with stage 1 breast cancer is about 6.5 years. This finding contradicted the approach of the oncologists, who claimed that it is necessary to delay breast reconstruction for at least two years, in order to ensure that there is no recurrent disease. The second study examined whether patients who don't undergo reconstruction live longer than those who do undergo reconstruction; no difference was revealed. Thus, reconstruction is not a factor determining life expectancy. "From this point on, the path to the era of immediate reconstruction was short, since it was clear that the woman's quality of life does not interfere with her health and her chances of a cure."
In terms of timing, there are two options for breast reconstruction:
a. Immediate reconstruction
This surgery is performed as a single procedure together with the mastectomy. The surgeon and the plastic surgeon work in parallel, in the same operating room. First, the surgeon resects the affected breast. At the same time, the plastic surgeon begins his part of the task and performs the reconstruction surgery. At the end of the procedure, the woman wakes up with a reconstructed breast, which is as similar as possible to the healthy breast.
b. Delayed reconstruction
In this method, there is a complete separation between the mastectomy and the reconstruction surgery, of a period of at least six months, with all the consequences: a double recovery period – recovery from two surgeries, additional possible complications, etc. In addition, the esthetic results are not as good as those achieved by immediate reconstruction.
The essential difference between the methods of immediate and delayed breast reconstruction is that, in the immediate reconstruction process, the surgeon does not remove the skin of the breast, but only the internal breast tissues. (There is no disease in the skin.) Thus, it is possible to use the original skin from the breast for reconstruction. The surgeon only has to fill in the internal part by placing an implant under the preserved skin, leading to much more beautiful results.
Three major methods commonly practiced today are:
1. Tissue expander – Using this method, a "balloon- like" device is implanted beneath the skin in the resected breast area, and is gradually inflated until sufficient skin area is obtained. The inflation is performed at the hospital, approximately every three weeks. The process lasts for about six months, and upon its completion, further surgery is required to replace the balloon with a permanent silicon implant.
2. Back flap - In reconstruction using the back flap method, skin and muscles are transferred from the back to the resected breast area. This flap is used as a cover for a silicon implant of a size similar to that of the other breast, giving the appearance of a natural breast. The hospitalization period is about two-three days, and does not exceed the hospitalization period required for mastectomy only.
3. Abdominal flap – Reconstruction surgery by this method is more complicated than back flap surgery. Therefore, it is performed mainly if there is a certain problem precluding back flap reconstruction, such as damage to the artery and nerve of the back muscle, or cuts and scars on the back. This surgery is suitable mainly for women with a sufficient amount of skin and fat tissue in the lower abdomen.
Instead of the silicon used in other surgeries for filling the volume of the reconstructed breast, fat tissue taken from the lower abdomen is used in this surgery. This tissue is transferred by the abdominal wall muscle carrying the blood vessels, and at this stage the tissue is shaped into the form of a breast. Since fat is used instead of silicon, the resulting sensation is very close to that of a natural breast. The required hospitalization period is about four days.
Another application of this method has been recently introduced in the Department of Plastic Surgery of Rambam, whereby transfer of the skin and fat tissue from the lower abdomen is combined with connection of the blood vessels by microsurgery. Using this reconstruction method, there is minimal damage to the abdominal wall, without impairment of the muscle functioning.
Which method is preferable, according to your opinion?
Dr. Moscona: "First of all, my preference is immediate reconstruction, because in delayed reconstruction or reconstruction by the inflation method (tissue expander), the woman comes out of mastectomy without a breast, and has to cope with probably the hardest period of the illness without a breast. This fact has significant impact on the mental strength that she must recruit in any case for her recovery process.
In contrast, after immediate reconstruction, she will appear to be similar, at least in terms of physical appearance, to what she was before, when she wakes up from the surgery.
"It is impossible to compare the cosmetic results of delayed reconstruction to those of immediate reconstruction. The skin is not preserved during mastectomy, if no immediate reconstruction is performed; the entire skin of the breast is removed. Thus, it is impossible to achieve good results, due to the long diagonal scar remaining after the surgery.
Which of the immediate reconstruction methods do you prefer?
Dr. Moscona: "My current preference is back flap reconstruction (although I have previously performed a large number of abdominal flap reconstructions with very good results). Regarding the external result, the abdominal and back flap reconstructions look identical. However, abdominal flap reconstruction requires more major surgery, with all its implications, and the hospitalization period is longer. In addition, there is some damage to the abdominal wall, manifested as a temporary function defect (which does not occur in back flap surgery). The biggest advantage of the abdominal reconstruction is the more natural appearance and feeling of the fat tissue."
"In comparison, there are almost no limitations associated with back flap surgery. The rate of complications is much lower, with earlier return to daily routine ─ within two three weeks."
Many women, including women from the "One out of nine" organization, are not enthusiastic, to say the least, about immediate reconstruction. One of the claims is that the reconstruction may interfere with early detection in case of recurrence of the disease, and may also interfere with chemotherapy.
Dr. Moscona: "Reconstruction does not interfere with chemotherapy; the opposite is true! The issue of early detection was also examined, and none of the studies revealed that reconstruction interferes with it. The chance that a recurrent tumor will appear beneath the reconstructed breast is very low. Most recurrent tumors appear on the external skin. However, using imaging techniques, it is very easy to diagnose a recurrent tumor within the muscle or fat tissue used for the reconstruction, especially with one of the many new imaging techniques currently practiced.
One of the claims appearing on the website of the "One out of nine" organization indicates that the immediate reconstruction is a prolonged, complicated and very painful multi-stage process composed of several surgeries, usually associated with a difficult recovery period, and that surgeons and plastic surgeons tend to present it as a procedure that is simpler than it really is…
Dr. Moscona: "First, how can you know what hurts after immediate reconstruction - the mastectomy or the reconstruction? It is impossible to distinguish between the effects of the various actions. Of course, there is pain, but it is not terrible. Recovery from the combined surgery is relatively easy, and is certainly worthwhile in view of keeping the body intact and the excellent results."
"Second, where did the story about the multi-stage process come from? For most women, reconstruction is completed in one operation. At present, many of the patients coping with breast cancer are young women and mothers, and keeping their body whole enables them to return to a healthy routine, both mentally and physically. Just imagine a family holiday at a swimming pool, for example… Of course, this is true for any woman at any age."
What about the claim that the rate of infection associated with all the reconstruction methods is higher than that associated with mastectomy only?
Dr. Moscona: "No way! Infection doesn't develop because of the reconstruction. On the contrary ─ transfer of healthy tissue (back or abdominal tissue) aids in preventing infection in cases of previous radiotherapy to the operated breast."
"There is no surgical procedure without complications; however, it is certain that the reconstruction procedure does not increase the risk of infection beyond that associated with mastectomy alone."