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Decisions in Breast Reconstruction

Autologous tissue reconstruction (left) and breast reconstruction using a tissue expander (right) are two of the most common reconstruction procedures following breast cancer treatment.

Like many cancer patients, those facing a breast cancer diagnosis have a lot of decisions to make, and recovery is a long process. But unlike some diseases, the road to recovery for breast cancer patients doesn’t end with treatment. For many patients who undergo mastectomy, breast reconstruction can be a step just as important as the treatment itself. Studies have shown that breast reconstruction helps enormously with a woman’s self-esteem and ability to put her cancer diagnosis behind her, and move forward with more confidence and comfort in her own body. But, breast reconstruction isn’t one size – or method – fits all, and recent research suggests the decisions patients make may have longer-term health effects.

Comparing complication rates, a recent study conducted by a team from Penn Plastic Surgery showed that patients who had reconstruction using their own tissue – known as autologous tissue reconstruction, or tissue flap surgery – were two times more likely to experience a complication in the first 90 days after surgery than patients whose reconstruction was done using implants. However, in the long term, patients who chose autologous reconstruction required fewer revisions surgeries than those with implants.

In autologous tissue reconstruction, a tissueflap of the patient’s own skin, fat, and in some cases muscle is moved from another area of the body (most commonly the abdomen, back, or thigh) to the chest.

“Breast reconstruction is enormously important following mastectomy,” said Joseph M. Serletti, MD, chief of the division of the Plastic Surgery. “There is substantial evidence that beyond physical appearance, reconstruction helps restore sense of self, thereby improving a patient’s psychosocial well-being. But it can be an overwhelming process for patients. Our hope is that our research helps to bring clarity to this important decision many women face.”

For Penn Plastic Surgery patient Eileen Edmunds, who underwent mastectomy more than six years ago and had her first reconstruction procedure earlier this year, the process represents a significant milestone in her fight against breast cancer.  

“For me, it was enormously important to undergo reconstruction after mastectomy, just so I could really put this chapter of my life behind me and move forward,” said Edmunds. “It was surprising to me how overwhelming even the smallest things were, like the first time I saw the bathing suit section in the store and realized I could get any one I wanted. As great as post-mastectomy bras and bathing suits are, and as grateful as I am to have had those options available, nothing feels as good as sitting by the pool and knowing it’s just my own healthy body again.”

In general, most clinicians will agree there’s no “best” reconstruction method, as each procedure comes with its own set of pros and cons. For example, while tissue flaps are better able to mimic a natural breast, the procedure is also more invasive and extensive, which Serletti suggests is likely the cause for the increased risk of complication.

Many factors may influence the type of reconstruction surgery a woman will have – including the type of breast cancer, her body type, and general health status and lifestyle – but studies show that the three most common methods (autologous, implant and tissue-expander, in which a balloon-like device is inserted into the breast to stretch the patient’s own tissue and prepare it for implant at a later date) are all generally safe.

Importantly, another recent study from Penn Plastic Surgery showed that despite disparities along racial and ethnic lines that exist in some areas of breast cancer treatment and reconstruction, African-American women do not have an increased risk of complications following tissue flap surgery compared to Caucasian women, meaning race should not be a factor for women choosing this method.

Overall, Serletti says revisions are a normal part of the process and most patients should anticipate at least one revision surgery in the first three years. Reasons for revision include addressing complications (such as postoperative hemorrhage, or surgical site infection), further reconstructing and symmetrizing the breast(s), and treating and managing recurring or new disease.

“Providing options to patients and setting expectations for the process, which can be lengthy, is an important part of this journey,” said Serletti. “Patients should be informed of the high likelihood of revisions no matter which approach they undergo. Using the information gleaned from research and working with their care teams, women can make informed, evidence-based decisions about the approach that is most consistent with their medical circumstances and aesthetic goals.”  

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