Breast cancer is the most common type of cancer and it is the third leading cause of death from cancer. Most women diagnosed with breast cancer are likely to have surgery as a mode of treatment. A patient may have one, or both breasts removed (mastectomy) if there is a very high risk of cancer in the other breast due to genetics, or family history. After undergoing surgery, a patient might opt for breast reconstruction either immediately after the breast cancer surgery, or later.
Breast reconstruction surgery involves restoring the shape of a patient’s breast which was removed enabling women to feel “whole” again. Many women tend to suffer from low self-esteem, depression, or face stigmatization in the community, as a result of having a mastectomy, which is a surgery that involves removing the entire breast.
There are two broad types of breast reconstruction procedures for women who have undergone mastectomy. There is autologous reconstruction, which involves using one’s own body tissues or an implant based reconstruction, which involves using either silicon or saline based material for the reconstruction. Autologous reconstruction may involve using tissue from the back or from the abdomen.
The current standard of care for autologous reconstruction in many centers worldwide is the ‘Deep Inferior Epigastric Perforator’ (DIEP) flap. A DIEP involves taking tissue from the patient’s abdomen and relocating it to create a new breast mound. Aga Khan University Hospital was the first Hospital in East and Central Africa to successfully do DIEP procedure recently which has now benefitted a number of patients.
The DIEP flap procedure is safe and recommended as an option for women seeking breast reconstruction after losing one breast, or both breasts, and in those who cannot have breast implants because they have previously been treated with radiation. A patient only requires one surgery and not more than a week in hospital, followed by a fairly short recovery period. As patient selection is key, a multi-disciplinary team with members from oncology, surgery, radiology and pathology will have met beforehand to discuss both the patient’s oncological care and surgical management options.
Before surgery, a team of health care specialists including a breast surgeon, plastic surgeon, anesthesiologist and nurse, review the patient’s medical history, and are present during the surgery
This technique involves a breast surgeon performing a specialized skin-sparing mastectomy that preserves a large skin envelope or a nipple-sparing mastectomy where appropriate, to preserve the nipple-areolar area, while removing the cancerous tissue. This is akin to coring out an apple, but preserving the peel. The plastic surgeon then takes a section of tissue from the patient’s abdomen and relocates it to create a new breast mound. The skin and fat below the belly button feels very similar to breast tissue, therefore, being the perfect choice to replace the breast tissue removed during surgery. A small incision is made in the abdominal muscle sheath to access the blood vessels. The prepared tissue is then disconnected from the body and transplanted to the chest using microsurgery to provide blood flow to the tissue.
The advantage of DIEP and other autologous reconstruction over implant-based reconstruction is:
- It has a more natural feel since it uses own body tissue
- Since it is your own body tissue, it ages with you and therefore gives one a natural symmetry with time and aging, unlike the implant-based reconstruction
- As the procedure involves getting some tissue from the tummy, women get a concurrent tummy tuck as well in the process.
Patient selection however remains key for any reconstruction procedures offered to cancer patients and different methods may work better in certain situations. It is always important to have a multidisciplinary team to discuss and bring their collective expertise together to decide on the best option for an individual patient.
Due to increased community awareness, early diagnosis and appropriate treatment, more patients are getting cures and living longer. A key concern for patients who complete their treatment is their quality of life after therapy. Whereas internationally, reconstruction is a critical part of the management of all cancers and essential to helping to re-integrate patients to full function, there has been a slower uptake of these services locally. One of the limitations to the growth of these services has been the previously held perception from care providers and insurances, that these procedures are merely cosmetic. As a result, many patients would have to pay out of pocket for their reconstruction. Luckily, this is slowly starting to change.
As we move towards more holistic approaches to the management of breast and all cancers, it is hoped that with continued advocacy from both health workers and from the community to policymakers, that we will able to make these skills and services more accessible to our populations. Cancer treatment can be a long, frequently harrowing and emotional journey. Let’s collectively do our best to help support all the components of care, including reconstruction services, that would greatly help how our sisters and brothers go through this experience!
By Dr Miriam Mutebi, Breast Surgical Oncologist and Dr Radovan Boca, Plastic, Hand and Reconstructive Surgeon at Aga Khan University Hospital, Nairobi.