Breast reconstruction: An interview with Dr Lyronne Olivier

BAVINA SOOKDEO

“Breast reconstruction should be considered as part of the breast cancer management process. The definition of health not only covers medical issues but also the psychosocial impact of disease. Breast reconstruction specifically targets the tremendous impact of breast cancer management, leading to restoration of self image.”

This what Dr Lyronne Olivier, oncoplastic and reconstructive breast surgeon and breast surgical oncologist, said when asked for advice or recommendations for breast cancer survivors who are considering breast reconstruction, but are concerned about the associated expenses.

A doctor for 17 years, Olivier fills many roles, including consultant breast surgical oncologist at St James Medical Complex, fellow of the Caribbean College Of Surgeons and the American College of Surgeons, member of the American Society of Breast Surgeons and the Prakash Fellowship Alumni University of Toronto, Canada, executive member of Society of Surgeons and an associate lecturer at the Department of Surgical Sciences, UWI.

Can you provide an overview of the types of reconstructive surgery options available for breast cancer survivors, and what factors determine the suitability of each option?

The reconstructive surgery options are:

1. Partial reconstruction: This approach is utilised in breast conservation surgery that involves a wide local removal of the breast cancer with clear surgical margins. Oncoplastic techniques, Volume displacement and volume replacement are the options for reconstruction to achieve oncological and good cosmetic outcomes.

The former involves partial breast removal (mastectomy) and utilising the residual breast tissue to fill the defect, while the latter involves partial mastectomy and simultaneous reconstruction of the breast, with a rotation of tissue flaps from another site.

Most patients are candidates for breast preservation and oncoplastic techniques. However, patients must be able to undergo adjuvant radiation therapy. Contraindications for radiation are generally a previous exposure to radiation at the foreseen site, active autoimmune connective tissue disease, pregnancy or pulmonary fibrosis.

2. Complete (mastectomy) reconstruction: Nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) are the breast-cancer-removal procedures prior to breast reconstruction. Nipple-sparing involves the preservation of one's nipple and skin envelope following removal of all the underlying breast tissue and cancer.

Patients without skin and nipple involvement as well as the absence of significant nipple downward descent (ptosis) and extensive skin may be candidates for this approach.

However, patients with cancer adherent to the skin and nipple may be a candidate for skin-sparing mastectomy.

Both of these options are contraindicated in inflammatory breast cancer.

NSM and SSM facilitate the opportunity for breast reconstruction via alloplastic or autologous techniques.

a. Alloplastic breast reconstruction: This approach utilises breast prosthesis/breast implants. Implants may be classified into tissue expanders or permanent breast implants (silicone/saline).

Most patients are candidates for this approach of reconstruction. The procedure can be performed immediately with the initial cancer surgery and patient discharge within 24 hours.

However, patients who have inadequate skin and tissue coverage for the breast prosthesis are contraindicated for implant reconstruction.

This may be overcome by another surgical technique for implant coverage with a latissimus dorsi flap creation.

b. Autologous breast reconstruction: The utilisation of tissue flaps to create a breast mound with techniques such as deep inferior epigastric perforator (DIEP) flap, transverse rectus abdominis myocutaneous (TRAM) flap and latissimus dorsi flap.

DIEP flap is considered to be the gold standard for breast reconstruction in specialised centres because of its natural texture and appearance. It involves microvascular techniques that re-implants a free tissue flap from the tummy to reconstruct a breast mound. This procedure takes approximately seven-nine hours and may have significant flap failure and reoperative rates.

History of previous abdominal surgical procedures may make candidates ineligible for DIEP. Tummy-tuck surgeries, TRAM flaps and abdominal wall procedures are examples of surgeries that may influence the availability of this surgical reconstructive option.

What is the typical timeline for breast reconstruction surgery after a mastectomy or lumpectomy? Are there any considerations for the timing of reconstruction?

The timeline for breast reconstruction following mastectomy can be classified into: immediate one-staged or two-staged breast reconstruction; and delayed one-staged or two-staged breast reconstruction.

Immediate breast reconstruction: This approach involves the application of breast reconstructive techniques at the time of the breast cancer surgery.

Implementation of autologous or implant-based reconstruction: One stage involves completion of this reconstructive process simultaneously with this surgical intervention.

Two stages generally involve the utilisation of a tissue-expander implant followed by completion of the reconstruction at a later surgical intervention.

Delayed breast reconstruction: The breast reconstruction is performed after the completion of the mastectomy and the adjuvant (post-surgery) treatments such as chemotherapy and radiation therapy.

Generally, this reconstructive process occurs (more) than six months after the last radiation therapy exposure, or two-three months after completion of chemotherapy.

How does breast reconstruction affect a patient's physical and emotional recovery after breast cancer treatment?

Breast reconstruction should be offered to all patients undergoing breast cancer treatment because of the psychological impact of the surgical interventions and its cosmetic outcomes.

Physically, breast reconstruction offers the semblance of one's breast in mastectomy patients. This will facilitate the positive outward appearance in clothing, both professionally and socially.

Emotionally, the absence of the breast affects women's femininity, motherhood, sexuality and body image.

Breast reconstruction may offer the potential to restore a satisfactory self-image leading better psychosocial sequelae post-breast cancer surgery.

Can you (briefly) explain the different techniques used in breast reconstruction, such as implant-based reconstruction, autologous tissue reconstruction, and a combination of both?

Implant-based reconstruction has become the most common reconstructive technique utilised, and accounts for greater than 70 per cent of all breast reconstructions.

The patient undergoes NSM or SSM and the skin envelope is created and the viability is evaluated clinically.

a. NSM: If the patient has viable skin coverage, direct-to-implant (DTI) saline or silicone breast reconstruction will be considered. The implant position would be discussed prior to surgery: prepectoral (above muscle) or sub-pectoral (beneath the muscle) are the two main options.

Implant coverage with acellular dermal matrix ADM or synthetic material such as vicryl mesh may be utilised for implant support and reduction in breast contractures.

Tissue expander (TE) may also be utilised in the two-staged approach. This prosthesis will be inflated every two to three weeks to the desired volume of skin stretch.

The TE will be exchanged to the permanent implant in a secondary procedure.

b. SSM: Two-staged approach with TE followed by permanent implant. This is required because the skin envelope is reduced with removal of the nipple-areolar complex and surround-skin envelope.

Autologous breast reconstruction can be performed with the gold-standard DIEP flap or TRAM flap, which involves the utilisation of lower abdominal wall tissue to recreate a breast mound. The procedure involves the "tummy-tuck" tissue as a flap, either free or attached to the rectus abdominal muscle in DIEP and TRAM flap respectively.

Both procedures give the most natural appearance and tactile sense when compared to prosthesis, but are longer surgical procedures, with additional donor site and surgical scars.

Nipple reconstruction may be required following autologous breast reconstruction. This can be performed by nipple-sharing techniques, localised tissue flaps and/or 3D nipple-tattooing.

Combinations of implant-based and autologous are used in one-staged or two-staged reconstruction such as latissimus dorsi (LD) flap and implant.

This approach can be used in delayed as well as immediate breast reconstruction.

The LD flap permits implant coverage as well as skin envelope if required to facilitate the reconstruction.

The latissimus dorsi muscle, on the back, is mobilised and rotated anteriorly to provide assistance in the reconstructive process. This robust flap acts as a "bailout option" in several complicated reconstruction procedures.

What are the potential risks and complications associated with breast reconstruction surgery, and how are they managed?

Potential risks and complications with breast reconstructive surgery are based on the surgical technique. Generally, the complications are as follows:

Infection: Implant and flap-loss secondary infection.

This is managed with perioperative and postoperative antibiotics. In severe cases, further surgical intervention and intravenous antibiotics may be required.

Partial/complete flap failure: Blood supply to the tissue affected by blockage secondary to blood clot or narrowed vessels, flap position causing blood-vessel kinking and blood-vessel injury.

This would be managed by flap removal and the implementation of an alternative reconstructive procedure, most commonly latissimus dorsi flap.

Loss of overlying skin sensation: In most cases recovering of nerve sensation may occur in two-five years.

Capsular contraction (CC): The natural response to any foreign body is for the body to create a capsule around the prosthesis.

Sometimes, this capsule tightens and compresses the implant resulting in pain and cosmetic changes (capsular contractures). There are various stages of CC that may or may not require surgical revision and excision.

Wound healing issues: Any surgical procedures have the inherent risks of reduced wound opposition and healing. Regular non-adherent dressing and negative-pressure dressing may improve and expedite the healing process.

Seroma and haematoma: Seroma are serous fluid collections secondary to surgery arising from fatty tissue, inflammatory exudates and lymphatic fluid.

Haematoma is a collection of blood. Generally small volumes are re-absorbed by the body and rarely, needle aspiration or surgical drainage are required.

What role do a patient's overall health and medical history play in determining her eligibility for breast reconstruction surgery?

Breast reconstructive surgery requires general anesthesia, and thus the patient's overall health and medical history play an integral role in the prerequisite for surgical intervention.

Thorough evaluations are performed and re-evaluated by the anesthesiologist prior to surgery. Generally, most patients whoare considered for breast cancer surgery will fulfil the criteria for breast reconstruction.

Diabetic patients require well-controlled glycaemic control, since this is directly related to an increased risk of infection and subsequent implant and/or flap failure. Patients' post-systemic chemotherapy therapy will require cardiac evaluation prior to surgery.

Are there specific post-operative care guidelines and recommendations that patients should be aware of to ensure a successful recovery after breast reconstruction?

The postoperative care guidelines may vary based on the surgical reconstruction technique. Generally, patients should closely adhere to the surgeon's advice on when to initiate normal activities, stretching, and massage therapy. Overhead lifting, strenuous exercising should be avoided for four-six weeks post-reconstruction.

Brisk walking may be recommenced after two-three weeks. No heavy lifting greater than ten pounds in the first four weeks. Postoperative supportive bra for four- six weeks.

Following six weeks and an uneventful healing process, one may increase the intensity of exercising, with an appropriate supporting bra.

Can you discuss the importance of rehabilitation (physical therapy) etc, in the recovery process for breast cancer survivors who undergo reconstructive surgery?

After breast reconstructive surgery, rehabilitation plays an integral role in the recovery process of patients. This major surgical procedure may result in the sensation of back, shoulders, upper arms and chest stiffness.

The physical therapy exercises are components of this process and will help in recovering full movement at the shoulder joint, improving the stiffness, reduction in surrounding swelling and more independence in daily activities.

Overall, rehabilitation exercises will get the patients back to their everyday lives.

What psychological and emotional support options are available for patients navigating the emotional aspects of breast cancer and breast reconstruction?

Non-profit organisations offer emotional support options for patients. The cancer survivors’ groups provide direct life experiences and cognitive techniques to alleviate the anxiety and psychological impact of breast cancer diagnosis and surgery.

EARS (Embracing All Real Survivors) Cancer Support Foundation is an NGO led by a breast-cancer survivor for more than 20 years. This support group directly navigates patients from diagnosis through surgical and adjuvant medical systemic therapy and radiation therapies.

Activities such as dragon boat render support mentally as well as physically, enhancing the quality of life to patients post-breast cancer treatment.

Can you explain any financial assistance programmes or resources that may be available to help patients with the cost of breast reconstruction, especially for those facing financial challenges?

The public system offers breast reconstruction.

However, in the private sector, breast reconstruction is covered partially by some insurance companies, based on one's insurance coverage.

Are there ongoing advances or research in the field of breast reconstruction that may have an impact on the options and costs associated with this procedure in the future?

Breast surgery research for breast reconstruction is currently based on preoperative imaging and planning for the ideal surgical technique for personalisation of care.

Thermography imaging is being used in the evaluation of flaps post mastectectomy prior to implant based reconstruction. The utilisation of robotic-assisted surgery to potentially improve surgical and cosmetic outcomes is also being currently assessed.