In this episode of PodMD, Australian and British-trained Specialist Plastic and Reconstructive Surgeon Dr Shiba Sinha will be discussing the topic of breast reconstruction, including the different types of breast reconstruction surgery available for women, how a surgeon determines the best approach to surgery, the risks and benefits associated with the procedure, when a GP should refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Shiba Sinha
Dr Shiba Sinha is an Australian and British-trained Specialist Plastic and Reconstructive Surgeon practicing in Melbourne. Dr Sinha obtained her medical degree at the University of Leeds, England. Following this, Shiba undertook a higher research degree focusing on the tissue engineering of fat at the O’Brien Institute in Melbourne and advanced Plastic and Reconstructive Surgery training in New South Wales and Victoria.
Shiba then undertook further fellowship training in breast reconstruction at the world-renowned Queen Victoria Hospital, East Grinstead in the UK. She also undertook numerous observorships in aesthetic breast and body surgery in the UK, Europe, and Australia.
Today, we’ll be discussing the topic of breast reconstruction surgery.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Shiba, thanks for talking with us on PodMD today.
Shiba : Thank you for having me.
The topic of today’s discussion is breast reconstruction. Shiba, can you give us a brief overview about breast reconstruction surgery?
Shiba: Breast reconstruction after mastectomy involves forming a new durable breast mound after a mastectomy or partial mastectomy for a breast cancer or for those patients who have familial breast cancer genes and requires bilateral prophylactic mastectomy. About 40% of patients with breast cancer will need a mastectomy. We know from the literature that breast reconstruction has improved psychosocial outcomes and has no adverse impact on breast cancer survival and locoregional recurrence. We know in Australia that the best outcomes in breast reduction are achieved in strong multidisciplinary teams.
Can you explain the different types of breast reconstruction surgery available for women who have undergone a mastectomy?
Shiba: The 3 main types of breast reconstruction are autologous: using a patients own tissues; alloplastic: implant based reconstruction and oncoplastic surgery used in partial mastectomy where the breast parenchyma can be rearranged or the use of local flaps. Breast reconstruction can be done immediately at the same time as mastectomy or delayed: at some time point after a mastectomy has been done and the patient is flat. The advantage of an immediate reconstruction is that the skin envelope is preserved and this usually leads to a better aesthetic result.
The commonest autologous reconstructions are free tissue transfers utilising microsurgical techniques. The workhorse flap for this is the Deep Inferior Epigastric flap (DIEP) which is an evolution of the TRAM flap. Excess abdominal tissue that would be removed in an abdominoplasty is dissected based on abdominal perforators, detached from the source vessel in the groin and then attached to the internal mammary system in the chest. In patients who do not have an abdominal donor site can have tissue transfer from the thigh in the form of gracilis flaps or Profunda artery perforator flaps. Less commonly used sites are the back (Lumbar artery perforator flaps) and buttock. Alloplastic reconstruction can be done in 1 to 2 stages using silicone implants. Lastly oncoplastic techniques include therapeutic mammoplasty (where the cancer cells can be removed in a breast reduction/lift specimen and the contralateral breast can be reduced at the same time. It also includes chest wall perforator flaps for partial mastectomy defects.
How does a plastic surgeon determine the best approach for breast reconstruction surgery for a patient?
Shiba: Multiple factors can affect the reconstruction that a surgeon and patient will decide on but the key is to come to SHARED DECISION MAKING and one which is HOLISTIC. This include the patient’s physical state, lifestyle considerations and how severe their breast cancer is and further treatment required. The key principle is that the cancer treatment is the priority. OPEN COMMUNICATION by the reconstructive surgeon is key to what can be realistically achieved. No surgeon can reconstruct a patient’s current breasts and the new breast will feel and act differently. It should be stated that it is absolutely fine for a patient who has had all the information regarding breast reconstruction to not proceed with any form of reconstruction. I also tell patient that breast reconstruction is not usually a one surgery as further small touch up procedures are usually needed.
What are the benefits and risks associated with breast reconstruction surgery?
Shiba: Implant reconstructions tends to suit younger patients who are having bilateral mastectomies who have not completed a family. It is suitable for patients who wants to avoid extra scars on the abdomen and want a shorter recovery time. The main complications with implants are they are not a lifetime device, the need replacing every 10-15 years, Rupture can occur at any stage, there is a 20 % rate of implant loss due to infection. Capsular contracture is as a result of the body forming an inflammatory reaction against an implanted foreign material. This occurs in 20% of cases and higher in implants that have been irradiated . Animation deformity occurs when the implant has been placed under the muscle and bothers some patients so much the implants have to be changed to above the muscle. Furthermore implant controversies have included breast implant illness and BIA-ALCL which is a blood cancer associated with certain macrotextured implants which are no longer used.
Autologous reconstruction has the benefit of being a lifetime results with a natural feel and results although the trade off is a larger initial surgery ; free flap surgeries last 6 hours for unilateral and 10 hours for bilateral procedures and a slightly longer recovery time of around 4-6 weeks due to the donor site morbidity. The risks of these procedures include anastomotic issues in the microsurgery which can lead to partial or total flap failure (1% risk in larger centres); haematoma, donor site issues (which are more common in thigh based reconstructions, DVT/PE. Later complications include asymmetry, fat necrosis and abdominal bulge and hernia.
Have there been any developments in treatment in the last years or are there any in trials or development now?
Shiba: Breast reconstruction is a dynamic field. Mastectomy techniques continue to evolve and nipple sparing mastectomies are offered when oncologically safe to do so. Autologous reconstruction remains the gold standard and advances in that include imaging techniques of the perforator anatomy. In the post operative phase enhanced recovery after surgery protocols are shortening the in patient stay. Certainly where I worked in the UK patients who had free flap surgery were being discharged on day 1-2.
In the implant space, prosthesis technology is always evolving. The trend is moving to placing the implant where possible above the pectoralis major muscle with the use of biological or synthetic meshes which hammock the implant. This is also aided by the use The longer term results of these are still ongoing.
What can patients do to prepare for breast reconstruction surgery?
Shiba: Pre-operative fitness or prehabilitation is very important prior to surgery as this will definitely shorten the recovery time. This can understandably difficult for the patients who need to have chemotherapy prior to surgery. Reducing BMI is important as BMI > 35 has been shown to increase surgical complications and operative time. Smoking and vaping cessation at least 6 weeks prior to breast reconstruction is key. I would recommend that patient’s seek out information from patient support groups about the lived experience of a breast reconstruction. Feedback from my patients is that speaking to other patients who have gone through similar experiences was very helpful. There are lots of good resources available through the Breast Cancer Network Australia and Pink Hope. Breast reconstruction is a major procedure and making sure that you have a good support network at home post discharge; an area at home to recover
What advice do you have for GPs in terms of referring or assisting patients for breast reconstruction surgery?
Shiba: GPs are key to helping women through the difficult process of a breast cancer diagnosis as they can act as the focal point for someone who is receiving lots of information from multiple different specialities. GPs can start the conversation early with patients even if it is not known whether they may not need a mastectomy and empower the patient to ask about reconstruction with their breast care team if this is something that they want. Furthermore they can refer patients to a MDT with a oncoplastic breast surgeon or plastic surgeon.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on breast reconstruction surgery?
1. Breast reconstruction options should be discussed with patients considering a mastectomy so they are empowered to make a decision.
2. The breast reconstruction journey is an individual process and the reconstruction should be tailored to the patient and their oncology treatment.
3. Breast reconstruction is best delivered in strong multi-discliplinary teams involving breast surgeons, plastic surgeons, oncologists and breast reconstruction nurses and higher volume centres.
Thanks for your time and the insights you’ve provided.
Shiba: Thank you