Breast Reconstruction

Breast cancer occurs in 1 of 9 women, and is therefore the most common type of cancer diagnosed in women. The American Cancer Society reported over 240,000 new cases of breast cancer in the United States in 2007 alone, with over 40,000 women ultimately succumbing to the disease the same year. In many instances, mastectomy is required to remove the tumor, leaving behind significant physical as well as psychologic consequences. It is therefore not surprising that the American Society of Plastic Surgeons reported over 57,000 breast reconstruction procedures in 2007.

Surprisingly, many plastic surgeons note that few women of East Asian descent, and far fewer women of South Asian descent, seek breast reconstruction following mastectomy. There is limited data on the reasons behind this low frequency. A study was performed in 1997 by the UCLA School of Public Health and Asian American Studies to explore the impact of breast cancer on Asian American women. The authors found that Asian American women chose breast conserving therapy and adjuvant therapy at a significantly lower rate than Caucasian women, opting instead for mastectomy. Another study performed in 2004 at the University of Texas MD Anderson Cancer Center showed that Asian American women underwent immediate breast reconstruction following mastectomy less frequently than white women.

Dr. Clara Lee, a plastic surgeon of Korean descent who practices at the University of North Carolina in Chapel Hill, believes that Asian women may have different views of their body image when compared to Caucasian women, and that these may be based on ingrained cultural norms. “Our cultural icons – Buddha, Confucius, and Gandhi – were completely selfless,” she states, “therefore, the thought of reconstructing a breast may simply seem vain and selfish to many Asian women who have traditionally placed their family’s needs above their own.” She also notes that other factors may contribute to a lower rate of reconstruction, including a tendency for oncologists to refer their Asian patients for reconstruction less often. This form of differential referral is seen in other areas of medicine, with the reasons behind them often quite complex. Further, while Caucasian women often request breast reconstruction on their own volition, Asian patients may not independently raise this topic with their physician. Another study from UCLA in 2003 identified additional issues including a lack of medical knowledge about breast cancer, concerns about cost, cultural beliefs about illness, language barriers, and psychosocial concerns related to worrying about children, burdening the family, and sexual health.

Regardless of the reasons for the low rate of reconstruction among Asian Americans, the psychological benefits of reconstruction have been documented repeatedly in clinical studies. In my Manhattan practice, one of my Chinese-American patients stated, “I wasn’t going to have reconstruction, but I’m so glad I did. I am able to look in the mirror again…” We in the plastic surgery community believe that the opportunity to obtain breast reconstruction, if desired, represents yet another advance in the fight against breast cancer by restoring physical appearance.

Whether breast reconstruction is performed immediately following mastectomy or at a later date, there are several options available. These include reconstruction with a prosthetic implant or reconstruction using the patient’s own tissue. The determination of the appropriate reconstruction for a given patient is dependent upon her body type, personal preference, and whether additional therapy is required for the treatment of cancer.

Implant reconstruction is the most common type of breast reconstruction. Following mastectomy, there is a relative skin deficit in the region. Therefore, implant reconstruction requires a period of tissue expansion to stretch out the remaining skin to allow room for a permanent implant. The tissue expander is a “balloon” that is placed beneath the skin and pectoralis muscle on the chest. Through a small valve in the expander, salt water is periodically injected to gradually fill the expander over several months. After a waiting period during which time the skin accommodates to its new size, the expander is replaced at a second operation with a permanent saline or silicone implant.

The patient’s own tissues can also be used for breast reconstruction. The TRAM (transverse rectus abdominis myocutaneous) flap is a procedure that involves the transfer of skin, fat, and muscle, with its blood supply still attached, from the lower abdomen to the chest to create a new breast. Although this surgery is more complex than implant reconstruction, the TRAM flap generally produces a more natural feel and appearance of the breast. In addition, the abdomen appears slimmer and flatter due to the removal of tissue. A variation of the TRAM flap is the DIEP (deep inferior epigastric perforator flap), in which only the vessels and fat are taken from the abdomen, sparing the muscles. Finally, the latissimus dorsi flap uses muscle and sometimes skin from the patient’s back to create a breast mound. In some cases, an implant is also placed underneath the transferred muscle to produce an adequately sized breast. In all cases, reconstruction of the nipple-areola complex can be performed at a later stage.

Because the goal of reconstructive breast surgery is to match the opposite breast, additional procedures to enlarge, reduce, or lift the unaffected breast may be suggested. The Women’s Health Act of 1998 requires group and individual health insurance plans that cover mastectomy to cover breast reconstruction surgery, including procedures performed on the unaffected breast for symmetry. Not surprisingly, the Act has had a major impact on the availability and psychologic and physical satisfaction of patients recovering from this devastating and common disease.

Asian women should take comfort in the fact that more and more physicians are aware of cultural differences in the decision to undergo post-mastectomy reconstruction. To find a board certified plastic surgeon in your area, contact the American Society of Plastic Surgery at www.plasticsurgery.org or 1-888-4-PLASTIC.

Nina S. Naidu, M.D. is a board-certified plastic surgeon practicing in New York City. Dr. Naidu received her medical degree from Cornell University Medical College and completed her general surgery and plastic surgery training at New York Hospital – “ Cornell Medical Center. She has authored numerous papers in the field of plastic and reconstructive surgery.

Dr. Naidu is an active member of the American Society of Plastic Surgeons, the New York Regional Society of Plastic Surgeons, the Medical Society of the State of New York and the New York County Medical Society. She maintains privileges at Lenox Hill Hospital, Manhattan Eye, Ear & Throat Hospital and the Center for Specialty Care. Visit www.naiduplasticsurgery.com