By Dr Teoh Mei Shi (Consultant Breast, Endocrine & General Surgeon)  & Dr Wong Thai Er (Consultant Plastic and Reconstructive Surgeon)

Dr Teoh Mei Shi is a Breast, Endocrine and General Surgeon. Dr Wong Thai Er is a Plastic and Reconstructive Surgeon. Both are consultants at Loh Guan Lye Specialists Centre. As a team they work together to treat the cancer and help reconstruct the breast to give patients a more positive outlook in their recovery from cancer.

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Over the last few decades, surgical treatment of breast cancer has undergone a paradigm shift from radical mastectomy that involves removal of whole breast and large portion of muscle underlying the breast tissue to breast conserving surgery and now oncoplastic breast reconstructive surgery. Concomitant advances in chemotherapy and radiotherapy have played major role in this shift.

Oncoplastic breast reconstructive surgery involves the oncological removal of breast cancer combined with reconstructive plastic surgery techniques to rebuild or reshape the breast for an aesthetically pleasing final outcome. The combined reconstructive surgery can be carried out immediately at the time of breast cancer surgery or as delayed procedure performed months or years later. The current practice of Breast Reconstruction results in single hospitalization saving time and cost with shorter time away from work. Moreover immediate breast reconstruction certainly helps them to regain confidence with positive outlook. 

Multidisciplinary discussion between patient, oncologist, breast surgeon and reconstructive surgeon is pertinent to decide the best approach for each patient for appropriate oncological treatment for breast cancer followed by appropriate breast reconstruction. 

Choice of Oncoplastic breast reconstructive surgery will depend on 

• stage and subtypes of breast cancer 

• breast size and volume

• adequate autologous tissue for reconstruction

• patient’s choice and expectation

• location of the breast tumor

• tumor response to neoadjuvant treatment 

Types of oncoplastic breast surgery

• Breast conserving surgery with volume replacement and volume displacement techniques

• Nipple-sparing / Skin-sparing mastectomy with autogenous tissue reconstruction eg Back tissue / Tummy tissue

• Nipple-sparing / Skin-sparing mastectomy with Implant reconstruction 

There are many options for breast reconstruction following surgery for breast tumour. As such, these options have to be discussed with the patients and the most appropriate option is then chosen and tailored for them. Many factors need to be taken into consideration during the discussion as these factors would affect not only the outcome of the reconstruction, but also the adjuvant therapies (radiotherapy and chemotherapy)

The options for reconstruction are:

• External prosthesis

• Silicone implant

• Fat injection

• Autogenous tissue flap reconstruction

External prostheses are made of foam-like material into well-designed breast-shaped prostheses, to be placed inside the inner wear. They are suitable for those who had undergone breast tumour surgery and do not want any reconstructive surgery at all. 

Commonly used for breast augmentation, silicone implants, can be used for breast reconstruction in selected cases. They come in various sizes and shapes, to be inserted after breast surgery. It is suitable for those who will not require chemotherapy and radiotherapy as both these therapies can affect the outcome and enhance the complications and risks associated with silicone implants.

Fat injection involves harvesting fat from either the tummy or the thigh and injected into chest. This technique requires multiple sittings of harvesting and injection to achieve the desired size as some of the injected fat shrinks after each sitting, thus can significantly elevate cost with this technique. This technique is also suitable for those who will not require chemotherapy and radiotherapy as both these therapies can affect can affect fat cell survival and the outcome.

Autogenous tissue flap reconstruction is still the gold standard in breast reconstruction. It involves harvesting the patients’ own tissue together with the underlying muscle and blood supply and the flap is then repositioned into the chest. Tissues commonly harvested are usually from the tummy (TRAM flap) or the back (LD flap). As these tissues have their own good blood supply, they have been well documented to facilitate healing, making it more robust and reducing complications and risks associated with radiotherapy and chemotherapy. Hence this method is strongly advisable for those patients who had undergone or going for chemotherapy and radiotherapy. For patients with advanced large breast tumour, this technique is also helpful for closure of chest wound and in preparation for chemotherapy and radiotherapy.

CONCLUSION

Breast cancer patients are now enjoying a longer lifespan due to better understanding of tumour biology with more advanced treatment options. By removal of the breast tumour coupled with choice of breast reconstruction, we aspire the survivors not only will enjoy a longer and better quality of life, but also live with restored confidence and esteem in their ongoing and future endeavours.