Breast reconstruction- pre-operative assessment and education

The following is a reproduction of one of my transcripts that was published in Breast Disease in 2002. It focuses on discussion of breast reconstructive surgery and I though it an appropriate addition to the BLOG of our website.

BREAST RECONSTRUCTION- PRE-OPERATIVE ASSESSMENT AND EDUCATION

– by Adam Lowenstein, MD, FACS

Breast reconstruction can be one of the most rewarding aspects of health care, not only for the patient, but for the surgeon as well. The diagnosis of breast cancer and its associated anxiety can be devastating to anyone. The plastic surgeon, presenting the possibilities of regaining at least a semblance of the original body form, can have an uplifting and profound impact on the patient’s attitude toward their diagnosis, treatment, and general well-being during this difficult time. The surgeon’s responsibility is to present reconstructive options in a clear, concise, and manageable fashion, while simultaneously determining both the viable and most favorable clinical pathways to optimize the patient’s outcome.

In many areas of medicine, especially surgery, a given diagnosis leads to a specific therapy, which hopefully leads to a predictable clinical outcome. If Mary’s gallbladder is inflamed and full of stones, it needs to come out. The treatment is driven by the diagnosis. In the area of breast reconstruction, however, the treatment is instead directed by the patient as a whole. Body habitus; activity regimen; medical, surgical, and social history all play significant roles in the decision of which type of reconstruction is best for any particular person, and no single operation is appropriate for every woman.

The following is an attempt to put down on paper the thoughts and interactions that occur between me and any new breast reconstruction patient. It will forego many of the technical details, pictures, statistics, and nuances that are presented elsewhere in this monograph. Instead I will try to convey the general process of the patient visit- from the initial meeting, through my own personal evaluation and bias formation toward a preferred method, and the presentation of all of the options to the patient. It is important to realize throughout that although I may have my own notion of what I’d like to do, my personal style is to present all reasonable options to the patient, with some guidance. Ultimately, it is the patient’s decision as to which type of operation, if any, is to be performed.

FIRST IMPRESSIONS

The initial interaction with my patient can be very telling. I have had more than one woman come to my office with wide eyes and the pre-conceived notion that I should simply decide and dictate the “right” thing to do. I have alternatively seen patients show up with a bag full of books, articles, and web site printouts ready to lecture me on the proper way to reconstruct a breast. The determination and motivation that the patient brings to the table is very important and this can significantly tilt the scales as to which type of operation I would recommend. A more involved operation may require an extra modicum of diligence on the part of the patient, and not every personality type is a candidate for a technical, potentially delicate microsurgical free flap. I have been fooled before, however, and patients who have initially seemed beaten by their diagnosis have pleasantly surprised me in their grace and strength through the reconstructive process.

Similarly, an assessment of the patient’s self-image begins early during the interaction, and this can help me immensely in understanding the patient’s expectations of both process and outcome of the reconstruction. A woman dressed in designer fashion is unlikely to be interested in an external prosthesis, and may be interested in the “tummy-tuck” benefits of an abdominal flap.

I find that much of these impressions can be elucidated from a smile, a handshake, and a simple question: “What can I do for you today?” A response of “I don’t know, Dr. Somebody just told me that I had to come here,” is very different from, “I’d like a breast reconstruction on the left, a lift on the right, and a tummy tuck like my sister! And can you do a facelift while you’re at it?”

CLINICAL HISTORY

As in every patient, relevant past medical and surgical history is necessary to obtain. Particulars include traumatic and surgical history relative to the breast, chest, abdomen, and back. The woman’s medical history of vascular issues, radiation, diabetes, latex allergies, and smoking history may have significant impact on the reconstructive decision.

KNOWLEDGE ASSESSMENT

It is very important to find out how much understanding the patient brings to the consultation, and therefore be able to gauge the amount and degree of information that needs to be presented to them. Many patients have friends who have undergone one or the other type of reconstruction, while others have spent every waking moment since their diagnosis reading and surfing the internet about the latest homeopathic trends. Most patients seem to have heard of implants and the possibility of using their own tissue, but are not aware of the indications and contraindications, risks and benefits of such operations. Occasionally the patient will be a medical care provider. I never want to be talking about “the muscles in your abdomen, like Arnold Schwarzenegger’s six pack” to someone with a PhD. in anatomy.

OPERATIVE INDICATIONS AND DECISIONS- MY THOUGHTS

As stated above, there is no single operation that is appropriate for every woman. There are a multitude of different reconstructions used by plastic surgeons around the world. Many surgeons will swear by their particular techniques, and as long as an adequate outcome is the frequent result, I believe that the plastic surgeon should use whatever operations she or he is comfortable performing. These may include Rubens’ flaps, gluteal flaps, or many others that I personally do not routinely employ. The following are basic choices that I utilize in the majority of patients.

No reconstruction (external prosthesis)- It is the responsibility of any involved physician to explain, although it may seem obvious, that surgical breast reconstruction is an option carrying particular risks- those of general anesthesia, as well as infection, wound problems, poor aesthetic outcome, breast asymmetry, and the need for further surgeries. As such, an excellent option for many women is an external prosthesis, worn in a brassiere, to create symmetry and form when clothed. Also, it is important to note that women who carry significant risk factors for surgery in general may be poor candidates for any elective operation and should give significant consideration to non-surgical options.

Saline tissue expander followed by placement of a permanent saline implant- Short of the external prosthesis, I feel this is the simplest form of breast reconstruction. I additionally feel that this procedure provides the least realistic reproduction of breast form. The patient must be told that this does involve placement of a foreign body into the chest wall, and has the associated risks of infection, deflation, and capsular contracture. This last issue must be discussed in detail, explaining the possibilities of deformation, asymmetry, and chronic pain that can be associated with the condition. Significant capsular contracture affected 20% of patients in one large study.1 It is also important to explain that this procedure involves two separate operations under general anesthesia, the first involving placement of the tissue expander below the pectoralis muscle. The inflations are subsequently performed at 2 to 4 week intervals involving percutaneous needles placed into the expander, so the patient must be willing to make frequent visits to the office. These reconstructions do not create the feel of the natural tissue, and I liken the postoperative situation to a balloon on the chest wall. Likewise, the natural ptosis of the breast is poorly reproduced, and therefore I emphasize that symmetry is best (and often only) observed when clothed. As with other options, I explain to every patient the contra-indications for this procedure, so they can understand my thought process. The implant is a poor choice in patients who have a history of chest wall radiation because of the increased risks of complications.2 A history of multiple local wound infections in the area, regional trauma, or a lot of local scar tissue are also relative contra-indications to the procedure.

Saline implant covered by a pedicled latissimus dorsi myocutaneous flap- For patients with a history of chest wall radiation who are not candidates for other procedures, this may provide an excellent alternative. I explain that this carries all of the problems of a foreign body placed into the chest wall, but also shares some of the disadvantages of autologous tissue transfer as described below. Because of this, my indications for this operation is the obese woman who cannot undergo free tissue transfer for some reason, but in whom an expander alone will be an inadequate reconstruction and “lost” in the adipose of the chest wall. The lower pole of the flap can be used to create an acceptable inframammary fold in these individuals, thus providing some definition to the reconstructed mound. Similarly, in very thin women who lack adequate soft tissue to mask the underlying implant, the addition of the extra myocutaneous tissue can provide a more natural feel. It is important to discuss the potential morbidity of the partial loss of the latissimus muscle, particularly in activities that involve a rowing or low pulling motion. A significant number of my patient population in Colorado are involved in cross-country skiing, and this has been a factor in the decision of a few of my patients.

Autologous tissue- pedicled TRAM flap- This is the reconstructive option of choice in patients who are appropriate candidates, and is the current gold standard to which all other reconstructive procedures should be measured.3 The TRAM flap provides the most realistic feel and appearance to the reconstructed breast, being largely comprised of fatty tissue harvested from the abdominal region. No other reconstruction presented here, except for the free TRAM as described below, can as adequately provide reproduction of the infra-mammary fold and the natural ptosis that is seen in normal breast morphology. All of this must be communicated to the patient, yet tempered with the understanding of the potential morbidity of partial or complete flap failure, umbilical necrosis, abdominal hernia, longer initial convalescence, and the potential for abdominal weakness as pertaining to such motions as sit-ups. The often-oval scar surrounding the abdominal skin paddle should be addressed. On the wall in one of my exam rooms is a musculoskeletal depiction of the human body, and I use this to explain the pedicled flap and its blood supply via the rectus muscle. I routinely emphasize that the TRAM flap involves two significant operations at the same time, in different areas of the body, as opposed to the prosthetic reconstruction requiring two smaller operations in the same region at different times.

Autologous tissue- free TRAM flap- Relative and absolute contraindications for the pedicled TRAM flap reconstruction should be discussed with the patient as a matter of education, so she can understand why this may be a good or bad option for them. Active smoking, vascular disease, diabetes, and obesity are routinely mentioned as problematic for the pedicled operation, and I use this as a segway to describe the free TRAM and it’s characteristics. I explain that this operation involves microsurgical technique, is for me a longer operation than any of the others, but has a very good success rate for the right patient. The increased risk of total flap loss versus the lower risk of partial flap loss is always discussed. I feel that if the pedicled TRAM is not contra-indicated, then this is my flap of choice. If, however, there exists concerning cofactors such as those mentioned above, or more than about 60% of the abdominal pannus is required for a reconstruction of adequate size, then I personally prefer the free flap procedure.

Symmetry Procedures- When appropriate, discussions regarding contralateral lifting or reduction are undertaken. Insurance coverage of such operations should be discussed to alleviate the patient’s concerns regarding expense. Individualized risks and contra-indications should be covered, as must postoperative expectations regarding scarring, size, and ptosis.

PHYSICAL EXAM

The physical exam follows the educational portion of the patient visit. At this point, the patient hopefully has at least heard, if not comprehended, a simplified decision tree pertaining to the choice of reconstruction, and therefore a rational conversation can ensue following the exam as to the preferred procedure to undergo. I ask the patient to undress and put on a gown while I temporarily leave the room. All exams are performed in the presence of a female chaperone. On exam I make note and speak aloud while evaluating the chest wall, noting the condition of the skin and subcutaneous tissue, as well as the presence of any tattoos indicating a radiated field. The size and degree of ptosis of the contralateral breast is examined. The abdomen and back are also carefully scrutinized, examining particularly the amount of subcutaneous fat and the presence of scars. Range of motion of the shoulder as well as muscle tone of the abdomen should be evaluated, as should the presence of abdominal herniation or diastasis of the linea alba. Potentially problematic skin lesions or rashes in these areas should be pointed out and addressed. All of these aspects of the exam are discussed with the patient to facilitate communication of my thought process. Following the exam, I ask the patient to redress and leave the room for a short period to allow her to get settled.

THE WRAP-UP

Now is the time that I ask the patient for her thoughts about what we have discussed so far. This allows me to get a feel for her understanding of our interaction, and gives me an impression of her tendency toward a particular reconstructive option. I find that through my discussions, the patient very often will have come to the same conclusions that I have regarding an operation of choice. I always ask for her opinion first. This allows me to agree with her in a great many cases, providing her with a very important sense of participation and empowerment in the decision making process. With those patients who have come to a different conclusion than I, it is vital to listen to their explanation of how and why they have come to this decision. Often they will bring up a very important yet omitted fact that will prove their choice more preferential than mine. Sometimes, however, they will voice inappropriate concerns or misunderstandings that need to be clarified. “Will I be able to play the piano after my operation?” may reflect a true misunderstanding of the function of the rectus muscle or recovery time, rather than a lead into a classic punch line, and these issues must be clarified at this time.

Uniformity in the conclusion of my consultation provides a standard plan for the patient. I insist on having the patient go home, think about the discussions that we have had, and talk about the situation with those close to her. I encourage her to carry a small note pad to write down questions that will come up over the following days so that she can return to the office in one to two weeks, with or without her family or friends, to discuss the decision further. This allows elucidation of the patient’s knowledge deficiency at the second visit. Here again my emphasis on patient education and understanding is revisited.

The short delay to the final conclusion also alleviates some of the patient’s anxiety about making an important decision in a hasty manner, and prevents cancellations of plans made in haste. An exception to this exists for patients who are planning immediate reconstructions and who therefore need to make a decision regarding the quickly approaching planned operative procedure. These patients are scheduled for a second consultation a few days, rather than weeks, after the first visit.

THE SECOND CONSULTATION

At the second consultation, the patient’s views are again addressed, as are mine. If the patient has made a choice that is ill-advised in my opinion, I explain my thoughts that have led me to such a conclusion, and I explain why I feel another procedure is more appropriate. I will perform a procedure that the woman prefers over my personal choice if there are rational, well understood reasons that the informed patient has used to come to her decision. This of course assumes the woman’s choice does not place herself or her reconstruction in jeopardy. I have happily never been faced with a patient who insisted on an unsafe course of action that countermanded my recommendation. More often than not, similar thoughts are shared between the patient and myself, and the first stage of our effort ahead has been successful. A mutual understanding of the reasoning and expectations regarding the patient’s reconstruction has been fostered by the end of my two stage preoperative consultation, and plans can be made appropriately.

REFERENCES

1) Gutowski KA, Mesna GT, Cunningham BL. Saline-filled breast implants: a Plastic Surgery Educational Foundation multicenter outcomes study. Plast Reconstr Surg 1997 Sep;100(4):1019-27.

2) Krueger EA, Wilkins EG, Strawderman M. Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy. Int J Radiat Oncol Biol Phys 2001 Mar 1;49(3):713-21.

3) Hultman CS, Bostwick J. Breast Reconstruction Following Mastectomy: Review of Indications, Methods, and Outcomes. Breast Disease 12 (2001) 113-130.