Hollywood, breast cancer and reconstruction surgery

 
In 2013 the Hollywood actress Angelina Jolie announced that she had both her breasts removed because she carried the BRCA1 gene.
 
Her bilateral prophylactic mastectomy highlights the fact that a woman whose mother or father carries a faulty BRCA1 gene has a 50% chance of also carrying it and a 60 to 80% higher risk of developing breast cancer.
 
Angelina Jolie exemplifies what many women with a family history of breast cancer are doing: testing for the BRCA1 gene; if positive, electing for a bilateral prophylactic mastectomy and after surgery, reconstructing their breasts.
 
Hollywood myths do women a disservice
In a New York Times article, entitled My Medical Choice, Jolie informed women about BRCA gene mutations and the challenges of breast surgery. Her efforts are overshadowed by the notion that breast surgery is quick and easy.

Hollywood images propagate the myth that reconstructive surgery quickly restores breast symmetry, improves body image, quality of life, self confidence and wellbeing. In reality, it's major surgery with significant risks that entails an extended series of operations and follow-up visits and can take three to nine months to recover from. 
 
Reconstructive surgery can leave women with scar tissue, persistent pain in the back or shoulder and hardened breasts that never look or have the same sensation as before treatment. Also, breast implants can rupture and cause infection. Within five years, 35% of women who have implant reconstructions undergo a revision.

A breast with an implant will not age naturally, while the surviving breast will. Up to 50% of implants used for breast reconstruction have to be removed, modified, or replaced in the first 10 years. So, a patient is likely to need more surgery to remove or replace implants during their lifetime. 

Increasing concern that women are not informed 
Breast cancer is the most common form of cancer in the UK and each year about 45,000 women are diagnosed with it, of which almost 12,000 die. Screening and new generation drugs have significantly improved breast cancer survival rates, but the number of women having breast reconstruction surgery is increasing.  This is partly because the incidence of breast cancer is increasing in younger women who are more likely to have the surgery.
 
According to Marc Pacifico, Consultant plastic surgeon at Queen Victoria Hospital, East Grinstead, "It's very important that women are fully informed about the risks and benefits of breast reconstruction surgery". 
Implants or tissue reconstruction
The type of reconstructive surgery a woman chooses depends on the location of the breast tumour, the size and shape of the breast that is being replaced, age, wellbeing and the availability of autologous tissue.
 
Techniques to reconstruct breast include: implant-only reconstruction, autologous reconstruction using the patient's own tissue and a combination of both.
 
Implants and tissue reconstruction
Breast implants are usually a two-stage procedure. First, an expander is placed under the chest muscle and slowly filled with saline solution during visits to the doctor after surgery. Second, after the chest tissue has relaxed and healed, the expander is removed and replaced with an implant. The chest tissue is usually ready for the implant six to 24 weeks after mastectomy.
 
Tissue reconstruction involves moving a flap of skin, muscle and fat from a patient's back or abdomen to the breast area, while keeping intact a pedicle or tube of tissue containing its supplying arteries and veins.
 
Free flap reconstruction involves tissue being detached from a donor site before it is moved. Microsurgical techniques are then used to rejoin its arteries and veins to those in the breast area. An advantage of this procedure is that tissue can be harvested from areas of a patient's body not adjacent to the breast, such as the buttock or thigh.
 
Gold standard versus implants 
Many surgeons regard free flap reconstruction as the gold standard. This is because a new breast is soft and natural-looking and it avoids some of the potential challenges associated with breast implants. Tissue reconstruction has the added advantage that the breast ages and changes size in a similar way as the other breast.  
 
However, free flap surgery is longer, more complex and leaves scars and only available in centres where there is microsurgical expertise.
 
Harvesting fat from one part of the body and re-introducing it to help reconstruct breast tissue is challenging because the body may reabsorb between 20 to 90% of the harvested fat, which then results in further interventions and unreliable outcomes.
 
According to Anne Wilson, a RAFT Surgical Research Fellow working on a project with Professors Peter Butler and Alexander Seifalian from University College London, "The introduction of stem cells into the fat-transfer procedure may reduce or eliminate the problem of the body reabsorbing the fatty tissue. For a woman undergoing breast reconstruction this would be significant as it would mean fewer visits to the operating room and better aesthetics".
 
Same time or delayed reconstruction
Another important choice women face with breast reconstruction is whether to have reconstruction at the same time as the mastectomy. Immediate breast reconstruction usually means less surgery, the chest tissue is not damaged by radiotherapy or scarring and this often means that the final result looks better.
 
Delayed breast reconstruction may be a better choice for some women who need radiotherapy to the chest area after a mastectomy and this can cause delayed healing and scarring. Sometimes, a woman may not know whether she needs radiotherapy until after her mastectomy. This can make planning ahead for an immediate reconstruction difficult.
 
Takeaway
Each year, some 18,000 mastectomies are performed in England alone. About 40 to 50% of these have breast reconstruction surgery. According to a recent survey by the British Association of Plastic, Reconstructive and Aesthetic Surgeons, more than 33% of respondents said that the risks and benefits of reconstructive surgery were never discussed.   
 

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