I have been diagnosed with intermediate DCSI. My surgeon has performed a lumpectomy and the margins are not clear. Currently, it is considered 3.5 centimeters and was told I would need the 6-week radiation treatment rather than the 1-week because of the size. I would rather not do another lumpectomy at this time and do a mastectomy to be safe. I'm a heavy woman and am currently a DD. What is the best reconstruction option?
Breast Reconstruction Options?
Doctor Answers 10
An option not discussed is to do a breast reduction with another lumpectomy followed by radiation. You would also do a reduction on the opposite breast. This does mean watching for development of cancer in both breasts. You may ask your surgeon about getting an MRI if you have not had one to check the extent of any DCIS in both breasts. If abnormalities are found in the opposite breast, then a double mastetcomy is something to consider. If you are going with a mastectomy, the options have already been listed. I will say strongly that a nipple sparing procedure is not ideal for large breasted women and I would not perform. This is backed up in the literature should anyone choose to read it.
Mastectomy avoids the need for radiation.
1) Based on the facts you present, a mastectomy is a good choice. You would be spared the possible complications of radiation, and you would not have to worry about a recurrence.
2) You may be a candidate for nipple sparing mastectomy, which psychologically, almost feels like not having a mastectomy.
3) Many women choose bilateral mastectomies, because the symmetry is better, and because you never have to worry about breast cancer again.
4) If you are a good candidate for a tummy tuck, breast reconstruction is done using your abdominal tissues (skin and fat). For most women, a tissue expander followed by an implant works well.
Breast reconstruction options?
Typically, implants in the setting of an irradiated breast has higher rates of complication, including infection, wound complications, capsular contracture, etc. Many surgeons, including myself, have placed implants to improve symmetry in these instances with excellent results. However, if your deformity is a contour issue with a soft tissue deficiency, placing an implant beneath the breast may actually worsen the deformity as it is not addressing the issue to "fill" the defect. For such problems, it may be a wiser decision to consider fat grafting for smaller defects, where fat is harvested for another area of your body and then reinjected into the defect, thus adding volume as well as having the added properties of fat graft stem cells. Autologous flaps such as local tissue, TAP, or LDMF may be needed for larger soft tissue defects. Of course, reduction of the other breast to create symmetry is an option, or a combination of procedures on both breasts. Best wishes!
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Dcis, implants, diep flap
DCIS can be multifocal, as it is the the ducts, and therefore it is not uncommon to convert to a mastectomy after a lumpectomy with positive or close margins. The good news is that you are candidate for several reconstructive options, using your own tissue, implant, or combination.
Mastectomy with sparing of skin and immediate reconstruction
Mastectomy with sparing of skin and immediate reconstruction is a good option as it avoids radiation and recurrence. Whether to spare the nipple, use your own tissue, or implant has much to do with your body habitus and aesthetic desires. DD sized breasts rarely have the nipple in a normal position and likely will require reduction in your breast skin envelope to yield an aesthetic breast reconstruction. It would be best to meet with an experience breast plastic surgeon to review the options, risks, and photos of the various surgeries.
Breast Reconstruction Options
Options for Breast Restoration
With positive margins from your lumpectomy, it sounds like you've decided on a mastectomy. It is likely that you will not require any radiation treatment after your completion mastectomy.
The good news is that you have many options to restore yourself after mastectomy especially with the elimination of any radiation therapy.. Furthermore,all aspects of your reconstruction will be covered by your insurance.
The two major categories for breast reconstruction are 1) implant-based and 2) autologous (using your own tissue). With proper patient selection, we obtain outstanding results with both modalities. However, reconstruction is a process that requires some steps to achieve the best results.
Options will include Saline/Silicone Gel implants, Autologous reconstruction with DIEP or SIEA or TRAM flaps, etc. There are pro's and con's to each option. No single reconstruction is the best for everyone. If you have excess tissue in your lower belly (i.e. have you ever thought you might beneft from a tummy tuck?), then you may be a good candidate for a DIEP free flap (reconstructing your breast using your own tissue without the need of an implant).
We often visit with out of town patients to help them with their reconstructive journey. And we work with several outstanding breast surgeons to facilitate immediate reconstruction for out of town patients. Please visit our breast reconstruction website listed below to learn more about your options.
Breast reconstruction options
A DD breast is very large and depending upon yoru body habitus will determine surgical options for reconstruction. Being that you are getting radiation,. some surgeons would opt to delay your reconstruction especially if tissue expanders and implants are being used.
Skin-sparing mastectomy and immediate reconstruction for DCIS breast cancer
The good news is that you do have options. Radiation is not always the best alternative even though it is typically offerred as "breast-conserving" treatment. Further, if you have to be placed on estrogen blocking medication such as tamoxifen (for ER-positive tumor types) these can have significant side-effects. There is a trend to what is called a skin-sparing mastectomy, and with DCIS sometimes a nipple-sparing technique that preserves all of the breast skin so a reconstruction can be done on an immediate basis with an implant and an Alloderm internal bra. With the mastectomy approach you probably wouldn't have to go on tamoxifen. However, the chances of complications with surgery are higher in overweight patients so discuss the risks and benefits of all options with you team. Definitely see a plastic surgeon before deciding.
Breast Reconstruction Options?
Sorry to hear of your predicament.
If there was ONE "best" solution in your situation, we would all be doing. Obviously, there are multiple solutions which are dependent on how the local general surgeons and Plastic surgeons work together. Most Plastic surgeons would prefer to do an IMMEDIATE reconstruction at the time of the mastectomy. The TYPE of reconstruction would be
- using the Tummy tissue as a pedicle (TRAM flap) - with or without additional hook-up to vessels ("turbo charging")
- using the Tummy Tissue as purely a microsurgical procedure (leaves a tighter more secure tummy)
- reconstruct the breast with an implant and using the Latissimus back muscle
- reconsruct the breast immediately with an implant and a "biological" (such as Strattice) hammock.
Speak to 1-3 Plastic surgeons and see what the prevailing advice in your community is.
Dr. Peter A Aldea
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.