1. science
2. medicine
3. surgery

SUMMER 2014 | 33
Discussing breast
reconstruction at the
time of breast cancer
surgery – rather than
afterwards – can bring
many benefits to patients.
M
astectomy and breast
reconstruction have, generally,
been considered as two separate
procedures – each following their own
separate discussion, often with different
surgeons. But the rise in oncoplastic
breast surgery as a sub-specialty has
been drawing attention to the benefits
of considering these two procedures as
closely related, and of the advantages if
they can be done as a single procedure.
Dr Deborah Cheung – specialist
oncoplastic breast surgeon, who works
from the Macquarie University Breast
Centre – says that planning the two
surgeries together and combining
them into one procedure can bring
functional, cosmetic and psychological
benefits to patients.
“Breast removal and reconstruction
should be tailored to each individual
woman, with a patient offered all
the options – including explanations
around benefits and potential
complications,” said Dr Cheung, who is
also a clinical lecturer at the Australian
School of Advanced Medicine. “Only by
approaching both procedures this way,
can the whole process bring the best
patient outcomes.
Thinking Ahead
Dr Deborah Cheung, Emma Korth
Being proactive
about Breast
Reconstruction
“All patients who choose to have a
mastectomy should also have a discussion
with their surgeon about immediate breast
reconstruction at the time. This allows for the
possibility of preserving skin and, if suitable,
the nipple – to provide the best possible
cosmetic result. Such an approach has
become increasingly important as women
survive breast cancer better and longer than
ever before.”
Knowing that a breast reconstruction is
to be part of a mastectomy will affect the
placement of incisions, for example, and call
on techniques to preserve all the skin of a
breast. These approaches improve greatly
on delayed breast reconstruction where the
skin may have been sacrificed and a surgeon
has to essentially ‘start all over again’ by
borrowing skin from another part of the body
or stretching the remaining skin with tissue
expanders.
Ultimately, a single operation means
fewer scars, more effective skin use
and, importantly, nipple sparing. So,
psychologically, because of the single
operation and the better aesthetic result, a
patient’s wellbeing is inevitably enhanced.
“Often patients think that a breast
reconstruction may mask breast cancer
recurrence or delay breast cancer treatment,”
explained Dr Cheung. “Many studies now
show, however, that breast reconstruction
does not impact negatively on breast
cancer survival, addressing a very important
misconception by many.”
Choosing a
single procedure
Orange resident Tracey Davis met with
Dr Deborah Cheung to discuss a partial
mastectomy for a large tumour in her
breast. She had considered having a breast
reduction in the past.
“I had enough breast tissue and I wanted a
breast reduction as well, and thus, the most
expedient way was for me to have the breast
reduction done at the time of the breast
cancer surgery,” said Tracey. “Not only was my
breast able to be reconstructed at the time
of the breast cancer excision, but I was able
to have both breasts reduced to the size and
shape of my preference.
“As I needed radiotherapy after my breast
cancer surgery, I also understood that a
breast reduction done after radiotherapy
would be fraught with a high complication
rate, and thus not feasible. I also needed to
have chemotherapy after the surgery, and
there was no delay in that, despite the more
complicated operation.”
Five days after meeting with Dr Cheung,
Tracey was booked into Macquarie University
Hospital and Dr Cheung performed
an oncoplastic resection, or a partial
mastectomy, and reconstruction as a single
procedure. The breast reduction to her other
breast gave better symmetry, size and shape
than before.
“When we met, Dr Cheung went through all
my options with me,” said Tracey. “I felt very
informed. While she advised on what she
thought would be the best course of action, I
had input into what I wanted cosmetically.
“I was in hospital for a few days. While I was
there, the lymphoedema nurse took my
measurements in case I need compression
garments at a later stage. My occupational
therapist nurse back in Orange was very
impressed that the hospital had been
proactive on this – although I haven’t had any
lymphoedema issues yet.
“I am very happy with the outcome. Scarring
is minimal and in areas not noticeable. The
fact that Dr Cheung could do the operation
quickly after seeing me was a huge relief.
Also, having the motel right at the hospital
meant my family could be close to me while I
was in hospital.”
Single surgeon,
staged procedures
Often breast reconstruction after a
mastectomy can be a very complex process
requiring a stepwise approach to improve
safety and optimise cosmetic outcomes. Even
if a mastectomy and reconstruction need to
be done as two separate surgeries, patients
can still benefit from selecting one surgeon
to see them through the process. Sydney
resident Emma Korth, at aged 32, underwent
a two-stage surgical procedure with Dr
Cheung, and said she benefited from having
a single surgeon experienced in oncoplastic
surgery.
“I had a bilateral skin and nipple-sparing
mastectomy,” said Emma, who had a
10-month-old baby at the time. “Five months
later, Dr Cheung did further reconstructive
surgery. The scarring is minimal and is hidden
underneath the breast, so I can wear regular
clothes and swimwear, and you’d never know
from looking at me that I’ve had extensive
breast surgery.
“Having the same surgeon for both
procedures meant that she could explain
the whole process, prepare and manage me
post-operatively for both surgeries. She was
extremely approachable and understanding
and coordinated all procedures.
“Also, choosing Macquarie University
Hospital for all my treatment – including
my chemotherapy – made the journey
so much easier. I really benefited from
the multidisciplinary team there, who
collaborated on my case regularly, and were
able to come up with the best options for me.
While I was there, I took part in the Look Good,
Feel Better program at the hospital, and ended
up participating in their promotional video on
the program.”
Incorporating
neoadjuvant therapy
Neoadjuvant therapy is a new approach to
breast cancer treatment and can play an
important role in oncoplastic surgery. Certain
patients are eligible for this approach, which,
when given to the right patient, has the
ability to downsize the cancer and allow for
less breast tissue to be removed, thus helping
to reduce deformity.
Patient Lan Fang – who had locally advanced
breast cancer – was able to have neoadjuvant
chemotherapy followed, at a later stage, by
breast reconstruction done at the time of her
breast cancer operation.
“She is amazed that her tumour shrank to
almost an undetectable size and that she
was able to have breast reconstruction
with a nipple-sparing mastectomy and
reconstruction,” said Dr Cheung. “She was very
pleased with her cosmetic result and is very
happy that having had chemotherapy first
allowed her to see her disease responding so
well to treatment.”
In cases where a patient undergoes
post-operative radiation therapy, other
considerations come into play for an
oncoplastic surgeon. If a patient undergoing
mastectomy and requiring radiation treatment
is also considering breast reduction, then
the reduction is best done at the time of
mastectomy, given that it is not always
possible following radiation treatment due to
the strong possibility of fibrosis developing.
In addition, radiation therapy has a higher
complication rate for larger breasts and so
combining reduction with a lumpectomy or
partial mastectomy can decrease fibrosis, and
help to make the dosing of radiotherapy more
even when a breast is reduced.
Such was the case for Narelle McKenzie who,
after a mammogram found a small lump
in one of her breasts, met with Dr Cheung
to discuss options for surgery. Because
chemotherapy and radiation would both be
part of Narelle’s post-surgical treatment, Dr
Cheung advised having a breast reduction as
a combined procedure with the lumpectomy.
“Given that we knew a breast reduction would
increase the effectiveness of the radiation
treatment, my advice was to combine both
procedures,” said Dr Cheung.
ABOUT DR CHEUNG
AND THE MACQUARIE
UNIVERSITY BREAST
CENTRE
Dr Cheung is a pioneering
oncoplastic surgeon in Sydney who
has performed oncoplastic surgery
for more than 12 years. She works as
part of multidisciplinary team at the
Macquarie Cancer Institute, which
includes oncologists, radiologists,
mammographers, lymphoedema
specialists, physiotherapists,
psychologists and social workers.
Macquarie University Breast Centre
prides itself on being able to provide
a multidisciplinary opinion for all
patients and offer them a plan of
management to best suit their
condition and their preferences.