Considering a lumpectomy?

You should know:

• Candidates for reconstruction after lumpectomy are usually women with larger breasts—a C or D cup.
• In some cases, having a completion mastectomy and breast reconstruction can eliminate the need for radiation treatment.
• Some women may be candidates for nipple-sparing mastectomy and reconstruction.
• Radiation treatments are a major factor in the timing of reconstructive surgery.

Understand your reconstruction options

According to researchers at the University of Michigan Comprehensive Cancer Center, patients who have breast-conserving lumpectomy surgery are less likely than mastectomy patients to have their doctors discuss the types of changes they can expect in their breasts' appearance.

The Michigan study also found that one-third of women who had a lumpectomy have an asymmetry between their breasts that greatly affects their quality of life, which can lead to depression and fear.

There have been many advances in breast-conservation therapy—including reconstruction after nipple-sparing mastectomy. “After nipple-sparing surgery, some women actually have a better shape to their breasts than they had before,” says Dr. Rappaport.

If you are having a partial mastectomy or lumpectomy, it is important to understand your reconstruction options—ideally, before you have your breast-conserving surgery.

Dr. Rappaport answers questions
about reconstruction after lumpectomy

How does choosing lumpectomy
affect my reconstruction options?

“Virtually all patients who undergo partial mastectomy require radiation—which alters your options for reconstruction. Patients who have a lumpectomy and subsequent radiation usually do not have implant reconstruction.”

What type of reconstruction
is typically done after lumpectomy?

“That depends on the size of your breasts. We usually do reconstruction through local tissue rearrangement in women with larger breasts—C or D cup or larger.

“Women with A or B cup breasts who have a significant distortion or appearance change after lumpectomy and radiation often go on to have completion mastectomy or flap reconstruction.”

Are there advantages to choosing a completion mastectomy over a lumpectomy?

“In some cases, yes. If a woman has smaller breasts and has a significant portion of tissue removed, then, from a cosmetic and reconstructive standpoint, it's usually easier to have a simple mastectomy and breast reconstruction. An added advantage is that these patients may not require chemotherapy or radiation.”

Does having a completion mastectomy always eliminate the need for chemo or radiation?

“No. Whether you will need radiation or chemotherapy depends on the tumor type, grade and location, and the size of the margins. Most of the time, a woman who is a candidate for a lumpectomy has a DCIS (ductile carcinoma in situ) or some type of very small, low-grade tumor. In these cases, performing a mastectomy in itself may be sufficient, along with sentinel node biopsy. These patients may not require chemotherapy or radiation.

“On the other hand, given the location of the tumor and the size of the margins, the proximity to the skin and the underlying muscle, a woman might require chemotherapy and/or radiation. That's why each woman's case has to be considered individually.

“Generally speaking, having a simple mastectomy in an appropriate case may eliminate the need for radiation as opposed to requiring radiation after a lumpectomy.”

Can the nipple be spared during mastectomy and reconstruction?

“Yes. In some cases, it is possible to preserve the natural nipple and areola through nipple-sparing mastectomy and reconstruction.”

How does radiation affect the breasts?

“Radiation has progressive, ongoing effects on the breast, which continue indefinitely. With a woman who has a lumpectomy, there is going to be contraction of that breast on a progressive basis.”

Can I have implants after radiation therapy?

“In most circumstances, patients who have radiation don't do as well if they have implants because of the skin contraction that occurs with radiation changes. If you have a fairly adequate volume of tissue and a soft breast and you choose implants, I will do that on occasion, but as a rule, I would prefer to avoid using an implant in a radiated breast.”

How does local tissue rearrangement work?

“Local tissue rearrangement uses a variant of a breast reduction pattern for larger-breasted women, and attempts to shift natural tissue into the area of defect from the partial mastectomy. That is usually best accomplished at the time of mastectomy. Local tissue rearrangement can be performed on a delayed basis, but with higher risk.”

In most cases, is the nipple left intact
after a lumpectomy?

“Yes, that's one purpose of breast conservation therapy. Nipple sensation may be altered and there might be some distortion of the nipple or areola, depending on how much tissue was removed and the size of the breast.”

Does breast conservation therapy
always give a better aesthetic result?

“Women who have breast conservation therapy are probably much more body image-sensitive to begin with, and don't want to lose that body part. The fact is that other reconstructive forms are available, which may give superior results in some cases.”