National Cancer Centre - Cancer Update

What is the profile of patients who have undergone breast reconstruction?

Majority of the patients are of the younger age group, ie, below the age of 50, of Chinese ethnicity and are working. 80% of the women who had the combined operation had early breast cancer, ie., in stages 0 to 2. Less than 10% are foreigners.

How new is breast reconstruction in Asia?

Breast reconstruction has been available for many years. The earliest cases in Singapore were performed in the 1980s. However, it’s only in the recent 5 to 10 years that we’ve seen a marked increase in patients requesting for breast reconstruction due to increased awareness.

Why is breast reconstruction not more widely done?

While doctors view breast reconstruction as a medial need, unfortunately, many Asian women feel that it is for cosmetic purposes only. They do not appreciate the psychological and emotional benefit of breast reconstruction. To many, being diagnosed with cancer is a life-threatening situation and there is no place for “vanity”. Thus, fewer Asian women opt for breast reconstruction compared to Caucasians due to such cultural differences.

What are the alternatives to breast reconstruction and when do women consider breast reconstruction, rather than these options?

When a patient requires or has had a mastectomy and decides not to have breast reconstruction, she is advised to purchase a prosthesis. This is a breast form or mound that maintains the physical appearance and sense of balance. It helps to relieve the strain on posture. Prostheses are available in a variety of sizes, shapes and colours. Some are designed to fit into a special bra while others can be attached securely to the chest using a special adhesive.

For women with early breast cancer and going for mastectomy, the option of breast reconstruction is discussed. They could talk to a plastic surgeon to learn more about the procedure to make an informed decision. Whether to have reconstruction or to wear a prosthesis has its pros and cons, and what is right for one woman may not be right for another. She has to make a decision she is most comfortable with.

How do most women react to their reconstructed breasts?

Almost all women are pleased and satisfied with the outcome and appearance. Personally, we have not had any patient who regretted her decision for reconstruction. Instead, many of them volunteered to counsel and share their experience with newly diagnosed patients.

“The flap is nourished by blood supply from one of the paired abdominal muscles.” Can you elaborate on this?

The breast can be created from skin and fat from the back or the tummy. When tissue is taken from the tummy, the fat keeps alive by getting its nourishment from the abdominal muscle. This way, the new breast remains soft and is natural to feel.

How long does the mastectomy operation take and how long for the breast reconstruction?

The mastectomy takes about 1.5 to 2 hours. Reconstructive procedures using tissues from another part of the body takes 4 to 6 hours and reconstruction with an implant takes about 2 hours.

How common is it to have mastectomy and breast reconstruction done in the same operation?

In Singapore it is very common now, given the expertise available and the close cooperation between breast and plastic surgeons. Nowadays, more than 90% of our patients who choose reconstruction have it done in the same sitting as the mastectomy.

However, it is important to highlight that combined operation is not suitable for all women who undergo mastectomy. The timing of reconstruction depends on several factors including type and stage of breast cancer, the need for further treatment after surgery, age and general health status. For patients with high risk of cancer recurrence, it is advisable to do the reconstruction at a later stage.

What are the chances of complications and what are these complication?

Chances of complications are less than 5%. Complications are rare - such as bleeding, infection, and partial loss of the new breast. This loss can happen when blood supply is insufficient particularly in patients who are obese or who are smokers. When this occurs, the reconstructed breast may be smaller.

10.

What are the key advantages of combining the two operations?

The patient wakes up with a new breast in place. The feedback has been that, emotionally, this is very gratifying to the women who undergo a mastectomy followed by immediate reconstruction. Instead of mourning for the lost breast, all their energies are channelled towards coming to terms with the new breast, healing well and carrying on with their lives.

11.

Is combining the two operations difficult?

It is not difficult. With increasing familiarity working together both breast and plastic surgeons have found it easy to operate concurrently, i.e., while the breast surgeon is removing the breast, the plastic surgeon is preparing the new breast so that as soon as the breast is removed, it is replaced with a new one.

12.

What is the recovery like?

The patient would be resting in bed for the first 2 or 3 days. After that, we encourage her to sit out of bed and even walk around in the ward. She can go home in about a week or 10 days.

An integral part of the recovery is also about the patient coming to terms with her new breast. We help reassure them as much as possible in terms of how to take care of it, how well it is healing, etc. we also offer help and advice on how to dress to give the new breast the support it needs during the recovery period, daily activities and exercise.

13.

Any pain after operation? How much scarring?

Some pain is expected and it varies from patient to patient. On our part we help with pain control by giving medication through the drip initially and later orally.

14.

Typically what do sufferers of breast cancer go through? Low self esteem? Depression?

When women are first informed of a cancer diagnosis, most would be in a state of shock and often disbelief and denial. Some would then suffer from depression, and, others anger and frustration (“why me? I watch my diet, I exercise, I don’t drink and smoke, etc.”) For some of those who have to lose the affected breast, they also have to deal with issues about their self-image and sexuality. Many are very worried about their husbands’ reaction, and even fear that their husbands might leave them because they have lost their femininity.

15.

How traumatic is the prospect of mastectomy and breast reconstruction for your patients?

The initial news that one requires a mastectomy is often very traumatic. However, the option of breast reconstruction actually offers comfort and confidence to those who are willing to consider.

16.

What is NCC’s/SGH’c success rate in breast reconstruction and in the combination procedure?

We have had high success rates (more than 95%).

17.

What difference does a successful breast reconstruction make in the life of your patients? What is the most dramatic change you’ve seen?

Actually for most of the women who are diagnosed with breast cancer and need a mastectomy, it is about being able to go on with their lives without too much of a change. That is what they seem to be most grateful for. Once they heal, most women come to terms with their new breast and seem to carry on as before with their everyday lives. On our part it is important to manage their expectations. We do this by spending a lot of time before the operation to explain the procedure and the expected outcome. We also discuss alternative approaches and get the patient involved in the whole process. The women need to go in for the surgery with realistic expectations. This is crucial for a successful result.

18.

How many of this combined operation is carried out in NCC/SGH annually? In Singapore?

70 women underwent breast reconstruction last year as compared to 50 in 2004. This year we perform 1-2 cases per week. We do not have nationwide figures. However, we feel that this campus probably performs the most number of cases a year in Singapore.

19.

Where you do think Singapore rank in this procedure?

Pretty high. Given the lifestyle, affluence, and education standards here, patients have high levels of expectation. So on our part we have to deliver high quality results.

20.

Why is it a good idea to do breast reconstruction in Singapore?

We have a good track record. Over the years our expertise in this area has grown from strength to strength. We are now called to share our views and techniques at regional and international medical meetings and in medical journals.

Over the years, we have had more women opt for reconstruction after a mastectomy. Women from the region have been coming here for reconstruction. So we are constantly building up resources and expertise to meet this demand.

Dr Tan Bien Keem

Dr Ho Gay Hui