Breast Reconstruction

The Best Candidates for Breast Reconstruction

Most mastectomy patients are medically appropriate for reconstruction, many at the same time that the breast is removed.

 

Still, there are legitimate reasons to wait. Many women aren't comfortable weighing all the options while they're struggling to cope with a diagnosis of cancer. Others simply don't want to have any more surgery than is absolutely necessary. Some patients may be advised by their surgeons to wait, particularly if the breast is being rebuilt in a more complicated procedure using flaps of skin and underlying tissue. Women with other health conditions, such as obesity, high blood pressure, or smoking, may also be advised to wait. History of breast radiation and smoking may put you at a higher risk of reconstructive failure, leading to more conservative approaches. Breast reconstruction is "elective" and patients should be medically optimized.

 

In any case, being informed of your reconstruction options before surgery can help you prepare for a mastectomy with a more positive outlook for the future.

 

All Surgery Carries Some Uncertainty and Risk

Virtually any woman who must lose her breast to cancer can have it rebuilt through reconstructive surgery. But there are risks associated with any surgery and specific complications associated with this procedure.

 

In general, the usual problems of surgery, such as bleeding, fluid collection, excessive scar tissue, or difficulties with anesthesia, can occur although they're relatively uncommon. And, as with any surgery, smokers should be advised that nicotine can delay healing, resulting in conspicuous scars and prolonged recovery. Occasionally, these complications are severe enough to require a second operation.

 

If an implant is used, there is a remote possibility that an infection will develop, usually within the first two weeks following surgery. In some of these cases, the implant may need to be removed for several months until the infection clears. A new implant can later be inserted, sometimes requiring tissue rearrangement. 80% of blood supply to the skin is taken with mastectomy, skin necrosis can occur, which may require debridement or removal of implant.

 

The most common problem, capsular contracture, occurs if the scar or capsule around the implant begins to tighten. This squeezing of the soft implant can cause the breast to feel hard. Capsular contracture can be treated in several ways, and sometimes requires either removal or "scoring" of the scar tissue, or perhaps removal or replacement of the implant. Patients who have had capsular contracture have increased risk of recurrence. There are diseases associated with breast implants and capsules which are very rare. BIA-ALCL is a lymphoma associated with implants, mostly textured implants, that occurs years after placement. Squamous Cell Carcinoma (SCC) of the capsule has also been seen.  Some women develop intolerance to implants, but that can improve with implant removal.

 

Reconstruction has no known effect on the recurrence of disease in the breast, nor does it generally interfere with chemotherapy or radiation treatment. Your surgeon may recommend continuation of periodic mammograms on the remaining normal breast. If you need radiation, it can affect the ultimate results of your reconstruction, leading to events like capsular contracture or implant exposure.

 

Women who postpone reconstruction may go through a period of emotional readjustment. Just as it took time to get used to the loss of a breast, a woman may feel anxious and confused as she begins to think of the reconstructed breast as her own. For patients who use their own tissue, risks include infection, wound healing issues, flap failure and bleeding.

 

Planning Your Surgery

You can begin talking about reconstruction as soon as you're diagnosed with cancer. Ideally, you'll want your breast surgeon and your plastic surgeon to work together to develop a strategy that will put you in the best possible condition for reconstruction.

 

After evaluating your health, your surgeon will explain which reconstructive options are most appropriate and available for your age, health, anatomy, tissues, and goals. Be sure to discuss your expectations frankly with your surgeon. He or she should be equally frank with you, describing your options and the risks and limitations of each. Post-mastectomy reconstruction can improve your appearance and renew your self-confidence -- but keep in mind that the desired result is improvement, not perfection.

 

Your surgeon should also explain the anesthesia he or she will use, the facility where the surgery will be performed, and the costs. In most cases, health insurance policies will cover most or all of the cost of post-mastectomy reconstruction. Check your policy to make sure you're covered and to see if there are any limitations on what types of reconstruction are covered.

 

Types of Implants

If your surgeon recommends the use of an implant, you'll want to discuss what type of implant should be used. A breast implant is a silicone shell filled with either silicone gel or a salt-water solution known as saline. We will discuss all the different implants along with risks and benefits.

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The Surgery

While there are many options available in post-mastectomy reconstruction, you and your surgeon should discuss the one that's best for you.

 

Implant-based reconstruction: Depending on your goals, anatomy, pre-existing conditions, need for post-operative radiation, quality of mastectomy flap and tissue expander or implant (direct to implant) can be done at time of the mastectomy.  Cadaveric dermis is used to help create the pocket for the implant at the time of surgery.

 

Tissue expander: A balloon expander is placed under the skin. Through a tiny valve mechanism in the expander, we will periodically inject a salt-water solution to gradually fill the expander over several weeks or months. After the skin over the breast area has stretched enough, the expander may be removed in a second operation and a more permanent implant will be inserted. The nipple and the dark skin surrounding it, called the areola can be reconstructed in a subsequent procedure, or now recreated with a 3D tattoo if the nipple was not spared. The valve is a magnet and patients cannot have MRI's with a tissue expander in place.

 

Many patients do not require preliminary tissue expansion before receiving an implant. For these women, the surgeon will proceed with inserting an implant as the first step. Patients who have silicone implants require MRI or high-def ultrasound at 5 years from placement and every 2-3 years after to evaluate for rupture.

 

Flap reconstruction. An alternative approach to implant reconstruction involves creation of a skin and fat flap using tissue taken from other parts of the body, such as the back, abdomen, or buttocks. The most common site is the abdomen, and can be done in delayed manner by placing the tissue expander first, getting the patient through any necessary subsequent treatment, and then having the "free flap" surgery.

 

This is called "Autologous tissue transfer," or using your own tissue or"deep inferior epigastric perforator flap procedure" - tissue can be used from the thigh, back, buttocks - all having different names. These surgeries entail dissecting the blood vessels from two sites on the donor and plugging them into blood vessels in the chest. The tissue will behave and change like the donor site. This procedure requires the skills of a plastic surgeon who is experienced in microvascular surgery as well. This type of procedure is done at major teaching institutions like in Boston or Lahey Health.

 

Using your own tissue includes two sites that are operated on, and not everyone is a candidate. There is a risk that the blood vessels may clot, creating flap failure. Patients are monitored early post-operatively. When the breast is reconstructed entirely with your own tissue, the results are generally more natural and there are no concerns about a silicone implant. In some cases, you may have the added benefit of a improved abdominal contour.

 

Follow-up procedures. Most breast reconstruction involves a series of procedures that occur over time. Usually, the initial reconstructive operation is the most complex. Follow-up surgery may be required to replace a tissue expander with an implant or to reconstruct the nipple and the areola or fat graft. Many surgeons recommend an additional operation to enlarge, reduce, or lift the contralateral breast to match the reconstructed breast. But keep in mind, this procedure may leave scars on an otherwise normal breast. Surgery to create symmetry is covered by insurance

 

Your New Look

Chances are your reconstructed breast may feel firmer and look rounder or flatter than your natural breast. It may not have the same contour as your breast before mastectomy, nor will it exactly match your opposite breast. But these differences will be apparent only to you. For most mastectomy patients, breast reconstruction dramatically improves their appearance and quality of life following surgery.

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