BREAST CANCER RECONSTRUCTION

Patients often believe breast reconstruction can be achieved in one surgery. The truth is that the nature of breast reconstruction typically requires more than one operation to provide the best possible outcome.

The number of procedures is variable depending on quality of the mastectomy, type of reconstruction chosen, and individual patient expectations. It is not unusual for patients to decide to have two or three secondary revision procedures after their initial breast reconstruction has healed.

During the second stages of breast reconstruction, I will have the opportunity to finalize the breast shape, enhancing the quality of the aesthetic appearance created during the initial operation. If needed, nipple reconstruction is accomplished at the time of any secondary revision surgery. Most staged revision procedures are done as outpatient surgery with an easier recovery than the original mastectomy and breast reconstruction.

I provide an individualized approach for every patient, offering the full range of immediate and secondary breast reconstruction options, customized to the needs of every patient.

The decision regarding nipple-sparing mastectomy is coordinated by your breast surgeon and your plastic surgeon.

Breast surgeons follow specific criteria that take factors such as tumor size and distance from the nipple into consideration.

Plastic surgeons also have criteria that they take into account, such as breast size, nipple areola position and the type of reconstruction planned. From a plastic surgery perspective, it is more challenging to preserve the nipple at the time of mastectomy in women with larger breasts, and women with breasts that are lower on their chest. In these situations, preserving the nipple may require a staged approach, beginning with a breast lift or breast reduction before proceeding with mastectomy and reconstruction.

Many women are good candidates for nipple-sparing mastectomy, particularly those facing risk-reducing surgery. Shared decision-making between the patient, the breast surgeon, and the plastic surgeon is needed to guide this decision.

Yes.

The Federal Women’s Health and Cancer Rights Act of 1998 mandates insurance coverage for any breast surgery, even when multiple procedures are needed.

This means that any surgery on the side of the lumpectomy or on the opposite healthy breast is covered by insurance, including breast enlargement with an implant, breast lift surgery, and breast reduction.

This also applies for women who had mastectomy on one side. When one breast is removed and reconstructed, surgery for the healthy breast is often required for symmetry.

For women with breast cancer, surgery to improve breast shape or breast symmetry is not considered cosmetic surgery. Even if the surgery is done to improve the contour of a healthy breast.

The decision for the type of surgery desired is made by the patient and her plastic surgeon, not by the insurance company.

Not every woman who has a mastectomy chooses typical breast reconstruction. Women who decide not to undergo a breast reconstruction procedure still have options to improve the appearance of their chest wall.

When not approached aesthetically, mastectomy closure often leaves excess skin and tissue, potentially creating contour deformities. Aesthetic Flat Closure is a surgical procedure that removes or rearranges excess breast skin and fat after a mastectomy to produce a smooth, flat chest wall contour. This can be done at the time of mastectomy or at a second stage. If needed, revision procedures such as fat grafting can further contribute to the best possible outcome.

Times are ever changing in the breast cancer world. In an effort to be more inclusive, The National Cancer Institute now includes Aesthetic Flat Closure in its dictionary of terms. This is exciting because it increases awareness regarding all of the options available to patients for their post-mastectomy bodies. In addition, recognition by the NCI can help in educating surgeons so they include this option in their discussion with patients.

Aesthetic Flat Closure IS a type of reconstruction and is a very powerful choice that deserves just as much care and respect as any other reconstructive surgery.

During breast reconstruction with implants, the implants can either be placed under the muscle (UTM) or over the muscle (OTM). Your plastic surgeon can help you decide which is better for you.

In the past, the standard approach to implant breast reconstruction required that implants be placed UTM.

Today, placing implants OTM is always preferred in my practice. But this can only be done if the quality of breast skin is sufficiently good after mastectomy. Sometimes, to prevent problems with healing, plastic surgeons have no choice but to place the implants UTM at the time of mastectomy.

The problem is that many patients with implants UTM have a feeling of tightness and develop animation or unnatural movement of their implants, particularly when they are active.

I now routinely perform corrective surgery to address these problems. To move an implant from UTM to OTM, the implant is removed and the pectoralis muscle is reattached to the chest wall where it belongs. The implant is then placed in a more natural position OTM. After this surgery, patients have much less tightness and their implant animation is resolved. 

If you are planning risk-reducing mastectomies and breast reconstruction, you should take the time needed to assemble your team.

It is important to remember that the quality of your reconstruction is only as good as the quality of your mastectomy.

The plastic surgeon who is an expert in breast reconstruction will know who the best breast surgeons are in your community and which breast surgeons provide the best quality mastectomy.

Make sure to allow your plastic surgeon to guide you early in the process of your decision making. Seeing the plastic surgeon who is expert in breast reconstruction first can help you determine your choice of breast surgeon.

Any plastic surgeon specializing in breast reconstruction should be experienced in the most advanced microsurgery techniques and should offer implant and natural-tissue options. They can help you determine which approach to mastectomy is best for you. This will not only depend on your breast size and breast shape, but on your desires and expectations.

It is never an easy task to make big surgical decisions related to risk-reducing mastectomy and breast reconstruction, especially when there is an overwhelming amount of information presented to you by doctors, family, and friends. But your first decision should be easy – see your plastic surgeon first, or at least make sure that a plastic surgeon participates in your decision making very early in the process.

After implant reconstruction you will wake up with a post-surgical bra that offers compression and a place for drains to hang (if applicable). It is important to keep the chest supported and compressed to keep swelling down and allow healing. 

Since something needs to be worn for 4-6 weeks around the clock my patients tell me they find comfort in sports bras (with zippers recommended as it may be hard to get one over your head).

Sensation after mastectomy can potentially be improved by reconnecting nerves that were cut during mastectomy to nerves that go to a flap during natural-tissue breast reconstruction.

While sensation lost after mastectomy can improve over time, reattaching these nerves can increase the amount of sensation that returns.

Natural-tissue flaps from the lower abdomen and thighs have nerves that can be identified and connected using nerve allografts to nerves that were cut at the time of mastectomy. With the help of an operating microscope, I now do this routinely at the time of natural-tissue breast reconstruction.

We now also offer nerve graft procedures using nerve grafts to reconnect nerves to the nipple areola at the time of implant reconstruction. In this way, when implant reconstruction is done simultaneously with nipple sparing mastectomy, the nerves to the breast can be preserved and attached to nerve endings under the nipple.

As with any other breast reconstruction option, the decision between tissue expander reconstruction and direct-to-implant reconstruction is shared between the patient, her plastic surgeon, and her breast surgeon.

From my perspective, whenever possible, the direct-to-implant approach is preferred. This allows us to avoid the expansion process. Also, after direct-to-implant reconstruction we are still able to do a second stage revision surgery if desired.

Before surgery, the decision between tissue expander and direct-to-implant approaches depends on individual patient expectations regarding breast size. For patients who want a final breast reconstruction larger than their original breast size, tissue expander reconstruction is generally preferred. Otherwise, if there is sufficient healthy breast skin to support an implant, the direct-to-implant approach is ideal.

In direct-to-implant cases I always have tissue expanders available in case the breast skin immediately following the mastectomy is not sufficient or healthy enough to support the final implant. This is a judgment call that is made in the operating room at the time of surgery.

In the overwhelming majority of patients, I am able to predict before surgery if they are better candidates for tissue expander reconstruction or the direct-to-implant approach.

It would be easy for me as a surgeon to give you the medical answer to this question. However, since I can’t speak from personal experience, I asked a patient this question and this was her response:

“YES! Implants feel much different than expanders.

Expanders are hard and at times painful to the touch, especially around the port. They don’t really move at all and they don’t feel natural. There is also the feeling of having your chest bound at all times, even when not wearing a bra. Fortunately, the expanders are only temporary.

Implants feel lighter, softer and look more natural than expanders. I found that they aren’t as heavy as my expanders were, and over time the tightness in my chest eased a little. For me, it took about 4-6 months for the implants to feel like they are more part of my body versus “accessories”. Of course, they will never feel like my natural breasts, but they are much easier to dress, workout with and sleep with comfortably.”

Breast implant profile refers to how far off the chest wall the implant will extend. It is important to understand that for any given implant volume, the higher the profile, the narrower the implant.

All implant manufacturers offer a variety of implant profiles. For example, Natrelle offers five profile options. Low profile projects the least and is the widest option. Extra Full profile is the highest projection implant and is the narrowest option for any given volume. In between these options we have Low Plus, Moderate, and Full profile options.

Following mastectomy, low profile implants are typically used for women that are not looking for larger breasts. Moderate offers more projection while the Full or Extra Full profiles are the most dramatic.

Deciding what profile implant is right for you is based on the look you want and your anatomy. Every woman’s body is different. It’s my job to understand my patients’ expectations and to make sure that they align with what is possible based on their anatomy. As with most breast reconstruction decisions, this is one that is shared between the patient and her surgeon.

After DIEP flap breast reconstruction, a woman should be able to have a normal pregnancy and delivery.

With DIEP flap surgery, the muscles of the abdominal wall are preserved. Even though skin is removed, pregnancy is not a problem because the abdomen expands slowly over a period of months.

I have had patients go on to have normal pregnancies following DIEP flap surgery. This issue most commonly comes up when I see young women with genetic mutations who are pre-disposed to breast cancer. As they plan their future, the question regarding pregnancy comes up as it relates to their breast reconstruction. The choice of type of reconstruction should not be affected by the decision to have a pregnancy.

Women preparing for mastectomy usually have an idea as to what size they want for their reconstructed breasts. Sometimes patients will tell me that they want a specific size and shape implant because that’s the size or shape that a friend of theirs might have. Unfortunately, choosing an implant is not so easy.

People come in many different sizes and different shapes. That’s why breast implants come in multiple different sizes and variety of different profiles.

It’s important to understand that every implant size and implant profile does not look the same in every patient. For example, the same implant will look completely different in a woman with a narrow chest as compared to a woman with a wider chest.

For women having breast reconstruction after mastectomy, choice of implant type (gel vs. saline), implant degree of cohesivity, implant profile, and implant volume must be customized to allow for the best possible outcome. While the choice of implant size and profile can be predicted to some extent before surgery, the final implant choice is frequently a game-time decision during surgery.

Since 1997, I have done thousands of breast reconstruction procedures in my practice. For implant breast reconstruction, my experience has been with Natrelle and Mentor implants. Taking patient expectations into consideration, I am able to rely on my experience when choosing implant type, size, and profile.

When a mastectomy and breast reconstruction are completed, breast tissue is elevated off of the muscle on the chest and separated from the overlying breast skin. This type of surgery leaves behind raw surfaces that cause your body to create fluid. This fluid is called serous fluid and is a normal part of your body’s healing process.

If this serous fluid accumulates under the skin, there is an added risk of infection and poor wound healing. Placing a drain prevents fluid from accumulating after mastectomy surgery and thereby expedites healing and recovery.

Drains are needed for both implant reconstruction surgery and natural tissue flap breast reconstruction. Drains may also be needed for major breast revision reconstruction procedures, but only if a new raw surface is created under the breast skin during surgery. Minor breast revision procedures and those where no new planes are created typically do not require drain placement.

My preferred type of drain is a round silicone tube with channels that drain the fluid into a bulb. This type of drain easily slips out when it is removed, with minimal discomfort. In addition, channel drains are less likely to get clogged or have other problems as compared to other types of drains.

Women frequently ask how many years after implant breast reconstruction they need to change their implants. The answer is that there is no preset time.

In the years after mastectomy and implant reconstruction, it is important to continue to be monitored by your doctors. Your plastic surgeon can tell you how frequently you need to be followed with regards to your breast implants. Whether they are saline or silicone, if you are not having any problems with your breast reconstruction, and you are comfortable with your implants, you shouldn’t need to change your implants.

The risk of implant problems increases over time. If there is a leak in the outer shell of an implant, then the implant should be changed. If a saline implant has a leak, the implant volume deflates, making it relatively easy to diagnose. On the other hand, a silicone gel implant leak might require a breast MRI to be diagnosed. Leaky or otherwise problematic implants can usually be changed as an outpatient procedure without a difficult recovery.