The most important thing for you to realize, whether you decide to have any breast reconstruction at all, is that you have choices. You will choose whether or not you are going to have a reconstruction, and most women have a choice of what type of reconstruction. You can also choose a reconstruction to be done later, after a mastectomy, although the results are not as attractive in general. I think this choice itself is a very important factor for a woman in terms of regaining control of her life after being told she has breast cancer.
The second thing to remember is that unfortunately, although most breast reconstruction results are good, there is nothing that I can do to give you back your lost breast in any real way. Much of the sensation of your breasts is lost, and although there is a gradual increase in sensation, it will never be normal. You are not likely to forget that you had to go through the trauma of a mastectomy and a reconstruction. However, a reconstruction can help to simplify your life in terms of clothing, bathing suits, bras, exercise and body image.
If you have fairly large breasts or have significant risk factors (diabetes, obesity, a history of smoking, recent chemotherapy), we may start with a tissue expander. A tissue expander is basically a partially-deflated, temporary implant which is placed underneath the muscles of the chest wall or under the mastectomy flaps. This can be done either at the time of the mastectomy, three months, or many years later, depending on the patient. Associated with the implant is a valve, which is on top of the implant. This valve is under the surface of the skin. Once the skin has healed enough (about one week), the expansion process can begin. This will involve anywhere from one to six sessions in which the skin over the valve is injected with a small needle and a certain amount of injectable saline is placed in the tissue expander. Each woman is different; therefore, each patient may have a different amount of saline injected. In general, the injection process is not a painful one, although there may be a sensation of tightness for a day or so following the injection.
The first phase of breast reconstruction using tissue expanders is this stretching of the skin – expansion. Tissue expansion is very much like pregnancy in that after pregnancy, most women find that they have new skin of their lower abdomen that they did not have before. The tissue expansion actually creates new skin for us to work with if necessary. The second stage is replacing the tissue expander with a permanent implant and enhancing the aesthetics of the reconstruction. During the second stage, minor adjustments will be made in terms of the placement of the implant(s) or of the nipple areolar complexes, if they were kept, or definition of the fold underneath the breast(s). At the time of the replacement of the tissue expander, I may also liposuction the side of your chest if necessary and usually do some liposuction of your abdomen to fat graft to make your reconstruction look softer and smoother and to hide the surface and contours of your implant. Breast reconstruction with tissue expanders is always a staged procedure.
More and more we may elect to bypass the expander stage and go straight to an implant. This is only possible in small to medium-breasted women for reasons of blood supply. It is somewhat riskier than using a tissue expander because I cannot deflate the implant if I am worried about blood supply and pressure on the skin. In reality, many patients will have a second procedure to adjust symmetry or for the added benefit of fat grafting, so I cannot promise just one stage, although direct to implant is generally less painful than an expander. Two things have happened in my practice in the last few years to enable me to do at least 80% of my implant-based practice “Direct to Implant” or DTI. The first is having a “delay procedure” to preserve and enhance the blood supply to the mastectomy flaps. (Please see “A Discussion about Nipple Delay” in the Discussions section and “Surgical Delay of the Nipple Areolar Complex in High-Risk Nipple-Sparing Mastectomy Reconstruction” under Publications on my website.) The second is that Johnston Willis Hospital acquired an imaging machine called “SPY” to help assess blood flow to the mastectomy flaps accurately at the time of surgery instead of guessing.
A procedure on the other breast may also be performed at the first or second stage to help give symmetry with the reconstructed breast. This procedure may be a breast lift, a breast reduction or a breast augmentation depending on the anatomy of the patient. By federal law, insurance must cover the necessary procedures on both breasts. Some patients will opt for a double mastectomy, but this is a decision to be made with your breast cancer surgeon.
The advantage of reconstruction with tissue expanders is that although this is usually a staged procedure, each stage is relatively short with a fairly brief recovery and less pain than a DIEP flap, latissimus flap or TRAM flap. The first operation takes 45 minutes to an hour per breast, and the second operation is generally less time. Another advantage is that the blood loss for each procedure is relatively small. Also, there are no additional scars on the body with this operation other than the original mastectomy scar.
The disadvantages of the procedure are that it is usually a staged procedure (two or more operations) and that although the size and shape of your reconstructed breast is not likely to change very much, your normal breast will continue to change size and shape, especially if you gain or lose weight. A reconstructed breast by an implant is never perfectly symmetrical with the normal breast. However in a bra, the difference should be unnoticeable, even in the long term. This is why a bilateral implant mastectomy reconstruction often looks better than a unilateral reconstruction.
Infection is a possibility after any surgery. The risk of infection after breast reconstruction with implants would be about 1% to 5%. Nonetheless, it is a serious problem because should a significant infection occur with an implant, sometimes this cannot be cured with antibiotics alone, and the implant would have to be removed, although it can be replaced. Also, because of the mastectomy, you may accumulate fluid (a seroma). This is the fluid that normally comes through the drain. Usually the body absorbs this, but occasionally this fluid will need to be drained in the office.
There are certain risks that are unique to implantable devices. The body reacts to a foreign material by placing scar tissue around it. This is similar to an oyster which, in response to chronic irritation, makes a pearl around a grain of sand. This scar tissue or “capsule” can either be a thin, soft, unnoticeable layer, or in the extreme, this can be a firm layer of scar tissue around an implant that can be uncomfortable or even change the shape of the reconstruction. Should this occur, additional surgery may be necessary to remove the scar tissue and replace the implant. The risk of capsular contraction is unpredictable because it depends on each patient’s healing capabilities. Smokers heal poorly in terms of infection and wound breakdown. You are advised not to smoke for at least 1 month before and after surgery. Nicotine screening may be necessary the day of your surgery. IF THE TEST IS POSITIVE, YOUR SURGERY WILL BE CANCELLED.
Obviously, any device can have a mechanical failure. An implant may rupture. The rupture rate for the implants I use is about 7.5% at 10 years. This can be from trauma (rarely) or normal wear and tear. If it should rupture, it can be replaced. Luckily, after your mastectomy and reconstruction, you will never need a mammogram on that side again, and this is one of the most common causes of implant rupture. The implants that I usually use in breast reconstruction are silicone gel. Silicone gel implants tend to feel more natural, but if they rupture, they may cause an encapsulation over time. There is less “rippling” visible with silicone gel implants. However, a slender woman with little fat and a thorough mastectomy (which will leave very thin skin flaps) will almost always feel the edge of her implant on the side of her breast, silicone or saline. The new silicone gel implants have a much stronger shell and more “cohesive” silicone which is less likely to spill or ripple and may encapsulate less. I can show you the difference between the new and old implants in the office. Saline gives more flexibility when choosing a volume but does not feel as natural and ripples much more. The bottom line is that there is no perfect prosthesis, and I will help you choose one in your comfort zone.
I need to caution you that radiation therapy, either before or after implant surgery, may cause marked scar tissue formation (encapsulation) around an implant. It also predisposes you to wound-healing issues, infection and implant loss. For this reason, an implant may not be the first choice reconstruction for these patients. Radiation can impact a reconstruction. If you have had previous irradiation, you are more prone to wound-healing issues and may not have a successful implant reconstruction. If you will need radiation after surgery, there is new evidence that an implant above the muscle may have less pain and deformity than under the muscle, although the skin is more delicate. This is still a controversial topic. Statistically, the patients most likely to have complications after reconstruction are significantly overweight, have large breasts which often require complex incisions, have high blood pressure, are diabetic, smoke or have been radiated.
There is a new technique for implant-based reconstruction called pre-pectoral reconstruction. In this technique, the implant is placed in front of the muscle instead of behind it. This avoids animation deformity, or the twitching of the top of the breasts, that significantly annoys about 25% of women. (Please see “Animation Deformity in Post Mastectomy Implant-Based Reconstruction” under Publications on my website). The other advantage is less pain, especially in the first few weeks after surgery. The disadvantages are that this is a new technique with no long-term follow-up as of yet. In addition, the implant is more visible and palpable and tends to ripple more. Several fat grafting procedures may be needed to hide the edge of the implant which is covered only by the patient’s skin and a sheet of allograft (sterilized cadaver skin). The final drawback to pre-pectoral reconstruction is that each sheet of allograft is extremely expensive, although this is covered by your insurance company. I will be glad to discuss the pros and cons of either pre-pectoral or sub-pectoral breast reconstruction with you.
I hope this information has not been overwhelming. I have tried to give you as complete information as possible so that you can make an informed decision. Nonetheless, I would like to emphasize that the vast majority of patients are glad they had an implant reconstruction and are quite satisfied with their results. It will be a pleasure to discuss breast reconstruction options with you. Please do not hesitate to call the office with any questions (804-320-8545).