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August 2011 Ask the Expert: Breast Reconstruction

During the month of August, Living Beyond Breast Cancer expert Ariel N. Rad, MD, PhD, answered your questions about breast and nipple reconstruction methods, the pre- and post-surgical process, factors that impact reconstructed breasts over time, the decision-making process and what questions to ask during the consultation process.

Dr. Rad may be contacted at:

The Johns Hopkins Hospital
(443) 287-6425
igorman2@jhmi.edu; arad1@jhmi.edu

You may also be interested in News You Can Use: Breast Cancer Updates for Living Well.

What are my options for breast reconstruction if I have a mastectomy?

Can I have reconstruction if I only had a lumpectomy?

What are the risks associated with breast reconstruction?

What if my natural breast does not match my reconstructed breast?

Can I still get cancer in my reconstructed breast?

Can I have implants if I had prior radiation, or need future radiation?

Am I an ok candidate for surgery? I have metastatic breast cancer, and one of my wishes is to leave this world with pretty breasts. More importantly, my breasts are quite sensitive in a happy way, but now I am too “hung up” by the optics to take advantage. So here are some details: I had a left breast over-the-nipple area lumpectomy (tumor was approximately 6 cm and also had sentinel node—they found 8 affected and took out 21). The surgeon did a nice job, but if my left breast were a car you would certainly classify it as a noticeably "dented.” I am not overweight (5'6" 150 lbs) but I do have some extra cargo in the love handle section. Would DIEP or SGAP be better, or maybe neither?

What are my options for replacing saline implants placed in 1994? What changes or improvements have been made?

Is it common for women who have had reconstruction using the latissimus dorsi muscle to feel as if they have a small rolled up newspaper under their arm? I have been told it is not lymphedema.

Is it common for women who have had reconstruction using the latissimus dorsi muscle to feel the muscle contract in the lower breast area when making certain arm movements?

My plastic surgeon plans to tattoo a nipple on my reconstructed breast. How successful are nipples made and grafted on? Are there any pictures of tattoo nipples?

I am 19 months post implant exchange reconstruction. I still have daily pain and cannot go without wearing a bra for much period of time. Is this normal?

My implants cause ripples that are very evident. My surgeon said he could try to remove the implant and tighten up the pocket and reinsert, but that I would face potential problems with "playing with them.” Do you have any thoughts or comments on the ripples seen with implants or how to improve them?

How common is the gluteal free flap procedure? How would I find a surgeon in my area who does this kind of procedure?

I got a lumpectomy in 1998. Though I asked at the time about the flap procedure and having a plastic surgeon on board, the breast surgeon said he was good and not to worry. I hate the way my lumpectomy has deformed my breast. The tumor was not small and my right breast is half the size of my other breast. Is it possible to undergo successful breast reconstruction without charge after all this time? If my right breast is the one that is deformed, will it be necessary to work on both breasts so they are even or just the right breast? I am no longer young (67) and wonder whether reconstruction is advisable.

Does what your stage is matter in determining whether to do reconstruction?

Does weight and/or BMI limit your choices for breast reconstruction?

Can you opt for a TRAM flap reconstruction if you have waited 2 or more years after mastectomy?

I have one reconstructed breast after a mastectomy and radiation treatment. My question concerns the nipple reconstruction. I had it done (by some sort of origami procedure with the skin), but it did not last. After a few short months the skin returned to being flat. The plastic surgeon who did my entire surgery (but is now out of insurance network) has said that this is because the skin is irradiated and it did not hold, but at the same time he advised that I could try again. Does it make sense to try again or will it never hold? If it does make sense and since I had the surgery once, any suggestions for justifying the repeated attempt to my health insurer?

What are the pros and cons of fat grafting to get rid of implant ripples?

Is it safe to get a decorative tattoo on a reconstructed breast when the skin is very thin?

I am a 7-year breast cancer survivor. I had ductal carcinoma in the left breast, stage IIB, no lymph node or BRCA gene involvement. I had 6 months of chemo and 8 weeks of radiation; I had a bilateral mastectomy with bilateral saline implants, and I had a cellulitis infection two times. I had two replacements on the left side; my last surgery was in 2007. I now have capsular contraction around the left breast—my plastic surgeon said he will not put in another implant due to radiation damage to my skin and due to the fact that the skin is too thin. Is this true? I did go for two opinions so far. One doctor said there would be no problem; he would just take out the implant and remove scar tissue. He told me that my skin is healed enough to replace with gel implants and he would do both to match. Two other docs told me this was impossible due to radiation damage. I'm so confused. My current doctor and two others recommend trans flap procedure; I'm scared and just don't know what to do, but I'm so tired of living in chronic pain from this implant. It also causes numbness and tingling down my arm and shooting pains into my chest—what do you think?

I had a lumpectomy (4 cm tumor), axillary node dissection (2 positive nodes), chemo and radiation 14 years ago. The left breast is significantly different than the right one (including not sagging). I'm considering surgery options. I have a large amount of "host" tissue elsewhere, so a DIEP is certainly an option. Does length of time after initial surgery have negative affects? Can this be combined with breast lift and possible DIEP augmentation of the other breast in order to create more symmetry?

Why should I have plastic or reconstructive surgery at a teaching hospital where I won't know if the attending I select will actually do the surgery himself or assign the case to one of the surgical trainees?

Can sexual activity cause an implant to move? I'm wondering specifically about the pressure from a male partner leaning on reconstructed breasts. The implants can be pushed to the side and I'm concerned that may cause the implants to be dislodged.

I had a latissimus dorsi flap reconstruction along with a saline implant in 2004. I'm in my 40s now. I would rather just have the implant permanently removed as I have troubles with capsular contraction, but I can't find a single plastic surgeon who will even talk with me about permanently removing my implant. Is this so uncommon a request? I'm guessing the latissimus dorsi can't be "undone," but surely the implant could be removed?

Question: What are my options for breast reconstruction if I have a mastectomy?

Dr. Rad: Trying to understand the whole spectrum of breast reconstruction is like trying to drink from a fire hydrant—it's overwhelming! I'll try to put it in a nutshell.

The simplest way for you to think about your options is to consider two different paths: implants or your own tissue. Each has pros and cons, and many different techniques may be used to achieve great results.

On one hand, implants are ideal for women who are very thin and athletic since they don't have much extra tissue (body fat) to spare. Implants are easy to use, involve the least down time, are safe (in 2007 the FDA lifted a 10-year moratorium on the use of silicone implants since their safety profile has since been proven), and last a long time (only 10 percent of women with implants will need replacements in the first decade).

The down side to implants is the fact that they don't feel exactly like your own tissue, they may rupture (it comes as a surprise to many women that you'll need an MRI scan every two years to monitor the implants), and you may need surgery to correct problems like capsular contracture. If you have had radiation therapy as part of your cancer treatment, the risk of having these problems is much higher (there is about a 50-60 percent chance of needing surgery to release scar tissue when implants are used in a radiated breast.)

On the other hand, using your own tissue solves all the dilemmas associated with implants. This generally involves borrowing skin and fat from the abdomen, although other tissue sources are available (the buttock region, inner thighs and back.)

One technique that I employ frequently is the DIEP flap. This is a highly complex microsurgical operation whereby the abdominal skin and fat (not muscle!) is carefully dissected and then transferred to the breast where the blood vessels are connected under a microscope with tiny sutures that are thinner than a human hair. Patients also have a tummy tuck in the process, which is a bonus! There are easier ways to transfer the abdominal tissue (such as the TRAM flap), but these remove the rectus abdominal muscles which significantly compromises core strength and integrity—I generally don't recommend this. The downsides to the DIEP flap are the longer recovery time, length of scars (though we have good treatments for scars now), and higher chance of complications. However, in the experienced hands of a microsurgeon, the DIEP flap is arguably the gold standard!

Question: Can I have reconstruction if I only had a lumpectomy?

Dr. Rad: ANY cancer-removing surgery, including lumpectomy, may result in a breast deformity that requires reconstruction. So, the short answer is "yes!"

"Breast conserving" techniques like lumpectomy are popular because they're quick outpatient procedures with minimal downtime, but a drawback to lumpectomy surgery is that it can result in a deformed contour (as well as the fact that it commits patients to radiation therapy which can cause other problems.)

The severity of the breast deformity depends on 2 factors: the size of the breast and the size of the lump. It's intuitive that removing a large lump in a small breast will result in a big divot. In these situations, plastic surgeons are involved to move breast tissue around in clever ways to restore a normal and attractive breast form.

One reconstructive technique that works well for certain patients having a lumpectomy is called "oncoplastic breast reduction." The ideal patient has large breasts, would like to have smaller, more lifted breasts, and has a favorable location of the lump (usually in the inner or outer regions of the breast). Using breast reshaping and lifting techniques (called "reduction mammaplasty"), patients can have a very aesthetic breast lift and reduction at the same time as their cancer removal. Usually, the scar goes around the areola and then straight down, like a "lollipop" shape, and then has a curved scar in the natural fold beneath the breasts. Depending on the location of the lump, the scar pattern that results may be different.

Question: What are the risks associated with breast reconstruction?

Dr. Rad: Breast reconstruction is generally safe. As with any surgery, there are risks associated with the operation and with anesthesia, and these relate to how many medical illnesses a patient has.

Heart disease, lung, kidney or arterial disease, tendency for developing blood clots ("deep venous thrombosis," or DVT), etc. are all major risk factors for significant complications during anesthesia. Risk factors for plastic surgery relate to a patient's ability to heal wounds.

The most important risk factor is smoking. Nicotine decreases blood flow through the capillaries, the tiny blood vessels that wounds depend on for optimal healing. A review study published this year in the American Journal of Medicine showed that non-smokers had a 41 percent reduction of complications compared to active smokers. For every week of abstinence from smoking there was a 19 percent reduction of risk, and stopping smoking at least four weeks before surgery was recommended to minimize this risk. I usually advise my patients to stop smoking eight weeks in advance, particularly with larger wounds under tension.

Aside from this, other risks of breast surgery include asymmetry and scars—while it is the plastic surgeon’s goal to create perfect symmetry and minimize scars, everyone heals differently so it’s hard to predict.

Question: What if my natural breast does not match my reconstructed breast?

Dr. Rad: Trying to make a reconstructed breast look similar to a normal breast is very difficult, particularly if a non-nipple sparing mastectomy (i.e. the nipple has been removed) was performed. While restoring normal contour, shape and projection are achievable goals, we don’t have perfect solutions for nipple reconstructions—and to the casual eye, it is quite apparent when one nipple is normal and the other has been reconstructed.

Nonetheless, nipple reconstruction techniques are generally very good and can give a natural result. If the normal breast has significant ptosis (or “droop”) then doing a mastopexy (or lifting) procedure is an excellent way to rejuvenate the breast and obtain better symmetry.

Question: Can I still get cancer in my reconstructed breast?

Dr. Rad: This question may be interpreted in different ways. If the question is, “Can I get a recurrent breast cancer after a mastectomy?” (regardless of whether a reconstruction was performed), then the answer is “yes.” However, the risk depends on many factors that determine how much of a risk there is (such as tumor size, involvement in the lymph nodes, etc.)

If the question is, “Does a reconstruction increase my risk for having a recurrence of breast cancer?” then the answer is emphatically “no!” In a meta-analysis study of 1444 mastectomies, no relationship was found between local recurrence of breast cancer after mastectomy and reconstruction. In other words, having reconstruction does not increase a woman’s risk of developing a recurrence of cancer.

Furthermore, using your own tissue for breast reconstruction does not affect the detection and treatment of local recurrence of breast cancer. The transplanted tissue (whether from the abdomen or back) does not turn into breast tissue; it stays as the same tissue and thus has zero risk of developing breast cancer. If a recurrence of breast cancer happens, it’s due to cancer cells being left behind after the mastectomy or the fact that the cancer has already spread to the lymph nodes. However, this is quite rare.

Question: Can I have implants if I had prior radiation, or need future radiation?

Dr. Rad: Technically, you can have implants after radiation. However, the risk of having problems such as capsular contracture (when the wall of scar around the implant constricts and squeezes the implant, giving the breast a bizarre shape and firm feel) increases significantly after radiation— it happens about 50-60 percent of the time. If it develops, capsular contracture may require surgical release of the scar tissue. While this may correct the problem in the short term, the chance of developing capsular contracture again in the future is even higher. The definitive solution for such a problem would be using your own tissue for reconstruction (such as a DIEP flap) and avoiding the use of implants altogether.

Other problems associated with radiation and implants include thinning of the breast skin making an implant more visible or palpable, and having a breast that is “frozen in time.” This means that that radiated breast doesn't age like the normal unradiated breast, and so over time the breasts would look different.

Question: Am I an ok candidate for surgery? I have metastatic breast cancer, and one of my wishes is to leave this world with pretty breasts. More importantly, my breasts are quite sensitive in a happy way, but now I am too “hung up” by the optics to take advantage. So here are some details: I had a left breast over-the-nipple area lumpectomy (tumor was approximately 6 cm and also had sentinel node—they found 8 affected and took out 21). The surgeon did a nice job, but if my left breast were a car you would certainly classify it as a noticeably "dented.” I am not overweight (5'6" 150 lbs) but I do have some extra cargo in the love handle section. Would DIEP or SGAP be better, or maybe neither?

Dr. Rad: Assuming that you are fairly healthy, my sense is that you are a reasonable candidate for surgery.

A noticeable “indentation” in the breast as a result of a lumpectomy is challenging to correct, especially after radiation therapy. You may have heard about injection of fat (called “fat grafting”) into breast tissue to fill in the dent, but this does not work well particularly if there is radiation damage to the tissues. Transferring healthy tissue with good blood flow to the area is the best way to correct the problem.

While a DIEP flap (a technique that borrows tissue from the abdomen) or SGAP flap (a more complex operation that borrows tissue from the buttock or love handle region) may work, these techniques are used primarily to restore the entire breast following a mastectomy rather than just to correct a lumpectomy “dent.” I would recommend borrowing tissue from the upper back region using a technique called the “TDAP” flap (the acronym stands for a mouthful of words describing the anatomy). I have done many reconstructions of these types of deformities using the “TDAP” flap with excellent results.

The technique is similar to the latissimus dorsi muscle flap that has been used for years, but the TDAP flap spares the muscle and borrows only the skin and fat. As a “perforator” flap (similar to the DIEP and SGAP flaps), it requires careful microsurgical dissection skills and very few surgeons offer it.

So why do we do it? Because patients recover much faster and pain is markedly decreased as compared to a latissimus flap, drainage tubes are used only for a few days, a functioning muscle is preserved (particularly important in athletic women), and problems such as seromas (fluid build-up that may require surgery to fix) are minimal.

Question: What are my options for replacing saline implants placed in 1994? What changes or improvements have been made?

Dr. Rad: Implants are safe and effective options, and they are a first choice in thin or athletic women. While saline implants are fine to use, they are not the first choice due to their unnatural feel, firmness and tendency to have visible ripples through the skin—these problems are lessened by the use of silicone implants.

Much of the controversy surrounding silicone was centered on implants manufactured before 1992 which, when ruptured, would leak liquid silicone creating a sticky mess that was difficult to clean up. The FDA imposed a 14-year moratorium on “old” silicone due to concerns about safety. This ban was lifted in 2006 when “cohesive gel,” or the “gummy bear,” silicone implants were deemed safe by FDA standards.

Today, implants are a good choice for certain women who are quite slender and who have not had radiation therapy. Even if you are not slender, you may still choose implants for reconstruction although you would also have the option of using your own tissue for reconstruction.

The reason implants are not my first choice when there is radiation damage is because there is a greater than 50 percent chance of needing surgery to release abnormal scarring around the implant, a process called “capsular contracture" which can distort the breast form, cause uncomfortable pressure on the chest and recur even after corrective surgery.

Question: Is it common for women who have had reconstruction using the latissimus dorsi muscle to feel as if they have a small rolled up newspaper under their arm? I have been told it is not lymphedema.

Dr. Rad: The latissimus dorsi flap is a common tissue transfer operation in breast reconstruction. The technique borrows the broad, flat muscle of the upper and middle back (the muscle that gives body builders “wings”) and tunnels it underneath the skin of the armpit in order to reach the breast.

Because of this tunneling, it is not uncommon to feel fullness in the armpit—this is the muscle flap passing through the armpit area as it goes to the breast. The sensations usually improve with time as the muscle atrophies, but it may also persist. While somewhat of a nuisance, the important thing is that it’s not dangerous to your health.

Question: Is it common for women who have had reconstruction using the latissimus dorsi muscle to feel the muscle contract in the lower breast area when making certain arm movements?

Dr. Rad: Yes, it is not unusual to feel contracting sensations in your reconstructed breast after a latissimus dorsi muscle flap. The latissimus muscle is our “chin up” muscle. In its native state, it spans the back and attaches to the upper arm bone (the "humerus"). Unless you’re a rock climber it’s rare to do “chin up” activities, but certain arm movements may give you the sensation of movement in your breasts. The bottom line is that it won’t hurt you.

Question: My plastic surgeon plans to tattoo a nipple on my reconstructed breast. How successful are nipples made and grafted on? Are there any pictures of tattoo nipples?

Dr. Rad: Congratulations—nipple reconstruction is the final mile of the marathon! I routinely do nipple reconstruction because it not only completes a beautiful breast form, but it also gives my patients a sense of normalcy and closure to their challenging journeys.

The techniques we use to recreate nipples depend on borrowing skin from the breast and rearranging it to form a cone or cylinder. While not perfect, it’s a good approximation of a real nipple.

Do a Google image search using “nipple reconstruction” as keywords, and you’ll see some nice examples of what they look like. The downsides of nipple reconstruction are that they flatten over time (though most women like being able to wear shirts without a brassiere) and that extra scars are placed on the breast. However, in my practice, areola tattooing is the final step and, when artfully done, can hide these extra scars.

Question: I am 19 months post implant exchange reconstruction. I still have daily pain and cannot go without wearing a bra for much period of time. Is this normal?

Dr. Rad: While not common after implant reconstruction, chronic breast pain may nonetheless occur. There are many sensory nerves that enter the breast skin (called “intercostal nerves”) that may be pinched, trapped or inflamed.

If your pain is only in one breast and it’s very focal (i.e. you can pinpoint it with one finger), then it’s probably a nerve branch end that has formed a painful neuroma which is a nerve's way of scarring. Neuromas are painful like "touching a raw nerve," as the saying goes. This may be an indication to do surgery to find the neuroma, remove it and then bury the cut end into muscle (this has been the only proven way to deal with neuromas). However if your pain is diffuse, affects both breasts and is “everywhere,” then this may represent a syndrome best treated with non-invasive approaches such as physical therapy, ultrasound, biofeedback or acupuncture.

Question: My implants cause ripples that are very evident. My surgeon said he could try to remove the implant and tighten up the pocket and reinsert, but that I would face potential problems with "playing with them.” Do you have any thoughts or comments on the ripples seen with implants or how to improve them?

Dr. Rad: If by “problems with ‘playing with them’” you mean that the rippling problem may come back or the surgery may not even work, then this may be true.

Ripples are a difficult problem to correct because there is a very thin layer of tissue (basically just skin) covering the implant. Imagine a plastic bag half-filled with water; you can see in your mind’s eye the wrinkles, ripples and folds in the bag as the water moves around. Now wrap a wet paper towel around the bag—you can still see the ripples. Now, wrap a thick towel around the bag—the ripples are much less visible because there’s more of a layer to hide the wrinkling. The skin layer is like the wet paper towel—it adheres to the implant and ripples show through. What you really need is an extra thick layer of tissue to hide the ripples, similar to the towel around the bag of water.

I recommend a tissue transfer operation such as a TDAP or latissimus dorsi muscle flap—this technique borrows tissue from the upper back and brings it to the breast area to add the extra layer of tissue between the implant and your skin. Alternatively, if you have extra fatty tissue in the abdominal or buttock area, removing the implants altogether and performing a DIEP or SGAP flap is a definitive way to get rid of the wrinkles (and the implant altogether) and give the most lasting, natural result.

Question: How common is the gluteal free flap procedure? How would I find a surgeon in my area who does this kind of procedure?

Dr. Rad: You’re referring to the “SGAP” flap, a highly complex technique that borrows tissue from the buttock region and transfers it to the breasts. Only a handful of plastic surgeons specializing in microsurgery offer this technique because it is so difficult to do. Nonetheless, in the right patients, the SGAP produces beautiful results with hidden scars.

One major downside of the traditional SGAP technique is that it can leave a long scar across the buttock and flatten it. My patients in whom I’ve used the SGAP have benefitted from a technical refinement that we described called the “LSGAP” flap. The LSGAP preserves the shape of the buttock by borrowing tissue from the love handle area. My colleagues and I published the first study that described this technique and then proved its reliability in patients.

My advice to you would be to find a plastic surgeon who routinely performs microsurgical breast reconstruction (this information is usually mentioned on surgeons’ websites). Microsurgeons who do DIEP flaps (at least 20 per year) will have the highest likelihood of performing SGAP surgery. However, your best bet is to have your care at large academic hospitals such as Johns Hopkins or MD Anderson, two centers that routinely offer SGAP surgery.

Question: I got a lumpectomy in 1998. Though I asked at the time about the flap procedure and having a plastic surgeon on board, the breast surgeon said he was good and not to worry. I hate the way my lumpectomy has deformed my breast. The tumor was not small and my right breast is half the size of my other breast. Is it possible to undergo successful breast reconstruction without charge after all this time? If my right breast is the one that is deformed, will it be necessary to work on both breasts so they are even or just the right breast? I am no longer young (67) and wonder whether reconstruction is advisable.

Dr. Rad: Every woman who undergoes surgery for breast cancer has access to reconstruction—the 1998 Federal Breast Reconstruction Law guarantees this. It also makes provisions for surgical symmetry procedures on the unaffected breast.

In your particular situation, it is likely that you will need to have reconstruction of your right breast as well as a lifting and reshaping procedure for your left breast. The exact technique I recommend would depend on what your breasts look like, where volume is needed and how much of a lift or reshaping your breasts require. There are many techniques in a plastic surgeon’s armamentarium, so my advice is to be assessed by a board-certified plastic surgeon who routinely performs breast reconstruction. Good luck!

Question: Does what your stage is matter in determining whether to do reconstruction?

Dr. Rad: Every woman, regardless of stage, should have access to breast reconstruction. The specific decision of what technique to use will depend on your goals, how well you feel and whether you’ve had radiation therapy.

Your goals may be to look good in clothing with the simplest surgeries and least downtime, or perhaps wanting only to have your own tissue for reconstruction.

In general, you should be in good health and finished with your cancer treatments; if you’re still undergoing chemotherapy, you will not feel well enough to undergo surgery and your white blood cell count (the infection-fighting cells) may not yet be normal.

Finally, radiation is a critical factor in determining whether you select implants or your own tissue. In general, with a history of radiation you have greater than a 50 percent chance of requiring surgery again following implant reconstruction. In these situations I usually recommend using your own tissue in the form of a DIEP, SGAP or TUG (taking the upper inner thigh tissue) flap.

Question: Does weight and/or BMI limit your choices for breast reconstruction?

Dr. Rad: If you’re considering using your own tissue for reconstruction, then a very low weight or BMI (the weight-to-height ratio) would make it difficult mainly because there isn’t enough tissue to use. In these women, implants are very useful particularly if they want to have larger breasts compared to the size with which they started.

However, if you have some extra fatty tissue in the abdominal or buttock regions, then you may be a good candidate for tissue reconstruction. Some women have a normal BMI but carry their extra fatty tissue in one place while being thin elsewhere. I had a patient who was very thin except for her upper buttock and “love handle” areas—I used these sites and performed LSGAP flap reconstructions. Borrowing tissue from her “love handles” actually gave her a thigh lift that improved the harmony of her body shape in addition to beautiful restoration of her breasts.

The short answer is that weight is an important factor to consider since certain options will be better for thin women, whereas other options will be better for plus-sized women. However, all women have options available to them.

Question: Can you opt for a TRAM flap reconstruction if you have waited 2 or more years after mastectomy?

Dr. Rad: The short answer is “yes,” provided that you’re an appropriate patient for such an operation.

With regard to timing of reconstruction, this depends on whether you’ve had radiation or not. Patients who have had radiation after a mastectomy are at higher risk of complications, including loss of a flap (according to a study published by MD Anderson just a few months ago), if their reconstruction is done within 12 months of radiation. So, having waited two years is certainly in the “safe” time frame.

A TRAM flap involves taking one half of the rectus abdominus muscles, your core muscles, while two TRAM flaps (for reconstruction of both breasts) would take the entire core abdominal muscles. At Johns Hopkins, my approach is to spare functional muscle so that you can sit up from bed, get out of a chair, be able to do a sit up and minimize the risk of bulges or hernias. Therefore, a DIEP flap is a superior option because this technique spares the rectus muscle. The downside is that a DIEP flap is much more difficult to perform and requires specialized microsurgical skill, equipment and staff. While you may not have access to a surgeon who performs DIEP flap reconstruction, when it is done well, a TRAM flap can have good outcomes. However, I generally do not recommend a double TRAM flap reconstruction as it results in too much weakening of the abdominal wall. Nonetheless, the DIEP technique is becoming more and more popular and patients are seeking surgeons who are skilled and experienced with the technique.

Question: I have one reconstructed breast after a mastectomy and radiation treatment. My question concerns the nipple reconstruction. I had it done (by some sort of origami procedure with the skin), but it did not last. After a few short months the skin returned to being flat. The plastic surgeon who did my entire surgery (but is now out of insurance network) has said that this is because the skin is irradiated and it did not hold, but at the same time he advised that I could try again. Does it make sense to try again or will it never hold? If it does make sense and since I had the surgery once, any suggestions for justifying the repeated attempt to my health insurer?

Dr. Rad: The flattening of a reconstructed nipple is one of the frustrating aspects of the technique.

A real nipple has support structure including tiny muscles that allow the nipple to change shape, have projection and contract. We can only approximate the size and shape of a real nipple, but since non-nipple skin doesn’t have the same support structure, it won’t last.

Radiation only makes the situation worse as the blood flow through the skin has been markedly reduced, and blood flow is key for these operations to succeed. While attempting another nipple reconstruction may be feasible, there is a 100 percent chance that the reconstructed nipple will flatten over time.

There are a few techniques that can help maintain nipple projection, such as using an injectable dermal filler (like Juvederm or Radiesse), however these are temporary and will dissolve over six to 12 months.

Question: What are the pros and cons of fat grafting to get rid of implant ripples?

Dr. Rad: Implant ripples are a problem that arises when there is only a thin layer of tissue to cover the implant. Imagine pulling a bed sheet over pillows on the bed. You will be able to see the hills and valleys as the thin sheet doesn’t have much bulk to cover the pillows. Now, imagine a thick down comforter over the pillows. The hills and valleys are much less visible. Ripples are caused by folds and waves in the implant shell, and these can be seen through very thin skin (like the sheet over pillows). When there’s a thick healthy layer of tissue to cover the implant, these ripples are much less visible.

It’s more common to have rippling problems when saline implants are used. If this is the case, then I would recommend switching to a silicone implant. If the rippling is persistent, or if it’s present with silicone implants, then I generally recommend that a “flap” procedure is performed.

The most common flap to correct this is a latissimus dorsi muscle flap—this technique borrows the broad flat muscle from the back area and transfers it to the breast. Adding a layer of healthy tissue between the implant and the overlying skin will give more “cushion” and hide any ripples (similar to the down comforter over the pillows).

Fat grafting is a great technique for filling, contouring and shaping breasts that have been reconstructed with a patient’s own tissue. To last a lifetime, the little globules of fat that are injected need to be surrounded by healthy tissue with a good blood supply. That’s why I often perform fat grafting after DIEP flap reconstruction—the DIEP flap tissue (which comes from the abdomen) is excellent, well-vascularized (i.e. good blood flow) tissue into which fat may be injected.

On the other hand, when an implant has been used, you can imagine that the only tissue into which fat may be injected is the thin layer of breast skin covering the implant (while the chest muscle--the pectoralis major--also covers the implant, it is only in the upper half of the breast). In other words, there is very little tissue to accept fat grafts, and therefore very little fat may be injected into a breast that has been reconstructed with an implant. Therefore, I don’t use fat grafting to correct ripples caused by implants.

Question: Is it safe to get a decorative tattoo on a reconstructed breast when the skin is very thin?

Dr. Rad: Tattoo ink is placed in the dermis, the thickest part of the skin. If you have had implant reconstruction, there is a layer of fat between the dermis and the implant no matter how thin the tissue layer is (unless the implant has caused excessive stretching of the skin). When done properly, the ink doesn’t penetrate below this tissue layer so it is exceedingly rare, if not impossible, to harm the implant. Seek the skill of a licensed professional tattoo artist. We refer our patients to an excellent artist in Baltimore named Vinnie!

Question: I am a 7-year breast cancer survivor. I had ductal carcinoma in the left breast, stage IIB, no lymph node or BRCA gene involvement. I had 6 months of chemo and 8 weeks of radiation; I had a bilateral mastectomy with bilateral saline implants, and I had a cellulitis infection two times. I had two replacements on the left side; my last surgery was in 2007. I now have capsular contraction around the left breast—my plastic surgeon said he will not put in another implant due to radiation damage to my skin and due to the fact that the skin is too thin. Is this true? I did go for two opinions so far. One doctor said there would be no problem; he would just take out the implant and remove scar tissue. He told me that my skin is healed enough to replace with gel implants and he would do both to match. Two other docs told me this was impossible due to radiation damage. I'm so confused. My current doctor and two others recommend trans flap procedure; I'm scared and just don't know what to do, but I'm so tired of living in chronic pain from this implant. It also causes numbness and tingling down my arm and shooting pains into my chest—what do you think?

Dr. Rad: You are in a difficult situation, but there are solutions to help you!

Radiation is a “double-edged sword”—on one hand, it’s necessary for cancer treatment; on the other hand, it damages tissue by destroying the blood supply to the breast skin. The tissue’s reaction to radiation injury is to form scars. Over time, scar tissue contracts and becomes woody and firm. You can imagine that when there’s an implant beneath a layer of scarred, damaged tissue, the contraction of the tissue will cause the implant to be squeezed or pushed up or to the side. Sometimes the squeezing effect causes the implant to put an uncomfortable amount of pressure on the chest. This process is called “capsular contracture” (the scar layer around the implant is the “capsule,” and it contracts abnormally).

In general, patients who have had radiation treatment and reconstruction with implants have a 50-60 percent chance of having capsular contracture requiring surgery. When it happens the first time, there is an even higher likelihood of it happening again. In my practice, I will always advise patients like you to have a “flap” operation in order to replace the implants with healthy, vascularized (i.e. with good blood flow) tissue.

The most common procedure I do is the DIEP flap—this technique differs from the TRAM flap (to which I believe you were referring) in that the DIEP flap spares the rectus abdominus muscles, your core muscles. If bilateral (both sides) TRAM flaps are used, then you would have no ability to sit up from lying down, get up from a reclining chair without assistance or do sit ups, yoga, and certainly not Pilates! Also, there is a higher rate of bulges or hernias with TRAM flaps.

If you have some spare fatty tissue in your lower abdominal area, I would recommend having your implants removed and DIEP flaps performed. If you have a thin abdomen, then I typically recommend borrowing tissue from the buttock area— this is called the SGAP flap. These techniques are performed by highly skilled microsurgeons and may not be available in your locale.

If microsurgery is not for you, then traditional latissimus dorsi flaps may provide some needed coverage of the implants in order to minimize your risk of further capsular contracture. Regardless, I agree with the “two other docs” who advised against the continued use of implants

Question: I had a lumpectomy (4 cm tumor), axillary node dissection (2 positive nodes), chemo and radiation 14 years ago. The left breast is significantly different than the right one (including not sagging). I'm considering surgery options. I have a large amount of "host" tissue elsewhere, so a DIEP is certainly an option. Does length of time after initial surgery have negative affects? Can this be combined with breast lift and possible DIEP augmentation of the other breast in order to create more symmetry?

Dr. Rad: Given that you have had radiation in the past and there is such asymmetry, it sounds to me like you will need to have a tissue transfer surgery such as a DIEP flap. For other readers, in a DIEP flap operation the microsurgeon borrows skin and fat from the abdominal area, disconnects it, and then transfers it to the breast where the tiny blood vessels are connected using suture thread that is thinner than a human hair. The DIEP procedure spares the core rectus abdominus muscles, a key difference from the outdated TRAM flap operation.

I routinely do DIEP flap surgery, and the length of time after your initial surgery (14 years) has no bearing on the outcome. You can still have an excellent result no matter how much time has elapsed. Because of this, I encourage all women who have not had breast reconstruction after a mastectomy to investigate your options, because you do have plenty!

With regard to your second question, yes, a breast lift can be performed on your unaffected breast for symmetry. You may not know that insurance companies are required to cover symmetry operations on normal breasts in addition to the reconstructive surgeries. I have done DIEP flap breast augmentation of normal breasts when a patient desires larger breasts in the setting of breast reconstruction. In general, this is a viable option.

Question: Why should I have plastic or reconstructive surgery at a teaching hospital where I won't know if the attending I select will actually do the surgery himself or assign the case to one of the surgical trainees?

Dr. Rad: At Johns Hopkins, we have surgical trainees who are there to assist in surgery and to learn. Their participation is important, as surgeons need assistants to help. Rarely do surgeons "assign" their cases to resident (trainee) surgeons. In fact, the attending surgeon is required to perform a "time out" before the surgery actually begins to ensure that the plan is clear and the operation can commence.

You should ask your surgeon directly. When patients ask me, I frankly respond that I am the one performing the surgery with assistants present.

Question: Can sexual activity cause an implant to move? I'm wondering specifically about the pressure from a male partner leaning on reconstructed breasts. The implants can be pushed to the side and I'm concerned that may cause the implants to be dislodged.

Dr. Rad: For this reason, in the first 2 months after surgery I generally advise against any direct pressure on breast implants. Beyond 2 months I feel that infrequent pressure as you describe has no long-term negative impact.

Question: I had a latissimus dorsi flap reconstruction along with a saline implant in 2004. I'm in my 40s now. I would rather just have the implant permanently removed as I have troubles with capsular contraction, but I can't find a single plastic surgeon who will even talk with me about permanently removing my implant. Is this so uncommon a request? I'm guessing the latissimus dorsi can't be "undone," but surely the implant could be removed?

Dr. Rad: You are correct—the muscle flap portion may not be "undone," however the implant may be removed. Your surgeon’s reluctance to remove the implant may stem from the fact that your reconstruction will essentially be reversed. It's hard to know why they do not speak with you about the subject.

Capsular contracture, the abnormal scarring and tissue contraction around an implant, is a difficult process to arrest or reverse. For patients such as you I generally recommend removing the implant and replacing the lost volume with a tissue flap such as a DIEP flap (tissue is borrowed from the abdomen), an SGAP flap (tissue is taken from the buttock/love handle region, though this is a very difficult operation) or a TUG flap (tissue is taken from the inner thigh region). These are highly complex microsurgical operations requiring special training, skills and resources that may not be available outside of large academic hospital centers.

Denver, CO  ·  September 13, 2014

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