August 2012 Ask the Expert: Breast Reconstruction
Frederick J. Duffy, Jr., MD, FACS, answers your questions that were submitted online during our August 21, 2012 teleconference on breast reconstruction.
I've had a unilateral mastectomy and reconstruction with implants in both breasts to reach symmetry. However, one breast still lies lower than the other. What is the procedure involved with lifting my own breast so it is symmetrical with the other that was removed?
If a woman post-mastectomy decides to purchase and use prosthesis with her insurance for several years and then later decides she wants implants, will that still be covered by the federal law and thus her insurance?
Can you explain the role and importance of CT imaging of the blood vessels prior to surgery and impact on flap failures? When you modify the remaining breast to make it even with the reconstructed breast, will the modified breast lose sensitivity from any injured nerve endings?
I had a central lumpectomy with radiation for Paget's disease. I'm on the fence about nipple reconstruction. The surgeon told me there is a 20 percent chance of failure (in which case, the nipple would turn black). Is there any way to know which patients might have a better chance at success? How painful is the surgery and its aftermath?
Dr. Duffy: We often see patients who have either an abnormal shape after a lumpectomy or asymmetry between the breasts due to a lumpectomy. The best option for reconstruction in those patients depends on the nature of the problem, where the lumpectomy was, etc., but as a very general guideline most of the same reconstructive options can be used.
Probably the most common choice for lumpectomy patients involves implants just for the ease of the procedure, but as with mastectomy patients, the choice is with the patient.
Question: I have had stage IV inflammatory breast cancer for nearly five years. I would like to consider reconstruction; however I consistently have lymphedema in my arm. Will the additional surgery aggravate or help my lymphedema?
Dr. Duffy: Many mastectomy patients have problems with lymphedema. Technically any reconstructive surgery on that side of the chest (regardless of which type of reconstruction you choose) could transiently worsen the lymphedema. However, in most cases surgeons are able to avoid the armpit area and thereby lessen the chance of this happening. In the hospital we utilize, and I am sure in most practices that do a great deal of reconstruction, there is a licensed manual lymphatic drainage therapist to assist after surgery if needed.
Question: I've had a unilateral mastectomy and reconstruction with implants in both breasts to reach symmetry. However, one breast still lies lower than the other. What exactly is the procedure involved with lifting my own breast so it is symmetrical with the other that was removed?
Dr. Duffy: This is fairly common, particularly in women whose natural breasts had already become somewhat ptotic, or sagging, with age. The procedure to correct this is a mastopexy, or breast lift, to lift the ptotic breast back to a position that better matches the other breast. Sometimes more is needed to revise the breasts and get them more symmetrical, but a lift is the main procedure to get them symmetrical.
Dr. Duffy: This is up to your oncologist, typically. If you are still having any problems following the chemo, such as anemia, then you would need to wait. You may want to also consider that there would always be a second stage procedure after the DIEP flap, which is usually done several months after the primary procedure, so it might be difficult to get all of the reconstruction done before the end of the year.
Question: If a woman post-mastectomy decides to purchase and use prosthesis with her insurance for several years and then later decides she wants implants, will that still be covered by the federal law and thus her insurance?
Dr. Duffy: As long as the law remains in place, it does not matter how long after the mastectomy that you choose to have reconstruction. In fact, it doesn't matter if you already had reconstruction but decided years later to do the reconstruction again with a different technique.
The federal law mandates coverage of breast reconstruction after a mastectomy regardless of the time frame or prior procedures.
Dr. Duffy: A DIEP (or a TRAM) essentially performs a “tummy tuck” of the abdomen using that excess abdominal tissue to create the new breasts. However, some women, particularly those who are more overweight, actually have excess tissue not just in the abdomen but also around the sides and even the back.
When the DIEP is done, it removes the excess tissue in the abdominal area but not around the sides or back. This can leave what some women call a “muffin top” effect on the sides. It can be corrected by carrying the excision around the side and back, but this would be considered “cosmetic” by the insurance company so not everyone is able to do this. Whether or not an individual patient would have this problem depends very much on her own build, and it is something her doctor can talk to her about during the examination to help guide her.
Dr. Duffy: I am not opposed to implants and do them regularly. However, if everything else were equal, I would prefer to do the DIEP on patients. Even with the vastly improved implants that are available these days, there is still no guarantee that implants will not need to be replaced at some point in the future.
By the way, there is a common urban myth that implants all have to be replaced every 10 years; this is not accurate. Implants only need to be replaced if there is a problem. For a woman who, as an example, has implants placed when she is in her 30s or 40s, she has a fair chance that at some point in the next 40-50 years she would need to have those implants replaced due to a rupture, leak, capsular contracture, etc. With a DIEP flap, once the flap is successfully completed there would be nothing more needed. It is all natural tissue and will be hers for the rest of her life.
Question: Can you explain the role and importance of CT imaging of the blood vessels prior to surgery and impact on flap failures? When you modify the remaining breast to make it even with the reconstructed breast, will the modified breast lose sensitivity from any injured nerve endings?
Dr. Duffy: While imaging of the blood vessels can sometimes provide information on whether the blood vessels may or may not work during the proposed surgery, it is not a definitive test. For this reason, it is my experience that it is not of sufficient benefit unless there is a reason to be concerned about the vessels such as due to a prior surgery in the area. Some surgeons do use the imaging regularly prior to a flap surgery, but I have not found that it provides enough information in most cases.
In most cases, any surgery done on the other breast (still a natural breast, no prior mastectomy) will not cause any loss of sensation. However, it depends on the procedures and healing process. For example, any patient who has a breast reduction, regardless of the reason, may experience some loss of nipple sensation. If a woman who has had a mastectomy needs the other breast reduced for symmetry, it is possible she would lose nipple sensation. However, it is not common for this to happen.
Question: I had a central lumpectomy with radiation for Paget's disease. I'm on the fence about nipple reconstruction. The surgeon told me there is a 20 percent chance of failure (in which case, the nipple would turn black). Is there any way to know which patients might have a better chance at success? How painful is the surgery and its aftermath?
Dr. Duffy: Because of the prior radiation, the chances of a nipple reconstruction failing is somewhat greater than in someone who had the same surgery but who did not have radiation.
If the reconstruction fails, the tissue of the reconstructed nipple does turn black, but it is then removed so you would essentially be back to what you have now without a nipple, except for perhaps some scarring in the area. In other words, you aren’t left with a black nipple.
Unfortunately, radiation is very difficult to predict, so it would be impossible to say for certain whether you are likely to have this happen or not.
In terms of discomfort after surgery, it depends in part on the amount of sensation you have there. Most patients have limited sensation in the area after a lumpectomy. If that is the case, then you would probably not have much pain after the surgery. The newly created nipple would be numb; recreated nipples do not have full sensation. The procedure is fairly minor and would likely be less painful and less recovery than the lumpectomy. Most patients who have a nipple reconstruction in our practice do it on a Friday, and they are back driving and doing things on the weekend and working on Monday.