November 2018 Ask the Expert: Breast Reconstruction

November 26, 2018

At our November 2018 Breast Cancer 360, Difficult Decisions: Breast Reconstruction, people who attended the program had more questions than our expert had time to answer.

As an extra November Ask the Expert, Living Beyond Breast Cancer expert and 360 panelist Clara N. Lee, MD, MPP, answered questions we missed during the program about her research, breast reconstructioninfo-icon options and side effects.

Remember: we cannot provide diagnoses, medical consultations or specific treatment recommendations. This service is designed for educational and informational purposes only. The information is general in nature. For specific healthcare questions or concerns, consult your healthcare providerinfo-icon because treatment varies with individual circumstances. The content is not intended in any way to substitute for professional counselinginfo-icon or medical advice.

During the 360 Dr. Lee said there was a way to participate in her research. Can you please share more information on that?

I am going to be starting a study in 2019, in which we will be collaborating with Living Beyond Breast Cancer. Please stay tuned for future updates about how to get involved.

Is it still possible to participate in Dr. Lee’s research on satisfaction/experience? Is it still going on?

The study on women’s satisfaction and experience after mastectomyinfo-icon is completed. We published findings in the Annals of Surgery  and in JAMA Surgeryinfo-icon in 2017 and in 2018; these links will help you learn more.   

How do you find a medical professional who can guide a person in choosing between various reconstruction options?

I think the reconstructive surgeoninfo-icon should really take this one, but sometimes it’s helpful to have someone else helping with this decision. Some breast cancer programs have a nurseinfo-icon, nurse practitionerinfo-icon or physicianinfo-icon’s assistant who does this.  

Is there any possibility of recovering some sensitivity in a breast that’s been radiated? I had no idea “skin changes” meant extreme loss of sensation. Can you have sensation after a mastectomy, or even after breast reconstruction?

The loss of sensitivity is primarily due to the mastectomyinfo-icon surgeryinfo-icon but possibly also the radiationinfo-icon. You can have sensation after a mastectomy and after breast reconstructioninfo-icon. It varies quite a bit among patients.

I have had three lumpectomies, and my breast didn’t look too bad but after radiation it looks deformed. I’ve consulted three plastic surgeons who offered radically different choices, one of which would leave me with a 6-inch scar on my ribcage. How do I evaluate my options?

Partial breast reconstructioninfo-icon, also called oncoplastic surgeryinfo-icon, is becoming an increasingly important option for women who have deformity or asymmetry after lumpectomyinfo-icon with radiationinfo-icon. The options vary depending on your body characteristics, your goals, your health and, to some extent, what the surgeoninfo-icon is familiar with. I recommend asking your surgeons why they made the recommendation they did. You could also go back to the surgeon you feel most comfortable with and ask about the other two options and the pros and cons of each. 

Are there ways to prevent necrosis when I’m having chemo? Does it depend on the type of chemo that’s being administered?

Chemo doesn’t cause necrosis per se. The main thing is to be adequately healed after reconstruction, before starting chemo.

I have heard of a one-step reconstruction process, without expanders. Is that an option? I had not heard it mentioned in the past.

Yes. Single-stageinfo-icon, or direct to implantinfo-icon, is becoming more common. It’s an option in many but not all women and depends on breast size, desired size, ptosis (drooping) and, to some extent, surgeoninfo-icon experience with the procedure.

Is delayed reconstruction after radiation an option? My experience was that if radiation was in play, reconstruction should be immediate.

Actually, when radiationinfo-icon is expected, most plastic surgeons recommend delayed reconstruction. This is because radiation generally affects the reconstructed breast, making it firmer, less natural or differently shaped. However, delayed reconstruction after radiation requires tissueinfo-icon transfer (flap) reconstruction. Sometimes, implantinfo-icon-based reconstruction is performed before radiation, especially if the patient really doesn’t want to have a flap or can’t have a flap. 

I’m thinking of flap surgery, and I wonder why expanders aren’t needed when using your own tissue. If I needed a small implant because of not having enough fat, would I then need an expander?

Expanders are generally not needed when using your own tissueinfo-icon because the tissue is large enough to create the breast shape. Sometimes an implantinfo-icon is placed under a flap, but an expander is usually not needed in that case because the flap has enough space under it to accommodate an implant.

I assume going flat is the option that has the fewest medical complications with the best physical health outcome. Why aren’t women who go flat provided a plastic surgeon to assure they aren’t left with dog ears, etc.? Insurance didn’t cover that for me.

Going flat is in fact the lowest-risk approach after mastectomyinfo-icon, in terms of complications. Most of the time, a plastic surgeoninfo-icon is not needed for a mastectomy, and breast surgeons/surgical oncologists are generally trained to be able to perform a mastectomy on their own. However, women who have very large breasts or very ptotic (droopy) breasts may benefit from having a plastic surgeon help with the closure to prevent dog ears. It’s unfortunate that insurance didn’t cover that. 

Which implants feel, or look, more natural?

I’m not sure there is good evidence that takes into account what women think or feel about this issue.

I still have a tissue expander 18 years later. I was told I can’t have an MRI because of a metal backing in the expander. But I don’t want more surgery. How long will a tissue expander last?

Tissueinfo-icon expanders are not intended to last forever. I recommend having them removed, even if it’s without placing an implantinfo-icon.

Can you explain the risk with textured implants for T-cell Lymphoma? I am having surgery in December to have the implants removed and new implants put in with fat grafting.

I think you mean Anaplasticinfo-icon Large Cellinfo-icon Lymphoma (ALCL). I don’t think it’s fully known why most cases of breast implantinfo-icon-associated ALCL have been with textured implants. It has been hypothesized that it’s related to how the texturing is created.

Does race play a factor in reconstruction success or failure, especially in terms of flap reconstruction?

I don’t believe it does, but I don’t know that anyone has specifically studied this question. I don’t know of particular reason why race per se would.

How does birth/pregnancy impact options for reconstruction? I want to be able to nurse from the breast that didn’t have surgery, so I am postponing reconstruction and hope to have both breasts done at the same time for evenness. Not sure if this is wise.

Birth and pregnancy before reconstruction do not really affect options for reconstruction later. However, if you have breast reconstructioninfo-icon and then get pregnant/give birth, the other breast is likely to change in shape or size, or both, in a way that the reconstructed breast generally will not. You may have some asymmetry. This can generally be addressed surgically, if you desire.

When choosing breast reconstruction, how often do the implants have to be replaced?

They do not necessarily need to be replaced. Breast implantinfo-icon companies have stated in the past that the risk of a leak is 7 percent over 10 years. In other words, among 100 women with a breast implant, in 10 years, 7 will have a leak, and 93 will not. So most of the time, they do not need to be replaced for leakage. However, sometimes they need to be replaced or revised because of capsular contracture (when scar tissueinfo-icon forms around the implant) or malposition (when implants move out of proper position).

The impact of breast reconstruction on my chest muscles was huge, and I was not prepared. Should I have gotten exercises or physical therapy to help with recovery?

Many women benefit from physical therapyinfo-icon after breast reconstructioninfo-icon, but not all women need it.

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