Breast reconstruction: What to know and life after surgery

Editor’s Note: This is the third in a series of articles recognizing Breast Cancer Awareness Month that will run in each weekly Health section through October. Topics will cover breast cancer statistics nationwide and in the Show-Me State, research, early detection and the importance of mammograms, how special medical navigators can assist breast cancer patients through their treatments, mastectomy reconstruction surgery and life after this procedure, and local organizations who raise funds and help those diagnosed with the disease, among other related subjects.

When a new patient comes to my office to discuss breast reconstruction, she has recently received life-changing news. She has just gone through the exhausting vocabulary and details of the diagnosis and treatment of breast cancer – mammogram, ultrasound, MRI, core needle biopsy, pathology, invasive breast cancer, DCIS, chemotherapy, radiation therapy, hormone therapy, sentinel node biopsy, lymphadenectomy, lumpectomy and mastectomy.

Regarding breast cancer, she has recently learned one-in-eight women will develop breast cancer in the United States. Most of these cases have nothing to do with genetic mutations. She now knows the risk of cancer increases with age, peaking at 50 and again at 70 years. If caught early, breast cancer is highly curable. Treatment usually requires some combination of medication, chemotherapy, radiation and surgery. She discussed with her oncologist how the decision for chemotherapy and radiation is based on a number of factors including the size of the tumor and whether or not the tumor has spread.

Her breast surgeon told her the main surgical options are: lumpectomy (removal of breast containing tumor) with radiation; skin-sparing mastectomy (removal of entire breast including the nipple), usually without radiation; nipple-sparing mastectomy (removal of all of the breast, preserving the nipple), usually without radiation; and performing an additional mastectomy on the opposite breast. She learned these options have come along ways since the early 1900s when it was recommended the nipple, most of the breast skin, pectoralis muscles, and all of the armpit lymph nodes be removed in all cases of breast cancer. She understands we now know it is safe to preserve the skin, muscle, lymph nodes and even the nipple when they are uninvolved with cancer.

After learning all of this during the last two weeks, my new patient probably finds herself somewhere amidst the grieving process over her new diagnosis. She bears the burden of dealing with the diagnosis but may also be dealing with questions about who will take care of her family or how will she pay for her medical costs. At the end of all of this come the questions of reconstruction: Should I get reconstruction? Should I “go flat?” Am I too old for reconstruction? Is reconstruction safe?

During the consultation, my desire is to provide answers to these questions and give a practical element of hope to her during this difficult circumstance. In a season of life when so much is bleak and beyond control, it can be refreshing to have a light at the end of the tunnel. Like most women, she just wants to look “normal” again in clothes. Breast size and shape are also important to her and appropriately tied to femininity and intimacy. Though not achievable for everyone, my goal for her is she would be happier with the appearance of her reconstructed breasts compared to her original size and shape.

The advancements in the surgery of breast cancer have made our job in reconstruction much easier and the outcomes so much better. Today, my new patient has many options. However, she’s read a popular New York Times article, which promoted a lot of misleading information about breast reconstruction. Certainly, forgoing reconstruction is an option for every patient. But, much more commonly, women do not know they have the option to have reconstruction. Today, there are many reconstructive options. The first decision is immediate versus delayed reconstruction. Immediate reconstruction is when the reconstruction is done in the same operation as the mastectomy. That approach generally creates the best final aesthetic. If patient conditions like diabetes or smoking make immediate reconstruction too high risk, I recommend waiting and beginning the reconstruction after she is healed from the mastectomy.

The second decision point is “autologous” versus “implant-based” reconstruction. Autologous reconstruction means I borrow a part of the patient’s body (often from the abdomen or back) to recreate the breast fullness without using an implant. These kinds of surgery are typically longer, more complex, and require a prolonged stay in the hospital. I often recommend autologous reconstruction where implants have failed or in cases of radiation. Implant-based reconstruction is the most common form of reconstruction in the United States and is what I recommend for most of my patients. The surgery can be done in about two hours (once the mastectomy is complete) and patients usually go home the next morning.

Whether choosing autologous or implant-based reconstruction, it is not unusual to have another surgery later to optimize the breast aesthetic. If breast expanders are used, then they will be exchanged for a soft implant two to three months after the first surgery.

Not too long ago, the standard incision for mastectomy was horizontal, like a stripe right across the middle of the breast. Now, I ask my colleagues to make a vertical incision around the nipple and down, which makes the final scar very similar to the one I would use for breast reduction or breast lift.

During the consult, we talk extensively about the possibility of complications, including bleeding, infection and need for other surgery. We discuss how infections and wound healing problems are always my biggest concern with reconstruction and all the steps we take to avoid it. These problems stem from the fact mastectomies remove vital blood supply from the flaps of breast skin we use to reconstruct the breasts. Of course, blood supply is the body’s most critical need for wound healing and fighting infection. We discuss the how smoking, diabetes and radiation therapy also hurt blood flow, thereby further increasing the risks of infections and wound problems. Thankfully, she does not have any of these issues.

After discussing all the options, my new patient has chosen to have skin sparing mastectomies on both sides and she is a good candidate for immediate reconstruction. When the mastectomies are complete, I am called in to perform the reconstructions. She is not sure what size she wants to be, so we use a tissue expander for her with a plan to exchange them in a minor surgery in two to three months. Two drains are placed on each side to remove fluid, which could potentially become infected after surgery if left alone. I partially fill the expanders, and she has good breast shape and volume before leaving the operating room. Overnight, some chest tightness is the biggest complaint but can be controlled with pain medicines and muscle relaxants. The next morning, I check the reconstruction and she is feeling well enough to go home. Most of the discomfort is in the first two to three days after surgery, but it gets a little better every day.

As the pain goes away, the drains become a more noticeable nuisance. They can be removed when the total fluid drainage is low. I instruct her to keep her elbows mostly at her sides for the first one to two weeks as chest and shoulder motion may create more fluid and increase the risk of problems. She is thankful when two drains are removed the first week, and the next two a week later. By three weeks, expanders are filled to her desired size and she returns to work able to wear the same clothes she did before. At four weeks, she has no restrictions and is anxious to have her expanders exchanged. About 10 weeks after surgery, it is a convenient time for her to schedule expander exchange to implants and nipple reconstruction. The surgery is uneventful, and she returns home the same day. She has nipple tattooing in four weeks to finalize the result. Sensation is not the same as it was before mastectomy, but she can feel her reconstructed breasts and they continue to be important to her intimacy. She wanted to be a little larger than before surgery but still look natural. She is pleased with the final size and shape.

A breast cancer diagnosis is devastating. But, for many patients, breast reconstruction represents hope, empowerment and the opportunity to be normal again. As a plastic surgeon, it’s a privilege for me to help women in a practical way during a very difficult season. On a final note, the internet and social media platforms can be educational and supportive but can also include scary and misleading sources of information. For my patients, I would recommend the American Society of Plastic Surgeon’s website for reliable information on breast reconstruction, plasticsurgery.org/reconstructive-procedures/breast-reconstruction.