When a woman has to face breast cancer, chemotherapy, a mastectomy and then breast reconstruction, she can begin to feel overwhelmed. Henry Lin, MD, a board-certified plastic/reconstructive surgeon at St. Jude Medical Center, understands the anxiety that the prospect of breast reconstruction can cause, and he also has seen the positive change that reconstruction has made in women’s lives. Dr. Lin answers frequently asked questions about reconstructive breast surgery.
Q. The prospect of any kind of surgery makes me nervous. Are breast cancer survivors who choose reconstruction glad they did?
A. Overwhelmingly, in my experience, patients who are good candidates for breast reconstruction are much happier when reconstruction is performed. This is supported by research. The psychological benefits are enormous. It restores a sense of wholeness, and emotional and spiritual well-being, that strengthens breast cancer survivors on their road to recovery.
Q. Will having breast reconstruction interfere with ongoing monitoring of my breast cancer?
A. Breast reconstruction does not interfere with ongoing monitoring of breast cancer. It is important that you continue to undergo routine self- and physician-performed physical exams on the mastectomy site for general surveillance. But once you have a mastectomy, there is no breast tissue left, so no further mammograms are necessary on that breast. Routine screening mammograms are still recommended for the opposite breast; however, these are routine procedures and you should feel confident that your reconstruction surgery will not hinder your ongoing preventive measures.
Q. What are my choices if I elect to have breast reconstruction surgery?
A. You have two options to consider for breast reconstruction: implant-based, or autologous reconstruction using your own tissue. In my practice, most patients choose implant-based reconstructions because post-operative recovery is easier, and no extra incisions are necessary to gather tissue from other parts of the body.
Q. What are the types of implants typically available today, and are there any safety issues with implants that I should be concerned about?
A. There are two types of breast implants currently approved for use: implants filled with saline, and implants filled with silicone gel. In the past, there have been concerns around silicone gel implants. This is because, in 1992, the Food and Drug Administration placed a ban on silicone implants due to allegations that ruptured implants lead to connective tissue disorders like lupus, rheumatoid arthritis, and fibromyalgia. These allegations were eventually shown to have no merit, and there is no proof of a connection with these disorders. Large studies done by Allergan and Mentor, the two largest implant manufacturers in the U.S., show no increased incidence of these disorders in patients who have had implants placed versus the general population. In 2006, the FDA re-approved silicone implants for use.
You can feel comfortable knowing that both saline and silicone are safe and successful materials for implants. Of the 93,083 breast reconstruction procedures performed in the United States in 2010, around half used saline and half used silicone gel.
Q. What does the process of implant-based reconstruction involve?
A. Implant-based reconstruction requires at least two surgeries. The first surgery involves placement of a tissue expander under the pectoralis major muscle. After the incisions heal, you will come to the surgeon’s office weekly for expansions until the expanders are fully filled. This process generally takes eight to 12 weeks to accomplish.
Q. Should I be prepared for pain when the implant is expanded?
A. Most patients don’t experience much pain during the expansion process. Some will take a an over-the-counter pain reliever for the first two days after each expansion. All patients are able to go back to their normal activities during the expansion period.
Q. Given that breasts are shaped differently, how can I be sure the implant will match my opposite, natural breast?
A. Once the breast has been fully expanded, we generally wait another six to eight weeks to allow the expander and tissues to settle prior to performing a second operation. At the second surgery, the tissue expander is removed from your breast and a permanent saline or silicone implant is placed. At the same surgery, we will perform a symmetry procedure on your opposite breast to make sure the breasts are as evenly balanced as possible. Each breast is different, so this procedure may be a breast reduction, a breast lift, or placement of an implant.
Q. When is autologous reconstruction the preferred choice, and what part of the body is the tissue taken from?
A. Autologous reconstructions are also an excellent option for breast reconstruction. They are usually recommended for patients who are going to need radiation therapy as part of their cancer treatment, or for those whose prior implant fails after receiving radiation. Radiation therapy can lead to complications—like asymmetries or infections--in an implant-based reconstruction. Bringing non-radiated tissue to the site provides a fresh blood supply, and additional healing potential, for the radiated chest wall. The most common areas to borrow tissue to make a breast is from the lower abdomen or the upper back. These tissues can also be used to supplement an implant reconstruction. Because these procedures require collecting tissue and muscle from other areas of the body, the recovery times are longer than with implants.
Q. Are there other advances in breast reconstruction that I might benefit from?
A. Ongoing strides are being made in breast cancer surgery, and new techniques are accompanied by more reconstruction options. For example, if the cancer is far away from your nipple-areolar complex and your nipple is well positioned on your breast, we can offer nipple-sparing mastectomies with implant reconstruction. The nipple-areolar complex is often the most difficult area to reconstruct, so it if can be spared, the reconstructive results can be very impressive. Since we are not removing any skin, for certain patients it is possible to place a permanent implant at the time of the mastectomy in a one-stage (direct to implant) reconstruction, without the use of a tissue expander.
Another exciting technique for breast reconstruction is something known as “onco-plastic” reconstruction. Implant-based reconstruction is often challenging for larger breasted patients, and it is certainly harder to match a reconstructed breast with an implant to a large, natural, opposite breast. For these patients, if the cancer is small, we can offer breast cancer removal with a lumpectomy and perform what’s called an “oncoplastic reconstruction.” We are essentially combining a lumpectomy procedure with a breast reduction. These procedures have an extremely high rate of satisfaction, as patients are able to have their breasts reduced at the time of lumpectomy. To complete the cancer treatment, patients who elect to have this type of treatment will still need to have radiation therapy.
Q. How soon after a mastectomy should I anticipate undergoing reconstruction?
In most cases, we are able to offer immediate reconstruction at the time of mastectomy. Timing of reconstruction is really dictated by the stage and oncologic treatment of breast cancer. For more advanced stage 3 or 4 cancers, it is common that chemotherapy and radiation will be involved as part of the cancer treatment. If radiation therapy is involved after your mastectomy, it is preferable to have radiation treatment completed prior to engaging in breast reconstruction. This allows me to examine the quality of the chest skin after radiation and plan for possible autologous reconstruction. If your skin quality is favorable after radiation treatment, it may still be possible to undergo tissue expansion and implant-based reconstruction.
Q. How do I choose the best surgeon for my breast reconstruction?
Every patient who is contemplating breast reconstruction should have a consultation with one or more board-certified plastic surgeons to discuss the benefits and risks of all reconstructive options. You should be prepared to ask questions of the surgeons, especially about the type of experience they have in performing the procedures they are offering. You should look at sample photos of reconstructed patients--pictures are the best way for me to educate my patients about the reconstructive process.
Communication and trust are vital in every patient-doctor relationship. Each breast reconstruction typically involves two to four surgeries before completion, so you should feel extremely well-informed about each procedure and be able to effectively communicate your concerns to your surgeon. My team is excellent at performing breast reconstructions, and I truly care about each patient as a person. I make sure that each patient gets the time he or she needs to understand each part of the reconstruction process. Most of my patients feel that they are treated like family.
How has breast reconstruction made a difference in your recovery from breast cancer? Share a comment below.
The Kathryn T. McCarty Breast Center at St. Jude Medical Center is a nationally-recognized Breast Center of Excellence, a recognition given to only five percent of centers in the U.S. by the American College of Surgeons Commission on Cancer.
This information is not intended as a substitute for professional medical care. Always follow your health care professional's instructions.
