May 2007: Reconstruction Updates

Reconstruction after radiation?

Question from Liz: What are the reconstructions for breasts treated with radiation? Can you still use implants?

Answers —Joseph Serletti, M.D., F.A.C.S.: You can. In my experience it's best if you work with a dedicated radiation oncologist. If you work with someone like that you can really maximize the results. When you combine radiation with implants there's always some potential for compromise. Even when you work with someone very dedicated to delivering the radiation and working around the implants, it still doesn't preclude some of the complications that we see. There are some patients with whom only an implant reconstruction is possible. Even when we have to deal with that in the setting of radiation, obviously we still go ahead with doing an implant reconstruction.

Jennifer Sabol, M.D., F.A.C.S.: I think there are some patients who have had a mastectomy and followed that with radiation who are now looking at a delayed radiation and are hearing delayed reconstruction and are often told that they are not a candidate for an implant because of the previous radiation.

Joseph Serletti, M.D., F.A.C.S.: The patients that Jennifer just talked about are probably the hardest patients to get a satisfactory implant breast reconstruction on. What we do in those patients is we combine a tissue expander with a latissimus flap, which is a skin and muscle flap from the back. With that combination we can usually get a successful implant reconstruction. What the latissimus flap does is provide some unirradiated muscle and skin which is brought into the radiated mastectomy area. This allows satisfactory expansion of the tissue. I want to emphasize, in most patients who've had irradiated mastectomies, the preferred method is to use an autogenous reconstruction, like the TRAM flap. But in patients who don't have adequate tissue for a TRAM flap, the latissimus flap with a tissue expander is a good alternative.

Reconstruction with quickest recovery?

Question from SarahL: I am contemplating a mastectomy and ovary removal after having gone through chemo and radiation, and after discovering I carry a BRCA2 mutation. I am just feeling like myself and I find planning this difficult. What of the many choices is the quickest recovery? I should say I am only 40 and several of my doctors believe I will be most happy with some kind of implant or reconstruction.

Answers —Jennifer Sabol, M.D., F.A.C.S.: I think it's fair to say this is a very difficult decision to make when you are finally feeling like a healthy individual again. But it's important to look at the long-term outcome. Many patients who have already received treatments for their breast cancer and find out that they are BRCA positive, ultimately continue to choose only very close observation and screening, unless they have another recurrence. If, however, this makes you very anxious, as it will in a number of young women, it's very important not to look for the quick fix, but to look for the best long term outcome, looking at several factors, some of which are your overall body shape, your expectations for a good cosmetic outcome, your athletic ability, and your overall health. These are just a few of the important issues, and I think Dr. Serletti will agree that while implants may seem like a quick short-term fix, they do require ongoing maintenance and may require several revisions to maintain an optimal cosmetic result. Maybe, Dr. Serletti, you can comment further about some of the types of reconstruction and what you would take into consideration when you see these patients.

Joseph Serletti, M.D., F.A.C.S.: Any patient, whether they're young or old, really needs to look at the long-term results. Obviously, it's more important for a younger patient like you are to look at the long-term results also. As with most patients, there are two options for breast reconstruction. Those are implant reconstruction, and then using the patient's own tissue, such as a TRAM flap, a DIEP flap, SIEP flap, or a gluteal flap. Most of us feel that in the proper patient, a reconstruction using the patient's own tissue will give the best long-term results over many years. Further, the recovery from most complex breast reconstructions using the patient's own tissue is typically about six weeks. In a patient who has had previous radiation, using the patient's own tissue is really the method of choice.

Burning pain after reconstruction?

Question from Stitch: Is it common to have a burning-like pain from the reconstructed breast? I have been told by my surgeon that I have some TRAM necrosis — is this bad? And will it resolve itself or will I need further repair? I had simple mastectomy with sentinel nodes and immediate TRAM reconstruction last year. No radiation or chemo. Thanks for your time!

Answers —Joseph Serletti, M.D., F.A.C.S.: It's not common to have long-term pain within the breast reconstruction. What your plastic surgeon is probably referring to is the areas of fat necrosis. These typically will not change over time. I'll ask Dr. Sabol to comment on the nerve pain following surgery.

Jennifer Sabol, M.D., F.A.C.S.: I think what you describe as burning pain does seem to be originating from a nerve. In most reconstruction, when you bring up the tummy tissue the nerves are actually transsected or cut, and therefore you should get no sensation from that tissue. What you may be experiencing is some pain from the sentinel lymph node biopsy site, which are the intercostal nerves. These often supply sensation to the skin over the lateral chest wall and the upper inner arm, and when they are regenerating, patients often describe a burning or raw type of sensation to the skin in these areas, even though there's no visible damage. This can take up to two years to stabilize and to go away, so I would not lose hope that your symptoms will eventually go away. On a very rare occasion, a pain specialist (anesthesiologist) may be able to localize the source of the discomfort and help with a nerve block.  You should discuss this further with the surgeon that performed the mastectomy.

Pain for how long after reconstruction?

Question from FA98: I'm 46 and just had mastectomy with immediate breast reconstruction (latissimus dorsi muscle). Until now no post-operative complication has been recorded. I feel pain in my back (donor site, without external scar) and on the scars. Is there an average time after surgery for the pain disappearing? Thanks from Belgium.

Answer —Joseph Serletti, M.D., F.A.C.S.: It's certainly normal to have discomfort in the back site, and even to some extent to the chest site that may refer back to your shoulder or back. This discomfort can occur for three to six months after the initial surgery. It's certainly something that should gradually get better over that three to six month period.

AlloDerm, saline implant pose encapsulation risk?

Question from MCragg: I recently have had a mastectomy with immediate reconstruction using AlloDerm and a saline implant. Are there any studies that have been done to evaluate the percentage of risk for encapsulation between AlloDerm and expanders? What is the alternative to having a breast reconstructed if encapsulation becomes a severe problem?

Answer —Joseph Serletti, M.D., F.A.C.S.: I don't know of any studies that compare capsular contracture using AlloDerm (chemical name: acellular tissue matrix) or not using AlloDerm. For most patients, the tissue expander is usually fairly hard and very firm, and very much unlike what we will ultimately get when we remove the tissue expander and put in the permanent implant. If someone gets a severe capsule after the final implant is placed, the alternative is to remove the capsule and the implant and try a different type of implant. If the capsule comes back after something like that, then we usually consider an alternative procedure that does not involve an implant, such as a TRAM flap or one of its muscle-preserving alternatives.

Editor's note: AlloDerm is donated human tissue.

Reconstruction options for thin skin?

Question from UandM: I had a tissue expander then an implant after my mastectomy. It started leaking and was removed and now the plastic surgeon says my pocket skin is too thin for another implant. What does this mean and how can I have my breast reconstructed now?

Answer —Joseph Serletti, M.D., F.A.C.S.: If the overlying skin is too thin, the alternatives are to do a latissimus dorsi flap in combination with an implant. That will bring healthier skin and muscle from the back around to the chest so that the overlying soft tissue can be successfully expanded and then accept a permanent implant. The alternative is to not use any implant and use a TRAM flap or one of its muscle-preserving alternatives.

Biopsy on implant? Chance of recurrence?

Question from LeticiaS: My aunt had a double mastectomy more than 5 years ago. She recently had a mammogram that looked suspicious and her doctor would like her to have a biopsy. My question is this: (1) Can a biopsy be done on an implant? and (2) What is the likelihood of having cancer recur after you have had surgery and have breast implants? Is prognosis good? Thanks for your help.

Answer —Jennifer Sabol, M.D., F.A.C.S.: If she truly had a bilateral mastectomy there should be less than 1 percent of the breast tissue still available to be at risk. Some patients may still develop a recurrence after the mastectomy and nationally that rate for early stage cancers is rather low, between 1 to 3 percent. But it may be as high as 20 to 25 percent if the cancer was initially locally advanced. It is considered unusual to order a mammogram on a reconstructed breast because there is generally very little left to see. If there is truly an abnormality seen on the mammogram, there are ways that a biopsy can be performed. In general, it's not the implant that is being biopsied, but the small amount of breast tissue left over or under the breast implant. Unfortunately, I'm not sure what you are referring to with your question about prognosis. However, patients with an isolated chest wall recurrence can be successfully treated, often with additional surgical resection of the recurrence, and radiation. So, surgery and radiation.

Can radiation damage affect reconstruction?

Question from DellaV: Because I am small, I have to have latissimus flap surgery. However, my plastic surgeon says my radiation treatment was very aggressive and my muscle and tissue is too damaged right now for the surgery. Can radiation cause this much damage and potentially create a situation where reconstruction would not give acceptable results?

Answers —Jennifer Sabol, M.D., F.A.C.S.: If Dr. Serletti doesn't mind I'd answer the portion of radiation therapy. Every patient responds to radiation differently and there are some subgroups of patients, specifically those that may have an underlying collagen vascular disorder that may develop profound fibrosis, or thickening, of the skin from a radiation treatment. As a general rule, it is best to allow this radiated skin to heal for at least 9 to 12 months prior to attempting some type of reconstruction, with the ultimate goal being the best cosmetic result possible. Maybe Dr. Serletti can comment more about the timing of radiation and reconstruction.

Joseph Serletti, M.D., F.A.C.S.: In general, the earliest that we would consider something to a radiated mastectomy site would be three months after the radiation. We do see some patients whose tissues have a more profound reaction to the radiation. In that type of patient, we usually wait, as Dr. Sabol has just spoken about, 9 to 12 months. Usually, at 9 to 12 months, in almost any patient, even someone who does not have enough abdominal tissue, we can usually do a satisfactory reconstruction using a latissimus flap. My sense here is that your plastic surgeon is concerned about the reaction that your chest's soft tissue has had to the radiation, and wants to appropriately wait for that to settle down before moving ahead with reconstruction. It would be a very unusual situation where no reconstruction could be offered in such a setting.

Is it ever too late for reconstruction?

Question from GrandmaP: I am 7 years out from my mastectomy surgery, yet sometimes I do regret my decision to not do reconstruction. Is it even a possibility for me at the point?

Answer —Joseph Serletti, M.D., F.A.C.S.: There is absolutely no time limit on delayed reconstruction. It can occur typically six months after the mastectomy, or up to 20 or 30 years after the mastectomy. The most important factor is when the patient is ready to move ahead with reconstruction.

Will reconstruction help chronic pain?

Question from EbbyS: I am hesitant about reconstruction because of chronic post-mastectomy pain (it's been 2 years). What impact does reconstruction have on chronic post-mastectomy pain? Does it tend to make it better or worse?

Answers —Joseph Serletti, M.D., F.A.C.S.: My experience has been that in many instances reconstruction actually seems to make the post-mastectomy pain better. That includes both implant reconstruction, but it is definitely more common following reconstruction using the patient's own tissue, like a TRAM flap. Now I'll ask Dr. Sabol to comment.

Jennifer Sabol, M.D., F.A.C.S.: While I know of no studies looking at the incidence of post-mastectomy pain prior to and after reconstruction, I agree with Dr. Serletti that anecdotally, patients seem to have an improvement in their pain if their pain was related to scarring and fibrosis. Patients that have other reasons for chest wall pain, such as fibromyalgia, will generally not notice a change in their symptoms, but as a rule will not worsen.

Reconstruction worth it in Stage IV?

Question from Carol: I have Stage IV breast cancer and had a left breast mastectomy. I would like to have my other breast removed and have reconstruction and yet I find that I don't have support for this decision. I hear that I should concentrate on staying healthy. Should I even consider reconstruction, or am I crazy to even consider what I think is a good option?

Answers —Jennifer Sabol, M.D., F.A.C.S.: While we never used to encourage patients with Stage IV disease to look for long term solutions, medicine has changed quite a bit. We now have breast cancer patients with metastases that are living with their cancer well beyond even 10 years. Given this, a reconstruction with a short period of disability may be very, very acceptable if your cancer is one that seems to respond well to treatment and is fairly local. Whether or not you consider a mastectomy on the contralateral breast is much more controversial. Some patients will actually require surgery on the opposite breast to simply make a reasonable match when they reconstruct the affected breast, and in this instance a mastectomy is very reasonable. I think it's important to make sure that your expectations are appropriate and that by removing the opposite breast you don't have the expectation that this will somehow increase your chances of surviving this cancer, but that you are doing this for peace of mind and improved body image. In the right circumstance, I think your choice is not unreasonable. I hope that you will find someone that is supportive of your decision.

Joseph Serletti, M.D., F.A.C.S.: Our practice has been to not categorically exclude any patient from breast reconstruction, even those with advanced stage disease. Our experience has been that many of our patients with advanced disease have remained alive years after their reconstruction. Of those patients who have died from their disease, they have lived an average of just under four years following their reconstruction. It has been our experience that providing a patient with advanced disease a reconstruction for four or more years has been a very positive experience for the patient and their family.

Reconstruction for IBC patients?

Question from Mare Kirschenbaum: Would you please talk about inflammatory breast cancer patients having reconstruction? If IBC patients have a recurrence before two years, can't this be a dangerous issue? Thank you.

Answers —Jennifer Sabol, M.D., F.A.C.S.: Inflammatory breast cancer patients need to keep in mind when they choose their reconstructive techniques that they will require a mastectomy, chemotherapy, and chest wall radiation to keep their disease in check. While it is true that inflammatory cancers tend to behave more aggressively, we are now starting to realize that those patients who respond well to chemotherapy can have a very good long-term outcome and that these patients should be offered reconstruction just as any other breast cancer patient with a lesser stage disease. We do not find that a reconstruction diminishes the patient's ability to survive their cancer or accept treatment in the form of chemotherapy or radiation, or hinders our ability to detect a local recurrence.

Joseph Serletti, M.D., F.A.C.S.: I can't even begin to estimate how many patients who have had inflammatory breast cancer that we have routinely moved ahead with breast reconstruction on. We have certainly never excluded a patient based on the diagnosis of inflammatory breast cancer and have generally had excellent long-term results in those patients.

Breast cancer after DIEP reconstruction?

Question from Cindy: Hi, my question is about DIEP reconstruction. I had mastectomy and tissue expander put in 4 years ago, then had infection 3 months later and had the implant removed, then had a Becker implant put in, and now have capsular contracture. My plastic surgeon is recommending DIEP, but my worry is that if I do this, what happens if I get breast cancer in other breast? Thank you.

Answers —Joseph Serletti, M.D., F.A.C.S.: For patients who have capsular contracture with implant reconstruction, an excellent alternative is to use the patient's own tissue. The most common site that we go to for that is the abdomen, and the most common way we perform that is as a DIEP flap. The abdomen can only be used once. In a situation where we are only reconstructing one breast, we typically harvest all of the lower abdominal tissue and then use what we need to match the opposite breast. When we reconstruct both breasts, we divide the lower abdominal tissue in half and use each half for breast mound reconstruction. In either setting, the abdominal tissue can only be harvested once. So, if the patient is only going to have one side reconstructed, she would need to have some other means of reconstruction should she get cancer in the opposite breast. The most common next alternative site would be the buttock.

Jennifer Sabol, M.D., F.A.C.S.: I think in patients such as yourself, it may be reasonable to ask your surgeon to estimate what the risks to the opposite breast are. Often, patients assume that they are much higher than when is truly predicted. Most patients who have a cancer have an expected .5 to 1 percent risk per year to the opposite breast. Obviously, the younger you are at diagnosis, the more years you have at risk. The patients with the highest risk to the opposite breast are those with the BRCA mutation, where the risk may be as high as 60 percent by the age of 70. In that situation, patients would often consider the prophylactic mastectomy on the contralateral side at the time of revising their reconstruction with a TRAM flap.

Pregnancy possible, safe after DIEP flap?

Question from Jenn: Is pregnancy possible or even safe after a DIEP reconstruction?

Answers —Jennifer Sabol, M.D., F.A.C.S.: Good question!

Joseph Serletti, M.D., F.A.C.S.: In my experience of probably over a thousand free TRAMs, DIEPs and SIEA flaps, we have had over ten patients become pregnant. One actually became pregnant just weeks after her breast reconstruction. Almost all of those patients were delivered by C-section because of the prior abdominal surgery. None of them had any issues with their pregnancy or delivery. At least one of those patients was able to deliver vaginally.

Which type of implant is the best?

Question from Rosie: Are there certain brands or types of implants that are better/safer than others?

Answer —Joseph Serletti, M.D., F.A.C.S.: There are basically two types of implants: saline implants which are filled with salt water, and silicone gel implants which are filled with silicone gel. While we offer both types of implants to any reconstruction patient, well over 90 percent of breast cancer patients choose silicone gel implants. The gel implants create a much more natural breast mound than the saline implants. No scientific organization has yet to prove a cause and effect relationship between gel implants and any harmful disease process.

What tissue is used for nipple reconstruction?

Question from RuthM: For nipple reconstruction, from which body parts other than the inner thigh can tissue be taken?

Answer —Joseph Serletti, M.D., F.A.C.S.: We try to keep nipple reconstruction as straightforward as possible. Virtually all of our nipple reconstructions are done in the office under local anesthesia. Basically, patients drive themselves to the office and drive themselves home or back to work. The way that we do nipple reconstruction is a two-step office process. The first step is to make the nipple projection from the skin that's on the breast reconstruction. We let that heal and six to eight weeks later, one of our nurses than tattoos the coloring for the areola.

Proceed with expansion after radiation?

Question from Anne Marie: Post radiation, I had expanders inserted 8 weeks ago and it is just now healing on the side that was treated with radiation. Is it safe to proceed with expansion? How can I know if my tissue will hold up as the skin and muscle are stretched?

Answer —Joseph Serletti, M.D., F.A.C.S.: That's not so much your decision, but the clinical decision your plastic surgeon needs to make.

Nipple-sparing mastectomy? Implants and mammograms?

Question from Janet: Can you speak to "nipple-sparing" mastectomy, and also the mammogram considerations for gel silicone implants?

Answer —Jennifer Sabol, M.D., F.A.C.S.: There have been only very small, limited series of patients who have undergone a nipple-sparing mastectomy. In general, these are patients that would be considered low-risk for recurrence of the cancer within the tissue leading up to the nipple, meaning that their cancers are small, far from the nipple, and do not appear to have a large intraductal component to their cancers. Having said that, it appears that the risks of having a recurrence in this area are very small. Most surgeons will resect the actual projectile part of the nipple, leaving the color of the areola intact. Patients should be aware that even in the best of hands, there is a 10 percent chance of losing some of the skin in this area due to an inherent poor blood supply, and that the nipple created will not have normal sensation or erectile function. Finally, all nipple sparing mastectomies should be discussed further with the plastic surgeon involved with the mastectomy, as many patients have nipples that have begun to sag and may not be in the appropriate position when a reconstruction is ultimately performed. As for the mammogram considerations for the implants, in general, if a mastectomy is performed no further imaging with mammography should be performed on that breast. This is not because of risk to the implant, but because there is essentially almost no breast tissue left to screen.

Mammograms after mastectomy?

Question from Sanche: My sister-in-law just attended a mammographer's conference in Las Vegas. The keynote speaker stated that one should still have yearly mammograms even after bilateral mastectomies with or without reconstruction to check the armpit and shoulder areas. Have you ever heard of this? I thought that once you've had a bilateral that an annual X-ray was the follow-up, with no more mammograms.

Answer —Jennifer Sabol, M.D., F.A.C.S.: I am unaware of any data that is supportive of further imaging with mammography for a breast that has had a mastectomy. The incidence of recurrence within the axillary lymph node with today's modern surgical techniques should be exceedingly low and not warrant screening in this population. I would, however, fully support a clinical breast exam to evaluate the skin over the reconstruction as well as the axilla for any evidence of recurrence.

What to do for encapsulated implant?

Question from Karen: 9 years post mastectomy w/breast reconstruction. Implant rejected — has encapsulated and does not feel or look presentable. HELP!

Answer —Joseph Serletti, M.D., F.A.C.S.: I think you need to go to a plastic surgeon who has a reputation for providing a broad spectrum of breast reconstruction. It sounds like you would be best served with removing the implant and using a reconstruction that uses the patient's own tissue, such as a TRAM flap or one of its muscle-preserving alternatives.

Okay to run marathon after TRAM surgery?

Question from DinaS: I am a marathon runner and am scheduled for free TRAM breast reconstruction in August and was wondering if it would be reasonable to think I would be able to run a marathon 7.5 months after surgery? Thanks.

Answers —Jennifer Sabol, M.D., F.A.C.S.: Congratulations, I give you a lot of credit for being able to run a marathon in the first place!

Joseph Serletti, M.D., F.A.C.S.: We have many patients who before free TRAM flap breast reconstruction have lived very active lives, including hard-core sports. We usually have patients hold back on resuming those activities until 6 weeks after their surgery. At 6 weeks after their surgery, they can gradually get back to normal activities, including the full spectrum of athletics. I would fully expect any patient of mine who has been a marathon runner to be able to run a substantial race 7 months after surgery.

Seroma common after surgery?

Question from MissAli: Can you comment on seroma after mastectomy and implant and reconstruction? I continue to develop this drainage.

Answer —Joseph Serletti, M.D., F.A.C.S.: Seroma is an uncommon but nevertheless present complication after both implants and autogenous reconstruction. I would say for most implant patients, we tend to leave it alone for fear of passing the needle into the seroma and potentially rupturing the implants or tissue expander. We tend to be somewhat more aggressive in removing the seroma fluid in patients who have had a TRAM flap reconstruction, since there's no implant to potentially rupture. Most seroma will be self-limited and will go away with time.

What is GAP reconstruction?

Question from Lissa: Could you tell me about GAP reconstruction? What is it, and for whom is it recommended?

Answer —Joseph Serletti, M.D., F.A.C.S.: GAP reconstruction is using the buttock tissues and instead of taking any muscle with that, just taking the skin and fat with a perforator. We usually do that operation in patients who do not have adequate lower abdominal for a TRAM flap. It makes a very nice breast reconstruction, but still is not as natural as the reconstructions we obtain with our TRAM flaps.

How long do saline implants last?

Question from Nancy: I had reconstruction done in 1993. My implants are saline. How long before these will have to be replaced?

Answer —Joseph Serletti, M.D., F.A.C.S.: I would say they need to be replaced when there's clinical evidence of rupture. Saline implants are filled with salt water and when the implants' shell develops a crack or a leak, the saline leaks out over a two to three day period. It's sort of like a slow leak on a tire. What the patient will notice is that their breast reconstruction over a day or two will get smaller and smaller. In that setting, the patient should see their plastic surgeon, reasonably promptly so that the implant can be replaced.

Types of diagnostic testing after mastectomy?

Question from Rosie: What type of diagnostic testing is available to detect recurrence of initially diagnosed cancer or new cancer in women who have undergone mastectomy with or without reconstructive surgery?

Answer —Jennifer Sabol, M.D., F.A.C.S.: The most appropriate and most common tool to use is simply physical examination. You have to remember that the layer of breast tissue left is generally less than 1/4 of an inch thick. Your fingertips are going to detect a small nodule within that skin flap much faster than any imaging study. In addition, cancers that recur after a mastectomy tend to appear more like a rash on the surface of the skin than they do a mass deep within the reconstruction. Finally, the other places to evaluate for recurrence are under the arms and within the axillary lymph nodes. Again, this is not a place well imaged by any current imaging modality; it is best evaluated on physical examination. Having said that, if imaging of the reconstructed breast is warranted, a breast or chest wall MRI is probably the most useful tool we have to date.