I had radiation and my surgeon says I can’t have implants. Is flap surgery my only option?

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Eva1962 asked:

I have had 16 rounds of chemo, three chemo medications, and 35 rounds of radiation. I’m triple-negative, BRCA-positive. Bilateral mastectomy removed two metaplastic sarcoma tumors with good margins and no spreading to lymph system. I’ve had a complete hysterectomy post treatment to prevent recurrence.

I have had three fat grafts with not-so-great results on my affected side (radiation). I do not want any flap surgery. I’m only interested in fat grafts. I asked my surgeon if a very small implant could be done. I have been advised by my plastic surgeon I cannot have implants after 35 rounds of radiation without a flap surgery (skin cooked and too thin)... is there any option for women like me other than the extreme flap surgery?

Answer:

I am glad you have done so well. With triple-negative breast cancer and a BRCA genetic diagnosis, we would also have recommended bilateral/double mastectomy. Post-mastectomy radiation does indeed make implant reconstruction very difficult. Implants in the setting of radiation are prone to capsular contracture (painful scar tissue around the implant), infection, and extrusion (the implant actually coming out of the incision).

Alternatively, we would love to believe that fat grafting (fat injections) alone can rebuild a breast, but it is almost universally unsuccessful. Breasts rebuilt from fat grafting alone are firm, fibrotic, and filled with oil cysts and half-dead fat. This is even worse in the setting of radiation. In addition, it takes multiple sessions/operations to see even modest results. The best answer for you and most patients is autologous breast reconstruction (flap surgery). I can tell that you are apprehensive about flap surgery. However, it should not be considered “extreme.” Some plastic surgeons portray it as such because it is time-consuming and technically difficult for them. However, the results are almost invariably better than implant reconstructions. The surgery takes a bigger up-front commitment, but the results are worth it.

Flap surgeries require less frequent long-term surgeries than both implants and fat grafting. The results both feel and look more natural. The reconstructed breasts will age naturally as you age. Flaps are definitely the best option for you. Seek out a group that specializes in breast reconstruction and offers both implant and flap reconstructions. Specifically, you want to see a group that does perforator flap breast reconstruction (the names of those procedures are DIEP flaps, GAP flaps, PAP flaps, TDAP flaps). Experienced reconstructive surgeons will work with you to pick the ideal donor site for your body shape and desired breast size.

— M. Whitten Wise, M.D.


M. Whitten Wise

M. Whitten Wise, M.D.

Dr. Wise is part of the reconstruction team at the Center for Restorative Breast Surgery in New Orleans, Louisiana. Learn more about Dr. Wise.


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