Corrective Breast Reconstruction: Getting the Results You Want

Dr. Marisa Weiss: Hello everyone. I'm Dr. Marisa Weiss. Thank you all for joining us today. You know that managing breast cancer treatment can be a long, complex process with unexpected challenges along the way. After breast reconstruction, the hope is that you can focus on healing and getting back to your regular life, but a cosmetic or medical issue with reconstruction can really keep you from feeling fully recovered both physically and mentally. Today we're going to talk about options for people who are unhappy or dissatisfied with their reconstructed breast or even after you've had part of your breast removed, we're going to call that lumpectomy. Or for people who have pain or discomfort that needs to be remedied. These issues can develop either after lumpectomy with or without radiation or after mastectomy.

And please remember that you're not alone if you're feeling frustrated, angry, discouraged, and a lot of other emotions that can go hand in hand with these types of issues. A corrective surgery may be able to help you, and I hope that what you learn today will empower you in your search for feeling better and feeling more like yourself and looking more like you want to be looking. First, I'd like to thank our generous sponsor, the Center for Restorative Breast Surgery. They are a longstanding supporter of breastcancer.org. Thank you so much for making this program possible. We have a phenomenal panel here with us today of our speakers. Dr. Anne Peled is co-director of the Breast Cancer Center of Excellence at Sutter Health, California, Pacific Medical Center in San Francisco. Dr. Peled is a board certified plastic surgeon with a background in both surgical oncology and reconstructive surgery.

Dr. Dhivya Srinivasa is founder of the Institute for Advanced Breast Reconstruction in Thousand Oaks, California. She is double board certified in both general surgery and breast plastic surgery and completed a fellowship in microsurgery. Dr. Sarosh Zafar is a double boarded certified microsurgeon in plastics and reconstructive surgery and general surgery at the Center for Restorative Breast Surgery and the St. Charles Surgical Hospital in New Orleans. Thank you all so much for being here and for doing what you're doing. You are a rare group of people with excellence in this really important area. I'm looking forward to getting your insights in just a few moments. As always, we look to you our breast cancer community for what matters most.

We'll be including many of your questions in the discussion today, including answers about who can have corrective breast surgery and when, the risks and benefits, options for creating symmetry, what to do when major issues occur after getting implants or having a flap reconstruction, which is when you use your own tissue to rebuild a breast, revision surgery on radiated skin or after an infection happened, finding the right surgeon, and how to pay for revision surgery. We'll get into all these topics and more in a few minutes. In preparing for today's webinar, we wanted to know about your satisfaction with the results of your reconstructive breasts after a mastectomy or lumpectomy, and here's what you told us. 85% of you said, "No, I don't really like my breast reconstruction, the way they look or the way they feel." And 15% says, "Yes, I'm happy with the results."

Now, these answers came from nearly 800 of you who signed up to join us today, and while it might not be surprising that so many people are dissatisfied given the topic we're here to discuss, it really underscores the importance of ensuring that you know your options so that you can feel more confident, comfortable, knowledgeable, and happy with your reconstructive breasts or your altered breasts after you've had partial breast tissue removal. And it's now my pleasure to welcome Dr. Peled, Dr. Srinivasa and Dr. Zafar. I'm going to start with Dr. Srinivasa Vasa. A lot of people have asked how they know if their recovery time and pain level are normal after reconstruction following a lumpectomy or mastectomy. Typically, what should people expect?

Dr. Dhivya Srinivasa: I think in general, and again, this is in general because recovery is such a personal process. In general, what I say is with a lumpectomy, the first three to five days, you're going to feel that incisional pain, that sharp pain throbbing. That achy throbbing will usually continue on for seven to 14 days. By two weeks, I find that most patients should be off of narcotics, on non-narcotic pain medicine. By six weeks, I expect that most patients are fully healed, and I think if at that point you're still feeling pain, it's important to talk to your doctor about it and help describe that pain because we have different medications that target different kinds of pain. You had mentioned nerve pain and like you said, when the nerves are cut from surgery, they're going to wake up and they're going to want to grow back, and that can be treated with very specific medications that are different from maybe a dull aching, throbbing pain.

For a mastectomy, in general, the pain does last a bit longer. I find that that sharp incisional pain can last up to two weeks. For another two to three weeks, I think most patients will experience that aching, throbbing type pain. Again, by about six weeks, I expect that most of that pain has gone, and if you're still insignificant pain, you should talk to your doctor about it, describe the pain the best you can, and keep track of what you're doing to help with the pain and what medications you're taking so they can help guide you for the best options.

Dr. Marisa Weiss: Yes, and after the nerves have been cut and they're ready to regrow, and of course you want them to regrow, they can have an attitude and hold a grudge and you might feel like flickers or zingers or crawly, itchy weird feelings both in the area of the breast. And if you've had a lymph node dissection, in the armpit, it can actually go down the arm to the elbow, sometimes in the back here. It really depends on the extent of surgery. And if you've had chemotherapy that decreases the ability of the nerves to heal like Taxol or Taxotere, it can push off the time that the nerves are healing and you might feel later on more discomfort than you had earlier on, and that might come as a surprise. Dr. Zafar, who is a good candidate for revision after reconstruction? Are there factors that make a revision surgery riskier or less likely to be successful?

Dr. Sarosh Zafar: Well, thank you so much for having me, Dr. Weiss. And before I answer your question, I just want to mention how startling your statistic was, that 85% of women are unhappy with their reconstruction. That's so upsetting as a breast reconstruction surgeon, and hopefully we can help people figure out how to get connected, who's a candidate, what are the right things to ask your surgeons and all the questions that I'm sure you have lined up for today. But just in terms of who's a good candidate, if you were healthy enough to have breast reconstruction surgery, you are probably, I would say 95% plus chance that you're a good candidate for a revision of your reconstruction. I think one of the biggest roadblocks that patients have is the fear of opening their bodies up again to surgery.

If they're unhappy with how their reconstruction went, that fear of, oh my God, am I going to feel even worse? Am I going to look even worse if I go and have surgery again? But most patients who've had reconstruction are going to be candidates for a revision of their reconstruction as well. Are there any things that will make your revision more or less risky or more or less successful? I would say that the one thing that can make revision surgery a little bit more difficult is probably radiation, and that depends on your radiation. And if you're out there, you know that your radiation might've been different from your friend's radiation, which could have been different from your cousin's radiation. So it does affect different patients differently. There's different types of radiation that can affect tissues differently.

But I'd say that radiation or other severe complications like infection. Implant related infections where you lose your implant, you lose all of that skin elasticity, you lose your skin envelope, those are a couple examples, but in general, most women are going to be candidates for revision if they've had reconstruction.

Dr. Marisa Weiss: Yeah. And I'm a breast radiation oncologist and I know the plastic surgeons and us, but radiation causes issues for breast reconstruction on a regular basis, I know that. But it's also true that radiation is a very effective method of treatment, especially for people who are at high risk for a problem after they've had mastectomy. So people, for example, who had inflammatory breast cancer. That's when the breast cancer enlarges a breast. Usually it affects the breast diffusely, it involves the skin. The skin can get pink, red and extra swollen, that the radiation is really key to reduce the high risk that it could be a problem again in the future. And so the dose that radiation is given to the skin is higher, making it more tricky to have reconstruction later. But you guys are amazingly well-trained to deal with those types of complications and when you bring the fresh-

Dr. Sarosh Zafar: Absolutely.

Dr. Marisa Weiss: And when you bring the fresh tissue in with fresh blood supply, then you can help that area heal and regain some of the health that you may have lost, or it may revitalize the area by bringing in fresh tissue.

Dr. Sarosh Zafar: Absolutely.

Dr. Marisa Weiss: Dr. Peled, I was going to ask you, a priority for many people is having breast symmetry so that you look even after lumpectomy or mastectomy. I know that's tricky because some people might have natural asymmetry, lopsidedness ahead of time, but when they're finished with all this, they want a nice set that looks good together. What are options for creating a more symmetrical appearance with one or both reconstructed breasts?

Dr. Anne Peled: So I think one of the things we know is a lot of this really depends on what you're looking at for your cancer treatment. So I say this with love, Dr. Weiss, as you know, my mom and sister are both breast radiation oncologists and we always say we can work with what we have with the effects of radiation if it means we're decreasing the chance of a local recurrence. But with radiation, we do know that things change over time. And so I think sometimes, especially if we're talking about lumpectomy where we're taking part of the breast, we know that if you do need radiation in that setting, the changes that may happen can take a year or sometimes even two years before we really have a sense of what that's going to look like. So sometimes women who may have larger breasts, breasts that are less dense, they may actually have a lot of volume change, they may have breasts that get higher and tighter.

And so it can be hard sometimes to predict what asymmetry is going to be, so what I would say to people is first off, know that we do have lots of options for symmetry. So for instance, in that setting, one of my favorite things to do is to try to do a lift or a little reduction on the other breast. So we're not going back for some of the radiation challenges that Dr. Zafar brought up, but we're able to just make the other side match so we achieve symmetry, but we're decreasing the risk of going back and radiated tissue. And then if we're thinking in the mastectomy setting, often even if people don't want to have a mastectomy on the other breast, which is very reasonable in many settings, we have options whether it's adding a small implant, if we need to adjust volume, whether it's doing a lift, adding fat grafting for volume.

So again, I think a lot of it is really figuring out how long are the treatment effects going to take for us to really go in, so when we do surgery, we're doing the very best thing at that time and allowing those changes to settle out.

Dr. Marisa Weiss: Right. I liken breast reconstruction to renovating a kitchen in the sense that you had your breasts before all this happened and you were fine. You knew what you had, and they were okay. They got older looking as you grew older and you know what your breasts look like. As soon as you go for reconstruction, just like as soon as you get a new kitchen, all of a sudden every detail matters. The depths of the cabinets, the distance from the stove to the refrigerator to the sink, the poles, the way the door opens and closes, the layout, the counter, everything. And it's amazing, I think part of the challenges of breast reconstruction is that you initially are so fearful because you've been diagnosed with breast cancer and you meet the breast cancer surgeon.

And then peripherally, you then meet the plastic surgeon and you don't really understand that you're actually going to have a longer relationship with that breast plastic surgeon, that you'll be seeing them often more frequently than your breast surgeon. And so a lot of it is patient education to really help people understand what to expect when they go through all these steps so that they know what your role is in their care and how incremental it is. You can't do it all in one fell swoop. The goal is to get you to a better place, but it can take a number of careful steps to tweak you to get to the right place so that you're happy at the end. Dr. Peled, just a follow-up to the question that we received about symmetries is this expression about uniboob. People say they don't want a uniboob. Can you describe what that means and suggestions for fixing that?

Dr. Anne Peled: Basically when people talk about uniboob, what they mean is that the central part of the breast, the part around your breastbone that is naturally a divider between your two breasts essentially gets opened up. And oftentimes this can be related to the way the mastectomy might be done. It can also be related to the way your tissues evolve over time. But if this does happen, fortunately we're able to fix it, whether it's making a choice to reinforce the pocket. So sometimes using a mesh and essentially recreating that space and closing that down can be really helpful. And then other times there are questions around should we put in a smaller reconstruction to take some of that pressure off of that area and allow for more space? But I would say fortunately, it's something we see less and less.

As my breast oncology surgeon hat, I've been really happy to see how thoughtful many breast surgeons are really taking on this idea of doing better and more thoughtful mastectomies around preserving blood supply and nerve supply in the breast borders. And so I think we're seeing less and less of that fortunately and are better at correcting it.

Dr. Marisa Weiss: Great. Well, certainly you guys are leading by example, and we are so grateful for that. Dr. Srinivasa, several people in our audience are asking, when do implants need to be replaced? Because they may have read somewhere that they expire at a certain time. And one person asked whether there's an option to go flat instead of getting replacement implants.

Dr. Dhivya Srinivasa: So for the first part of the question, generally the most common thing I hear from patients would be, do I need to get them replaced every 10 years? I think that's the most common statistic that's out there. And I think that 10-year marker came from two things. One, the most common implant warranties last about 10 years. And the other thing would be in general, statistically women are likely to need something about every 10 years. So if your implants have no issues, they're soft, they're not bothering you, there's no reason to have surgery to replace them just because it has been 10 years. That said, if you're having really tight scar tissue around the implant, there's malposition, it's ruptured, those would be reasons to meet with a surgeon to talk about replacing them or going flat. Having a flat aesthetic closure is always an option at any point in your reconstructive journey, including after removal of breast implants for reconstruction.

Dr. Marisa Weiss: Thank you. How many people come back and say, I like my implants, they're okay, but I actually want to be bigger? And so rather than going flat, they want to have an enhancement of what they have.

Dr. Dhivya Srinivasa: I find that it happens often that women want to go bigger, but when I try to discern what it is that they specifically dislike about their breast reconstruction, it's not necessarily that they want the implants to be bigger, but it may be that, especially with under the muscle implants and as they age, the implants have moved. They don't look like they did when they were first placed. They may have dropped or bottomed out, they may have fallen down and out. And so what women are missing are the natural cleavage and upper pole fullness that's most often visible with clothing and in bathing suits, for example. So if that's the case, it may not necessarily be that you need bigger implants, but rather repositioning of the implants, possibly going to above the muscle, like Dr. Peled said, placing a mesh to recreate the pocket to enforce those implants to sit closer together and give you natural cleavage.

So it does come up often, but I think it warrants further discussion to know what exactly is bothering the patient so we can fix it the right way. And the answer may not necessarily be simply upsizing the implant.

Dr. Marisa Weiss: Okay. Thank you. Thank you. Dr. Zafar, can you explain what capsular contracture means and the options you have to fix it? And then after you fix it, are there steps or things you can do to keep it from happening again?

Dr. Sarosh Zafar: Sure. Capsular contracture is basically scar tissue that forms around your implant, and I like to think of it as a shield that your body makes around the implant to separate it from the rest of your body, protect your body from something that is foreign. And for the women out there who had to have ports placed for chemotherapy, your body also creates a capsule around a port, just like if you had an artificial knee or a hip. Specific to breast implants, when that capsule or that scar tissue starts to become thick or tight, it can start to change the shape of your implant. It can move the implant so that sometimes it sits higher or sits off to the side. It can sometimes, what's very, very difficult to handle is shift your nipple position, and sometimes in the worst cases it can create pain and discomfort.

Some of the things that we do to make it better are if you still want to go the route of implant reconstruction, removing the implant, removing most or all of the capsule, placing a fresh implant, potentially adding dermal matrix. In patients who've had radiation, it's probably a little bit more challenging to overcome capsular contracture just because of the nature of radiated tissue. But ultimately, if you keep having problems with capsular contracture and we can't get ahold of it, especially we're a little bit biased at our center because many, many women come to us to have their implants removed and have that replaced with their own tissue, but ultimately replacing that implant with your own tissue can overcome capsular contraction.

Dr. Marisa Weiss: Interesting. Thank you. Dr. Peled, we received a question asking if corrective surgery can return sensation to the nipple and the breast to give you back your playground. What's possible with that?

Dr. Anne Peled: So I would say in our practice we do a lot of primary nerve-sparing, nerve reconstructing mastectomies, and ideally if you're someone that's in that decision process or you've had a lumpectomy and maybe think of mastectomy, the best time to keep sensation is at the time of mastectomy. But if that hasn't happened, what we find is we can actually go back and look for nerves to reconstruct. So for decades now, people have been going back and using flap reconstruction, and you can take a nerve with the flap. You can also look for a nerve in the chest and you can actually do a nerve reconstruction during the same time as the flap. Lots of studies have actually shown that that increases return of sensation, and people can, especially if you're bringing up a big piece of skin with the flap, in a delayed setting, you actually can get great sensation back to the skin.

It's been more recently though that people are actually thinking about doing it with implants. And the reason for that is because unlike with a flap where you can bring a nerve with you, when you're going back in a setting of an implant, you don't know what the nerve's going to be like till you get there. So we do a lot of these in our practice, and unfortunately, I don't know until I get in there, is there going to be a great nerve to find to reconstruct? Is it going to be scarred in? Is it going to be way back in the chest where I can't get it? But what I always say to people is, if you're thinking about a revision, ask your surgeon if they'll be willing to look for nerves and try to reconstruct them because there's no harm in looking.

And if we are able to find a nerve, we're happy to do a nerve reconstruction with nerve grafts and really try to give people back skin or nipple sensation. So I would say it's definitely possible, but sometimes we don't always know how likely it's going to be successful until we get in there.

Dr. Marisa Weiss: And it's not just sensation, you want an erogenous, you want it to feel a good sensation, and that's the goal, of course, is to try to help people recover that if possible.

Dr. Anne Peled: I think that's the dream, right? That's what we all would hope is our highest bar. But to be honest, I always think about one of my friends who had mastectomies before we started doing these sensation sparing ones, and she said she puts on a sports bra and doesn't know it's on. So I think unfortunately with traditional mastectomy, a lot of people will literally tell you it's like they had lidocaine to their entire chest. And so I think what I would say is we strive for what you mentioned, but even if you're someone that misses what it feels like when you feel warm water in the shower on your chest or you feel what it's like to have a family member hug you, it's possible to get back to that even if we can't quite get back to that ultimate goal of erogenous sensation. So I guess they would hold that hope for people of asking, even if it gets better, most people are still so grateful for something.

Dr. Marisa Weiss: Yes, absolutely. Thank you. Dr. Srinivasa, how often do you hear people report that they're not happy with the way that the donor tissue site has healed? Wherever you borrowed the tissue from, that is what I mean by the donor tissue site, after flap reconstruction. How often is that an issue and what can be done to help with scarring or preventing things like hernias or other things at the tissue donor site?

Dr. Dhivya Srinivasa: Sure. So anytime we're doing flap reconstruction where we're taking skin and fat, and hopefully in a muscle preserving fashion, and moving it for a breast reconstruction, we call that autologous reconstruction. Auto meaning your own, logous meaning tissue. The goal being we can reconstruct the breast without an implant, but it means we're taking it from somewhere and we refer to that as the donor site. So donor site complications, honestly, the data is all over the place. My general recommendations are to ask your plastic surgeon for before and after photos that mimic your starting point so you can have an accurate understanding and calibrate your expectations for what it's going to look like. So how high is the scar scar placement? You had mentioned hernias.

Hernias are far more common when the D-I-E-P or DIEP flap, which is taken from the abdomen is perhaps not done as a true DIEP flap and more like another acronym we use called a TRAM flap. And the difference between these acronyms is the utilization of muscle along with the flap. When you move the muscle from the abdomen, you're at higher risk for a bulge. It can also happen with DIEP flaps, but it's much, much less common. So I would say it really depends on your micro neurosurgeon. How do they do the operation? You just have to ask them, say, hey, do you see this? How often do you see it and how do you fix it? Bulges or hernias can generally be fixed with tightening the abdominal wall or placement of a mesh in some cases.

Scar placement. Sometimes the scar can be lowered at a revision, sometimes not. I personally really like to use lipo contouring and liposuction techniques to help contour the abdomen and also utilize that fat for fat grafting. I think in general, discussing a revision is just really important. Every surgeon has their own philosophy or ethos on how they approach this. For me personally in my practice, I tell patients, hey, we got a lot to get done at the time of your mastectomy. Especially if we're connecting nerves and we're sparing skin and nipple and all of that. My goal is to thoughtfully transfer the tissue and do a good job to try and make the tummy look as much like a tummy tuck as possible. But it's not the exact same thing as a tummy tuck.

However, there's this operation called the revision that we can do as an outpatient, a minimum of three months out from surgery, longer if you'd like. And that's really the opportunity to fix issues at the donor site. So it's a long-winded answer, but I think I would say in general the most important thing is know that revisions are an option. Talk to your surgeon about revisions and their general philosophy on it and what can be done, even from the beginning if possible. And try and get a good understanding of before and after photos what you can expect and whether your surgeon is someone who does the operation in a truly muscle sparing fashion.

Dr. Marisa Weiss: What about for people who were overweight before this whole thing started and now they're on these new medicines or they've had bariatric procedures, they've had significant amount of weight loss and now things are hanging in a way that they weren't upfront? Is that a reason for revision?

Dr. Dhivya Srinivasa: Absolutely. It still can cause issues at the donor site, so we can definitely go back and excise additional skin. Plication is the term that we use for tightening the abdominal wall or bringing muscles back together. So repeating that plication is always an option. And usually things don't just change in one spot, so if you've had fluctuations in your weight, you may also notice it in your breast. So that may be an opportunity to not only address the donor site, but you can utilize the fat that you take from the liposuction to help contour the donor site to then reinject as fat grafting back into the breast as well.

Dr. Marisa Weiss: Okay. Thank you. Thank you. Dr. Zafar. Someone asked if switching their implant from under the muscle to over the muscle is now the right thing to do, something they should check out, and can you talk about what goes into this decision? What are your insights there?

Dr. Sarosh Zafar: I think Dhivya touched on this a little bit earlier, and I really liked how she described that. It just depends on what the problem is that you have with your implant. And so it ends up being really a conversation with your surgeon and you just openly, honestly telling your surgeon, hey, this is what I like about my implant. This is what I don't like about it. Specifically, I think this question might be related to some patients who when their implant is behind their muscle, every time they activate their pec muscle, which is something we activate all the time throughout the day, especially when we're exercising, it can squeeze the implant, push the implant down and out. And that's something that we call animation or hyper animation deformity, which is just a big word for saying the muscle pushes the implant and just looks strange, unnatural and odd.

For some women, switching the implant to sitting on top of the muscle can be an option. You just have to know that if you have a very thin mastectomy flap and you don't have much tissue behind your skin that was left over, sometimes it can make where the implant meets your chest wall look very obvious, like an obvious switch from implant to your chest wall. One other option that some patients may consider if they talk to their surgeon is going in and dividing the little nerve that goes to your pectoralis major muscle, and that's called a pec nerve neurolysis. And sometimes that can soften the function of your muscle and stop some of that hyper animation deformity and can soften or blur that line.

And so there are a few different options that go into it, but do I think everyone who has their implant behind their muscle should shift it to above their muscle? Absolutely not. It's really a conversation with your surgeon and a physical exam and your surgeon looking at what happens when you activate your pec muscle.

Dr. Marisa Weiss: Right. And just the comment about trying to leave the muscles alone and trying to use skin and fat to recreate the breast is an important consideration because every time you modify the muscle, that muscle might not work as well in the location where it lives, like sit-ups in your belly area. Or if you're using the muscle back under right behind your armpit area here, I know a pediatrician who had reconstruction who couldn't flip the babies as much because she couldn't twist in the same way. Likewise, if you do remove an implant from under the muscle and the pectoralis major muscle, the one right underneath the breast area, and that muscle's now have been stretched out to accommodate that implant. Will that muscle get back to work and will ever get its to back so it can do its job again in a right way? Or does it stay stretched out in semi-retired mode kind of thing?

Dr. Sarosh Zafar: It depends on the situation, but some of us naturally as women have super thin, smaller pec muscles. Some of us as women have really nice hearty muscles, and it probably depends on some genetic factors. Probably depends on how much your nerves have been stretched, how long you've had the implants, how long something called muscle atrophy has set in, which is where if you don't use that muscle for a long time, it will lose its function. So I think again, case by case basis. But I do find that a lot of our patients who have their implants behind their muscle, they come to see us because they hate the way it feels, looks or functionally they have a problem with it, who get those implants removed and have the muscle put back down on their chest wall and have a flap instead. Almost unanimously, the morning after surgery they say, "Already I feel so much better."

Dr. Marisa Weiss: Wow, it's amazing what we adapt to. Human beings can adapt to all kinds of circumstances, and just because you adapt doesn't mean it's a healthy thing physically or emotionally.

Dr. Sarosh Zafar: Correct. Absolutely.

Dr. Marisa Weiss: And I know all of you in your practice have discovered this and I'm a dual citizen, both a doctor and a breast cancer survivor, and I'm fascinated every day how in everyone's life there's always more things going on than just their breast cancer. They've got kids with issues, they have work issues, they have other medical problems. Women lead a complicated life and the reconstruction ends up being an opportunity for them to feel better about themselves and go back to a new normal that they can feel good about. Dr. Srinivasa, how do you manage the fat necrosis after flat reconstruction surgery, and what kind of revision may be needed? And can you explain what that fat necrosis is?

Dr. Dhivya Srinivasa: Absolutely. So when we do a flap like a DIEP flap where we're transferring the fat and skin, it's based on the blood flow that we transfer with it. Either in the short term or over time, that blood flow may be insufficient to reach every last bit of fat that we transferred. So in that case, you can develop something called fat necrosis or a death of that fat, which then becomes... Either it can be oily and bubbly, it can be liquidy, a thick white liquid, or it can form a hard knot or a hard ball. And expectedly, in a woman who's already been through a breast cancer diagnosis or has a genetic predisposition, that can be particularly stressful. So if you are concerned that you have developed fat necrosis or those hardened areas of fat after a flap transfer, it can definitely be addressed.

It falls on a spectrum. It could be a tiny little bit of fat necrosis, it could be a lot of fat necrosis. For smaller areas of fat necrosis, it depends on how much it bothers you. For some women, they say, "It doesn't bother me at all." It looks completely normal on imaging and we don't have to do anything. For some women, it's anxiety provoking that it's a lump and they can feel it. Or imaging may look abnormal, so they may choose to do a biopsy or we can excise it at a revision and then send it to pathology. If it's a large area of fat necrosis, which is uncommon but can happen after a flap, I first like to remove the entire area of fat necrosis and see what the defect is. If it is something that I can fix with fat grafting, that's a great option.

Sometimes though, it's not something I can fix with fat grafting. And in those cases I've actually gone back in and done a smaller flap from somewhere else. If they already had the flap from the tummy, we can also take fat from the love handle area, from the inner thigh, from right below the buttock crease and we can move those flaps to fill that defect and then recontour the breast, again with soft all natural tissue, but to replace the fat necrosis that occurred.

Dr. Marisa Weiss: Now, when you use liposuction technique, you fill up a syringe with, let's say fat, and you mix it up and then you put it back into an area where there's a concavity or some kind of indentation or you just want more fullness there. What's the chance it's going to stay there and get the blood supply it needs so that you don't get fat necrosis again?

Dr. Dhivya Srinivasa: That's a great, great question, and it depends on the hole that you're injecting it into. So if you remove a large piece of fat necrosis and you have a big hole, if you were to just put fat in there, it wouldn't survive. The way fat grafting works is that the fat you inject doesn't have blood flow with it like a flap does. It is depending on the environment to grow blood vessels in and around it and form new blood supply that then supplies the fat that you injected. So it depends on the quality of area you're injecting to. You can't inject into a vacuous hole, but you can try and inject into the tissues around it to help fill it in from the outside in. And if that tissue has been radiated, the fat may not take very well.

If the tissue is otherwise really healthy and the flap is otherwise really healthy, then you have a good chance that most of the fat will take because you're injecting it or placing it into a healthy environment where those blood vessels will grow back.

Dr. Marisa Weiss: Okay, thank you. Dr. Zafar, if you're seeing a patient who's about to have mastectomy and they're at high risk or something, you know that it's likely that they're going to need radiation at some point in their care after their breast surgery reconstruction, maybe they had chemotherapy upfront, whatever it is. How do you coordinate or work together with your radiation oncologist to minimize the risk that radiation will interfere with the best result of your plastic surgery? How do you communicate and how do you optimize the ultimate result when you know someone's going to have radiation?

Dr. Sarosh Zafar: You always have to start, I think, with a conversation with your radiation oncologist and understand what type of radiation does a patient need? How much? What's the field? Can I temporarily put an implant in at the time of their mastectomy? Should I go ahead and do a flap at the time of their mastectomy? What does their donor tissue look like? How much extra tissue do they have in other parts of their body that we could potentially use? And so ultimately, there are a lot of factors that go into it, but having that open communication with your radiation oncologist, just like having that open communication with medical oncology, is pretty critical in making sure that patients are getting the best care that they can. And that's why just like in major cancer centers, the team-based approach is always the best option.

I think it's always really nice as a patient to ask those questions to both your plastic surgeon and your radiation oncologist. And that can help you understand as a patient what you need, what's the best option, and how to make an educated decision about what's going to be the best thing for you.

Dr. Marisa Weiss: And generally speaking, your own tissue reconstruction gets along better with radiation than implant reconstruction. And sometime, given that you know after radiation there might be a little shrinkage, some plastic surgeon might make that side that you know is going to get radiated maybe a little bit fuller, just knowing to anticipating that effect.

Dr. Sarosh Zafar: Absolutely.

Dr. Marisa Weiss: Okay. Thank you. And Dr. Peled, what advice do you have for people looking for the right plastic surgeon to do a corrective procedure? We know how highly trained you all are and how much expertise and experience you've had to gain over the years. How do you find that plastic surgeon to do that special work?

Dr. Anne Peled: So I guess I would start on, I think what you're hearing from all of us, and as you said as well, unfortunately unlike, say, breast augmentation where the results are much more predictable, these are surgeries that are, to some degree, less predictable based on other factors, based on other treatment that might be needed. There are procedures that often we are doing more than one surgery to get the results that we want. So I think in that setting when I would say is even primary reconstruction can be challenging for some people. And so I would certainly start by going to someone that this is what they do. And that, wonderfully, you can see on people's websites, you can see on what people do on social media. What are they talking about? How are they answering questions and does it make it clear that they're someone that really is committed to breast reconstruction?

I think the next piece of it is that revision surgery can be tricky, as you said and I've had this myself also being on the breast cancer survivor piece of it. It feels a little bit elective sometimes and it sometimes feels tricky to put yourself out there again to go in and think about it. And I do think a lot of people live unhappy for many years because they're cancer free and feel like they should just be appreciating that. And I think in that context, people feel very different about what would merit a revision to them or what wouldn't. I see some patients that I personally look at their results, I'm like, "Oh, I wish they were better." And they're super happy and living their life and great. And conversely, people I'm so happy with and they see things that really bother them.

So I think what you need is you need to be able to see someone who listens to you, who really asks you in your life, your day-to-day, what bothers you about your reconstruction and allows for the possibility of fixing that regardless of what they think and what they bring into it, but actually what you think and what you bring into it. One of the best ways to figure that is talking to practices with prior patients that they'll connect you with. So having practices that have a buddy system, that have a social media presence with patients talking to each other is really helpful. And then I think the final thing is going on these larger groups, chat rooms. I always say little caveat with this is that unfortunately no surgeries are perfect. Every single one of us on here is going to have some surgeries that don't go the way that we hope.

And so I think it's really important to try to stay open-minded if you do go on these forums to know that you're going to get a range of opinions about different providers, different surgeons, different outcomes. But again, I think the ultimate thing is really going to someone that you know is truly committed to this and to cutting edge techniques and is constantly learning about breast reconstruction.

Dr. Marisa Weiss: Absolutely. And as you were saying, really asking people what are they satisfied with? What are they less than happy about? And what are their goals? And really to match it up with what's realistic. And what I know each one of us just realizes is every day that each patient we take care of is so unique. And if you are in the forums and you hear from someone else, oh, I did this, I did that. It may be great for them, but it may not be great for you. And I've seen people who've had, for example, the aesthetic flat closures. They heard it was a great thing to do, but their body was different from the person that they got advice from. And they may have a big belly, and then they go flat up top and all they see now is their belly.

So they might come forward at that point and say, you know what? I thought I was making the best decision at the time, but now I'm reconsidering. Maybe I'm in a new relationship. My mother had mastectomy without reconstruction at age 75, and she was widowed at 83 and met this great guy at 90. He was 90, she was 83. And he was fine with it, but she did look into her options at a later time, like, what about making something here that's lovely and fun to play with? Life evolves, and you can always revisit this aspect of your care. Dr. Srinivasa, what do patients need to understand about paying for corrective surgery, knowing that not all specialized surgeons accept all insurance plans? And what would Medicare or insurance cover if accepted by the surgeon? And what language do you need to use and to demonstrate what it is that you need and hopefully get it covered?

Dr. Dhivya Srinivasa: There's a lot that I could say about this. This could be a webinar unto itself. This is how I break it down. One, understand whether your surgeon is in network or out of network with your insurance plan. The office should readily be able to tell you that as you make the consultation appointment. The surgeon is not the only piece, you also need to think about the facility where they do surgery and sometimes the anesthesiologist. There are three different pieces that you have to understand. So your surgeon can be out of network, but the facility and anesthesiologist could be in network. So once you know what each part is, then you have to understand what your insurance plan covers. Most PPO plans have an out of network benefits part of the plan. So you want to know what your out of pocket maximum is. That's the question to ask when you're talking to your insurance.

That said, that still doesn't answer all the questions of how much do I owe? What are they going to charge me? Because different out of network practices have different billing practices. So it's important that you get connected way ahead of time, way before you're rolling into surgery, with the finance person in the office, ask the questions of how much do I owe? And if what you owe them is higher than the out of pocket out of network maximum, then you are likely eligible for reimbursement from your insurance back to you on the backend, and that would require you to submit some paperwork and what we call as a super bill. If you're seeing an in network surgeon, then it's just per your plan and your deductible and your co-insurance. So it should follow the same thing it did with your original surgery as long as the plan itself hasn't changed.

So as you're navigating this, the one thing I like to tell patients is that if you are seeing an out of network surgeon, it's important to be able to explain to the insurance company why. Because most insurance companies that have these PPO plans with out of network benefits have something known as a gap exception, also known as a NAP exception with certain plans, or a letter of agreement, or a single case agreement. These are all sort of related terms. I'm going to say it again. Single case agreement, letter of agreement, gap exception or NAP exception. And all of these words sort of mean the same thing, which is in certain situations, the insurance company will acknowledge that you need to see this out of network provider because they're offering you something novel or different or something that will fix your problem that the in network provider was unable to provide.

And in that case, they will directly negotiate with your surgeon who's out of network so that you aren't paying the out of network fees, but that the insurance company absorbs that for you. And I recommend to all patients that are being seen by an out of network provider, you have a conversation early with the office about do you guys participate with the letter of agreement, single case agreement, NAP exception or gap exception? And then be able to say why you need to see that surgeon. Is it a flap that they do that your in network surgeon doesn't do? Is it that one told you you are a candidate and one told you that you're not? Is it because you have complications and you have lost trust? Continuity of care is a big one. Maybe you saw them when they were in network and they've since gone out of network.

So being able to understand what qualifies you for a gap exception can then help you create a strong argument for why you deserve to have that. And if you don't get the gap exception, then make sure you understand which parts of your care are out of network, what your out of network out of pocket maximum is, and whether the office will provide you a super bill.

Dr. Marisa Weiss: Wow, thank you. That's a lot of really important information. So basically get to know upfront how to prepare for this whole conversation, which includes knowing how it's going to be covered and what the cost will be and how to manage that. And of course, the office has experience with that.

Dr. Dhivya Srinivasa: Yes.

Dr. Marisa Weiss: Dr. Zafar, before we wrap up, are there any risks for having corrective breast surgery that we haven't talked about already? And what more do people need to consider when talking about this with their surgeon?

Dr. Sarosh Zafar: I think we covered a lot today, but I think one of the biggest risks is just the fear of asking, the fear of reaching out, the fear of the unknown and what's going to happen. And I would say that reaching out to your network, getting your support and talking to different surgeons is probably the best thing that you can do. When you meet with your plastic surgeon, one of the most critical things, in my opinion just imagining as a patient what it would feel like, which I'm not a breast cancer patient, but imagining that one of the most important things is going to be, is this surgeon listening to what I'm saying? Are they processing what I'm saying? Are they understanding what I'm looking for? And feeling comfortable enough with that person where you can openly say, hey, this is what I really like. This is what I don't like.

And then that surgeon's responsibility, in my opinion, is let me do what I can based on your anatomy, let me get you the best outcome that you can possibly achieve based on your anatomy. And I would say that if you can find that kind of happy medium, I think that's the key. If you go and you meet a plastic surgeon and you don't feel that from them, I think you should go and try to meet more people. Imagine it's just like walking into a shopping mall and walking into different stores and saying, hey, this is actually what I really like and this is what fits me, and this is what I feel like looks good on me. And I wouldn't be shy about that as a patient. I think all of us as plastic surgeons have had patients who came and met us and went and had surgery with someone else. And all of us know that that's part of taking good care of patients, is they have to be comfortable with you. And it's nice if you're comfortable with your patients as well.

Dr. Marisa Weiss: Absolutely. Yeah, absolutely. Thank you. That's really important. I appreciate all that empathy that you all have. Dr. Peled, what words of encouragement can you share with everyone here today who is dealing with complications after reconstruction?

Dr. Anne Peled: So I think the first thing that I'll say is that fortunately, technology techniques options just keep getting better and better. And I always tell people, I feel so lucky to be a breast cancer and breast reconstruction surgeon in this day and age with everything we have. Good example, for instance, is people that when maybe they had surgery, their only option really was an implant-based reconstruction because they didn't have anyone who was trained in some of the advanced microsurgical techniques that the lovely surgeons on with me are both experienced in. And now we do have those techniques, so we can take someone that maybe wasn't thought of to be a flap candidate 10 years ago, and now eventually they are able to have a complicated and more advanced kind of breast reconstruction with a flap. So I would say techniques and technologies are better.

The next thing is there's more access. So again, we have multiple people now throughout the country who are trained in more advanced techniques and able to offer more options and have more in their toolbox for complications. And then I guess the last thing is to know that you're not alone. Again, I, on a personal level have had two revision surgeries myself. It happens. Things happen. This is something we all know and you'll find many other patients who've been in this setting. And I think just knowing that it's okay to bring up, it's okay to acknowledge, it's okay to find a different surgeon if for whatever reason your surgeon doesn't feel like the right fit. You're the only person who wakes up in your body every day, and it matters how you feel, not how we feel. So I really think making sure that you feel comfortable with that is important.

Dr. Marisa Weiss: Absolutely. And there's no emergency. It is important to take the time to find that right fit and to find the right moment. And it might be that you meet somebody and they say, okay, let's have a plan here before we move forward. We have to help you stop smoking, for example. You're in this big weight loss effort here, let's wait for you to get closer to your goal weight before we move forward. There's a lot of nuances here that you work with every day, but even having a plan in place can really make people feel a lot better. And I would also say that the community at breastcancer.org has been extraordinary, really helping each other through it, but in also fighting for insurance coverage for these specialized procedures that insurance companies were trying to pull back from. So we want to just thank everyone in the breastcancer.org community and the extended community who have worked so hard to advocate for yourself and for each other.

So I think that's actually the last question for today. I want to thank you so much, Dr. Peled, Dr. Srinivasa and Dr. Zafar. You've done a great job. Before we go, I just want to quickly summarize some of the important information that was shared today. We'll also email links to you with articles and interviews to help you as you look into your options. You've heard today, and there are such a wide range of circumstances that can lead someone to having or considering corrective breast reconstruction. Things like you've heard, discomfort, pain, tightness, a change in the shape or the size or the way it feels, the position of the breast, and maybe some lopsidedness asymmetry that may have developed. Maybe an implant ruptured. Maybe there was a capsule that formed around the implant that made it tighter and uncomfortable and hard. Maybe there was fat necrosis that needed to be dealt with, and maybe you had some other issue.

These are just some examples, and of course, for each individual, you might have your own unique situation that represents your challenge. But if you notice symptoms that concern you, it's best to see your doctor as soon as possible and to ask if what you're experiencing is normal for the type of reconstruction that you had and considering other risk factors that are going on in you specifically. When it comes to finding the right plastic surgeon, one of the key takeaways is to remember that corrective reconstruction is not the same as breast reconstruction. There are specialists who are, as you can see, highly trained and skilled, experienced and committed in fixing those problems that occur after reconstruction. It's a challenge. It gives them the chance to use all their skills to give you a result that we all hope is better for you.

During a consultation, ask about their experience, and if they can share the before and after pictures that our guests suggested. We'll email you a longer checklist of questions you might want to consider asking. We know how stressful it can be to worry about paying for all the medical bills, including the cost of corrective reconstruction on top of everything else, along with any medical and emotional issues you might be facing already. So it's good to get ahead of it by finding out before your procedure, like our panel said, to find out exactly what is covered, what is your out of pocket cost so that there can be no surprises, and if there is a cost, that there's a plan for managing that cost. You want to be sure to confirm if the plastic surgeon takes your insurance or if you will need to pay in full since, as our panel said, not all specialized surgeons take insurance or are in your network.

But these specialized plastic surgeons are used to dealing with people who are outside their network, and they usually have a strategy in place or steps that you can take to figure it out. Talk with your health insurance provider and your plastic surgeon to get all the details, including how much travel will be needed, especially if you don't live near your surgeon. Don't worry about your surgeon's feelings. You're getting corrective surgery. This is the time to really focus on what you need to become happier with and more satisfied with your results. Don't worry about the feelings of your prior plastic surgeon or team. This is a fresh conversation and exploration into what you need to get the best outcome possible.

You can find much more information about reconstruction on breastcancer.org. We'll email you with related links, including a recording of today's discussion and the questions and answer section of today's presentation. We hope that all of these resources help you make the best decision for your care so you can live the best life possible. That's what we're all committed to, to helping you in that way. And I want to give an extra shout-out to thank Dr. Peled, Dr. Srinivasa, Dr. Zafar, and to all of you for joining us, and also to thank our generous sponsor, the Center for Restorative Breast Surgery in New Orleans. Take care everyone, and thank you so much.

Q: How many surgeries does it take to get reconstruction correct after a double mastectomy following radiation and chemotherapy?

A from Jamie DePolo: That depends on what type of reconstruction you have. It's a good idea to talk to a plastic surgeon.

Editor’s Note: It’s common for the breast reconstruction process to involve more than one procedure. Sometimes it involves several procedures over a period of months. Also, there are some steps that you may or may not opt for — for example, some people choose to get their nipple(s) reconstructed and/or to get 3D nipple tattoos, while others choose to only reconstruct the breast mound.    

Q: Is there a risk of delayed detection of cancer recurrence with a pre-pectoral implant after mastectomy? Is this something that has been studied and reported on in literature?

A from Dr. Anne Peled: This has been something that has been brought up as a concern, but as flaps have been placed over the muscle for decades without increased challenges with detecting a recurrence, plus the fact that much of the chest wall can still be assessed on physical exam, the oncology community feels comfortable with pre-pectoral reconstruction for almost all patients.

Q: With aesthetic flat closure, is there a revision that can be done with “dog ears” in the axilla? Could this surgery remove more lymph nodes, as lymphedema is a concern and already a problem? Thank you.

A from Jamie DePolo: I believe that a revision can be done to get rid of dog ears. This page may be helpful for you.

Q: I'm a huge fan of Breastcancer.org. Can you discuss laws requiring plastic surgery consult/information be given to all bc surgery patients?

A from Jamie DePolo: Thanks for your kind words. The WHCRA of 1998 covers your question, I believe. 

Editor’s Note: I don’t think there are laws specifically requiring that your medical team inform you of your breast reconstruction options. You may in some cases have to advocate for yourself and arrange for a consultation with a plastic surgeon to learn about your breast reconstruction options. However, it’s important to know that there are federal and state laws requiring some types of health insurance plans to cover breast reconstruction after a mastectomy or lumpectomy (which could include covering consults with plastic surgeons to learn about your options). Read more about those laws. 

Q: How long does cording take to disappear?  What is the chance that it will never go away? Thank you.

A from Dr. Anne Peled: Physical therapy can help a lot to help cording go away and “break up” the cords. For most people the cording will go away eventually with exercise and physical therapy.

Editor’s Note: Read more about treatments for cording (also known as axillary web syndrome). 

Q: I had a lumpectomy and radiation to my right breast 8 years ago. Now the scar tissue is very hard and my breast is much smaller than my left one.  What can I do?

A from Dr. Dhivya Srinivasa: It is possible to resect the hardened area and either perform local tissue rearrangement or place a “flap” there — which is using skin and fat from your own body. Keep in mind, operating after radiation does have risks that need to be discussed in detail before proceeding.

Q: I had breast implants already when I was diagnosed with invasive ductal carcinoma in my right breast in 2017. I had reconstruction on my right breast, an implant placed and changed out the left implant for another. I’d like to completely remove my left implant, and, really, both implants, but I don’t know what that will look like. Right now I’m very “lopsided” and very unhappy with how this looks and how bras and shirts fit. No chemo or radiation.

A from Jamie DePolo: Thanks for joining us. I'm sorry you're unhappy. You may be a candidate for flap reconstruction, using your own tissue.

Editor’s Note: In addition to flap reconstruction, you could also talk with a plastic surgeon about other options, including having explant surgery and going flat or seeing if there are other procedures that could help restore balance if you opt not to get your implants removed, such as fat grafting. 

Q: Is there more post-op pain with sensation-sparing mastectomy?

A from Dr. Anne Peled: Some people do “feel more” in the early post-operative period, but long term, people have much less pain when nerves aren’t injured in sensation-sparing mastectomy compared to traditional mastectomy.

Q: Does gabapentin help with sensation-sparing mastectomy pain? Does it affect the sensation after mastectomy (cause more numbness)?

A from Dr. Anne Peled: It can definitely help if there is increased pain in the early post-op period — most people don’t need it more than a few weeks/maybe a month after surgery.

Q: What can I do to ensure I get the best result after my expanders are removed? I’m 7 weeks post bilateral mastectomy.

A from Jamie DePolo: One of the best things is to talk to your plastic surgeon about your expectations and the results you want. You can ask to see pictures of women that had the same breast surgery and reconstruction that you will have.

Editor’s Note: See before and after photos of several types of breast reconstruction and corrective surgeries. 

Q: After my double mastectomy, I have had a delayed expander placement and it feels awful. I will have the DEIP flap procedure. What happens if I do not have enough fat tissue from my belly?  Do I have added surgery in search of more fat somewhere else?  This seems challenging and would insurance cover extra?

A from Jamie DePolo: Definitely talk to your plastic surgeon about reconstruction options if you don't have enough fat for a DIEP flap surgery. Your surgeon should be able to advise you ahead of time about this.

Q: What levels of sensation can be expected with a nerve-sparing, nipple-sparing mastectomy?

A from Dr. Anne Peled: We find in our practice that many people do regain sensation throughout their breast and nipple, often including nipples that respond to touch and temperature. Many different factors play into the amount of sensation eventually regained.

Q: When nipples are moved in reconstruction surgery, do they lose sensation and look different?

A from Jamie DePolo: If nerves are cut when the nipples are moved, they will lose some or all sensation. In some cases they look different, but definitely talk to your surgeon about this before reconstruction.

Q: I had a double mastectomy in 2006. I had bilateral silicone implants two years later. Both implants were the same size. However less tissue had been removed from my non cancerous breast. This breast was okay the first few years but has since developed extensive bruising and tenderness. Is it too late to have revision surgery. I am 87 years old. Is age a factor?

A from Jamie DePolo: If you don't have any other health conditions that would hinder your recovery, then schedule a consult with a plastic surgeon to discuss your options.

Q: I had two reconstructive surgeries each of which was followed by a massive infection causing excision in both cases. How common is that? I had a full uniteral mastectomy, no radiation.

A from Dr. Dhivya Srinivasa: If both reconstructions were implant-based reconstructions (including expanders) — then it is not uncommon to get a recurrent infection if you had one previously. I would recommend considering “flap” surgery, where we can use your own skin and fat and blood flow to help reconstruct the breast while also combating infection risk with the healthy blood flow.

Q: Can you talk about removing dog ears after a mastectomy?

A from Dr. Dhivya Srinivasa: Having “dog ears” after a mastectomy usually means a peak of skin at either end of the incision. These can often be fixed, however, this would require lengthening the incision depending on how large the “dog ear” is.

Q: Can capsular contracture caused by radiation recur and also cause implant rupture?

A from Dr. Dhivya Srinivasa: Yes, it can recur and it can also contribute to rupture.

Q: Is it feasible to revise a 22 year old droopy TRAM flap graft?

A from Jamie DePolo: I believe so. You may want to schedule a consult with a plastic surgeon.

Q: Risks from an aesthetic standpoint of multiple revisions. ex: scarring, skin issues, shaping etc.

A from Jamie DePolo: The risks are very dependent on your personal health history. It's a good idea to talk to a surgeon about your unique situation.

Q: Can you explain again how bringing fresh fat and skin is beneficial to the reconstruction process?  

A from Dr. Anne Peled: This is specifically mentioned in the setting of radiation, when skin or tissue may be scarred in or not have great blood supply, which impacts healing — bringing in fresh tissue with a flap from another part of your body can make it softer or bring in fresh skin to allow for removing skin that isn’t well-healed.

Q: I had a right mastectomy in 2022 and had chemo. My plastic surgeon only offered implants, but I would really like to have my left mastectomy and at the same time remove my implants that I don't like and have a Flap done on both the right and left breast. Is this possible?

A from Jamie DePolo: It may be very possible, but depends on your unique health situation. You might want to schedule a consult with a plastic surgeon to discuss your options.

Q: How much fat can actually be transferred for FLAP?

A from Dr. Dhivya Srinivasa: Depends on where it comes from! I just performed flaps last week and moved 1500 grams of tissue! Depends on your body type and where we take the tissue from.

Q: Can I have fat grafting done to increase breast size after having DIEP flap revision later?

A from Dr. Anne Peled: Yes! This is a great option for adding a little volume and also helping the edges of the reconstruction look most natural. You can also have a hybrid reconstruction with an implant placed under the flap

Q: I had a double mastectomy, direct to implant. Then I had 30 unexpected radiation treatments ending this past September. In March, I had exchange surgery but I am more unhappy now than I was right after the surgery in March. The radiated breast is higher and harder than the other droopy looking breast. In addition, I wanted to be the same size that I had been naturally (C cup); the plastic surgeon gave me smaller breasts. Can this be fixed?

A from Jamie DePolo: There should be some options for you. You may have to consult with several plastic surgeons to find someone who will give you exactly what you want.

Editor’s Note: Read more about corrective reconstruction and ways of correcting asymmetry.

Q: If you are having a mastectomy with radiation should reconstruction be put off for a year to allow chronic changes to occur?

A from Dr. Dhivya Srinivasa: Generally, plastic surgeons will recommend waiting a minimum of six months. Up to a year is completely reasonable and common.

Q: My bilat mastectomy w/ implants failed miserably. What’s recommended BMI? I was morbidly obese at the time of the mastectomy. I’m losing weight now and plan to be at my “normal BMI” by the time of my recon.

A from Jamie DePolo: While women with higher BMIs have a higher risk of complications, the “What this means for you” part of this story has images of people with higher BMIs who had good results.

Q: What is the % of success on fat grafting?

A from Dr. Anne Peled: Most studies show 50% to 70% of fat “takes”, but this varies especially if radiation has happened before, which decreases take.

Q: Should I get imaging for my implants/ cancer screen- bilateral mastectomy and what should that be and how often? Will insurance cover that?

A from Dr. Anne Peled: There is not a typical recommendation to screen for cancer recurrence after mastectomy, just physical exams, but we do recommend getting a high-resolution ultrasound or MRI to assess implants starting at 6 years and then every 2 to 3 years.

Editor’s Note: Read more about mammograms after mastectomy and after reconstruction. Also, if you have silicone gel-filled breast implants, the FDA recommends you receive periodic MRI or ultrasound screening to check for possible implant rupture and other complications. Getting health insurance to cover screening for breast implant rupture can be challenging, so you may have to ask your doctor’s office for help.

Q: I’m fine with the size of my breast, but I have underarm fat that wasn’t there before and it feels awful.

A from Dr. Dhivya Srinivasa: Oftentimes, release of underarm scar tissue and liposuction can improve this. However, on radiated tissue, it may be more difficult to fix.

Q: I have a dent from my lumpectomy. Can that be corrected?

A from Dr. Anne Peled: Fat grafting can be a great option in this setting, sometimes tissue around the area can be moved in to fill it as well.

Editor’s Note: Read more about reconstruction options after lumpectomy. 

Q: How long typically does it take after taxol chemotherapy and herceptin treatments can reconstruction surgery begin?

A from Dr. Anne Peled: We recommend waiting 4 to 6 weeks after taxol. It’s okay to have reconstruction during herceptin treatment, though

Q: Would someone with preexisting breast and/or UE lymphedema be a suitable candidate for reconstruction? Will it further exacerbate their lymphedema?

A from Jamie DePolo: Because everyone's situation is unique, it's best to talk to a plastic surgeon about this.

Q: What can be done when the implant slides in the armpit and there is a hollow part where the breast was (on the chest area)?

A from Dr. Dhivya Srinivasa: Utilization of mesh can help redefine the ”pocket” — or the home for the implant. The surgeon can tack down the area where the implant slides and help move it closer towards the middle.

Editor’s Note: Read more about options for correcting implant displacement. 

Q: My cancer diagnosis was occupational and covered by workmans comp. The plastic surgeon made my left breast bigger to handle the radiation. He thought I would be doing more than 10 radiation sessions and expected the left breast to shrink more. What are my options at this point?

A from Jamie DePolo: A consultation with a plastic surgeon can help you figure out the best options for your unique situation.

Editor’s Note: read about some potential options for correcting asymmetry after reconstruction. 

Q: Does daily massaging of the mastectomy scars really prevent scar tissue from forming?

A from Dr. Anne Peled: There is some data that the physical pressure of massage can help soften the scar tissue — while it may not prevent it, it hopefully will soften it.

Q: Does the type of radiation affect the options, ie: I had Proton (targeted) radiation that stopped at the tumor.

A from Jamie DePolo: While proton therapy is less likely to damage surrounding tissue, it can still cause some damage. Most plastic surgeons recommend waiting until at least six months to a year after radiation is done to have reconstruction, but I don't think it limits your options.

Q: My surgeon says he would not fix my breasts because I am on blood thinners.

A from Jamie DePolo: I'm sorry about that. Blood thinners can make surgery a risk, but you may want to get a second or third opinion.

Q: I have had two flap surgical procedures in the past, but I still have problems with everything being uneven. At what time frame would it have been too long to go back for correction?

A from Jamie DePolo: There really isn't a time limit on when you can have a revision. The best thing to do is talk to a plastic surgeon.

Q: I already have capsular contracture with expanders in. Does that mean I will have them with my implants too?

A from Dr. Dhivya Srinivasa: It is more likely you will develop capsular contracture if you already have it — that said, it does not mean it cannot be fixed! Talk to your surgeon about risks of capsular contracture and things you can do to decrease that risk.

Editor’s Note: Read more about options for correcting capsular contracture.

Q: Is it normal to still have numbness in the breast and nipple two years post lumpectomy?

A from Jamie DePolo: Unfortunately, it can be.

Q: I had a DIEP Flap with implants - hybrid. I had a revision but I still feel like one is bigger and has more upper pole fullness than the other. Is it possible to have additional fat grafting to increase upper pole fullness on the smaller one? My implants are above the muscle.

A from Dr. Anne Peled: Yes! This is a great way to help with upper pole fullness and symmetry.

Editor’s Note: Read more about fat grafting.

Q: I am a three-time breast cancer survivor who didn’t like the reconstruction after my first mastectomy. Now I have had a second mastectomy. Would it be advisable to have reconstruction to correct the first reconstruction and also have reconstruction on the other side? FYI, my first reconstruction had a problem due to radiation.

A from Jamie DePolo: Your plastic surgeon is the best person to answer that. Be very clear about the results you want.

Q: I went through chemo, double mastectomy/lymph node dissection, and radiation for triple negative breast Ca in 2010. I had DIEP bilateral breast reconstruction in 2011. Unfortunately, not too long after, I was diagnosed with treatment-related myelodysplastic syndrome requiring a bone marrow transplant. So, I had to give up my focus on minor follow up corrections to focus on the BMT. I still have numbness in my entire reconstructed breast area. Is it too late for any corrections?

A from Jamie DePolo: I don't think it's ever too late for corrections, but it's best to discuss your options with a plastic surgeon.

Q: With fat transfer into the lumpectomy breast, does the body absorb some of the fat so it would affect the size of the breast?

A from Dr. Anne Peled: Yes, we know that not all of the fat will take, so we try to overcompensate and put in more fat than we need, to hope that enough will stay and not get absorbed to improve the area as planned.

Q: What can be done to reconstruct a nipple?

A from Dr. Anne Peled: There are a lot of small tissue reconstruction techniques that can be done around the nipple to make it project, and sometimes a small area of tissue matrix can be placed there.

Editor’s Note: Read more about nipple reconstruction techniques. 

Q: Is DIEP surgery possible after multiple abdominal surgeries?

A from Dr. Anne Peled: It really depends on the type of abdominal surgeries — some bigger surgeries, especially higher up on the abdomen (i.e. not just gynecologic surgeries with low scars), may make it so the vessels to a DIEP are not available any more.

Q: Are saline implants safer than silicone?

A from Jamie DePolo: This page has a lot of information.

Editor’s Note: Many of the risks of breast implant surgery apply to both saline and silicone-filled implants. However, it’s important to know that it’s harder to recognize when a silicone-filled implant has ruptured. (That’s why periodic imaging with ultrasound or MRI to check for rupture is recommended.)  

Q: I had a SMX Nipple sparing surgery with immediate reconstruction. However, I started having fluid retention after my last drain was pulled 5 weeks later. Radiation started 2 months after surgery but about 13 sessions in, I had to have an explant due to my skin thinning and opening up. (They did try to save the skin and put in a smaller implant, but a week later the original hole was still open and so they pulled the implant out in the office and stitched me closed.) That was Sept 2023 and Radiation ended Oct 2023. I now have a belly button like breast with 2 large seromas noted in my June MRI. Thank goodness I am NED, but I have limited mobility and tightness and fluid retention. I don't want to cause more problems, but I would love to gain some QOL and maybe even have something more normal looking. How can I ensure that any additional surgery would help and not cause more issues?

A from Jamie DePolo: You may want to talk to some plastic surgeons to see what options may be best for you. It can help to look for someone who specializes in corrective reconstruction.

Q: I had a double mastectomy in June 2023 and expanders were inserted to stretch my skin. In April 2024 the right expander became infected and pus leaked from the incision. The infected expander was removed. I’m left with what appears to be “balled up skin.” The left expander is still in, and that’s also the side I had breast cancer. Both sides are hard and unsightly. How should I address reconstruction? My chemo treatments will be completed at the end of August.

A from Jamie DePolo: You may want to schedule consultations with a couple plastic surgeons to discuss the options that are best for your individual situation.

Q: I had a lumpectomy of my right breast and SLND. After chemo (taxotere and carboplatin) and 28 rounds of radiation, my affected breast is firmer, higher and smaller than my other breast which sits lower (as expected with age). A year after radiation, I still am treating radiation fibrosis and lymphedema. The changes in my breasts makes dressing difficult. Could I be a candidate for some surgical intervention to address this issue?

A from Dr. Anne Peled: Yes, this is not uncommon unfortunately. Physical therapy and lymphedema therapy will hopefully help to soften the breast over time. At some point you could consider a surgical revision of the other breast to improve symmetry if you wanted.

Q: How long after reconstruction can you get a revision?

A from Dr. Anne Peled: Any time! Insurance is required to cover it at any point if you’ve had a history of breast cancer.

Q: Would you go over how often to screen breast implants with MRI and when to replace them? What's the risk of not replacing them?

A from Dr. Anne Peled: We recommend starting at 6 years and then every 2 to 3 years afterwards to screen implants. If they have ruptured, we typically recommend considering replacement.

Q: How many times can you have a revision so that it doesn't seem like cosmetic surgery? What other options do you have for a bigger stomach now with no breasts, I was told that it would then be considered cosmetic surgery.

A from Dr. Anne Peled: If you’ve had a history of breast cancer, reconstruction revision should be covered at any time. Unfortunately, liposuction of the abdomen or a tummy tuck would be considered cosmetic surgery.

Q: Does insurance have to cover nerve grafting to regain sensation?

A from Dr. Anne Peled: Some insurance companies unfortunately still see this as experimental, but we’re working on changing this!

Q: Do we have a number % of bc patients choosing not to reconstruct breast(s)?

A from Dr. Anne Peled: This is a difficult number to determine because some patients choose not to have reconstruction and others just don’t get offered reconstruction or have access to it.

Q: Are there limitations on BMI before reconstruction? I asked for an aesthetic flat closure, which I did not get. Now I am considering reconstruction.

A from Dr. Anne Peled: Very sorry that your initial surgery did not go as planned. Some practices do have BMI cut-offs, but many do not and instead look at other potential medical issues that may impact the safety of reconstruction instead of just BMI alone.

Q: Can you talk about how to improve scar tissue/pain post diep flap on the radiated side? What's the best way to get your range of motion back?

A from Dr. Anne Peled: Physical therapy and lymphatic massage can be incredibly helpful for this, both for in-office treatments and also to give you at home exercises you can do.

Q: Can you see a different surgeon if you don’t feel heard from the one who did the original procedure?

A from Dr. Anne Peled: Definitely! You are the only person who wakes up in your body every day and deserve to see someone who makes you feel heard.

Q: In my experience, insurance only covers if the surgeon/hospital is in network...In my case they were out of network and I had to pay out of pocket for DIEP Flap and revision…

A from Dr. Anne Peled: There are some differences in insurance plans in terms of whether or not they will cover out-of-network providers. Unfortunately, some will not cover out-of-network care at all.

Q: If I do have a FLAP done for reconstruction, is there a chance of cancer returning in the breast? Also, would you still have to have mammograms or ultrasounds of the breast yearly?

A from Dr. Dhivya Srinivasa: Flap reconstruction does not increase the risk of recurrence. Having flap reconstruction itself does not require additional imaging, however your medical or surgical oncologist may request it for other reasons specific to your cancer.

Q: If you have/had an explant, should the alloderm mesh also be removed?

A from Dr. Anne Peled: Sometimes it can be very difficult to remove if it’s already incorporated into the mastectomy skin flap and really doesn’t need to be removed in this setting, but it should be removed if it’s not incorporated and just sitting freely around the implant at the time of explant.

Q: How many nerves are usually reconnected during sensation-sparing nipple-sparing mastectomy? Which nerves?

A from Dr. Anne Peled: It really depends on the patient's anatomy. The nerves that are reconstructed are intercostal nerves.

Q: I had bilat mastectomy 2022, and I finished rad TX in Jan 23. have not restored my function on my Lt arm due to axillary Sx. My question is, the plastic surgeon said the only option I have to have the best outcome is DIEP? How long does this procedure take, and what is the % of effectiveness of this procedure?

A from Jamie DePolo: Here is info on DIEP flap. 

Q: Thank you. I had a segmental mastectomy and contralateral reduction with chemo and radiation in 2021. Very pleased with outcome. Then ovarian cancer with surgery and chemo ending in dec 2023 with BRCA1dx now. Would like to have bilateral mastectomy with DIEP flap but getting different thoughts from surgeons Re timing. How long should I wait and generally are risks significantly higher with radiation and multiple rounds of chemo?

A from Jamie DePolo: Most surgeons recommend waiting at least six months after radiation before having reconstruction. See this page. 

Q: If fat injected into a lumpectomy site is more than needed as to insure it takes, does that mean there will still be uneven breast size post procedure and for how long?

A from Dr. Anne Peled: The lumpiness/swelling around fat grafting usually resolves within 6 weeks to 3 months.

Q: If I want to change providers within the same office, can my insurance deny that? I'm not comfortable with my current surgeon, and I've heard of others being denied to see someone else.

A from Jamie DePolo: It's best to call your insurance provider and ask.

Q: My plastic surgeon would not "revise" my belly button in the revision post DIEP flap. What are the reasons a surgeon would not revise if a patient requested it? TIA

A from Dr. Dhivya Srinivasa: In general, if you are not getting what you want from your surgeon, get a second opinion from someone who is an expert in what you are seeking.

Q: What about Medicare? Does Medicare typically cover corrective surgery?

A from Dr. Dhivya Srinivasa: Yes! they should cover it as long as there are documented reasons for needing the revisions as it relates to your mastectomy and/or reconstruction.

Editor’s Note: Read more about insurance coverage for corrective surgery.

Q: Do any of you do the mastectomy part as well as the reconstruction?

A from Dr. Anne Peled: I’m dual-trained in both surgical oncology and plastic surgery (which is how it’s done in most other countries), but most surgeons in the US are either surgical oncologists or plastic surgeons.

Q: Sorry if I missed this, but how long does an implant last?

A from Dr. Anne Peled: We say 20 to 25 years with the current implants available.

Q: I was a cup size C/D when I had DIEP. Emphasized to my surgeon that I wanted no larger than size C and to place them much higher on my chest. I ended up with size DDD and they are about at my waist. My second opinion surgeon said my new DIEP 'breasts' were anchored to a lower rib than they should have been. Is it true-are the new breasts anchored to ribs. If so, which rib is optimal, in general?

A from Jamie DePolo: Here is info on DIEP flap. 

Q: Hi, it is almost 2 yrs, I am still having severe pain at Sx site and all on my chest, arms. Is this normal?

A from Dr. Dhivya Srinivasa: Severe pain is not to be expected. I would recommend meeting with your surgeon. You may have a neuroma or nerve issue causing this.