Understanding your reconstructive options after breast cancer
For women experiencing breast cancer, the process of healing is challenging and often confusing. This is especially the case for women who choose to undergo mastectomy or lumpectomy as part of their treatment process. Not only have they survived the disease and course of treatment, but they may feel they have also lost a part of themselves along that journey.
One option available is breast reconstruction. This field of procedures involves a variety of techniques used to rebuild the removed breast tissue, helping to reshape and restore confidence.
What exactly is breast reconstruction, and how does this procedure work? What are the steps before and after the procedure? Is breast reconstruction suitable for all interested patients? To learn more about the stages of breast reconstruction and what patients can expect, we reached out to ASPS Member Surgeon Nima Naghshineh, MD, MSc, FACS.
ASPS: How often is breast reconstruction following mastectomy or lumpectomy requested at your practice?
Dr. Naghshineh: Breast reconstruction following mastectomy or lumpectomy is a common procedure requested in my practice, as nearly half of my practice is dedicated to breast cancer reconstruction. In the early 2000s, less than 30 percent of patients nationwide underwent breast reconstruction. Currently, depending on the region, nearly 70 percent of mastectomy patients are being offered some form of reconstruction, and we are seeing similar trends for lumpectomy patients too. The Women's Health and Cancer Rights Act of 1998 created a significant impact on both awareness and insurance coverage of these services.
ASPS: Who are the patients that typically come to you for breast reconstruction? Have they already undergone mastectomy or lumpectomy, or are they still preparing for this step?
Dr. Naghshineh: I have the privilege of seeing patients during all stages of their cancer and in varied age groups. Though many of my patients are referred to me for evaluation for breast reconstruction prior to their cancer surgeries, some find their way to me afterwards.
Breast cancer reconstruction options can vary dramatically based on whether the reconstruction process is started at the time of the initial cancer surgery or whether it is done in a delayed fashion afterwards. Unfortunately, some of the patients I see come to me after they've already received a lumpectomy or mastectomy. In those situations, they either chose not to see a plastic surgeon beforehand or were encouraged to wait, not knowing how that could limit their reconstructive choices later. Because of that, I'm passionate about spreading awareness about the importance of reconstruction education.
Ultimately, knowledge is power, and even if someone chooses not to pursue reconstruction at the time of their mastectomy or lumpectomy, it's best to do so with all the information in hand. The message I would want all breast cancer patients to receive is that regardless of how certain they are of whether they want breast reconstruction, they should absolutely seek a consultation with a plastic surgeon experienced in various forms of breast reconstruction. Doing so ensures that they learn all their reconstructive options and make an educated decision about what is right for them.
ASPS: What are the steps involved in determining the right course of action for breast reconstruction with a patient?
Dr. Naghshineh: This is a particularly important topic of conversation because a significant amount of planning goes into determining which reconstructive options are best for the patient. When it comes to cancer treatment, it goes beyond what oncologic or cancer surgery the patient is having, as it often involves other treatments such as radiation and chemotherapy. These treatments, which can be done before or after the cancer surgery, can significantly impact the patient's ability to heal and may increase the risks of complications such as infection. Certain reconstructive options are more impacted by some of these treatments than others.
The first step in determining the right course of action for the patient is understanding their entire treatment plan. However, it is not uncommon to see changes in these plans during treatment based on the surgical findings or postoperative pathology, so it is also important to help a patient understand the ways we may pivot together.
Other considerations include the patient's existing medical comorbidities (health conditions), presurgical breast size, postsurgical breast size wishes, as well as personal factors, such as limiting downtime or avoiding additional scars or donor sites. Of course, the type of cancer surgery being done is also critical. Lumpectomy versus mastectomy requires different reconstructive approaches, while the different types of mastectomies – nipple-sparing vs skin-sparing vs simple mastectomies – can also impact your reconstructive choices.
ASPS: What are the different methods of breast reconstruction? Do you find that one method is typically more popularly requested than another?
Dr. Naghshineh: Breast reconstruction options generally fall under two categories – implant-based reconstruction and tissue-based reconstruction. Tissue-based reconstructions are often referred to as "autologous" or "flap" surgeries.
The most common form of reconstruction is implant-based. As the name implies, these reconstructions require the use of prosthetics that are permanently placed to restore volume. These breast implants have specific considerations that need to be discussed with the patient extensively prior to surgery. Implant-based reconstructions are the most common choice nationally, as their recovery tends to be faster and more comfortable. Implant placement procedures are also shorter in duration and do not require a donor site from the patient.
Autologous reconstructions utilize the patient's own tissue to create "flaps" that recreate volume and shape for the reconstructed breast. It does not typically use prostheses like breast implants, though they may require it for additional volume. Since the patient's own tissue is being used, that means a part of their body must act as a donor for that tissue. The most common donor sites are the abdomen, back or lower extremities, with the final choice depending on the patient and the surgeon's considerations. These reconstructions offer natural-looking results, but require microsurgical expertise, have greater discomfort with longer recovery periods and have the potential for donor site-related complications. However, they also often avoid certain issues related to breast implants, such as rupture, rippling or capsular contracture.
ASPS: What is the typical preop process for breast reconstruction? Are there any differences between how you would have patients prepare for other cosmetic procedures?
Dr. Naghshineh: The preop process of breast reconstruction is similar to many other surgeries, including cosmetic procedures, with certain nuanced considerations. Like with many surgeries, there needs to be a thorough evaluation of the patient and their candidacy for reconstruction. In my practice, this includes a thorough consultation, getting preoperative lab work and imaging studies, as well as clearances from their primary care physicians and specialists.
As they are a cancer patient, collaboration with other surgeons and medical specialists is critical to ensuring successful outcomes. Many breast cancer patients often have simultaneous procedures by two surgeons and are being followed by an oncologist and radiation oncologist, all of whom may have additional therapies that may impact their recovery and results. Therefore, close communication with all members of the team is essential. I often tell my cancer patients that their care is truly a team effort, and communication and collaboration amongst the medical team is paramount.
ASPS: What is the typical postop process for breast reconstruction?
Dr. Naghshineh: All surgical patients require postoperative care and surveillance; however, breast cancer patients in particular need closer observation and frequent follow-ups due to the nature of their condition and surgeries. These follow-ups are necessary to assess the patient's health and the surgical sites, as well as to monitor for any potential complications in the immediate postoperative period. Reconstruction patients in my practice are seen regularly and often in the first two months of their recovery, to monitor for any complications, adverse reactions, or other matters that require prompt attention.
In the setting of implant-based reconstructions, the procedures are most commonly performed on an outpatient basis. Though the reconstruction can be performed in a single procedure, there is often the use of an intermediate temporary prosthetic called a tissue expander. This is used to create the space needed for the permanent breast implant, which is placed during a second stage of surgery. Postoperative care in this setting often requires in-office placement of additional volume in the form of saline, which can be done as often as weekly, depending on the goals and needs of the patient.
For autologous reconstructions, the procedure often requires a hospital stay, which can range in duration from one to four days due to the complexity of the procedure and the monitoring required.
ASPS: Do you have any additional tips or advice for patients who are interested in pursuing breast reconstruction following mastectomy or lumpectomy?
Dr. Naghshineh: Know your options, even if you don't end up choosing them. The greatest takeaway I want all my patients to have is that they should explore all their options. Seek consultation from surgeons who offer implant-based and/or autologous-based reconstructions and compare your options to see what is best for you. Most importantly, I advise women to do this before their cancer surgery, whether mastectomy or lumpectomy, as waiting to seek consultation afterwards can greatly limit their options and impact their results.
To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.
