Possible Risks and Complications of Breast Reconstruction
I recently had the privilege of discussing some of the of possible risks and complications of breast reconstruction with Dr. Minas Chrysopoulo from PRMA plastic surgery. The interview was done for #AllThingsCancer a program put out by the Anti-Cancer Club. The two basic choices for breast reconstruction after mastectomy are implant based and autologous breast reconstruction (“flaps”). There are pros and cons to each option. What is important to emphasize is that for most patients, each option usually includes a staged approach involving more than one procedure for the best results.
Implant breast reconstruction involves replacing the tissue removed by the mastectomy with a saline or silicone filled implant. In most cases, a temporary implant known as a tissue expander is placed first to help shape the new breast. The tissue expander is then replaced by a permanent implant at a second surgery.
Autologous “flap” techniques use the patient’s own skin, fat, and sometimes muscle, along with its blood supply from one part of the body and transfers it to the chest to create a new breast. Autologous reconstruction therefore leaves an additional scar in the area where the tissue is removed. Typically, the tissue is taken from the abdominal area, as in a DIEP, SIEA, or TRAM flap. Click on each link for an explanation of all three of these methods. While the abdomen is the most favored area to use as a source of tissue for flap reconstruction, other areas of the body can also be used depending on the patient’s body habitus.
Abdominal Wall Hernia and Bulge
There are unique risks involved with each of the above mentioned abdominal flap breast reconstruction procedures. The major difference is what happens to the rectus abdominis (sit up muscle). The DIEP and SIEA flaps both spare the muscle completely which is important for preserving core strength long term and minimizing the risk of complications like abdominal bulging and hernia. There are 3 types of TRAM flap performed, each of which sacrifices varying amounts of abdominal muscle. The pedicle TRAM flap tunnels the muscle with its blood source from the abdominal area up into the chest cavity to form the new breast. The risk of developing a hernia or bulge is far greater after a TRAM because these procedures sacrifice some or all of the rectus abdominis muscle. In experienced hands, the risk of a hernia or bulge after a DIEP flap is 1% and 3% respectively because all the abdominal muscle and its nerve supply is preserved.
Even in a DIEP flap, motor nerves powering the abdominal muscles can be compromised during surgery. When a motor nerve is severed during a DIEP flap, a well-trained microsurgeon can repair this nerve at the time of the procedure minimizing and even preventing a hernia or bulge after recovery. Ask your plastic surgeon if this is something they routinely perform.
In addition to following your doctor’s post-operative instructions, the best way to minimize the risk of abdominal wall complications is by preserving all the abdominal muscle and the motor nerves that power it at the time of surgery. It is certainly worth having this conversation during your consult.
Capsular contracture is the biggest long term risk for implant based breast reconstruction. Capsular contracture is essentially the body’s natural healing mechanism to “wall off” the implant, making a capsule of scar tissue around the implant. In some women, this scar capsule is very soft. Others develop a more aggressive, firm capsule which contracts and squeezes the implant. This can cause the implant to move, become distorted, and even painful. The risk of capsular contracture is significantly higher in patients who have had radiation.
Radiation and Reconstruction
In the presence of radiation, the risk of developing a complication after implant increases significantly. Some patients don’t have a choice when it comes to which type of reconstruction they can have. For example, for low BMI patients with little or no excess tissue implant reconstruction can be their best option. The key is open communication with all team members involved: your breast surgeon, radiation oncologist, and your plastic surgeon. Not all radiologists follow the exact same protocol or deliver the radiation in the same way. Those who are more experienced at treating breast reconstruction patients are more likely to tailor the way the radiation is administered to reduce the risk of implant complications, without compromising cancer care. Be sure to communicate the reconstruction option you are choosing with all team players so appropriate adjustments can be made.
While all surgery has risks, tissue reconstruction is a much safer option when radiation is part of the treatment plan. The timing of the flap reconstruction relative to the radiation therapy is something very important to consider. Flap breast reconstruction can be performed before or after radiation but a lot depends on the experience of the breast cancer team and radiation oncologist in particular. For many patients not undergoing care in high volume centers, the safest approach in terms of minimizing complications is to perform the flap reconstruction after all the breast cancer treatment, including the radiation, has been completed. Again, the key is communication.
The Value of a Team Approach
What does it take to have a good outcome? How do you coordinate all of this with your team when you’ve just been given the overwhelming news of a diagnosis?
As Dr. C states, “The onus has been placed on the patient” to bear most of the responsibility for this. We hope this video gives you action items to discuss and information to share with that team to maximize the best possible outcomes and minimize or eliminate possible risks for whatever reconstruction you choose. It’s all about finding the right group of individuals; it’s about a multi-disciplinary approach. Find a team that works together every day. This can be challenging, but well worth the effort, in my humble opinion. Having my mastectomy in one state and reconstruction in another had its unique considerations but my results are beyond my expectations.
There are a few reasons for the success of my DIEP flap from my perspective:
- My breast surgeon is a proponent of breast reconstruction and she was the first to inform me about DIEP flap.
- My breast surgeon successfully performed a skin and nipple sparing mastectomy leaving a skin envelope for my plastic surgeon to work with during my DIEP flap surgery.
- My plastic surgeon is highly skilled with an incredible success rate.
Note: Some breast surgeons like to leave a clean, smooth look after mastectomy. This doesn’t allow the reconstructive surgeon as much tissue to work with at the time of the DIEP if you’re having delayed like I did. The key is to communicate this to your breast surgeon. It doesn’t negate having flap surgery later but certainly gives the plastic surgeon more skin envelope to work with if you know you may be having reconstruction in your future after mastectomy.
Dr. Chrysopoulo covered so much more throughout the interview. Watch the entirety of the interview here on the Anti-Cancer Club site.
Hematoma: blood collection/Seroma: fluid collection
Listen to the great explanation that Dr. C gives of this possible risk and the care taken for these conditions in both implant and autologous based.
Enhanced Recovery After Surgery = ERAS
Read this philosophy and protocol that some centers, including PRMA, are now adopting. ERAS is being adopted and implemented as these practices are helping patients recover more quickly. A lot of good work on ERAS has come of out of Mayo in the past few years as it is gaining momentum even in other medical disciplines. Length of hospital stay, drains, Foley catheter, help with preventing post-operative nausea, pain management techniques and other topics are covered. It is very fascinating and has changed just in the two years since my DIEP!
A huge debt of gratitude to Dr. C for his time and expertise.