Episode 16: Options for Breast Reconstruction after Mastectomy

When a person faces a mastectomy due to breast cancer, they have options to reconstruct their breasts. The options include using an implant, using the patients own tissue, or choosing to remain flat with aesthetic flat closure. Dr. Steven Pisano of PRMA, Plastic Reconstructive Microsurgical Associates, in San Antonio, Texas discusses all the options for breast reconstruction after mastectomy in Episode 16 of the DiepCJourney podcast.

The Voice of an Expert in Breast Reconstruction after Mastectomy

Dr. Pisano is one of the original founders of PRMA in San Antonio. He started the practice in 1994 with partner Dr. Peter Ledoux to serve the San Antonio area with general breast reconstruction surgery. Since that time, they will be on track by the end of 2021 to perform over ten thousand flap breast reconstruction surgeries for patients from all over the world.

They now have a team of eight highly skilled microsurgeons working together daily to enhance the lives of those affected by breast cancer. Their surgical techniques include various flap surgeries, implant reconstruction, oncoplastic surgery, and restoring feeling after mastectomy with TruSense?.

No One-Size Fits All in Breast Reconstruction

The type of breast reconstruction a person chooses is based on personal preference. At PRMA, they practice the shared decision-making model. Each patient determines which option for breast reconstruction after mastectomy is best suited for them based on their goals and personal preferences married with the expertise and evidence-based information the surgeons provide.

Implant breast reconstruction is the overwhelming choice for breast reconstruction. Almost all plastic surgeons can perform implant breast reconstruction making it more accessible for patients. Generally speaking, the initial implant is temporary. At the time of mastectomy an expander is placed. The surgeon then fills the expander with sterile salt water. Subsequent fills take place in an office setting.

After fill is complete, the second stage of implant surgery involves exchanging the expander with an implant. There are times when fat grafting is done in another procedure. The fat provides the additional material to smooth edges and any rippling that may take place. Dr. Pisano points out implant reconstruction in the setting of radiation can cause capsular. Radiation reduces the risk of recurrence; however, it causes injury to the native skin and breast tissue causing it to lose elasticity. This can increase infection rates and would healing. Implants often have to be removed because of this. At PRMA they often convert implant reconstruction to tissue reconstruction for a number of reasons, including radiation post implant surgery.

Specialized Tissue Breast Reconstruction as an Option after Mastectomy

Tissue options for breast reconstruction are more specialized requiring additional training to accomplish within a  surgeon’s given geographic area, thus making access for patients more difficult. This is referred to as flap surgery. There are various areas of the body with a blood source to reconstruct the breast. Often referred to as the gold standard, DIEP flap is the most commonly performed flap or tissue reconstruction at PRMA.

DIEP flap breast reconstruction involves transplanting a block of tissue that includes fatty tissue and a blood source. This type of breast reconstruction brings circulation and new tissue to the breast area from the abdominal area creating a warm soft breast that looks and feels much like the native breast tissue. The beauty of the DIEP flap is no abdominal wall muscle is used and compromised.

Breast Sensation and Other Flap Breast Reconstruction

Sensation! Yes! At PRMA they have been performing nerve reconstruction for a number of years and are experts in the field of protective and sexual function nerve reconstruction. The surgeons there pay close attention when retrieving tissue from the lower tummy picking up one or more sensory nerves that ordinarily would bring sensation to the abdominal area. These abdominal sensory nerves are hooked up to a recipient nerve in the chest wall that can bring sensation to the DIEP flap. At PRMA this procedure is known as TruSense?.

When DIEP flap is not possible due to anatomic build of the patient, sometimes referred to as body habitus, there are other areas of the body where flaps with a viable blood source can be used. Prior abdominal surgery does not preclude a woman from having DIEP. Many patients at PRMA have previous abdominal surgery. Blood vessels sometimes need to be checked pre-surgery with imaging when needed in the presence of prior abdominal surgeries.

Patient Safety in Breast Reconstruction

All newly diagnosed patients at PRMA have their medical records reviewed. Many have already seen a breast surgeon. Special time and consideration are given with a coordinated care team that looks at tumor biology, treatment like chemotherapy and radiation. All this weaves into the decision as to when to have surgery.

Dr. Pisano points out his team works with breast surgeons in the area. They hear from them if the patient is a suitable candidate for immediate, or in the setting or radiation, they consult together to determine delayed flap reconstruction may be the best option.

Choosing No Reconstruction after Mastectomy

In our discussion in Episode 16, Dr. Pisano, and I both discuss in his lifetime as reconstructive surgeon and my work as a patient advocate, we have moved from an assumption , if you are at a plastic surgery consult, you are there to get a reconstruction. It is simply not true in all cases anymore. Some women, for personal choices, do not require reconstruction. In these instances, the practice of a shared decision-making conversation is imperative to make the chest wall as aesthetically pleasing as possible, known as aesthetic flat closure.

In so doing, you do not eliminate having recon in the future. It is a win/win for both the patient and surgeon. Dr. Pisano says his job is to listen, take cues from patient, and go from there, the very essence of a shared decision-making conversation!

Breast Reconstruction: More Than One Option

Real-life, real-world situations in Dr. Pisano’s clinic day presented themselves on the day of this interview. He points out all options for breast reconstruction after mastectomy is about respect for choice.

Seek experience, find surgeons who are passionate, whose practice is breast reconstruction at the core of their everyday work. Then, he points out, these kinds of surgeons will approach you with a great deal of confidence due to collective experience. I personally added the word compassion. The perfect combination of traits in your breast reconstruction team is confidence and compassion.

Enjoy the entirety of Episode 16: All Options for Breast Reconstruction after Mastectomy here in . Thanks Dr. Pisano!

Disclaimer

References made to my surgical group, surgeon and healthcare team are made because they are aligned with my values and met my criterion after I did research of their practices and success rates. Any other healthcare provider that displays the same skill, compassion education and outreach to patients will be given consideration and recognition on this website.  The information contained on this website is not a substitute for or should be construed as medical advice. Please consult a licensed physician for medical advice.