You have been diagnosed with breast cancer or find you are at high risk of getting breast cancer and are facing a mastectomy. Now what? If you choose to reconstruct your breast what does this process look like? Dr. Santosh Kale, MD, MBA is my guest on Episode 20 and planning your Breast Reconstruction, of the DiepCJourney podcast . He is a board-certified Plastic and reconstructive microsurgeon who practices in Gahanna, Ohio at Midwest Breast and Aesthetic Surgery outside of Columbus, Ohio. Along with his team at Midwest Breast he specializes in breast reconstruction (implant and tissue-based), aesthetic breast surgery, body contouring, and lymphedema surgery.
Patient Considerations in Planning Their Breast Reconstruction
Patients are inundated with information at the beginning of a diagnosis or finding they have a genetic mutation. They see an oncologist, breast surgeon, plastic surgeon, radiologist, and other medical specialists. Where does a patient begin the research and planning for their breast reconstruction? Is timing important if you are currently undergoing treatment, either chemotherapy or radiation? Are lifestyle considerations important in the decision process? What if one must travel outside of their city to a well-qualified microsurgeon if they choose DIEP flap? Is travel possible after this type of surgery?
Each individual case will vary. The discussion we have today covers many of these topics in general terms for patients to begin to consider as they plan their own reconstructive Journey. Our goal is to provide this information to assist you at your consultation in preparation for your breast reconstruction surgery.
How the Breast Surgeon Can Assist in Planning Reconstruction
Dr. Kale shares with us that the reconstructive process can begin soon after your diagnosis with your breast surgeon. The breast surgeon will typically work with or be aware of a few plastic surgeons. Depending on what the patient will need in terms of chemotherapy, radiation therapy or even if they are thinking of reconstruction or not, the breast surgeon can direct them to what the patient might need. He goes on to say it is incumbent on the patient to begin research on a surgeon. Find out more about the surgeon, their credentials and experience for example, then find out if that surgeon will be a good fit for them.
Working with a breast surgeon and plastic surgeon is an important part of their coordinated care. Dr. Kale says he will see patients who are seeing both the breast surgeon and plastic surgeon on the same day. The benefit is the patient begins to coordinate their plan for surgery at the same time. On the other hand, Dr. Kale says there can be benefits to having a bit of separation between one physician and another. A patient’s attention span can only process so much. He recommends taking a family member to take notes. You can discuss concerns and questions with the family member before and after the visit, making the visit with each provider that much more comprehensive.
Telehealth in Planning Breast Reconstruction
Dr. Kale includes in our discussion during Episode 20 and planning your breast reconstruction by pointing out telehealth allows him to start by going over some of the basics. This includes:
- Going over the patient’s medical history.
- Laying the Groundwork for types of reconstruction.
- Discussing implant, tissue, and a combination of tissue and implant reconstruction.
The diagnosis of breast cancer is a “go, go, go, time sensitive issue” as Dr. Kale states. Meeting a week after the initial telehealth consultation results in a patient having two visits to be able to ask questions. This allows the patient to organize thoughts, ask more questions, and begin to make the decision they feel is comfortable for their breast reconstruction in between each visit.
Planning Breast Reconstruction When on Chemotherapy
I ask the question, “If someone is on chemotherapy currently, can they begin this process of thinking about it or even starting reconstruction in some instances? The treatment regiments can differ from patients to patients after the initial diagnosis. Some patients will start with chemotherapy before they go on to have surgery. Dr. Kale can begin his conversation with patients about reconstruction either before chemotherapy or during chemotherapy, revisiting the discussion toward the end of chemotherapy.
Toward the end of chemotherapy, a patient will get restaged. Imaging studies will be done again to help monitor the progress of chemotherapy. It gives Dr. Kale and his team an idea if any additional treatment will be needed, the biggest of these concerns being radiation treatment. Radiation impacts the order and sequencing in which they do things for reconstruction.
Planning Breast Reconstruction in the Setting of Radiation
Another important topic we discuss in Episode 20 of planning your breast reconstruction is radiation. When radiation is part of the treatment after a breast cancer diagnosis, the wait time to begin reconstruction can vary from about three to six months. Some of this will be based on each surgeon’s preference in terms of what they are comfortable with. This will vary. It can also depend on the types of changes a person will experience after radiation and how quickly those changes resolve. The changes can include:
- Inflammation
- Swelling
- Redness and “angry” looking skin.
- Tightness of the skin.
Dr. Kale considers each of these factors once a patient has completed radiation before beginning the reconstruction process.
Time Sensitive Diagnosis in Planning Reconstruction
I am asked by those with a genetic mutation putting them at high risk of getting breast cancer, will my case be scheduled when a surgeon is available next? This question is presented to me in the breast cancer community I serve since women affected by breast cancer are anxious to know when they can be scheduled for reconstruction. I tackled this tough to answer question with Dr. Kale. He explains in the presence of an active breast cancer diagnosis, this is considered a time sensitive situation. It’s not to say a genetic mutation is not a time sensitive situation. He says, “It absolutely is.” This is a determination the coordinated care team must make based on some factors such as:
- Age
- Lifestyle
- Life events for the patient
A patient who has an active breast cancer diagnosis often presents with a shorter window of time to get to surgery than one without an active breast cancer diagnosis or one who has just finished chemotherapy. They typically accommodate everyone as best they can, but the time sensitive diagnosis is obviously, and understandably prioritized.
When logistics come into play and a patient wants to begin the reconstructive process, one option is to begin with a tissue expander. This can alleviate the patient’s anxiety of not having a mastectomy in a timely fashion. The tissue reconstruction can then proceed later.
The Day of Breast Reconstruction Surgery
Dr. Kale synthesizes what the day of surgery is like from a patient’s perspective and his perspective as a surgeon in Episode 20 of planning your breast reconstruction. The day begins for the patient around five to six in the morning, arriving at hospital around five thirty or six a.m. Each hospital is different but there will be a check-in process. The patient will see several people the morning of surgery.
- The nurse who will take care of you in the pre-operative area.
- The nurse who will take care of you in the surgery suite.
- The anesthesiologist.
- The breast surgeon if mastectomy is planned at the time of reconstruction.
- The plastic surgeon.
There are a lot of people asking you the same questions repeatedly along with signing quite a bit of necessary paperwork. The breast surgeon and plastic surgeon will then ask you to stand up so they can mark you for what they will need to do in surgery using a marking pen to plan incisions at the breast and area of the body they will do the tissue reconstruction for.
Breast Reconstruction Recovery
Dr. Kale tells us depending on the type of reconstruction chosen you can be in surgery for give or take two to three hours for implant-based reconstruction and from five to eight hours for tissue-based reconstruction. Patients will then go to recovery where all areas of the body that are involved in surgery will be monitored and checked by the nurses. A patient can expect to have drains at surgical sites that can be both the breasts and area of the body the tissue was harvested for reconstruction.
The patient is taken to the room where they will stay for a tissue reconstruction for between two to three days. The number of days can vary depending on how the individual patient recovers. In either circumstance, whether it is implant-based or tissue reconstruction, the key to making the transition home easier for patients is to control pain and monitor post-surgery and post-anesthesia nausea. I share the importance of communication with the hospital and surgical practice when returning home. Have those numbers available for any necessary phone calls to answer questions and concerns after release from hospital during recovery.
Post Surgery Recovery from Breast Reconstruction at Home
How much a patient can lift is always a priority after most surgeries. In the setting of breast reconstruction surgery, Dr. Kale states they recommend lifting no more than five to ten pounds. When you can go back to lifting more weight depends on how the recovery goes and, in most instances, the protocol of the individual surgeon. Dr. Kale does emphasize the importance of keeping the joints moving because stiffness is “a real thing”. Movement of joints and working on range of motion is a critical part of recovery. Check out this resource for range of motion exercises from the American Cancer Society.
Driving can resume once the patient is off narcotic medication, the patient is comfortable driving, and your family is comfortable with you driving. Even after these three things are met, Dr. Kale feels it is important to go on a small test drive first before making a longer drive. This is exactly what I did after my DIEP flap breast reconstruction. I didn’t realize how much upper body strength and mobility it takes to drive.
Returning to Work after Breast Reconstruction
Dr. Kale tells us if you have a job that requires weights, lifting a certain amount of weight as part of your job requirement, it may be in the range of eight to twelve weeks. For a patient who does work from home, he points out these individuals want to begin working as soon as possible and can within reasonable considerations of individual recovery. Some patients have the benefit of returning to work with restrictions if they do not work from home. Dr. Kale says overall, a six-to-eight-week time off work is reasonable to expect for tissue-based reconstruction. He suggests budgeting more time than you think you will need. It says it is easier to dial it down than to ask for more time off work.
From diagnosis to recovery Dr. Kale gives the listener a realistic timeline in Episode 20 for planning your breast reconstruction. You can listen to the entirety of the interview here: