Online Health Chat with Stephanie Valente, DO, FACS, and Graham Schwarz, MD
November 14, 2014
Approximately one in eight women in the US will develop breast cancer in their lifetime. From diagnosis to treatment to reconstruction after a mastectomy, there is a lot of information available on breast cancer and breast reconstruction.
Breast reconstruction surgery is an option for women who have lost a breast due to breast cancer or other conditions. Reconstructive surgery replaces skin, breast tissue and the nipple that is removed during the mastectomy. There are several considerations when choosing breast reconstruction – primarily, when to have the surgery and the type of surgery to pursue. Should the reconstruction be performed at the same time as the mastectomy or should it be delayed? Does the timing of the surgery depend on the breast cancer treatment received? What type of surgeon should be consulted and what questions should be asked? What happens if there is a breast cancer recurrence after reconstruction? There are so many issues to explore and it is important to seek experts for answers.
About the Speakers
Stephanie Valente, DO, FACS, is a fellowship-trained breast surgeon who specializes in the treatment of breast cancer as well as benign breast disease. She is certified by the American Board of Surgery in general surgery with fellowship training in breast surgical oncology. She serves as the Program Director for the Breast Surgery Fellowship at Cleveland Clinic. Dr. Valente earned her medical degree from Ohio University College of Osteopathic Medicine. She completed her surgical residency at Akron City Hospital and her breast fellowship at the University of Southern California.
Graham Schwarz, MD, is a plastic and reconstruction surgeon in the Dermatology & Plastic Surgery Institute. He received his medical degree at the UMDNJ-Robert Wood Johnson Medical School and completed his fellowship in reconstructive microsurgery and breast reconstruction at the Memorial Sloan-Kettering Cancer Center. His specialties for surgery for breast cancer include microsurgical breast reconstruction (DIEP, SIEA, SGAP, TUG flaps) and vascularized lymph node transfer for lymphedema.
Let’s Chat About Breast Reconstruction
Breast Cancer Surgery Basics
dnte: How often do men get breast cancer? Does it end up with a mastectomy? If so, does it require reconstructive surgery?
Stephanie_Valente,_DO,_FACS: About two percent of all breast cancers occur in males. Usually, they occur at a more advanced stage because men don't get screening mammograms or breast exams. Because of the larger size of the cancer compared to the breast size at the time of diagnosis, a mastectomy is usually the best option. However, if a small breast cancer is found, a man could have a lumpectomy and radiation. It is always possible for a man to have reconstructive surgery.
El49en: How is a nipple reconstructed?
Graham_Schwarz,_MD: There are a variety of ways, but usually breast skin or skin from the tissue flap is folded in a special way to make a projecting nipple. A small skin graft may be used for the areola. Tattooing may be used for coloration.
Vail: Would you discuss implants versus flaps for reconstructive surgery?
Graham_Schwarz,_MD: This is a very important question and is very much dependent on your breast cancer treatment, your body type and personal goals. Both types of breast reconstruction are usually performed in stages. Implant reconstruction, in general, involves a shorter recovery and can achieve very good results for many women, especially those who are undergoing bilateral mastectomy. Flap reconstruction achieves a breast from your own tissue and doesn't require ongoing implant monitoring. Both have numerous advantages and disadvantages, which should be discussed with your reconstructive plastic surgeon. Please also see the Cleveland Clinic Department of Plastic Surgery webpage for more comprehensive information.
sankers2: Which is a better option for reconstruction, implants or tram flap? Is there a time frame that implants need to be replaced?
Graham_Schwarz,_MD: This is a great discussion to have with your plastic surgeon because it is dependent on many factors. Today’s implants have a low chance of rupture or leak. That being said, it is common to require additional surgery at some point in your life after you have completed the reconstructive process. This may be related to implant position, scar formation or problems with the implant device.
bunnykins: I am considering prophylactic mastectomies because I carry the breast cancer gene. Should I pursue reconstruction at the same time? What are the benefits vs. risks, please?
Graham_Schwarz,_MD: In most cases, including prophylactic mastectomy, immediate reconstruction can and should be performed. This takes full advantage of one's own breast skin and gives the best aesthetic result.
Ronnie2: I understand that an implant can occur after a mastectomy, but if you have a lumpectomy, are you just stuck with a defect in your breast like there is a scoop out of the breast tissue? I am rather shy about asking these questions that may appear dumb and simple, but it is what is on my mind.
Stephanie_Valente,_DO,_FACS: After a lumpectomy is performed, the breast tissue is stitched together to help prevent a defect or divot from occurring. Many times, the breast surgeon and plastic surgeon work together so that someone with a large lumpectomy has a tissue rearrangement closure to help prevent this. This is called oncoplastic surgery. If the cancer is too large for a lumpectomy, then a mastectomy would be recommended.
Ronnie2: How is a decision made between a lumpectomy and a mastectomy? Why is one done versus the other?
Stephanie_Valente,_DO,_FACS: Someone with a small breast cancer usually has the decision between either a lumpectomy or a mastectomy. Most times, if you choose a lumpectomy, you will need to also undergo radiation therapy as well. Some choose a mastectomy because they don't want radiation. Lumpectomy allows you to keep your breast. Some women with a larger breast cancer only have the option of a mastectomy.
Sara: Does fat grafting via lipofilling from the thighs into a reconstructed breast increase the risk of cancer recurrence?
Graham_Schwarz,_MD: At this time, fat grafting (aka lipofilling, lipomodeling) is not thought to increase the risk of cancer in a reconstructed breast after mastectomy. This is being actively studied. It is often used as a complementary technique to achieve better contour and symmetry. It is important to know that some portion of the fat graft will be reabsorbed by the body. Less commonly, portions of the fat graft can become nodular and appear as a small lump. This can be differentiated from cancer recurrence by physical exam by your surgeon and through imaging read by an experienced breast radiologist.
Sister C: When is radiation therapy NOT recommended following breast cancer surgery?
Stephanie_Valente,_DO,_FACS: For invasive breast cancer, radiation therapy is usually always recommended.
Sandy123: So, why was radiation not recommended for my invasive lobular stage 1A?
Stephanie_Valente,_DO,_FACS: I am sorry, I do not know the specifics of your situation to comment. If you would like to come in to the Breast Center for a second opinion, please call 216.444.3024.
samantha4: Will reconstruction interfere with chemotherapy?
Stephanie_Valente,_DO,_FACS: Chemotherapy will be scheduled to start four to six weeks after your surgery. Most often, you are healed from your reconstruction surgery and can begin chemotherapy at that time without any issues.
Life After Surgery
Sandy123: How does having a breast implant affect the ability to exercise – that is, jogging, running, doing upper body resistance work, water aerobics, swimming? Same question for during the expander phase. After expander/implant placement, is there a lifelong need to be extra careful to avoid exposure to any kind of infection source? Is it necessary to sleep on my back forever in order to prevent problems after implant surgery? I am not a back sleeper and, in fact, it causes me problems with my lower back to sleep that way.
Graham_Schwarz,_MD: Implants should not affect your ability to exercise. It is not generally recommended to do exercises that focus on your chest/pectoral muscles, but you should feel free to do the vast majority of things you did before mastectomy. During expansion, the same is generally true as long as you are sufficiently healed from your surgery. The key is to discuss these questions with your plastic surgeon. The goal of reconstruction is to restore form and get women back to looking and feeling their best.
Sister C: Following breast cancer surgery, how long is it before tissue remodeling is complete and tenderness stops?
Stephanie_Valente,_DO,_FACS: Usually, it is a good month before the tenderness improves, although, depending on the extent of surgery, it can take up to a year before things are back to normal.
Sister C: What is the average length of time for tissue to feel more normal (e.g. reduction in swelling, tenderness etc.) following breast conserving surgery and radiation?
Stephanie_Valente,_DO,_FACS: Recovery time after surgery and radiation can take up to a year.
14petluver: When my mastectomy was done, I planned to have reconstructive surgery and so the surgeon left as much extra skin as possible. After all I've been through in the last three years, though, I just can't face another surgery. The extra skin looks horrible. I hate wearing the prosthesis, but I was told I'd be "off balance" if I didn't wear it. I just don't know what to do.
Stephanie_Valente,_DO,_FACS: The extra skin can be removed to allow the implant to lie flatter against your chest wall. However, this also would require another surgery, which it sounds like you don't want to do. Sometimes, people place a sock or a fluff in their bra as an alternative to the heavy prosthesis. You could always try that.
14petluver: I had almost constant problems with my port and finally had it removed after completion of the treatment due to nearly constant pain. My range of motion is worse on that side than on the side of my mastectomy. Does this sound within the range of "normal," or should I insist that something more be done. And if so, what would you suggest?
Stephanie_Valente,_DO,_FACS: You could always see a physical therapist, who could help with your range of motion. Your doctor should be able to give you a referral.
Adam: I had a skin-sparing mastectomy with the insertion of an expander, and at almost five weeks, manifested an infection (fever, redness), even though I was on prophylactic clindamycin, because one of my drains was still in. I was switched to doxycycline, and two weeks later was hospitalized with IV vancomycin. I am now back on oral doxycycline.
Plastics and Infectious Disease have been working together to hold the infection at bay, and to hopefully get me expanded to the right size before removing the expander and either replacing it with a different expander or with the permanent implant. This has all been very disheartening, and I have been on antibiotics since 8/25/14. Today is 11/5/14. Does this course of action seem appropriate? A fellow breast cancer survivor told me that they start antibiotics prior to the mastectomy. Would that have helped?
Graham_Schwarz,_MD: This sounds like a difficult situation that you are facing. I suspect that you did receive a dose of antibiotics in the operating room before surgery, which would be very appropriate. Additional preoperative antibiotics are not indicated (in the days prior to your surgery).
Unfortunately, all breast surgery (with reconstruction) carries a risk of infection. It is hard for me to say without knowing all the details, but it sounds like the course of treatment that you are on is aggressive, yet appropriate. It is most important that your plastic surgeon and infectious disease doctor are working together in a coordinated way with you to minimize additional problems.
drswig: Hello Dr. Schwarz and Dr. Valente: I am a result of the innovative breast reconstruction surgery of Dr. Schwarz. It has been over two years. I am an advocate for this choice due to my experience and the fantastic success of this surgery. My questions to either one of you are: "What has changed in the last two or so years with breast reconstruction surgery? Are there any new advanced techniques?" I am always interested in new information on this subject to share with others. I always look to the Cleveland Clinic website for information and make suggestions to others to do so.
Graham_Schwarz,_MD: Hi drswig! Glad to hear that you had a great experience with our multidisciplinary breast cancer team at the Clinic, and I am looking forward to seeing you at your yearly follow-up! While the DIEP flap reconstructions that you had are still considered "state of the art," some techniques are noteworthy. In some cases, we can perform microsurgical breast reconstruction or implant-based reconstruction at the time of a nipple sparing mastectomy. This can be done in a single stage to allow for fewer overall cancer and reconstruction surgeries.
tammy2: What are the latest techniques in breast reconstruction? As a surgeon, which option do you think has the best outcomes?
Stephanie_Valente,_DO,_FACS: For a mastectomy, a woman can elect to preserve her skin and nipple envelope. This is called a nipple-sparing mastectomy. The incisions can be placed in hidden view. Reconstruction can be with either silicone or saline implants. It can also be with a patient’s own tissue, such as the tissue from their belly, giving them a tummy tuck at the same time. All options have very good outcomes from both a cancer recurrence and cosmetic standpoint. A discussion with your doctor will result in the best choice for you.
Moderator: Thank you everyone for participating today; and thank you, Dr. Valente and Dr. Schwarz, for your insightful answers to our questions about breast cancer surgery and reconstruction.
Stephanie_Valente,_DO,_FACS: Thanks for joining us today! It was a pleasure to interact with all of you. If you have any further questions, please feel free to contact the Breast Center at 216.444.3024.
Graham_Schwarz,_MD: Thanks for allowing us to answer your questions today. If you would like to discuss breast reconstruction further, please contact the Cleveland Clinic Department of Plastic Surgery at 216.444.6900.
To make an appointment with Dr. Valente, Dr. Schwarz or any of the other Cleveland Clinic Breast Center specialists, please call 866.223.8100. You can also visit us online at clevelandclinic.org/BreastCenter.
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On Cleveland Clinic
Cleveland Clinic's Breast Center offers a full array of collaborative services, from initial screenings and diagnosis to innovative treatment and supportive counseling. Our personalized multidisciplinary team approach ensures that you will receive the care that is best for you.
Cleveland Clinic Breast Centers at Main Campus, Beachwood Family Health Center and Fairview Hospital have been awarded a three-year full accreditation designation by the National Accreditation Program for Breast Centers (NAPBC), a program administered by the American College of Surgeons. Accreditation by the NAPBC is only given to those centers that have voluntarily committed to provide the highest level of quality breast care and that undergo a rigorous evaluation process and review of their performance. A breast center that achieves NAPBC accreditation has demonstrated a firm commitment to offer its patients every significant advantage in their battle against breast disease.
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