Online Health Chat with Graham Schwarz, MD, FACS
Thursday, October 1, 2015
Approximately one in eight women in the US will develop breast cancer in their lifetime. When initially diagnosed with breast cancer, a person faces both survival and quality of life issues. The decision whether to pursue breast reconstruction after a mastectomy or lumpectomy is intensely personal – and sometimes confusing. There are many different options to be considered.
Following a mastectomy, patients have a wide variety of sometimes confusing reconstructive options. The breast can be reconstructed using natural tissue (referred to as autologous reconstruction) or using implants or expanders. The decision is determined based on a patient's personal desire and cancer staging, as well as body and health condition. Both implant-based and autologous procedures have advantages and drawbacks, and both types of reconstruction may be compromised by subsequent radiation therapy. It is imperative that consultation with a plastic surgeon early in the treatment planning, as part of a multi-disciplinary breast cancer team, is important for women considering reconstruction. Most of the reconstructive efforts would require stages of operation, and they are coordinated along with the cancer treatment.
About the Speaker
Graham Schwarz, MD, FACS, is a plastic and reconstruction surgeon in the Dermatology & Plastic Surgery Institute. He received his medical degree at the Rutgers University-Robert Wood Johnson Medical School and completed his general and plastic surgery residencies at Weill Cornell and Columbia University Medical Centers. He completed subspecialty fellowship training in reconstructive microsurgery and breast reconstruction at Memorial Sloan-Kettering Cancer Center. He specializes in all forms of breast reconstruction and has additional expertise in microsurgical breast reconstruction (DIEP, SIEA, SGAP, TUG flaps) and vascularized lymph node transfer for lymphedema.
Let’s Chat About Reconstruction Options After Mastectomy or Lumpectomy
Timing of Reconstruction
thrush: Can reconstruction be done in the same surgery as a mastectomy?
Graham_Schwarz,_MD,_FACS: Absolutely. In most cases, reconstruction can and should begin at the time of mastectomy. This is called immediate breast reconstruction. In certain limited instances, however, such as a particularly aggressive cancer, it is advisable to wait until cancer treatment is completed. This is called delayed breast reconstruction. It is important to understand that breast reconstruction after mastectomy is a process and usually requires one longer surgery and additional same day surgeries to maximize symmetry and recreate the nipple and areola.
cnway: How long after a mastectomy is too long to wait before breast reconstruction surgery? Is there a time period after a mastectomy when reconstruction can no longer be done?
Graham_Schwarz,_MD,_FACS: There is no time limit that excludes the ability to have breast reconstruction. Delayed breast reconstruction may be performed at any time in healthy individuals. We have worked with women who are many years out from their mastectomy.
JulesD125: Does having a previous lumpectomy cause any challenges for then turning around and having a mastectomy?
Graham_Schwarz,_MD,_FACS: Thank you for this question. A previous lumpectomy may impact the planned incision for the mastectomy and the type of reconstructive options to consider. As part of a multidisciplinary team, your breast oncologic surgeon and plastic surgeon will plan the mastectomy approach together. In particular, radiation as part of prior breast conservation therapy (lumpectomy and radiation) may increase the risks associated with mastectomy and reconstruction.
Feelings and Appearance
mtue49: Will the reconstructed breast be the same size as my remaining breast?
Graham_Schwarz,_MD,_FACS: An important part of the reconstruction process is to achieve balance between both breasts. The steps of breast reconstruction include restoring the breast contour, maximizing symmetry between sides, recreating the nipple and areola if removed, and providing appropriate coloration through tattooing.
JulesD125: Is it inevitable to lose sensitivity with a mastectomy?
Graham_Schwarz,_MD,_FACS: Generally, sensitivity is lost following mastectomy as the breast tissue contains nerves that give sensation to the breast skin and nipple. Over time, women may regain some degree of sensation in the reconstructed breast skin. It is not usually the same as it was prior to mastectomy.
SamH: How do I know if I’m a candidate for a nipple-sparing mastectomy? Is this a procedure Cleveland Clinic performs?
Graham_Schwarz,_MD,_FACS: While traditional mastectomy involves removing breast skin and the nipple, breast surgery has evolved toward a more tissue-sparing approach when safe to do so. Increasingly, women are now able to undergo nipple-sparing mastectomy, which has the potential to result in a more natural result. We have extensive experience with this procedure at Cleveland Clinic. It is important to note that women who will benefit from this approach need to have a lower stage breast cancer and have a breast size and shape that will allow for a safe and cosmetically appealing result. Consultation with your breast doctor and plastic surgeon will help you determine if you are a good candidate.
al789: What are the latest techniques in breast reconstruction? As a surgeon, which option do you think has the best outcomes?
Graham_Schwarz,_MD,_FACS: Great outcomes can be achieved with a variety of techniques. Outcomes very much depend on your medical history, body size and shape, and personal goals. Generally, there are two main approaches for breast reconstruction, one that uses implants and one that uses your own tissue.
In traditional implant reconstruction after mastectomy, a tissue expander device is positioned behind the chest muscle, and the skin is closed. The skin and muscle are stretched in preparation for placement of a permanent implant. A more recent advancement is the ability to pair a nipple-sparing mastectomy with a permanent implant at the time of the initial surgery. This can allow for the number of reconstruction surgeries to be reduced.
Tissue flaps have a variety of advantages, including a more natural feel and appearance, and excellent durability. We offer microsurgical breast reconstruction with perforator flaps (DIEP, TUG, GAP flaps). These highly specialized procedures greatly reduce problems at the site from which your tissue is borrowed.
amanda: I'm considering an implant for reconstruction. I'm curious about durability. Can implants "pop" and how much force does that take?
Graham_Schwarz,_MD,_FACS: It is rare for implants to pop with normal activity (including exercise). While rupture and leak rates are low following reconstruction (less than 6 percent to 10 percent at 10 years), very forceful impact may cause problems. These types of injuries may cause you to be checked out by a doctor anyway.
september: Will implants last or will they need to be replaced after a certain number of years?
Graham_Schwarz,_MD,_FACS: Implants do not have an expiration date. However, if you are young, you will likely need a same day surgery related to your reconstruction (for contracture, malposition, leak or rupture) at some point in your lifetime. Ninety percent to 95 percent of women do not have rupture or leak of recent generation implants at 10 years post implantation.
Surgery and Recovery
Deb_80: I have had breast reconstruction and am not completely happy with the results. Is another procedure an option for me? Or is that out of the question? I have been trying to keep realistic expectations.
Graham_Schwarz,_MD,_FACS: Oftentimes, women have a number of options available to them even if they have already undergone reconstruction. It is important to have a consultation with a plastic surgeon so that you can discuss your medical and surgical history and have a full assessment. Depending on your unique situation, certain options for revision may be more appropriate than others.
Hollins: I have been reading about flaps, and it says you can take skin from either the abdomen or the back. Is one site better than the other?
Graham_Schwarz,_MD,_FACS: In women who have never had treatment for breast cancer, we generally favor the abdominal skin and fat for breast reconstruction. Back tissue is a very good option in certain circumstances, and an implant is often required to achieve optimal breast volume. A visit with a reconstructive surgeon can help you iron out which site is best in your case.
amanda: How long after my mastectomy and reconstruction will I have a limit on how much weight I can lift?
Graham_Schwarz,_MD,_FACS: Usually, we ask patients not to lift, push or pull more than 10 pounds for four to six weeks after surgery. As part of your rehabilitation after mastectomy, exercise is important to maintain your range of motion. Your treatment team should provide you with instructions for these exercises before you have your procedure.
megr: I was wondering which reconstruction is the easiest on a person as far as the recovery. I realize this may vary from person to person. I'm an active 70-year-old who passes for being in my 50s. I exercise for at least one and a half hours six days a week, so I'm in good shape. I am considering reconstruction since having a mastectomy recently. I'm also considering having my other breast removed since I'm very large. This seems to be the perfect time for this or at least a reduction since I wear a size 32 "F" bra. I'm not overweight. I'm 5'3 and weigh 129 pounds. Do you have any input as to what would be best for me at my age as far as recovery?
Graham_Schwarz,_MD,_FACS: It is most likely that an implant-based reconstruction will be the shortest recovery for you. However, it may require more than one surgery to reconstruct your breast since you have already had a mastectomy. You will likely need a tissue expander placed to stretch skin and muscle for a permanent implant. Your physiologic age is far more important than your chronological age. You may be a candidate for either type of reconstruction and may consider breast reduction versus mastectomy unless there is a medical reason for a mastectomy. I would be happy to see you in consultation to help figure out which set of options would best suit your goals.
patti: I had a double mastectomy with DIEP reconstruction in November 2012. I have since developed a hernia and am looking to get it repaired. Can any surgeon repair this or would I need to see a doctor who is affiliated with DIEP hernia repair?
Graham_Schwarz,_MD,_FACS: It would be a good idea to see a plastic surgeon who is familiar with DIEP reconstructions. If needed, that doctor can enlist the help of a general surgeon. I would encourage you to obtain your operative report from your DIEP surgery and bring that, as well as any imaging (CT scans) you may have had done, to your appointment.
That is all the time we have for questions today. Thank you, Dr. Schwarz, for taking time to discuss breast reconstruction options.
Graham_Schwarz,_MD,_FACS: Thank you all for joining me today. I hope I was able to answer some of your questions regarding breast reconstruction. Please visit our website for further information. Have a great day.
To make an appointment with Dr. Schwarz or another Cleveland Clinic plastic surgery specialist, please call 216.444.5725 or toll free 800.223.2273, extension 45725. You may also visit clevelandclinic.org/breastreconstruction.
For More Information
Cleveland Clinic plastic surgeons offer a wealth of experience in specialized breast cancer reconstruction. They are focused on delivering the highest quality care while providing the individualized attention you need to help you weigh your options. Cleveland Clinic plastic surgeons offer excellent support to patients with breast cancer and understand the process necessary in treatment to achieve desired results and regain self-esteem. Our personalized multi-disciplinary team approach ensures that you will receive the care that is best for you.
You may view before and after photos of patients who have had breast reconstruction and learn more about breast reconstruction options at Cleveland Clinic at clevelandclinic.org/breastreconstruction.
Cleveland Clinic Health Information
Learn more about breast reconstruction options. For additional health information, visit clevelandclinic.org/health.
Cleveland Clinic Treatment Guide
Download the Breast Reconstruction Guide to learn about reconstructive options after treatment for breast cancer. The guide contains up-to-date information regarding timing and techniques used to reconstruct a breast, as well as before and after patient images. It is intended to help increase awareness about breast reconstruction options when working with a reconstructive surgeon.
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