Women who are 65 or older are often thought to be at more risk for complications after breast reconstruction, but a new study shows that isn’t necessarily the case.
Analyzing records for 40,769 women who had unilateral mastectomy between 2005 and 2012, researchers identified 15,093 women who were age 65 or older at the time of their surgery; almost 11% of these older women had breast reconstruction, compared to 39.5% of mastectomy patients who were younger than age 65.
When researchers compared 30-day complication rates between the two age groups, they found:
- complication rates were similar among women who had reconstruction with breast implants.
- for the most part, rates of post-surgical complications after autologous tissue flap reconstruction (with a woman's own natural tissue)—longer hospital stays, more frequent complications, and more re-operations—was similar: about 7% of the older women developed post-surgical complications after breast reconstruction, compared to about 5% of younger women.
- women in the 65+ group who had autologous reconstruction were more likely to suffer venous thromboembolism than their younger counterparts.
Venous thromboembolism (VTE) is a blood clot that forms in the leg or lung that breaks loose and travels in the blood. Overall, the rate of VTE among women who had autologous breast reconstruction was just 1%. Women who were 65 and older developed VTE 4 times more often than their younger counterparts; women between ages 70 and 75 developed the same problem 6 times more often.
Study authors suggested that, "Older patients should be counseled that their age does not confer an increased risk of complications after implant-based post-mastectomy breast reconstruction. However, they should be counseled that their age may confer an increased risk of VTE.”
The somewhat higher risk of VTE doesn’t necessarily preclude older women from having autologous breast reconstruction, but it does indicate that more precautions, such as the use of blood-thinning medications, should be taken with older women.
Source: Butz DR, Lapin B, Yao K, et al. “Advanced age is a predictor of 30-day complications after autologous but not implant-based postmastectomy breast reconstruction.” Plastic and Reconstructive Surgery. 2015 Feb; 135(2):253e-61e.
The National Comprehensive Cancer Network, a consortium of the nation’s leading cancer experts, and the American Society for Clinicial Oncology set national guidelines for treating various cancers. Both groups recommend post-mastectomy radiation therapy for women with locally advanced breast cancer (cancer cells in 4 or more lymph nodes). Radiation is a crucial part of treatment for these women, because it greatly reduces recurrence and improves survival.
A new study, however, shows that only 65 percent of women who meet these guidelines actually have recommended radiation.
Using the National Cancer Data Base, researchers at Louisiana State University examined the medical records of 56,990 women who were diagnosed and treated for with N2/N3 breast cancers between 1998 and 2011. They were surprised to find that 35 percent of the women did not have recommended radiation after mastectomy; the study authors had expected a much higher rate of compliance.
But why wouldn’t women who are at high risk for recurrence and potentially life-threatening consequences follow through with a recommended treatment? None of the following factors seemed to independently influence compliance or noncompliance:
- average age was 58 years
- 96% had health insurance
- 98% resided in urban communities
- 83% had no co-morbidities (medical conditions that would preclude having radiation)
- 82% received chemotherapy
- 81% were Caucasian
- 59% were from a comprehensive community cancer programs
Only three factors were associated with compliance: being alive 30 days after surgery, being readmitted to the hospital within 30 days of surgery, or having chemotherapy (women who were treated with chemotherapy were 5.4 times more likely to have radiation therapy). These were statistical factors—none of the women were actually interviewed. The researchers could not tell from the medical records whether patients were unaware of their need for radiation therapy, if they refused it, or what their reasoning might be, indicating a need to additional research.
Source: Chu QD, Caldito G, Miller JK, et al. “Postmastectomy radiation for n2/n3 breast cancer: factors associated with low compliance rate.” Presented at the Southern Surgical Association 126th Annual Meeting, Palm Beach, FL, November 30–December 3, 2014. (http://www.journalacs.org/article/S1072-7515%2815%2900025-3/abstract
If you’ve had a mastectomy
followed by reconstruction, should you continue having mammograms? The answer is generally no, but maybe, depending on your circumstances.
Mammograms are recommended to detect early breast cancers; since almost all breast tissue is removed during mastectomy, mammograms are no longer required. Breast reconstruction doesn’t affect breast cancer recurrence or new tumors, so it doesn’t influence whether or not you should have continuing mammograms. Your mastectomy, however, does. The American Cancer Society recommends that “women who have had total, modified radical, or radical mastectomy for breast cancer need no further routine screening mammograms of the affect side (or sides, if both breasts are removed).”
Annual mammograms are
advised for women who:
- have unilateral mastectomy--routine mammograms are recommended on the healthy breast.
- had a subcutaneous mastectomy (an outdated type of nipple-sparing mastectomy that left breast tissue at the base of the nipple).
In some cases, your physician may recommend post-mastectomy imaging:
- a baseline mammogram after breast reconstruction so an unusual area that develops can be scanned and compared.
- a mammogram, ultrasound or needle biopsy to determine whether a lump in your reconstructed breast is scar tissue, necrosis (a hardened area where fat cells have died), or something more suspicious.
- periodic mammograms or MRIs if you have an inherited BRCA mutation or a strong family history of breast cancer that puts you at high risk for recurrence (the value of mammograms and MRIs in this case hasn’t been proven, but some physicians do recommend extra surveillance for high-risk women).
Breast reconstruction with silicone implants
is an exception to the screening-after-mastectomy rule, but it is meant to check for possible “silent ruptures,” rather than detect breast tumors. The FDA recommends MRI screening of silicone implants 3 years after silicone implants are placed in the chest, and every 2 years following, for as long as the implants remain in place. (This isn’t recommended for saline implants, which deflate when they leak or rupture.) Insurance doesn’t usually pay for these MRI screenings, but they are important, since a ruptured silicone implant may not cause any visible symptoms.
After mastectomy with or without reconstruction, you should continue to monitor your breasts with monthly self-exams and an annual clinical exam by a health care professional.
Before (left) and after (right) immediate stacked DIEP flap reconstruction of left breast and lift of opposite breast. Images provided by Dr. Frank J. DellaCroce and The Center for Restorative Breast Surgery, LLC.
If you’re having unilateral mastectomy
—removal of one breast—to treat breast cancer, and you would like to have that breast reconstructed, you have three alternatives from a cosmetic perspective.
Your healthy breast can be:
- Modified. The size of your remaining breast can be enlarged with a breast implant, reduced and/or lifted. This option gives your breast a makeover that you might have been otherwise reluctant or unwilling to do, and combined with breast reconstruction, your “girls” may be made bigger or smaller and positioned back where they used to be.
- Removed and reconstructed. If you have a high risk for contralateral breast cancer (cancer in the opposite breast), your oncologist will probably recommend that you consider removing your healthy breast as well to reduce your risk of developing a future breast cancer there. If you make this choice, you’ll have bilateral, rather than unilateral mastectomy, and both of your breasts can be reconstructed at the same time. From a cosmetic perspective, this is the best likelihood of a better match of size, shape and position, with nipples that are equally centered.
- Left alone. Of course, you always have the option to leave your remaining breast exactly as is. If you prefer not to have it surgically altered, your plastic surgeon will try to match your reconstructed breast as closely as possible. Your breast can be recreated with an implant or your own tissue. If your healthy breast has given in to gravity, however, building the missing breast with a tissue flap reconstruction using your fat is the best choice for a good match, because the living tissue can be shaped to conform, while a breast implant cannot.
Autologous (tissue flap) breast reconstruction
is a fancy term that means using your own tissue to rebuild breasts after mastectomy. Fat and skin (and sometimes muscle, depending on the surgical technique and surgeon’s skill) can be taken from just about anywhere you have too much of it.
The abdomen (DIEP
procedures) is the most common source for autologous breast reconstruction, because that’s where many women have excess fat that they would love to see minimized or disappear altogether. Other fat sources for breast reconstruction include the upper or lower buttocks, and the inner thighs, another area where we women tend to collect deposits of hard-to-get-rid-of fat.
If you’re interested in autologous breast reconstruction but you’re blessed with a fit and trim tummy, your “love handles”—the outer hips just above the buttock—may provide adequate volume for your reconstructed breast.
The Lumbar Artery Perforator (LAP) flap uses fat and skin from the hip, without sacrificing muscle. Removing a flap of tissue from this area leaves a horizontal scar where the waist meets the upper buttock. Hip flaps can also be combined with flaps from the abdomen or other areas to produce the overall desired breast volume.
Some interesting notes about LAP flaps:
- Because the muscle isn’t removed or divided, recovery is somewhat quicker and less painful than tissue flaps that harvest muscle.
- The procedure slims the hip area (a bonus!), which can be difficult to reduce with diet and exercise.
- The resulting scar can usually hidden by most underwear and bathing suit bottoms.
Because most plastic/reconstructive surgeons do not perform LAP procedures, one of the most difficult aspects of choosing a LAP flap is finding a plastic surgeon
who has the skill, expertise and experience to do it.
Women who have breast reconstruction
with saline or silicone breast implants
sometimes develop rippling, the appearance of visible ridges or wrinkles in the implant that show through the skin. Rippling usually develops on the outer perimeter of the reconstructed breast: on the side, bottom or in between the breasts. It may be especially visible on the top of the breast when you lean forward. It is more likely to be visible in very thin women. What Can Be Done About Rippling?
Unfortunately, massaging, exercising or special skin products cannot get rid of rippling. In most cases, correcting the problem involves a trip back to the OR for revision surgery with one of the following fixes. Replace the implant.
Swapping out an implant sometimes eliminates rippling:
- Opt for a larger size. Implants that are too small for the pocket under the muscle can shift until they settle at the bottom of the breast, creating less volume and potentially more rippling at the top. This is often the case when the pocket is too large for the implant, or the remaining breast skin is very thin or damaged.
- Switch to silicone. Silicone implants ripple less than saline implants; this is particularly true of cohesive gel "gummy bear" silicone implants that fill out the shell more smoothly and consistently than less viscous forms of fillers.
- Replace textured with smooth. Textured implants are designed to minimize capsular contracture and to keep teardrop-shaped implants in place so that they don’t move around (or tip over) in the pocket. The roughened surface stabilizes the position of the implant by sticking to tissue (somewhat like Velcro), and that can cause rippling. Add more saline.
All saline breast implants, regardless of size, shape or model, have a recommended minimum and maximum amount of saline that should be added. (Silicone implants, on the other hand, are filled and sealed at the factory and cannot be altered.) An implant, for example, may have a recommended fill range of 300-330cc. Adding 300cc will create a softer breast, but also increases the likelihood of developing ripples, wrinkles, and folds in the implant shell, and that can eventually cause the implant to rupture. Adding 330cc is less likely to create rippling but will result in a breast that is not quite as soft. In this example, “underfilling” (adding less than 300cc) or “overfilling” (adding more than 330cc) may cause the implant to fail, and may void the manufacturer’s warranty. Add an acellular dermal matrix.
Covering the areas of rippling with a layer of acellular dermal matrix
(e.g., AlloDerm or Strattice) creates an additional barrier between the implant and the breast skin. Reposition the implant.
Unlike implants that are used for augmentation and can be positioned either in front of or behind the muscle, implants used for breast reconstruction are almost always placed under the muscle, since the breast tissue has been removed. A few recontructive surgeons (very few!) prefer to place breast implants over the muscle. In this situation, rippling that develops may be improved or rectified by repositioning the implants beneath the muscle. Add some fat.
Depending on the circumstances, a few small injections of fat liposuctioned from hips, thighs or stomach can make ripples less noticeable.
A newly-published study in the January issue of Plastic and Reconstructive Surgery (the official medical journal of the American Society of Plastic Surgeons) found that women who have breast reconstruction with their own tissues are more satisfied than women who have reconstruction using breast implants.
Although the study wasn't large--just 92 women who had reconstruction between 2006 and 2010--it's not the first time that women have expressed greater satisfaction when they have natural tissue reconstruction. This type of surgery is certainly more intensive, invasive and requires a longer recovery than reconstruction with implants, but it also produces breasts that look and feel more natural and don't have the inherent problems that come with breast implants (including eventual replacement).
In this study, 47 women had natural tissue reconstruction; most used their own abdominal tissue to recreate their breasts. The remaining 45 women had breast implants.
Here are some key results
(based on a 100-point scale) and differences between the two categories of women:
Natural tissue reconstruction:
- Average age: 51
- Average overall satisfaction with breast reconstruction: 82
- Average satisfaction with reconstructed breasts: 75
- Reconstruction delayed an average of 21 months after mastectomy
- More likely to have radiation therapy
- Higher average body weight
Breast implant reconstruction:
- Average age: 44
- Average overall satisfaction with breast reconstruction: 74.5
- Average satisfaction with reconstructed breasts: 65.5
- Reconstruction performed immediately (with mastectomy)
- Women were more likely to have bilateral reconstruction. (Many chose preventive double mastectomy to lower their high risk of breast cancer due to a BRCA gene mutation.)
Study authors emphasized that both methods of breast reconstruction provided good outcomes, with similar scores for quality of life, and that complication rates were similar between groups, although the natural tissue reconstruction group had a higher rate of secondary corrective surgeries.
Discussions about whether or not women should have breast reconstruction after mastectomy are like politics: everyone has an opinion.
Navigate around the Internet for a bit and you'll find vehement blogs against reconstruction, arguing why women should stay flat after mastectomy. You'll also find the polar opposite view: strongly-worded positions in favor of breast reconstruction.
As women, we are all different. We have different goals, different likes and dislikes, and decidedly different
opinions of what is right for each of us. Some of us feel the breast reconstruction journey is worth the effort, and that is just fine. Others consider it a waste of time and effort, and that is also fine, because what is right for one isn't necessarily right for all.
Breast reconstruction is a deeply personal decision, no matter what the outcome. For many of us, the decision is an easy one, whether we decide to have our breasts recreated or not. For others, it's an emotionally difficult and confusing decision, and the answer doesn't always come easy.
Probably the best thing about breast reconstruction is that it is an option
, meaning that each of us has the right to decide whether or not we want to have it, without others second-guessing or condemning our decisions. And that's why I appreciated "Why I Don't Miss My Breasts Anymore
" by Kansas poet laureate Caryn Mirriam-Goldberg, as featured earlier this month on the Huffington Post.
What is especially noteworthy about this post isn't that the author lost her breasts, chose not to have them rebuilt, and is okay with that decision, but how eloquently she speaks for us to understand and respect the decisions of others who find themselves in the same situation.
Breast reconstruction is not always a quick or easy decision---nor should it be. It should be the thoughtful result of carefully gathering information, understanding your options, and then (and only then) making an informed decision about what is right for you.
1. Any plastic surgeon can perform breast reconstruction.
In most U.S. states, any licensed physician can perform plastic surgery, including breast reconstruction. But there are good reasons why you don’t want a hand surgeon or a cosmetic surgeon who rarely (or never) does breast reconstruction to do your procedure. Breast reconstruction is a specialized, artistic endeavor that requires a particular experience and skill. You’re more likely to be satisfied with your results when you choose a board-certified plastic surgeon
who frequently performs the procedure you want, and who has a good track record of satisfied patients. Consulting with two or three (or more) reconstructive surgeons is a good idea before choosing one. 2. Reconstruction makes it harder to find a recurring cancer.
Breast reconstruction has no impact on future cancers. Nor does it get in the way of detecting future cancers in the breast. Recurrence is unlikely after mastectomy, but leftover cancer cells can form a small tumor under the skin, near the mastectomy scar or in the little breast tissue that remains. A recurrence in the chest muscle is possible, but is even more unlikely. 3. Breast reconstruction must be done with the mastectomy.
Although there are definite cosmetic advantages to having immediate breast reconstruction
with mastectomy, delayed reconstruction can be performed months or even years after mastectomy. Immediate breast reconstruction has many advantages: it decreases visible scarring, saves most of the natural breast skin, and doesn’t require another surgery and recovery down the road to rebuild the breasts. For some women, nipple-sparing mastectomy is also an option; nipples and areola are typically removed if reconstruction is performed at the same time as the mastectomy.
4. Implants are dangerous.
Breast implants carry inherent risks, including capsular contracture, rupture and the need for eventual replacement. But despite being studied more than any other medical device, no scientific study has found that breast implants cause illness. A 2011 FDA advisory identified a very small risk of anaplastic large cell lymphoma, a systemic disease that may occur in the surrounding scar tissue. The estimated risk for women with breast implants is just 60 cases among the 5 – 10 million women worldwide who have saline or silicone implants. 5. Reconstructed breasts don’t look natural.
Breast reconstruction is a highly individual affair, and results are not always the same for every woman. The overall look of the new breasts depends on numerous factors: Your own tissue, the type of reconstruction you have, and most importantly, the expertise of your plastic surgeon. Whether you have implants or use your own tissue, advanced reconstructive techniques can produce new breasts that are symmetrical and look natural. Many women have reconstructed breasts that cannot be distinguished from natural breasts. 6. Reconstructed breasts have no feeling.
During mastectomy, fine nerves beneath the skin that provide most breast sensation are severed when tissue is removed; this typically results in a loss of sensation over much of the front of the breast. Nerves do regenerate, particularly in women who have immediate reconstruction and retain most of their breast skin. The amount of sensation after reconstruction varies widely among women, but most women remain numb in much of the breast. Some feeling usually remains or reoccurs over time in the upper, outer and lower perimeters of the breast.
Women who have natural tissue reconstruction tend to regain more sensation than women who have breast implants, because nerve endings in the chest (if they are not damaged during mastectomy) sometimes spontaneously connect with nerve endings in the flap. 7. Having chemotherapy or radiation for breast cancer delays breast reconstruction.
At one time, patients were routinely advised to delay their reconstruction until their radiation or chemotherapy was completed, but that’s no longer the case for most women. Chemotherapy doesn’t automatically mean you have to wait to have reconstruction, although if you are obese, smoke or have a health condition that threatens healing, your oncologist may recommend that you postpone your reconstruction until you complete your chemo regimen and your white count has recovered enough to have surgery.
Radiation makes breast reconstruction more difficult, but it doesn’t entirely preclude it. Radiation therapy tends degrade the blood flow and elasticity of the remaining chest tissue and muscle—that is why reconstruction with breast implants can be problematic after radiation therapy. (Although some surgeons are having good results by adding an acellular dermal matrix like Alloderm to replace missing breast tissue around the implant. Generally, natural tissue flaps are considered to be a better reconstructive option after radiation therapy. 8. Something always goes wrong.
Any surgery has a potential for complications, and breast reconstruction is no exception. Most women who have breast reconstruction, however, do not experience problems. Serious problems are uncommon, but the risk of infection, a negative reaction to anesthesia, delayed wound healing, excessive bleeding, hematoma, seroma and an unsatisfactory cosmetic result are possibilities. (Another good reason to find a skilled and experienced surgeon for your procedure.) 9. You have to live with your results, even if you don’t like them.
Ideally, your physician’s skill and your honest communication will result in breasts that look the way you want them too. But when that doesn’t happen on the first try, your new breasts can be made bigger, smaller, higher, lower, more symmetrical or better shaped. It often means another short trip to the OR, but most problems can be fixed. 10. Insurance must pay
Federal law requires group health insurance plans that cover mastectomy to also pay for the costs of breast reconstruction, including the cost of procedures needed to produce a symmetrical appearance. The law does not require an insurer to pay for any surgeon or any procedure; an HMO, for example, can still require that you go to an in-network surgeon. (For more info on insurance, see the "Clarifying Your Legal Rights to Breast Reconstruction"
blog dated 11/10/2014.)
We all know that women are at risk for breast cancer, but that threat extends to men as well, and it’s just as serious.
Women are about 100 times more likely to develop breast cancer as men.
The estimated lifetime risk (to age 80) is less than 1% for men, compared to about 12% for women. (The risk is greater for men who have a BRCA gene mutation: 2% with BRCA1, 8.4% with BRCA2.) Nevertheless, male breast cancer does occur. It’s more common in men over the age of 60, although males of any age can be diagnosed.
Because men have far less breast tissue than women, a man’s tumor tends to spread through a greater portion of the breast than the same size tumor in a woman. And that means that lumpectomy usually isn’t an option. Treatment for male breast cancer usually requires mastectomy. The nipple, areola and breast tissue, which lies almost completely beneath the nipple, is removed (a total mastectomy). Some underarm (axillary) lymph nodes may also be removed (a modified radical mastectomy) and tested to determine whether cancer has spread beyond the breast. Treatment may also include radiation therapy and chemotherapy, depending on the nature of the tumor.
Like mastectomy in women, the surgery leaves a diagonal or horizontal scar across the chest. Men don’t typically need reconstruction after mastectomy, because the amount of tissue removed isn’t usually enough to disfigure the breast. A small flap reconstruction is possible, particularly when removal of a tumor in the chest wall leaves a concave chest. Nipple reconstruction, if desired, is also an option. Some men find that having a tattoo that simulates the nipple and areola makes them feel visually more balanced when they’re shirtless.
Men interested in reconstruction should speak with a board-certified plastic surgeon who specializes in male breast reconstruction, if possible. Breast reconstruction in men is rare, however, so this might be difficult. In any case, it’s a good idea to find a surgeon who is experienced with breast reconstruction. It’s best to consult with a plastic surgeon before mastectomy, so that immediate reconstruction is an option, unless some other health issue precludes that. In that case, delayed reconstruction (at some time other than the mastectomy) is also an option.
A local or online men’s cancer group can address these concerns and help patients deal with diagnosis and treatment.