As recently as the 1980’s, most women with breast cancer had a modified radical mastectomy and very few had the choice of plastic surgery for reconstruction. Cancer surgeons felt that women should be happy to have the cancer removed and often paid little regard to the emotional impact of this disfiguring operation. Some pioneering plastic surgeons understood the emotional impact for women of losing one or both breasts. The scar and deformity served a constant reminder of the disease. Wearing clothing normally was difficult to impossible. Weight imbalances between a normal breast and the lost breast were uncomfortable and hindered activities and exercise. Surveys and studies of patients showed a tremendous negative impact of breast cancer surgery. Problems include: increased rates of depression, worse overall emotional well-being, feeling less feminine, less like their pre-cancer selves, and severely reduced relationship and sexual well-being. The impact on hundreds of thousands of women and their loved ones was tremendous.
The early plastic surgery reconstruction options seemed miraculous at the time. Instead of needing a prosthesis in a bra, implants or patients own fat were placed under the skin to create a new breast mound. Results were rarely spectacular or natural, but patient satisfaction rates were very high. As techniques have been refined over the past three decades, the results have gotten better and better. With improved flap techniques and spectacular surgical, anesthesia, and implant advances, patients generally have far superior outcomes than even 10 years ago.
Even with great progress in surgical techniques, outcomes are still rarely as good as what nature provided in the first place. There are exceptions, where the reconstructed breasts is considered an improvement over the pre-mastectomy shape. These great outcomes are more frequent in patients who have very large or small breasts to start, and reconstruction provides what they consider a more ideal size and contour. But for the most part, a reconstructed breast has limitations-- visible scars, somewhat unnatural shape, occasional imbalances in size and shape between the left and right breasts, and perhaps some numbness or discomfort. As long as the patient can wear clothes normally and looks balanced and full in the middle part of the breasts, which shows in clothing, then patients are usually happy. When the breast is balanced in size and shape as well as comfortable, patients are usually delighted with outcome.
Each patient is so different in terms of their starting size and shape, the extent of their disease, and the treatments they will need afterward. This is why no two breast reconstruction patients are completely alike and why outcomes vary so much.
When a patient is not happy with their outcome, it is usually because of a mismatch between their expectations and what is actually achievable with current breast reconstruction techniques. It is remarkable that some patients can be entirely happy with an outcome that the surgeon considers below average, and some are dissatisfied with a truly terrific outcome. So much of results lie in the individual’s perception. How the changes after mastectomy affect each person is highly individual, and each woman’s feelings should be accepted, supported and discussed with her doctor and care team in order to help her along the path of healing.
Just because a woman is not satisfied with her outcome does not mean there is nothing that can be done to improve the results. Plastic surgery is very much like sculpture, and working on the human form is more challenging than working with stone, wood or metal! Having a chance to reflect on an outcome, come back and make adjustments and allow for the dynamic process of healing really helps. Over time, surgeons can make minor tweaks to the result that can typically improve the shape, comfort and patient happiness.
The main causes of dissatisfaction after breast implant reconstruction are as follows:
-Failed implant reconstruction from poor healing, seroma, skin loss, or infection
About 7% of patients may have to have their implant removed because of poor healing over the implant. Sometimes the skin overlying the implant has inadequate blood supply to heal, other times the body generates excessive swelling fluid reaction to the implant (seroma) that impairs healing. Both of these conditions provide “nutrition for bacteria” and can result in infection and need to remove the implant. Patients with the following risk factors are more likely to have a failed first go at reconstruction: Overweight, multiple medical conditions (high blood pressure, diabetes smoking, known healing or bleeding problems), need for chemotherapy after surgery, previous radiation therapy, thin skin flaps, or skin tension too tight over implant. If an implant needs to be removed , it usually happens within a couple weeks after the mastectomy surgery. Patients typically heal well. All hope is not lost! Patients can go on to successful reconstruction. Typically, I advise waiting until after all cancer treatments are complete. Then, placing a new tissue expander and resuming reconstruction is possible. Healing risk of problems is much lower in this setting, as the skin and tissues over the implant are now stable and healed, not the freshly operated on skin flaps immediately after a mastectomy. If a patient has had previous radiation therapy, then bringing in non-irradiated, healthy skin is essential. The latissimus flap from the back is typically ideal and can create a natural pleasing shape over an implant. Abdominal-based flaps are also helpful in patients with an ideally sized donor site and can result in fantastic outcomes in the proper patient.
Inadequate size : too little projection or too large, heavy and broad
Many patients feel that the implant reconstruction does not provide the desired amount of size and breast projection. Too little projection is the most common size complaint. Sometimes there are limits to how large an implant or how much tissue expansion one can safely undergo after mastectomy. But once the body is well healed over 12 months or more, there is no reason that additional volume cannot be added with a better shaped implant or addition of fat grafting. Often this group of patients started with a single stage direct to implant reconstruction, or had a limited amount of skin to accommodate a larger or more shaped implant. With a combination of changing from a round implant to a more natural shaped implant and fat grafting (taking fat by liposuction from the abdomen or thighs), results can be gratifying to patients and surgeons alike.
Implants that are too broad , heavy or large more often occur in patients who have larger breasts or more excess to start. Downsizing implants and narrowing the skin and soft tissue coverage can usually make significant improvements in a relatively brief outpatient surgery. Patients often feel less discomfort from downsizing the heavier implant to one that stretches the tissues less.
There are 3 major breast implant manufacturers in the U.S.-- Allergan, Mentor and Sientra. Each offers a variety of shapes and sizes to get the best results possible, and each have a similar safety profile. Our practice has found Sientra shaped gels to offer the best results in softness and shape. Mentor has some implants with excellent projection for a fuller look that we like using. Allergan is a long-time implant leader as well, with a large variety of shapes and sizes available.
Rippling or hollowing of the upper chest
Sometimes in thin skinned patients, the round implant does not adequately recontour the upper chest. A mastectomy removed breast tissue all the way up to the collarbone, and the abrupt transition from a round implant to the thin chest muscle and ribs can sometimes look unnatural. Creases and ripples in the skin can develop. A change to a higher projected implant with more height, along with fat grafting, can help.
Poor Nipple shape or position
Sometimes nipple reconstruction shifts or does not turn out as planned as the body heals. In other cases the natural nipple is preserved, but forces of skin contraction during healing result in an improper contour or position. Reconstructing the nipple and areola with a combination of minor skin flaps and eventual tattooing for repigmentation can result in great improvements, with a very realistic appearance of the breast. The nipple reconstruction really brings the breast reconstruction to life. By making nipple and breast more realistic, patients can get dressed each day without a strong visual reminder of their mastectomy surgery, and they can focus on the important matters of the day. A small outpatient procedures can really make a tremendous difference.
Tightness of the implant capsule causing pain or deformity
The natural healing mechanisms of the body result in internal scar and contracting of the skin and muscles around an implant. Usually, the scar capsule that forms is helpful- keeping the implant in a proper position. On occasion, maybe as many as 1 in 5 patients over time, the capsule continues to contract and tighten, causing displacement of the implant and discomfort. Sometimes the capsule is quite normal but the weight of the implant exerts force on the muscles of the chest, causing soreness. There are a variety of treatment options, form a surgical release of the capsule, adding some additional tissue to support the implant (acellular dermal matrix graft, such as Alloderm) or in severe, recurrent cases, use of a tissue flap surgery or removal of implants altogether. The bottom line is, there is no reason to live with discomfort or deformity. Seek out a plastic surgeon who performs this type of revision implant surgery all the time. There are times when your result is good enough and it’s best to leave things alone. You can make this decision with the help of a caring and talented plastic surgeon.
Congratulations on making it through breast surgery. Best wishes for years and decades of good health!
To learn more about breast reconstruction options, contact Dr. Suzman. Dr. Michael S. Suzman operates at Rye Ambulatory Surgery Center in Westchester County , NY, and is on faculty at White Plains Hospital, Greenwich Hospital in CT, and serves as a Clinical Instructor in Surgery at Weill Medical College of Cornell University in Manhattan, NYC, Division of Plastic Surgery.