I had a lumpectomy and radiaiton 18 years ago and 9 years ago (first left, then right breast).1 year ago I was genetically tested and carry the BRAC1 gene. I had a full hysterectomy 9 years ago. Now I am considering a mastectomy and reconstruction. My breast doctor and plastic surgeon both feel I am a candidate for nipple saving mastectomy and immediate silicon implant. I am very small breasted, have no obvious evidence of radiation, and heal well. I am still fearful of healing due to radiation.
Mastectomy and Reconstruction Following Radiation
Doctor Answers 10
Mastectomy and reconstruction following radiation.
There are many options to breast reconstruction including implant-based and flap-based procedures. The complication rate with implants following radiation is reported as high as 60-70% in some studies. Flap reconstruction is usually recommended, but there are several centers who perform implants following radiation with great success and results. I typically prefer flaps, such as the DIEP flap. Other flaps are the conventional TRAM, latissimus flap, SGAP/IGAP, and, TUG.
You are a candidate for other procedures, if you are willing to continue with your journey for a reconstructed breast. Flaps such as those above, including others, are available. The decision to continue with this will be your decision and what you are willing to go through. There are risks and benefits with everything that we do in Surgery - discuss the various options with a board certified plastic surgeon who will educate you on all of the options and help you to decided if breast reconstruction or which procedure will be best for you. Hope that this helps and best wishes!
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Three basic forms of breast reconstruction exist. You can use your own tissue, implants or a combination of the previous two techniques. Your own tissue can be used in the form of the DIEP flap, PAP flap, SGAP flap or fat grafting. Implants can be done in one stage or two stage. Two stage reconstructions are started by placing expanders at the time of mastectomy. Once they expanders are placed they are able to be inflated as determined by wound healing. The final time consists of combining any of the above techniques.
If you are interested in being seen in Austin please give us a call. I know this is a difficult time for you. The majority of my practice is devoted to reconstruction for women with breast cancer or who are BRCA+
Options for reconstruction
Implants should never be used alone in a radiated breast unless it is combined with another flap for coverage. A TRAM flap is just one tool used in breast reconstruction. It sacrifices your stomach muscle. Another is a DIEP flap which also uses your belly tissue but does not sacrifice your stomach muscles. It essentially uses the same tissue that would be discarded in a tummy tuck but relocates the tissue to create a breast. A third option is the Latisimus flap (back muscle); its best use is along with an implant. These "autologous" tissue (your own tissue) can be used in any breast reconstruction. Women prefer it because it is their own tissue. It is also an excellent option for someone who has had radiation. You should consult with a plastic surgeon who offers all three of these methods as well as the implants, so that you have the best choice of options.
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Reconstruction after mastectomy and radiation
For patients who had radiation, they are at higher risks for implant-related complication (capsular contracture) as well as wound healing (delayed healing and wound dehiscence). As long as you are well informed about potential risks/complication, you can proceed with implant-based reconstruction. Please remember that all reconstructive options (both the autologous and implant-based reconstruction) have pros and cons. Please discuss with your plastic surgeon all your options/limitations/alternatives/potential risks. Good luck to you.
Radiation and reconstruction
I would also have concerns. Once radiated always radiated is what I was always taught. Having a lot of experience with nipple sparing reconstruction, I would be concerned of healing in the area between the nipple/areola and the incision. The removal of the breast tissue will challenge the blood flow . The one caveat being that it has been a long time , but be vigilante of skin changes and keep in contact with your BC Plastic Surgeon.
Breast reconstruction after radiation therapy
With regard to an implant reconstruction, prior radiation therapy may increase the risk of capsular contracture, though placement of the implant beneath the muscle and using Alloderm as part of the reconstruction may help. Many other surgical factors (for example mastectomy flap thickness) may also play a role. As part of your discussions with your plastic surgeon, you may wish to ask what long term outcomes (at least 5 years) your surgeon has had with the proposed treatment, as issues like capsular contracture can take several years to develop.
My response to your question/post does not represent formal medical advice or constitute a doctor patient relationship. You should continue to follow-up with your plastic surgeon in order to receive formal evaluations and maintain your doctor patient relationship.
Radiation and breast reconstruction
While there is a higher risk of capsular contracture with implants and radiation, it does not mean you are destined for failure. The other issue of healing from mastectomy and immediate reconstruction in the face of previous radiation is a function of things beyond radiation (i.e. thinness of flaps, size of breast, size of implant, location of scars, etc.). When planned well, risks are minimized, and you can certainly have a successful outcome. One option is to have expanders availabe at the time of mastectomy in case the flaps look compromised and your plastic surgeon feels placinhg an expander instead of a final implant would be safer. The other option is to plan for serial implants (i.e. smaller implant initially as a spacer followed by the final implant a few nonths later as a planned staged procedure.
Robin T.W. Yuan, M.D.
You multiple options
Breast reconstruction with implants works well in most women with previous radiation.
This really has to be carefully individualized after physical exam. But particularly with small breasts you should do fine.
It's true that there are somewhat increased risks after radiation. But every option has risks. You have increased risk of a new breast cancer if you don't have the mastectomies and an entirely unacceptable outcome for your body image and your appearance if you have mastectomies without reconstruction.
The other option of course is to use flaps (from your abdomen most commonly) for reconstruction. And this is what we do when there is evidence of radiation damage. But flap surgery is long, can be complicated, and also has significant risks (of flap failure, for example).
So I have a feeling that your doctors are right.
Radiation effects and Breast Reconstruction
I appreciate your concerns about the effects of radiation and breast reconstruction. This remains a problem for plastic surgeons and patients. It sounds like you have the information you need regarding your options. I am sure your surgeons will do their best to decrease your risks of complications, but go into it prepared. Hopefully you will heal well and not have any problems, but if you do you may need additional surgery. Your surgeons will discuss this with you and what surgery you may need in case you have an implant exposure or healing issue.