Hearing the words “you have breast cancer” can be a frightening and paralyzing experience for any woman. Not only are you confronted with a wave of emotion, but shortly after you are faced with many critical and immediate decisions – What doctor should I see? Should I have a mastectomy or lumpectomy? What treatment is best for me? For some women, the choice of having have breast reconstruction or not, and the thought of more surgery in addition to cancer treatment, is overwhelming.
It’s important to know that advancements in plastic surgery have made breast reconstruction much less daunting for patients. In most cases, reconstruction can begin at the same time as the cancer surgery. New approaches ensure patients recover more quickly, have less pain and experience better results than 10 or even five years ago.
Over the last few years, there have been several improvements that have revolutionized the reconstructive process.
Microsurgical DIEP flap reconstruction has become the "gold standard" for tissue-based breast reconstruction. This technique uses excess skin and fat from the lower abdomen, similar to what would typically be discarded in a tummy tuck, to reconstruct the breasts. While an older technique, the TRAM flap reconstruction, used the same tissue, it also required taking abdominal muscle to ensure blood supply to the tissue when it was moved to the breast. Using advanced imaging and surgical techniques, the DIEP flap now allows the tissue to be safely transferred without taking any muscle—thus minimizing pain, weakness and recovery time. This complex microsurgical tissue reconstruction used to be primarily limited to only a few centers across the country, but now Northwell Health System is one of the largest providers of this advanced reconstructive technique.
Changes have also occurred in implant-based reconstruction. Implant reconstruction used to entail placing implants behind the chest (pectoral) muscles. This could result in movement of the implants, or "animation deformity," when muscle contraction occurred and in long-term tightness and discomfort. Surgeons are now placing breast implants in front of the chest muscles, a strategy known as pre-pectoral implant placement, to minimize implant movement and significantly reduce the pain and length of recovery for the patient. Because the muscle is no longer covering the implant, most patients with pre-pectoral implants benefit from fat injections, also referred to as secondary fat grafting, as an outpatient procedure to thicken the overlying tissue and provide a more natural appearance.
An alternative approach to pre-pectoral implants and secondary fat grafting, is to combine microsurgical tissue transfer with implant reconstruction. This “hybrid" solution may enhance the aesthetic results over either technique alone. Many patients prefer the feel and natural appearance that a DIEP flap reconstruction provides, however they lack enough tissue to match the breast volume they desire. In this situation, placing a smaller implant under the transferred tissue enhances the tissue reconstruction, similar to how a breast implant is often used to cosmetically augment the shape and volume of a natural breast. At the same time, the tissue helps to protect and camouflage the implant so there is seldom the need to fat graft. Northwell surgeons are among a small group that has significant experience with this approach.
Another major advancement in reconstruction recovery relates to the lymph nodes that are commonly sampled in the armpit to ensure cancer cells have not migrated from the breast. When cancer cells are found in the lymph nodes, multiple additional lymph nodes are removed to assess the extent of involvement and to guide further treatment. A common side effect of lymph node removal is swelling of the arm, a condition known as lymphedema. Lymphedema can become a chronic problem for patients, causing infections and disfigurement as well as interfering with normal activities. Because lymphatic channels are so small, it has been difficult for surgeons to visualize and repair them, until recently. Advances in microsurgical equipment and lymphatic imaging are allowing surgeons to actually identify and repair these microscopic structures at the time of lymph node removal, helping reduce the risk of developing lymphedema. Northwell has also been a leader in bringing this advanced reconstructive procedure to our region.
Members of the Northwell Health team recently published a study describing an innovative multimodal approach for pain control in breast reconstruction, which is more effective in reducing pain and eliminates the need to use opioids for many patients. Because of this, patients can now avoid the uncomfortable side effects of narcotics that slow recovery.
The new technique substitutes non-steroidal, anti-inflammatory medication for opioids and uses long-acting nerve blocks that work locally to minimize pain at the surgical site. Anesthetic injections are given during the surgery to block nerves and provide local pain relief for the first two to three days, when the pain from surgery is typically the greatest.
This development has already led to a 95 percent reduction in narcotic use by patients and, in turn, reduces the risk for narcotic dependency after surgery. Patients are now experiencing less pain overall and are no longer exposed to the bloating, nausea and lethargy that was typical of the post-surgery experience in the past.
One of the most significant outcomes of the innovations in care is that patients can now be home and resuming their ordinary routine much sooner. Even with microsurgical reconstructions, the patient is up and walking the day after surgery and usually can leave the hospital on the second day, a significant improvement over the traditional four to five days in the hospital. For implant reconstructions, most patients are home the next day.
While the full recovery process can be slightly longer for those undergoing tissue reconstruction rather than reconstruction that uses only implants, most patients return to work by three to four weeks, resume light exercise by six weeks and full exercise by 12 weeks.
Finally, it’s important to know that your cancer treatment will always come first as your doctors coordinate your care. Breast and plastic surgeons work very closely with medical and radiation oncologists to ensure you are given the best care in a coordinated fashion. Breast reconstruction is now considered an integral part of the cancer treatment plan. Any patient undergoing breast cancer surgery should have a reconstructive evaluation so they’re informed about their options.
The bottom line is that you and your doctors will work together, and with you, to determine the best path forward and ensure you are comfortable with your treatment plan. Eradicating cancer is the primary concern, but given the excellent prognosis that most breast cancer patients have, breast reconstruction and maintaining quality of life after surgery are important considerations that are achievable for most women.