The Women's HealthCare and Cancer Act of 1998 mandates insurance coverage for breast reconstruction after mastectomy. Many insurance companies also cover lumpectomy reconstruction as well, however all procedures must be prior authorized with insurance prior to proceeding.
Who Is a Good Candidate?
Breast reconstruction is a very personal decision. It can be done at the time of the mastectomy surgery, or at a later time when patients are done with other treatments such as chemotherapy or radiation. Dr. Kayan performs many revision surgeries on previous reconstruction patients as well on patients whose surgeons have moved or retired, or patients who want a fresh perspective on how to improve their current breast reconstruction results using newer evidence based techniques. Typically, breast reconstruction is done in stages, and the method of reconstruction depends on whether or not a patient has had or will have radiation treatment after their lumpectomy or mastectomy.
1st Stage of Reconstruction
The first stage of breast reconstruction previously consisted of placement of a tissue expander at the same time that the mastectomy was performed. The tissue expander was a non-permanent implant that was injected with sterile saline in the clinic post operatively to slowly expand the breast skin in size. Today, it is much more common to skip the tissue expander step and go straight to placing a permanent saline or silicone implant at the time of the mastectomy. This is called "direct to implant" reconstruction, and can safely be done, even if it is known that the patient will need post operative chemotherapy or radiation.
The location of where the implants is placed has also been evolving. Previously, all expanders and implants were placed underneath the chest muscles (subpectoral) to provide adequate coverage of the implant or expander after the breast tissue was no longer there to cover it. With the development of very reliable tissue support substitutes known as Acelluar Dermal Matrices ("ADM's"), it is becoming more common to place the implants in a pre-pectoral location. This means that after the mastectomy is done, the final silicone or saline implant is wrapped in a material of donated human tissue (our practice uses Alloderm), and the implant/Alloderm construct is secured on top of the chest muscle, thus disrupting normal anatomy less and leading to much less post-operative pain. The extra layer of tissue also helps disguise the implant better and provides protection against the body mounting a robust foreign body reaction to the implant.
The only situations under which we use tissue expanders are if a patient wants a much larger breast size after reconstruction, or if there is the need to remove a lot of the breast skin if it is involved with cancer. Patients who smoke and have not stopped by the time of their surgery are usually still offered reconstruction in the form of tissue expanders placed underneath the muscle, because direct to implant reconstruction in a pre-pectoral position is too risky to perform because the skin has less robust perfusion due to the effects of nicotine, and complications are common.
After 1st stage reconstruction, patients typically have their incisions closed with dissolvable sutures and glue. There will be 1 drain on each side, and patients are usually wrapped in a compressive ACE wrap with gauze, and spend one night in the hospital. Depending on the hospital where the surgery is performed, there is an option to do a paravertebral block, which is an injection of local anesthetic done in the pre-operative area that can help greatly with post-operative pain.
1st Stage Recovery
Showering can be resumed after 48 hours, even with the drains in place. Patients will usually want to wear the ACE wrap 24/7 until the drains are out, then should switch over to a compressive front closure sports bra for a total of 4-6 weeks after surgery. The drains usually are removed after 2-3 weeks, which is the necessary amount of time for the Alloderm to incorporate and most tissue swelling to resolve. Patients will be required to take antibiotic pills the entire time their drains are in to prevent infection. Most patients take prescription pain pills for 1-2 weeks after surgery, and can resume driving a car once they are off these medications. Over head reaching is not permitted for 2 weeks after surgery, and it is recommended not to lift over 5 lbs or engage in high end exercise for 4-6 weeks after surgery.
2nd Stage of Reconstruction
Further procedures can be done after the initial implant placement. These procedures are sometimes referred to as the 2nd stage of reconstruction, although this terminology is becoming obsolete as it was previously used to describe the removal of tissue expanders and placement of final saline or silicone implants. These procedures most commonly involve nipple reconstruction and fat grafting, but can also include scar revision, implant pocket revision, or replacement with larger or smaller implants. All of these revisional surgeries are done as outpatient procedures, and do not require an overnight stay. Insurance does typically cover these procedures, however they must be prior authorized.
Fat grafting is used to help add an extra layer of tissue to help improve symmetry that cannot be improved via implants alone. Because there is no breast tissue left to cover the implants, there can sometimes be some divoting or rippling visible through the skin. Fat grafting involves removal of fat from areas such as the stomach, love handles or inner thighs and injection of this fat into the skin of the breast overlying the implants to help thicken the layer of tissue and hide the implant better.
Nipple and areolar reconstruction can be done in many ways. The most common is to build a nipple bump out of the skin on the front of the reconstructed breast, then have the areola tattooed. The areola can also be reconstructed with a skin graft from the inner thigh or lower abdomen. We commonly fat graft as well underneath the nipple reconstruction to give a more natural look to the areaola and more long term projection to the nipple reconstruction.
Another option gaining popularity is a 3D nipple and areolar tattoo. There are several well known artists in the country who are experts in this, and are well known for their excellent and very realistic work.
After a lumpectomy and/or radiation for breast cancer
treatment, breast tissue can shrink or pull due to
scarring, and can adversely affect breast symmetry to
a noticeable degree. Lumpectomy reconstruction
most commonly consists of a scar revision and fat
grafting to the radiated/post-lumpectomy side, as
well as a matching procedure to the non-cancer side
side as a lift or reduction. The placement of breast
implants in a radiated breast (after a lumpectomy) is
not typically advised because of the high risk of implant
complications such as infection and capsular contracture.
Radiation and Reconstruction
Radiation treatment is sometimes necessary as part of breast cancer treatment, and it can affect how reconstruction is done. If implants are placed at the time of the mastectomy, radiation can be done around the implants. The radiated breast can be slightly firmer and sit higher, however with the placement of implants in front of the muscle in a pre-pectoral position this has not proven to be as much of an issue. If radiation has been done previously and patients are pursuing reconstruction in a delayed fashion, a tissue expander or implant alone is not always possible, and new tissue in the form of a local or free flap must often be considered.