It’s hard enough being diagnosed with breast cancer – or with the BRCA gene that predisposes women to breast cancer – without the additional stress of navigating the myriad options for breast reconstruction. Unfortunately, although chemo and radiation have improved a lot, mastectomy is often necessary to eradicate cancer cells. Researching breast reconstruction can be daunting because there are a lot of variables that have to be taken into account. The ideal reconstructive option depends on several factors. For example –
- Will you undergo a partial or a total mastectomy?
- Is a double mastectomy (i.e. both breasts) planned?
- Will the mastectomy be performed without removing the nipple (i.e., nipple-sparing mastectomy)?
- Will you need to have radiation after surgery?
- Have you had any previous surgeries on your back, abdomen, or thighs?
Many of these questions can only be addressed through a discussion with your breast cancer surgeon who is designing your overall treatment plan.
Breast reconstruction after mastectomy is a multi-step process, and one which has to be highly personalized for your particular situation. Regardless of which surgical technique you choose, there are usually at least two surgeries involved. So I always tell patients that reconstruction is a journey that can take up to a year or more. I’m fully committed to being your guide along this journey. The most important thing, however, is to treat the cancer appropriately. So I like to stay in close communication with your breast cancer surgeon to make sure we are working as a team and always prioritizing the cancer treatment.
Total mastectomy reconstruction
To put it simply, there are two ways of reconstructing a breast –
- With an implant, or
- Without an implant
Across the United States, most women undergo a reconstruction using implants. However, more and more women are choosing to undergo reconstruction without implants, using their own tissues. This type of reconstruction (called “autologous reconstruction” or “free tissue transfer”) involves moving skin and fat from another location on your body to your chest and reshaping it into a breast. There’s a whole alphabet soup of such techniques, depending on whether these tissues are taken from your back (latissimus, LD, MSLD, TAP), your abdomen (TRAM, MS-TRAM, DIEP, SIEA), or your buttocks and thighs (PAP, SGAP, IGAP). Dr. Nagarkar most commonly uses the DIEP, PAP or LD flaps, as he feels these have the most cosmetic outcomes both in terms of your breast shape and size, as well as the scars and contours of the areas the tissues were taken from. The right choice for you depends on the answers to many of the questions mentioned above, but also on your health history, and most importantly, on your goals and desires for reconstruction.
Partial mastectomy reconstruction
Partial mastectomy involves removing only the cancerous tissues of the breast, but leaving the rest of the breast gland, skin and fat in place. Generally, patients who have a partial mastectomy will also undergo radiation therapy after their surgery. Partial mastectomy reconstruction is very different from total mastectomy reconstruction, because the focus is on reversing any distortion of the breast caused by the loss of tissues, while achieving symmetry with the other breast. With partial mastectomy reconstruction, close communication between your plastic surgeon and your breast surgeon is critical. Often, Dr. Nagarkar will perform a procedure called “oncoplastic reduction,” where he will work with your breast surgeon to design the partial mastectomy surgery in such a way as to achieve a result equivalent to a breast reduction or a breast lift. Then he can simultaneously perform a breast reduction or lift on the other breast to give you a cosmetic and symmetric result.
What to expect during your consultation:
During your consultation, you should expect to discuss your overall medical history, details of your breast cancer history, any surgeries or procedures you have undergone, and medications and supplements you use. Dr. Nagarkar will have a full discussion with you about your reconstruction options. After meeting Dr. Nagarkar and his nurse, you will also have medical photographs taken in the office to assist with the surgical planning.
Who is a good candidate for breast reconstruction:
Most patients who are undergoing mastectomy can be good candidates for reconstruction. The exact type of reconstruction depends greatly on a number of factors that are specific to your cancer, your body, and your medical history. You can plan on having a detailed discussion with Dr. Nagarkar about your goals and expectations and the types of reconstructive options available to you.
How to prepare for surgery:
Once you, your breast surgeon, and Dr. Nagarkar have designed a treatment plan for your breast cancer reconstruction, you will schedule a date for your initial reconstruction, which may be on the same day as your mastectomy. Generally, your breast surgeon will have obtained laboratory tests and possibly imaging such as mammograms or MRIs, but Dr. Nagarkar will let you know if any additional laboratory tests are required. If you are a smoker, you must completely stop smoking and refrain from any nicotine-containing smoking cessation aids (such as patches or gums) for 6 weeks before and after surgery. This is critical as smoking increases the risk of significant complications. Finally, you will discuss with Dr. Nagarkar which medications and supplements you should stop taking before surgery, and which ones you can continue. You will get detailed written instructions for pre- and post-operative care. In addition, you will receive any postoperative prescriptions you might need so that you can have them filled by your pharmacy in advance.
What to expect on the day of surgery:
Breast reconstruction surgery is an inpatient surgery – that is, you should expect to spend a night in the hospital to recover. The length of surgery depends on whether your mastectomy and reconstruction will be performed at the same time, and the reconstruction option that you have chosen. Surgery may last anywhere from 3 to 15 hours depending on the complexity of the case. You should plan on having nothing to eat or drink after midnight the night before surgery. Dr. Nagarkar will provide you with more detailed instructions on what to expect after surgery once your treatment plan has been finalized.
What to expect after surgery:
Results
Breast reconstruction surgery is a multi-stage affair. You should not expect to see your final result after your first surgery. If you had temporary implants placed as the first step in reconstruction, you may find that your reconstructed breasts are quite small and deflated at first. This will change as the temporary implants are slowly inflated. On the other hand, if you had an “autologous” reconstruction with your own abdominal tissues, you might notice that your breasts are almost the same size and shape as they were before your mastectomies. Regardless of the procedure you had, patience is critical, as your final result may not be apparent for 6 months to a year after surgery.
The first few days
Recovery after breast reconstruction varies tremendously. At the simplest end, patients who undergo a partial mastectomy and an “oncoplastic reduction,” can have a very rapid recovery, and are able to restart simple activities like walking, writing, typing and so on, a day or two after surgery. On the other hand, if you have a double mastectomy and reconstruction with your abdominal tissue (DIEP flap) on the same day, you might spend 3 to 4 days in the hospital, followed by a couple of weeks of feeling somewhat under the weather while you regain your energy.
Pain
Depending on the procedure you had, narcotic pain medications may only be needed for a few days, or for 1-2 weeks. You should be able to switch to anti-inflammatory over the counter medications like Tylenol and Ibuprofen over time.
Incision care
Your incisions will usually be closed with internal absorbable sutures, and surgical glue. You can start showering after your drains have been removed, and you should take sponge baths as long as the drains are still in place. Bathing, swimming, getting in a jacuzzi etc. should not be done until at least 3 weeks after surgery. You may have a surgical bra or an abdominal binder to support your incisions. We will provide you more instructions on how to use these garments. You should protect your fresh scars from sun exposure for at least 6 months after surgery, because they are extra sensitive to sunlight during this period. Dr. Nagarkar may discuss special scar care techniques such as silicone sheeting or moisturizers with you. If you are prone to forming keloids, it is very important that you discuss this with him prior to your surgery.
Drains
Most patients require drains (little plastic tubes to remove any fluid that collects underneath the skin) that are placed during surgery – these drains are removed a week or two after surgery in the office. Before you are discharged from the hospital, we will show you how to take care of these drains at home.
Diet
You can return to your regular diet after surgery, but for the first day or two, stick with lighter meals. Anesthesia can sometimes make your digestive system a bit sensitive, and having a double cheeseburger the evening after surgery is not recommended. You should refrain from high-sodium foods because salt may increase swelling or prolong the time required for your swelling to resolve. If you had reconstruction with your own abdominal or thigh tissue, you should refrain from foods with caffeine such as coffee, soda, or energy drinks for 2 weeks after surgery.
Work
Recovery after breast reconstruction varies greatly on the specific procedure you had. You may only need to take a week or so off work, or you may need 4 to 6 weeks. Dr. Nagarkar will discuss this with you in greater detail once your surgical plan has been determined.
Activities
You will be able to go back to non-strenuous activities such as walking, using a computer, writing, and so on, immediately after surgery. You should not lift anything over 10 pounds (or a gallon of milk), for at least 2-3 weeks after your surgery to allow your tissues to heal.
Driving
You can resume driving once you are no longer taking narcotic medications, and when you feel that you are in full control of your car. This often takes a couple of weeks.
Exercise
Aerobic exercise such as yoga, running, cycling, barre, etc., must be stopped for three weeks to allow the tissues to heal. Lifting over 10 lbs may be restricted for up to 6 weeks depending on the procedure you had. Strenuous activity too early in the recovery brings a high risk of bleeding, which can cause significant complications.
Follow-up visits
You will see Dr. Nagarkar in the office usually within a week of leaving the hospital to examine the incisions and ensure that you are healing appropriately, and possibly to remove the drains. If you underwent reconstruction with a temporary implant, you may have regular weekly visits for a month or so while the temporary implant is slowly inflated. During your visits Dr. Nagarkar will continue to monitor your healing and will start planning the next steps in your reconstruction with you.
To meet Dr. Nagarkar in person, schedule your consultation or call us.