breast reconstruction

When Is the Best Time to Have Breast Reconstruction Following a Mastectomy

PJ Hamel Health Guide November 22, 2009
  • Q. I’m having a mastectomy, and after hearing about the various choices I have for reconstruction, I’ve decided to have an implant. Now I have to make the decision whether to have the implant done right away, or wait till later. Help, I’m stuck!

    A. One-stage (immediate) reconstruction with an implant is done at the same time you have your mastectomy; two-stage (delayed) is done at some point in the future, after the mastectomy scar has healed. Here are some advantages and disadvantages of each:

    One-stage (immediate) reconstruction means only one surgery, which means lower cost, less time spent under anesthesia, and less time spent recovering. It also means a slightly longer recovery time (than from a straight mastectomy), and more chance of an infection, which could delay your cancer treatment.


    The main advantage of two-stage (delayed) reconstruction is that it gives you time to consider your choices: of surgeon, dates, and type of implant. Right now, your mind may be so filled with cancer worries that you don’t want to make yet another decision; for you, a delayed reconstruction may be the answer.

     

    However, delayed reconstruction also involves two surgeries, which means greater cost, more time spent under anesthesia, and a longer amount of time spent recovering. It also might mean your insurance won’t cover it; some insurance companies cover only one post-mastectomy treatment, so if you purchase a breast form and claim it on insurance while you’re waiting for implant surgery, they may refuse to cover the subsequent implant surgery.

    If you feel calm and strong and reasonably certain about the path you’re taking, immediate reconstruction is probably for you. If you have serious doubts about any of it–the surgery itself, the surgeon, what type of implant to choose–you may want to take more time making this important decision, and have reconstruction done later down the road.

    Q. I also have to decide on silicone vs. saline. I’d heard silicone gives a better result, but wasn’t it banned or something? What’s up with that?

    A. After 20 years of usage, silicone implants were banned by the F.D.A. in 1992 as being unsafe. One study found that as many as 69% of women with implants experienced ruptures, resulting in the implants becoming hard and painful. Some claimed leaking silicone traveled through their bodies, causing cancer and autoimmune disorders, such as rheumatoid arthritis.

     

    A class-action suit by women against several implant manufacturers resulted in settlements in the women’s favor, and triggered the withdrawal of the implants from the market. Despite the legal settlement, however, there’s no reliable research showing that implants – silicone, or saline – cause immune system disease, or increase cancer risk. And this year, the F.D.A. lifted the ban, claiming silicone implants, while they may still rupture and be painful, are basically safe.

     

    The advantage of silicone implants over saline is that they’re softer, hang more naturally (though still not as naturally as reconstruction made from your own body tissue), and assume a more natural shape than saline.

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    The advantage of saline is that, if you’re worried about silicone, a ruptured saline implant simply leaks saltwater into your body, not silicone. However, the new silicone implants are  a "Gummi-Bear" type consistency, and much less likely to leak, even if they rupture; so many women are opting for silicone over saline.

    So, which should you choose? Sorry, I have no magic answer here. Once again, do your research, make your decision, and don’t second-guess yourself. Go forward with confidence that you’ve done what’s best for YOU.

    Q. What exactly happens during surgery?

    A. There are two methods a surgeon may use to build an implant. First, he or she may simply place the implant behind the chest muscle (or, less commonly, in front of the chest muscle) after having removed your breast tissue, and close up the skin.

     

    This works best for small-breasted women; or for women who are having a bilateral mastectomy, and are happy with small breasts post-implant.

     

    Second, the surgeon may remove your breast tissue, then place an expander – a hollow sack – behind (or in front of) your chest muscle, and close up the skin. This expander is equipped with a valve, through which saline can be pumped. Over the course of several months, more and more saline is pumped into the sack, gradually stretching your skin. When the skin has been stretched enough to accept the size implant you want – generally, the size that comes closest to matching your other breast – the sack is removed, and the permanent implant put in its place.

     

    This method works well for larger-breasted women. Its disadvantage lies in the fact that it can be a fairly uncomfortable process, and it involves additional surgery (to replace the expander with the implant).

     

    So, are you a candidate for an expander, or would you do fine with just a one-step implant? Don‘t worry, your surgeon will take a good, hard look at your body and make a recommendation. (Be aware that some surgeons believe ALL women want larger breasts, and automatically suggest going the expander route. If you’re fine with small breasts, insist on foregoing the expander, no matter what the surgeon says!)

    Q. Will an implant interfere with any future mammograms?

    A. This is a tricky subject. First, you may not need future mammograms on your implant side; if you’re having a total mastectomy, there’s no breast tissue left to examine.

     

    If you’re having a partial mastectomy, then depending on where the implant is placed, it could interfere with the ability of the mammogram to do its job. In addition, the compression necessary to get a clear reading increases the chance of your implant rupturing, which then requires another surgery to remove the implant.

     

    Finally, be aware that implants sometimes cause a buildup of scar tissue, which not only can be painful and make the breast change its shape, but can make it difficult to identify any possible tumor.

    These possible side effects with implants should definitely be discussed with your surgeon; and if he or she seems at all vague about what effect the implant might have on future cancer detection, see if you can get a better opinion from your oncologist.


  • In addition, discuss with your surgeon what happens if your implant ruptures or leaks, or whether it has a limited lifespan (and, if so, how long). It’s good to thoroughly understand all the possible consequences before you have this surgery done, so that you’re not surprised if any “repairs” become necessary down the road.