Big thank you to new-to-town-plastic surgeon, Dr. Melissa Mueller, for an excellent Grand Rounds presentation this week on Breast Reconstruction. I learned so much from her, and I look forward to working with her in our Sonoma County community. 

A recording of Dr. Mueller's excellent presentation is available HERE. If you care for women in Sonoma County, you should definitely watch this.

Here are my notes:

• 1 in 8 women will develop breast cancer in their lifetime
• 80% of women w/breast cancer have breast conserving therapy (i.e. lumpectomy)
• of 20% of patients who undergo mastectomies, 40% get breast reconstruction, the majority implant based
• in SoCo, less than the national average of patients get reconstruction, likely due to lack of access to modern breast reconstruction in the area
• Breast reconstruction after cancer treatment is associated with improved self-image, decreased depression and anxiety, better body image, improved self esteem,  and overall improved emotional, social and sexual functioning
• Some studies showing highest satisfaction with autologous reconstruction
• The 1998 Women's Rights and Cancer Rights Act guaranteed reconstruction for women getting mastectomy (national)
• California state law goes further and requires that ALL insurers (including Medi-Cal) must cover reconstructive surgeries (initial and subsequent) after breast cancer treatment, initial and subsequent implants (if patient needs an exchange)
• includes mastectomy AND lumpectomy
• includes contralateral breast symmetry procedures
• Breast reconstruction may be a "silver lining" to getting cancer

Type of breast reconstruction after breast cancer depends on type of surgery.

After Lumpectomy (i.e. Breast Conserving Therapy or Partial Mastectomy)

All women in CA are eligible for oncoplastic reconstruction as well as contralateral breast symmetry

To be eligible for a lumpectomy (vs. mastectomy), the size of breast cancer must be small in relation to the size of breast. After the lump is removed, there will be a hole in the breast, which needs to be filled. This can be done in two different ways:

• volume displacement: uses surrounding breast tissue to fill that hole--> that breast will be smaller and may require tissue rearrangement, reduction, lift/mastopexy
• volume replacement: brings adjacent tissue outside the breast to restore the original breast size (e.g. back, side wall/bra fat, implants)
• the contralateral breast will need to undergo symmetry procedure either immediately or delayed fashion 
• this can happen at same time and/or after radiation
• radiation causes collateral damage and decreased breast volume by 10-15%, tightening of the skin, nipple uplift
• if reconstruction is happening before radiation, the breast that will be irradiated will be left slightly larger to allow for radiation changes

After Mastectomy, there are two categories of reconstruction

• implant based: most commonly performed with tissue expander placed at time of mastectomy. Expander is inflated q1-2 weeks until desired size is achieved, then is replaced with implant (saline, silicone)
• autologous: using patient's own tissue, make a breast mound with patient's own tissue, from abdomen/thigh/buttock/back (abdomen most common)

Reconstruction Timing 

post-mastectomy reconstruction also can happen immediately (at time of mastectomy) vs. delayed

    overall anesthesia time is less if doing delayed (in two parts)

    if done delayed, another advantage is that final pathology is received (margins) to know if radiation will be required

of note, breast skin cannot be expanded after radiation treatment, so if a patient wants an implant-based reconstruction, they need to have fully inflated before radiation tx

in advanced cancer, pts should focus on adjuvent therapy prior to reconstruction

but for patients who have the choice, more immediate reconstruction is associated with better outcomes

Implant-based reconstruction

under vs. over pectoralis mm

historically, implant has been placed under the muscle because the tissue makes implant less visible

however, recently prepectoral breast reconstruction is gaining in popularity-- less pain, no animation deformity (doesn't move when pectoralis moves)

fat grafting (i.e. liposuction) can help make the implant less visible in both cases

for some women, surgeons can place implant at time of mastectomy--> fewer total surgeries

    -have to have small breasts (A/B cup), want to stay same size, pts with nipple in correct place

    -mastectomy is stressor to breast skin, so heavy implants can create a second stressor to the skin which can compromise blood flow to the skin

Autologous reconstruction: 

create a breast mound using patient's own tissue (so you don't need an implant)

most common and most popular donor site is abdomen (deep inferior epigastric perforator flap)-- surgery similar to tummy tuck, kept alive by suturing to internal artery and vein in the chest

Fat grafting (ie liposuction--> injected with syringes after implant or autologous ( to disguise)

Counseling women for cosmetic results they may expect w/mastectomy

• chest wall can be concave after surgery
• lateral chest adiposity is not removed
• dog ears (standing cone deformity)

BIA-ALCL

A word on very rare condition/complication from breast implants called Breast Implant Associated Anaplastic Large Cell Lymphoma

associated between textured devices-- both textured tissue expanders and implants (these are no longer used)

Incidence of association: 1/30K implants placed--> 949 total cases worldwide

On average 8-10 years after implant (at least 1 year)

Sudden fluid collection (collecting within a matter of days) or a new mass associated with the capsule around the implant

There has been a recall on all textured implants

FDA doesn't currently recommend removing the devices because it is unknown if removing them decreases lymphoma risk, but if patients feel uncomfortable having the device in their body, insurance will cover their replacement or removal

Ultrasound vs. MRI to evaluate, aspirate 50cc of fluid should be sent for pathology and immunochemistry