Rethink Real Talk: Ask the Surgeons
This past February we had the pleasure of Dr. Fahima Osman and Dr. Waqqas Jalil join us live on Zoom for a Rethink Real Talk. Clearly this is a topic that the community needed to discuss as we weren’t able to address everyone’s questions live at the event.
Lucky for us, both surgeons agreed to help us answer some of the most asked questions we weren’t able to get to. Check out their answers below.
Remember, this is not a replacement for medical advice or regular check-ins with your healthcare team, so please check in with your own doctors before making any decisions about your care.
Is it typical for patients to go in for revision surgeries after their initial breast reconstruction surgery? If so, what issues get addressed?
This answer usually requires a bit more in-depth response, but in general it is very dependent on the type of reconstruction done initially.
Tissue based (autologous) reconstruction will typically require “less” revisional surgery as the breast tends to age normally. If they require revisional surgery it is usually a result of the “process of aging” and usually cosmetic in nature.
On the flip side, implant-based reconstruction will typically require more revisional surgery. This is both a result of the patient and the implant aging together. In a setting where the patient hasn’t received radiation, I usually advise at 10-15 years post implant based reconstruction there is a 35-45% revision rate. These revisions can include anything ranging from the breast implant needing replacement, excessive scar or capsule development, changes as a result of aging, the patient no longer wants implants, and a few more that go outside this discussion.
If radiation is in the patient’s history, we generally tell them their revision and complication rates go up significantly. They are still candidates for breast reconstruction, but the surgeon needs to have a detailed discussion with them.
During the talk it was mentioned that there has been a rise in requests for aesthetic flat closure. Do you think flat closure is offered to patients as readily as reconstruction or do you think there is a bias/push for reconstruction? Any tips for patients to help them confidently communicate their wishes?
I think we do push for reconstruction as a default option, however, if a patient strongly desires not to have breast reconstruction, we are supportive of their decision. I would recommend that patients who would like to have an aesthetic flat closure let their surgeons know that they are aware of reconstruction, however, after much thought and time, they prefer to have flat closure and are confident about their decision. Our role is to educate patients about their options and ensure that patients understand the pros and cons of each treatment option. I think the majority of surgeons would support a decision to go flat after counselling patients on their options.
When would you recommend that a patient have pre-pectoral vs sub-pectoral surgery and does either restrict future surgery options? Do implants move/flip more commonly for a certain type? What are the patient’s options if their surgeon only does one type?
I always recommend for the patient to have a discussion with their surgeon regarding sub-pectoral vs pre-pectoral surgery. Although pre-pectoral is the newest trend in implant based breast reconstruction, sub-pectoral can still be advised based on surgeon and institution.
When patients who have already undergone sub-pectoral placement of implants and are now having symptoms or issues as a result of the placement being under the muscle, they need to book a consultation with their surgeon and discuss their options for conversion.
The conversion from sub-pec to pre-pec is usually done to help relieve the patient from things such as pain, animation and displeasing aesthetic result. The surgery does not restrict future operations but if there is anything you have specifically in mind make sure you discuss it with your plastic surgeon.
Generally, with the newer implants we place in 2021, flipping or moving has become less of an issue in either pre-pectoral or sub-pectoral reconstruction.
The last part of this question is the most difficult to answer because it truly depends on the centre you are getting your treatment for breast reconstruction. I can only say that broadly in Canada we offer either tissue-based or implant-based reconstructions.
IF there is a desire to have a specific operation and the center cannot provide it, then you can have a discussion with your surgeon to see if a referral to an outside institution is possible.
Does fat grafting after a lumpectomy to fill in a dent affect a patient’s risk of recurrence or overall survival? Can you get implants after a lumpectomy and radiation?
While fat grafting lumpectomy defects are possible, some people voice concerns about recurrence and survival. At this point, there is no data to suggest that fat grafting procedures cause cancer recurrence and impact survival. There is ongoing research on the stem cells that are present in the fat cells and their impact on recurrence, but at this point it is all theoretical.
After lumpectomy and radiation, you can certainly get implants, but it is often not recommended due to the very real and significant problems that can occur around capsular contracture and other implant related issues long term secondary to the radiation. Every case isn’t the same so there are scenarios that exist where you can still have breast implants, it just requires an in-depth discussion with a plastic surgeon.
What is standard follow-up with your surgery patients? Does this change depending on their surgery type?
This can vary with surgery type, but in general we usually say follow ups post-surgery happen at one week, three weeks, six weeks, six months and then yearly after that with your plastic surgeon.
For oncology, we recommend follow up two weeks post surgery to discuss the pathology, then in six months for a check up, then alternating every six months with their medical oncologists.
When is an expander a good option? Are they safe to radiate on? Does amount of time / number of expander fills depend on size of implant?
An expander can be a good option for breast reconstruction, but again it is highly dependent on your centre. Often times we place an expander in the breast when we know patients will be getting radiated. Once the radiation and expansion are complete, we then can safely do the permanent reconstruction in an effort to offset the damage the radiation has done. Another setting we place implants in is often when the patients present to us delayed (already having had their mastectomy). In this scenario there is a lack of skin and soft tissue so we have to place an expander under the skin and gradually inflate it so it can recruit over time the required skin.
Expander fills are generally done on an as needed basis. If you have an 800 cc expander in, it could take 3-6 visits before it is entirely filled.
The reason for the range is patient comfort, because as you can imagine the inflation process can be uncomfortable. So, at each visit we generally stop the expansion process when the patient states discomfort. IF the patient isn’t in a lot of discomfort, then their expansion process happens quicker when compared a patient who is in discomfort sooner in the process.
How often do implants need to be changed? Does this change depending on implant type?
Generally, implants do not have a lifetime warranty. Their need for change is highly dependant on a patient-to-patient basis. For example, if a patient has had radiation it’s more likely than not that they will need an implant exchange sooner than somebody who hasn’t had radiation.
There are a few more scenarios that play out this way as well.
In Canada, we generally use two types or brands of implants (Allergan and Mentor). At this time, we are not advocating one’s superiority over another. Both are safe and have equally efficacy.
How long after reconstruction surgery would you recommend waiting to get a nipple tattoo?
I would recommend waiting three months or more depending on if you are having wound healing issues.