Revision after Breast Reconstruction/Reconstruction After Lumpectomy and Radiation
It is not uncommon for patients who have had breast reconstruction surgery to require more than just a single procedure. The 1998 Federal Women's Health and Cancer Rights Act stipulates that any insurance plan providing coverage for mastectomy surgery must also provide coverage for breast reconstruction. In addition it must also cover the alternate breast to insure adequate symmetry. The Act also ensures coverage for revision of a previously reconstructed breast and for nipple reconstruction procedures.
By definition Breast Revision surgery may involve correcting complications or deformities from previous reconstructive breast surgery after mastectomy, or correcting the disfigurement of the breast after lumpectomy and radiation. It also can include revisions of the breast following a breast reduction or an elective, cosmetic procedure such as breast lifts and augmentations. In order of frequency the most common reconstructive procedures that require revision are:
- Revision after breast reconstruction following mastectomy
- Revision after Lumpectomy and Radiation
- Revision after Breast Reduction
- Revision after cosmetic breast surgery (augmentation, breast lift).
The scope of this article will focus on revisions following mastectomy and lumpectomy post radiation.
The most common physical findings that are treated with revision surgery after mastectomy are:
- Breast Asymmetry (one breast larger than the other)
- Implant issues including: deflation, displacement, scarring and or rippling on the edge of the implant.
- Loss of proper definition and position of the folds beneath the breast
- Firmest, nodules or indentations because of scarring or tissue damage by radiation.
- Malposition or absence of the nipple areolar complex
Revision after Reconstruction following Mastectomy
The patient in PHOTO A can clearly benefit from Revision Surgery. She underwent a left modified mastectomy 5 years prior for the treatment of breast cancer. Her right breast was not treated. Reconstruction consisted of the placement of an implant on the left and the reconstruction of the left nipple. There was severe scarring around the implant on the left, asymmetry, malposition of the nipple on the left and a misplaced fold beneath the reconstructed breast. The revision procedure included:
- A repositioning of the fold beneath the left breast
- Replacement and release of scarring around the implant
- Micro-fat injections for contouring of the revised breast
- A breast lift to the right breast to restore symmetry
- Micro-fat contouring of the right breast
The patient elected to decline reconstruction of her left nipple.
Techniques: fat injections, tissue rearrangement, soft tissue flaps.
Breast Revision and Reconstruction after Lumpectomy and Radiation
After lumpectomy and radiation the most common physical findings are:
- Breast Asymmetry (because of the tissue removed to cure the cancer)
- A distortion of breast shape near the surgical site (dent, bulge)
- A displacement of the nipple areola on the affected breast
- Firm or indurated soft tissue and skin following radiation damage
The patient in PHOTO B underwent a Lumpectomy with Radiation for breast cancer in her right breast. Unfortunately she suffered a recurrence of the right breast cancer and elected to do a full right mastectomy to remove the tumor and the radiation damaged skin. The reconstruction procedure was designed to immediately reconstruct the right breast with the lower abdominal wall tissues (TRAM Flap) and then do a breast reduction with lift to achieve symmetry. A right nipple areola reconstruction was part of the procedure. Her results are noted 3 months after surgery.
Closing: Revision of the reconstructed breast and the breast that has undergone Lumpectomy and Radiation can be challenging because of the presence of more scarring from previous surgery and with the tissue damage caused by radiation treatment. But if each patient is approached with a comprehensive and individualized plan, a more that acceptable result can be attained.
Joseph W. Rucker M.D. F.A.C.S
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