Advances in Post Mastectomy Breast Reconstruction: Nipple Preservation

Dr.-Constance-M-Chen

Mastectomy has changed a great deal over the years. Long gone are the radical mastectomies of your grandmother’s day which removed not only breast tissue but also extensive breast skin, lymph nodes, and underlying chest muscles. By the 1980s, the most common approach was the modified radical mastectomy, which left the chest muscles intact.

Since then, the standard mastectomy is the simple mastectomy in which all of the chest muscles, most if not all of the lymph nodes, and most recently, the nipple and areola complex are all preserved. When combined with an immediate breast reconstruction at the time of the mastectomy, these techniques produce a superior cosmetic result while eliminating diseased tissue.

Nipple-sparing mastectomy has become more widespread as more breast surgeons realize the importance of the nipple-areola complex to patients after surgery. Looking and feeling normal and whole improves self-esteem both for women who are losing a breast to cancer and for those who are considering prophylactic (or preventive) mastectomy because they are at high risk for breast cancer due to family history or because they carry a genetic mutation.

Dr. Constance M. Chen

Women who are considering skin and nipple-sparing surgery must be evaluated for factors such as the size, location, and nature of the cancer to ensure that they are good candidates for the procedure. Imaging and examination are performed to look for tumor in the nipple and to rule out symptoms such as nipple discharge that might indicate the presence of disease in the nipple.

During surgery, all breast tissue is removed and the breast specimen is submitted to pathology to ensure that there are no cancer cells in or near the skin and nipple complex. Nipple preservation is possible with both small and large breasts and can be used when reconstruction is to be either with implants or with a woman’s own tissue (‘autologous reconstruction’).

Many women are candidates for nipple-sparing mastectomy, in which the nipple is preserved during the mastectomy. For women whose nipple has been resected a more traditional type of mastectomy, however, it is possible to surgically reconstruct the nipple to recreate a complete breast.

Dr. Constance M. Chen

The primary benefits of skin and nipple preservation are the superior aesthetic outcome and the resulting psychological boost. The combination of skin and nipple preservation with autologous reconstruction produces a soft, warm, natural breast that may be difficult to distinguish from the woman’s original breast.

The risk of breast cancer is considerably greater for women who inherit a genetic mutation, such as the BRCA1 or BRCA2 gene, that makes a woman more likely to develop breast cancer. As more women become aware of their risk, those who test positive for the harmful mutations face the difficult decision of whether to reduce their risk by undergoing bilateral prophylactic mastectomy – preventive removal of both breasts.

These women may wonder if surgery that conserves the nipple will leave in place breast tissue that might be subject to cancer. The experience of thousands of women and their healthcare providers has been that nipple-sparing mastectomy is safe for women with genetic mutations and a major study in 2017 confirmed that prophylactic surgery essentially eliminates the risk of cancer with or without breast reconstruction.

(‘Oncologic Safety of Prophylactic Nipple-Sparing Mastectomy in a Population With BRCA Mutations’ by Jakub et al, was published in the Journal of the American Medical Association in September 2017.) The report concludes that nipple-sparing mastectomies are ‘highly preventive’ against breast cancer in a BRCA population.

For women with no indication of disease in or near the nipple, including those with BRCA mutations, a nipple-sparing mastectomy essentially eliminates the risk of breast cancer and offers the opportunity for state-of-the-art breast reconstruction that maintains both the woman’s health and her sense of self.

 

About Dr. Constance M. Chen

Constance M. Chen, MD, is a board-certified plastic surgeon in New York City with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine.

Dr. Chen is frequently invited to lecture nationally and internationally on new advancements in breast reconstruction and the surgical treatment of lymphedema. She is the author of three books, five book chapters, and fifty journal articles. She has also won numerous awards for her work in plastic and reconstructive surgery at the local, regional, and national levels.

Dr. Chen has developed a reputation in the community for the personalized attention that she devotes to her patients. She is committed to aesthetic restoration of the breast and body, and enjoys helping her patients achieve overall well-being. At the end of the day, there is nothing more important to her than the joy she hopes to bring to her patients’ lives. Come into the beautiful world of Dr. Constance M. Chen.

 

 

 

 

 

Breast Reconstruction Specialist Dr. Constance M. Chen Offers Tips for Patients

Among women who opt for reconstruction after losing a breast to mastectomy, 80% undergo reconstruction with implants. “Many women see implants as the quickest, simplest reconstructive option”, says plastic surgeon and breast specialist Dr. Constance M. Chen. “Their other choice – natural-tissue reconstruction – requires a more complex surgery and longer recovery time”. However, studies have shown that the risk of cosmetic and health problems with implants in the first few years is significant and the risks increase over time. Implants aren’t expected to last forever. Most have a ten-year warranty although many will have to be removed before that.

Studies have shown that the risk of cosmetic and health problems with implants in the first few years is significant and the risks increase over time. Implants aren’t expected to last forever.

Dr. Constance M. Chen

Implants fail for many reasons. Different types have different characteristics that women must weigh against their individual requirements and preferences but all implants are foreign bodies and pose the risk of comfort and cosmetic problems. Dr. Chen describes some of the common complications and unsatisfactory results of implant reconstruction and provides tips on corrective measures and on options if implants have to be removed.

Infection can develop in the tissue around an implant, often in the days or weeks following surgery. That said, infection has been seen 20 years after implant surgery. Women with breast implants should take antibiotics if they undergo teeth cleaning or colonoscopy. Signs of infection are redness and swelling. Treatment with an antibiotic may be sufficient; if it isn’t, the implant may have to be removed.

Capsular contracture is a tightening – or contracting – of the scar tissue that forms around the implant as a natural reaction to the presence of the implant. The capsule is usually soft and barely noticeable but it may become hard and painful, like a calcified shell that develops around the implant. Symptoms of contracture usually develop gradually and may be noticed first as a feeling of mild tightening.

As contracture increases, the breast may appear misshapen and become very firm and painful, especially when lying on it. Treatment is to remove the implant and capsule surgically, but the capsule will reform and usually become harder more quickly. In some cases, the implant may be replaced with a new one wrapped in acellular dermal matrix to try to reduce capsular contracture; in others, natural-tissue reconstruction may be the best option.

Rupture becomes more likely as an implant ages. Saline implants may appear deflated or misshapen. Silicone implant ruptures are either silent, or they present as unusual pain due to the irritation to the surrounding tissues. Since silicone implant ruptures are silent, the FDA recommends breast MRIs for surveillance every 2-3 years for women with silicone implants. Ruptured implants are generally removed as long as the patient is healthy enough to tolerate surgery.

Displacement of the implant can occur for several reasons, one of which results from the placement of the implant under the chest muscle (sub-pectoral placement). Placement of a breast implant under the chest muscle can cause the breast to feel tight and painful, and flexing the chest muscle can also cause the implant to shift visibly under the skin and distort the breast.

The problem can be corrected by removing the sub-pectoral implant and placing a new implant above the muscle (pre-pectoral). A prepectoral breast implant is closer to the natural anatomy of the breast, because the natural breast is also above the chest muscle. The new implant may be wrapped in acellular dermal matrix to provide some additional soft tissue protection under the skin.

Many women who have had unfortunate experiences with implants prefer not to try again, even with a different type of implant or modified surgical procedure. They turn to natural tissue breast reconstruction, also known as autologous reconstruction, which is the ‘gold standard’ of breast reconstruction. Natural tissue breast reconstruction uses a woman’s own tissue to create a breast that is soft and warm and that lasts a lifetime.

Feeling cold occurs because there is no blood supply to the implant and because the skin that remains after the removal of breast tissue can be quite thin. Fat-grafting can help by adding additional ‘padding’ over the implant, but it is often of limited utility. A better solution is natural-tissue reconstruction, which recreates a soft, warm living breast.

About Dr. Constance M. Chen

Constance M. Chen, MD, is a board-certified plastic surgeon in New York City with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine.

Dr. Chen is frequently invited to lecture nationally and internationally on new advancements in breast reconstruction and the surgical treatment of lymphedema. She is the author of three books, five book chapters, and fifty journal articles. She has also won numerous awards for her work in plastic and reconstructive surgery at the local, regional, and national levels.

Dr. Chen has developed a reputation in the community for the personalized attention that she devotes to her patients. She is committed to aesthetic restoration of the breast and body, and enjoys helping her patients achieve overall well-being. At the end of the day, there is nothing more important to her than the joy she hopes to bring to her patients’ lives. Come into the beautiful world of Dr. Constance M. Chen.