Mercy supports National BRA Day, or Breast Reconstruction Awareness Day, which is Wednesday, October 21, 2020. It is part of the Breast Reconstruction Awareness USA campaign led by the American Society of Plastic Surgeons and The Plastic Surgery Foundation.
Breast reconstruction is one step in a cancer patient’s journey, and it’s a conversation that often begins soon after a diagnosis.
A big part of this step is education, said Dr. Stephanie Koonce, a breast surgery specialist and plastic surgeon with Mercy Fort Smith.
“Breast reconstruction is something that I really feel patients should know about, because when you look at the data, particularly in rural communities, or even in communities where they just don’t have as many plastic surgeons … patients don’t always get offered breast reconstruction,” she said. “I think it is absolutely something that is every woman’s basic right to know about. It doesn’t mean every woman should have breast reconstruction. Everyone needs to know they have that choice.”
Dr. Koonce said many women don’t realize their insurance covers not just mastectomy but also follow-up breast reconstruction. The federal Women’s Health and Cancer Rights Act of 1998 requires most group insurance plans that cover mastectomies to also cover breast reconstruction. Many insurance plans will also pay for breast reconstruction after a partial mastectomy or lumpectomy.
“I’ve had patients come to me and say, ‘I’ve been saving up for five or six years and now I have enough money for a reconstruction.’ So, I think the education (about insurance) is a big deal,” Dr. Koonce said.
Breast reconstruction often takes place very soon after a mastectomy, but that is not always the case.
“When we talk about breast reconstruction, the first thing we talk about is the timing and whether or not you’re a candidate. So, you can have an immediate reconstruction or a delayed reconstruction,” Dr. Koonce said.
Immediate reconstruction, the most common option, is done at the time of the mastectomy. Delayed reconstruction can occur anytime – two days later, two weeks later or even two decades later, Dr. Koonce said.
“We try to talk to patients as soon as they get the diagnosis. It doesn’t always happen, and that’s OK, because the most important part is having the cancer taken care of,” she said. “But I’ve had patients come to me who’ve had a mastectomy 20 years before, and they say, ‘I’m tired of wearing a prothesis, I want breast reconstruction.’”
Dr. Koonce feels it’s optimal for the patient to work with the plastic surgeon at the same time she is talking to the oncologist and the general surgeon, even if she is not planning to have an immediate reconstruction, so that reconstruction can be mapped out for the future.
“Patients feel like you have to make a decision all at once, and you don’t,” she said.
Oncoplastic surgeries (combining oncology with plastic surgery) are an option for cancer patients. Doctors often can do a breast reduction when the patient wants to have a lumpectomy or radiation and not a mastectomy. Patients get a lift and a smaller breast and get the tumor taken out at the same time.
“Those patients do really well, because they get the benefit of a breast reduction and they get the tumor out. So it’s different than a mastectomy,” Dr. Koonce said.
Dr. Koonce also sees patients who are positive for a breast cancer gene and want to have pre-emptive mastectomies. The reconstruction process is much the same as it would be for a cancer patient.
“I have a fairly large number of patients who are in their 20s and 30s who are BRCA-positive,” Dr. Koonce said. “If you look at their lifetime risk of breast cancer, it’s so high that having a prophylactic mastectomy will decrease the rate of them dying from that disease.”
There are two types of reconstructions: implants and autologous, as well as a combination of the two. Implants are more common and are a quicker procedure, where the patient can return home after one day or less. Autologous reconstructions involve using the patient’s own tissue, usually from the back or stomach, and require a hospital stay of four or five days.
“The benefits of autologous is it’s your own tissue. Some women don’t want to have implants,” Dr. Koonce said. “A lot of patients like the idea of having a ‘tummy tuck’ during the procedure and want to have the autologous reconstruction.” A breast created from a patient’s tissue can be reattached to the blood supply and provide sensation, something Dr. Koonce says is a big deal.
There are patients who can’t have that type of procedure, including some who have previously had abdominal surgeries or those who don’t have enough extra tissue to use, she added. Overweight patients may not be able to have the autologous procedure because of the risk of developing a hernia afterward. If the patient is continuing on radiation therapy, autologous reconstruction may not be an option.
Nipple reconstruction is also a part of the procedure.
“It’s kind of the final bit of reconstruction,” Dr. Koonce said. The options for re-creating a nipple can involve using a portion of the breast that was noncancerous or using skin from places like the ear. Surgeons are even using tattoos created by a 3D printer to create a nipple.
Technology has made a big difference in the breast reconstruction process, Dr. Koonce said. Procedures such as fat grafting – where fat is removed from one part of the body and moved to the breast – has been a game-changer. The fat is washed and processed before being moved to the breast and helps with changes that occur because of radiation, softening and smoothing out the skin.
Implants are also better now, with “gummy bear” (gel-based) implants now available. Saline implants can also be an option, depending on the patient’s preference.
Free-flap reconstruction was also an important innovation, Dr. Koonce said. Sometimes doctors can take the nerve or sensation from the abdomen and glue it together with the nerve that provides sensation to the skin.
“That’s not something we’ve been able to do before,” she said.
Even incisions during mastectomies and breast reconstructions have changed.
“We actually do the incisions in more of a cosmetic way, so the incisions go kind of up and down or to the side now, so it really preserves the shape of the skin envelope and allows us to do a good breast reconstruction,” Dr. Koonce said.
Follow-ups to reconstruction can vary but usually involve a visit in a week, then a visit every few months, depending on the patient. The operation itself may involve more than one procedure, something that may make women a little nervous. The second procedure tends to be for making tweaks to the reconstruction or taking out a breast tissue expander.
“Breast reconstruction is a process,” Dr. Koonce said. “It’s not a one-and-done situation.”
There are very few women who wouldn’t qualify for a breast reconstruction, Dr. Koonce said. She has helped patients who are diabetic, heart-attack survivors and more.
“I’ve got a lot of tricks in my bag, and so there have not been many patients where I’ve had to say, ‘I can’t help you. There’s nothing I can do,’” she said.