Who is a candidate for breast reconstruction?
Candidacy for breast reconstruction is mostly based upon your overall health, smoking history, the nature of your breast cancer treatment, and your body shape and size:
1. Overall health. There are several forms of breast reconstruction, some more complex than others. Still, all forms of breast reconstruction require some form of surgery so it is critical that a patient undergoing breast reconstruction be healthy enough to do so. At times, reconstructions requiring shorter operative times are performed for patients with more background medical issues.
Diabetes and autoimmune diseases like rheumatoid arthritis and scleroderma can increase the risk of wound-healing problems and infections because of the nature of the disease (i.e., diabetes) or the medicines used to treat them (i.e., prednisone or anti-TNF monoclonal antibodies used to treat autoimmune disease). Clotting disorders may also increase the risk of breast reconstruction performed with flaps whereas bleeding disorders or agents used to prevent blood clots can increase the rate of post-operative bleeding with any reconstructive procedure.
2. Smoking. Several studies prove that smoking increases the chances of having problems after breast cancer removal and reconstruction. Nicotine from cigarettes constricts blood vessels so that less blood flow reaches the remaining breast skin and other tissues. This leads to higher rates of wound healing problems and infections whether you are reconstructed with an implant or your own tissues. Unfortunately, nicotine is also found in nicorette gum, chewing tobacco and nicotine patches so these alternatives to smoking are also a problem. If you smoke and need help quitting, you may wish to consider medicines like Wellbutrin or Chantix to quit before having breast reconstruction surgery.
3. Nature of your breast cancer treatment. The treatment of your breast cancer is always the first priority, and reconstruction is only performed when it will not affect your breast cancer treatment. Breast cancer treatment may include a mastectomy or a lumpectomy (partial mastectomy), chemotherapy before or after surgery, and radiation after surgery. All of these therapies, when considered in conjunction with the other factors discussed here, can affect what type of reconstruction you can have, when you can have it, and may also impact the quality of the results.
Chemotherapy can impact wound healing and is usually delayed for 6 weeks after surgery. Similarly, if chemotherapy is required before surgery, the surgery is usually delayed for about 4 to 6 weeks after chemotherapy. Some forms of chemotherapy, such as Herceptin, may affect cardiac function. Your oncologist or cardiologist is likely to monitor your heart while your are on Herceptin and may recommend delaying further reconstructive surgery until heart function has recovered, in the event that this is an issue.
Radiation therapy significantly affects the timing and, possibly, the type of breast reconstruction that is recommended. Radiation delays wound healing and can cause the skin to darken and tighten. Patients who require radiation as part of their breast cancer therapy may have more difficulty with breast implants used for reconstruction. Often, definitive reconstruction may be delayed for months after radiation and may include reconstruction using your own tissues to help replace some radiated skin.
4. Body Mass Index (BMI). The body mass index is a measurement relating your weight to your height. Patients with a BMI over 30 are considered obese on the BMI scale, 25-29.9 is overweight, 18.5-24.9 is normal, and <18.5 means you are underweight. BMI does not take muscle mass and percent body fat into account and so people with particularly athletic builds may have an artificially high BMI.
In general, however, patients with a BMI over 30 do not have as good an aesthetic result as patients with a normal BMI. Depending on how fat is distributed, patients with a BMI of up to 40 may still be candidates for microvascular free TRAM or DIEP flap breast reconstruction. A TUG flap may also be used in patients with a BMI of up to 40. A latissimus flap with an implant is probably the most reliable and aesthetic operation in patients with a BMI over 35. Implants are usually an option in these patients, as well, but may not look as natural as a latissimus flap or a TRAM or DIEP flap.
Patients with a relatively low BMI may not have enough tissue to use for a breast reconstruction and are typically best served with either a tissue expander or direct-to-implant breast reconstruction.
A BMI over 30 can be associated with an increased risk of wound healing problems, fat necrosis (development of hard lumps due to fat that has died from a lack of blood flow), infection and persistence of extra fat and skin in the armpits and flanks.
5. Previous surgical history. Previous surgery may prevent you from having certain types of breast reconstruction. A previous tummy tuck and liposuction of the abdomen prevents your surgeon from reconstructing your breasts with a TRAM, DIEP, or SIEA flap (i.e., using your abdominal tissues for a breast reconstruction). Certain abdominal scars may also prevent your surgeon from doing these operations, but not necessarily so and this needs to be evaluated on a case-by-case basis.
Previous chest surgery may prevent you from having a latissimus flap breast reconstruction and previous thigh surgery such as a thigh lift or vascular bypass surgery in the thighs may prevent you from having a TUG flap.
6. Realistic expectations. Every case of breast reconstruction is unique, and not every patient can have as aesthetic a breast reconstruction as the next person because of the factors we have mentioned. Having realistic expectations is very important to ensure that you are satisfied with your results. Examining photos of patients who look like you before surgery, who have required similar breast cancer treatments, and who underwent the same types of reconstructive operations will give you the best sense of what you can expect.