Navigating Prophylactic Mastectomy & Breast Reconstruction in BC
In this session, Dr. Kathryn Isaac reviews the options for breast reconstruction following prophylactic mastectomy.
Q&A with Dr. Kathryn Isaac
How do you gauge blood flow in a potential patient?
This is done both before surgery and during the surgery. Before the surgery, scars and skin quality can indicate that there may be problems with blood flow. During the surgery, the skin blood flow is examined clinically and with a special tool which uses fluorescence to detect areas of skin that have normal blood flow (shown by normal fluorescence) and areas of skin that have poor blood flow (which do not show fluorescence
Is it possible to remove the nipple post-mastectomy and breast reconstruction?
Yes.
Have you heard of nerve grafting (or nerve-sparing reconstruction)?
Do you think this could improve feeling post mastectomy? Yes. Nerve grafting can be done for implant-based reconstruction and nerve coaptation can be done for tissue-based reconstruction. There is research to support that nerve grafting or coaptation can improve feeling of the breast skin post mastectomy and I do agree with these techniques and research. However, it does not necessarily work thus it is not always performed. If this is important to you, discuss it with your reconstructive surgeon prior to your mastectomy.
When should implants be replaced?
There is no set time interval at which point implants need to be replaced however they are not expected to last a lifetime and thus you can expect that they will need to be replaced over a lifetime. Are there signs/symptoms that indicate they should be replaced? Capsular contracture is the most common sign - this is a tight feeling or appearing breast that can also be painful. This might indicate a rupture of the implant. Thus, if you have a capsular contracture, it is recommended to have imaging to assess for implant rupture. Five to six years after implantation, it is recommended to have your implants checked with imaging, even in the absence of a capsular contracture, to assess for a rupture. MRI or ultrasound can detect a problem with the implant. Or should they be replaced within a certain timeline? They don’t need to be replaced if there is no rupture or concerns but if there is a rupture, they should be replaced. A rupture will be evident if a capsular contracture develops, or the rupture will be detected by imaging (ultrasound or MRI) if it has occurred, and you feel that the breast is otherwise normal (this is considered a silent rupture i.e.. no signs or symptoms).
Does 1st-degree relative living in another country have the right to come home for the process if she has cancer?
I am not the best person to answer this - best to check with Ministry of Health given there are many details/circumstances that may need to be considered.
Can you have reconstruction if you have had a lumpectomy and radiation in the past?
Yes - the reconstructive options may be more complex or limited - best to discuss with your surgeon.
When you mention “higher risk reconstruction surgery,” is it similar to an aesthetic plastic surgery?
I would suggest that all of the breast reconstruction surgeries and aesthetic plastic surgeries I perform are similar in terms of the potential for benefits and risks. The "higher risk reconstruction surgery" refers to the possibility of complications that require further surgery.
What is the wait time to get a prophylactic mastectomy in BC?
It is dependent on the hospital (resources available) and the surgeon (their practice type). Across BC, there is great variability ranging from 6 months to 5 years. I would suggest that if you are interested in undergoing risk reducing mastectomy and reconstruction, you meet with the general surgeon (surgical oncologist who will perform the mastectomy) and the plastic surgeon to understand your options and decide when would be the right time for you.
How long does LATS flat surgery take? TUG?
Approximate times for the following reconstructions for both breasts are Latissimus dorsi flaps 4- 6 hours; TUG: 6-10 hours: DIEP 6 -10 hours, implants 2-3 hours.
If the time came to remove implants - end of life for the implant. Can a person at that time choose to not have them replaced?
Absolutely.
With the reduction of breast cancer after a double mastectomy not being zero, should we then be getting a baseline MRI done?
What is the follow up screen protocol post-mastectomy? With a mastectomy, 95-98% of the breast tissue is removed - not 100% of all tissue and cells. Thus, it is considered risk reducing surgery, not eliminating the risk. This is true for both mastectomy alone and mastectomy with reconstruction. Given the very small risk remaining, no further screening is recommended and no subsequent baseline MRI after mastectomy. However, if there is a concern that develops, imaging is recommended.
What is the recovery like for an implant swap after 10-15 years?
it is usually a day surgery, meaning you go home that same day. It is variable but you can expect an approximate 4-6week period of time where you may be restricted from lifting, swimming, exercise.
Have you found pre-pectoral implants placement can be done without a cellular dermal matrix?
Pre pectoral reconstruction requires some form of internal support of the implant so that the breast skin is not the main source of support. Acellular dermal matrix is one form of internal support. There are other forms including animal-derived meshes and synthetic meshes which can be used. Also, in certain circumstances, when a patient is large breasted and would like to significantly reduce their breast size after mastectomy, their own skin can be altered and internalized to be used instead of a mesh.
When you have a silicone implant rupture, does the scar capsule get removed due to silicone particles that have leaked?
Yes.
Would you know if the patient moves to another province after the surgery, if they're still covered by their health plan?
Yes, they are if they move to another Canadian province. Some small adjunctive procedures for a breast reconstruction are covered in some provinces and not in others but the vast majority of reconstructive procedures are covered across Canada.
I have been waiting for reconstruction since 2017, but tissue expander has random sharp pains under it. Should this be checked with ultrasound?
I would meet with your surgeon to discuss this. If you have had a tissue expander in place since 2017, it would be best to have it assessed by your plastic surgeon.