Who Is a Candidate?
Many factors play a role in determining whether a patient is a good candidate for breast reconstruction. These factors are discussed below.
Because all types of breast reconstruction require some form of surgery, it’s critical for patients to be healthy enough to undergo an operation. For patients with diabetes and autoimmune diseases like rheumatoid arthritis and scleroderma, the risk of wound healing problems and infections is higher because of the nature of the disease or the medicines used to treat them. Clotting disorders may increase the risk of breast reconstruction performed with flaps. And bleeding disorders or agents used to prevent blood clots can increase the rate of postoperative bleeding with any reconstructive procedure.
Several studies have shown that smoking increases the chance of having problems after breast cancer removal and reconstruction. Nicotine from cigarettes constricts blood vessels, causing less blood to flow to remaining breast skin and tissue. This leads to higher rates of wound healing problems and infections, whether reconstruction involves an implant or a woman’s own tissue. Smoking alternatives like nicotine gum and patches – as well as chewing tobacco – also contain nicotine and cause similar problems as smoking. Patients who smoke and need help quitting may want try using prescription medicines like Wellbutrin or Chantix before having breast reconstruction surgery.
Nature of Your Breast Cancer Treatment
Treating breast cancer is always the first priority. Reconstruction is only performed when it will not affect treatment. Breast cancer treatment may include:
- Mastectomy or lumpectomy
- Chemotherapy before or after surgery
- Radiation therapy after surgery
All of these therapies can affect what type of reconstruction patients can have, when they can have it and possibly the quality of the results.
Chemotherapy, which can impact wound healing, usually is delayed for six weeks after surgery. Similarly, if chemotherapy is required before surgery, the surgery is usually delayed for about four to six weeks after chemotherapy. Some types of chemotherapy, such as Herceptin, may affect heart function. An oncologist or cardiologist is likely to monitor a woman’s heart while she is on Herceptin and may recommend delaying further reconstructive surgery until heart function has recovered, if 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 the use of a patient’s own tissue to help replace some affected skin.
Body Mass Index (BMI)
Body mass index is a measurement relating a person’s weight to his or her height. Patients with a BMI over 30 are considered obese on the BMI scale. A score of 25 to 29.9 is overweight, 18.5 to 24.9 is normal, and 18.5 or less is underweight. BMI does not take a person’s muscle mass or percentage of body fat into account. People with particularly athletic builds may have an artificially high BMI. (Click here to calculate your BMI.)
In general, patients with a BMI over 30 do not have as good a 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 breast reconstruction using certain flaps (a piece of tissue taken from another part of the body), including TRAM and DIEP flaps. 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 operation in patients with a BMI over 35. Implants are usually an option in these patients as well, though they may not look as natural as reconstruction involving a flap.
Patients with a relatively low BMI may not have enough tissue to use for breast reconstruction. The use of tissue expanders and implants or implants alone usually is recommended with these patients.
A BMI over 30 can be associated with an increased risk of wound healing problems, fat necrosis (the development of hard lumps from fat that has died from a lack of blood flow), infection and the persistence of extra fat and skin in the armpits and flanks.
Click here for a chart that rates reconstruction options for women with various BMI ranges.
Previous Surgical History
Previous surgery may prevent a patient from having certain types of breast reconstruction, particularly those involving flaps. This includes a previous tummy tuck, liposuction of the abdomen, abdominal scars, previous chest surgery or previous thigh surgery (such as a thigh lift or vascular bypass surgery). Surgeons will determine whether these previous surgeries will affect a patient on a case-by-case basis.
Every case of breast reconstruction is unique, and all patients will not have the same outcomes because of the factors mentioned above. Having realistic expectations is very important. Patients may want to examine photos of women with a similar appearance before surgery who have undergone similar breast cancer treatments to get a good sense of what to expect from their reconstruction options.