Patience is key in Covid-era breast reconstruction

During the Covid pandemic, it is prudent for patients newly diagnosed with breast cancer to focus their priorities. Oncologic treatment is primary whether this means oncologic surgery, chemotherapy and/or radiation therapy. Reconstructive treatment can wait, and it can wait a long time, says Constance M. Chen, M.D.

A diagnosis of breast cancer is overwhelming at any time. But what does it mean for women who were diagnosed during the Covid pandemic and how does it affect decisions about post-mastectomy breast reconstruction?

For starters, the fundamentals of cancer treatment remain the same. Patients need to work with their oncologists to decide upon the best course of therapy. Women should fortify themselves with good nutrition and exercise and pay attention to their mental health. Masks and social distancing are essential to avoid complicating treatment. Once the basics are addressed, breast cancer patients should know that post-mastectomy breast reconstruction can be delayed without compromising the final aesthetic outcome.

The paramount goal of breast cancer treatment is to prolong and maintain quality of life, and women need to remember this during the Covid pandemic. And while treatment options may vary depending on the aggressiveness of a tumor, some basic facts remain the same. Oncologic treatments such as ablative surgery, chemotherapy and radiation therapy should take precedence over reconstructive treatment. Furthermore, a delayed breast reconstruction can be just as good as an immediate breast reconstruction as long as there is teamwork and thoughtful planning between the oncologic surgeon and the reconstructive surgeon.

During the Covid pandemic, many women may decide to delay breast reconstruction, because hospital resources may be more limited. Furthermore, delaying breast reconstruction minimizes anesthesia time and recovery after the oncologic procedure, which curtails challenges to the immune system. By diminishing trauma to the body from surgery, the potential for postoperative complications such as infections and wound healing problems is also decreased, which reduces the subsequent need for frequent in-person postoperative visits — important during a pandemic.

For patients who want immediate breast reconstruction, they should recognize the risks and benefits of the different types of breast reconstruction. In the short term, tissue expander and implant-based surgery is a quicker and easier operation for a healthy patient, but some patients may suffer long-term negative reactions to the foreign body. In the long term, natural tissue breast reconstruction integrates best with the body, but the bigger operation may be a harder recovery in the short term. For high-risk patients — such as those with nicotine exposure, diabetes, a BMI (Body Mass Index) greater than 30, history of radiation therapy or other medical comorbidities — the safest course may be simply to delay reconstruction to reduce the risk of infection and wound-healing problems.

Whether breast reconstruction is delayed or immediate, most patients want their new breasts to look and feel as much as possible like normal, living breasts. The gold standard in breast reconstruction is nipple-sparing mastectomy and natural tissue breast reconstruction, which gives a patient soft, warm breasts that grow and shrink as she gains and loses weight. With careful planning, this can be accomplished even with a delayed breast reconstruction. A woman does not need to compromise on her ultimate breast reconstruction if she and her plastic surgeon can persuade her oncologic breast surgeon to perform a nipple-sparing mastectomy, no matter how large her breasts.

A nipple-sparing mastectomy sets up a patient to achieve the ultimate breast reconstruction. In a nipple-sparing mastectomy, the breast surgeon needs to make sure that she does not remove any breast skin and all the skin is left intact as if there is going to be an immediate breast reconstruction. If she cannot salvage the nipple for oncologic reasons, she can resect the nipple-areola complex alone and close it with a purse-string closure. This preserves the entire breast skin and creates the framework for a normal breast shape. This may be challenging for some breast surgeons to accept, because they will be focused understandably on the immediate postoperative appearance of a flat chest with empty excess skin and may worry that the breast skin will look deformed until the delayed breast reconstruction. It is vital to accept the temporary wrinkled appearance of the breasts, however, to ensure enough skin during the ultimate delayed breast reconstruction. Even in large-breasted women, the breast skin will retract during the time between mastectomy and reconstruction, and it is always possible to resect excess breast skin later if necessary. However, skin that has been resected at the time of mastectomy can never be replaced.

There is no limit to how long to delay the ultimate breast reconstruction, but patients should heal completely from the initial mastectomy because tissues can be friable and delicate in the immediate postoperative period. For a delayed breast reconstruction, it is best to wait at least three months to allow the body to fully recover from the first oncologic surgery, but longer periods are perfectly acceptable and even preferable as the extra time only gives the body a chance to heal more fully. In addition, by undergoing oncologic and reconstructive surgery in stages, patients can confirm clear margins prior to breast reconstruction. For patients who need radiation therapy, breast reconstruction should be delayed at least 6 months after radiation is completed. By delaying reconstruction, patients give their body a break. Risk of recurrence of the primary tumor is highest in the first 18 months after treatment, so some patients may wait one to two years or even later to go back to the operating room for breast reconstruction. No matter how long the wait, it is crucial to complete oncologic treatment first and then allow the body to recover fully from the essential oncologic treatment.

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