When it comes to breast reconstruction, a lot has changed over the last 20 years, particularly in terms of improved patient education about surgical options, enhanced recovery after surgery, advances in surgical techniques and now more aesthetic results. Gone are the days where “as long as you look okay in clothes” is good enough. The bar needs to be set a lot higher says Tucson, AZ plastic surgeon Raman C. Mahabir, MD. “Patients deserve to have high expectations for a symmetrical, soft, natural look. We want women who have experienced breast cancer to feel beautiful the minute they step out of the shower and see themselves the mirror.”
Increased Patient Education
Recent changes in legislation over the last decade have helped to ensure that women facing breast cancer are educated on their reconstructive options following mastectomy. Dr. Mahabir says his passion for helping breast cancer patients regain a sense of wholeness after mastectomy led him to spend time in Washington, D.C. where he was part of the team that successfully had the “Breast Cancer Patient Education Act” signed into law in 2015.
“We were able to show that on average, less than 30% of women are told that breast reconstruction is an option after mastectomy. In major cities and academic centers, these rates are higher, however, the numbers quickly drop in suburban and rural areas,” he explains. “With the new law in effect, all hospitals performing mastectomies for breast cancer, are now required to provide patients information on breast reconstruction options. Our hope is that by providing this valuable information early in a woman’s breast cancer treatment journey, that she will feel empowered to seek a board-certified plastic surgeon in her community and undergo breast reconstruction.”
Enhanced Recovery Protocols and Nerve Blocks
Recent developments in anesthesia have markedly improved the experience for breast cancer reconstruction patients. According to Dr. Mahabir, we now understand the role for treatments before, during, and after surgery to ensure a fast and comfortable recovery. The before focuses on the new “enhanced recovery after surgery or ERAS” protocols. ERAS involves minimizing the disruption in eating and drinking before surgery, giving pain medication before the patient goes to sleep to help “trick” the brain and minimizing medications during surgery. During surgery, nerve blocks using Exparel®, a specially formulated slow-release local anesthetic that lasts 3-4 days are often performed, which dramatically reduce discomfort after surgery. Dr. Mahabir adds, that by understanding and implementing these novel strategies before and during surgery, patients have improved comfort levels. “Most of our patients use nothing more than Tylenol and Ibuprofen to manage their discomfort after surgery and have minimal need for narcotics.”
Placing Implants Above the Muscle
While tissue expanders are commonly used for breast reconstruction, Dr. Mahabir says newer techniques allow for his patients to skip that part of the process. “We now place implants above the pectoralis muscle at the time of mastectomy, all in one stage. Our patients love this technique because they experience less pain and discomfort by not having their muscles altered. This way, they can avoid the process of serial tissue expansion, and it takes less steps to obtain a beautiful surgical result.”
Using a Patient’s Own Tissue
Natural tissue reconstruction techniques have also evolved over the years and offer mastectomy patients excellent long-term satisfaction without need for repeat surgeries over the course of their lifetime. “We essentially do a tummy tuck and transplant the spare skin and fat from their tummy to the chest to create a warm, soft, natural breast mound. Our patients who prefer not to have an implant or who cannot have an implant due to radiation, love this option. It’s a win-win: you get a flatter, tighter tummy and new breasts all in one operation. It is the gold standard of restorative breast surgery,” says Dr. Mahabir.
The final step in breast reconstruction involves restoration of the nipple areola complex. Three dimensional tattoos can visually recreate a nipple, areola and even the Montgomery glands (smaller bumps in the areola). It avoids another surgery, has an easy healing and recovery process and best of all, the patient is awake to provide direction on size, color and appearance. “We have recruited one of the top areola tattoo artists in the country and are grateful to have her services available to our patients so they can have their areola tattoo performed in a safe environment,” says Dr. Mahabir.
Starting a dialogue with your surgeon can be as simple as asking “Where will my implants be placed and how will my pain be managed after surgery?” Don’t be afraid to ask! Many patients either take a passenger seat to their reconstruction or are too overwhelmed with information and never broach the issue with their doctor. But by not initiating a discussion, you’re missing out on the opportunity to have a voice in choosing from the options you’ll be given.
“It’s okay to make yourself a priority. You are worth it. You deserve to love the way you look and feel!” says Dr. Mahabir.
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