Topic: Lift/Reduction to radiated breast?

Native Mainer,

I sympathize w/you.  I am glad I found an Onc. the first time around who I felt comfortable with (he was a Dana Farber prior) and my Rad Onc in NH works in Dover and Boston and was great along w/the rad team.  They even gave me a graduation diploma!  They let my daughter come in and watch what goes on w/rads.  I think w/the recon I will have to look at a variety of Docs to find the best one.  I am thinking that it may not be for a while before I do surgery.  July will be 1 year out from rads.  I might wait a little longer to really do some research on PS's.  Let me know if you find one that rocks!

C

Wow.............as  a frind of mine said.............did you ever think you'd be having this discussion making these decisions(like amputating body parts) 2 or 3 yrs ago......the answer is NO WAY!.  My seroma is right in the middel side of the breats...almost unavioidable.......I'll discuss the cosmetic issues w/ the PS monday.................yeah the thought of a hot/heavy boyfriend mortifies me but............what are ya gonna do?  I still know eventually it will look beter than ever...just wanna get over the current seroma/infection/DIScomfort!  and I WILL!

goodnight!

I'd heard about gradation certificates when someone got done rads.  All I got  at my last rad treatment was "See you tomorrow." They called me a couple days later to tell me I was supposed to see the rad doc and get a follow up appointment before I left that day.  Like I had any idea I needed to ask for those things that day. . . .

Jane - you sound really organized and that is good - let us all know how things go tomorrow.  I have the airconditioner on at home - I hate to do it because of the expense and the environment - but I really cannot tolerate the heat.

 My breast surgeon suggested I wait at least 6 monthsafter completing rads to consult the PS.  I waited 9 and then began the process.  It can be slow.   So I am very glad to have waited 18 months post before actually going through with the surgery...I can't imagine how the healing would have progressed if I had done this any sooner. 

My radiated breast continues to feel 'weird' as compared with the other.  I am just planning on getting used to it, because I think it will always feel different.

How is everyone else doing?????

Ok, sooooo!  what a long and fruitful day!

I started w/ a quick drive by my (now) new LE therapist to buy a comfortable bra since that has become an oxymoron.  I met a woman w/ severe lymphedema who had complaete axillary dissection(and all were negative) about 20 yrs ago...shewas a sort of pioneer for tram..and had unilateral.  We chatted a bit and she was very sweet and honest...and still is a believer that the treatment is NOT worse than the cure......

I bought another bra, only 60 and no major irritation at the incredibly sensitive axilla/lateral L lumpectomy scar....Then onward to my local PS appt.

I had e-mailed him last pm a brief...(I know hard to believe I could be capable of such!) description of when we met....last oct.....I wrote  great e-mail and listed, bulleted my points/questions.......When I checked e-mail this am he had written me back...he earned big points...I also thanked him in person and explained I knew histime(as well as mine) was valuable so I was trying to be as organized as possible.

I REALLY like this guy/surgeon.....but I'd rather be his pt in about 10 yrs....when he has more under his belt.  He easily signed the RX the LE therapist had written out for me just an hour or 2 before I saw him........I can't see my BS(and they're colleagues from fellowship at MD anderson together) for a couple weeks and the nurse practitioner wouldn't write for the LE therapy...and on and on.  Bottom line...he's only done about 50 DIEPs and I did address the entire issue I'm having w/ privacy....being naked w/ the people I work w/ every day.....He said all the right thingss.......just the pics I was shown of his work aren't what I need them to be...................sooooo, onward!  I want to keep him in my refernece book and will but more than likely he won't be my recon surgeon.

Meanwhile I had an e-mail back from NOLA and I will have consult for  bilat mastect on august 3rd......and they'll go ahead and schedule(w/ no pressure...I am not obligated) for mid late sept.

General consensus was surgery/recon at leats 6 mos post rads.  I did hear from local PS that the venous return on the L is usually smaller and presents more problems........good to know esp sinc I had L lumpect/rads....apparently just a common anatomical issue.

The appt w/ the LE therapist was the best.  My swelling/feelings of fullness in the L arm/axilla, and pitting edema in the L breast are real as confirmed....but the difference is 1-3%. The plan is to get into CLD, MLD, etc, etc...and the fact that this girl is a PT...she 'll help/guide me w/ workouts which have been a ,major issue.  I have 3 days/wk the next few days.....I'll have to get back but am very positive and encouraged!

better stop for now....sweet dreams all!

jjd  

Reconstructing the Radiated Breast

by Jane Petro, MD

This type of surgery includes all of the pitfalls of any breast procedure

With the promise of maintaining breast integrity, women are opting more frequently for breast-conservation therapy rather than mastectomy in early-stage breast cancer.

Lumpectomy, combined with postoperative radiation therapy, offers the possibility of a simultaneous cancer cure, low local recurrence rates, and maintenance of body image.

In reality, the appearance of the breast after this treatment may be unsatisfactory, due to a number of factors. Lumpectomy may deform the breast, leaving unsightly and poorly planned scars in the upper visible quadrant. Scars from port placement for chemotherapy are often midway between the clavicle and the breast. Resection of lower-quadrant tumors may deform the nipple location, increasing the appearance of breast asymmetry.

Radiation may cause soft-tissue contraction, skin discoloration, and scar-related exaggerated deformity. Reconstruction with an implant has one of the highest complication rates, severely affecting the result due to radiation. Reconstruction with well-vascularized flap tissue, such as a TRAM, is not immune to radiation damage, either. Women disappointed by their result then seek consultation regarding options for achieving a more aesthetically satisfactory result.

Thus, the cosmetic breast surgeon may be faced with a patient requesting correction of the changes seen in the breast after treatment for breast cancer. Whereas many of these patients will have such surgery covered as a reconstructive procedure, the patient may instead decide to seek cosmetic treatment. An understanding of radiation tissue effects is, therefore, important for any surgeon performing cosmetic breast surgery.

Surgery of the irradiated breast includes all of the pitfalls of any breast procedure, including scarring, nipple malposition, contracture, infection, postoperative pain, and the additional hazards related to unpredictable healing in radiated tissue.

SIGNIFICANT ISSUES

Although radiation techniques developed over the last 20 years have reduced the incidence of significant skin burning, ulceration, and wound breakdown, the long-term effects of radiation on skin and soft tissue, including fibroblast proliferation and other aspects of wound healing, are still significant.

Our understanding of the long-term effects of radiation is still evolving, and many traditional theories of tissue response are challenged by a new understanding of scarring, healing, oxygenation, and fibrosis.

Ross Rudolph, MD, a cosmetic surgeon based in La Jolla, Calif, has over the years contributed enormously to our understanding of the biology of radiated tissues. He has postulated that the chief culprits of impaired healing in radiated tissues, rather than resulting simply from impaired microcirculation, are the result of tension in the surgical wound, long-term cellular impairment in proliferation, and cellular nutrition.¹

Newer radiation technology, such as Intensity Modulated Radiation Therapy (IMRT), with its ability to conform and homogenize the dose within the target area, minimizes "hot spots" or excess dose in tissue that likely leads to some of the more cosmetically unappealing effects a cosmetic surgeon encounters.

Constant communication with and education of radiation oncologists is of utmost importance. Working with a radiation oncologist experienced in immediately reconstructed breasts benefits not only cosmetic outcomes but also cancer control. Paying attention to host factors (diabetes, smoking, etc), cancer factors (margin status and location, lymphvascular invasion, skin involvement), and surgical factors (pedicle blood supply, etc) are critical.

Undoubtedly, there have been cases of a radiation oncologist delivering 6,000 cGy or more to certain areas where 4,500 cGy or 5,000 cGy could have sufficed. Delivering appropriate doses to the tissues at greatest risk for recurrence-while protecting the pedicle's blood supply and skin from excess dose-can often be accomplished with IMRT and careful clinical and dosimetric planning.

Recently, Peerbeck and his coauthors, working at the Karolinska Institute in Sweden, completed a prospective study of the radiated breast, evaluating the microcirculation of the skin and breast parencyhma at 1, 3, and 5 years following conservation surgery and radiation. They found a statistically insignificant difference between the radiated and the contralateral breast.²

Individual reactions to radiation therapy include early and late responses. Severe skin burning during treatment and late fibrotic effects on soft tissue do not correlate.³ Because of this, surgeons have had difficulty predicting how well any patient will respond to surgery in a previously radiated bed.

Whereas groups have documented the effects of radiation on implant and flap reconstruction,^4,5 there is little clinical literature available that covers reconstruction of the previously radiated breast.

Spear has noted, "Radiation of any type did affect aesthetic appearance, symmetry, contracture, and hyperpigmentation." His recommendation that reconstruction be delayed, if radiation therapy is indicated, contrasts with today's emphasis on immediate reconstruction.

THE PROMISE OF STEM CELLS

An exciting new development, not yet ready for routine clinical application, is the use of adult stem cells. Rigotti and his group have reported significant improvement in clinical situations, including frank ulceration, as well an impending implant extrusion, capsular contracture, and scarring contracture, by the use of stem cells extracted from remote-site liposuction aspirate.

The extraction process is tedious and occurs over several days. This preliminary study implies a reversal of the deleterious effects of radiation, and promises to facilitate cosmetic rehabilitation of the injured breast.

My practice includes a group of dedicated oncologic breast surgeons and plastic surgeons who provide an oncoplastic approach to breast cancer treatment.

Ninety percent of mastectomy patients undergo immediate reconstruction, and 50% of lumpectomy patients have an oncoplastic approach to their resection, including, when necessary, contralateral symmetry procedures.

When the excision site of breast cancer is closed with breast reduction-type rotation of tissues, as in reduction mammoplasty, I have seen few immediate complications and no late radiation complications. My study is in its fourth year and involves a large series (to be reported in the future).

Newer radiation technology, which includes dose planning by a radiation oncologist who should be experienced in immediately reconstructed breasts, has reduced the complications that have plagued immediate reconstruction in the past.

The use of the pedicle tissue techniques to fill the defect-rather than simply pulling tissues together or allowing a seroma to form, as some surgeons have suggested-also improves results.

An excellent review of the oncoplastic options for the primary treatment of breast cancer is summarized by Choi and colleagues.⁷

In addition, patients request revisions of their surgery after treatment elsewhere. In analyzing these patients, it is important to evaluate their complaints and wishes regarding both the target (radiated) breast and the contralateral breast.

The history taken includes a detailed review of the surgery, radiation, and chemotherapy received to date, an oncologic evaluation for metastatic disease, and (if necessary) mammography and/or MRI of both breasts.

Patient requests range from reduction of the contralateral breast only or scar revisions, to augmentation or complete reconstruction of the irradiated breast.

CONCLUSION

Even minor scar revisions on the radiated breast require an extra amount of attention to patient expectations and care in execution.

Assessment of the scar site may indicate available tissue for filling defects locally that, at the time of surgery, are not as compliant as anticipated. Wound-healing problems are associated with radiated tissues seems a reasonable assumption.

When planning a surgical procedure on a previously irradiated breast, be sure to consider the full range of options, educate the patient completely about the risks, and do not expect a perfect result.

Edited to add:

REFERENCES

1. Rudolph R. The effects of radiation on neovascularization. Plast Reconstr Surg. 1996;98(1):136-139.
2. Perbeck LC, Celebioglu F, Danielssen R, Bone, et al, Circulation in the breast after radiation and conservation surgery. European Journal of Surgery 2001;167:496-500.
3. Lopez E. Guerrero R, Nunez MI, et al. Early and late skin reactions to radiotherapy for breast cancer and their correlation with radiation-induced DNA damage in lymphocytes. Breast Cancer Res. 2005;7(5):R690-8.
4. Spear SL, Ducic I, Low M, Cuoco F. The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications. Plast Reconstr Surg. 2005;115(1):84-95.
5. Spear SL, Onyewu C. Staged breast reconstruction with saline-filled implants in the irradiated breast: Recent trends and therapeutic implications. Plast Reconstr Surg. 2005;105(3):930-942.
6. Rigotti G, Marchi A, Galie M, et al. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: A healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg. 2007;118:1409-1422.
7. Choi JY, Alderman AK, Newman LA. Aesthetic and reconstruction considerations in oncologic breast surgery. J Am Col Surg. 2006;202(6):943-952.

Hi Betsy and NativeMainer- I have known Tom since 1984.  I am godmother to one of his daughters.  I'm sorry Mainer that you didn't have a good experience with his group.  I work in a hospital and my former partner is an MD and I know very well that people can be very different in their work personas and their 'real selves'....

Mainer - I live in Los Angeles and all my care has been local.   Tom Openshaw is a personal friend....

My surgery was Tuesday and I seem to be healing well. The drain came out yesterday and I've even taken my first shower!  I ended up having the lift/reduction only on the unaffected side. My PS left the rad side alone accept for making a small incision in order to move up the nipple a bit . So far I have no complaints except my left arm /shoulder is really sore (side of the lift). Is this common or did something strange happen to it during surgery? I know there was quite a debate before surgery on where to put the IV so it wouldn't be in the way.My neck and toes were discussed but finally the PS said just put it in my left arm. I wonder if they kept my arm in a weird position so it wouldn't be in the way.

Thanks for asking. I had my surgery done at St. Joseph's Hospital, Nashua NH. My PS (Chatson) practices in NH and Mass and was listed in NH magazine as one of the best doctors for Plastic Surgery. My shoulder/arm still a bit sore. Is this normal? Under my arm is sore. The PS did say he removed some tissue from the side so maybe that is what I am feeling.My radiated side appears to be healing. I should mention I am 1 1/2 years out from rads. I had to wait since I had breast lymphodema from Rads and anitestrogens. Now that I am off all meds (can't take them) the swelling has finally subsided.

 I have to say they look good.

 May 07 had  tumor surgery, 2 surgeries later wound up with partial mastectomy and finished radiation Aug. 07. In March 08 I had a mastopexy to radiated breast..It was only particially successful due to the rad. tissue.It took 7 months to heal and was an ordeal. In Sept 09 I am having a modified TRAM, muscle sparing,  and they will remove all the old rad tissue and put all new there. I don't see it as losing anything, I see it as gaining something. My rad. breast is hard, sometimes painful, sometimes itchy and has some scarring and half is missing. I am looking forward to having it all removed and new tummy tissue placed there and my breast skin and nipple over that. Good as new. and tummy tuck besides. Rad. tissue is a PS nightmere, get rid of it.  

 I am happy to hear you are doing so well Holly. I am not seeing a big difference between my 2 sides but very little was done to the rad side.

 I am surprised you had the same chemo as me with no lymph node involvement. Was it because you are triple negative? My margins are a bit too close in my chest (local mets) so it was a given for me. I hope you continue to experience great healing.

  Same to you Holly. Today was my 2 week checkup. Everything looks great. I was told I am healing so well that minimal scarring will likely occur. lol, I was offered a scar reduction program. Between the huge lumpectomy scar running down the middle of my chest, and a port scar, I can't say I am all that worried about a few more scars showing. I am just happy to be the same size and height on both sides again.

I think since my scar really does sit in the middle of my chest it really can't be removed. I never had a breast lump. I had a lump show up in my chest which really confused the diagnosis.

As anyone have there implants put under the chest muscle?