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One in eight women will develop breast cancer. This correlates with an approxi­mately 12% average risk that a woman will develop breast cancer in their lifetime. A woman may decide to proceed with breast reconstruction in varying forms and for many different reasons. In the non-cancer setting breast reconstruction can take the form of breast augmentation, fat grafting, tissue transfers, or silicone injections. These interventions may seem indolent to the patient, but to the surgi­cal oncologist and the breast radiologist even these benign procedures can lead to challenges in future breast cancer screening.

A patient who undergoes breast augmentation will still need to undergo screening mammography in order to provide early cancer detection. For the patient with breast implants who needs to undergo routine screening mammography there are some spe­cial concerns that should be noted. Patients who have implants are often concerned that the mammogram itself will rupture them, and this is not true. What does need to be considered is that it becomes increasingly more challenging to compress the breast appropriately for the patient with breast implants and all the breast tissue may not be seen clearly. The tissue near the implant will be hard to compress and thus achieve the magnification necessary to see the calcifications or architectural distortion that may indicate an abnormality. Approximately 20% of a patient’s breast tissue may not be visualized well after breast augmentation when undergoing screening for breast cancer.

The breast cancer patient’s journey into survivorship often is felt to begin in the post-operative period. For the patient who chooses to undergo mastectomy with reconstruction that journey begins with accepting an entirely new body image; and for a woman, the loss of an organ very deeply tied into their gender identity, sexual­ity, and maternal nature. From a technical perspective long term complications after mastectomy and reconstruction include numbness to the skin of the mastectomy flaps, loss of the nipple areolar complex in many cases, post-operative pain, and lymphedema. If adjuvant radiation is required after mastectomy with reconstruction this can increase the risk of lymphedema noted as well as the previously described risks of capsular contracture and skin rippling after implant reconstruction. In general the skin sparred at time of mastectomy can become darker, thicker, and have decreased wound healing capabilities. All these aspects can be combined into a cosmetic result that is less pleasing then imagined prior. The risk of a patient’s breast cancer diagnosis necessitating adjuvant radiation should thus be broached to allow for complete disclosure, often leading to a recommendation for delayed reconstruc­tion should that risk be high.

In the post-operative period there also remains a risk that the patient will develop a wound infection or wound dehiscence, leading to implant removal for those patients who chose to undergo an implant based reconstruction. For the patient who under­goes a nipple sparing mastectomy there is a noted risk of loss of the nipple areolar complex. The mastectomy flaps themselves are at risk of ischemia and thus tissue loss that may require debridement, skin grafting, or other procedures not excluding removal of the implant to allow for wound closure and another attempt at delayed reconstruction. In the patient who undergoes autologous tissue transfer reconstruc­tion, as noted prior, the wound related challenges discussed also apply to the site of tissue harvest. If abdominal muscle is taken at time of autologous tissue transfer this infers an associated risk of abdominal wall hernia formation that should be taken into consideration.

In the peri-operative to immediately post-operative period after autologous tissue reconstruction there is a risk that the whole tissue graft will be lost should a post­operative complication occur, such as venous outflow obstruction or arterial occlu­sion. In certain settings leeches can be and have been applied to the reconstructed breast flap in an attempt to alleviate venous congestion and preserve graft function. This would be quite a troubling and unexpected event to the patient who is unaware that this is a potential outcome. In the setting of autologous tissue transfer reconstruc­tion it can be also noted that areas of fat necrosis can develop that can be quite large and concerning. Tissue contracture may occur to a degree that necessitates fat graft­ing or other surgical approaches to filling the defect that remains. Multiple procedures may be necessary to achieve the final outcome desired and close clinical follow up is often required during this period to ensure optimal outcomes and that a recurrent cancer does not develop.

The journey for the patient with a breast related concern or breast cancer that includes breast reconstruction is one that is delicate to navigate. The path forward must be directed by that individual as it is a very personal one. Though they may have many care givers, family members, and/or friends who are full of opinions, only the individual involved can even begin to fathom how the outcome will affect them emotionally and physically. It is the job of the physician to discuss as clearly as possible all the options available to the patient and all the potential risks and benefits of the paths they might choose. They must establish clear expectations as to what the pre and post-operative outcomes may look like. It is also important that the physician and institution of which they are apart work to provide all the resources that a patient may need to face all aspects of their care, even if it is simply additional time to process all that is happening.

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Chapter 3