New Option After Mastectomy

Before Deborah Cohan had a double mastectomy and breast reconstruction five years ago, her plastic surgeon explained that he would “create a little pocket” behind her chest muscle and “slip the implant in.”

Her doctor glossed over the part of the procedure in which the large pectoralis major muscles are detached from some underlying ribs, pulled off the chest wall, then stretched out for several months to accommodate breast implants. The process can weaken the muscle and left Cohan, an obstetrician, with chronic pain that made it difficult for her to work at a computer, let alone deliver babies.

She had tingling and numbness when she raised her arms and was too weak to open a jar or a heavy door.

“I had all these symptoms, and I couldn’t figure out how they were related, but I knew they started after my reconstruction,” said Cohan, 49, of Berkeley, California. Like many cancer survivors, however, she was reluctant to complain. “You’re so happy just not to have cancer, and feel like you should be grateful you’re alive — not complaining to your doctor that your chest doesn’t feel good.”

But in April, Cohan had the reconstruction redone, this time with the implants placed on top of the pectoralis major muscles instead of underneath them.

Cohan is still recovering but, she said, “my chest wall pain is gone. And in my first conscious moment after surgery, I took the deepest inhalation I had taken in 4 1/2 years.”

Placing breast implants under the chest muscle, a procedure called post-pectoralis or sub-muscular placement, has been the standard approach to implant breast reconstruction for decades. But now some surgeons are placing the implants on top of the muscle, in an effort to reduce complications like pain, weakness and breast deformities that can occur with sub-muscular implants when the chest muscles are flexed.

The alternative approach is made possible in large part by the use of biological mesh products — called acellular dermal matrices — that can substitute for muscle to cover, protect and support breast implants, said Dr. Hani Sbitany, an associate professor of plastic and reconstructive surgery at the University of California, San Francisco. Sbitany is also a consultant for Allergan, a manufacturer of the mesh products.

Doctors started placing implants under the pectoralis muscles in the 1970s because women were developing infections, painful scarring and other serious complications when the implant was placed under the skin. The muscle supported the implant, reducing those complications but introducing new ones.

Sbitany said that since he started talking about the new option, known as prepectoral breast reconstruction, he has been besieged by patients who have had submuscular implants for five, 10 or 15 years and want the reconstruction done over. Artificial breast implants are the most common method of breast reconstruction after mastectomy.

When patients want them replaced, Sbitany said, he removes the implants, places the pectoralis major muscle back where it used to be and inserts new implants on top of the muscle, using biological mesh to support them under the skin.

“There is no question that putting the implant below the muscle causes increased rates of pain and chronic discomfort with any physical activity — not in every woman, but in a consistent number of patients,” said Sbitany, who operated on Cohan this year. He is the author of a new study, to be published in the journal Plastic and Reconstructive Surgery early next year, looking at outcomes for women who had prepectoral breast reconstruction followed by radiation therapy.

One downside of the new procedure is the high cost of acellular dermal matrix products, which may not be covered by insurance. One doctor estimated the extra material needed to do the new implant could double the cost of the reconstruction surgery.

Sbitany acknowledged the material can be costly, but noted that the new reconstruction method can be done in one operation, at the same time as the mastectomy, instead of dragging out for months and requiring a second surgery. Patients are often able to manage with much less pain medication, he said.

Another concern about the new approach is that women who need treatment with radiation therapy could potentially experience more infections and other complications since the implants are closer to the skin.

“Radiation and reconstruction are not good friends,” noted Dr. Marisa Weiss, a radiation oncologist who founded the website breastcancer.org. Overall, 1 in 3 women who have breast reconstruction after mastectomy experience a complication within the next two years.

In his new study, to be published early next year, Sbitany examined the outcomes of his own patients, including a small number who had radiation. He found no real difference in complication rates after radiation, regardless of whether the implant was placed above or below the muscle, though women who had implants placed above the muscle had a slightly higher rate of infection.

Still, there is limited research on prepectoral implant reconstruction or how women do long term. Many surgeons are not familiar with the technique and have not adopted it in their practice. “There will be less pain in general with a prepectoral implant, but you can’t say they won’t have any chronic pain, because sometimes that’s from the mastectomy itself, not the implant,” said Dr. Deanna J. Attai, a breast surgeon and assistant clinical professor at the David Geffen School of Medicine at the University of California, Los Angeles.

“But if you don’t have to go through the tissue expander process” to stretch the muscle “and can go straight to implant — that’s a definite improvement.” Still, she noted, “it’s not an option for everyone.”

Weiss agreed. “The selection of the patient is critical here,” she said. The ideal candidates are nonsmokers who are otherwise healthy and opting for small implants, which weigh less than large ones.

Cohan said it’s important for women to know all the options that are available. “Women who want reconstruction should have as many choices as possible, and there should be truly informed consent, so we know what we’re getting ourselves into,” she said.