New procedure eases pain of breast reconstruction after mastectomy

Nurse anesthetist Shari Frontz works with breast cancer patients and hoped she'd never become one herself. "I watch breast cancer surgery all the time. I didn’t want to be on the other side of the table."

But when her fear became a reality after a mammogram last fall, Frontz focused on figuring out where to get the best treatment and how to look and feel her best after a mastectomy to remove the cancer. The Columbia, South Carolina, nurse zeroed in on Hollings Cancer Center at the Medical University of South Carolina, and came across something that surprised her. 

It was pre-pectoral breast reconstruction, a new way to rebuild the breasts of women who have mastectomies. A surgeon puts the implant over the pectoral muscle instead of under it. Doctors say it's less painful and gets more natural-looking results than sub-pectoral reconstruction. It can be done immediately after a mastectomy, or, if the woman would prefer to wait, she can have the implants added later.

"As far as I know, and I’ve been a nurse anesthetist for 10 years, I've never seen this procedure," Frontz said. "I said, 'This is what I want to do if I’m a candidate. Have one surgery and be done.'"

Pre-pectoral breast reconstruction has only been available in the U.S. for a few years, and it's still only done at select hospitals. MUSC Health is one of the first sites in the state to offer it. Plastic surgeons Kevin Delaney and Jason Ulm specialize in the procedure.

Basically, it’s an option for almost anyone who is getting a mastectomy," Delaney said. "Most commonly that’s breast cancer, but it's also for women who are getting prophylactic mastectomies, if they have the BRCA gene, for example." BRCA genes raise the risk of breast cancer, and a mastectomy can reduce that risk. 

Pre-pectoral breast reconstruction is also for women who have had sub-pectoral breast reconstruction and are having problems with their implants, including capsular contracture, which means the body has formed a hard shell around the implant. Sub-pectoral implants can also, in some cases, lead to a feeling of tightness and discomfort, and they may not move as naturally as the women would like. 

Ulm said the procedure can make a dramatic difference in those cases. "If everything goes as planned, the feel and shape and the way the breast looks are much improved. Much better."

However, Delaney said, pre-pectoral breast reconstruction is not safe for women who have had radiation because their blood flow is different and they have an increased risk of complications.

Frontz knew the question of whether she would need radiation would impact her options. She got her answer after breast cancer surgeon Nancy DeMore removed sentinel nodes to see if the cancer had spread beyond her primary tumor. The test came back negative. "I didn't need radiation therapy."

She had her mastectomy and reconstruction in November, about a month after her diagnosis. Two months later, she's recovering – and pleased. "I think the results look amazing. I’m very happy with the results."

Delaney and Ulm described how they get those results for Frontz and other women.

First, they said they have the right equipment. "We have all the tools to help us do it successfully," Ulm said. That includes a machine that does an angiogram during the procedure, giving the surgeons a real-time look at how blood is flowing to the skin. That helps them make decisions as they operate, reducing the risk of complications.

They also have a process they feel confident about. Delaney said their role during surgery begins after the mastectomy is complete. "At the same surgery, typically we’ll either put in an implant or a tissue expander," Delaney said. "A tissue expander is like a spacer. It’s inflatable with saline or air," he said. 

The implant or expander goes into a pocket made from a dermal matrix, which is specially-prepared tissue from donated skin, and carefully attached to the chest wall. "The blood vessels from your body grow into it," Delaney said.  "Within several months, it’s actually like a living, breathing part of you."

Ulm said placing the implant over the chest muscle instead of under means it's more flexible because it's closer to the skin. "Putting it above the muscle can relieve some of the tightness they may feel. You also have decreased animation, which is movement of the breast when they're doing activities."

And since the surgeon doesn't have to cut the chest muscle, there's much less pain and restriction of movement.

But Ulm said patients should keep in mind that they will probably need more procedures after the surgery. Because the implant is closer to the surface of the skin than it would be if it were under the muscle, the doctors often need to add fat taken from elsewhere in the woman's body to create a thicker layer between the implant and the skin's surface. 

Both he and Delaney said it's well worth it, calling the procedure part of a larger shift in their approach to breast reconstruction. "We already offer the most complex reconstruction, with DIEP and microsurgery," Ulm said. "This is the other end of the spectrum as far as implant reconstruction goes. It's the way most reconstructions are going to go in the future."

Delaney called it a paradigm shift, and Frontz agreed. "I don’t think people know about it," the nurse said. "I think I got the best of what’s possible, and I didn't need to go out of state to get it."