ACTION PLAN : BREAST RECONSTRUCTION

What is breast reconstruction?
Breast reconstruction is a non-cosmetic type of breast surgery for women who have had a disfigurement from infection, trauma or most commonly from procedures like a lumpectomy or mastectomy. Breast reconstruction surgery can rebuild the breast mound, nipple and areola, as needed, usually over a period of time and a series of separate procedures. 

Can all women have breast reconstruction?
Most women who have had part or all of a breast removed are able to have breast reconstruction. There are a variety of reconstructive options and you may not be a candidate for all types. You and your plastic surgeon will discuss which type of breast reconstruction is best for you.

Is breast reconstruction part of treatment?
No, breast reconstruction is not medically necessary. Breast reconstruction does not prevent, remove or treat any form of breast cancer in any way. Cancer treatments including lumpectomy, mastectomy, chemotherapy, radiation and hormone therapy are designed to delay, prevent or remove breast cancer cells. Reconstruction is a separate procedure to rebuild a breast after a lumpectomy or mastectomy.

Breast reconstruction is an elective procedure, so you can choose to have it done or not. Breast reconstruction is a very personal process and not everyone in your support group may agree with your actions. Breast reconstruction is not for everyone. Don’t feel pressured by outside influences to undergo a reconstruction if you do not wish to. Ultimately, you are the person who will have to live with your decisions.

Is breast reconstruction a covered benefit?
Yes, federal law requires insurance plans to pay for breast reconstruction whenever the patient decides to undergo the procedures.

Who will perform my breast reconstruction?
Breast reconstruction is done by a plastic surgeon who is a member of a large breast cancer team. Other team members include doctors and nurses from many different departments including primary care, general surgery, radiology, anesthesiology, oncology and radiation oncology. The timing and the type of reconstruction you have may be significantly influenced by treatments from any one of these team members or your current medical and social situations. Your cancer treatment(s) will take priority over reconstruction.
 
When do I see a plastic surgeon?
You can see a plastic surgeon at any time after your breast cancer diagnosis. You do not need to have made a decision about whether or not to have breast reconstruction before you see a plastic surgeon. Your surgeon will help you make that decision.

What are the non-surgical options to breast reconstruction?
Many women decide that they do not want to undergo any further surgeries after a mastectomy and may choose to "go flat" or wear a prosthesis.

What is a breast prosthesis?
A prosthesis is an artificial breast form that fits in a bra cup to give you the appearance of a natural breast under your clothing. There is no breast present when clothing is removed. Many women find wearing a prosthesis an effective and suitable long-term choice. You can always decide to undergo surgical reconstruction any time later if you are dissatisfied with a prosthesis.

What are the advantages of a prosthesis?
With this choice, there are no additional complication risks or increased recovery time after mastectomy. In addition, there are no additional scars after mastectomy. There is no need for surgery on the opposite breast so it matches the reconstructed breast.

What are the different types of reconstruction procedures?
There are three major types of breast reconstruction.

• Silicone gel or saline implant reconstruction
• Autologous abdominal tissue reconstruction (using tissue from your belly)
• Autologous back tissue reconstruction (using tissue from your back)

Each method usually requires multiple surgeries and takes time to achieve a final result. Sometimes, your surgeon will use a combination of these methods to reconstruct your breast.

Can I choose the reconstruction procedure I have?
In most cases, you can choose the reconstruction procedure you want, but not every procedure is right for every woman. Choosing the type of breast reconstruction to have depends on many factors including your personal preference, how much risk your’re willing to accept and what you are willing to go through to complete a reconstruction. It also depends on your body shape and weight, history of past surgeries, smoking history, current medical condition and whether or not you need further cancer treatment.

For example, most surgeons will not perform immediate reconstruction if you smoke. Smoking can reduce blood circulation, affecting your ability to heal and fight off infection. Too much or too little belly tissue might prevent you from having an autologous abdominal tissue reconstruction; implants could be a better choice. Not having enough back tissue could make abdominal tissue reconstruction a better choice. Your doctor will help you choose a reconstruction method that gives you the best chance for success.

How long does it take to recover from reconstruction surgery?
Recovery time can depend on many factors including the type of reconstruction procedure you have and your overall health. Keep in mind that reconstruction involves several surgical procedures and each requires time to recover.

Usually, for implant reconstruction, it takes about 2 to 6 weeks to recover from tissue expander placement and about 1 to 4 weeks to resume your normal activity after your permanent implant.
Generally, for the first back tissue reconstruction surgery, you can plan on a hospital stay of about 1 to 2 days and 2 to 6 weeks to get back to your normal activity.

For the first abdominal tissue reconstruction surgery, you can plan on a hospital stay of up to a week and about 4 to 8 weeks to recover.

How long does it take to complete the reconstruction process?
Breast reconstruction is a complex, multi-step process that can take up to a year. It may take longer if you have complications or need to delay reconstruction to have chemo or radiation therapies.
Here's a general reconstruction timeline:

• Step 1: First surgery to create a breast mound. This surgery is usually the most complicated procedure in the reconstruction process.
• Step 2: About 2 to 6 months later, a second surgery makes any changes to the reconstructed breast and/or makes adjustments to your opposite breast to achieve symmetry. Sometimes, a follow-up surgery will be needed to make adjustments to one or both breasts.
• Step 3: Surgery to reconstruct a nipple and areola.

Will a reconstructed breast look or feel like a natural breast?
No, a reconstructed breast will never look or function like the breast Mother Nature gave you. You will not feel the same sensations as you did with your former breast. This is not a “real” breast, but it will give you a nice breast shape under your clothes. Without clothing, you will notice a difference.

Will reconstruction surgery leave a scar?
Yes. Scars will form after all surgeries.

There will be visible scars on the reconstructed breast, on the “normal” breast if symmetry surgery is performed, as well as on the back or abdomen if tissue is used from those areas. The scars on the two breasts may look different from each other. Their visibility will be dependent on each patient’s genetics and how they form a scar.
The scarring process usually takes up to a year. There is a great amount of variability with scar formation. Darker skin usually forms darker scars while lighter skin usually forms lighter scars. Sometimes scars can be irritated, itchy and even painful. Too much scarring may affect the size, shape and look of the breast.

When is breast reconstruction done?
Breast reconstruction can be started at the same time as a disfiguring surgery like a lumpectomy or mastectomy. This is called immediate reconstruction.  As soon as the breast cancer surgeon removes part or all of the breast, the plastic surgeon starts the reconstruction process. Breast reconstruction can also be done any time after a disfigurement due to cancer surgery, trauma or infection. This is called delayed reconstruction. 

What are the advantages of immediate reconstruction?
Immediate reconstruction may result in a more natural looking breast with smaller scars after cancer surgery. It may decrease the number of surgeries and time required to complete your reconstruction because you’ve started reconstruction at the same time as your mastectomy surgery. There’s also the psychological advantage of waking up from mastectomy surgery with the beginnings of a rebuilt breast (or breasts).

What are the disadvantages of immediate reconstruction?
Immediate reconstruction generally carries a greater risk of complications due primarily to infection and skin loss from blood circulation problems. Medical problems and previous treatment including diabetes, breast size, previous surgery, smoking, chemotherapy and radiation may increase these risks. Complications of immediate reconstruction may delay your healing and thus delay your cancer treatments after mastectomy. You must be completely healed after surgery to continue with these treatments that will affect your survival. Therefore, a prohibitively high complication rate may make this option not good for some women. You will need to discuss your situation with your surgeon.

Who are the best candidates for immediate reconstruction?
In general, women may be good candidates for immediate reconstruction if they are willing to accept more risk in order to avoid waking up completely flat after their mastectomy. This technique is usually reserved for early clinically staged breast cancer patients (Stages I and II) who do not require post mastectomy radiation. Radiation can delay healing and make infections harder to fight off. Immediate breast reconstruction is usually avoided in inflammatory breast cancer or if cancer spreads to other parts of the body (Stage IV). Most surgeons will not perform immediate breast reconstruction if you smoke. Smoking can delay healing causing incisions to open which increases the risks for infection. 

What are the advantages of delayed reconstruction?
By separating the cancer treatment process from the breast reconstruction process, women reduce “information overload.” They can concentrate on beating the cancer first then dealing with reconstruction options and aesthetic outcomes later. Delayed reconstruction allows for a trial period with a breast prosthesis. Waiting to reconstruct the breast allows examination of the final pathology and determination of which cancer treatments may be required prior to beginning the reconstructive process. This ability to determine and complete all recommended cancer treatments separate from the reconstruction process can lower the risk of needing to delay cancer treatment due to complications.

What are the disadvantages of delayed reconstruction?
Delayed reconstruction leaves larger scars and a less natural looking reconstructed breast which makes it more difficult to achieve symmetry in unilateral breast reconstruction. Delaying reconstruction may be psychologically more traumatic for some women because you awake from your mastectomy completely flat. In addition, the reconstruction process is slower because it will increase the number of surgeries required to complete the process.

Who are the best candidates for delayed reconstruction?
In general, patients who undergo delayed reconstruction want to reduce their risk for complications and don’t mind being flat until completion of their cancer therapies. Surgeons recommend delayed reconstruction for large tumors in higher staged patients (Stages III and IV) who have a high likelihood for needing post-op radiation. Performing a delayed reconstruction after radiation usually requires some form of autologous (using your own tissue) breast reconstruction to improve form and lower risk.

What types of implants are available?
There are several types of implants available. Your plastic surgeon will help you choose the type of implant that will give you the best breast shape possible.
Saline breast implants are filled with sterile salt water. If the implant shell leaks, a saline implant will collapse and the saline will be absorbed and naturally expelled by the body.
Silicone breast implants are filled with silicone gel which feels similar to natural breast tissue. If the implant shell leaks, the gel may remain within the implant shell, or may escape into the breast implant pocket or surrounding tissues. A leaking implant filled with silicone gel will not collapse.
Gummy bear implants are a type of silicone implant that’s firmer than the traditional silicone implant so they may better mimic a natural tear drop breast shape in some women. Due to its firmness, this implant is less likely to show visible “wrinkling” of the implant in the upper chest. It maintains its shape even if the implant shell breaks.

How long do implants last?
Implants generally need to be replaced every 10 to 15 years because their outer shells harden, leak or break. If you’re not having problems with the implant, it does not need to be replaced.

Are implants safe?
Yes. Extensive medical studies have established that both silicone and saline implants are equally safe to use. There is no correlation with the use of silicone implants and the development of certain inflammatory diseases such as lupus, Rheumatoid arthritis, etc. Both saline and silicone implants have similar risks and complications.

What if an implant leaks or breaks?
Both saline and silicone implants can rupture and leak due to 
normal wear and tear. The current silicone implants have highly cohesive silicone inside with the consistency of a gelatin and the risk for silicone moving outside the breast pocket is very low when compared to the original implants with liquid silicone.

With silicone implants, it’s usually not possible to tell if the implant breaks because the silicone remains in place and does not deflate. On the other hand, saline implants deflate and the water is absorbed by the body when the outer shell breaks. There are many different ways to look for implant ruptures including physical examination, mammogram, ultrasound and MRI.

What’s involved in implant reconstruction?
Implant reconstruction can be done as an immediate procedure or as a delayed procedure. Sometimes, implants can be placed in just one step; sometimes, the process involves two or more steps.

Implant reconstruction usually begins with the placement of a tissue expander underneath the skin and muscles of the chest wall. During the next few weeks or months, you will come into the office to have the expander slowly filled with saline. This process stretches the skin and muscle in order to create a “pocket” for a permanent implant. The timing for the expansion procedure varies, but it’s usually repeated every few weeks until the “pocket” is the appropriate size.

About 2 to 4 months after the expansion process is complete, the tissue expander is removed and replaced with a permanent silicone gel or saline implant. There are many different sizes and shapes of implants. Your plastic surgeon will help you choose the permanent implants that are best for you. Sometimes during immediate reconstruction, you won’t need to go through the tissue expander process. Your permanent implant can be placed right away.

Your surgeon might also use a process called “fat grafting” to increase the camouflage over the implant. Fat grafting can reduce rippling or wrinkling of the implant (which can be seen through the skin) and soften the transition between the implant and the chest wall. This area can appear like a “dent” in the breast. The fat grafting process involves removing fat rom another part of the body, cleaning it and then injecting it to fill a dent. This fat may not always survive. The transferred fat sometimes forms hard scar lumps or cysts. Sometimes dents can form in the fat donor site.

Recovery from implant placement usually takes about 1 to 4 weeks.

What are the risks and/or possible complications?
As with any surgery, there are risks and possible complications. Complications may ultimately change the type, timing and final look of a reconstructed breast. Complications may occur at any point in the reconstruction process and could prevent completing a reconstruction. Complications may delay critically needed chemotherapy or radiation therapies which can affect survival.
Surgical complications may include:
Infection
Seroma (fluid collection)
Skin necrosis (sin death)
Bleeding
Anesthesia risks

Implant complications may include:
Capsular contracture
Wrinkling/rippling
Rupture
Malposition
Erosion/exposure

Some of these complications may require further surgery to remove or replace your implant. Your plastic surgeon will review these risks during your office visits and answer any questions.

Infection
The risk of infection is usually higher with implant placement during immediate reconstruction than with delayed reconstruction. Unfortunately, some implants that get infected have to be removed and the body needs time to fight off the infection. Sometimes, it’s possible to “salvage” an implant after infection. Salvage efforts include antibiotics or possibly having surgery in order to wash out the pocket and place a new implant or use another reconstruction technique after some time has passed.

Seroma
A seroma is a collection of fluid around an implant. Seromas occur at a higher rate when acellular dermal matrix (donated, cleaned skin tissue) is used. A seroma may, on rare occasions, cause pain and/or discomfort and require prolonged drainage with needle aspiration or drain tubes. An infected seroma may cause the potential loss of the implant.

Skin necrosis
Poor skin circulation over the implant can cause skin necrosis (skin death). The risk for this complication is higher with immediate reconstruction and in patients who have undergone previous radiation treatments or have a history of smoking or prior breast surgery. Skin death will increase the risk for infection and possible loss of the implant. This complication usually requires another surgery to remove the affected dead skin. The amount of skin remaining will determine if implant reconstruction is still possible.

Bleeding
Bleeding may develop after any surgery and may require an urgent return to the operating room. If enough bleeding occurs, blood transfusions may be necessary to keep the patient’s blood pressure normal. Significant bleeding can lead to a hard, tense breast and may even cause circulation problems leading to skin necrosis (skin death). Necrosis usually requires an urgent return to the operating room to prevent skin loss.

Anesthesia risks
All surgery carries some risk including heart attack, stroke, deep vein thrombosis (blood clots in the legs), pulmonary embolism (blood clots in the lungs), allergic reactions to medications, death and others. These risks are variable and increase with age, chronic medical problems (obesity, diabetes, hypertension, peripheral vascular disease, etc.) and smoking.

Capsular contracture
Capsular contracture may occur when the scar tissue that forms around all implants gets thick, hard and compresses the implant. This can cause changes in the way the implant looks and feels.

All implants may develop capsular contracture over time. There is a higher risk of this complication with immediate reconstructions and after radiation therapy. Covering the implant with autologous tissue (your own tissue), especially following radiation, gives the best chance at reducing the risk for this complication. Severe capsular contractures will cause some discomfort and may make the implants look asymmetric and deformed. Treatment may involve removing the scar and replacing the implant. Changing from a smooth implant to a textured implant or from a round implant to a shaped implant may also help with this problem, but there is a higher likelihood of hardening occurring again as it is usually caused by your body’s unique response to implants.

Wrinkling/rippling
Thin tissue covering the implant may cause the folds of the implant shell to be seen through the skin. This can be improved with many techniques including injecting fat or placing acellular dermal matrix (donated, cleaned skin tissue) over the implant. In addition, exchanging a soft implant that is more likely to wrinkle with a firmer implant (gummy bear) that is less likely to wrinkle may reduce this problem. In severe cases, doing autologous reconstruction with a flap will give more coverage to reduce visible wrinkling.

Rupture
Over time, an implant’s silicone rubber shell can weaken and break from normal wear and tear. The current silicone implants have highly cohesive silicone inside with the consistency of a gelatin and the risk for silicone moving outside the breast pocket is very low when compared to the original implants with liquid silicone. With silicone implants, patients can’t tell when the implant breaks because the silicone remains in place and does not deflate. On the other hand, saline implants deflate when the outer shell breaks and the water is absorbed by the body. There are many different ways to look for implant ruptures including physical examination, mammogram, ultrasound and MRI.

Malposition
Implants may end up sitting in the wrong place (malposition). There is a higher risk of this complication during immediate reconstruction as compared to delayed reconstruction. Acellular dermal matrix (donated, cleaned skin tissue) may be used to help prevent this problem. Teardrop (not round) implants may also rotate, causing the breast shape to change and look unnatural. These complications usually require another surgery to correct.       

Erosion/exposure
The tissue covering the implant may thin and possibly open to expose the implant. This may happen at any time. Thinning tissue can be augmented with placement of acellular dermal matrix (donated, cleaned skin tissue) or autologous tissue coverage. The risk for this complication is greater in breasts with infections, previous radiation therapy and in patients with thin skin and soft tissue cover.

What is abdominal tissue reconstruction?
Abdominal tissue reconstruction is a surgical procedure to create a breast mound using a football shaped “flap” of tissue taken from your abdomen below your belly button. Your surgeon moves this flap to your chest wall and forms it into a breast shape. Abdominal tissue reconstruction can be done as an immediate procedure or as a delayed procedure.

What’s involved in abdominal tissue reconstruction?
There are two commonly used techniques to perform this procedure. One is called the pedicle flap technique, the other is known as the free flap technique.

The pedicle TRAM (transverse rectus abdominus myocutaneous)
flap is the most commonly used abdominal breast reconstruction technique. For this procedure, your surgeon takes skin, fat and the entire rectus muscle from your abdomen and tunnels it up to your chest. One end of the muscle and its blood supply are left attached to the abdomen like an “umbilical cord.” This becomes the blood supply for your “new” breast. This procedure usually takes about 4 to 6 hours to finish, but sometimes it requires two surgeries to complete the transfer.
The free TRAM flap procedure takes the same “football,” including the whole rectus muscle with its blood vessels, and completely detaches it from the abdomen. The surgeon then re-attaches the abdominal blood vessels to the chest after removing one or maybe two ribs.

There are variations on both techniques. Your surgeon will help you choose the best option based on your body type and overall medical condition.

You can plan on a hospital stay up to a week after abdominal breast reconstruction surgery and about 4 to 8 weeks to get back to your normal activity without any complications.

Will the surgery leave a scar?
Yes. Scars will form after all surgeries. Abdominal tissue reconstruction leaves two surgical sites and scars – one where the tissue was taken from the abdomen and one on the reconstructed breast.

The visibility of scars on the abdomen and breast will vary depending on the genetics of the patient. Some scars grow thin and are difficult to see while others grow thick, raised and dark. Some patients may even form a keloid, which is a thick form of scarring more common in people with dark skin. The scar on the abdomen spans the entire abdomen from hip-to-hip. The scar on the breast is variable depending on when the reconstruction was started. In immediate breast reconstruction, the scar may be around the old areola, which has been replaced by the abdominal skin. In delayed breast reconstruction, the abdominal skin shape is variable but usually is in the shape of a football.

What are the risks and/or possible complications?
The risk for complications is higher with abdominal tissue reconstruction and recovery takes longer than for implant or back tissue reconstruction.

As with any surgery, there are risks and possible complications. Complications may ultimately change the type, timing and final look of a reconstructed breast. Complications may occur at any point in the reconstruction process and could prevent completing a reconstruction. Complications may delay critically needed chemotherapy or radiation therapies which can affect patient survival.

Complications may include:
Infection
Seroma (fluid collection)
Flap necrosis (flap death)
Bleeding
Abdominal hernia
Wound opening
Pneumothorax (collapsed lung)
Skin patches
Anesthesia risks

Some of these complications may require further surgery. Your plastic surgeon will review these risks during your office visits and answer any questions.

Infection
Infection may occur anywhere there is an incision. Treatment usually involves antibiotics and possible drainage of the infection. If a seroma becomes infected, surgery is usually required to remove infected fluid. Infections increase the risk for hernia formation at the abdominal donor site.

Seroma
A seroma is a collection of fluid in the space where the abdominal tissue was removed (donor site). The risk is increased in severely obese patients. Drains can reduce, but not eliminate, the risk of seroma.  Drains are usually needed for 1 to 3 weeks.

Flap necrosis
Poor blood circulation to the skin or fat can cause flap necrosis (flap death). The risk is increased in severely obese patients. Fat necrosis is more common with pedicle flaps than free flaps and it may require further surgery to remove these portions of the flap or sometimes the entire flap. Performing a pedicle flap in two staged surgeries (delayed procedure) may reduce this risk. Problems with the connection of vessels in free flaps could cause loss of blood flow to the skin and fat resulting in total loss of the reconstruction. This complication usually requires another surgery to remove the affected tissues and then using an alternate type of reconstruction.

Bleeding
Bleeding may develop after any surgery and require an urgent return to the operating room. If enough bleeding occurs, blood transfusions may be necessary to keep the patient’s blood pressure normal. Sometimes, a smaller amount of bleeding occurs to form a blood collection called a hematoma. A hematoma in the abdomen may require another surgery to remove the old blood. A hematoma in the breast may cause circulation problems with the flap resulting in tissue necrosis (tissue death). This usually requires an urgent return to the operating room.

Hernia
After using abdominal tissue for breast reconstruction, intra-abdominal fat or intestines could bulge through an abdominal wall tear.  This risk is increased for patients with a higher BMI or when the entire rectus abdominus muscle is used during pedicle or free TRAMs. Hernias may require multiple surgeries to correct. Sometimes, abdominal wall weakness occurs instead of a hernia. This may lead to the formation of an abdominal bulge or lower back pain due to body core weakness. Placement of mesh can help reduce this risk but not eliminate it.

Wound opening
Abdominal wounds may require months to completely heal. The abdominal incision may open, especially if a seroma, infection or both are present. This risk is increased in smokers, severely obese patients, women who’ve had prior abdominal surgeries, and after radiation. Sometimes the wound can be cleaned as a minor procedure and the wound re-closed.

Pneumothorax (collapsed lung)
The lung may collapse during a free flap when the chest vessels are isolated. If the collapse is significant, a chest tube is placed and may stay for several days lengthening your hospital stay.

Skin patches
Large patches of different color skin are often present after autologous breast reconstruction. This is especially the case with delayed reconstructions after radiation therapy. Quite often, large areas of damaged skin are replaced with normal skin from other parts of the body to allow for a better breast shape and reduce healing complications.

Anesthesia risks
All surgery carries some risk including heart attack, stroke, deep vein thrombosis (blood clots in the legs), pulmonary embolism (blood clots in the lungs), allergic reactions to medications, death and others. These risks are variable and increase with age, chronic medical problems (obesity, diabetes, hypertension, peripheral vascular disease, etc.) and smoking.

What is back tissue reconstruction?
Back tissue reconstruction is a surgical procedure to create a breast mound using a football shaped “flap” of tissue transferred to your chest from the area below your shoulder blade. Back tissue reconstruction can be done as an immediate procedure or as a delayed procedure.

What’s involved in back tissue reconstruction?
To perform back tissue reconstruction, your surgeon rotates the football-shaped flap from your back to the chest through a tunnel in your armpit. The blood vessels are left attached to the armpit and act like an “umbilical cord” to keep the tissue alive while it heals. If more breast volume is needed, your surgeon may place a tissue expander beneath the flap.

An implant is often used in conjunction with back tissue, especially when there is not enough skin and fat on the back to fill out a reconstructed breast and make it similar to the size and shape of the opposite breast. For women with small breasts, the back tissue may be enough, so the implant isn’t always needed.

Usually, it takes less time to recover from back tissue reconstruction than from abdominal tissue reconstruction, but more time than using implants alone. You can plan on a hospital stay of about 1 to 2 days and 2 to 6 weeks to get back to your normal activity.

Will the surgery leave a scar?
Yes. Scars will form after all surgeries. Back tissue reconstruction leaves two surgical sites and scars – one where the tissue was taken from the back and one on the reconstructed breast.

The visibility of scars on the back and breast will vary depending on the genetics of the patient. Some scars grow thin and are difficult to see while others grow thick, raised and dark. Some patients may even form a keloid, which is a thick form of scarring more common in people with dark skin. The scar on the back spans the entire side of the back. The scar may run vertically, horizontally or diagonally depending on way the skin is oriented on the muscle. The scar on the breast is variable depending on when the reconstruction was started. In immediate breast reconstruction, the scar may be around the old areola which has been replaced by the back skin. In delayed reconstruction, the shape varies but usually is in the shape of a football and placed on the central or lower half of the breast.

What are the risks and/or possible complications?
As with any surgery, there are risks and possible complications. Complications may ultimately change the type, timing and final look of a reconstructed breast. Complications may occur at any point in the reconstruction process and could prevent completing a reconstruction. Complications may delay critically needed chemotherapy or radiation therapies which can affect patient survival.
Surgical complications may include:
Infection
Seroma (fluid collection)
Flap necrosis (flap death)
Bleeding
Wound opening
Shoulder weakness
Lymphedema
Skin patches
Anesthesia risks

Some of these complications may require further surgery. Your plastic surgeon will review these risks during your office visits and answer any questions.

Infection
Infection may occur at both the back and breast surgical sites. Treatment usually involves antibiotics and possibly surgery to wash out and replace an implant, if used. If an implant is present that can harbor bacteria, it may need to be removed if the infection fails to clear. If a seroma becomes infected, surgery is usually required to remove infected fluid.

Seroma
A seroma is a collection of fluid in the space between the skin and the muscle layer in the back (donor site) or around the implant pocket in the breast. Drains can reduce, but not eliminate, the risk of seroma. Drains are usually needed for 1 to 3 weeks.

Flap necrosis
Poor blood circulation to the skin, fat or muscle can cause partial or complete flap death (flap necrosis). This may be caused by certain medical problems, previous surgery that damages vessels or damage to vessels during the transfer to the chest. Tissue loss increases the risk for infection and possible implant loss. This complication usually requires another surgery to remove the affected skin. The amount of skin remaining will determine if back tissue reconstruction is still possible.

Bleeding
Bleeding may develop after any surgery and require an urgent return to the operating room.  If enough bleeding occurs, blood transfusions may be necessary to keep the patient’s blood pressure normal. Sometimes, a smaller amount of bleeding occurs to form a blood collection called a hematoma. A hematoma in the back may require another surgery to remove the old blood. A hematoma in the breast may cause circulation problems with the flap, resulting in tissue necrosis or an increased risk of capsular contracture around an implant. This usually requires an urgent return to the operating room.

Wound opening
Wounds may require months to completely heal and may open, especially if a seroma, infection or both are present. This risk is increased in smokers, obese patients and after radiation. Sometimes the wound can be cleaned as a minor procedure and the wound re-closed.

Shoulder weakness
Shoulder weakness may occur on the side from which the back (latissimus dorsi) muscle is transferred. Studies show about a 7% decrease in strength but the loss is usually noticed only by very athletic women.

Lymphedema
Same side arm swelling (lymphedema) may start or worsen, if already present, when lymphatic damage occurs during the tunneling of the flap through the armpit. If this happens, permanent use of an arm compression device may be necessary. The risk for infection of the arm is increased.

Skin patches
Large patches of different color skin are often present after autologous breast reconstruction. This is especially the case with delayed reconstructions after radiation therapy. Quite often, large areas of damaged skin are replaced with normal skin from other parts of the body to allow for a better breast shape and reduce healing complications.

Anesthesia risks
All surgery carries some risk including heart attack, stroke, deep vein thrombosis (blood clots in the legs), pulmonary embolism (blood clots in the lungs), allergic reactions to medications, death and others. These risks are variable and increase with age, chronic medical problems (obesity, diabetes, hypertension, peripheral vascular disease, etc.) and smoking.

Will a reconstructed breast mound have a nipple and areola?
A reconstructed breast mound will usually not have a nipple and areola. They can be added in a separate procedure or procedures.

When is nipple and areola reconstruction done?
A nipple and areola are typically created after breast mound reconstruction is complete. This is often the last step in your breast reconstruction and many women think adding a nipple and areola as the “finishing touch.”
Usually, the process starts after your new breast has had time to heal, which is usually about 2 to 4 months. Your nipple and areola can be reconstructed at the same time or in separate procedures.

What’s involved in nipple and areola reconstruction?
There are several ways your surgeon can create a nipple and areola. The most common way to reconstruct the nipple is to take a bit of skin and fat on the reconstructed breast and form it into a nipple shape. Taking tissue from the breast mound may slightly change the mound’s shape and size. The nipple may also lose its projection over time and tend to flatten out.

Another technique uses a portion of your opposite breast nipple to create a new nipple on the breast mound. This type of nipple does not tend to shrink or flatten out. Sometimes, the grafted tissue does not survive and has to be removed. In that case, your surgeon may use another form of nipple reconstruction.
Your areola may be reconstructed using skin taken from another part of your body. Skin grafts generally don’t fade over time but may change color or develop scars. Some or all of the tissue may not survive the grafting process and have to be removed.  Problems at the donor site may include scarring, wound opening and infection.
Tattooing can also be used to reconstruct your areola, nipple or both. This is a relatively fast and easy way to recreate the “look” of a nipple and areola, but there is no texture or dimension to this technique and it may appear painted on. Many times, a surgeon will use different shades of color to make the flat tattoo look more 3-dimensional. Tattooing will tend to fade over time and may need “touching up” in the future.
Nipple and areola reconstruction are typically done as outpatient procedures with local anesthesia. The recovery period is usually the shortest of all the breast reconstruction procedures you’ll have.

There’s typically less post-op pain and fewer complications.

What is nipple-sparing reconstruction?
Nipple-sparing reconstruction is a special type of mastectomy that removes just the breast tissue and leaves behind the entire breast skin, nipple and areola. This procedure is usually reserved for women who are having a mastectomy as a preventive measure or who have early stage tumors that are far away from the nipple. You will need to discuss with your cancer surgeon if you are a candidate for this type of reconstruction.

Is there a risk of cancer recurrence in nipple-sparing reconstruction?
Historically, surgeons removed the nipple and areola to eliminate the ductal tissue within the nipple in order to reduce cancer risks.  Many breast cancers originate in the cells that line the ducts. Therefore, women who have a nipple-sparing procedure knowingly leave behind ductal tissue in their breast. There are no long term studies that show how this technique affects survival or cancer recurrence.

What is opposite breast reconstruction?
Sometimes, a reconstructed breast does not match the opposite breast. Getting the reconstructed breast and the opposite breast to look alike is difficult unless surgery is also performed on the natural breast.

What’s involved in opposite breast reconstruction?
An opposite breast adjustment usually involves either a breast lift, breast reduction, or breast augmentation with an implant. This adjustment procedure is often done 3 to 6 months after the first surgery in the reconstruction process, to make sure the reconstructed breast has had time to heal and settle into its final size and shape.

Opposite breast reconstruction is usually done at the same time as the second surgery in the reconstruction process, either when a tissue expander is replaced with an implant or when adjustments are made to an autologous breast reconstruction.

Even with these adjustment procedures, your breasts will never be exactly the same — but they’ll be closer than they were.
Will the surgery leave a scar?
Yes. Scars will form after all surgeries. The visibility of scars will vary depending on the genetics of the patient. Some scars grow thin and are difficult to see while others grow thick, raised and dark. Some patients may even form a keloid, which is a thick form of scarring more common in people with dark skin.

Scars may travel completely around the nipple (donut), or around the nipple and straight down to the crease (lollipop), or completely around the nipple and straight down to the crease and within the crease (anchor).

Does an implant in the opposite breast affect getting a mammogram?
Although implants are safe, they can interfere with the detection of breast cancer because they can block the view of a tumor on a mammogram. To meet this challenge, we use a special mammography technique to move the implant out of the way to get a clear view of the breast tissue. Even so, there’s still a risk for missing some cancers, especially in the early stages.

What are the risks and/or possible complications?
As with any surgery, there are risks and possible complications.
Infection
Seroma (fluid collection)
Fat/skin necrosis (fat/skin death)
Nipple necrosis
Nipple malposition
Loss of nipple sensation
Bleeding
Wound opening
Anesthesia risks

Some of these complications may require further surgery. Your plastic surgeon will review these risks during your office visits and answer any questions.

Infection
Infection may occur anywhere there is an incision. Treatment usually involves antibiotics and possible drainage of the infection. If a seroma becomes infected, surgery is usually required to remove infected fluid. If an implant was placed, there is risk for implant loss. Infections may also cause nipple necrosis (nipple death).

Seroma
A seroma is a collection of fluid in the breast. This may cause discomfort and pain resulting in prolonged drainage with needle aspiration or tube drains. A seroma increases the risk for infection and possible implant loss, if present. Drains can reduce, but not eliminate, the risk of seroma. Drains are usually needed for 1 to 3 weeks.

Skin necrosis
Poor circulation in the breast tissue may cause skin death (necrosis) or internal scarring that feels like hard lumps. This may cause worry of cancer recurrence or discomfort in a bra. Sometimes, this tissue has to be removed or biopsied.

Nipple necrosis
Poor blood circulation or damage to the nipple or surrounding skin during surgery can cause nipple and areola death. Tissue death increases the risk for infection and possible implant loss, if used. This complication usually requires another surgery to remove the affected skin. The amount of skin remaining will determine if the nipple needs to be removed and reconstructed. If circulation problems are detected during the operation, the nipple/areola may be removed and placed on the skin as a graft. This is called a free-nipple graft.

Nipple malposition
The nipple and areola can shift position so they do not match the position of the nipple and areola on the reconstructed breast. A nipple in the wrong position must be surgically relocated or removed, although this is not always possible.

Loss of nipple sensation
Adjustment procedures to the opposite breast may cut nerves to the nipple, creating permanent loss of nipple sensation.

Bleeding
Bleeding may develop and even require an urgent return to the operating room to prevent skin/nipple loss, scar formation and fluid formation. Larger amounts of bleeding may cause a larger blood collection which may result in circulation problems in the skin and possible necrosis. Blood around an implant may also increase the risk for capsular contracture.

Wound opening
Wounds may require months to completely heal and may open, especially if a seroma, infection or both are present. A wound opening may require that an implant be removed, if used. The risk of wound opening is increased in smokers, obese patients and after radiation. Sometimes the wound can be cleaned as a minor procedure and the wound re-closed.

Anesthesia risks
All surgery carries some risk including heart attack, stroke, deep vein thrombosis (blood clots in the legs), pulmonary embolism (blood clots in the lungs), allergic reactions to medications, death and others. These risks are variable and increase with age, chronic medical problems (obesity, diabetes, hypertension, peripheral vascular disease, etc.) and smoking.

Does the need for cancer treatment such as radiation or chemotherapy affect breast reconstruction?
Yes. The need for radiation or chemotherapy always takes priority over reconstruction. That means you will likely need to delay reconstruction until you’ve finished cancer treatment. You may also need to choose a reconstruction procedure that is compatible with changes to your skin or tissues that may be caused by your cancer treatment.

What is the purpose of radiation therapy?
Radiation helps prevent cancer spread and recurrence “locally” when the cancer is found in the breast and axillary lymph nodes. Radiation therapy is necessary for all patients after lumpectomy and in some patients after mastectomy. Doctors use various factors to determine the need for radiation, including: tumor size, presence of tumor in the lymph nodes, tumor aggressiveness and how close the tumor is to the surgical margins. A margin is the amount of normal tissue between the edge of a tumor and the edge of the removed breast tissue.

How does the need for radiation affect reconstruction?
Radiation prevents cells from growing by causing cell death, scarring and decreased blood flow to the area. This creates a hostile environment for growing cells which is good for preventing cancer spread but bad for surgical healing.

All surgical risks are increased in an area that has been exposed to radiation. Tissues do not heal well after radiation. Sometimes incisions open up after surgeries due to poor circulation or infections. Some tissue may even have necrosis (death) after surgery due to this poor circulation. For these reasons, surgeons may want to delay the start of reconstruction until months after radiation therapy is complete.

If you’ve already started reconstruction and then find you need radiation, your surgeon may delay completing your reconstruction until you’ve finished therapy. Even so, radiation may damage your reconstruction and affect your final cosmetic result.

Implant-only reconstruction can be severely affected by radiation, since the skin may no longer be pliable enough to stretch over an implant. If an implant is already in place, a surgeon may choose to cover it or replace it with your own tissue (such as from your back or belly) that has not been exposed to radiation. This lowers the complication risks by improving circulation and brings in soft pliable tissue which gives a more natural shape.

Radiation and the impact on implants is something that needs to be discussed carefully with your surgeon.

What is the purpose of chemotherapy?
Chemotherapy helps prevent cancer from spreading “globally” throughout the body.

How does the need for chemotherapy affect reconstruction?
Breast reconstruction surgeries cannot be performed during chemotherapy. Therefore, your reconstruction process is placed on hold until chemotherapy is completed.

What questions should I ask my plastic surgeon?
Your plastic surgeon will help you decide if you’re a good candidate for breast reconstruction and, if so, the type of breast reconstruction that may be most appropriate for you. During your consultation, the surgeon will discuss your reconstructive options, including the risks and benefits for each procedure. You will also discuss the expected outcomes from reconstruction. Learning as much as you can about reconstruction before the first visit with your plastic surgeon will prepare you to partner with your doctor in choosing the best way to proceed with breast reconstruction. Go to your first visit with some questions. Here’s a start:

• Am I a good candidate for breast reconstruction?
• What type of breast reconstruction might be best for me?
• What’s the best timing for my reconstruction?
• What risks do I face?
• What results can I expect?

What is a lumpectomy?
A lumpectomy, sometimes called breast conservation therapy, is a surgical procedure to remove just the breast cancer turmor along with a rim of surrounding tissue called a “margin.” The rest of the breast is left alone. This technique is usually reserved for early stage breast cancers that are only in one area of the breast and not multifocal (multiple parts of the breast). This technique may also be used when a patient has received chemotherapy before any surgery, shrinking the tumor to a small size so that it can be completely removed without undergoing a mastectomy.

During or after a lumpectomy, a pathologist examines the tumor and the surrounding tissue to make sure there are no cancer cells in the margin. It can take 1 to 2 weeks after surgery to confirm complete removal of the cancer. If margins are “positive” (not clear), multiple surgeries may be required to clear the cancer from the breast. This form of therapy for invasive cancer is almost always followed by whole breast radiation therapy to reduce the risk of the cancer returning. Radiation therapy is sometimes not necessary for non-invasive cancers.  As compared with mastectomy, lumpectomy surgery with radiation preserves more of the native breast while maintaining similar survival rates.

How does a lumpectomy affect the look of a breast?
Although a lumpectomy preserves more normal breast tissue than a mastectomy, deformities may occur depending on the size of your breasts, where the cancer is located, and how much breast tissue needs to be removed to get rid of the cancer. Immediately after a lumpectomy your body fills in that hole with fluid so your breast looks like nothing was done to it except for a scar. However, radiation is necessary to reduce the chance of cancer coming back and improve survival rates. Unfortunately, radiation worsens lumpectomy deformities by shrinking the entire breast on average 10 to 20% causing the fluid pocket to collapse and pulling down surrounding tissues This distorts the breast by leaving dents and/or pulling the nipple in awkward directions in addition to changing the skin color, and increasing breast tissue density, skin thickness and scarring.

What is partial breast reconstruction?
Partial breast reconstruction is a surgical procedure to either close or fill in the hole left behind after the tumor and margin have been removed.

When is partial breast reconstruction done?
Immediate reconstruction is performed at the same time as the lumpectomy. Immediate reconstruction is usually performed for localized breast cancer (one area) and not multifocal disease (more then one area) and when there is very low risk of leaving cancer behind. If cancer has been left behind after lumpectomy and partial breast reconstruction, it may be difficult to find the area where the cancer came from in order to remove more tissue and get clear margins. Sometimes in these situations, a total mastectomy is required to guarantee cancer removal.

Immediate-delayed reconstruction is performed 1 to 3 weeks after the lumpectomy to allow examination of the pathology and confirm cancer removal prior to starting the reconstruction. This technique is usually favored for women with larger or multifocal tumors when the risk for leaving cancer behind after lumpectomy is higher.  By waiting for the pathology results, the cancer can be confirmed gone. If the margins are not clear, another surgery to remove more tissue may be performed more easily since no reconstruction has taken place and the location of the cancer has not been changed or masked by the reconstruction technique. Unfortunately, this guarantees at least two surgeries to complete the process.

Delayed reconstruction is performed after the lumpectomy and radiation have been completed. This procedure is often challenging because of the adverse effects of the radiation therapy which increases the risks for complications especially due to infection and blood circulation problems. Because of breast tissue damage caused by radiation, this technique usually requires complex tissue transfer of a large volume of autologous tissue either from the abdomen or the back.

What are the risks and/or possible complications?
As with any surgery, there are risks and possible complications.
Infection
Seroma (fluid collection)
Bleeding
Fat necrosis (fat death)
Nipple necrosis (nipple death)
Breast disfigurement
Breast asymmetry
Wound opening
Positive surgical margin
Anesthesia risks

Some of these complications may require further surgery. Your plastic surgeon will review these risks during your office visits and answer any questions.

Infection
Infection may occur anywhere there is an incision. Treatment usually involves antibiotics and possible drainage of the infection. If a seroma becomes infected, surgery is usually required to remove infected fluid. If an implant was placed, there is risk for implant loss. Infections may also cause nipple necrosis (nipple death).

Seroma
A seroma is a collection of fluid in the breast.  A seroma may cause discomfort and pain and increase the risk for infection. Drains can reduce, but not eliminate, the risk of seroma.  Drains are usually needed for 1 to 3 weeks.

Bleeding
Bleeding may develop after any surgery and require an urgent return to the operating room.  If enough bleeding occurs, blood transfusions may be necessary to keep the patient’s blood pressure normal. Sometimes, a smaller amount of bleeding occurs to form a blood collection called a hematoma. A hematoma in the breast may cause circulation problems resulting in tissue necrosis. This usually requires an urgent return to the operating room.

Fat necrosis
Breast fat may die and form hard, painful lumps of scar tissue after rearrangement during reconstruction surgery. Sometimes, these lumps need to be removed which may further disfigure the breast.

Nipple/areola necrosis
Poor circulation to the nipple and areola may cause tissue death (necrosis). This risk is higher when tumors are near or under the nipple/areola complex and after radiation therapy. Sometimes the nipple/areola complex has to be removed completely and grafted back onto the breast after rearranging the tissues and closing the skin. This is called a free nipple graft. If this is necessary, your nipple will be completely flat, have no sensation and lose some pigmentation. Sometimes the tissue does not survive this process.

Breast disfigurement
The goal is to minimize any disfigurement of the breast but this is not always possible. The breast will change dramatically after radiation therapy and any scarring within the breast will worsen and potentially distort the surrounding breast tissue.

Breast asymmetry
There will always be some breast asymmetry due to scarring, volume changes and radiation therapy. How much asymmetry will be dependent on many variables including the size of the breast, location and size of the cancer, and the patient’s response to radiation therapy.

Wound opening
Wounds may require months to completely heal. The incision may open, especially if a seroma, infection or both are present. This risk is increased in smokers, severely obese patients, women who’ve had prior abdominal surgeries, and after radiation. Sometimes the wound can be cleaned as a minor procedure and the wound re-closed.

Positive surgical margin
Positive surgical margins can complicate reconstruction and require a second surgery to remove the tissue and get a “clean” margin. However, when a lumpectomy and partial breast reconstruction are performed at the same surgery (immediate reconstruction), the deep breast tissue has been rearranged and it may not be possible to go back in and remove the cancerous tissue. Therefore, a total breast mastectomy must be performed to completely remove the cancer.

Anesthesia risks
All surgery carries some risk including heart attack, stroke, deep vein thrombosis (blood clots in the legs), pulmonary embolism (blood clots in the lungs), allergic reactions to medications, death and others. These risks are variable and increase with age, chronic medical problems (obesity, diabetes, hypertension, peripheral vascular disease, etc.) and smoking.

How do surgical wounds heal?
Wounds heal either by primary intention or by secondary intention.

Healing by primary intention occurs when the two edges of a surgical wound are brought together and allowed to heal while directly touching each other. Wounds are commonly closed with sutures or glue. No granulation tissues form between the skin edges, which usually results in a thinner, less visible scar.  This type of wound usually is water tight after 24 to 48 hours. There is also less contraction (shrinkage) of the scar with this method.

Healing by secondary intention occurs when two skin edges cannot be brought directly together because the wound is too big or tissue has been lost. Therefore, granulation tissue fills the wound bed and the skin will re-epithelialize from the wound edges to seal the wound. It may take the wound days or months to become water tight depending on the size of the wound. There is more contraction of the wound compared to primary intention, possibly resulting in distortion of the surrounding tissues. However, this is variable depending on the patient’s genetic response, location of the wound, and looseness of the surrounding skin. This method results in wider more visible scars with different color, texture and contour than nearby skin.

What factors affect wound healing?
There are many factors that affect wound healing, including:
Nutrition
Medical conditions
Medications
Smoking
Chemotherapy
Radiation

Nutrition
Good nutrition is vital to the body’s ability to create the building blocks necessary to heal a wound. The risk for wound healing problems increases with an Albumin of less than 2 (marker for long-term nutrition over the past 3 months) or a pre-albumen less than 20 (marker for short-term nutrition over the past month).

Medical conditions
Medical conditions such as diabetes, vascular disease and high blood pressure can cause poor tissue blood flow that impairs wound healing. Diabetes increases the risk for infection due to decreased immune function, slower collagen syntheses, decreased blood vessel formation and decreased scar strength, all of which lead to a high risk of wound dehiscence (wound opening). Glucose levels of more than 200 mg/dL are associated with worse outcomes.

Medications
There are many different types of medications that can inhibit wound healing and the ability to fight off infections. Steroids, which are commonly used for many types of medical problems, can affect wound healing. Steroids both slow down the wound-healing process and suppress the immune system, increasing the risk for wound infection and dehiscence.

Smoking
Smoking has a negative effect on wound healing due to the direct toxic effects of smoking and the vasoconstriction caused by nicotine. Smoking has been shown to significantly increase the risk for infections and wound dehiscence by decreasing the function of cells that fight off infection and produce collagen. These conditions may linger for months after stopping smoking.

Chemotherapy
Chemotherapy prevents cells from dividing. This is good for killing cancer but bad for healing and fighting off infections.

Radiation
Radiation prevents cells from growing by causing cell death, scarring and decreased blood flow to the area. This creates a hostile environment for growing cells which is good for preventing cancer spread but bad for surgical healing. All surgical risks are increased in an area that has been exposed to radiation. Tissues do not heal well after radiation. Sometimes incisions open up after surgeries due to poor circulation or infections. Some tissue may even have necrosis (death) after surgery due to this poor circulation.

Will reconstruction surgery leave a scar?
Yes. Scars will form after all surgeries.

There will be visible scars on the reconstructed breast, on the “normal” breast if symmetry surgery is performed, as well as on the back or abdomen if tissue is used from those areas. The scars on the two breasts may look different from each other. Their visibility will be dependent on each patient’s genetics and how they form a scar.
The scarring process usually takes up to a year. There is a great amount of variability with scar formation. Darker skin usually forms darker scars while lighter skin usually forms lighter scars. Sometimes scars can be irritated, itchy and even painful. Too much scarring may affect the size, shape and look of the breast.

Will scars fade over time?
Many scars end up thin, flat and pale over time. These are considered “normal” scars. But not all scars fade over time and can become unsigntly, itchy and even painful. These “abnormal” scars are caused by the genetic over-response of a patient’s healing process.

Abnormal scars may be wide and raised, but remain within the borders of an injury or wound (hypertrophic scar).
Scars may be thin or thick and may grow beyond the edges of an incision (keloid scar).
A dark halo may form around a scar (post inflammatory hyper-pigmentation).

What are hypertrophic scars?
Hypertrophic scarring is characterized by wide, raised scars that remain within the original borders of an injury. They have a rapid growth phase over the first six months after injury with a gradual regression over a 1 to 3 year period to a flat and wide scar. There is more risk for this type of scarring when the tissue is closed under tension or if an infection is present. These scars may be unsightly, itchy and even painful prior to their regression. Hypertrophic scars are more common in darker-skinned people, but may happen in anyone. It may be possible to prevent these scars by avoiding undue tension, infections and avoiding healing by secondary intention. (Healing by secondary intention occurs when two skin edges cannot be brought directly together because the wound is too big or tissue has been lost. Therefore, granulation tissue fills the wound bed and the skin will re-epithelialize from the wound edges to seal the wound.)

In high-risk patients, silicone gel or sheeting is recommended as the first line therapy. Some people may require intralesional injections of steroids, but these may thin the skin, cause hypo-pigmentation and form small blood vessels in the skin. Pulsed-dye lasers are also effective in improving the texture, redness, size and pliability of these scars. Ultimately, scar revision can be performed by cutting out the scar and re-suturing the wound, thus starting over and allowing the wound to heal again. The biggest risk after scar revision is recurrence of the hypertrophic scar.

What are keloid scars?
Keloid scarring is characterized by firm, large tumor-like scars that extend beyond the original borders of the injury. These scars do not regress spontaneously and can develop several years after injury. These are unsightly, disfiguring, and are very symptomatic with itching, redness, and pain that does not spontaneously resolve with time. Keloid scars are more common in darker-skinned people, but can happen in anyone. It may be possible to prevent these scars by avoiding surgery if possible, avoiding undue wound tension, preventing infections and avoid healing by secondary intention. (Healing by secondary intention occurs when two skin edges cannot be brought directly together because the wound is too big or tissue has been lost. Therefore, granulation tissue fills the wound bed and the skin will re-epithelialize from the wound edges to seal the wound.)

In high-risk patients, silicone gel or sheeting is recommended as the first line therapy. Some people may require intralesional injections of steroids during the healing process, but these may thin the skin, cause hypo-pigmentation and form small blood vessels in the skin. Pulsed-dye lasers are effective in improving the texture, redness, size and pliability of these scars. Ultimately, revision of the scar can be performed by cutting it out and re-suturing the wound, thus starting over and allowing the wound to heal again.  Multiple rounds of steroid injections are required after scar removal. Sometimes, low dose radiation therapy may be used to reduce the risk of keloid recurrence after scar revision. However, there is a small risk for other cancers to form in the future after radiation therapy. The biggest risk after scar revision is recurrence of an even larger keloid scar.

What is post inflammatory hyper-pigmentation?
Post Inflammatory hyper-pigmentation occurs when cells that form pigment in the skin are induced to form even more pigment during the healing process. This may produce a dark “halo” around scars after the healing process is complete. This is more common in darker-skinned people who have more pigment-making cells in their skin. Treatment is directed at decreasing the amount of inflammation present by avoiding healing by secondary intention and placing topical steroids to decrease inflammation. In addition, topical bleaching creams (hydroquinone) or retinoic acid creams (tretinoin) may be used to help reduce some hyper-pigmentation.

Can the look of scars be improved?
The visibility of scars is primarily dependent on a patient’s genetic ability to form scars. Surgical incisions that are placed in difficult-to-see areas and allowed to heal by primary intention with sutures or glue will encourage thin scar formation. Complications from infections and delayed healing may lead to wound dehiscence (wound opening) which requires healing by secondary intention. This creates a wider scar with a different contour, color and texture than the surrounding tissue, resulting in a more noticeable scar. In addition, there is more potential for wound contraction resulting in possible distortion of the surrounding structures.

What treatments and techniques might improve the look of a scar?
Sunscreen
Sunscreen helps prevent post inflammatory hyper-pigmentation by preventing ultraviolet light from stimulating the pigment cells in the skin. Most surgeons recommend using a sunscreen of SPF 35 or higher. Start using the cream about 1 to 2 weeks after surgery after the wound is completely closed and continue for at least one year.

Scar massage
Massaging a scar helps flatten it more quickly by releasing enzymes that increase the pliability of the scar. Don’t start until the wound has had adequate time to heal, about 14 days after surgery. Apply enough pressure to blanch the scar and massage for 10 minutes twice per day for at least 1 to 2 months.

Hydration ointments
Hydration ointments help by maintaining moisture in the scar. They are effective in decreasing scar symptoms (pain, itching and tightening) but it is unclear and variable on how much they help with improving the scar appearance.

Petrolatum-based ointments
Applying petrolatum-based cream three times per day for one month has shown a reduction in the redness of post-surgical scars.

Microporous hypoallergenic paper tape
Wearing microporous hypoallergenic paper tape continuously for three months after surgery has been shown to decrease scar volume and reduce the risk for hypertrophic scars. The tape decreases tension on the scar.

Silicone gel or silicone sheeting
Silicone gel or silicone sheeting can reduce the pigmentation, vascularity, height, pain and itchiness of scars. Silicone gel should be applied twice a day for 6 months. Silicone sheeting should be worn at least 12 hours a day for 6 months after surgery.

Pressure dressings
Pressure dressings have been shown to improve keloid scarring, especially with regards to keloid scars on the ear.

What products might not improve the look of scars?
Vitamin E
There is no improvement in the cosmetic appearance of post-surgical scars treated with vitamin E as compared with petrolatum-based ointments. In fact, some studies show a higher incidence of rashes caused by vitamin E relative to other ointments.

Scar creams
There is no improvement in the cosmetic appearance of post-surgical scars treated with non-silicone based scar creams as compared to petrolatum-based ointments.  

Herbal/alternative medicine
There are no clinical studies evaluating herbal/alternative medicines and it is unclear if they improve scar appearance.