Thinking about Breast Cancer and Breast Reconstruction During the Coronavirus Pandemic

By Dr. Constance M. Chen

A diagnosis of breast cancer is devastating at any time, but it can seem impossible to sort out your best options in the middle of a global pandemic. When healthy people everywhere are already overwhelmed with survival, what are the options for a woman who has just been presented with a cancer diagnosis?

Fortunately, as much as life has changed during this time of social distancing, the basic issues of cancer treatment remain the same. Patients need to evaluate their disease with the help of their oncologists to decide upon the optimal course of therapy. Women need to strengthen their immune systems via diet, exercise, and mental health. They may want to explore groundbreaking metabolic approaches to cancer treatment. And social distancing may even help protect patients who are trying to heal and recover from the stresses of cancer treatment. Finally, breast cancer patients should take this time to pause, and realize that they do not need to accomplish all of their long-term goals immediately. Specifically, breast reconstruction can take a back burner to oncologic treatment without any lasting compromise to the ultimate aesthetic outcome.

The first step is to realize that even in the time of coronavirus, the ultimate goal of breast cancer treatment should remain to prolong and maintain quality of life. While the treatment pathway may be very different depending on the aggressiveness of your tumor, some basic facts remain the same. Oncologic treatment - surgery, chemotherapy, radiation therapy - take precedence over reconstructive treatment. Furthermore, with careful planning, this does not mean that any later breast reconstruction needs to be inferior due to delays. Oncologic treatments can proceed without compromising the subsequent aesthetic outcome as long as there is cooperation between the oncologic surgeon and the reconstructive surgeon.

What types of outcomes are possible depend on the oncologic treatment that is needed, which again, should always take precedence over the reconstructive treatment. For example, if a patient has a less aggressive small tumor and she is being offered lumpectomy and radiation or mastectomy, she can move forward with a lumpectomy. If her margins are clear, she can elect to have a mastectomy at a later date when she would have otherwise had radiation, or she can proceed with radiation therapy. Radiation therapy does have the disadvantage of changing the skin quality of the breast, so that it becomes more stiff and fibrotic than the healthy breast tissue, and radiation can thus permanently and negatively impact breast reconstruction at a later date.

For patients who decide to undergo mastectomy, breast reconstruction during the time of coronavirus is ill-advised. Delaying breast reconstruction during the time of coronavirus may save your life, and it will not ultimately affect your aesthetic outcome. For some patients, there may not be a choice presented anyway since all elective or non-emergent surgeries, including breast reconstruction, are currently prohibited in some states. Regardless, a life-saving mastectomy that removes your tumor takes precedence over prolonging your surgery and anesthesia time with breast reconstruction, so even hospitals that have canceled and prohibited all elective surgeries should allow an essential mastectomy alone to proceed without breast reconstruction.

The advice to delay breast reconstruction during the time of coronavirus holds true for all types of breast reconstruction. Overall, there are two basic types of breast reconstruction: implant-based breast reconstruction and natural tissue breast reconstruction. Implant-based breast reconstruction involves placing a tissue expander or implant either under or over the pectoralis muscle to recreate a breast mound. The tissue expander or implant itself challenges the immune system, however, as it is a foreign body. Even a direct-to-implant over-the-muscle implant reconstruction has a higher risk of wound healing problems than mastectomy alone, and in the time of coronavirus should be avoided. Placing a tissue expander is arguably less stressful to the body than an implant - especially if it is placed over the muscle - but it still requires frequent visits to the plastic surgeons office to inflate the expander. Natural tissue breast reconstruction is ultimately the least stressful to the body from an immune standpoint, but it is the most stressful in the short term since it requires wound healing from both the donor site (abdomen or legs) as well as the chest area. During the time of coronavirus, patients should be focused on their oncologic treatment, and if that includes mastectomy then they need to recover from their oncologic surgery as quickly as possible.

For patients who want the ultimate aesthetic result after surgery, and who want their reconstructed breasts to look and feel as close as possible to their natural breasts, the gold standard in breast reconstruction is a nipple-sparing mastectomy and natural tissue breast reconstruction. With planning and patience this can be achieved with a delayed breast reconstruction. A woman does not need to compromise on her ultimate breast reconstruction if she and her plastic surgeon can convince the oncologic breast surgeon to perform a nipple-sparing mastectomy no matter how large her breasts. Many breast surgeons may want to place a tissue expander as a placeholder until natural tissue breast reconstruction, and this is certainly a possibility. But for women who do not want a foreign body in place at all, and are understandably concerned that even a temporary tissue expander can affect their immune system, then they can leave their chest flat with floppy excess skin including the nipple-areola complex. It is unattractive during the interim and until the ultimate breast reconstruction, because the breast will look shriveled up and empty (similar to a breast with an unexpanded tissue expander), but once the final reconstruction is performed then the skin envelope will be refilled as if the breast reconstruction was performed at the time of mastectomy.

The key to achieving the ultimate breast reconstruction is the nipple-sparing mastectomy. The breast surgeon needs to make sure that she does not remove any skin during the nipple-sparing mastectomy and that she leaves all the skin intact as if there is going to be an immediate breast reconstruction. If she cannot salvage the nipple for oncologic reasons, she can resect the nipple-areola complex alone and close it with a pursestring closure but otherwise preserve the entire skin envelope. This may be difficult for many breast surgeons to accept, because many breast surgeons will naturally focus on the postoperative appearance of a flat chest with empty excess skin, and may be concerned that the breast skin will look deformed until the delayed breast reconstruction. It is crucial, however, to accept this extremely wrinkled appearance of the breasts in order to have enough skin during the ultimate delayed breast reconstruction. Even in large-breasted women, the breast skin will retract during the intervening time (between mastectomy and reconstruction) and it is always possible to resect excess skin later if necessary. Remember, skin that has been injudiciously resected at the time of mastectomy can never be replaced.

When it comes to how long to delay the ultimate breast reconstruction, there is really no time limit. It is preferable, however, to heal completely from the initial mastectomy, because tissues can be friable and delicate in the immediate postoperative period. To allow the body to fully recover from the first oncologic surgery, a minimum of three months after the initial mastectomy is best. During the time of coronavirus, however, longer periods are perfectly acceptable too. A patient may want to make sure that her margins are clear, and that she does not need radiation therapy. If she does need radiation therapy, then she should delay her breast reconstruction until at least 6 months after radiation is completed. Some patients may want to make sure that they do not have any recurrent disease. Risk of recurrence of the primary tumor is highest in the first 18 months after treatment, so some patients may want to wait until after 1-2 years or even later to go back to the operating room for breast reconstruction. No matter how long the wait, the most important principle is to complete oncologic treatment first and then to allow the body to fully recover from the essential oncologic treatment. This is the best preparation for the ultimate breast reconstruction. While it may be psychologically difficult and even traumatic to look at a flat chest with floppy and empty breast skin during the interim, it does not compromise the ultimate aesthetic outcome of the final breast reconstruction at all.

We are living in a difficult time when some hospitals are overflowing with coronavirus patients, and lack the capacity to take on patients for elective surgeries. Breast reconstruction may be prohibited at this time. Furthermore, even when hospitals begin to open to non-essential surgeries, a woman recovering from breast cancer may not want to be the first person to schedule elective surgery as hospitals slowly open to non-coronavirus patients, especially with potential concerns about later waves of disease. Current studies indicate that 50-70% of people infected by COVID-19 are asymptomatic, so it may not be clear who in the hospital is virus-free. The virus has been found lingering in airborne droplets in the hallways outside hospital patient rooms so masks should be worn continually. Caution is advised during the time of coronavirus. For patients who have been newly diagnosed with breast cancer, priorities should be kept straight. Oncologic treatment is paramount - whether it is oncologic surgery, chemotherapy, and/or radiation therapy. Reconstructive treatment can wait, and it can wait a long time. Planning, patience, and prudence will conserve your body’s precious resources during this time, and it will not compromise your ultimate outcome. If you are willing to accept a temporary and interim period of an unreconstructed body, you can still have a delayed breast reconstruction later in time and achieve optimal success in beauty and health.