After Breast Implant Reconstruction:
Following Up on Informed Decisions
by Pat Battaglia
After her breast cancer diagnosis in 2010, Kathy C. consulted with a number of physicians before settling on a treatment plan that included a carefully considered decision to undergo a bilateral mastectomy – removal of both breasts – with implant reconstruction. The surgery and healing went as expected, and Kathy’s life as a young mother gradually resumed its busy pace. Family time was all the more precious to her, and she became a treasured member of the Coalition’s diverse and supportive survivor community.
Breast cancer isn’t a single disease and no two people who face this diagnosis are the same; the treatment protocols and surgical options available to individual patients are complex, varied, and personal. Many, but not all, who undergo a mastectomy choose to have reconstructive surgery, and implant reconstruction is one of several techniques that plastic surgeons use to recreate the shape of breasts that have been removed.
Some reconstruction methods involve transferring tissue from another part of the body to the breast area; this is known as autologous reconstruction. Implant (or nonautologous) reconstruction is different. During this procedure, a plastic surgeon most often inserts a tissue expander, a temporary device that can be injected with saline solution, into the breast area. In a series of office visits that take place in the weeks and months afterward, the plastic surgeon (or a member of their team) gradually fills the expander. This allows the surrounding skin and muscle to slowly stretch and adjust, creating space for a permanent implant. When this process is complete, the expander is surgically removed and the implant inserted in its place.
However, when it comes to breast implants, “permanent” is a relative term. “Breast implants are not considered lifetime devices,” said Dr. Howard Langstein, a plastic surgeon who spoke at a Coalition Evening Seminar in February of 2022 entitled Breast Implants: Understanding the Risks.* He shared the latest FDA guidelines on breast implants, issued on October 27, 2021, which state that, “Even if you have no symptoms, you should have your first ultrasound or MRI at 5-6 years after your initial implant surgery and then every 2-3 years thereafter. If you have symptoms at any time or uncertain ultrasound results for breast implant rupture, an MRI is recommended.”1
Most implants will eventually need to be replaced, as Dr. Langstein noted in his presentation, and patients should be informed of that fact prior to their surgeries. The newly released FDA guidelines address breast implant details through several actions, including new labeling requirements and a checklist of potential complications for surgeons to review with their patients prior to surgery.1 As with all surgeries, the risks and benefits are carefully weighed to empower informed decision-making about these procedures.
Virtually all breast implants, whether used for reconstructive or cosmetic purposes, will cause the body to form a protective layer of scar tissue called a capsule around the device. This is normal. However, in some cases, the capsule thickens and tightens around the implant. This may cause it to change shape and, in a few instances, to rupture. The condition is called capsular contracture, and it is the most common complication following breast implant surgery. It is also one of the most common reasons for surgical replacement or removal of implants.2
Five years after her surgery, Kathy noticed rippling in one of her reconstructed breasts. After consulting with her surgeon, she underwent an MRI which showed that capsular contracture had caused her implant on that side to rupture and leak. Even though the other implant was still intact, Kathy and her surgeon decided it would be best to replace both of them. The surgery was scheduled and completed. Kathy healed well and, once again, life went on.
Another five years passed and she began to consider the monitoring protocol her plastic surgeon had advised; it was time to schedule an MRI to monitor the integrity of her implants. When Kathy called her imaging center, she learned that according to the center’s protocol, a mammogram would be scheduled first, and then an ultrasound if needed based on the mammography results. If more information was still needed, an MRI would be considered. “I hadn’t had a mammogram in ten years,” Kathy stated, recalling that her surgeon had advised her that these screenings were no longer necessary after her bilateral mastectomy. She was unsure about how to proceed.
Meanwhile, Jennifer (Jen) D. was experiencing a similar situation. “My OBGYN felt a lump or bulge during a routine appointment and suggested that I see my plastic surgeon to determine what it was,” she shared. Recalling Kathy’s first experience with her implants, Jen reached out to her and learned of her current dilemma. They have remained in touch, sharing their subsequent experiences with each other and with us at the Coalition.
Jen acted on her OBGYN’s suggestion. “My plastic surgeon ordered an ultrasound to determine whether it was capsular contracture. When I was going to schedule the ultrasound, I was told a mammogram would need to be completed first.” Like Kathy, Jen was hesitant. But, offered the reassurance she would receive a specific type of mammogram that uses less pressure on the breast area than a typical screening procedure, she agreed. Based on the results of that mammogram, the radiologist recommended an ultrasound, which confirmed capsular contracture. In reviewing the imaging results with Jen, the radiologist let her know the mammogram had not yielded any information that was useful in her case. He suggested that for monitoring her implants in the future, she should schedule a mammogram, then ask to consult with him when she checked in for her appointment. “I will tell them you don’t need a mammogram,” he said, and would order an ultrasound instead.
With capsular contracture confirmed by ultrasound, Jen recently underwent surgery to replace her implants and is now healing.
Screening mammograms after a mastectomy are a matter of medical advisement, and recommendations from different sources can and do vary. However, after implant reconstruction, the criteria of the American College of Radiology state that, “There is no relevant literature to support the use of mammography for screening in this clinical setting.”3 Individual recommendations are based on individual circumstances. For instance, a diagnostic mammogram may be advised if a symptom such as a lump, thickening, or rash occurs. Those who have undergone nipple-sparing mastectomy may be advised to have yearly screening mammograms due to the amount of breast tissue left behind in some instances. In any scenario, mammography is not regarded as a reliable way to monitor breast implants.4
To learn whether insurance coverage might play a role in which imaging procedure(s) might be recommended for monitoring patients with breast implants, I contacted Excellus Blue Cross/Blue Shield, a major health insurer in our area. I was directed to their corporate medical policy for approval of MRI to assess the integrity of breast implants: “To confirm rupture of silicone or saline breast implants, when necessary, in patients whose ultrasound is nondiagnostic of rupture.”5 At this writing, this policy is under review. Excellus has no separate policies for mammography or ultrasound of the breast and preauthorization is not required for these procedures. Corporate policies vary among insurance carriers and are subject to revision. Those with implant reconstruction may find it worthwhile to check with their insurance carriers to determine their individual coverage.
Mammography is currently the most reliable method of detecting breast cancer. Digital mammography, in particular, identifies 85% of cancer cases.6 Mammograms are not, however, the current standard of care for monitoring breast implants. The FDA guidelines state that ultrasound and/or MRI are the preferred modalities depending on patient circumstances.
Kathy, in seeking the procedure(s) to monitor her implants that will yield the most useful information, remains steadfast that a mammogram isn’t needed for her. “I shouldn’t have to fight this hard to get my implants checked,” she maintains.
Those who undergo surgery for breast cancer will live many years with the results, and informed decision-making is vital. The field of medicine is not static, nor do most patients expect it to be. As new information comes to light, new guidelines emerge, and standards of care change and evolve over the course of time. Ideally, those in the aftermath of a breast cancer diagnosis make informed decisions using the best information available to them at the time. However, conflicting advice among different providers can be difficult to sort through. Ultimately, the decision rests with the patient. It’s not an easy place to be. The situations survivors have shared with us at the Coalition regarding long-term follow-up care for their breast implants, illustrated in the stories of Kathy and Jen, speak to a need for clear, consistent messaging among providers whenever possible. And when that isn’t possible, evidence-based, informed decisions are in the hands of those who will live with the results – the survivors.
*A recording of this seminar is available. Contact firstname.lastname@example.org.
This story appears in the Summer 2022 edition of Voices of the Ribbon newsletter.