Expanders vs LD FLAP when rads are an issue

Public Archive
1

Hi, I am 41 and will have a mx at the end of this month followed by rads in Sept. I am thinking of having a recon so I was given two main options:

  1. Expanders put in on the day of the mx, which would be replaced with more permanent silicone implants at some point after the rads
  2. go flat after mx, and 6 months after rads do an LD FLAP recon (with implants because I am not fat enough)

LD FLAP sounds like a big operation to me (I was told it takes 5-6 hours and then 8-12 weeks to recover) and it would happen exactly at the time when I would start to feel well again after this terrible treatment, so I fear it would set me back and would ruin yet another spring/summer (my kids are only 3 so it matters to me). I really hate the idea of that.

I would much prefer the immediate expanders because I would get through the toughest side of the treatment now rather than next year, and the operation doesn’t sound as big, as it only concerns the breast area. The problem is that I heard from many directions that the risk of capsular contracture (CC) when the radiotherapy is done on a breast with expanders (or implants in general) in place is significantly higher. I haven’t been given specific figures so I find it difficult to decide between the two options. I would be prepared to have minor surgery to then try to fix problems due to CC but I would like to know statistically how many reconstructions end up looking good when done with expanders-then rads-then permanent implants incl additional small corrective surgery if needed.

I would really appreciate to hear about other people’s experience or what everyone else has been advised to do by their surgeon. Also, I would like to know whether the LD FLAD is such a big ordeal or not.

2

Hi I started of with the smaller op the mx with expander implants.Then it was decided that I needed radiotherapy. After radiotherapy the expander implant went hard. The breast surgeon then suggested that I should have the LD flap operation with a silocone implant. I took her up on this. She found during the operation that she needed to put an expander implant again. This will be gradually filled with saline and then exchanged.
If I knew what I know now I would have had the LD flap to start with. It is a long op but the same day I was able to watch the tennis,drink a cup of tea and eat a biscuit. I was in bed for two days due to a collapsed lung but was very well looked after and given plenty of pain relief. I had a catheter whilst in bed which I hardly noticed.I had the op on the Wednesday and came home on the Monday with one drain in. Am still taking things very steady but am able to make snacks and potter about. Am still taking pain relief but have some discomfort some of the time rather than pain. My children are grown up the youngest is nearly 17. You would need someone to help look after them at first. It is doable im certainly not brave when having things done,just a bit fed up that its taken 19 months to get to this stage. Do all the research you can and talk to as many people as you can who have had either op.

3

Hi Barbwill

Macmillan do a really good section on the different recons and what’s involved. The general consensus seems to be that the LD flap will give a better cosmetic result, but on the downside it is a bigger op and possibly carries the risk of more complications.

macmillan.org.uk/Cancerinformation/Cancertreatment/Treatmenttypes/Surgery/Breastreconstruction/Breastreconstruction.aspx

Different surgeons/teams have different preferences as to what they offer and will/won’t do, but my understanding is that you may have one, if not two, other options. (sorry to complicate things!)

  1. Skin sparing mx, with a temp implant, followed by the LD flap recon + implant - keeping as much skin as poss at the start means that you end up with fewer scars, both on your back and on the new boob.

  2. More controversal, but an immediate LD flap recon.

I had MX to left breast and immediate LD flap +implant recon on the 26th Jan.

I didn’t have enough tummy fat to consider those options with no implant but not skinny and was a 34/36 C/D cup (depending on weight and bra make!) before surgery, so needed the implant, but not too big to have to consider a reduction on the ‘good’ side. I’m 49 and my boobs, tho quite good, certainly weren’t as perky as when I was in my 20s.

My plastic surgeon (who took over once the BC surgeon had done the MX and lymph node removal) has done a great job of matching my ‘new’ boob to the old one - even down to the right level of ‘droop’!

Had hardly any pain post surgery - didn’t need morphine pump. Had op late Fri, out of bed on Sat and walking the corridor on Sun. A week in hosp - they didn’t let me go til all drains removed. Did get a seroma on back that needed draining a few times, but that resolved itself quite quickly. I was driving and back at work (part time for a couple of weeks at first) 6 weeks post op.

Five months post surgery and the new boob is really starting to feel like it belongs to me - obviously don’t have the same level of feeling and it still feels a bit firmer and heavier than the other one, but improving all the time. It’s a bit bigger than the other one but this may still alter (particularly with the rads I’ve now got to have) and I have a port in the implant so it can be adjusted at a later date if needed. It’s a bit perkier (they are now nicknamed Pinky and Perky) than the other, but all of this is totally unnoticable in bra and clothes - and I’m wearing lowish cut tops with a totally natural cleavage. Still in a sports bra 24/7, but I think that mainly cos I’ve got used to it and find it v comfy compared to my previous underwired lace numbers!

My scars around where the nipple was and on back are improving all the time ( I do use Bio Oil). I can see that the nipple area scar will be v difficult to spot in a year or two. The scar on my back is bigger and more ‘serious’, but still improving and is covered by my bra strap. Where they passed the muscle thru under my arm is now a bit bulkier than the other side - but everyone else says that they don’t notice it - and have worn quite fitted t-shirts.

My shoulder and under my arm still feel a bit stiff and tight, but I have virtually full range of movement, strength and am back gardening and horse riding - albeit carefully!

I’ve found out that they are also now recommending rads. I knew at the start that it was a possibility, but went ahead with the recon with the full support of both surgeons. The recon has no effect on the effectiveness of these, but as you know radiotherapy can adversely effect the recon - mainly due to the risk of capsulation round the implant, causing hardening. This was a calculated risk I took - my plastic surgeon said that even if that happens and, worse case, down the line I need the capsulation removed and a new implant, the final cosmetic result will still be better than a delayed recon. That’s also a much smaller op, than having to go through two major ops in the space of 12-18 months.

Overall I’m very pleased and don’t regret my decision. Sorry for such a long reply, but hope it’s helped.

Good luck!

4

Hi

I went around the block before I came to my decision about mx and recon.

Rads have always been on the cards for me. Im a 36 B/C. I’m 42.

I was offered just an implant at first, with the understanding that if it went hard I’d have it removed and then have LD. Reading up on this it seemed like a certainty that this would happen and I didn’t see the point in having a procedure that would then lead to another so I got a 2nd opinion (I got his name from a daily mail article about best breast surgeons - I’ll try and find the link if you want it and pm you).

He said LD straight away with no need for implant. We were thinking that we’d go with him but decided to listen to the original consultant after she’d had her team meeting.

What was great was that, without prompting, she said that they had decided that LD straight away was the best way, with a small implant to lift away from chest wall and to counteract shrinkage of rads. So we went with her.

I’m 12 days on. I had 4 nights in Hosp (I asked to stay an extra night). Op on fri, walking the corridor on sun. My arm movement is ok but again I asked to see a physio before I was in and during my stay so that it wasn’t stiffening up at all.

Im really quite pleased with ‘Babs’. LDs start with a bulge under the armpit but with normal movement and gravity it shifts to the front - this is happening already and she feels softer. Obviously I’ve still got rads to get thru but they’re hoping that because they’ve made her bigger she will shrink to match. The front scar is literally where the nipple was and so not bad at all. The back one I can see will be fine once settled. I have a seroma, which I’ve had drained once (no pain) and seems to be slowing down.

Crikey! Long post. Pm if you think I can help. X

5

And another thing! All chest wrinkles have been stretched away!
X

6

I’ve had an LD flap done on both sides. One last year which was immediate and I went on to have chemo and rads. My implant has gone hard, but it is rare for this to happen. They spread the rads over 25 days with a reduced dose to try and avoid this, but I had to have a bolus during rads which directs the rays onto the skin and directly below, which they think caused the problem.
Cosmetically I am pleased with the result. They both look good.
The recovery from the op was fine. Yes it is long. The first op I was up the same day, the second time I was up and about the next day. I did the exercises and have full movement back in both arms. I spent 5 days in hospital both times, came home with drains both times. After about 2 weeks felt fine and could manage cooking etc for my family (3 children aged 5,10 and 13), was driving after 2 weeks and walking around to get some exercise with no problems. Swimming after 4 weeks.
My BCN recommended 6 weeks recovery time and I have to say after 3 weeks felt fine. I go back to work next week, which is 7 weeks after the op.
The only thing is getting used to the new feelings, some numbness.
Good luck with your choice.
cat

7

Saw two surgeons yesterday and I was told that in slim women who need rads, reconstructions often don’t look great. I was told that immediate expanders option has 50-60% chance of failing, and LD flap with implant underneath, my only other option on the NHS, has about a 30% chance of failing. We then went through the other pros and cons and I decided that in my particular circumstances most of the other considerations weigh all in favour of the immediate expanders.
I also realised that I am not prepared to go to great lengths for the recon at this point, given that I also need to still take the other breast and my ovaries/womb out so still a long road ahead. Going for ld flap with implants would mean putting my life on hold for another 3 months during summer/autumn of next year, when my kids will start proper school in Sept. Just not the right time, I went through 5 years of infertility and IVF to have them, I don’t want all their early years to be affected by this stuff.
And what’s the point to go through a much bigger operation next year when the final result is not going to be that great anyway. I have realised that to me it doesn’t matter that much in the end, I’ve had a good look at the breastfree website and I see that women can look good breast free even in a bikini, so if things go really bad I am happy to go for that option.
And if I change my mind I can always try with LD flap in the future.
Also, interestingly the surgeon told me that ld flaps with an implant tend to end up looking not great after a couple of years because the muscle transplanted from the back tends to thin and disappear.
So that’s it, I’ll tell the nurse prob on Monday that my decision is taken, they’re going to order my new breasts in and the old ones will expire in just over two weeks. I don’t think I can ever be prepared to see a part of my body go, like I never felt prepared for the hair loss, but I didn’t react badly to the hair loss in the end. I still get a huge amount of stares everywhere I go and I just don’t think it would be like that if I was breast free, no one would really notice apart from my husband. He’s not thrilled at the idea but he agrees and supports me fully.

8

Hi,
this is my experience; I had a mastectomy after neo adj chemo I had to have chest wall rads so was told no immediate recon as my surgeon likes the chest skin to settle for min 12 months after rads.
I had ld flap with implant done 18 months after mastectomy. Now 9 months on it looks fantastic, I have had a lipofill to fill in a small dent and on mon will have my other side lifted and reduced to match with another lipofill.
The ld flap op for me lasted nearly 10 hours I was in hosp for a week and took 10 weeks off work, the 1st lipofill was done 6 months later ( this has helped soften the damaged area) and I was fine after 2 weeks mainly sore and bruised where the fat had been removed.
The rads have damaged my skin especially where I had the extra boosts and made the area under this firm but because I waited for my recon this was not drastically affected, my result is good and when I wear a low cut top no one can tell which is the good one and which is the recon.
I also have full movement in my arm.
On the down side I have a 12 inch scar on my back as they needed to take a greater amount of skin than usual as my tumour had attached itself to my skin,but this is fading rapidly. Then there is the longer time spent recovering and the time spent in and out of hosp over the last 12 months.There is numbness on one side of my back , I was already numb on my chest wall so no difference there.
I no longer notice this but I have to be aware not to lean against hot things as I would burn and not feel it.
For me this was a good choice and one I know I would do again, my result has been good and having lived breast free for 18 months I felt that this was the right thing for me.

Good luck with your decision.