Possible problems with breast reconstruction

Breast reconstruction techniques have been improving for more than 20 years. There are fewer and fewer problems. But some women do have complications after surgery.

Problems immediately after surgery

Blood clots 

After surgery, you're at risk of blood clots developing in your legs. There is also a small risk of a blood clot in your lungs.

To prevent blood clots, your nurses get you up as soon as possible after your operation. They encourage you to move around or do your leg exercises.

To help reduce the risk of blood clots you may have injections to thin the blood (anticoagulants) before, during and after your surgery. Your surgeon will talk to you about this beforehand if you need to have this. 

They may also tell you to stop taking particular medicines for a week or so before your surgery.

Also, during and after your operation, you wear special stockings (called anti embolism stockings or TEDS). 

Wound infection

Infection is a risk in any surgery. If you develop an infection after breast reconstruction, you will need to rest and take antibiotics. Usually, this clears up the infection over a week or so.

Symptoms of infection include:

•    a temperature of above 37.5C or below 36C
•    redness around the breast    
•    fluid seeping from the wound (discharge)
•    feeling cold or shivery 
•    Feeling generally unwell 

If you’ve had an implant reconstruction and the infection continues your surgeon may need to take the implant out. You may need to wait for about 3 months before having another implant.

A wound infection can be a major problem and can delay further treatment. Chemotherapy drugs will stop the natural healing process. You usually start chemotherapy when the infection has cleared up and the wound has completely healed.

 Fluid under the wound  (seroma)

After any surgery, it is normal for the area to produce fluid. You might have two or more drains into the wound to drain off the fluid. The drains are usually long thin tubes attached to vacuum bottles. Even if you have drains, fluid can sometimes collect under the wound and create a swelling. This is called a seroma. If blood collects, it is called a haematoma.

Sometimes the fluid will be reabsorbed by the body and the swelling will go down on its own. But if the fluid doesn't go away after a few days, your surgeon or breast care nurse will remove it using a small needle and syringe. 

If you’ve had an implant reconstruction and the fluid continues to build up, you might need to have the implant taken out and replaced with another one later.

Seroma used to be quite common after flap reconstruction from the back. But surgeons have improved techniques so that it is now much less likely.

Flap failure

The main problem with body tissue reconstruction is that the flap of tissue used to make the new breast might die. With a flap that stays connected to its original blood supply (a pedicled flap), this is much less likely. 

Free TRAM flaps and DIEP flaps have to be disconnected and reconnected to a new blood supply. With these techniques, some people can develop problems with the flap blood supply in the first 48 hours after surgery. If this happens, you will need to go back to the operating theatre urgently to try to save the flap. 

About 3 out of every 100 (about 3%) flaps fail completely and the cells in the whole flap die. If this happens, you will need to have surgery to remove the flap.

If your flap fails completely and is removed, you will need to recover fully from the operation. You usually have to wait about 6 to 12 months before you can try to have reconstruction again.

Loss of sensitivity

Your reconstructed breast will feel different to your other breast and have less sensation. After surgery, you might have numbness or pins and needles. The sensation may improve over time but for some people, it may not.

Longer term problems with implant reconstruction

There can be problems after implant surgery, whether you have tissue expansion or the implant put in directly.

Hardening and changing shape of the implant

The main long term problem after implant surgery is that a fibrous covering might form around the implant. Silicone is safe but it is still foreign to the body. It is a normal reaction for the body to form a fibrous capsule around it.

Over some years, the capsule can shrink and squeeze the implant. Doctors call this capsular contracture. It makes the breast painful and hard and changes its shape. If the shape changes a lot, the implant might need to be taken out and replaced.

Leakage of the implant fluid

Many women worry about the implant developing a leak. With newer types of implants, the risk is much less likely. But you could get leakage if you have some major injury or blow to the breast.

Minor bumps and bangs won’t cause a leak and nor will air travel. If the implant does leak, it can make the lymph glands under your arm swell up.

Do contact your doctor or breast care nurse if you notice a swelling or lump, if the breast is painful or the shape of the breast appears different. The implant will need to be removed and replaced if the implant has leaked. 

Unequal breasts 

Over time your reconstructed breast may no longer match the other one. This can happen if you lose weight or the implant moves. In this situation, you usually have surgery to try to get a better match. It's not usually possible to make the breasts exactly the same on both sides. But your surgeon might be able to make them more equal. 

You could have an operation on your other breast if your weight changes. Or the surgeon could replace the breast implant with a larger or smaller one.

A need to replace the implant

Some implants may need to be replaced after 10 or 15 years or so.

A rare type of lymphoma of the breast

Some women who have implants develop a rare type of lymphoma of the breast, but this is very uncommon. This is called anaplastic large cell lymphoma (ALCL) and usually develops some years after your implant surgery. It’s not clear why this happens. There is ongoing research to try to understand more about this condition and how it develops.

You will have regular follow up appointments after surgery and your surgeon will check for any signs of lymphoma. Let your surgeon know if you notice any lump in the breast or if the breast becomes swollen. This type of lymphoma is usually easy to treat with surgical removal of the lymphoma and the implant.

Longer term problems with body tissue reconstruction

There are possible problems after reconstruction surgery with body tissue.

Loss of part of the flap

Loss of tissue in part of the flap can happen with any body tissue breast reconstruction. It is more common with TRAM flaps that keep their original blood supply (pedicled TRAM flaps) and with DIEP flaps.

The blood supply to part of the flap is lost and the tissue in that area dies. First of all, the area becomes painful and hard. Then the affected part of the flap shrinks, making a hard scar within the breast. You may also end up with a smaller breast. This problem is more common in heavy smokers or people with poor circulation.

Dog ears

With abdominal flap reconstruction, little folds of skin and fat can sometimes develop at either end of your abdominal scar. Doctors call these dog ears because that’s what they look like. Most small dog ears settle with time, but you may eventually need to have a small operation or liposuction to get rid of them. You can have this under local anaesthetic, usually about 6 months after your original surgery.

Abdominal hernia

A hernia is a hole or weakness in a muscle wall that allows the structures behind the muscle wall to push through. After abdominal flap reconstruction, there is a small risk of an abdominal hernia in the future because the surgeon removes part of the abdominal muscle.

Hardening of the flap (Fat necrosis)

Sometimes the flap may become hard. This may develop a few weeks after surgery. This is called fat necrosis. This may cause an infection and you may see fluid leaking around the reconstruction site.  Although this is rare it is important to contact your surgeon or specialist nurse if the area feels hard, or you have any concerns. 
 

More support and information

You are likely to have emotional ups and downs after surgery for breast cancer and breast reconstruction. Even months afterwards, many women find it helpful to talk about their feelings and ask about things that worry them.

Your breast care nurse is probably your first source of support. They can talk you through a lot of worries and put your mind at rest. 

Other women who have already been through similar surgery can also be a great help. You can ask your nurse or doctor to put you in touch with someone who has had similar surgery or similar complications.