Possible problems with breast reconstruction

Breast reconstruction techniques have been improving for many years. There are fewer and fewer problems. But some women do go on to have complications after breast reconstruction surgery.

As with any operation, there is a risk of complications. A complication is anything that happens after surgery that makes your recovery more difficult. For example, wound infection is a possible complication after any surgery.

Before offering surgery to you, your surgeon makes sure the benefit of having the operation outweighs the possible risks.

Your surgeon will talk to you about the possible complications of the surgery and having a general anaesthetic before you sign the consent form to have the operation. The doctors and nurses monitor you very closely after the operation to check for any problems.

Some of the possible problems after having breast reconstruction surgery include:

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 

Contact your 24 hour advice line immediately if you have any of these symptoms and think you might have an infection.

If you’ve had an implant reconstruction and the infection continues your surgeon may need to take the implant out and clean the area.

Depending on how bad the infection is your surgeon may put in a tissue expander. You might have this put in straightway or after a short period of time. This helps keep the skin and empty space open so you can have a new implant at a later date. Sometimes your surgeon may wait for a few weeks before doing further surgery.   

A wound infection can be a major problem and can delay further treatments such as chemotherapy, radiotherapy or targeted cancer drugs. These can all impact the natural healing process. You usually start further treatment when the infection has cleared up and the wound has healed.

Fluid build up 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.

Having surgery to remove all or most of the lymph nodes in your armpit (axillary lymph node dissection or clearance) can increase the chance of a seroma lasting.

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 breast reconstruction with an implant and seroma fluid continues to build up you are at risk of developing problems. This could mean 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. However, surgeons are using different techniques to help lower the chance of a seroma forming.

Build up of blood under the skin (haematoma)

If blood collects under the skin it is called a haematoma. The breast may be painful and swollen. You might have to have another small operation to remove the blood.

Break down or loss of skin, nipple or areola (skin necrosis)

Sometimes part of the original breast tissue, nipple or areola can die because there is a poor blood supply. A possible sign is the area may change colour, turning the skin darker.

You are more at risk if you:

• smoke
• have had radiotherapy to the area before
• have a connective tissue disease such as rheumatoid arthritis or lupus

If this happens your surgeon might monitor the area and see if the skin will heal itself. If you have a tissue expander in place they might deflate it to take some pressure off the skin. Or you may need another operation to remove the dead skin and further surgery to make the breast symmetrical to the other breast.

This all depends on the size of the area affected, how severe it is and where it is.

If you notice any unusual changes let your breast surgeon or breast care nurse know straight away.

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 (hard) 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.

Contact your doctor or breast care nurse if you notice:

• a swelling or lump
• the breast is painful
• the breast feels different 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 Non-Hodgkin lymphoma of the breast. But this is very uncommon. This is called breast implant associated anaplastic large cell lymphoma (BIA-ALCL). This usually develops many 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.

Let your surgeon or breast care nurse know if you develop any unexplained swelling of the reconstructed breast with an implant. Or you have noticed new lumps in the breast or armpit following breast reconstruction with an implant.

Wrinkling or rippling appearance

Sometimes an implant can show rippling or a wrinkle appearance in the breast. This is more common in thin women. And more common with saline implants rather than silicone implants.

Your surgeon might use a surgical mesh to help hide and increase thickness of the breast to prevent this from happening.

Another way to help lessen this appearance is having lipomodelling or lipofilling. This is when your surgeon injects fat that is taken from another area of your body and injects it into the breast to help reshape it. 

Longer term problems with body tissue reconstruction

There are possible problems after reconstruction surgery with body tissue.

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)

This might happen if the blood supply to the fatty tissue isn’t good enough. This can cause the flap to develop a hard lump which is a collection of dead fat cells. It can develop a few weeks after surgery.

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. 

Longer term problems with any breast reconstruction

Scarring

You'll have a scar. The size and shape of your scar will depend on the type of surgery you have had.

Scars are quite noticeable and red to start with, but they get paler and less noticeable over time. Some scars can be quite thick and raised (hypertrophic or keloid). Talk to your surgeon or breast care nurse about any worries you might have about your scar.

Shoulder stiffness

Your shoulder might become stiff and painful after breast surgery or removal of the lymph nodes.

Your breast care nurse or a physiotherapist will show you exercises to do after your operation to help improve movement in the shoulder.

Problems after lymph node removal

If you had surgery to remove lymph nodes in your armpit (axilla), you might have other problems after surgery.

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.