**5. Life after breast reconstruction**

The long-term effects of breast reconstruction after mastectomy in the prophylactic setting or in the breast cancer patient must also be mentioned at this time, as they are quite significant. The long-term outcomes these patients must contend with include physical and psychosocial concerns. The physical ramifications of breast reconstruction include but are not limited to; post mastectomy pain, long-term surveillance of the reconstructed breast, continued maintenance of the reconstructed breast, and decisions around nipple reconstruction/tattooing. The psychosocial aspects include loss of self, loss of sexual identity, loss of libido, and inability to connect with their partner physically and emotionally.

In regard to the physical components of life after breast reconstruction, post mastectomy pain may be the most common complaint noted among patients. Physical therapy, injections with local anesthetics, muscle relaxants, and medications for nerve pain can be used to assist in control of these symptoms. If the nipple areolar complex was removed at time of surgery, a decision must be made as to whether or not the patient would like to proceed with reconstruction of the nipple areolar complex. This may be performed via multiple different techniques, including 3-D tattooing. The long-term maintenance of the reconstructed breast previously mentioned can include things such as fat grafting and tissue transfers should areas of deficit be noted. Should the patient undergo an implant base reconstruction and reach the shelf life of that implant, the implants may need to be replaced. Long term maintenance of the reconstructed breast can also include further evaluation if new concerns develop, imaging of new findings with appropriate tissue diagnosis if necessary, and biopsy of areas of fat necrosis contained within the breast reconstructed with autologous tissue. Revision of the reconstruction may be required based on the cosmetic changes that appear overtime.

Long-term surveillance of the reconstructed breast and evaluation for cancer recurrence entails clinical exams at the discretion of the medical oncologist and surgical oncologist. This frequently means clinical exams every three to four months for the first two years and biannual exams between the second and fifth year after diagnosis. Yearly breast exams at the very least to follow. There would be no need for screening mammography to be performed after bilateral mastectomy with reconstruction, though imaging may be used in the diagnostic setting to work up a new breast related complaint.

The psychosocial ramifications for the patient after mastectomy with breast reconstruction are much harder to elicit and to quantify. Many if not most patients do not feel comfortable discussing with their doctors the most intimate aspects of their personal lives. It is noted however that many woman who have undergone these procedures have trouble with a negative body image, feeling that they are hideous to themselves and others post-operatively. They can sometimes feel less than human in losing a part of themselves. They can certainly feel like they have lost an essential part of what makes them a woman, harming their sense of gender and sexual identity. Physical intimacy with a significant other or spouse is a challenge for these individuals and many of them do not engage with their loved ones on that level for a prolonged period of time. A woman's breasts are also deeply rooted in their maternal nature as well and that loss can be devastating to a young woman looking to having children or with young children at home [6, 7].

Patients who are facing the decision to undergo or who have had a mastectomy with reconstruction are then faced with feelings of anxiety, confusion, fear, and often depression. The loss of a breast can leave a woman feeling that they will never be seen

as beautiful again. If they are unmarried they might feel that they will never find a husband, get married, and have children as they had hoped. Those with spouses or significant others may feel that they will be viewed as unattractive and untouchable and continue the spiral into a lack of desire for intimacy. In addition, for the many woman whom anti-estrogen therapies are recommended, they may suffer from side effects that further decrease their libido and may actually make intimacy painful. Preoperative, post-operative, and survivorship resources should be offered in counseling, psychological therapy, support groups, and management of treatment related side effects to ease the journey [6, 7].

#### **6. Conclusion**

The journey for the patient with a breast related concern or breast cancer that includes breast reconstruction is one that is delicate to navigate. The path forward must be directed by that individual as it is a very personal one. Though they may have many care givers, family members, and/or friends who are full of opinions, only the individual involved can even begin to fathom how the outcome will affect them emotionally and physically. It is the job of the physician to discuss as clearly as possible all the options available to the patient and all the potential risks and benefits of the paths they might choose. They must establish clear expectations as to what the pre and post-operative outcomes may look like. It is also important that the physician and institution of which they are apart work to provide all the resources that a patient may need to face all aspects of their care, even if it is simply additional time to process all that is happening.

The ramifications of the decisions these patients make extend throughout the remainder of their lives. The surgery that the patient undergoes will forever alter how their breast care will be provided, the ability of the breast care team to provide breast imaging, their breast exam, and their options for breast cancer surveillance. It is also worthy of reiterating that no surgery is without a risk of requiring additional surgery and this idea must be explored. The short term and long term complications of surgical intervention are significant as well and must be acknowledged, as should their risk for breast cancer development prior to surgery.

Beyond the immediately pre and postoperative changes noted after a patient undergoes breast reconstruction, the breast patient who undergoes mastectomy with reconstruction for breast cancer may necessitate some additional attention. The breast cancer survivor after mastectomy with reconstruction has increased physical and psychosocial needs related to treatment. Local treatments like radiation can increase the complication rates noted after reconstruction as well as increasing the risk of lymphedema associated with axillary surgery. Post-surgical range of motion may be an issue necessitating a physical therapy referral. Pain management may also need to be addressed.

The emotional component of breast cancer surgery should also be reemphasized as it is often under-appreciated and overlooked. Support groups, counseling services, psychological services should all be used as appropriate to ensure the mental health of the patient. Distress screening to evaluate for issues concerning to the patient should also be performed at regular intervals to ensure the patient's needs have not changed from prior discussions. Side effects related to systemic therapy should routinely be evaluated and treated as appropriate as they may have implications in regard to the emotional as well as physical components of their care.

*Screening, Surveillance, and Survivorship after Breast Reconstruction DOI: http://dx.doi.org/10.5772/intechopen.112914*

Notably, in this setting surgical intervention does not only affect the individual it also can alter their relationships with others. The loss of a breast, no matter how cosmetically pleasing the outcome, alters the patient's self-image and with that their ability to feel like the whole and beautiful woman that they are. Their friends, family, and significant others are sure to see this in the way they relate to them; especially as far as moments of intimacy with their romantic partners. Relationship counseling or marriage counseling is an option that can be explored in this particular setting.

The surgical oncologist as well as the plastic surgeon and the remaining breast care team should strive to provide truly holistic care for their patients that takes all of the aforementioned points into consideration. All these concerns should be brought up and addressed at the earliest point possible to ensure the best physical and emotional outcome for the individual involved. Referrals should be made to appropriate team members if a patient's needs fall outside a particular area of expertise. The person as a whole must be incorporated into their care with their unique personality and goals of care taken into consideration; as it is only when we look at all aspects of an individual's needs that we can then provide the care that they deserve.

#### **Acknowledgements**

I would like to acknowledge and express my gratitude to all the mentors who contributed to my training and my patients who allowed me to care for them.

#### **Conflict of interest**

I have no conflicts of interest beyond the fact that my perspective may be biased as I am approaching this topic from the perspective of a breast surgical oncologist.

#### **Author details**

Karinn Chambers ECU Health, Greenville, NC, USA

\*Address all correspondence to: chambersk22@ecu.edu

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
