Double Mastectomy With Saline and Silicone Implants:
A Case Study: Author Christine Talbot SRN MLD DLT
Family History
- Eldest sister, cervical and bowel cancer
- Second sister, oestrogen dominant breast cancer - BRCA2 (BReast CAncer gene 2)
- Patient, triple-negative breast cancer - BRCA2 (BReast CAncer gene 2)
Patient History
- Oophorectomy 2022, due to familial BRCA2. (No known parental history of cancer)
- Right twisted knee 2022
- Double Mastectomy March 2022 plus seven lymph nodes removed right side
- Post mastectomy neck pain
- Spontaneous fracture of T11 and rib fracture 2023
Mastectomy Procedures 2022
March
- Double mastectomy with insertion of saline expanders under the muscle
- Post operative pain and infection in the left scar line within seven days.
April-May
Sporadic saline expansion, planned inflation to 400mls, then silicone of 250
- Non healing of the left wound site, black and pitting, wound glued
- Left breast muscle collapsed and left saline expander leaking
June
Expanders removed, area cleaned, muscle rebuilt, expanders replaced, antibiotics 2/52
August 1st
- Chemotherapy delivered through the saline expanders
- Leg oedema three weeks into chemotherapy, abdominal swelling, heaviness felt in the
- pelvic floor worse during drug therapy
- Olaparib (Lynparza®) (new drug for BRCA related cancer)
September
Left expander re-leaked, never filled properly
January 2023
Planned replacement of saline to silicone implants
March
Radiotherapy 15/52, prostheses became encapsulated
Manual Lymphatic Drainage, 20.06.2023:
The patient was referred for lymphatic drainage by her sister whom I had treated for breast surgery related lymphoedema,
From Mrs S’s consultation, it was clear she had had a catastrophic year as a result of sub-standard surgery leaving her very misshapen and damaged. Her chest was very tight, the breast implants were adherent to the chest wall with little to no movement, the rigidity of the pectoralis muscles inhibited arm movement and the shoulders were pulled up and forward which would account for her post operative neck pain. I was concerned by the level of swelling in her abdomen and Mrs S was upset by the increasing size of her legs which were clearly oedematous presenting with bilateral pitting oedema to the malleoli, the Stemmer at this point was negative.
I thought, hoped, that the presentation of lymphoedema to the lower trunk and legs was a cumulative backflow due to restrictive flow through the upper trunk and shoulders, caused by muscular rigidity and implant compression to initial vessels. The implants were too big, the chest was heavily scarred, distorted and disfigured in shape causing lymph congestion around and below the implants, lymphatic pouch formation in the axillae and below was tracking laterally along the latissimus dorsi towards the spine.
Mrs S was referred to a local lymphoedema clinic for laser scar therapy to the affected areas in a vague attempt to soften the tissues enabling a modicum of pain relief.
Mrs S was in a significant amount of pain overall but was somehow admirably managing to cope with family life, work and her imminent wedding abroad.
Practitioner concern:
In my opinion the implants needed to be removed in an attempt to reinitiate lymphatic flow through a very damaged, scar ridden area and to free up the trunk in order to re-establish some form of mobility and relieve and realign the shoulder uplift and scapula irregularity. I advised Mrs S to go well out of area preferably to top centres in London for a second opinion and to think carefully if she was offered an option of replacing the implants to a smaller size or to make good with what was left following the original double mastectomy. It was at this point I broached the sensitive, emotive subject as to how important breasts were to her and her partner.
I was concerned about the patency of blood supply to an already traumatised operative site following the double mastectomy, radiotherapy, infection and leakage. The propulsion of lymph flow relies upon stimuli from the autonomic nervous system and muscle contraction against vessels, both systems were affected by the surgery and surgical aftermath and could be further compromised in subsequent procedures. We did discuss more local centres but I felt this required specialist expertise. Mrs S had been told the new BRCA related drug Olaparib had to be taken continuously for a year without any surgical intervention which could prevent the removal of the implants, prolonging and worsening over time her lymphoedema status and overall mobility.
Optional surgical refashioning possibilities:
Mrs S was referred locally to a surgeon specialising in Diep Flaps where interim options were discussed should she wish to consider and undergo the lengthy Diep procedure at a later date but she would need to reduce her abdominal weight. In my opinion this gain was lymph related not fat. Even at this point I felt a Diep was far too challenging for her body to cope with and recover from. On the advice of Mrs S’s breast nurse a third, more local opinion was sought, this surgeon proposed to remove the oversized implants from under the rib cage, replace with smaller silicone implants which would be sited on top of the muscle, the scar tissue was to be divided and pig or calf skin fashioned into a saddle support.
At this stage in order to relieve constant discomfort and pain Mrs S opted for the smaller silicone implants with surgery scheduled for 16th November 2023. This could be a temporary solution in preparation for a later planned Diep Flap should Mrs S follow that option. The surgeon considered the rigidity of the breasts was possibly due to chemotherapy related vascular damage and she was referred for a vascular opinion and scan. Nodular lumps appeared on the scan, the November operation was rescheduled for January 2024, re-scanning the chest prior to surgery in the hope these nodules were lymphatic engorgement which would resolve. Mrs S’s oncologists were concerned at the close proximity of the respiratory nodules to a major blood vessel which ruled out radiotherapy. Thankfully Mrs S’s complex case was referred on to specialist oncologists and respiratory physicians in London.
January 2024 Guys Hospital
Rescanning showed two lung nodules, there was concern about an enlarged sternal lymph node close to a major blood vessel. In February Mrs S was to undergo a bronchoscopy to assess the lung nodules with possible biopsies or removal under key hole surgery.
February 2024
Two lung nodules were removed from the left lung.
Mrs S hopes the implants will be removed in October 2024 if the chemotherapy is controlling the tumours.
Following the surgery a 360 blood test detected tumour cells in the blood. Review of the last pet scan showed nodularity in the left and right lung and chest wall. As Mrs S put it, ‘unfortunately not a good prognosis’ but she is hoping chemotherapy will bide her some time.
Practitioner Observations and Concerns
I was concerned about the patency of blood supply to an already traumatised post operative site following the double mastectomy, the encapsulated scarred silicone implants, radiotherapy, infection and leakage and whether the insertion of new, smaller implants would be viable and how these may further impede lymph flow through the trunk to the neck. If the implants failed and the area became necrotic this could be catastrophic requiring plastic surgery with possible skin grafts which would be reliant on a good blood supply, I highlighted a particular case as I felt it was imperative Mrs S was fully appraised of the risks having already suffered so much.
Practitioner’s opinion:
At the first MLD appointment I was horrified to see the level of surgical disfigurement and physical disablement caused. Having over the years treated other breast patients with similar life changing surgeries performed by her particular surgeon I was familiar with his style but this was worse, possibly due to the failure of the expanders under the muscle, the damage to the muscle and the fact subsequent radiotherapy had been applied over silicone implants. The surgeon failed to respond to any further calls from the patient considering his work was satisfactorily complete as in his opinion he had removed her cancer, when he heard Mrs S was seeking local second and third opinions his secretary made contact to arrange an appointment, again his proposals were blasé and high risk.
In conclusion:
I am most grateful to Mrs S for agreeing to share her experience and photographs to accompany her case report, she feels it is important for others facing invasive surgery to be fully informed of all the options, all the risks and the expected and unexpected outcomes of various operative procedures and to be guided not to choose or accept the awful implants imposed upon her. Mrs S had a mere routine thirty minute appointment with the consultant to discuss his choice, she was not offered any pre op forums to speak with others and felt she and her partner were very uninformed and unsupported. Mrs S has been left with significant distortions on her chest which do not resemble breasts and have totally altered her health and well-being.
Tragically Mrs S is left with an outlook that is shortening her life long before time unless the current chemotherapy is able to hold back her cancer and bide her more time.
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This video contains images related to mastectomy surgery for educational purposes
