Breast reconstruction after COVID-19

By Daniel Liu, MD

The modern world has transformed since March 2020 when the COVID-19 pandemic took hold in the United States. COVID-19 affected all aspects of life, resulting in drastic policy measures in an effort to “flatten the curve.” Early in the pandemic, non-urgent breast reconstruction procedures were restricted by healthcare facilities to protect vulnerable patients and preserve hospital resources. ASPS even recommended that microsurgical autologous breast reconstruction be delayed, due to the need for higher resources and prolonged hospitalization compared with implant-based reconstruction.

At the time of this writing, the world has confirmed more than 200 million cases (36 million of those in the United States) of COVID-19, resulting in more than 4.3 million deaths (more than 600,000 in the United States). Multiple waves of infection caused by variants of COVID-19 continue to affect both the economy and healthcare system. However, the introduction of multiple, highly effective COVID-19 vaccines is nothing short of a medical miracle. In other words, COVID-19 has essentially become a preventable disease. Immunized individuals can enjoy a radical risk reduction in contracting the virus, spreading the virus, hospitalization, serious illness and death. This remains the best way that breast cancer patients can protect themselves while undergoing treatments including breast reconstruction surgery. So far in 2021, hospitals in developed countries have not been overwhelmed with COVID-19. Nevertheless, rising hospitalizations among unvaccinated individuals may threaten hospital capacity and delay elective procedures again.

COVID-19 accelerated the pace of innovation across all specialties treating breast cancer, ultimately improving care and reducing costs. Plastic surgeons embraced the rise of telemedicine to meet new patients and efficiently provide follow-up care without travel. There has been an emphasis on more short-recovery procedures, such as direct-to-implant breast reconstruction. Most surgeons have finally adopted Enhanced Recovery After Surgery (ERAS) protocols, liposomal bupivacaine for pain control and outpatient reconstructions to reduce hospital stay. Some questions remain about potential thrombotic complications after COVID-19 infection, which could affect the risk of undergoing microsurgery, and evidence will be forthcoming.

Experts acknowledge that COVID-19 is here to stay. Preoperative screening has become commonplace before surgery and chemotherapy. Antibody-level checks could become part of risk assessment. Infection-control safety protocols remain in place across hospitals and clinics, which limit the number of caregivers to support patients in the hospital. Universal masking will be required in the foreseeable future in healthcare settings.

Nevertheless, it is important that women do not put off getting treatment because of COVID-19 fear. Vaccinations are now widely available, and the healthcare system is better equipped to handle spikes in new COVID-19 variant cases. Experience over the past 18 months has shown that immediate breast reconstruction is safe with all of these precautions in place. There is no evidence that either COVID-19 or the vaccine interferes with anesthesia. Still, undergoing surgery temporarily places extra strain on the immune system. For patients who have recovered from COVID-19, the American Society of Anesthesiologists (ASA) recommends waiting from four weeks (for those with no symptoms or mild symptoms) to 12 weeks (those admitted to the ICU) before having elective surgery.

Because the COVID-19 vaccines available in the United States do not contain live viruses, they can be safely used in people with weakened immune systems – including cancer patients. The vast majority of people with breast cancer or a history of cancer should receive a COVID-19 vaccine. Minor side effects are to be expected and represent a sign that the vaccine is working by mounting an immune response. Women who have undergone axillary lymph node removal could theoretically experience transient lymphedema as a side effect and should ask to have the vaccine injection in their opposite arm or upper thigh. Some people have experienced enlarged axillary lymph nodes under one arm, which is harmless, but may lead to unnecessary stress and additional testing. The Society of Breast Imaging recommends that women try to schedule their routine screening mammogram at least one month after vaccination. Recently vaccinated patients undergoing scans to monitor cancer progression (such as PET/ CT) may lead to misinterpretation of enlarged lymph nodes, and coordination will be essential to reduce wasted scans. Regarding the timing of elective surgery, the vaccine should be administered at least one week before surgery so that symptoms, such as fever, can be correctly attributed to vaccine side effects rather than surgery. Vaccination can also occur once patients are recovered, one to two weeks after breast surgery, to be assessed on an individual basis.

If the current COVID-19 vaccines continue to be effective, the pandemic should be nearly over in developed countries. For the short term, COVID-19 will likely become a seasonal illness, until global vaccination can be achieved. Challenges lie ahead including revaccinating against variants, treating long COVID and mental-health issues. Humans are remarkably adaptable, and your surgeons remain committed to helping you navigate through breast reconstruction in a safe environment.

ASPS member Daniel Liu, MD, is a boardcertified plastic and reconstructive surgeon at Cancer Treatment Centers of America® in northern Illinois. He specializes in all forms of breast reconstruction and is passionate about promoting public education on breast reconstruction and plastic surgery.