Breast reconstruction for GPs: implants, DIEP, radiation, and a failed salvage

Kate — introducer

Opens the session. Otter’s first line is badly garbled: “Australia, Sleeping Cancer Research and Treatment Center, Chris O’Brien Lighthouse, Sydney.” Read as the Chris O’Brien Lifehouse in Sydney (Otter wrote Lighthouse). This page does not invent a hospital title beyond that.

Oncoplastic breast surgeon (Otter rendered the name as “Dr Kick”)

Trained at Chris O’Brien Lifehouse, Sydney; now Gold Coast. Otter heard “Dr Kick.” We do not invent a corrected surname. She thanks Kate, then spends the talk on reconstruction options — mostly implants — with two good outcomes and one that was not. A later same-evening radiotherapy talk (Selena) sits at breast-radiotherapy.drkotha.com. Same-day medical oncology: breast-treatment.drkotha.com. Same-day imaging: breast-imaging.drkotha.com.

Audience (Speaker 3) and a closing voice Otter could not label

One usable question: why subpectoral in the salvage case. The last 20 seconds of the recording are unusable (“How expensive / does it create / to her self called the student”).

Who was speaking — and what Otter mangled

Kate introduces an oncoplastic breast surgeon. Otter’s first sentence is almost unusable: “Her in the field of oncoplastic breast surgery at Australia, Sleeping Cancer Research and Treatment Center, Chris O’Brien Lighthouse, Sydney, Dr. Kick have continued to expand…”

What we can use: she is an oncoplastic breast surgeon, trained at Chris O’Brien Lifehouse in Sydney (Otter wrote Lighthouse), now working on the Gold Coast (Otter later said “Gulf Coast”). Otter rendered her name as “Dr Kick.” This write-up does not invent a surname. We do not promote her to a title she did not claim.

She thanks Kate — “You make me sound amazing” — and sets the brief: options for breast reconstruction, mostly implant reconstruction, some good outcomes, then a patient who did not have a good outcome, “just to show you how stressful it can be.”

Why reconstruction matters

Demand and awareness are up. “It’s not all about lumpectomies and mastectomies anymore.” Otter wrote “2050 odd years” for how long reconstruction has been taken away from women; read as the last 20–50 years, with a real focus only in the last decade. Informing women what they can and cannot have is, in her words, “integral to care in the modern breast cancer age.”

Not everyone can have reconstruction. A lot of the talk is how to tell a woman no, and why.

Why it still matters when it is possible:

• Body image through the whole cancer journey — whether reconstruction sits at the beginning or at the end.
• Psychosocial benefit and long-term quality of life.
• When it goes well: restoration of identity, a part of the cancer journey women can feel more positive about.

Options sit in two big buckets: implant-based (this talk) and autologous — using the woman’s own tissue. On a smaller scale, oncoplastic techniques after a large lumpectomy (Otter: “lumbectomy”): a small flap twisted in from the chest wall or abdomen to fill the space.

What it comes down to, as she listed it: can they have it up front, or does it need to be delayed? Private or public? Tumour type. Breast size. How healthy they are.

Implant pathway: DTI versus expander, prepectoral versus subpectoral

Her main operation is direct-to-implant (DTI) reconstruction: take out the breast tissue, leave the nipple or not, replace the space with an implant in the same sitting. She tries to avoid expanders when she can, because that avoids a second operation to swap expander for implant.

Expanders are still common on the Gold Coast. She uses them in high-risk patients, or if radiation may be coming. “It all depends on what you’ve been taught and which approach you take,” plus the patient’s tissue, the tumour, and adjuvant or neoadjuvant therapy.

You can radiate an expander or an implant. Same foreign-body risks either way: capsular contracture in the short or long term, depending how the woman reacts.

Where the implant sits

• Prepectoral — on top of the muscle. This is what she tends to do more of. Better long-term aesthetic. Less capsular contracture (the scar capsule around the implant tightens). Less animation deformity (the implant rides up and down when the woman flexes her pecs). Animation happens in cosmetic augmentation too, but it is harder to see when there is still breast tissue in front of the implant. After mastectomy it can be distressing.
• Subpectoral — under the muscle. Older reconstruction default. Muscle plus skin over the implant. In the salvage case below she chose this on purpose because the woman was high risk.

In questions at the end: reconstruction started behind the muscle because that is where augmentation had moved; only in about the last 15 years has practice switched toward the surface. Closer to the surface means a higher infection risk. Otter heard the historical “on-muscle” line as “carbon muscle.”

Pros of implant-based, as she put them

Shorter surgery. Faster recovery — assuming no significant complication. Modern implants: “You can run over the implants with Mac trucks, they will not burst.” She mentioned videos online. This page is not a product claim; it is what she said about durability.

Risks she wants women to hear

• It is a foreign body.
• Infection is the biggest early risk.
• Rippling — after mastectomy you only have skin and a bit of fat between implant and the outside world.
• Skin death or nipple death — depends how thick the skin is. “You’ve got to get the flap just right, like Goldilocks.”

Autologous: DIEP preferred over TRAM, lat dorsi for salvage

Own-tissue reconstruction. The name most GPs still hear is TRAM (transverse rectus abdominis myocutaneous flap). Practice has moved.

Wrong patient for a big autologous case, as she put it: “obese, smoking, elderly woman would not be the right patient for this.”

Otter wrote “Diep,” then later “that’s the DF.” Read as DIEP both times. This page does not invent another flap abbreviation.

Nipple-sparing versus sacrificing

Two reasons she sacrifices the nipple:

• The nipple is involved with cancer.
• The breast is too big for implant-based reconstruction. “You can’t stick a 1000 cc implant into a breast space and expect that skin to live.”

If it is only the nipple involved, you can sacrifice the nipple, take some of the skin envelope (a lift), and still place an implant. Nipple and skin involvement more broadly “will really negate reconstruction” unless it is just nipple.

After nipple-sparing, she warned: they lose innervation of the nipple (Otter: “innovation”). The areola (Otter: “are older”) stays dilated out. It will not go back in.

Immediate versus delayed, public versus private

Immediate versus delayed comes down to tumour type, whether they need neoadjuvant chemotherapy, and whether she is worried about radiation.

On public versus private, Otter captured two lines that sit in tension. First: in the public sector they do a lot of delayed reconstructions because of availability and timing — more flat mastectomies, then delayed reconstruction later. Then: “The beauty of the public sector, a lot of women are able to get the immediate reconstructions and get that majority of the time the surgery out of the way.” That second line may be a mix-up with private, or a contrast she did not finish. This page does not silently rewrite it. The clearer teaching point is the first: public patients more often wait, and go flat in the meantime.

There is a genuine case for delay even when theatre is available. If she is worried about radiation, she can look at the skin after radiotherapy and decide whether delayed reconstruction is still on the table. “As much as we love radiation… it does cause a big problem with the implants and the expanders when you’re trying to re-expand that skin out.”

If she is worried a woman is not a reconstruction candidate, she reaches out to colleagues, including radiation oncology: is she going to need radiation after chemotherapy? Then: should I reconstruct this woman or not? “There’s a lot of thought and steps before anyone gets a reconstruction.”

Patient selection: smoking, vaping, BMI about 32

“Selection is huge.”

• Smokers: no. Not within three months. Vaping as well. She had just seen a woman vaping CBD: “not a chance.” Ramifications are huge. Implant loss “breaks my heart,” and it delays the cancer journey and adjuvant therapies. Be strict.
• If she does not trust the history, a cotinine test (Otter: “contentine test” — “the smoker’s blood test”). Only really useful for about the last one to two weeks. Close to the operation you can cancel.
• BMI cut-off 32 — same as for autologous, and she is pretty strict with it for breast reduction too. Above that, “the healing is just terrible.” You do not want that with an implant under the skin.
• Nipple and skin involvement, as above.

Expectations again: remind them it is not an augmentation.

Fluoroscopic skin-perfusion check

New-ish theatre technology she highlighted: a fluoroscopic technique to check the skin. Inject something, turn the lights off, see whether the skin is very well vascularised. If it is not, you can decide then that they are too high risk for reconstruction. “They’ve got all this technology that we didn’t used to have.”

She did not name the dye on the recording. This page does not invent indocyanine green or any other agent for her.

Two implant outcomes she showed

Family history, likely BRCA, wanted smaller, keep the nipple

A woman a year or so ago. Strong family history and a diagnosis Otter heard as “brachytore” — most likely BRCA; we do not invent a specific gene. Main technical problem: her nipples sat quite laterally. The “perfect” nipple sits on the meridian, in the middle. Put an implant in, and you can push an already-lateral nipple even further out. She wanted to go smaller and keep the nipple, so the surgeon could not throw away a lot of skin.

Post-op: went a bit smaller. Nipples came a little more inward — not at the beginning; they “came good after a while.” Early compression marks: you can get a bit of lymphoedema at the start because the skin has fewer places to drain lymph. If you did not know, you would not know there were implants. A good outcome.

Cancer side plus contralateral prophylactic

Cancer patient. A little lateralisation of the right nipple — that was the cancer side. She wanted a prophylactic mastectomy on the other side. The warning the surgeon gives: you do not live longer because I take the breast off, and a complication can delay the next therapy.

Post-op: skin a lot thinner on the cancer side. Stretch marks. A little rippling. Otter: “her cans was quite large, so I had to keep that flap very, very thin.” Read as the cancer (or the breast) was large, so the remaining skin flap had to be thin. Four months post-op. Nipple innervation gone; areola stays dilated.

Pitfalls: infection, necrosis, revisions

“Pitfalls, they’re everywhere.”

• Infection.
• Skin and nipple necrosis — her biggest pitfalls of late. Flap loss / flap failure is less her problem than a plastic surgeon’s (Otter: “flat loss,” “flat failure”).
• Revision surgery after radiation, or for rippling: fat grafting to thicken the skin, or replace the implant if there is capsular contracture.

Emotional impact of complications: months, up to years, depending how bad. Bad enough, and it stops adjuvant chemo, adjuvant radiation, adjuvant endocrine tablets. Her own mental health is affected too. “It’s a combination of how to manage all these together.”

Radiotherapy challenge in one sentence: she has cleared what she thought were margins, the tumour has come back almost twice or three times the size, they need radiation, the implant is radiated, then contracture, infection, skin and wound breakdown — “you didn’t potentially foresee that at the beginning.” Timing of whether you reconstruct at all is critical. Companion talk: radiotherapy after reconstruction.

Fat grafting: “like putting a fat cell into that skin, it thickens it up really well,” and it can sit well with an implant. In the salvage case below, it did not save her.

Last structural point: the more you operate, the more complications you get.

The failed-salvage case: 2017 lumpectomy to 2025 implant loss

She was about 50; the surgeon thinks 56 when they first met. Cancer in 2017 with a different doctor. Lumpectomy, then radiation. Recurrence within six months post-radiation. Opted for bilateral mastectomy. Not offered reconstruction at the time — likely because of the radiation. Came about six years later wanting reconstruction.

The radiated-side skin was thick, robust, “actually quite good.” They went through the options. She wanted expansion.

April 2025: expanders in, subpectoral (“low muscle space”) because she was high risk. Otter also captured “she’s also got a long term board in” — unclear; this page does not guess (burden? drain? comorbidity?). “I’ve got a two sides problem” — bilateral. Extreme allergic reaction to tape, which settled. Expansion itself was fine. Needle into the expanders for saline the whole way: a space at high risk of infection. No infections. Skin expanded out perfectly.

Second operation: remove the expanders, fat-graft the skin to thicken it, put in the implants. Healed well. Home two weeks post-op.

Five weeks later, weekend call: febrile, fluid coming out of the radiated chest wall, skin breaking down. Implant on view. Straight to theatre. Always try to salvage. She placed a device like a big VAC that runs saline in and suctions it out over about 12 hours, left for 48–72 hours, back to theatre, swab the cavity until negative for bacteria — designed to clear biofilm. In hospital until swabs are negative.

Swab negative. “No more Staph” (Otter: “staff”). Implant back in on 29 November. Healed after New Year. Then an email: skin broken down again. Implant on view, a little dark. Muscle starting to regress. Dressings, vacuums, antibiotics. The woman “just psychologically had enough.” This had been a journey since 2017. They took both implants out. She has healed well. “That unfortunately was my effort at delayed reconstruction that failed.”

The woman had been offered autologous reconstruction — own tissue, get rid of the radiated tissue — and did not want it.

The GP’s role

“The most important role”: early education and counselling, and optimisation.

• If reconstruction can be delayed, that window is a chance for smoking and vaping cessation.
• Psychosocial support if it has not been offered in the private sector or at the oncology service they attend.
• Survivorship: five years of seeing the surgeon and seeing you. Scan anxiety — “am I going to get it back?” — especially in younger women, who have longer to live through it.
• Mental health plans and allied health plans. She has a lymphatic physiotherapist in her rooms. Advocate for as many of those plans as possible. “It just helps with our overall journey through it all.”

Closing, on complications (Otter: “participations”): “What matters most is how you manage them… Be open, be honest, and be there as much as you can.”

Take-home messages for clinic

1. Speaker: an oncoplastic breast surgeon, Lifehouse Sydney then Gold Coast. Otter rendered the name as “Dr Kick” and the hospital as “Lighthouse.” Do not invent a surname. Kate introduced. Companions: imaging, medical oncology, radiotherapy.
2. Reconstruction is part of modern breast-cancer care. Not everyone can have it. A lot of the job is telling women no, and why. Body image, psychosocial benefit, quality of life. It is not an augmentation.
3. Her default implant path: direct-to-implant, often prepectoral (better look, less contracture, less animation). Expanders commoner on the Gold Coast; useful if high-risk or possible radiotherapy. You can radiate expander or implant — same foreign-body risks. Infection is the big early risk. Rippling and skin/nipple death depend on how thick the skin is. Goldilocks flap.
4. DIEP preferred over TRAM (TRAM takes muscle → hernias). Six to twelve hours, about six weeks, abdominoplasty, more natural, no implant. Gold Coast women less keen than Sydney. Lat dorsi is salvage for radiated skin, not first-line. Wrong autologous patient: obese, smoking, elderly.
5. Sacrifice the nipple if it is involved, or if the breast is too big for a living skin envelope over a huge implant. Nipple-only: sacrifice it and still reconstruct. After nipple-sparing, innervation is gone; areola stays dilated.
6. Immediate versus delayed: tumour type, neoadjuvant chemo, likely radiotherapy. Public more often delayed / go-flat first — Otter then said a contradictory “beauty of the public sector” line about immediate reconstruction; do not silently rewrite it. If radiotherapy is likely, delay and inspect the skin afterwards, or do not reconstruct.
7. Selection: no smoking or vaping within three months (including CBD vape); cotinine if you do not trust the history; BMI cut-off about 32; involved skin often rules it out. Theatre fluoroscopy: inject, lights off, check skin perfusion — she did not name the dye.
8. Pitfalls: infection, skin and nipple necrosis, revisions, fat grafting, implant exchange for contracture. Complications can delay adjuvant treatment. More operations, more complications. Fat grafting thickens skin; it did not save the salvage case.
9. Teaching case: 2017 lumpectomy + RT → recurrence at six months → bilateral mastectomy, no reconstruction → years later delayed expanders (April 2025, subpectoral) → exchange + fat graft → infection at five weeks on the radiated side → instillation VAC, re-implant 29 November → breakdown after New Year → both implants out. She declined autologous. Lesson: radiation is the enemy of an implant, and still vital. Oncology before aesthetics.
10. GP role: early education, optimisation (especially stop smoking/vaping if there is time), psychosocial support, survivorship and scan anxiety, mental-health and allied-health plans, lymphatic physio. Be open, honest, and there.

Dr Kotha · Gold Coast · breast-reconstruction.drkotha.com