Reconstruction: A choice after breast cancer treatment

My cousin Gail Katz could have told me how surgery and chemotherapy saved her life. Instead, she told me how breast reconstruction saved her soul.

Gail was 42 when she was diagnosed with breast cancer for the first time. The tumor was small, a bit over one centimeter, and had not spread to her lymph nodes. But because she was relatively young, her doctor recommended chemotherapy and radiation after her lumpectomy.

During the next several years, Gail's mother and maternal aunt were diagnosed with the same condition, which prompted Gail's visit to a genetics counselor and subsequent genetic testing. The news was not good. She carried the BRCA2 gene, putting her at risk for additional cancer.

Ten years later, a malignancy recurred in the same breast, and Gail knew that her only option was a mastectomy. She was stunned, however, at her doctor's suggestion that she might want to have her other breast taken off as well.

"It was a shock," Gail says, "almost too much to absorb. I sat in the doctor's office and I felt as though he was talking through me, not at me. The thought of losing two breasts was devastating."

Gail has a lot of company. According to oncologist Morton Kahlenberg, a spokesperson for the American Society of Clinical Oncology, from l00,000 to 125,000 women in this country undergo mastectomies each year. More women are having them to prevent future cancers because, like Gail, they are genetically vulnerable and cannot tolerate the anxiety of waiting until they feel the dreaded lump or for the mammogram that may reveal a cancer.

However, according to a study reported at last year's conference of the American Society of Breast Surgeons, only 20 percent of eligible women choose to have breast reconstruction despite legislation requiring that insurers cover the surgery. Some women don't want to undergo another procedure; others, especially those who don't live near major medical centers, are not offered the option.

In Philadelphia, Gordon F. Schwartz, director of the Breast Care Center of Thomas Jefferson University Hospital, says 90 percent of women he treats with mastectomies choose reconstruction. Oncologist John Glick of the University of Pennsylvania's Abramson Cancer Center says his practice is to refer all women, with their permission, to a plastic surgeon so they know the options: "No one should do without reconstruction because she hasn't been educated about that choice."

Until the mid-1970s, women who had mastectomies had to endure life without breasts. Their only option was an external prosthesis, an artificial breast worn in the bra, which didn't offer much solace when they took a shower or passed a mirror. Their doctors were focused on curing their patients' cancers, dismissing the emotional trauma of losing so significant a part of the body.

"Yes, they had lost a breast and had to walk around with this enormous scar across the chest wall," says Carlin Vickery, a New York plastic surgeon with a 30-year history in breast reconstruction, "but the attitudes of doctors were that these women could wear a prosthesis and go on to have a merry life."

That scenario didn't happen; it was indignant women refusing to silently accept their deformed bodies that prompted the dramatic changes of the following 10 years. R. Barrett Noone, a Bryn Mawr plastic surgeon and author of the textbook Plastic and Reconstructive Surgery of the Breast, calls 1973 to 1983 "the golden decade in plastic surgery." New techniques permitted reconstruction of the lost breast. In 1982, Carl Hartrampf in Atlanta revolutionized breast reconstruction by originating what became known as the TRAM flap, the use of abdominal tissue to create a breast.

At first, the procedure was done well after the mastectomy had time to heal. But, shortly after Hartrampf's findings were published, Noone accepted a patient's challenge to do the procedure at the same time as her mastectomy. To Noone's knowledge, this is the first time the procedure was done that way. The results, Noone recalls, were "not cosmetically perfect," but the woman lived happily with her reconstruction until she died of emphysema 23 years later.

Today, breast surgeons and plastic surgeons ideally work in tandem to ensure women that they will enter the operating room with a breast and can leave with one. "Breasts are essential to feeling whole," Gail says. "It isn't only the way you look in clothes, it's the weight our culture gives to breasts, the association with sexuality, and your dependence on your breasts for sensation in a sexual relationship. When I realized I would be able to have breasts after my mastectomies, it lessened my anxiety and made all the difference in my outlook."

The best time for a woman to see the plastic surgeon is before the mastectomy is done. "They have already gone through the double hit, knowing they have cancer, then the attack on their femininity," says Noone. "I'm able to give them positive news."

Vickery says, "First it's all about the cancer. Just let me live. Once they've dealt with that, it's all about how they look."

There are two main reconstruction options, depending on what a woman prefers or what her body dictates she can have. To help make the decision, Vickery takes inventory of each patient. "How big is her lesion? What is the quality of the skin? Does she have teacup breasts, ballerina breasts, or sagging breasts? Has she nursed? Will the mastectomy be followed by radiation? What does the abdomen look like? Is the woman 20 or 30 pounds overweight or is she skinny and goes to spinning class six days a week?"

Many surgeons and patients prefer reconstructing a breast with the person's own tissue, which usually comes from the abdomen (Hartrampf's TRAM flap). Here a heavier woman has an advantage. The skin, fat, blood vessels and at least one abdominal muscle are moved from the abdomen to the chest, giving the woman a "tummy tuck," and the surgeon the ability to sculpt a soft, supple and permanent breast covered with the patient's skin saved from the mastectomy. In more advanced micro surgery, no abdominal muscle is used, just tiny blood vessels that seed the skin and fat that will be transferred. This method, says Vickery, is the gold standard, but the operation is tedious, technically demanding, and requires the skills of a trained microsurgeon. While traditional TRAM flap surgery is lengthy, maybe four hours, microsurgery because of its delicacy can take as long as six.

The upside of flaps? Their success rate - how they look, how they feel, and how they survive over time - is high, 98 to 99 percent. While mastectomies seriously compromise nerve sensation, nerves have a greater capacity to grow back in women who have this procedure. "The breasts won't have that sexual sensation," says Vickery, "but they won't have that woody, rigid, Barbie doll feeling either." And once you get past the surgery and recovery, it's permanent. You're done."

Nonetheless, not every woman can have or wants this procedure. Libbie, 62, who didn't want to give her last name out of privacy, says she didn't want a hip-bone to hip-bone scar across her abdomen and didn't relish the thought of lengthy surgery with a long recovery.

In such cases, implants of either saline or silicone are a viable alternative. In fact, 70 to 80 percent of women who have reconstruction choose implants; like Libbie, they prefer to avoid a second surgery and a longer recuperation. Most opt for silicone because they say it looks and feels more like natural breast tissue. In what is usually a staged procedure, the mastectomy will be followed immediately with the insertion of a tissue expander, a balloon-like device placed under the pectoral muscle, the fan-shaped muscle that goes across the chest wall. If the skin remaining from the mastectomy can't cover it all, a substance called AlloDerm - cadaver skin that has been sterilized and treated to retain collagen - can be sewn to the bottom of the muscle, then covered with skin. In a second and often a third or fourth procedure, a saltwater solution is injected into the expander until it has reached the desired breast size and can be exchanged for a saline or jell-filled silicone implant.

Implants have a shelf life, whether they are inserted for reconstructive or cosmetic reasons. "Ten years is about the average," says Neal Topham, chief of plastic surgery at Fox Chase Cancer Center, who often works with breast surgeon Marcia Boraas. When saline implants rupture, he says, they deflate immediately, the breast collapses, and the liquid is absorbed by the body.

Silicone ruptures can be asymptomatic for a long time, so the FDA warns women that at three years, then every other year thereafter, those with silicone implants should have MRIs to detect leakage. Although no evidence suggests that leaking silicone causes trouble, a ruptured insert - either saline or silicone - will be removed and replaced.

No implant is perfect. Underfilled saline implants will ripple. They often feel less comfortable than those filled with silicone because they are firmer and don't move freely. No matter the type of implant, patients often complain of a bandlike tightening around their chest. And there will always be another operation to replace the first implant. "My patients," says Vickery, "know it when they leave my office."

Nipple and areola reconstruction is the last step in re-creating the breast, often done as day surgery. Some women opt not to do it; others forgo the nipple reconstruction but have the areola tattooed.

"In my experience," says Topham, "patients say they would do reconstruction again if they had to. But my goal is that they go on living and forget about me."

Rebecca Rutenberg of Wynnewood, a renal social worker, has had two mastectomies and two breast reconstructions, five years apart. One was done with a TRAM flap, the other with a silicone implant.

"Long-term," Rutenberg says, "I like the TRAM flap better. It is major surgery and a long recovery, but it's permanent and easier to live with. The implant moves around, you can almost hear it swishing, so I have to sleep with a bra." She says if her implant ruptured, she would not replace it. "I'm 63, I'm small, and it doesn't feel that important to me now. A good padded bra would be just fine."