by Eve Jacobs
ince rules of politeness dictate, even in 2007, that the topic of breasts does not dominate a conversation, let’s get it off our chests right now — breasts count. They count in a big way for women of all cultures and ages and they count for men, too, of course.
For women, their breasts are often a worry. Too big, too small, too jiggly, too long, heavy, too droopy, no bounce, too low, not firm, hurt when you run, huge, don’t fit in the bra, don’t fill out the sweater, one bigger than the other, flat, sagging, not perky, floppy, out of proportion, unattractive.
But embedded in those gripes is their very importance to a woman’s definition of self. So a diagnosis of breast cancer has enough momentum to rattle the soul, but the thought of being left with one breast or none can knock a woman down.
In 2006 alone, half a million American women underwent cosmetic or reconstructive breast procedures, according to the American Society of Plastic Surgeons. More than 360,000 women chose breast enlargement with saline or silicone implants; 104, 455 had reduction procedures; and 56,176 had breast reconstruction after mastectomy.
For women forced to contemplate mastectomy, 1998 was a pivotal year: The Women’s Health and Cancer Rights Act was passed, requiring insurance companies to cover costs for reconstruction of a breast lost to cancer. The law also covers procedures on the opposite side to create breast symmetry. In the past decade, the numbers of reconstructive and cosmetic procedures have multiplied, and plastic surgeons have become quite skilled at creating an aesthetically pleasing breast.
“Just get the cancer out” is the immediate reaction of most women newly diagnosed with a breast malignancy. The good news is that the majority will be able to choose their treatments from several different options.
“Seventy-five percent of women who have breast cancer surgery have breast conserving surgery [lumpectomy],” says surgical oncologist and breast disease specialist Thomas Kearney, MD, an associate professor of surgery at UMDNJ-Robert Wood Johnson Medical School (RWJMS) and The Cancer Institute of New Jersey (CINJ). “The other 25 percent falls into two groups—those who choose mastectomy and those for whom breast conserving surgery is not an option.”
Kearney’s job is to take out the cancer. A mastectomy, he explains, removes all breast tissue from the breast. “Once women know that breast conserving surgery and mastectomy have the same survival, most will not choose mastectomy,” he states. When the cancer is “multi-centric,” meaning in more than one quadrant of the breast, or if the breast has been previously radiated or the tumor is very large, preserving the breast is not a possibility, according to the surgeon.
He says that nationwide, many women undergoing mastectomy are not offered immediate reconstruction. “Most women get their care from a good general surgeon, not a surgical oncologist and a plastic surgeon,” he says. “When there’s a multidisciplinary approach, as we have here, women benefit.”
But many women threatened with the loss of a breast hit the Internet to ferret out their options for recreating that important part of themselves. Restoring a breast to closely match the other side is the ultimate goal. “We want to eliminate any reminder of the cancer and allow patients to focus on the other important things in their lives,” says plastic surgeon Philip Wey, MD, clinical associate professor of surgery at RWJMS and a partner at Plastic Surgery Arts in New Brunswick.
Whether cancer is in the picture or not, breast surgery is customized, allowing the patient to make many of the choices, according to Wey. His patient, Tona Shuler, 39, was diagnosed with breast cancer last year and started treatment with eight weeks of aggressive chemotherapy, followed by removal of her right breast in January 2007. Reconstruction was not offered at the time since it was unclear if radiation treatments would be needed. In February — after being told she would not need radiation therapy — Shuler started a multi-step reconstruction involving transfer of skin and muscle from her back (called a latissimus flap), the insertion of a balloon-type tissue expander to stretch the skin, and, eventually, placement of a silicone breast implant.
“I went through some tough times, but I’m really happy now,” she says. “I want other young women who have lost a breast to know that they have the power to get back that important part of themselves.”
Another of Wey’s patients, Monique Roche, a mother of two young children, was 33 when her breast cancer was diagnosed. She had a “skin sparing” mastectomy on October 25, 2005, with immediate reconstruction that combined a latissimus flap and a supplemental implant. She chose to also enhance her other breast.
“Sometimes reconstructive surgery can offer an unanticipated gift,” says the plastic surgeon. “The new breast may have a better appearance than the original and the mirror may turn out to be more friend than foe.”
Claudia Ahle’s decision to have surgery was not motivated by disease. She had always thought her breasts were too small and contemplated breast enlargement, or augmentation, for two decades. “I never felt very attractive,” she says. So, at the age of 39, she consulted with Wey and finally decided to have implant surgery, which changed her self-image and outlook. “I feel so much more attractive in my clothes, and so much better about myself,” she says. “I couldn’t be happier.”
Wey says that he admires Dolly Parton’s talent, but rarely does a woman tell him that she wants to emulate the country singer’s look. When consulting with him on breast enhancement, most women say they would like full, but natural-looking, breasts,
Silicone implants were once again made available to women over the age of 22 in November 2006. At that time, the FDA approved the implant not only for reconstruction but for cosmetic purposes as well, after a nine-year moratorium in which the device’s safety was scientifically evaluated. Often referred to as a “gummi bear” implant, the new device contains a more cohesive gel, which is considered more stable in the event of implant rupture or leakage.
Wey says that although both saline and silicone implants can provide excellent results in properly chosen patients, the new cohesive and form-stable silicone devices have some advantages over saline. Softer and more natural to the touch, they are lighter and are associated with fewer visible ripples or wrinkles. Like all commercially manufactured devices, they may eventually rupture or leak, says the surgeon, so women are expected to perform frequent self-exams and monitor the appearance, shape and symmetry of their breasts.
Kearney says a “typical” case calling upon the dual skills of a surgical oncologist and a plastic surgeon would be a 55-year-old woman with a breast mass in one quadrant and calcifications in another quadrant. “This woman would be offered immediate reconstruction at the time of the mastectomy—or it could be delayed if she prefers,” explains Kearney, who says that reconstruction generally requires volume (stuffing), covering (skin) and a nipple or areola complex.
When Kearney’s job of removing the cancer and surrounding breast tissue is done, he steps out of the OR and the plastic surgeon steps in (literally). According to Wey, there are many options he discusses with a woman prior to surgery, including reconstruction exclusively with an implant; rebuilding using a combination of a woman’s own tissue and an implant; or creating a new breast using only the patient’s own tissue.
Inserting an implant is one of the oldest and still a very common way to reconstruct a breast. The technique is fairly simple: in most cases, a tissue expander is inserted under the skin and chest muscle, and the surgeon periodically injects a salt-water solution to gradually fill the expander over several weeks or months. When the skin over the breast area has stretched enough, the expander is removed in a second procedure and a more permanent implant — either silicone or saline — is inserted.
For women who want to go the all or more natural route, fat, skin and muscle can be moved from another area of the body to the chest area. These procedures are more technically challenging—and time under the knife is longer—than for inserting an implant. “Flap” surgery is doctor-speak for this kind of operation.
The TRAM flap procedure takes the transverse rectus abdominus muscle from the stomach area and transplants it, along with the overlying skin and fat, to the chest. Another flap procedure takes the lattimus dorsi—the long muscle of the back—and some skin and tunnels them under the armpit to the chest wall, where they are fashioned into a pocket. With this method, there is often not enough fat in that area to provide volume, so an implant is placed inside the natural pocket to restore symmetry.
Microvascular free flap surgery means the tissue that is being moved to the chest does not stay attached to its original site and so is cut off from its original blood supply. Donor sites for this complex reconstruction method include the abdomen, thighs and buttocks.
Wey recommends that patients be offered a newer surgical method called skin-sparing, or partial skin-sparing, mastectomy, which removes the breast but leaves the skin envelope behind. “It’s a bear of a surgery but it provides the best result,” says Kearney, “and we are able to do that here.”
“Restore, rebuild, make better” is the mantra of these two surgeons, who understand that beating disease is no longer the end-stop in many women’s battle against cancer. Feeling beautiful has curative powers that science is not yet able to measure.