Your Breast -- Again
Reconstruction Can Give Cancer Survivors Back Some Of What at They’ve Lost
By Christina Elston
A diagnosis of breast cancer means you could lose your life, and that’s scary. Thankfully, more than 80% of women now survive their breast cancer when it’s caught early.
But what about that other thing you lose when you have breast cancer? You know, your breast?
Mary Flaherty knows a thing or two about that. She’s lost both breasts – and had both rebuilt. And with technology and survival rates improving, more and more women are turning to breast reconstruction to get “back to normal.”
As a reconstructive surgeon affiliated with John Wayne Cancer Institute at Saint John’s Hospital in Santa Monica, Caifornia, Jay Jensen, M.D., sees a lot of these women. “The most important thing for me is asking a woman how important her breast is to her,” Jensen explains.
“For most women, it’s real important.”
Flaherty was just 32 years old, with two young children, when she received her first cancer diagnosis in 1989. She chose to have her breast removed and was offered either a DIEP flap reconstruction (see sidebar on reconstruction techniques) or an implant. Flaherty opted for the DIEP flap with tissue from her abdomen. “The abdominal seemed like a really good bet, since you get a tummy tuck and a breast at the same time,” she says.
She and her husband wanted a third child, but the procedure would weaken her abdomen too much to sustain a pregnancy, so Flaherty waited seven years before her reconstruction. “So in the meantime, I discovered the joys of external prosthesis,” she laughs. “I remember taking an aerobics class once and it flew out across the room.”
Funny incidents aside, Flaherty says the prosthesis became be a daily reminder of her cancer experience.
Susan Downey, M.D., a Santa Monica reconstructive surgeon and clinical professor at the Univeristy of Southern California, says many women have this issue. She even had a 75-year-old patient who came back for reconstruction 15 years after her mastectomy. “She said, ‘I guess I just put it in the back of my mind and I didn’t realize how much it bothered me,’” Downey says.
Learning a New Language
The onslaught of information a woman receives with her diagnosis is “akin to learning a new language,” says Flaherty. But there’s time to learn and think things through.
“This is one cell that has been dividing, probably for years,” Jensen explains. “Breast cancer is rarely an emergency.”
Downey says surgeons should explain all available reconstruction options – which depend on the stage and type of cancer, the type of treatment needed, and the patient’s general health – and recommends bringing a friend or family member to these meetings. “Definitely take somebody else with you,” she says.
Jensen advises taking a tape recorder to meetings, and often gives patients reading material and Web site recommendations.
Breastcancer.org is one site he’s found helpful for patients.
Jaco Festekjian, M.D., a reconstructive surgeon with the Revlon/UCLA Breast Center, recommends UCLAplasticsurgery.com, the American Society of Plastic Surgeons, and plasticsurgery.org, and advises asking your surgeon about the chance to talk with previous patients. “I think that’s the best reliable source for what to expect,” Festekjian says.
Putting Together a Team
It’s also essential to have your surgeons working together. “I think you need to be treated by a team,” advises Jensen, explaining that this brings “checks and balances.” An oncologic surgeon aggressively focused on treating the cancer, plus a reconstructive surgeon focused on a good cosmetic result, will yield the best all-around care. “That is the model that has evolved in Los Angeles,” Jensen says.
Festekjian recommends seeking out a surgeon with board certification, who is experienced in every possible sort of breast reconstruction and performs at least 20 to 30 cases per year of routine reconstruction, and 50 or more per year involving microsurgery (again, see “Reconstruction Lingo”). He does 60 to 70 microsurgeries per year, and double that many routine reconstructions. But Jensen, who has been in practice for 20 years, adds that you also need to look at a surgeon’s experience over the course of a career.
A Breast From Your Belly?
One of the first decisions to make is whether to have reconstruction as part of the mastectomy operation, or whether to wait. Festekjian and Jensen are strong advocates of immediate reconstruction, because it is easier to reconstruct (and sometimes yields a better cosmetic result) right away.
Downey agrees that it is easier to reconstruct the breast immediately after the mastectomy, but says some patients are so overwhelmed with their cancer treatment that they can’t face the reconstructive decision. “I think that if a woman is not ready to make that decision, she doesn’t have to,” she says.
After the birth of her third child, Flaherty underwent a 12-hour DIEP flap reconstruction of her breast, plus followup surgeries and nipple reconstruction. And she was delighted with the result. “It feels pretty natural,” Flaherty says. “It’s your own tissue.”
Recovery time with reconstruction methods that use natural tissue is 4-6 weeks, as compared with 2-4 weeks for methods using an implant, according to Festekjian. And there can be some loss of muscle around the site where the tissue is harvested.
A Breast In a Bag?
In 2002, when Flaherty’s third child was 10 years old, she found a cancerous lump in her other breast and was treated with a mastectomy and chemotherapy. She had used up her spare abdominal tissue on the first breast, and this time opted for a tissue expander and implant.
Flaherty found the expander slightly uncomfortable, but not painful. And the expander let her “test drive” the feel of saline. She didn’t find it firm enough, and opted for a silicone implant instead.
Flaherty says her recovery time was far less with the implant, but if she had the choice, she would go with a DIEP.
Interestingly, in a 2003 survey of female reconstructive surgeons conducted by Downey, 54% said they would choose reconstruction with an implant over one with natural tissue. Downey speculates that they, like many of her patients, wouldn’t want to lose muscle or have trauma to an additional site, and prefer the shorter recovery time.
Either way, Flaherty says it isn’t like having your original breast back. You lose sensation, and though you get used to it, it’s strange. “Initially, probably more with the implant than the flap, you feel like there’s a foreign object sewn to your chest,” she explains.
Since the point is to have two breasts alike, reconstructive surgery isn’t limited to the breast with cancer. And Downey points out that Federal law requires insurance companies to cover surgery on the opposite breast, including either a lift or reduction to make the pair match, depending on a woman’s preference.
“I’ll say, ‘Which breast are you happier with?’” Downey says.
Next comes the nipple. In some cases, the treating surgeon can now save the skin and nipple, and the reconstructive surgeon can place an implant beneath it.
If the nipple isn’t spared, doctors create a new one by folding and grafting skin, then tattooing it to match the opposite breast.
Downey says many women find this essential. “I don’t think it’s her breast again until we make the nipple,” she explains.
Flaherty, however, didn’t think it was important, and asked her doctor why she needed nipple reconstruction. “The doctor jokingly said, ‘In case you’re ever in a wet T-shirt contest,’” she laughs.
T-shirts aside, Flaherty enjoys being able to wear what she wants (with a prosthesis, you have to avoid certain kinds of bathing suits, tank tops, and anything with even minor cleavage) and she’s happy with both her new breasts. She jokes: “They’re kind of better than the original when you hit 51 years old.”
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