PROCEDURES OF THE BREAST: BREAST CANCER AND RECONSTRUCTION: EXPLORING THE OPTIONS, PROCEDURES AND PERCEPTIONS

Breast cancer. It is the leading cancer diagnosed in women in America. This year, it will affect the lives of more than 180,000 women for the first time – and end the lives of 40,000 more. Thanks to proactive efforts like National Breast Cancer Awareness Month celebrated in October, the disease doesn't automatically mean a death sentence. However, the impact breast cancer has on the lives of its victims is arguably life altering – and not easily erased.

In this article, we will share the experiences of five women who have survived the disease, as well as the expertise of several American Society of Plastic Surgeons (ASPS) members who specialize in breast reconstruction after breast cancer. It is our hope that the information presented in this article will serve as a valuable resource in your journey through breast cancer treatment and recovery.

Fear. Shock. Denial. These are just a few of the emotions women experience upon learning they have breast cancer. Jayne Siebold, of Hinsdale, Ill., was 49 when she was diagnosed with the disease and explains her initial reaction to the news. "When the doctor confirmed it was cancer, I remember thinking, 'They can't be talking about me, this must be a mistake.' Then the fear kicked in."

Barbara Taylor of Dallas went into physical shock. "Everyone I had ever known or heard of who had the disease died from it. So the fear I experienced initially was completely overwhelming, virtually crippling."

When Sue Kocsis of Omaha, Neb., was diagnosed she was 34 years old and the mother of three little girls. "The entire process was extremely overwhelming. It took visits to five different physicians before the cancer was actually diagnosed, so in the beginning I was relieved to know just what I was dealing with – but felt a tremendous amount of anger toward the doctors who kept telling me it was just fibrocystic disease and nothing to worry about."

The treatment of breast cancer involves a physical change to the body. As a result, it can have a profound psychological impact. "A woman's breasts are deeply rooted in her sense of femininity...her role as mother and nurturer, " says Jack Bruner, M.D., of Sacramento, Calif. "Therefore, facing the loss of one or both breasts can be very traumatic." Dr. Bruner recommends that every women diagnosed with breast cancer request information about reconstructive options from their general surgeon and seek the opinions of several plastic surgeons prior to surgery.

Almost any woman who loses her breast to cancer can have it rebuilt through reconstructive surgery. And discussion about reconstruction can start immediately after diagnosis. Ideally, you'll want your breast surgeon and your plastic surgeon to work together to develop a strategy that will put you in the best possible condition for reconstruction.

There are several reconstructive options available after mastectomy. Typically, your plastic surgeon will make a recommendation based upon your age, health, anatomy, tissues and goals. The most common procedures include skin expansion followed by the use of implants or flap reconstruction.

Flap reconstruction is a more complex procedure than skin expansion. Scars will be left at both the tissue donor site and at the reconstructed site, and recovery time is longer than with an implant. However, when the breast is reconstructed with one's own tissue, the results are generally more natural and concerns related to implants are non-existent. Recovery times for both procedures range from six months to one year, or longer, depending on individual circumstances.

This common technique combines skin expansion and subsequent insertion of an implant. Following mastectomy, your plastic surgeon will insert a balloon expander beneath the skin and chest muscle. Through a tiny valve mechanism buried beneath the skin, he or she will periodically inject a salt-water solution to gradually fill the expander over several weeks or months. After the skin over the breast area has been sufficiently stretched, the expander is removed in a second operation and a more permanent implant – either saline or silicone – will be inserted. Some expanders are designed to be left in place as the final implant. The nipple and dark skin surrounding it – called the areola – are reconstructed in a subsequent procedure.

An alternative approach to implant reconstruction involves creation of a skin flap using tissue taken from other parts of the body, such as the abdomen, back or buttocks. In one type of flap surgery, the tissue remains attached to its original site, retaining its blood supply. The flap, consisting of skin, fat and muscle with its blood supply, are tunneled beneath the skin to the chest, creating a pocket for an implant or, in some cases, creating the breast mound itself without need for an implant. Another flap technique uses tissue that is surgically removed from the abdomen, thighs or buttocks and then transplanted to the chest by reconnecting the blood vessels to new ones in that region.

Breast cancer affects women differently depending on their age, marital status and self-image, as does their attitudes about reconstruction. No matter how they feel about it, Glenn Davis, M.D., of Raleigh, N.C., stresses that "every woman should be afforded the choice of undergoing reconstruction as part of her breast cancer treatment, and provided adequate facts to make an informed decision.

Unfortunately, many women are not given the option or the information they need to make an informed decision about reconstruction. According to Christine Horner-Taylor, M.D., of Edgewook, Ky., the women who don't undergo reconstruction procedures after losing a breast to mastectomy have many reasons for doing so. "Many women have told me the reason they didn't have breast reconstruction was because their general surgeon didn't recommend it or didn't mention that it could be done at the same time as the mastectomy. If the women are older, their surgeon may have decided they don't really need to go through it," she says.

Other reasons women pass on reconstruction include their unwillingness to have any more surgery than is absolutely necessary and an inability to weigh all the options available while they're struggling to cope with a diagnosis of cancer.

Not all women are good candidates for breast reconstruction. According to Dr. Horner-Taylor, "Women who have had a mastectomy or Lumpectomy with radiation are typically not strong candidates for skin expansion reconstruction. Radiation changes the characteristics of skin tissue, causing a variety of complications ranging from excessive scar tissue development, to blood supply and overall healing problems."

Dr. Davis feels that while radiation does present some difficult challenges, it doesn't automatically rule out the possibility of reconstruction. "While each circumstance is different, I strongly believe that if there is enough good tissue to work with, reconstruction remains a viable option for most women," he says.

Dr. Bruner notes that patients that are emotionally unstable should probably postpone reconstruction. "Coping with the reality of breast cancer is an extremely overwhelming process. If a woman cannot understand the risks and limitations of reconstruction prior to her mastectomy surgery, I would recommend she wait."

Misconceptions abound regarding breast cancer reconstruction. "Most misconceptions are fueled by a lack of information," says Dr. Bruner.

Common misconceptions include having to wait up to one year to safely undergo reconstruction, reconstruction makes it difficult to identify cancer if it recurs, and reconstruction interferes with cancer treatments, such as chemotherapy.

"Wrong on all counts," says Dr. Horner-Taylor. "Reconstruction can take place immediately following mastectomy with little complication. In the case of implants, reconstruction may take longer if the patient has to undergo chemotherapy, but otherwise doesn't interfere with the process."

Managing patient expectations is one of the most important aspects of breast cancer reconstruction. It is important for women to remember that the goal of reconstruction is improvement, not perfection. "Be sure to discuss your expectations candidly with your plastic surgeon, and expect nothing less than total honesty from him or her in return," says Dr. Horner-Taylor. "It's always smart to get the opinions of several plastic surgeons before moving ahead."

To ensure reconstructive surgery has the desired outcome, breast symmetry procedures – surgery to the other breast – is usually also part of the reconstructive process. "Symmetry procedures either reduce, lift or reshape the remaining breast to ensure a better match to the reconstructed breast," says Dr. Bruner. He goes on to note that symmetry procedures can be an ongoing process, with periodic adjustments necessary to correct the affects of the aging process. ASPS is currently pushing for legislation to ensure women have access to symmetry procedures as part of their reconstruction treatment after breast cancer.

Dolores Glover, Siebold and Kocsis all decided to undergo reconstruction procedures – Siebold at the same time as her mastectomy, Glover 10 years later and Kocsis one year later. Glover and Siebold opted for skin expansion with implants. Kocsis decided to go with flap reconstruction.

"Breast reconstruction was the number one motivation that got me through the most difficult times of my treatment," says Siebold. "The breast reconstruction, although excellent, will never look or feel the same as a natural breast. However, not having to stuff my bra with fillers is a great relief, and I truly feel like a complete woman again."

Glover was never given the option of reconstruction at the time her cancer was diagnosed and her mastectomy performed. She was 38. "I was so busy being a mom to my two children and a wife that I didn't think about reconstruction initially. I also didn't want to endure any more pain or surgery, although my oncologist strongly recommended it," she says. However, every time she caught a glimpse of herself in the mirror, she was reminded of her disfigurement. "I felt deformed, and that feeling never went away until I had reconstruction. I eventually did use a prosthesis, but still wasn't happy with the results." Ten years after her mastectomy, Glover finally decided to have breast reconstruction. "I'm glad I had it done. It helped me to find closure and feel normal again."

For Kocsis, breast reconstruction was a completely mind restorative process. "The day I had my reconstructive surgery was the day I took my life back," she says. She first learned about flap reconstruction through a local support group and decided to undergo the procedure one year after her diagnosis. "I liked the idea of using natural tissue for the reconstruction, and once I made the decision to have surgery, I actually looked forward to having it done." The reconstruction was a success and Kocsis is thrilled with her results. "I really feel great about my decision and the end result. In fact, my family and I celebrate the date of my surgery every year as my re-birthday." Kocsis is now active in public education efforts for breast cancer and reconstruction, writing articles, conducting interviews and giving presentations.

Davis decided not to undergo reconstruction, although she was prepared to go through with it until the day before her mastectomy. "I just decided that I didn't want to be under anesthesia or on the operating table that long," she says. And five years later, she's confident she made the right decision. "It was more important to me to focus on treating the cancer. My breasts are not that important to me, they don't define who I am as a person."

The decision to undergo breast reconstruction is an intensely personal one. All of the ASPS members interviewed for this article agree that the decision should be made by the patient, not by treating physicians. "It really is a quality of life issue," says Dr. Davis. "And it doesn't matter how old the patient is or if they're married or single. All women should have the option, if they want it."

The most important tool available to women coping with breast cancer is information. "Women need to get as much information as they can, from doctors, cancer organizations, support groups and other women," says Dr. Bruner. "And they shouldn't be afraid to ask the tough questions, as many as necessary to increase their comfort level with their treatment and aid in their recovery process."