Rebuilding After Breast Cancer: Options
WHEN SHERRI LANDRIEU WAS DIAGNOSED WITH BREAST CANCER last spring, she knew she was in for the fight of her life. Like many mastectomy patients, the forty-seven-year-old New Orleans businesswoman believed that reconstruction would be a vital part of her psychological recovery. So she did some investigating of her own and was surprised to learn she had more reconstruction options than she originally thought.
Of course, no single method of reconstruction is right for every woman or, for that matter, is risk-free. Indeed, many women prefer simply to wear a prosthesis and bypass the additional surgery and its residual effects, which can include a loss of sensation to the breast and substantial scarring. As Landrieu discovered, evaluating all the options, from implants to tissue transfers, is essential.
PROCEDURE: Saline implants
WHAT’S INVOLVED: The insertion of implants requires two separate surgical procedures. First, a tissue expander, which looks like a deflated plastic bag, is implanted under the pectoral muscle (the mastectomy incision site is usually reopened to insert the implant). Over a period of time, the doctor fills the “bag” with saline from a needle, stretching the skin gradually to accommodate the implant. The expander is later replaced surgically with a more permanent implant.
WHO: Most women are candidates, although large-breasted women may choose to undergo a reduction on the other breast to achieve symmetry. Very small-breasted women can sometimes skip the expander step and simply have an implant inserted under the chest wall. Saline implants are ideal for women undergoing a double mastectomy but may not be appropriate for women who have received or will undergo radiation therapy, as they reduce the skin’s elasticity.
PROS: The surgeon can adjust the implant’s volume according to the size of a woman’s breast and the amount of skin and muscle available.
CONS: “These are not lifetime devices. They have to be replaced,” notes V. Leroy Young, M.D., professor of plastic and reconstructive surgery at Washington University School of Medicine in St. Louis. On average, an implant lasts from ten to fifteen years. But a replacement could be needed much sooner than that because implants can occasionally leak, rupture or cause the surrounding tissue to harden.
WHAT ABOUT SILICONE? Silicone implants, which look and feel more natural than their saline counterparts, were taken off the U.S. market as of 1991. But they are still available to reconstruction patients involved in clinical trials. An Institute of Medicine study has since concluded that silicone implants do not appear to cause autoimmune disorders. New, sturdier silicone implants are currently available in Europe and may be on the market here within the next few years.
MAMMOGRAMS FOR WOMEN WITH IMPLANTS: Since both saline and silicone implants may cause difficulties with mammogram readings, the American Cancer Society recommends seeking out accredited facilities with technicians who are trained in manipulating an implant to get the best possible images of the breast.
Women who are not good candidates for implants or who are put off by the downsides may be interested in reconstruction using tissue from another part of their own body. Though tissue can be taken from the back or buttocks, the most common source is the lower abdomen. These procedures involve abdominal and breast scarring.
PROCEDURE: TRAM (transverse rectus abdominus myocutaneous) flap
WHAT’S INVOLVED: During a four-hour operation that can sometimes be performed at the same time as the mastectomy, excess skin, tissue, blood vessels, fat and at least one abdominal muscle are tunneled up from the abdomen to the chest by loosening an abdominal muscle (to which the tissue remains attached). The muscle’s blood vessels nourish the transferred skin and fat.
IDEAL CANDIDATES: Women with some abdominal fat. This procedure poses a greater risk of failure (as does any surgery) for women who smoke, are obese or have such medical conditions as diabetes or vascular disease, which can impair blood circulation.
PROS: This procedure goes hand in hand with a skin-sparing mastectomy technique that allows the breast surgeon to remove malignant tissue through an opening around the areola. The nipple, which may harbor cancer cells in the milk ducts, is removed and disposed of. (Later, a new nipple can be crafted from tissue taken from a donor site and repigmented during an in-office tattooing procedure.) The skin left behind serves as a kind of envelope for the tissue transferred from the abdomen.
CONS: The surgery and the recovery period are both lengthy. According to Jay Meisner, M.D., assistant clinical professor of plastic surgery at Mt. Sinai and Beth Israel hospitals in New York City, up to 20 percent of patients experience some minor hardening of the transferred tissue, which may resolve over time or require additional surgery. About 5 to 10 percent may develop abdominal weakness, a bulge or herniation. In very rare instances, the blood supply fails and the flap does not heal successfully.
PROCEDURE: Free TRAM flap, a variation of the TRAM flap
WHAT’S INVOLVED: During a lengthy surgery, a small chunk of muscle roughly the size and shape of a Saltine cracker, along with the surrounding fat and skin, is removed from the abdomen and reattached microsurgically in the chest.
IDEAL CANDIDATES: Serious athletes who don’t want to risk the potential for abdominal weakness associated with the TRAM flap. Women with circulation concerns (smokers, women who are obese or have conditions such as diabetes), because this procedure involves less damage to the blood vessels, so circulation is less impaired.
PROS: The procedure has the same advantages as the traditional TRAM flap, with the additional advantage that only a small part of the muscle is used, reducing the risk of abdominal weakness.
CONS: The surgery is complicated and the failure rate–as much as 5 percent at the finest breast centers–is higher than it is with the garden-variety TRAM flap. “It’s tragic when a patient who comes to the hospital hoping for a new breast ends up with a wound and has lost a portion of her own tissue,” notes Sumner Slavin, M.D., chief of plastic surgery at Beth Israel Deaconess Medical Center in Boston.
PROCEDURE: Perforator flap
WHAT’S INVOLVED: With this new microsurgical technique, abdominal fat and tissue connected to a blood vessel are dissected from the abdominal muscle, leaving that muscle intact, then transferred to the chest. Known as a perforator flap for the tiny perforator blood vessels that nourish the transferred tissue, this surgery takes longer than the free TRAM flap procedure, depending on the size of the surgical team and its experience.
IDEAL CANDIDATES: According to Robert J. Allen, M.D., chief of plastic surgery at Louisiana State University Health Sciences Center in New Orleans, almost all reconstruction patients are candidates.
PROS: The abdominal muscle remains intact, eliminating concerns about abdominal weakness or herniation.
CONS: New and technically challenging, this procedure is not widely available yet or universally embraced. As a result, its failure rate is likely to be higher than it is for other techniques.
In the end, Landrieu opted for the perforator flap procedure, and likens the level of discomfort to what she experienced during her recovery after the C-sections she had to deliver her children. She is thrilled, however, with the result: “As far as I’m concerned, I still have my breast, and it’s very natural.” And not having to mourn the loss of her breast, she says, leaves her with more emotional energy to grapple with the disease that claimed it and move on with the rest of her life.
In most states, insurance coverage for post-mastectomy reconstruction is mandated by law, but this coverage extends only to the affected breast.