Women Have Choices after a Mastectomy
Article by Jason Brett Lichten, MD
Columbus Plastic Surgeon
When Phyllis was diagnosed with breast cancer, she felt like she had been “hit by a truck.” In the few weeks since her OB/Gyn discovered a lump during her annual check-up, she had seen a general surgeon who recommended a mastectomy. She was then referred to me to discuss her reconstruction options. She was overwhelmed – both by the diagnosis and by the flood of information she was expected to digest in a short time. Unfortunately, Phyllis’s experience is all too common. When women are diagnosed with breast cancer, they often have to make life changing decisions in a matter of weeks. It can be a mind-boggling experience.
The good news is that women now have more choices in the types and the timing of their surgical reconstruction and that external support systems are better than ever before.
Why do I need reconstruction?
The short answer is that you don’t need reconstruction, but you are entitled to it. The Women’s Health Act of 1998 requires group health insurance plans to cover all phases of breast reconstruction after breast cancer, including surgery on the opposite breast for symmetry.
Many women opt not to have surgery. Instead they either do nothing or wear a prosthetic breast form in a bra, which can work very well. Claire, one of my patients, opted for surgical reconstruction. Claire said she would “recommend reconstruction because it’s not the first thing you think of when you wake up in the morning and the last thing at night. I think if you didn’t have reconstruction, it would be a lot harder to get over having breast cancer.”
What are my choices for reconstruction?
Advances in surgical techniques have given women more choices to restore their appearances after mastectomy. The right procedure varies for each woman, depending upon her body type, treatment plan, lifestyle, general health, the shape and size of the breast and the goals she has for the procedure. The plastic surgeon and the patient will work as a team to determine the best procedure for her.
Some women choose to have their surgeon insert a breast implant to create a shape resembling the other breast. This procedure is done in several steps. First, the surgeon inserts a tissue expander, which is basically an empty balloon in the shape of a breast implant. Over a few months, the expander is enlarged through a port with saline injections. The tissue expander helps to slowly re-create the skin and breast pocket. Approximately six months to a year later, the tissue expander may be removed in a second surgery and replaced with a breast implant. The implant can be either saline or silicone depending upon patient preference.
Another choice is to use the patient’s own tissue, muscle and skin to rebuild the breast, using a flap. The most common types of tissue flap surgeries are the TRAM (transverse rectus abdominus musculocutaneous) flap, which uses abdominal tissue and muscle, the LD (latissimus dorsi) flap, which borrows them from the back and the Free Flap. In most cases, the TRAM flap provides enough tissue to completely rebuild the breast. This approach can also result in a tightening of the lower abdomen, simulating a tummy tuck. An LD Flap can be used with our without an implant, which will add fullness to the breast. The most common type of free flap procedure is a DIEP Flap (deep inferior epigastric artery perforator) in which skin and fat from the abdomen are used, but the muscle is not.
The TRAM, LD and free flaps are more complicated surgeries than implants and recovery is longer. The benefit of these surgeries, however, is that the results may be more natural because the breast is being reconstructed from the patient’s own tissue.
Both the tissue expander and the flap surgeries will likely involve additional follow up procedures after the breast has had a chance to heal.
During a mastectomy, the nipple is usually removed with the breast in case it contains cancerous cells. After the breast reconstruction has healed, a plastic surgeon can recreate the nipple using a small skin graft or through a local procedure on the breast. The areola (the dark circle around the nipple) can be recreated with either a skin graft or by tattooing the area to match the opposite breast. Nipple and areola reconstruction are usually done as separate, outpatient procedures.
Additionally, if the first surgery was only done on one breast, your surgeon may suggest a surgery on the opposite breast to improve the symmetry of the two breasts. This may be breast lift, a breast reduction or an augmentation.
When should I have the reconstruction done?
Reconstruction can often begin on the same day as the mastectomy. In those cases, a general surgeon will perform the mastectomy and then the plastic surgeon will come in to begin the reconstruction. For some women, like Claire, immediate reconstruction had both physical and emotional benefits. “I would definitely recommend the experience of having a mastectomy with immediate reconstruction. If I had just had the mastectomy and waited for the reconstruction, I probably would have never come back.” For Claire, the motivating factor was to minimize the number of times she had to recover from surgery. She felt that her treatment plan was “already in process,” so the immediate reconstruction allowed her to “just keep right on going without turning back.”
Where can I find other women having the same experience?
Friends and family are always a terrific form of support and you should lean on them as much as you can. My patients have also found it very helpful to reach out to support groups and to attend breast cancer events. My office has done a number of fundraisers for the American Cancer Society and Komen Columbus. Claire came to one of these events as did another patient, Roberta. I knew that both women had been diagnosed with breast cancer and had undergone mastectomies with immediate reconstruction in the last few months. What I did not know, however, was that the two women had worked together 20 years before and had lost touch. They reconnected and are now close friends again. They were able to lean on each other during their treatment. Claire says, “It definitely helped us get through the pitfalls when we were going through the same things, feeling the same things, hurting in the same areas.” Now, Claire and Roberta are co-captains of a Relay for Life team, working to raise money for cancer research and to help other cancer patients.
What questions should I ask my plastic surgeon about reconstruction?
When going to the doctor’s office, it is always helpful to have a list of questions prepared to ask the doctor. This is especially true at an appointment for breast reconstruction. Following is a list of questions you should be sure to ask your plastic surgeon:
- Are you Board Certified in Plastic Surgery?
- What are all my options for breast reconstruction?
- What are the steps in each procedure?
- What are the possible risks and complications for each type of reconstruction, and how common are they?
- What if my cancer recurs or occurs in the other breast?
- Will reconstruction impede my cancer treatment?
- What kinds of help will I need as I go through the process?
- How much pain or discomfort can I expect, and for how long?
- When will I be able to resume my daily routines?
- How long will it take to complete my reconstruction?
- Can I see before and after pictures for each procedure?
A diagnosis of breast cancer can be overwhelming, but it doesn’t have to be devastating news. Women are being diagnosed earlier and survival rates can be very high. Scientific innovation gives women more reconstruction options with more natural looking results than ever before. Creating a team with your support system, general surgeon, oncologist and plastic surgeon is critical to your success.