When a woman is diagnosed with breast cancer and learns she will have to undergo a mastectomy, reconstructive surgery might not be the first thing on her mind — but sooner or later, it’s a decision she will have to make.
And like most things, it’s not as easy as it seems.
It’s an intensely personal decision, and in fact, a majority of women choose not to have any type of reconstructive surgery — but those who are interested have many options to explore.
Longtime plastic surgeon and Eastern Niagara Hospital Medical Director Dr. Bruce Cusenz said there is no perfect answer, although a woman considering reconstruction should meet with a plastic surgeon to discuss options long before the procedure takes place.
“Ideally, the breast oncologist would refer the woman to the plastic surgeon for a consultation, and they would work together,” Cusenz said, although he admitted that that isn’t always the case.
However, if a woman is seeking out a surgeon on her own, or is looking for information, they should always look for “The Symbol of Excellence in Plastic Surgery” which means that the doctor is board certified or that the website is reliable.
“The Internet is full of bad information. Anyone can develop a website,” Cusenz said.
Breast reconstruction surgery is on the rise, but not for the reason many people might think.
Cusenz said that more women than ever are having mastectomies — rather than lumpectomies — which were popular 25 years ago.
“What’s happened is that today, they are able to distinguish between different types of breast cancer, and certain types have better survival rates with a mastectomy. Some women are even opting to have healthy breasts removed because they have the (BRCA) gene,” Cusenz said.
Basically, women considering reconstructive breast surgery can choose to either have a breast implant, which requires a months-long skin expansion procedure so that the implant can eventually be placed under the skin, or “flap reconstruction,” where tissue — including skin, fat and muscle — from the woman’s back or abdomen is used to create the breast “mound.”
Both methods have their advantages and disadvantages, and in some cases, one or the other procedure may not be possible depending on the woman’s medical condition.
“The wildcard is radiation,” Cusenz explained, saying that when most women undergo a mastectomy, it is followed by chemotherapy, then by radiation. Unfortunately, the radiation can burn and affect the quality of the breast skin, making it more difficult, or sometimes impossible, to work with.
If a woman chooses flap reconstruction, it is done immediately following the mastectomy. When the skin is taken from the back, the flap can be tethered to its original blood supply, and there may be enough flesh to create a breast mound; otherwise, an implant may still be required. If the flap is taken from the abdomen, microsurgery may be required to reattach blood vessels.
If a woman chooses to go the implant route, a tissue expander is placed under the breast skin and follow-up visits to the doctor will be required to gradually fill the expander with saline solution until there is enough skin to place over the permanent implant.
“The skin is stretched just like it is during a pregnancy, so it can expand gradually,” Cusenz said.
Cusenz said that today’s silicone implants are safe and don’t leak like some of the earlier versions. “The new generation of implants is light years ahead (of the older versions). There is almost an infinite number of shapes and sizes to choose from,” Cusenz said.
Flap reconstruction requires a longer recovery time, but an implant requires weeks of follow-up visits as well as another surgery to place the permanent implant. With a single mastectomy, additional surgery may also be required to make the remaining breast “match.”
So which is the best choice?
“There are distinct advantages and disadvantages to both. You’re always juggling balls,” Cusenz said. “Most of the time when I see a woman, within the first few minutes I know what’s best for her. The rest of the consultation is where I convince her that it’s her idea.”
With either type, follow-up visits are required to reconstruct the nipple and areola. The coloring on the reconstructed nipple area is done with medical tattoos.
The good news is that with everything else women who are facing reconstructive breast surgery have to think about, they won’t have to worry about paying for it — by law, insurance companies have to cover the cost of reconstruction, as well as any surgery needed on the existing breast to make it “match.”