When Tina Nelson found out she had breast cancer this April, she opted to have a double mastectomy even though cancer was detected in only one breast. "I thought it was a good idea because of my family history," she says. "My mother had breast cancer twice in her 50s."
Before her surgery, Nelson, 47, was told about the choices available to her for breast reconstruction. The information, she recalls, was overwhelming. "Breast cancer is very scary because you are told you have it, yet you are supposed to make all these decisions on what you are going to do."
Breast reconstruction is a very personal decision for a woman. "It can improve a woman's quality of life," observes plastic surgeon Dr. Leslie V. Cohen, associate director of the Wound Healing Center at Retreat Doctors' Hospital. "It helps them move past the emotional consequences of breast cancer. When you look in the mirror you don't see a mastectomy but instead you see a restored breast form."
However, a recent study led by a University of North Carolina researcher — and published in July in the Journal of the American College of Surgeons — calls into question how much difference breast reconstruction actually makes in patients' quality of life. "The take-home message from our study is that breast reconstruction is right for some women and not so much for others," says Dr. Clara Lee, assistant professor of surgery and director of research at the UNC School of Medicine. "It really depends on a woman's preferences, in other words, what's most important to her."
Some women may decide against breast reconstruction for health reasons or because of worries about more surgery and the possibility of complications. Most choose it, however. According to the American Society of Plastic Surgery, breast reconstruction rose 39 percent from 2007 to 2008, when there were a total of 79,458 reconstruction procedures performed.
Bethann Canada says making the decision to have reconstruction after her double mastectomy in 2008 was a "no-brainer" for her. "I was 50 years old with a couple of good years left in me," she jokes. "I wanted to come back to normal. I wanted other people to see that even though I had something really bad happen, I could come back and be myself again."
Women who decide to have breast reconstruction can choose implants or a procedure that uses their own tissue. The choice depends on a number of factors, including a woman's medical history and physical condition.
"You have to take an in-depth health history," because a person's general health affects the healing process, explains nurse practitioner Tina Lucas of the VCU Health System's division of plastic and reconstructive surgery. "Do they have diabetes? Do they smoke? Are they obese? Have they had previous abdominal surgeries or radiation in the past?" Radiation changes the tissue and skin, she adds.
Women can have breast reconstruction at the time of their mastectomy or afterward, when they have finished chemotherapy and radiation treatments. Women who opt for implants go through a multistage procedure.
"The cancer surgeon does the mastectomy, and we come in and put in tissue expanders," explains Dr. Neil J. Zemmel, a plastic surgeon with Richmond Aesthetic Surgery in Midlothian who works closely with the Bon Secours breast cancer team. An expander is an inflatable implant that is placed under the skin and inflated with saline during the healing process. After a few months, when the patient has recovered from the surgery, the tissue expanders are removed and replaced with a permanent saline or silicone implant.
The saline implants currently in use were approved by the Food and Drug Administration in 2000. Cohesive-gel silicone implants were approved in 2006. Risks associated with both include hardening of the area around the implant, rupture of the implant, additional surgeries and breast pain. Of the two choices, Zemmel believes that silicone implants have a softer texture. "The viscosity of the gel mimics breast tissue more than saline," he says.
The downside to silicone implants is that the FDA recommends that a woman have an MRI every three years to make sure that the implant is intact.
The life expectancy of an implant is about a decade. "After 10 years we know that the risk of rupture increases due to strain on the material," says Cohen. An implant would then need to be replaced.
There are two or three procedures using a patient's own tissue for breast reconstruction, but most patients choose to have what is called a TRAMflap procedure. This is a larger, more involved operation than an implant and has a longer recovery period, from six to 12 weeks. "We take extra tissue from the abdominal wall and transplant it to the breast," Zemmel explains. "The main drawback is that it can weaken the abdominal wall."
Risks for TRAMflap surgery include scarring on the abdomen. But there is an advantage, Cohen says. "You can improve the overall contour of the person's body, using tissue that would be similar to a tummy tuck."
Opting for TRAMflap can be a difficult decision. "There is no substitute for the look and texture of one's own tissue," Zemmel says. "But you're always robbing Peter to pay Paul. You are creating a donor site on an otherwise healthy part of your body."
After breast reconstruction, women can choose to have nipple reconstruction, where some of the tissue is rearranged from the reconstructed breast to create nipples, and they can have an areola (the circular area around a nipple) tattooing procedure. "Most women have all three procedures," Lucas says.
In Virginia, insurance covers breast reconstruction and surgery to reestablish symmetry between the two breasts.
After their surgeries, Nelson and Canada elected to have silicone implants. Nelson currently has tissue expanders. They will be replaced with implants after she finishes chemotherapy and radiation. Nelson is excited about the eventual outcome. "Out of all this bad, I will probably never have to wear a bra again," she says, noting she will drop from a double-D to a C cup.
Canada is likewise pleased with her decision. "I was very proud of myself for having gone through this. Getting the implants and this January getting my hair back were huge milestones. It's a relief to have it all behind me."