Informed decision is key when considering mastectomy
By most estimates, nearly half of all women who undergo mastectomy will choose to have breast reconstruction, either immediately following the mastectomy surgery or at a later scheduled date. But a diagnosis of breast cancer is traumatic enough.
How can a woman know if breast reconstruction is right for her?
Essentially, an informed decision is key. And the best time to gather that information is before it’s ever needed.
The general surgeon who performs the breast cancer surgery will likely initiate the discussion about reconstructive techniques. Since 1998, when the federal government passed the Women’s Health and Cancer Rights Act, health insurance groups that provide medical and surgical benefits with respect to mastectomy are also required to provide coverage for breast reconstruction in connection with that mastectomy. This coverage includes reconstruction of the other breast to produce symmetry between both sides.
The simplest reconstructive procedure would be place implants beneath and muscle underlying the mastectomy flaps, according to Dr. Henry W. Neale, with the Division of Plastic, Reconstruvie and Hand Surgery of the University Surgical Group at the University of Cincinnati.
The implant would be inserted through the same incision as the mastectomy, so only one incision, with one scar, would be present. These implants would be either saline or silicone.
Silicone implants are still available for use by cancer patients and are preferred by some because of silicone’s ability to contour better than saline. Ongoing studies have yet to confirm the specific danger from silicone breast implants, but the FDA has restricted usage to women under strictly controlled medical trials until safety is assured. Contact the American Cancer Society for more information.
The next type of reconstruction would involve muscle flaps. A TRAM flap uses tummy tissue and muscle from the abdominal wall to rebuild the breast, and a back flap uses the latissimus dorsi muscle from the back. In both these procedures, the tissue and muscle are tunneled under the skin from their original positions and maintain their original blood supply.
In a “free flap” procedure, tissue (muscle, fat and skin) from the buttocks, thigh or tummy is completely cut off from its blood supply and reattached at the chest. The free flap would be the most complicated of these procedures because of the microsurgery involved to establish a new blood supply.
The exact procedure selected would depend upon the extent of the cancer and the degree of mastectomy needed, along with patient input. The general medical health of the patient exclusive of the cancer would also be a factor.
According to Dr. Michael Columbus of The Plastic Surgery Group, also in Cincinnati, some individuals, such as diabetics or smokers, would run a higher risk of wound complications from flap procedures because of the needed blood supply to the reconstructed area.
Diabetics have an obvious disadvantage with possible circulation problems, but how does smoking affect the flap procedures?
“Smoking shrinks the small blood vessels under the skin and the subcutaneous tissue and basically renders everything that much more susceptible to spasm in the vessels, where the tissue will just die,” Columbus said. Both Columbus and Neale try to convince smokers to stop smoking before undergoing a flap procedure.
Even morbid obesity could affect flap procedures, especially the TRAM flap, since obese patients tend to be more prone to developing blood clots after surgery. But as with any surgery, all contraindications need to be evaluated, with each patient examined as an individual.
Another factor to consider is how to select a plastic surgeon. Most often a woman’s mastectomy surgeon will make recommendations regarding the plastic surgeon, but a woman needs to be completely comfortable with her selection based on her own evaluation.
Columbus encourages questions. “You want to ask everything that you thought was important to you… and if they won’t answer them for you, then go find somebody else.”
Make sure the plastic surgeon is board-certified. Being board-certified means they have completed medical school, an approved and accredited general surgery residency and an additional period of plastic surgery training. Ask to see credentials.
Neale says women should check on the doctor’s background and experience. “Maybe to some extent how many of these he does a week, a month, a year.”
Ask to see a portfolio of the plastic surgeon’s work – to have a realistic expectation of the surgery results -and for a list of patients who have had the surgery and are willing to share their experience.
Women should also ask about limitations of the various techniques. Using one stomach muscle for the TRAM flap is fairly well tolerated, according to Columbus, “but two muscles is a bit hit. Most people won’t be able to do sit-ups.”
His patients may respond “I don’t do sit-ups anyway” but what he really means is you lose your sit-up muscle and won’t be able to pull yourself up from a flat, on-your-back position.
In the end, what’s most important is getting on with life after mastectomy. Whether or not that involves reconstruction is a very private decision.
Talk to women who’ve had reconstruction and those who’ve had mastectomy alone. Make sure you get all your options before you make your final decision.
Jan Hawkins is a freelance health care journalist residing in northern Kentucky.