Sandy Lee, 48, of Santa Monica says she responded calmly at first when she learned she had breast cancer and that her left breast would be removed in a modified radical mastectomy.
But she quickly realized her life had caved in on her: “You get stunned. I wanted to know that they were going to make me live. It was my only thought. Just let me live.”
With survival on her mind, the thought of losing a breast didn’t overwhelm her at first. “I don’t think I realized how important it was,” she recalled one day recently.
Yet as the surgery approached, she began to get a clearer idea of what her body image meant to her self-esteem. “As I thought about it, I became very emotional,” she said.
Surgery, Therapy and More
Lee then went through two major events. The first was the surgery, which was followed by eight months of chemotherapy and her apparent cure. The second was that after Dr. Janet Salomonson, a plastic surgeon, concluded Lee was a candidate for breast reconstruction, the procedure was started while Lee was still anesthetized.
Breast reconstruction--which allows a woman to avoid the haunting specter of mutilation--has come into its own within the last decade.
It is an advance in therapy almost as important as the developments of more effective surgical, radiation and chemotherapy methods, which have transformed breast cancer, when detected early, into an increasingly curable disease. And it is an advance not without controversy.
The number of all simultaneous and delayed reconstructions performed in the United States each year is unclear. The latest figures from the American Society of Plastic and Reconstructive Surgeons date back to 1984, at which time the group estimated 98,000 were done that year, up from 20,000 in 1981. The organization doesn’t plan to revise the figures until next year.
Dr. Robert McKenna, a Los Angeles cancer surgeon and former president of the American Cancer Society, and other cancer and plastic surgery experts say that all women who have breast cancer consisting of a tumor less than 2 inches in diameter and little or no spread of cancer cells to the lymph nodes can routinely have simultaneous breast reconstruction. Yet, they say, only about 25% actually do.
Other published estimates, according to Dr. Robert Goldwyn, a Harvard Medical School plastic surgeon who recently reviewed the situation in the New England Journal of Medicine, indicate only about 30% of potential candidates for immediate reconstruction have the procedure.
The existence of the simultaneous procedure “is not well known,” Goldwyn said, and many patients don’t know or aren’t told that the contemporary version of mastectomy has survival rates identical to so-called lumpectomy, which came into favor because the immediate surgery is less disfiguring.
McKenna said modern detection, relying on mammography, make it possible to find breast cancers far earlier than ever before. Half of the cancers he treats now, McKenna said, are less than an inch in diameter and of those, three-quarters can’t be felt and are evident only in X-ray examination.
The strategy for breast reconstruction is controversial for several reasons. First, McKenna and other cancer and reconstructive surgery specialists are occasionally at odds over the frequency with which a breast can be cosmetically rebuilt during the same cancer-treatment surgery.
Plastic surgeons point out that surgeons in cities like Washington are extremely receptive to the simultaneous surgery, while those in other cities--including New York and, to a lesser extent, Los Angeles--have been slower to accept it.
Then too, said Dr. John Little, director of the division of plastic surgery at Washington’s Georgetown University Medical Center and an internationally known expert on reconstruction, many cancer specialists still prefer to treat the organic disease first and deal with what they perceive as strictly cosmetic questions later.
At the same time, Little said, the women’s movement has played a large role in making women more inquisitive about options not only for surviving cancer but for emerging from the ordeal with their body images intact.
“One of the things that we’ve begun to understand is that we men used to say (to women with breast cancer): ‘You should be satisfied you’re cured.’ ” said Dr. Gary Brody, a Los Angeles plastic surgeon known to be on the forefront of reconstructive techniques. “For a lot of women, that’s fine, but for those who want (their bodies to resume a normal appearance) it is very important. Nobody should be making those decisions for them.”
Brody, Salomonson and many other plastic surgeons also routinely advocate reconstruction--usually after a few months--for serious cancer cases. “I think that reconstruction really says something to the patient that we (doctors) really believe this is a treatable disease or we wouldn’t be doing the surgery,” Salomonson said.
The field has evolved rapidly. Among the techniques available for reconstruction in conjunction with mastectomy are these:
--The tissue-expander implant: This device is like a balloon that is installed under the chest-wall muscle by a plastic surgeon, after the breast tissue is removed in a mastectomy. Over the next few weeks or months, the expander is inflated with salt water until it is about 50% larger than the size of the eventual breast, to allow stretching of the muscle and skin. Once the tissue has been stretched into shape, a permanent implant is installed in a comparatively minor procedure. The expander can be used in both types of reconstruction.
--Immediate installation of the permanent implant: The permanent silicone or saline-filled implant is inserted under the chest muscle during the cancer operation. Women who are small-breasted and whose cancers are not so extensive that mastectomy requires removal of large amounts of skin are candidates for this. The implant can also be inserted months after the surgery.
--Transplanted muscle tissue from other parts of the body: In some women, particularly those who lose a large volume of tissue in the mastectomy, muscle can be transplanted from the abdomen or the back of the shoulder. The advantage of these techniques is that no foreign object is introduced into the body. The disadvantage is that, especially in the abdominal muscle transplant, there may be permanent compromise of the areas from which the transplant muscle is removed. Tissue transplants are usually done on a delayed basis.
--Newer tissue transplants from other areas of the body: The first of these techniques, detailed earlier this year by Dr. William Shaw, a New York City plastic surgeon, relies on transplanting fat, muscle and skin from the buttocks.
--Nipple reconstruction: Rebuilding of the nipple is usually done several months after the initial surgery. This is necessary because swelling at the time of the cancer operation makes placement difficult and could result in the nipples being out of line. Last weekend, plastic surgeons meeting in Toronto heard a report of a new nipple reconstruction technique that uses skin removed from the opposite, undiseased, breast and preserved by freezing. More established techniques include transplanting skin from other parts of the body.
Even for women who had breast cancer surgery many years ago, reconstruction is often possible. Leila Kleiman, a 51-year-old Westside woman, had her surgery in 1973 but it was not until she met Santa Monica plastic surgeon Dr. Harold Clavin that she began to seriously consider reconstruction.
An artist, Kleiman had gained weight after her surgery and had begun to feel her entire personality had changed: “I started thinking of myself rather than as the young, athletic person I had always been, as a middle-aged kind of dowdy person.”
Today, she said, with her left breast rebuilt--including creation of a replacement nipple--she has noticed the tone of her work has changed dramatically.
“I’m not so consumed by this constant thought of being lopsided,” she said. “The whole coloring of the way I perceive my work is changing. It’s amazing. My whole outlook is changed. I lost 40 to 50 pounds. It’s as if the clock has been turned back for me 15 years.”
Psychologists who have investigated the role of reconstruction in the psychological health and overall recoveries of women who have and have not had the procedure agree the technique can be crucially important.
UCLA psychologist David Wellisch has published a variety of studies on the psychological ramifications of breast reconstruction which found that, among other things:
--Only 25% of women who underwent immediate reconstruction fit a screening profile for “high distress;" 60% of women who delayed reconstruction experienced emotional trauma.
--A reconstituted nipple made a significant difference in one group of research subjects who included 33 women who had the procedure done after their cancers and 26 who did not. Women who had nipple surgery reported that they felt a greater degree of a sexual sensitivity than women who did not have such surgery and that they found their nude appearance pleasing.
“Women say reconstruction makes them feel more whole,” Wellisch said. “The cancer experience is not as painfully evident.” But Wellisch said the importance of breast restoration as a whole and nipple replacement, in particular, varies among women--even among younger women, some of whom are comfortable without any of the procedures and some who say they could not have faced the cancer diagnosis without knowing their appearances could be restored.
In an article in a recent issue of the Medical Journal of Australia, Dr. Christopher Magarey said reconstructive techniques are increasingly able to make it possible for breast cancer to “be a positive turning point in a person’s life.”
Magarey also said there is more evidence now that psychological factors may influence survival rates in breast cancer and that reconstructive surgery--immediate reconstruction, in particular--can directly affect the outcome of a woman’s disease.
But McKenna and breast reconstruction experts across the country again point out that, while most of the techniques have existed for a decade and the simultaneous procedure has been reliably available for at least five years, many cancer surgeons still resist offering it to potential candidates.
“Some surgeons just don’t want to do it. It’s a little more difficult,” said Cedars-Sinai Medical Center plastic surgeon Dr. Eugene Worton, a past president of the California chapter of the American Society of Plastic and Reconstructive Surgeons. “And I think one reason more of it isn’t done is a lack of coordination between the tumor surgeons and the reconstructive surgeons.”
“It’s like anything that’s new,” McKenna said. “If you’ve always bought a gasoline car and they come out with one that runs on methanol orethanol or something, you probably won’t buy it. You’d want to see if it’s a proven product--as good or better than what we had before. It takes time--maybe 10, 15 or 20 years.”
Even cancer surgeons who are not enthusiastic supporters of immediate reconstruction in all cases agree that rebuilding the breast has become such an integral part of the treatment of cancer and that modern techniques are so well refined that the decision between lumpectomy and mastectomy should be influenced by availability of reconstruction.
Because lumpectomy must be followed by radiation therapy, there has been some concern about latent effects of X-ray exposure and even the ability of some cancers to more easily reappear years later because radiation has failed to eliminate the disease.
Dr. Marjorie Fine, a Santa Monica cancer surgeon, said that while she often recommends against simultaneous reconstruction, she believes the availability of breast-restoring surgery soon after cancer treatment makes today’s mastectomy with reconstruction the treatment of choice.
“It’s the operation I would have if I was diagnosed,” she said. “It really is the best surgical treatment we know of for breast cancer. It surgically removes the diseased organ and that makes detection of recurrence easy.”
Fine said that, as one of the few female cancer surgeons in Southern California, she is often sought out by women who are terrified by their diagnoses and believe she will be more inclined to give them surgery that permits retention of body image.
In patients who are so clearly driven by the psychological considerations of breast cancer, Fine said, she often consents to simultaneous reconstruction in order to get the patients to agree to timely treatment of their cancers.
While breast augmentation techniques were developed as early as 1893, reconstruction of a breast after cancer surgery had been done only rarely until about 20 years ago and early operations using silicone gel implants often resulted in disfiguring complications in which tissue fresh from the insult of surgery proved too easily able to reject the plastic implants.
There also used to be a philosophy, according to McKenna and Wellisch, that reconstruction should be delayed for as long as five years after cancer surgery because of unfounded fears that reconstruction could aid cancer recurrence and because women would benefit psychologically from living with their deformities.
McKenna and Dr. John Bostwick III, an Emory University reconstruction expert, speculated that reconstruction is best known to sophisticated, more economically upscale women and that poor patients remain ignorant of its availability.
Bostwick said the economic distinctions are unfortunate because even possibly terminal breast cancer patients from any background may benefit from the psychological effects of reconstruction. “I think the worst thing you can do for a woman with a poor prognosis is to tell her she has not hope and you’re not going to reconstruct her,” Bostwick said.
Worton, Bostwick, Goldwyn and other prominent plastic surgeons across the country agreed that even today’s advanced reconstruction techniques are incapable of producing an exact duplicate of the original breast. Some scarring always remains and the reconstructed breast is often of a slightly different shape and texture than the natural one.
“I never want to imply that when they (patients) wake up it’s totally back to the way it was presurgically,” Salomonson said. “It never will be. We can say you can get back to the point that, in a bra and clothing, they will be their pre-reconstructive size, but it’s not going to look (nude) as if there had been no operation.”
“I think it’s very difficult to say, ‘This is best,’ or ‘This isn’t the best,’ ” Worton said of the many options available in breast cancer treatment and subsequent cosmetic surgery. “If you were talking about a washing machine, you could say, ‘We tested them all and Maytag is the best.’ But that’s basically because the machines are washing clothes.”
Salomonson said she has often gone to unusual lengths to accommodate the cosmetic needs of recovering cancer patients. She recalled one episode in which a patient who had had tissue expander surgery had a long-standing commitment to attend a social event at which she was to wear a low-cut evening dress. But the woman’s expander was still inflated oversize.
So Salomonson had the patient bring the gown to her office the afternoon of the event, deflated the expander so the dress had an appropriate appearance and then reinflated it the next morning.