New Mastectomy Technique Banishes Specter of Disfigurement
The topic was breasts, so no one seemed very surprised when the speaker clicked up a slide of a topless woman.
At first glance, everything about the picture on the screen looked ordinary enough. It showed the chest of a fit-looking woman, probably 40-something. Her breasts were medium size, free of sag and perfectly symmetrical.
The audience stared. That seemed natural, too, since this gathering was sponsored by the American Cancer Society, and the man at the lectern was a plastic surgeon. And on second look, something about the woman’s right side was ever-so-slightly off. Exactly what was hard to say. Maybe the nipple area was a shade darker than the other. Or perhaps the outline of the areola was a bit too sharp.
For those in the room who could not see the difference, the surgeon offered some help: “I’ll point out the reconstructed side, because it’s not always obvious.”
Yes, reconstructed. This woman’s right breast was created by the surgeon. It looked uncannily like its mate and undoubtedly like the one it replaced.
Dr. Joseph J. Disa went on, talking about circumareolar incisions and transverse rectus abdominis myocutaneous flaps and such, walking his audience through the state of the art of the modern mastectomy. And art it is, this reinvention of an old operation.
Until the 1980s, little thought typically was given to the physical aftereffects of breast cancer surgery. The standard operation was not much changed from the one Dr. William Halsted introduced in the 1890s, the radical mastectomy. It removed the breast and the lymph nodes in the armpit, leaving a hollowed-out space and a scar.
The first big change came in 1985, when doctors proved that it is often enough to remove just the cancerous lump, not the whole breast. Now roughly half of women with breast cancer get lumpectomies. But for a variety of reasons--the size of the tumor, the stage of the disease and the preferences of patients and doctors--mastectomies are still a common surgical approach to breast cancer.
Yet even though it is still called a mastectomy, the results in the hands of a skilled surgical team may bear no resemblance to the disfiguring operation that makes this word so dreaded by women.
Over the last three or four years, surgeons at several medical centers have developed a remarkable new method of reconstruction. It restores the shape, the appearance and the feel of the patient’s missing breast, using her own breast skin and other body parts as building material. And it leaves almost no scars.
The operation is becoming standard at Memorial Sloan-Kettering Cancer Center in New York City, where Disa works, and other elite medical centers. Doctors call it the complete skin-sparing mastectomy with immediate autologous tissue reconstruction.
Here’s what that means. First, the autologous part: In the 1980s, plastic surgeons began reconstructing severed breasts using tissue salvaged from their patients’ tummies. They move it from the spare tire to the chest, where they shape it into a breast. The results are often very good, but there are definite drawbacks. Sculpting the exact shape and droop of the other side is often impossible, even though the new breast looks fine under clothing. Naked, though, it can be a patchwork of scars and colors, since skin from different parts of the body does not match up exactly.
However, the real breakthrough is the skin-sparing aspect of the new approach. Instead of lopping off the entire breast, cancer surgeons simply hollow it out. First they cut off the nipple and discard it. Then they work through this opening to remove all the tissue inside, leaving just an empty sack, or skin envelope, as they call it.
Next, they fill up this envelope with salvaged fat and muscle, usually harvested from the belly but sometimes from the back or butt. After a couple of months, they fashion a perpetually erect nipple and areola with skin removed from the upper thigh, using stitches to make the little bumps called Montgomery glands. Finally, they darken it with tattooing.
When all goes well--and surgeons say the results are excellent about 80% of the time--women tend to rhapsodize about the results. Among those who feel this way is Celeste Oranchak, a fund-raiser for a theater in Englewood, N.J.
When doctors discovered a tumor on her right breast, Oranchak explored all the possibilities. Eventually she chose a mastectomy. Because she is slender and her breasts are small, taking out just the lump would have been disfiguring.
Now her reconstruction is almost complete. The last step will be for Disa to tattoo her newly crafted nipple, making it the same color as the other.
“It looks like the real thing and feels like the real thing,” says Oranchak. “When I look in the mirror, I see two breasts that look almost exactly the same. Clearly, I can wear everything I want, strapless dresses and sheer tops and all that kind of thing.”
Like many others who have had this reconstruction, Oranchak is eager to talk about it, to tell other women facing breast cancer and mastectomy that they can come through the ordeal whole.
“I’m not diminishing the whole journey by any means, but women need to know it’s not as bad as some may have perceived,” Oranchak says. “Women should know there are options that are exquisite.”
An exquisite mastectomy? It is so hard to believe that surgeons grope for superlatives to describe their results.
“I’ll bet the average layperson could not tell one of these women has had a mastectomy,” says Dr. Darrick E. Antell of St. Luke’s-Roosevelt Hospital Center in New York City. “It’s that good. I can’t imagine it looking any better.”
Almost every doctor, it seems, has stories of patients who go for mammograms or checkups, only to have medical folks fail to recognize that their breasts are reconstructions.
Dr. Melvin Silverstein of USC tells of a little experiment he performed recently. With a mastectomy patient’s approval, he told a medical student he would undrape the woman for three seconds. Then he would cover her up again. The student’s task: Pick out the original breast.
“The medical student looked and got it wrong,” says Silverstein, still glowing over the encounter. “To me, that tells you how remarkable this is.”
A Complex Procedure
Still, with all its advantages, this kind of mastectomy is not for all patients--or for all surgeons.
The operation is done in two stages. First, a cancer surgeon hollows out the breast. Then a plastic surgeon fills it up.
Skin-sparing mastectomies are considerably more difficult than the ordinary kind. Cancer surgeons must clean out the breast working through a small keyhole, the missing nipple. They must leave just enough tissue so the skin survives, but not enough to hide stray cancer cells. Those who do breast cancer surgery only on occasion probably will not--and probably should not--give this a try.
For plastic surgeons, reconstruction after skin-sparing mastectomies is actually easier than rebuilding breasts from scratch.
“All one needs to do is fill that envelope,” says Dr. Luis Vasconez of the University of Alabama. “One matches the other breast in just about every case.”
Nevertheless, this is major surgery, especially when doctors fill the breast with living tissue rather than with a saline-filled implant. Often they make a hip-to-hip slice just below the bellybutton to gather filler. They cut away a section of abdominal fat, but they leave it partially attached to the rectus muscle, which supplies the tissue with blood. Then they tunnel beneath the skin, sliding the piece of flesh up to the empty breast.
Increasingly, though, doctors cut the tissue out entirely before they put it into the breast. This is even more difficult, because it requires microsurgery to reattach blood vessels. But it’s the only option if the patient is too thin to give up belly tissue and doctors have to find flesh elsewhere, such as the back or buttocks.
Whatever method is used, if the woman’s breasts are large or saggy, surgeons will sometimes suggest reducing the size of the healthy one and giving it a lift.
“One of the most difficult things to do is get symmetry,” says Dr. Martin Moskovitz of Baylor College of Medicine in Houston. “It’s much easier to operate on both breasts at the same time. You have to ask, Why do we want to reconstruct a drooping breast?”
Plastic surgeons say they don’t push this option since lots of women are perfectly happy with how they look. But coming out of surgery with a flatter tummy and more shapely breasts is a definite possibility.
The operation often takes six to eight hours. Certainly its length and complexity are a consideration, and there are others. In a small percentage of cases, part of the transplanted tissue dies, possibly ruining the results. Tinkering with tummy muscles can weaken the stomach wall and increase the chance of a hernia. Furthermore, a poorly placed biopsy scar can make the procedure difficult or even impossible.
The operation is offered only to women with early-stage cancer that has not spread. Their tumors must be relatively small and not involve the skin. Really large breasts are difficult to duplicate simply because they require so much flesh.
Some women opt for mastectomies over lumpectomies because they cannot stand the thought of keeping a cancerous breast. Others want to avoid the radiation therapy and frequent exams needed to guard against recurring cancer after lumpectomies.
Still, many doctors believe that, when possible, woman are better off keeping their own breasts by opting for lumpectomies. For one thing, even when all goes perfectly, a reconstructed breast lacks the sensation of the original. Women have some feeling, but the faux nipple is numb.
For those who choose mastectomy, however, the skin-sparing approach has clearly revolutionized the entire process. While the primary goal still is to cure cancer, doctors say they can now make appearance a priority too.
“My goal is to allow them to look good in a bra, a bathing suit and evening wear and do whatever they want to do without having to fiddle with a prosthesis,” says Dr. Louis Bucky of the University of Pennsylvania.
Judy Lewis, a college administrator from White Plains, N.Y., imagines she would have done fine with an old-fashioned mastectomy. After all, life is more important than breasts. But her reconstruction allowed her avoid that personal challenge.
And the result? “I think I look fantastic,” she says. “But it’s so comfortable, so natural, I don’t even think about it.”
Carol Nashold, a retired bond trader from Edwards, Colo., put her reconstruction to the ultimate appearance test. She went topless on a beach in France. No one stared.
“For me, the biggest thing was that I never felt mutilated,” says Nashold. “I remember my mother and her scar. Her body was mutilated. My body is intact.”
