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Breast Reconstruction Underutilized

Sunday, October 14th, 2012


Pink ribbons remind most of us that October is National Breast Cancer Awareness Month. But many women know little about one part of the breast cancer experience, breast reconstruction after a mastectomy or partial mastectomy. To combat this, a national campaign has started to educate women about the options available. The kick off for this is October 17th, BRA Day (Breast Reconstruction Awareness Day).
Recent studies have shown that 7 out of 10 women undergoing some type of mastectomy are not made aware of breast reconstructive options. Thus, there are thousands and thousands of women walking around without one or both breasts, because they don’t know the options available to them. In fact, only 1 in 5 women with a mastectomy undergo reconstruction. Although some of those that do not have reconstruction do so by choice, the majority do not do so due to ignorance of their choices.

One of the most common reasons for women’s ignorance is that their doctors neglect to inform them. Some mistakenly think that reconstruction at the same time as the mastectomy can reduce the chance of cure. Others believe wrongly that recurrences of breast cancer can’t be diagnosed if reconstruction is done. Some may be practicing where there are no plastic surgeons at their hospital and, thus, assume that the cancer treatment and reconstruction cannot be coordinated. Some just may not realize that reconstruction is an option.

All of this is in spite of national legislation, the Women’s Health and Cancer Rights Act of 1998. This was intended to increase the options available to women with Breast Cancer and encourage Breast Reconstruction. It required any insurance company that pays for a mastectomy, to also cover breast reconstruction surgery. This included Medicare and Medicaid. The law further stated that the company’s clients must be told about the coverage. By doing so it defined breast reconstruction as not simply cosmetic surgery, but a medical necessity for the physical and emotional well-being of breast cancer patients. In the fourteen years since this law was enacted there has been almost no increase in breast reconstruction after mastectomy.

Why is breast Reconstruction deemed to be so important? Very simply, loss of the breast causes both mental and physical problems. From around the age of 10 the breast is synonymous with femininity and part of what defines womanhood. I am frequently told they “no longer feel attractive,” or that they were “outgoing and now have become an introvert.” Additionally, the asymmetry of weight can lead to shoulder, neck and/or back pain and difficulty sleeping. Although Dr. Buchanan has worked for years to make breast reconstruction available to women, some regional hospitals are now also recognizing this.

To correct this, there are a number of options. These can be divided into two major choices, timing and method. Timing is either immediate or delayed. With immediate reconstruction, the initial reconstructive surgery is done at the time of the mastectomy. This restores a mound (though sometimes not to the final volume) and reduces the number of surgeries and the time to complete restoration of the breast. It also prevents the skin from contracting and making any reconstruction harder. Data has shown that it does not interfere with cure of the cancer or reduce the acceptance of the new breast into the woman’s psyche. Delayed reconstruction can be anywhere from 24 hours to many years.

There are basically two reconstructive methods, use of an implant or use of one’s own tissue. Each has variations and the two can be combined. Occasionally, especially with large breasts, an implant can be placed under the tissues after the mastectomy and the reconstruction of the mound is complete. The nipple/areola is reconstructed a later time. If the remaining tissues are too tight to allow the final volume to be inserted initially, an expander (an implant containing a valve) containing a smaller volume is placed and then expanded, thus stretching the overlying skin safely to the final size. It is then exchanged for the proper sized implant.

Because the scar around the implant can contract and make the implant feel firm and some women’s desire not to have anything foreign, one’s own tissue can be used. Most commonly this is taken from the abdomen or back. Occasionally, at some specialized centers, tissue from the buttocks is used, reattaching the tissue microsurgically. When taken from the back the tissue is simply transferred from the back to the chest based on a long artery and vein. Frequently an implant is also used to reduce the scar to the back. Using the tissue from the abdomen is probably the most common and the most aesthetic, since one gets a tummy tuck at the same time as the reconstruction. This can be done by leaving the flap attached by its vasculature and just rotating it, or it can be done microsurgically. Both methods have pros and cons.

Since a true reconstruction requires the two breasts to match, and some breasts just cannot be matched by reconstruction, remodeling of the other breast to match the reconstructed one is also mandated by the 1998 law. This is very frequently required with implant reconstruction and commonly needed with tissue reconstruction.

As I said earlier, October 17th is BRA Day. For more information, go to BRADayUSA.org. The spokesperson for this effort is the singer Jewel. To further education of women about breast reconstruction, she released the single “Flower” on August 12th, and part of the proceeds goes to this effort. This song can be downloaded from iTunes.

Dr. Buchanan has extensive experience in breast reconstruction and is presently on the Breast Reconstruction Work Group of the American Society of Plastic Surgeons writing clinical practice guidelines for physicians around the country. He works year round in Highlands at the Center for Plastic Surgery.