Plastic Surgery Is Not for Everyone: Options Following a Mastectomy

A woman with a breast cancer diagnosis faces many sudden choices, and in the emotional frenzy, reconstruction decisions may get short shrift

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Lisa Wychgram Kluzik of Lafayette, California, was 38 years old, with a son in the first grade, when she found out that she had breast cancer. When the disease recurred after an initial lumpectomy in 2001, physicians recommended a mastectomy and more chemo. Because Wychgram works for a medical malpractice firm, she was privy to the risks and complications of Transverse Rectus Abdominis Myocutaneous (TRAM) flap surgery. "With the TRAM flap, you end up like a patchwork quilt," she says. She declined reconstruction.

"Already I had an idea of what could go wrong," Wychgram says. She didn't want implants, either. A friend had those inserted after undergoing bilateral mastectomy. "They kept becoming infected, so she had them removed."

After surgery, Wychgram visited a specialty shop that sells standard mastectomy bra inserts, but she was unhappy with her asymmetric appearance and felt uncomfortable. "I play tennis, and when you wear an 'off-the-shelf' prosthesis, it's like putting a water balloon on your chest," she says. "It's heavy. It doesn't move with you."

Following years of frustration, an Internet search led Wychgram to Irene Healey, a sculptor and anaplastologist -- a creator of absent body parts -- who founded New Attitude. Healey's Toronto-based company uses laser-scanning and modeling software to create individualized breast prostheses. Wychgram traveled to Canada for a detailed consultation.

When the custom-designed prosthesis arrived, Wychgram's son, then 11 years old, noticed the difference right away. "Oh my gosh, you're even," he said. "You look great, mom."

Now, at 49, Wychgram has no regrets about her decision to skip reconstruction. She plays tennis, does yoga, and skis -- activities she says might be limited if she'd had implants or other chest-wall surgery. The custom prosthesis was expensive, but worth it: "Oh, definitely," she says. "I'm going back to get a new one."

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Every year, 80,000 or so women have one or both breasts removed for a cancer-related condition in the United States. Plastic surgery to reshape the breast, long within the purview of wealthy women, has become routine in some communities. Since President Clinton signed the Women's Health and Cancer Rights Act of 1998, which mandates that Medicare, Medicaid, and most insurers cover the costs, the proportion of women undergoing reconstruction has doubled. Now, some say, perhaps the pendulum has swung too far: The decision for women after mastectomy isn't if they'll have plastic surgery, but how and when.

In 2011, newly-diagnosed patients are plugged into a treatment plan that incorporates reconstruction from the get-go. Well-meaning physicians may assume that surgical generation of a breast mound helps a woman heal psychologically. A husband or lover taking a supportive or selfish stance on the matter -- or the patient herself -- might consider reconstruction a strange silver lining, among many alleged lifts of the breast cancer experience. Why not go for a better look?

What may come as a surprise is that some women, including young patients, may not opt for reconstruction even when the costs are covered. The reasons vary: Rowers, windsurfers, swimmers, and other athletes avoid potential weakening of abdominal and chest muscles; mothers fear not being able to lift their children; others worry, plainly, about the time and costs of extra surgery and the long-term complications of implants or grafts.

In the past decade, a handful of companies have developed technology to match pieces to a woman's shape, flesh tone, areola, and nipple. The custom-designed, external prosthetic devices simply insert into a bra and provide good, sometimes superior cosmetic results in clad women. Yet few patients or doctors know about this safe, lower-cost alternative to plastic surgery.

When they do choose reconstruction, their options are more varied than they once were.

Plastic surgery has come a long way since Dr. William Halsted advanced a surgical technique for aggressively treating breast cancer in the late 19th century at the Johns Hopkins Hospital. In that era, women often held off seeking care until the tumors were bulky, typically piercing the chest wall and spreading to lymph nodes near the clavicle and armpit. Halsted developed a method to remove the entire breast, underlying pectoralis muscles and glands. The radical mastectomy became standard treatment for patients with breast cancer until the modern era.

In 1895, Dr. Vincent Czerny, operating at the University in Heidelberg, reported constructing a soft tissue mound on a woman's chest after mastectomy. He removed a lipoma -- a benign fatty tumor -- from a woman's flank and stuck it onto her chest wall. In the early 1900s, other surgeons experimented with grafting strips of muscle and fat to form flaps of tissue over mastectomy sites.

Halsted, who was highly influential, cautioned his colleagues against surgical manipulation of the chest wall for cosmetic purposes. He warned that by manipulating the wound after mastectomy, the surgeon might inadvertently spread tumor cells. Reconstruction could mask a tumor's recurrence, he advised.

What's more, these procedures were generally unsuccessful. Infections were frequent. Inadequate blood supply to the primitive grafts led to gangrene and, sometimes, fatal results. Through most of the 20th century, the process involved multiple procedures, delays, complications and, ultimately, failure. It wasn't until 1963, with the introduction of silicone gel implants, that the field of breast enhancement -- what doctors call augmentation mammoplasty -- was born.

Presented by

Elaine Schattner is a physician and journalist based in New York City.

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