Breast reconstruction / surgery

Angelina Jolie, and her breasts, are used to massive media attention, but none so much after she went through an elective double mastectomy and reconstructive surgery. Jolie opted for this controversial elective surgery after finding out she was BRCA1 positive and stood an 85% chance of developing breast cancer and a 44% chance of developing ovarian cancer in her lifetime.

The American Society of Plastic Surgeons estimates only 30 percent of women are made aware of reconstruction options before having a mastectomy, which is why I think it is important for all women to stay current on the ever-evolving world of cancer treatment and post-reconstruction options.

Chances are, every woman reading this article right now is either battling breast cancer or knows someone who is or has. There are more than 2.8 million breast cancer survivors in the US, but breast cancer is still the second leading cause of cancer death in women, exceeded only by lung cancer. We have all heard the saying “The best defense is a good offense” and staying informed for ourselves and our sisters is the first offensive move in the defense against cancer.

Nobody knows this better than industry-leading Cosmetic Plastic and Reconstructive Surgeon, Dr. Stephen McCulley. This Nottingham, England-based doctor is a pioneer in his field, and his open and honest approach to consultations made him the ideal person to ask these difficult questions.

1. What are the main reasons why a woman would choose CPM (Contralateral Prophylactic Mastectomy) over breast conserving surgery?

Treating a breast cancer that is localized to one part of the breast can be equally well treated by lumpectomy and radiotherapy versus mastectomy. Therefore, for up to 75% of breast cancers, there is no reason to recommend mastectomy. Where mastectomy is advised, this is because the cancer size is deemed too large or it is present in different areas.

However, even when a cancer can be successfully treated by lumpectomy, women are given the choice between this and mastectomy and some women just prefer the idea of the whole breast being removed even if there is no cancer advantages to doing so. These reasons vary, but are often around fear of the cancer coming back or anxiety about the remaining breast even though the evidence may not support this from a “cancer risk’ perspective. This patient who wishes to ‘remove the breast’ can also present a request for the other breast to be removed or CPM. It must be emphasized that when a woman has evidence of breast cancer genes, BRCA I and II or a very strong family history, this request is much more common and has the basis of a very high risk of cancer in the opposite breast at some time in their lives. However, for most patients without a family history, the risk of cancer in the opposite side is still very small.

The evidence for removing both breasts with a cancer gene, but no active breast cancer supports a significant reduction in incidence of breast cancer, although does not yet support a “survival advantage.” When a patient presents with a breast cancer, the evidence for removing the other breast on cancer grounds does not have any standing. This does not mean it will not reduce the risk of a cancer, it probably will, but the risks to that patient are already in the cancer they have and not one possible in the future.

This option of removing the contralateral or opposite breast is supported by many surgeons, but is a complex decision. Without scientific evidence for any breast cancer survival benefit, it is really being done for two possible but very real reasons. The first is the anxiety of the patient and how they wish to move forward with their treatment; knowing the breast tissue is gone is reassuring for many patients. Secondly, and less obvious, is that reconstruction with implants can look better in certain patients when done on both sides, as opposed to just one side. This is because implant reconstruction is not ideal at matching a natural opposite breast over time. A contralateral mastectomy should never be recommended by a doctor for this reason, but the threshold for offering it when the patient requests it may be lowered in certain situations.

2. What are the benefits to using the patient’s body parts such as tummy or back as opposed to implants?

Breasts which are reconstructed from your own tissue are “alive” as they are made up of living tissue. Therefore, they feel warmer, softer, can gain or lose weight and are better match for a soft, opposite breast. They also stand the test of time much better and have very few needs for later revisions. By contrast, an implant reconstruction tends to deteriorate over time and has a much higher revision rate in the first 10 years. Although, implants can still give some very good results, are less involved operations, and do not create scars elsewhere on the body. Both have their place.

3. Why don’t surgeons use live tissue implants on patients who don’t have cancer but are looking for a torso makeover? (Or do they?)

You can sometimes add natural tissue to the breast in massive weight loss patients. The major reconstructions using your own tissue do have risks, and it can be difficult to justify doing them in a cosmetic patient, hence it is unusual to offer it.

4. The quote below was taken from the Susan G. Komen foundation website. Why do you believe we are seeing an increase in rates of CPM, and do you agree that it should be a concern to the medical community?

“For reasons we don’t fully understand, rates of CPM are on the rise. Between 1998 and 2003, rates of CPM in the United States more than doubled from 1.8 to 4.5 percent. And, among women having a mastectomy instead of lumpectomy, the rate of CPM increased from 4.2 to 11.0 percent. Women choosing CPM tend to be younger, Caucasian and have a higher educational level.  While there are many reasons a woman might choose CPM, the surgery has its own risks.  Also, the health benefits of CPM are unclear.  Hence, the unexpected increase in rates of CPM has caused concern among some in the medical community.”

It is on the rise. I think it is a combination of the increased testing for cancer genes, the increased awareness of it [CPM] as an option, and lastly the rise in reconstruction with breast implants where the outcomes are often better when done both sides. It is difficult to know if that is a real effect as surgeons would not actively advise mastectomy on these grounds.

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5. I can’t imagine how difficult it would be to select an oncologist; likewise, I am sure it is also difficult for women to determine the best plastic surgeon. What advice would you give women in this position?

Look at the qualifications and specialist registrations and the experience they have had. Ask about the number of operations they have had and outcomes. You can also look at forums and ask patient support groups. Often if they work in both a government and private practice this reflects a specialist interest in this field.

6. Many women stress over asking for a second opinion despite doctors, typically saying they support and encourage this practice. Unfortunately, many people still feel uncomfortable, as if they are insulting the doctor. Are doctors just being polite or do they actually believe in the importance of a second opinion? How would you recommend a patient if they asked for another opinion?

I would just say it straight. This is a big decision for them, and they would like to gather some opinions before making a decision. A good specialist will not feel threatened by this, and if they do, that is their problem not yours. If you want to make them feel better about it, tell them it was really helpful, but you would like to think about it and will get back to them or that you just want to get some more information first.

Stephen McCulley is one of the few consultants in the UK that offers both the cancer surgery and the full spectrum of breast reconstruction options. Stephen is registered with the General Medical Council (No 3336078) and on the specialist register for Plastic Surgery, is a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the British Association of Aesthetic Plastic Surgeons (BAAPS).