Ever wonder what goes through the mind of a breast cancer survivor? To say they are hyper-cognizant and self-conscious is an understatement. Whether it’s stepping out of the shower and seeing their body in the mirror or trying to fit into their favorite exercise clothes or even instigating intimacy with their partner, these survivors find themselves in a different realm.
In the latest episode of Future of Health from Providence St. Joseph Health, we talked to Dr. Tiffany Grunwald M.D., FACS, about her work rebuilding women’s breasts after cancer.
“Breast reconstruction,” Dr. Grunwald says, “is about freedom. It’s about getting back to your life.”
But before Dr. Grunwald and her patients ever enter the operating room, so much of her job, she says, is showing her patients what their options are. And there are more options than you might guess. From the mastectomy to the “when” and the “where” of the reconstruction procedure to the different types of breast reconstruction procedures available, breast cancer-survivors have more choices than ever before.
If you’re more of a listener than reader, you can listen to the full interview with Dr. Grunwald here.
Here are some of the top takeaway insights from the interview.
- Breast reconstruction for cancer survivors is more common than ever
Breast reconstruction surgery is dramatically more common today than it was a few decades ago. In 1995, Dr. Grunwald says, only around 8% of breast cancer survivors received breast reconstruction. It’s a stark contrast compared to today’s rates of breast reconstruction; following an invasive cancer, about 54% of women choose to have breast reconstruction. And following a less-invasive, early stage cancer, about 63% of women choose to have reconstruction.
What drove the dramatic increase in popularity of reconstruction? According to Dr. Grunwald, it started with a group of motivated women who went to Washington DC in 1998 to enact the Women’s Health and Cancer Rights Act. Often abbreviated as the WHCRA, this federal law provides broad protections to patients that elect to have breast reconstruction following a mastectomy.
You can learn more about the law here, but some key elements include
- Applies to two types of insurance coverage: group policies offered by employers or unions and individual health plans
- Insurance must cover all stages of breast reconstruction relating to mastectomies, surgical procedures to ensure breast symmetry, and prostheses and any related treatment to address complications relating to the surgery, including lymphedema.
Although the WHCRA provides these protections to all breast cancer survivors, “Truthfully, in the United States,” Dr. Grunwald says, “only about 60% of women are offered immediate breast reconstruction after cancer treatment.” For this reason, it is crucial that women are aware of all the options available to them.
- There are two major types of breast reconstruction surgery
Depending on the patient’s health, body type, and her preferences, there are two main types of breast reconstruction procedures: saline or silicone implants, as well as flap procedures (also called an autologous tissue reconstruction). Both procedures come with their own advantages and disadvantages.
- Most common type – 75%-80% of women opt for synthetic implants
- Recovery is easier and faster
- Simpler than flap procedures
There are two steps in the synthetic implant procedure
- Tissue expanders are placed under the pectoralis muscles in the chest that are gradually filled with saline over a couple of weeks to ensure the skin and muscles can accommodate the implant. This often happens at the time of the mastectomy
- After 6-8 weeks, the expanders are removed and replaced with the implant
Some patients are better suited to newer techniques of direct-to-implant reconstruction or placement of the implant in front of the muscle.
Dr. Grunwald notes that breast implants are not a lifetime device. “Patients will outlive their implants.” Implants require maintenance, and have a warranty of anywhere between 10-20 years, which means another surgery will be necessary later down the road.
Type #2: Flap procedures
- Uses a woman’s own tissue to restore the breast
- Tissue is typically removed from the lower abdomen or muscle from upper back
- Provides a more natural-feeling breast
- Ages more naturally than synthetic implants
- A more complex procedure that can add 3-8 hours to the mastectomy surgery
Flap procedures means you are now operating on two parts of the body, leaving an additional surgical site with risks of complications. Despite the extra risks and potential for complications, women who choose reconstruction with their own tissue tend to be more satisfied over time.
- Reconstruction can be immediate or delayed
Although most patients and surgeons prefer to perform breast reconstruction at the same time as the mastectomy, some doctors choose to delay a patient’s reconstruction. Whether the reconstruction is performed immediately along with the mastectomy, or later down the line, it is still covered by the WHCRA. Exactly when a patient undergoes reconstruction depends on the stage of the cancer, the medical condition of the patient, remaining treatments, and largely depends on the patient’s preference.
There are a few reasons a patient might choose to combine her mastectomy with her reconstruction. First, it reduces the number of surgeries, time off work and costs. Perhaps most importantly, combining a mastectomy with reconstruction helps women cope and feel normal by having their “new” breast immediately after surgery.
Other reasons for delaying reconstruction include:
- Extenuating health concerns, such as obesity or diabetes
- Patients who are smokers have a higher risk of serious wound complications
- Lack of awareness of paring mastectomy with reconstruction (70% of women who do not receive breast reconstruction at the time of their mastectomy are simply not aware of the option)
There are also personal reasons however that might move a patient to delay her reconstruction surgery. After a mastectomy, lumpectomy or radiation therapy, and possibly chemotherapy as well, some patients say they just don’t feel ready to think about enduring another procedure, and choose instead to wait until they feel up to the task.
- Staying true to your body
Everyone has a different idea and aesthetic ideal about what a natural breast ought to look like. According to Dr. Grunwald, the best thing you can do, when planning your breast reconstruction surgery is to stay true to your body. Breast reconstruction is all about restoring your body to what feels healthy.
Dr. Grunwald prides herself on talking to patients about all options, and focuses on finding a balance between what the patient wants and what she feels is safest. For instance, the volume of implant is a frequent topic, and when a patient wants to push the limits beyond what is anatomically right for their body type, reconstruction can pose undue health risks. According to Dr. Grunwald, the key is to ensure natural-appearing outcomes in any plastic surgery. Seeing a Board Certified Plastic Surgeon is key to learning all of your options.
- Age is not a factor
Every year around 250,000 women are diagnosed with breast cancer, and of those 250,000 women, 40% are over the age of 62. Fortunately, according to a study by the University of Michigan, older women who had a mastectomy and reconstruction procedures saw no additional post-surgery complications compared to younger women. In fact, compared to younger women, older women reported even greater sexual, physical, and psychosocial well-being after their reconstruction surgeries. It’s never too late.
This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.
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