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Dec. 4, 2022

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Breast cancer patients face major decision post-mastectomy

Reconstruction? Implants? Leave flat? Options have pros, cons

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Breast cancer survivors Jaron Farley, right, and Brenda Fletcher Gaston chose different paths after mastectomy. Farley had implants that had to be removed nine years later; then she underwent DIEP flap reconstruction. Gaston decided to go flat.
Breast cancer survivors Jaron Farley, right, and Brenda Fletcher Gaston chose different paths after mastectomy. Farley had implants that had to be removed nine years later; then she underwent DIEP flap reconstruction. Gaston decided to go flat. (Taylor Balkom/The Columbian) Photo Gallery

After going to the doctor for a pulmonary angiogram in the summer of 2020, Jaron Farley heard news she hadn’t expected: Her breast implant had ruptured, and there was a chance she’d need it replaced.

“Later they told me it was rubbish on the inside,” the Vancouver resident said. “There was no leakage but something that needed to be taken care of. He also said the implant was migrating up, which I hadn’t really noticed.”

Rewind nine years, when Farley was diagnosed with breast cancer. At the time, reconstruction stood out to Farley as the least invasive and quickest to heal of the options her doctor presented. She underwent a mastectomy in December 2011 and implant reconstruction the following April.

Farley remembers feeling overwhelmed by the tsunami of information that follows a breast cancer diagnosis.

“Unfortunately, I didn’t do a lot of research,” Farley said. “I just wanted to get it done. So I decided to go with the implant without really looking into it.”

After mastectomy, patients can choose to get breast implants, have their breasts reconstructed from fat and skin taken from elsewhere on their bodies (known as an autologous procedure), or leave their chests flat.

Influx of implants

Implant-based procedures made up about 75 percent of 137,808 breast reconstructions performed in 2020, according to data from the American Society of Plastic Surgeons.

The appeal of implants is easy to understand. Out of the two primary reconstruction options — implant and autologous — implant requires only one surgical site and is often done at the time of the mastectomy.

Implants come in two forms: silicone or saline. Dr. Allen Gabriel, a Vancouver plastic surgeon specializing in implant reconstruction, prefers silicone. If the gel implant ruptures, the “gummylike” substance will remain in the same place without leaking into the pocket where the implant is held as saline would, he said.

“Patients will say they don’t want silicone but what they need to understand is that the outside shell is exactly the same silicone,” Gabriel said. “There’s a security or comfort in knowing that the shell isn’t going anywhere.”

Patients also have to consider whether they want the implant placed under or over the pectoral muscle. Although placement underneath enables visible muscle animation, Gabriel strongly advocates for reconstruction on top of the muscle. It’s less invasive with less discomfort and has a shorter recovery than implantation under the muscle, he said.

Nonetheless, implants have some drawbacks. They come with a risk of capsular contracture, in which scar tissue develops around the implant. Because this can cause a silent, unfelt rupture (as in Farley’s case), women should undergo MRI screening every two years.

“An implant isn’t a lifetime device,” Gabriel said. “There’s 100 percent chance they will have another surgery in their lifetime.”

Autonomy to choose autologous

Although implant reconstruction is undoubtedly the most popular, evidence points to the benefits of autologous reconstruction.

Unlike implants, autologous reconstruction uses tissue from another part of the body to form a new breast. Most commonly, skin tissue is taken from the lower belly, called a DIEP flap procedure.

For women who have had prior radiation, this is their only feasible long-term replacement option, Gabriel said.

When Farley faced another decision nine years after her implant reconstruction, she opted for the DIEP flap procedure. Farley said she feels more comfortable knowing that her reconstructed breasts come from her own skin.

“It just felt really weird to have a foreign object in my body,” Farley said about her initial implant. “It didn’t feel like part of me, and I felt the change right away. It’s quite a difference having your own tissue.”

Tissue is usually taken from the belly, sometimes from the thigh or buttocks. Risk of infection is significantly lower than implants. It’s a permanent procedure that’s able to age with the patient.

Recovery time is longer. Patients wait as long as six weeks to return to normal activities. Post-autologous reconstruction patients must stay in the hospital for as long as 72 hours for monitoring.

Opting out

Women have another option after mastectomy. They can forego breast reformation procedures altogether and leave their chests flat.

Brenda Fletcher Gaston of Vancouver vividly recalls walking with her husband down a Costco aisle in December 2019 when she received a call from her doctor. A biopsy found negative breast cancer, a rare and aggressive form.

“Within a day or two I said, ‘You know, if I have to have surgery … I am going to have a mastectomy,’ ” Gaston said. “ ‘I’m going to have a double and I’m not going to have a reconstruction.’ I was just really clear in my head from the get-go. And he was real supportive.”

Gaston underwent chemotherapy every two weeks until her double mastectomy and breast removal in March 2020. Full recovery from surgery took six weeks, but by week three, Gaston felt back to normal with minor pain and restrictions.

“It felt like tons of pressure,” she said about the first few weeks. “Like you’ve got on the world’s tightest bra.”

Under the Women’s Health and Cancer Rights Act of 1998, all health insurance plans that pay for mastectomy are required to cover prosthesis and reconstructive procedures.

In June 2020, the National Cancer Institute added the term “aesthetic flat closure” to its dictionary to ensure that the procedure is covered by insurance like other reconstructions.

Information formation

Dr. Allison Nauta, a plastic surgeon specializing in autologous reconstruction at Providence Medical Center in Portland, reiterated the importance of patients’ health, including factors such as body mass index and iron count.

“I think that none of these operations are one and done,” Nauta said. “We’ll get as close as we can to symmetry, but there might be smaller things that you might want to pursue in the future. I think it’s an important conversation to have.”

To avoid overwhelming breast cancer patients, Dr. Toni Storm, a breast cancer surgeon for Vancouver’s Compass Oncology, emphasizes the importance of staggering the information they receive.

“You’ve got flight or fight going on,” Storm said. “It’s like taking a drink through a firehouse. As providers, it’s important we give our patients an opportunity to digest.”

Storm provides her patients with a binder of information and offers to go through it at their pace.

“It’s unique to each and every woman,” Storm said. “What people deserve … is the opportunity to be given their options and to understand their options.”

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