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Before Breast Cancer Strikes Staff Report
Medically Reviewed by Dennis J. Hurwitz, M.D., FACS

Before Breast Cancer StrikesBreast cancer is responsible for one of every three cancer diagnoses. And, according to the American Cancer Society, it is the second leading cause of cancer death in women. Some women who have relatives stricken by breast cancer and other risk factors are surgically removing nature’s own and having new breasts reconstructed by plastic surgeons. .Studies on various aspects of preventive mastectomy and breast reconstruction are springing up during October -- Breast Cancer Awareness Month.

Deborah Barnes, a 53-year-old paralegal in Glen Ridge, New Jersey, was terribly worried about the breast cancer in her family. Her grandmother died of cancer in the 1960s and, more recently, her mother and sister both suffered from the dreaded ailment. Eventually, alas, cancer developed in one of Deborah’s breasts.

“The hardest phrase you’ll ever hear is when a doctor says: ‘You have breast cancer,’” Deborah told “Your whole world stops.”

But she did not settle for removing only the cancerous breast. After studying her options and the risks for yet more cancer, she opted for a double mastectomy to rid herself of the breast that showed no symptoms -- yet.

Immediate Breast Reconstruction

While she was still on the table, surgeons rebuilt breasts from tissues in her abdomen and from other areas of her body. It’s known as IBR, or, immediate breast reconstruction.

“I’m now cancer-free and even the clerks in fitting rooms helping with bathing suits don’t realize I have reconstructed breasts,” Deborah says.

Prophylactic mastectomy is not as widely done as breast reconstruction, a procedure performed on some 70,000 women in 2003, according to the American Society of Plastic Surgeons (ASPS.)

But more women are taking a look at the rates of breast cancer among their female relatives and wondering if, or when, the Big C will strike them.

Guidelines for preventative mastectomy aren’t carved into stone, but women with histories of pre-cancerous cells, relatives with breast or ovarian cancer or mutations in several breast cancer genes – revealed through genetic testing – often opt for more counseling, watchful waiting, soul searching and, sometimes, prophylactic mastectomy.

The dagger aimed at the heart of such women seems to be deadliest when several close relatives develop the disease before age 50, if she is a smoker, (especially if she started as a teenager or young adult,) and if she has been on hormone replacement therapy.

“Women whose fathers have had breast cancer are at an even greater risk than if their mothers had it,” says Loren Schechter, M.D., a plastic and reconstructive surgeon near Chicago.

Mourene Tesler in Denver, Colorado, knew her mother had three episodes of breast cancer while her sister suffered two episodes of cancer.

“We didn’t have genetic testing in 1986,” Mourene says, “but after looking at my, and my family’s history, my doctor figured my odds of getting breast cancer again were about 80 percent.

“The decision was sort of made for me,” Mourene says. “I had three children at home and the doctor capped his discussion by advising: ‘If you’ve got the guts, have the operation (preventative mastectomy”).

She had the procedure, received implants right after the double mastectomy and says she has received no complaints from her husband of 40 years during the last 17 years about the state of her bosom.

However, Mourene’s sister did not have a preventative mastectomy, developed breast cancer in 2000 and died of ovarian cancer shortly afterwards.

“The doctors told us both: ‘By the time we find cancer in your breasts, it will have spread to other organs,’” Mourene recalls.

Bugbear Genes

Before Breast Cancer Strikes At the highest risk is the woman who has already lost one breast to cancer and has a female relative with the ailment. That patient stands about a 50 percent chance of developing cancer again. Overall, about one in 500 women carry the gene mutations that usually lead to breast (or ovarian) cancer. The bugbear genes – known as BRAC 1 and 2 -- are present in at least one of every ten breast cancer patients under age 40.

About all the National Cancer Society can reveal about preventative mastectomy is the procedure lowers chances of still more cancer by 90 percent for high risk women.

The good news is, plastic surgeons can build breasts anew. Proclaims the ASPS: “Reconstruction of a breast…is one of the most rewarding surgical procedures available today.”

Techniques to reconstruct the breast have come a long way with new options that use the body’s muscle and skin.

Surgeons favor rebuilding the breasts immediately after the mastectomy so the patient doesn’t wake up and discover missing breasts; the shock can last a lifetime. Moreover, the imbalance created by a missing breast can affect the patient’s spine. In many cases, it is medically necessary to wear prosthesis to make sure the upper torso remains in balance.

In one type reconstruction, known as tissue expansion, the surgeon inserts an implant under the skin and, sometimes, the first layer of chest muscle (pectoralis) after he or she has created a pocket for it. The doctor then inserts a balloon-like expander under the tissues and periodically injects a solution through the skin into a tiny valve to pump up the device. After several episodes, sufficient space is created for an implant.

“Breast reconstruction has come a long way in ten years,” says Dr. Schlecter. “Ten years ago, just about everything – skin, fat and muscle -- was removed.”

More positive things happened when surgeons found they could leave some muscle. And then later, they found they could leave more skin.

“Many other practitioners and health care specialists will examine a reconstructed breast and not be able to tell it from the real thing,” says Valerie J. Ablaza, M.D., at The Plastic Surgery Group in Montclair, N.J.

Like Pumping Up a Tire

“It’s just like pumping up a car tire, little by little,” says Mourene Tesler.

Tracie Metzger of Cincinnati, Ohio, was diagnosed with cancer in one breast at 34 and, although she had no other cancers in her family, decided to have the other breast removed for peace of mind and so that her reconstructed breasts would be symmetrical. A harsh regime of chemotherapy caused Tracie to drop to her lowest body weight ever so she had no tissue nor fat to spare for the reconstruction. So her doctors decided she was also best suited for tissue expanders followed by implants.

But during the course of treatment, Tracie discovered more young women in her area were breast cancer victims. So she co-founded Pink Ribbon Girls, a web-based support and educational organization for younger women, active in four states. For all her good works, The American Society of Plastic Surgery conferred its first Patients of Courage award on Tracie.

In another case, a psychologist (who asked to be anonymous) knew her mother, her aunt and both grandmothers had breast cancer. At age 36, and with her family complete with three small children, she saw a genetic counselor who found her BRAC 1 gene showed a mutation meaning she, the psychologist, has a 90% chance of developing breast cancer (and an 80% chance of developing ovarian cancer) sometime during her lifetime. Two weeks later, she underwent a double mastectomy, followed by skin expansion and implants.

“I remember sitting in the breast center somewhat annoyed,” she says. “I had to wait because another woman was getting the results of a breast biopsy. I looked up and saw a pale, shaking and scared looking woman coming out of the doctor’s office. Her face told me the news had been bad. And the thought struck me, I would not change a single minute of my experience for hers.”

The Real Deal

Before Breast Cancer Strikes Known as a TRAM (transverse rectus abdominis myocutaeous) flap reconstruction, the rebuilt breast is made from tissues in the patient’s abdomen. Other flap reconstruction procedures create a breast using skin, fat and muscle from the patient’s back or buttocks. Surgeons say the work includes a rebuilt nipple; the rebuilt breast and nipple is virtually indistinguishable from the real deal.

In some procedures, like the one had by then 34-year-old Deede (who also asked not to be identified) of Inverness, Illinois, the surgeon – working totally under the skin -- creates a breast under her mastectomy scar by pulling part of her stomach muscle up into the chest.

“When I awoke from anesthesia and found only one breast, my first thought was I was happy it was gone,” says Deede. “The surgery site was not pretty to see but I knew I could be there for my little guy -- a 14-month-old son -- for at least the next ten years.”

Some surgeons use a similar technique known as the DIEP (deep inferior epigastric perforator flap,) a procedure that takes tissue from the patient’s abdomen – but without sacrifice to the stomach muscles. Surgeons who use the DIEP process say the operation creates a natural looking breast that results in less pain and allows the woman to return to normal activities more quickly.

“The problem with the conventional TRAM flap is when tissues from the lower abdominal is transferred to the woman’s chest, some or all of the stomach muscle go with it,” says Gregory Dumanian, M.D., a plastic surgeon at Northwestern Memorial Hospital in Chicago. “Thus, the TRAM flap can result in complications including weakness in the abdomen, which makes it hard to sit or lay down and may create abdominal hernias or bulges in the stomach.” The flap from the stomach is reconnected to blood vessels in the chest using microsurgical techniques.

“There’s no need for a breast to have a muscle in it, because a normal breast gland does not have muscle, either,” Dr. Dumanian says. “DIEP results in a natural looking, natural feeling breast.”

Yet another reconstructive procedure, known as EARLi, uses muscle from a woman’s back to rebuild a breast.

“Plastic surgeons have a number of techniques for recreating realistic nipples,” says Richard Lopchinsky, M.D., a clinical associate professor of surgery at Mount Sinai School of Medicine. “Virtually all surgeons feel the nipple is a high risk area for recurring cancer and remove it during the mastectomy.”

No Bathing Suits

Before Breast Cancer StrikesYet another mastectomy patient who asked for anonymity lost a breast to cancer and was told to wear prosthesis. But she found the device clumsy and heavy. She even became nervous and embarrassed about answering the door in her own home because she could have forgotten the prosthesis or it had slipped out of place. She would not be seen dead in a bathing suit and desperately wanted to boost her self-esteem, body symmetry and lessen her acute feeling of self-consciousness so she had an autogenously (using the body’s own fat) breast construction followed by an operation to correct her other, pendulous breast (mastopexy) and, six months later, a nipple and areola reconstructions.

“She had a remarkable change in appearance and attitude after her breast reconstruction,” says Dr. Schechter. “She was far more outgoing and proudly wore a two-piece swim suit when healed.”

Still another method of breast reconstruction is known as EARLi procedure.

“Losing a breast or living with a deformed breast after cancer can be devastating,” says Neil Fine, M.D., a plastic surgeon and inventor of the EARLi operation at Northwestern Memorial Hospital in Chicago. “Our research team wanted to limit scarring and the need for so many mastectomies.”

The operation harvests the muscle in the rib cage commonly referred to as ‘lats.” Physicians know it as the latissimus dorsi. Experts say that muscle is only necessary for those who want to be Olympic class swimmers or those who do many chin-ups. Working under the skin, the surgeon performs, not a mastectomy, but a lumpectomy to remove the tumor while leaving the nipple intact. The latissimus dorsi muscles are then rolled up to fill up the breast pocket.

Studying Patient Outcomes

According to Dr. Fine, who invented the EARLi operation, only a handful of surgeons offer the procedure which can replace many mastectomies.

Nobody seems to be tracking the numbers of patients who opt for preventive mastectomy. But it’s becoming common enough that more experts are studying patient outcomes, and reporting the results in professional journals.

Before Breast Cancer Strikes According to Richard J. Bold, M.D., associate professor of surgical oncology at the University of California Medical Center in Sacramento, women who undergo mastectomy for breast cancer can have their bosom rebuilt at the time of surgery without delaying additional treatment. Nobody had studied the topic before so doctors weren’t sure if the breast reconstruction should take place in another operation.

“Immediate breast reconstruction is growing in popularity because it improves psychosocial well-being and self-image,” says Dr. Bold who studied 128 women with breast cancer who underwent 148 mastectomies.

“Seventy percent of the women subjects were pleased with the results of their breast reconstruction,” says John Semple, M.D., a plastic surgeon and study co-author in Toronto, Canada, who studied a group of 37 high-risk women who opted for preventive mastectomies followed by immediate breast reconstruction.

But whatever technique is used, more and more women are aware of the danger and are getting tests and using self exams to guard against breast cancer.

To view Before and After photos of Breast Reconstruction surgery, Click Here.

If you have any more questions about this topic or would like more information Click Here.

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