Prof Carol-Ann Benn explains why it’s okay to be a Barbie Girl and see a reconstructive surgeon before cancer surgery.
There are certain medical consults that are taboo or hidden. Seeing a psychiatrist and a plastic surgeon are two of them. Do you see the analogy? Barbie Girl…or “Life is plastic…once diagnosed.”
So, whenever a person (mainly lady, occasional gent) is diagnosed with a breast cancer, I always suggest a consult with a plastic surgeon (technically a reconstructive surgeon) prior to any discussion regarding breast cancer surgery.
Why it’s okay to see a plastic surgeon
The problem is: unless I do an intro to the team of amazing plastics and recons, I get the “Why do I need to see a plastic surgeon?” comment.
Let me start with why it’s okay to see a plastic surgeon. Every time one of them suggests they can fix my eyes, my nose and my breasts. Never mind the shrapnel damage three large kids can do to your body. I bleat, “I’m not that kind of Barbie Girl, more a Kendra.”
But heading out for surgery you don’t need or want is different to surgery you need to have. If you need surgery; don’t be misguided and not understand that surgery comes with cuts on the surface; and significant shark bites inside (this is what one of the team calls my footprint after cancer removal). Tissue is distorted and moved around inside, and this should always be done with a person who has an eye for décor detail.
Oncology surgery is based around one rule: take it out, pick your clean margin. And, actually it doesn’t matter what it looks like until you are months post-radiation, looking at a breast that can’t have more surgery (without significant problems) and thinking (Gloria-Gaynor-style) I survived. But I look like a victim out of Jaws!
It’s for this reason that all women, post-diagnosis and discussion in a multi-disciplinary unit (once the rules of engagement and order of treatment are established) should discuss reconstruction, be it immediate or delayed.
I’m not a big delayed gratification type of person (this is like delayed reconstruction). The problem with saving the sweets till the next day, is that we steal them in the night and have darkest before dawn thoughts.
What is breast reconstruction?
This is the ability to repair the defect left by the oncology operation. This can be either post-breast-saving surgery (which is most commonly done today, and should go hand in hand with radiation), or post-mastectomy (which is usually nipple- and skin-saving unless either are involved with tumour).
Note to all, having a mastectomy doesn’t mean that a person doesn’t need radiation or oncology treatment. And, you can’t have a bilateral mastectomy to avoid chemotherapy, endocrine (the most googled (tamoxifen)) or any other oncology treatment.
Rules of play
Before a cancer surgery is performed, we need to assess the extent of the cancer. This can be tricky and shouldn’t be solely based on what the surgeon feels. I’ve seen patients who’ve had surgery and the cancer has been completely missed.
The roadmap prior to surgery is the assessment of biology (behaviour of the tumour; extent of surrounding no invasive cancer (DCIS); and the busyness of breast tissue assessed radiologically). For this mammogram, ultrasounds and the birds eye view of the MRI are used.
This pre-surgical assessment is what I call CPR (clinical, pathology and radiology) and anyone knows CPR is the basic medical lifesaver technique.
Marking the tumour before surgery
Once this has been discussed with you, your treating team must have the following safety briefing: How is the area of the tumour going to be marked prior to surgery? The breast on the outside isn’t the same as what the breast looks like inside. Marking the area where the cancer is prior to any treatment is essential.
Many women today start with oncology treatment prior to surgery. Thus, placement of V-markers or Magseeds prior to starting treatment ensures that when the cancer shrinks away, the oncology surgeon knows where it was.
One day we may just target the area with cryo-surgery or radiation, but in 2019 we still take out the area surgically.
A few days prior to surgery, the surgical navigator may arrange for the patient to see a radiologist who will mark out the area of the cancer, either with wires (on the day) or hidden markers (one of my favourite is a Magseed which is magnetic).
The unit in which you undergo treatment may have other ‘Barbie accessories’ to ensure that the cancer is out safe and sound, such as a machine in theatre.
Otherwise, the time in theatre may be longer and the tumour may need to be taken to the radiology unit. And/or a pathologist in theatre to ensure that the margins from the cancer surgery to normal tissue margin is wide enough.
Why should we do it at the same setting?
With it being reconstructive surgery, there is a school of medicine called Enhanced Recovery After Surgery (ERAS), which studies the effect of surgery on many recovery factors.
One of significant importance is that of cancer – surrounding oncology surgery and the potential risk of potentiating cancer. So, therefore, one surgery for oncology trumps two, three or four.
Why not just take the cancer out and close? Well, once you’ve had radiation, it’s problematic, to say the least, to operate.
What are the principles of engagement for cancer surgery and reconstruction?
Where do I start? We are all different. Thus, have different surgical risk factors that affect surgery. When you have an operation, you need to remember as with travel, there are a few rules.
You can’t travel without your passport: have full feedback from a reputable multi-disciplinary meeting prior to travel. This should be from an independent oncology navigator in the unit. In other words, not the surgeon giving feedback to cut, or the oncologist telling you that you should have chemo.
You can’t take off unless cleared by the tower: the physician and, in particular, the cardiologist must assess risks for surgery. Then, it’s all about the pilot (anaesthetist) and safety prior to surgery. This is critical.
Certain medical conditions predispose to more potential complications prior to any surgery. Any conditions that affect wound healing, such as obesity, diabetes, smoking, and others will possibly alter what options are presented around reconstruction, or affect potential delays in wound healing.
Have you noticed that all Barbie Dolls have the same high-gravity defying, perfect, equal C cup breasts? Now, in real life, all our breasts are asymmetrical (one bigger than the other and there are so many different types of breasts that, a revolting island holiday T-shirt of breasts and fruit springs to mind). Breasts can be like lemons, melons, etc.
Never mind that gravity hates women more than men. And, the nipple line may have started at the mid humeral (arm half way mark), but age and having children make sure that it doesn’t stay there.
Furthermore, the quality of breast tissue varies. Some breasts are fatty (like cutting into butter) and others are like cutting into cake, and others fruitcake.
All these issues are considered when you see the reconstructive surgeon prior to surgery.
The involved breast
From tumour position to size. Both that of the tumour and breast is important. Besides size, shape of the breast is equally important. The oncology and reconstructive team discuss where the cancer is in the breast. Location is critical. How close to the nipple and could the nipple be involved, or be one of the close margins? Is the cancer close to the skin and will skin need to be taken?
So, cancer surgery is not just a simple there it is and cut it out. The type of surgery that is offered as well as the amount that is probably going be excised requires detailed planning. Understandably, cutting a small area out of a big breast is easier than out of a small breast. But larger breasts can be unforgiving, in terms of the quality and amount of fat in the tissue with resultant areas of fat necrosis (dead internal fat) being higher.
Let’s get size perspective. An 8mm cancer is the size of a little pink sweet. A 12mm cancer is the size of a Jelly Tot. A 25mm cancer is the size of a Liquorice allsorts.
This doesn’t include the margin that the surgeon and pathology team need to ensure that the cancer local recurrence rate (chance of the cancer growing back) is small.
The opposite side
Why operate on a normal healthy breast? Well, you don’t need to. BUT, in the long-term, the most complaints we see, as patients move from cancer fear to living the new you, is dealing with asymmetry of the other breast. Besides the scars of the cancer surgery, the fact that their breasts look different and are different sizes concerns them.
Other treatment issues that create discussions prior to surgery are: Does the person require radiation or not? Having an idea pre-surgery and planning for this is better than surprises post-surgery.
An added discussion that is critical today (if available and covered by medical aid) is that of intra-operative radiation and whether it’s to be considered. This very technical but useful contribution to treatment requires detailed reconstructive planning, in terms of placement of radiation balls and attention to skin and tissue safety.
The signature of the breast is the nipple areolar complex. Understanding the blood supply and that it can be variable, creates many a stressor to the reconstructive surgery. When a tumour is close to the nipple, or when a skin- and nipple-sparing mastectomy is performed, a biopsy under the nipple is done to check there are no cancer cells.
Approaching a cancer excision and reconstruction isn’t as simple as putting a dress on Barbie. But, is more akin to planning a whole wardrobe, with the understanding that dressing a Barbie Doll is not as simple as it looks. Plus, we know that Barbie is more attractive in clothes.
So, don’t accept an excision without understanding reconstruction and what it means for women. We deserve to feel comfortable in our skin.
MEET OUR EXPERT – Prof Carol-Ann Benn
Prof Carol-Ann Benn heads up breast cancer centres at Helen Joseph Hospital and Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established Breast Health Foundation.