The nirvana of the perfect breast

The Past

In 1998, I started a journey, looking for answers as to why so many women in South Africa were having (modified radical) ablative mastectomies.

And why breast conserving surgery was still being performed by generalists who did not understand basic plastic surgery techniques that prevented distortion of the breast, compounded by radiation therapy, which further distorted the breast mound leaving already assymetrical breasts (yes all of ours are) even more misformed. I questioned if it was the fault of the surgeons not trained in oncoplastic surgery, the fear of cancer spreading that caused rushed emergency surgery, or more sadly possibly the lure of a bird in the hand.

How difficult is it to remove a breast, take out a chunk, remove some lymph nodes, this is easy “charge” surgery? In fact the senior surgeon at the hospital where I was working was quick to comment that this was bread and butter surgery for the general surgeon. I feel patients should not get the minimum, but rather the whole cake with the icing on it too.

I also was under the misconception that the reason for such a high divorce rate around breast cancer was that men could not accept their partners with deformed breasts or a a missing breast. It took me many years to realise that the reason why breast reconstruction is so important is that we women are forever comparing ourselves to what is considered media norm. We stand on scales regularly , chase our “target” weight with diets. Fuss with hair and makeup, and think that if we don’t we will be less attractive to the opposite sex.

How much more important is it then that the focus of femininity – the breast – should be present and not mutilated? How will we feel sexually attractive, and thus be able to engage in the mating ritual with our partner if he has nothing to feel, or if it is fake or deformed?

And unlike men (the wonderful simple creatures that they are) geared to the end of the sexual act, us women are geared to the beginning of the sexual act. We need to feel good and in the mood. Sexual priming helps, and sadly if we are not happy with what we see, or perceive others to see, we don’t engage.

Fortunately over the last 40 years in mainly Europe and to a lesser extent in the US, there has been a great recognition of the value of using reconstructive techniques to allow breasts to look similar to their opposite number, or to create Barbie breasts (plastic, and sometimes truly fantastic), whilst treating and removing a breast cancer.

It has seemed that South Africa, isolated at the tip of this large continent, took 20 years before finally realising that (mainly thanks to womens’ pressure, and not doctor’s) breast cancer surgery should not be bread and butter work for the general surgeon, and a woman should not be told you need to survive for a year before we will consider reconstructing your breast.

Present 

So thank goodness today we are able to offer women multidisciplinary breast cancer care, including detailed oncoplastic (I prefer reconstructive as a term) combined meetings discussing the best ways to remove a cancer and the many ways we can reconstruct part of or a whole breast.

So the dilemma that now arises is how to choose? The doctor has mentioned that a breast saving operation is equal in survival to a mastectomy, so let’s save the breast.

Oh, hold on, what did the clinician say? If you have a breast saving operation, you need radiation! What are the side effects? Can your breast get burnt? Are you radioactive to your grandchildren and family?

Maybe you should choose a mastectomy. But don’t you lose your nipple then? What if the prosthesis that is used leaks and has to be removed? Does it need to be replaced in 10 years? Is there a lifetime guarantee? What was that data about silicone – is it safe?

So back to breast conserving surgery. If we can save part of the breast, certain important factors should come into play. How big is the breast, what is the symmetry between the 2 sides, where is the tumour, and how big is the tumour?

One option is to make both breasts smaller. This is great for big breasts, and droopy breasts (ptotic breasts).

What if you have a not so droopy B or C cup? Your breast saving options are then to import a small or larger amount of tissue from the surrounds, fat below the breast, or tissue from the side, or the muscle and tissue from the back….that can actually make a fair sized breast.

So what about the muscle from the back? Do you need it?

Well yes, otherwise it would not be there. The lat flap as it is colloquially known in oncoplastic circles, is that muscle you see protruding out like a wing in the gym bunny boys. It is not an arm muscle but part of shoulder girdle and armour of the back (yet not a true back muscle).

We use it for free rock climbing or pulling yourself up to the chin bar (you can’t and don’t do that, neither can I!).

Gymnasts and circus performers use it. Day to day use would be levering yourself out of a bath (not the safest exit manouvre) or pushing on a chair to hoist yourself up. We don’t remove it when using it for reconstruction, we merely change its position from back to front. We place the scar down the side, so you won’t have a scar across your back. Most of us hide the scar in the posterior axillary line, an imaginary line running from the back of your armpit down your side. We encourage exercise after a lat recon, swimming (after your doc has given the go ahead) is particularly good for all lat recovery.

Yes, you can save the breast and take out the nipple areolar. Some central cancers in women who require radiation, are best managed by a central excision of the cancer and reconstruction usually via a breast reduction pattern with a disc for the making of a neo nipple down the line.

Remember again, breast saving goes hand in hand with radiation. Most radiation oncologists will explain the minimal risks of radiation including radiation burns. Radiation changes today are far less than 15 years ago, and the long term breast shrinkage is not seen so much. However, remember that a radiated breast is a bit like Han Solo on ice – it is not going to move in time. Your other breast will still pick up weight if you do and droop more over time. Remember, gravity is not our friend, so expect changes over time in your breasts.

Breast saving also means mammograms and ultrasounds at least yearly. With this goes the anxiety and the fear that something else is found.

Remember, breast cancer does not hop from one breast to another. Recurrence or second primaries can occur, though statistically it is more dangerous getting in the car and driving to Durban over the Easter weekend. Dealing with the anxiety of going for mammograms is another story altogether. For most women who were not expecting their cancer diagnosis in the first place, going for a follow-up mammogram is particularly traumatic.

So because of all the above you have decided to have a mastectomy.

You have heard that today one can choose to have both breasts off, scoop out the insides, save the nipples, put prostheses in immediately and both breasts will look identically like Barbie’s. It is safe and has the added bonus of no radiation or mammograms. Is this finally the nirvana of the perfect breast reconstruction? I think not.

A lesson we have sorely learnt in women who are smokers, is that no matter how much they proclaim to cut down, data about low Vitamin D levels and increased wound problems is also coming to light. What if your plastic breast is giving problems in 5 or 10 years? Will it? Maybe not. Can it? Maybe yes.

We know that for women who already have prostheses, who do not need radiation, this option is a great option. And for others with strong family histories or dense breast that make radiologists frown every time one goes for a mammogram, this may indeed be an option.

But to the crux: there is no nirvana, there is no perfect breast reconstruction. Going through the trauma of a breast cancer diagnosis invariably means some sort of ablative surgery, and as we get smarter and smarter at reconstructing breasts, as the talents of our able fingered plastic and reconstructive surgeons improve, one must still remember that only GOD makes perfect breasts.

Future

What does the future hold? The trend is less is more. So we are moving away from mastectomies, back to breast conservation, even tumour freezing techniques (this I trained in in 2000, clearly now back in fashion). Remember, it is your body, and your temple, there are rules and guidelines and no absolutes. Participate in your treatment options, and try to think past the immediate and consider how you will feel post cancer treatment in 2 years, 5 years and 10 years time.

Yes you will get there… 9 out 10 women do. There is no nirvana of the perfect reconstruction, there is no perfect body, only airbrushed visuals. We all look at hail damage, age damage and body changes over time. It is how you choose to see yourself in the looking glass Alice, that counts.