One Size Does Not Fit All: Boobs, Bras, Bilateral Mastectomies
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Now that bilateral mastectomy is part of the vernacular--thank you, Angelina Jolie!--we have become more familiar with the concept of breast cancer, surgery and differing motivations for action. It all sounds pretty simple, right? You get diagnosed, you go for surgery, you have radiation, maybe chemotherapy, then life, with any luck, moves forward.
The truth, however, is that both women at high risk as well as the recently diagnosed are bombarded with various options, and it can all become very confusing, very quickly. Although it’s tempting to hear what a celebrity or friend is doing and conclude that you should do the same, every woman’s diagnosis, risk, and health profile is unique. What’s right for one could be completely wrong for another, even when symptoms, age, and other factors seem the same.
Ultimately, the medical team wants either to cure the patient with breast cancer (so she never has to hear the words “your cancer has come back”) or to reduce a high-risk woman’s likelihood of developing it with prophylactic surgery and make them feel good about--or at least comfortable with--their decision.
Here’s an incomplete list of the myriad of options presented to women:
- Lumpectomy and radiation
- Lumpectomy and intraoperative radiation
- Lumpectomy and APBI (accelerated partial breast irradiation) followed by a short course of radiation
- Mastectomy without reconstruction
- Mastectomy and direct-to-implant reconstruction without prophylactic treatment of the opposite side
- Mastectomy and direct-to-implant reconstruction with prophylactic treatment of the opposite side
- Mastectomy and delayed reconstruction with expanders, then implants with prophylactic treatment of the opposite side
- Mastectomy and delayed reconstruction with expanders, then implants without prophylactic treatment of the opposite side
- Mastectomy and autologous tissue reconstruction: DIEP, LSGAP, TUG, Latissimus, stacked or not stacked (see The Language of Breast Cancer).
Then, there are the issues around nipple preservation.
Now you see why it can all seem overwhelming and confusing for the patient, family and friends.
As mandated during the Clinton Administration, physicians are required by law to present all treatment and reconstruction options to patients. This includes a visit to a plastic surgeon for option discussion.
Not all options are appropriate for an individual patient, however, and all factors should be considered. “The diagnosis of breast cancer often comes as a shock to patients,” according to Dr. Ariel N. Rad, a board certified, Johns Hopkins-trained plastic surgeon practicing in Washington DC and northern Virginia. “It’s important for patients to have things explained to them in plain terms that they can understand and remember.”
Geographic and social considerations also come into play. Patients who live hours from a radiation oncology facility may chose mastectomy alone when given the option, or they may need to undergo radiation, even if it means spending 6 weeks in a hotel because the hospital is too far from their home, as many women in the western states find themselves doing.
Decisions may also depend on the extent of the cancer at diagnosis and the plan for chemotherapy. Some patients need chemotherapy first, and then have the opportunity to reassess their reconstruction options down the road.
Body type plays a role as well. For example, the surgeon can take skin and fat from a woman’s inner thigh or tummy and make it into a breast, so in many situations reconstructive surgery turns out better when a woman has extra fat around her midsection. Dr. Rad points out, “DIEP flap – which borrows fat from the abdomen – or the SGAP flap – which borrows from the ‘love handle’ area – can be accomplished in patients with ample fat in these areas. Complete breast rebuilds with patients’ own fat eliminates some potential implant problems. The DIEP flap also has the added benefit of a tummy tuck, and similarly, patients with love handles can have a slimmer hip and waist area. Patients should not expect to be having a full body makeover, but they are often thrilled with a slimmer figure as a result of the surgery.”
Dr. Rad emphasizes that, “Each patient is unique, which requires that the choice of reconstruction be customized not just by medical factors, but also by patient lifestyle, career, family commitments, hobbies, athletics, and other factors.” Young children, busy professional lives, and personal preferences play a strong role in the decision of what type of reconstruction is best for patients, and all three of these probably played at least a supporting role in Angelina’s decision, if we were to take an educated guess.
Dr. Maggie DiNome, a Harvard trained surgeon at Saint John’s Health Center in Los Angeles, takes the time to discuss all of the various treatment options with her patients because, more often than not, from a medical standpoint, there may be more than one right answer. “It really is our job, as treating physicians, to make sure that our patients understand their options, and to help them arrive at a decision that is right for them. I think one of the most confusing concepts for patients to grasp is that a more aggressive surgery (ie. mastectomy) doesn’t mean a better survival outcome, or that a mastectomy makes chemotherapy unnecesary. Helping a patient understand the goals of our treatment recommendations and reconciling them to their goals will lead to the right decision. Because of our medical progress, women now have a choice, and that is perhaps the most empowering advance we have made in cancer care.”
“The choices for reconstruction afford women control of their bodies at a time when they feel such a loss of control. Of course women want to cure their cancer first and foremost, but being able to feel whole again should not be considered a narcissistic evil. When women wake up from surgery, they should not be made to feel that unnecessary pain and suffering are the price to pay for restoring their bodies. Their drains should not be causing them pain because they are dangling untethered, and their incisions shouldn’t be irritated by an ill-fitting surgical bra.” In short, their bras should not look like they were designed in the Middle Ages. “At Saint John’s in LA,” continues Dr. DiNome, “we send all of our patients home in an innovative, beautifully and thoughtfully designed surgical bra—the Pink Surgical Bra—so that our patients have all the advantages of a modern age recovery garment. Cutting edge treatment requires cutting edge innovation of accessories that accelerate healing as well. It’s all about healing the patient from the inside and out.”
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