Some Thoughts About Breast Reconstruction After Cancer

With the incidence of breast cancer at nearly one in eight females, I see patients with this diagnosis almost every day in Encino and the Los Angeles, California areas.  The patients that I treat are in various phases of care, ranging from newly diagnosed to survivors beyond five years.  Nowadays, many are receiving chemotherapy and radiation, and many are undergoing mastectomy rather than breast-conserving lumpectomy.  As one member of a team of specialists, the plastic surgeon tries to focus on the restorative aspect of breast cancer care.

Patients with new cancer diagnoses are faced with an early decision of lumpectomy and radiation versus mastectomy.  While conserving the breast is an appealing idea, it does not work well for many women, and can result in a deformed breast that is difficult to improve.  I have also seen a number of cases that developed cancer in the remaining breast tissue left behind after lumpectomy in spite of radiation treatment.  Nevertheless, I tend to advise the option of breast preservation if it is likely to give a good cosmetic result.  If not, the mastectomy, which removes almost all of the breast tissue from the cancer site, may be the better option.

Patients who are potential candidates for mastectomy should, ideally, see the plastic surgeon early on in the workup process to ascertain the role of plastic surgery for them.  There is no substitute for a detailed and thorough examination, assessing each patient for options involving both implant approaches as well as body tissue reconstructions.  I have heard so many women say, “I wish I knew that before . . .,” as they had never seen a plastic surgeon until they were already healing from the mastectomy.  As a general rule, use of implants and expanders are shorter procedures involving less hospitalization.  Implants are limited in how they can be placed and used to shape a breast, do not fare well in areas that have had or will have radiation, and can be difficult to match to an opposite “natural” breast.  Because of these limitations, they often work better in cases of double mastectomies.

Tissue reconstructions can require longer operative and hospitalization times, but offer advantages in shaping and in radiated areas.  Their success relies on adequate blood flow into the tissues,  a factor that the plastic surgeon is attentive to throughout the surgery and post-operative period.  The two most common sources of body tissue are the tummy and the back areas.  Not everyone is a good candidate for this approach; your plastic surgeon can guide you.

Some words of advice if you are facing breast cancer or know someone who is . . .

      1)    Take a deep breath, and try to stay focused to make the best choices you can.  Experienced plastic surgeons know that you are sometimes under short time constraints to make decisions about your care, and they will try to give you as much information as possible.  Meet with them as early as possible.

      2)    With the current state of chemotherapy and additional treatments, survival with this diagnosis has made great progress in the last few decades.

      3)    The changes in your body tissue that result from a course of radiation may never go away.  They may have a major impact on your reconstruction in the future.

      4)    If a lumpectomy will likely deform your breast in a way that could disappoint you, think carefully about whether the mastectomy option would be a better choice.

      5)    All other factors being equal, the body tissue reconstruction frequently offers the best long-term result.

      6)    If you need reconstruction after mastectomy, good integration of your plastic surgeon with the other members of the team is a strong advantage.

                                             To your health,

                                             Saul R. Berger, MD, FACS

                                           www.DrBerger.com

Some Thoughts About Medical "Tourism"

A couple consulted with me some time ago about a number of cosmetic issues.  Both had traveled to a Central American country for cosmetic surgery.  Both individuals had multiple procedures to the face and body, including facelift, brow lift, breast surgery, tummy tuck and more.  Frankly, it was difficult for them to know where to begin describing the problems that resulted, including sutures that still needed to be removed more than one year after surgery, scars that left them looking “strange,” and residual cosmetic issues that were never corrected.  In actuality, they began the consultation acknowledging that they had made a “big mistake” in traveling for surgery, but were trying to maintain a positive attitude in moving forward.  What was their prime motivation for surgery in another country?  Cost.  They spent about 50% of the cost of similar surgery in the U.S.  Some of their problems were correctable, and some were not.  Ultimately, they never underwent additional surgery -- they were not able to budget for the corrective work.  How did they find and “screen” the cosmetic surgeon who treated them?  The internet.

The desire to look one’s best and the benefits of improved appearance on both a personal and professional level have been recognized for many years.  Interestingly, there are many studies in the field of sociology that have documented measurable advantages, on a societal level, to possessing beauty and attractiveness.  Studies have even documented this fact across cultures and geographical boundaries.  The wild popularity of such relatively “simple” procedures such as Botox Cosmetic and the billions of dollars spent on skin care attest to our desire to “look our best” as much as possible.  Despite the current state of the domestic and world economies, individuals are still seeking aesthetic treatments and surgeries.  In order to reduce costs, some people have traveled to other destinations for their treatments.  Is it worthwhile to travel abroad for cosmetic surgery, and what are the risks?  What is involved in “surgical tourism?”
 

Some years ago, medical tourism described upper social class individuals traveling to countries for specialized skin care, spa therapies, mineral baths, or other unique treatments in pampering settings such as cities in the Mediterranean.  In more recent times, it has become commonplace for foreigners to travel to the U.S. for treatments that were either unavailable or associated with major delays in their native country.  The escalation in health care costs in the U.S. along with advances in aviation travel have increased the volume of Americans seeking medical care outside the U.S. for everything from organ transplants to cardiac surgery.  Specifically in the area of cosmetic surgery, people have traveled for procedures such as liposuction, facial cosmetic surgery, tummy tucks and much more.  In almost all cases, the motivation for travel is a lower price.  The obvious question is: are those savings justified?

While there is no definitive answer to this question, and there are certainly skilled and competent surgeons practicing around the world, what risks do patients face when traveling abroad for surgery?  The risks fall into several general categories:

1. Competency risk – does the physician have the necessary training to perform the procedure(s) safely and to achieve desirable results?  It can be very difficult for Americans to ascertain the quality of training and certification outside of the U.S.  Satisfactory results in a friend or family member may not translate to your results.
2. Facility risk – does the facility follow the safest protocols to ensure sterilization of instruments and proper function of equipment?  Are there contingency plans for emergencies?  Do they have the latest equipment should something untoward occur?  As medical director for an ambulatory surgery center in Encino, California, I can tell you that we use many safety systems about which most patients are unaware.  Did you know that we confirm the reliability of every sterilization cycle by using a separate biological test?  Did you know that we maintain a completely autonomous power backup system that automatically activates in the case of regional power loss so that surgery is not interrupted?  Did you know that an independent technician performs regular site visits and checks every piece of electronic and anesthesia equipment for proper function and maintenance?  These are just a few examples of many.
3. Follow-up risk – how does a patient propose to get the follow up care and information that they may require?  Most surgeries require a full healing period of at least 12 months.  Once returning to the U.S., patients no longer have the chance for direct “hands on” evaluation of their surgery by the practitioner.  What if they experience a problem or require some minor adjustment, such as a scar revision?
4. Complication risk – how do patients handle complications, such as infections or keloid scars?  What if their medical insurance does not cover the complications of such elective cosmetic procedures?  Are complication risks higher because of travel itself?  For example, prolonged airplane travel could increase the risk of a clot in a leg vein, with the risk of a life-threatening clot moving to the lungs.

So, is it worthwhile to travel for surgery?  Of course, price has to be figured into any assessment for cosmetic surgery.  But I advise my patients to make sure that cost is not their prime motivating factor.  Remember, surgical tourism can result in medical problems, and any savings could be easily wiped out.  Caveat emptor!

To your health,

Saul R. Berger, MD, FACS