Fw: Reconstruction or destruction?

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Sent: Saturday, August 25, 2001 11:39 AM

Subject: Reconstruction or destruction?

> http://www.thecourier.com/

>

> Reconstruction or destruction?

>

> EDITOR'S NOTE -- This is the first installment in a five-part series

> exploring the controversy surrounding breast reconstruction surgeries.

> Names of those who spoke about their surgeries have been changed at the

> women's request.

>

>

> By LAURA TUCKER

>

> FAMILY EDITOR

>

>

> In a society where image is everything, the news of breast cancer can be

> devastating. A mastectomy can leave a woman with low self-esteem or poor

> body image. Or, it can leave a woman feeling fine, overwhelmed with relief

> that the cancer is gone.

>

> What arises is a question of medical ethics. Are plastic surgeons preying

> upon the vulnerability of women facing mastectomy? Are breast

> reconstruction surgeries necessary or do they pose more risk than benefit?

> Should a woman have the right to choose the surgery, knowing the risks

> involved? Are surgeons bound to inform patients of all risks and are they

> following that practice?

>

> The issues have been raised, leaving legislators looking at a rainbow of

> gray trying to find black and white. Is there a clear answer?

>

> While breast reduction and enhancement surgeries have been available for

> decades for cosmetic reasons, the heart of the most recent controversy

> concerns a bill started with good intentions. The Women's Health and

> Cancer Rights Act of 1998 granted a cancer victim the right to have

> medical insurance pay for breast reconstruction following a mastectomy.

> The procedure had been elective. According to figures from the American

> Society of Plastic Surgeons (ASPS), a total of 29,607 breast

> reconstruction surgeries were conducted in 1992. In 1998, the year of the

> bill's passage, that number increased to 69,683 and to 82,975 in 1999, an

> increase of 180 percent from 1992 and an increase of 19 percent from 1998.

>

>

> " , " a local resident who asked that her real name not be used, said

> she doesn't think that increase is coincidental. She is one of several

> women who, after being diagnosed with breast cancer, underwent a

> mastectomy and breast reconstruction surgery which turned out badly. She

> said she was railroaded into the Tram Flap surgery by an unethical plastic

> surgeon who presented her with little information about the possible side

> effects.

>

> said the Women's Health and Cancer Rights Act of 1998 is being used

> as an instrument for unethical surgeons to prey upon women who are already

> in a state of emotional turmoil. She charged that some plastic surgeons

> present breast reconstruction options as if they were part of the cure for

> cancer. But in reality, reconstruction has nothing to do with the cure or

> treatment of the cancer. She said she wants to prevent other women from

> undergoing the pain and agony she has endured.

>

> She said the Tram Flap surgery is a drastic, life-altering surgery which

> she would never have chosen had she been better informed. The procedure

> takes tissue and muscle from the abdomen, stretching it to the chest to

> form a new " breast. "

>

> She noted that undergoing the procedure would preclude a person from being

> able to carry a baby because the abdomen could no longer support a growing

> fetus. Hernias are common in those who have had this surgery, and necrosis

> (the death of tissue moved to the breast area) is also a possibility.

> Missing abdominal muscles and permanent numbness in the operation site

> leave those who undergo the procedure unable to do sit-ups or perform

> other movements which would require those muscles. She said women are

> being kept in the dark -- as she was -- about these after-effects.

>

> Many women have related their experiences to and also on Internet

> sites dedicated to the issues of breast reconstruction. Several said they

> resorted to a Tram Flap or similar procedure after having problems with

> breast implants, their first choice after mastectomy.

>

> " Glory " said " gel bleed " from her implants had left her sick and without

> the use of her left arm. She said she was told she would be left with a

> concave chest if she did not replace the implants. She had her Tram Flap

> surgery in March 1994. It lasted 13 hours. Two days after surgery she went

> into pulmonary edema, fluid on the lungs, and was placed on life support.

> She finally pulled through, but six weeks after the surgery she was still

> having trouble walking and had a large bulge on her right side below her

> hip-to-hip incision. In July, she had a hernia repaired with surgical

> mesh, but she herniated again in six weeks. In September 1995 she had

> hernia repair surgery, during which the mesh which had adhered to her

> intestines was removed. She developed pneumonia and an ileus (paralyzed

> intestines) following the surgery. In January 1996, Glory underwent hernia

> repair surgery again and a lump was found in her left breast. The lump was

> removed. In 1997, she underwent a hysterectomy and hernia repair, from

> which she developed a bacterial infection.

>

> Glory said she still has occasional pain in her abdomen, is numb from just

> beneath her breasts to her pubic bone and has chronic back pain. She is

> not permitted to lift anything over five pounds.

>

> " Pam " said she underwent a radical mastectomy in 1975 at age 27. In 1980,

> she had a Latissimus Dorsi Flap. This procedure cuts a portion of the

> latissimus dorsi muscle in the upper back, pulls it under the arm and

> attaches it to the chest to form a breast. Like the Tram Flap, this

> procedure takes a football-shaped piece of tissue from the donor area and

> grafts it to the chest as well.

>

> Pam, who is from Idaho, said she was never told the latissimus dorsi

> muscle is needed to keep the shoulders straight, or that the operation

> would affect the way she walks. She said her surgery gave her a lifetime

> of pain and physical therapy.

>

> " Reconstruction surgeries are a multi-billion dollar business for plastic

> surgeons who prey on the self-image of vulnerable women. While plastic

> surgeons perform thousands of these surgeries each year, they are silent

> on how many of each reconstruction surgery they do and the cost of them.

> They are silent on failures. There are no studies of long-term

> reconstruction patients... Meanwhile the insurance companies keep paying

> for reconstruction surgeries that guarantee putting a woman back into the

> doctor's office on a regular basis. Reconstruction surgeries are just

> another page in the plastic surgeon's retirement plan, " Pam wrote.

>

>

> EDITOR'S NOTE -- For every reconstruction surgery nightmare, there's one

> that seems to have been the operation of a woman's dreams.

>

> Looking good

>

> EDITOR'S NOTE -- This is the second installment in a five-part series

> exploring the controversy surrounding breast reconstruction surgeries.

> Names of those who spoke about their surgeries have been changed at the

> women's request.

>

>

> By LAURA TUCKER

>

> FAMILY EDITOR

>

>

> Women who have had successful breast reconstruction say they feel for the

> women who by surgeon error or unforeseeable complications have suffered

> trauma from their experiences. However, they said, they feel the decision

> for surgery should be the individual's right.

>

> An area resident who responded to a request from the Courier for

> information from women who have undergone breast reconstruction surgeries

> said she had a Tram Flap in 1991.

>

> " It still looks good 11 years later, " said.

>

> had her breast reconstruction surgery done in Brazil, where she was

> living at the time. She said the procedure she underwent was a bit

> different from the standard Tram Flap procedures being done now. Two

> muscles from her abdomen were moved to create one new breast. Her belly

> button was surgically moved upward because the displacement of tissue in

> her abdomen left it sagging very low. Also, a nipple was constructed and

> attached to her new " breast. "

>

> said the doctor who operated on her took a great deal of time in

> explaining the procedure and the expected results. She said he was both an

> oncologist and a plastic surgeon and that his father had been a forerunner

> in breast surgery. She did not suffer any necrosis (tissue death), and

> noted the doctor had told her no surgeon in the United States did the

> procedure the way he did it. She said her doctor told her most surgeons do

> not bring up enough blood supply with the tissue.

>

> It was not an easy operation, said. It was two months before she

> felt capable of entertaining people in her home again, and at first she

> walked hunched over.

>

> attributes some of the success of her surgery to the fact that she

> was very healthy before she underwent surgery, without any chronic

> illnesses or difficulties which may have been compounded by the surgery.

> Following the operation she had some physical therapy for her arm.

>

> She also got all the information she could to make an informed decision

> about surgery.

>

> " I demanded and got albums (photographs) of women before and after the

> surgery. I like to be prepared, " she said. She's a woman who insists on

> being in control of her destiny. said she had to fight to be allowed

> to remain awake during her biopsy, and that she flatly refused to sign a

> consent form giving the surgeon permission to remove her breast if cancer

> was detected during that procedure.

>

> She said she chose the mastectomy because she had a lot of cysts in her

> breast. Her mother died of breast cancer at the age of 46. She said she

> found a doctor who could do the mastectomy and reconstruction all at once,

> and she then made her decision. She admitted, however, that once she

> decided to have the reconstruction, she didn't want to hear anything else.

>

>

> " I felt once I had made the decision, 'Don't tell me anything I don't want

> to hear,' " said.

>

> Many patients have the same sort of attitude -- they've made a decision

> and don't want to hear that complications could arise. still feels

> she made the right decision and admits she was lucky that complications

> didn't arise.

>

> " I can do everything, " she said of her physical abilities. She admitted

> there are some actions she can't do the way she used to. For example, she

> can't do sit-ups and it has become second nature to her to reach down and

> grab a thigh in order to pull herself up from a prone position. She has

> had no hernia problems. She lacks some feeling in her abdomen and new

> breast, but after 11 years she doesn't notice. At first it was annoying,

> now she is used to it.

>

> " For me it's been wonderful, " said of the Tram Flap, and given a

> choice she would definitely do it again. She said she often forgets she

> ever had cancer because when she looks in the mirror, she looks normal.

>

> The Flap procedures are radical, but many doctors favor them over implants

> because they use the patient's own tissue. Public outcry over the dangers

> of silicone gel implants led to huge lawsuits and most plastic surgeons

> will not use them now, even though they are not completely off the market.

> Those opting for implants are turning to saline-filled.

>

> , whose Tram Flap procedure in 1999 left her disabled, said the

> problem with saline implants is that the envelope for the saline is still

> made of silicone, which she says can break down and " bleed " into the body,

> creating all sorts of physical problems.

>

> Some women, however, have been pleased with their implants. At the age of

> 61, area resident elected to get a saline implant. That was in 1997,

> and she has had no problems. The implant is not perfect -- she has to use

> a little padding and had to undergo reduction on her other breast to make

> them equal in size.

>

> " But, at least I don't have to carry all the paraphernalia (associated

> with a prosthesis), " she said.

>

> knows all about that, having had a prosthetic breast before opting to

> try the saline implant. Her prosthesis was heavy and awkward. When

> traveling, she had to carry the special suitcase in which it was contained

> and she couldn't wear a bathing suit because it showed. Also, on a hot day

> working out in the yard, if sweat made her clothing see-through, the

> prosthesis could be seen. The whole business made her self-conscious.

>

> She chose the mastectomy, she said, because she couldn't face the idea of

> having a continued risk of cancer.

>

> " I just really felt I couldn't face it and said to the doctor, 'Do what

> you have to do,' " she said.

>

> She took a year to decide to have the implant and first asked for a

> reference. She was given the name of a 71-year-old woman who told her she

> was very happy with her implant.

>

> said she feels no one should have the right to make the choice

> concerning breast reconstruction for another woman. She said people are

> wrong who say mastectomy patients should learn to simply accept their

> bodies the way they are and be thankful they survived the cancer.

>

> " They don't think a thing of having a (dented) car repaired and turn

> around and have a fit if a woman has reconstruction, " she said.

>

> She said it came down to the wire -- just three days before surgery -- for

> her insurance company to say it would pay for the implant. She said she

> would have paid for the surgery herself if it hadn't.

>

>

> EDITOR'S NOTE -- Plastic surgeon organizations were not willing to discuss

> breast reconstruction issues, or the specifics of any cases, on the

> record. One area plastic surgeon, however, agreed to address

> reconstruction procedures and noted that the key to successful surgery

> often lies in the patient being well-prepared.

>

> Women who have had mastectomies have several reconstruction options

> available to them.

>

> First, there is the non-operative prosthesis which fits into one's bra.

> While such prostheses do not require surgery, many women say they are

> uncomfortable, do not look real under clothing and are inconvenient.

>

> Implants are another option. Generally speaking, most plastic surgeons

> will only use saline-filled implants. Implants are placed either over the

> pectoralis muscle (subglandularly) or partially under this muscle

> (submuscularly), the latter being the most common among reconstruction

> patients. Possible complications from these implants include

> deflation/rupture, capsular contracture, pain, additional surgeries,

> dissatisfaction with cosmetic results, infection, hematoma/seroma, changes

> in nipple and breast sensation, calcium deposits in tissue around the

> implant (visible on mammograms and sometimes mistaken for possible

> cancer), delayed wound healing, extrusion, necrosis, breast tissue

> atrophy/chest wall deformity and connective tissue disease.

>

> There are also tissue flap reconstruction procedures. A tissue flap is a

> section of skin, fat and muscle that is moved from the stomach, back or

> other area of the body to the chest area and shaped into a new breast. The

> most common of these surgeries are the Tram Flap and the Latissimus Dorsi

> Flap.

>

> During a Tram Flap operation, the rectus muscle in the abdomen is cut and

> a section of tissue is removed from the abdomen, and both are funneled to

> the missing breast area to form a new breast. The operation often leaves

> the stomach area flatter in addition to forming the new " breast. "

>

> A Tram Flap procedure takes several hours of surgery and several days of

> recovery time in the hospital. Recuperation from a Tram Flap takes two

> months to a year. Patients will have temporary or permanent muscle

> weakness in the abdominal area and a large scar across the abdomen, as

> well as possible scars on the reconstructed breast.

>

> In a Latissimus Dorsi Flap procedure, a skin flap and muscle are taken

> from the back and funneled to the mastectomy site to create a new

> " breast. " This procedure also takes several hours of surgery with a stay

> in the hospital of two or more days. Daily activity can be resumed in two

> to three weeks. There will be temporary or permanent muscle weakness and

> difficulty with movement in the back and shoulder. There will also be a

> scar on the back and possibly scars on the reconstructed breast.

>

> Informed decision

>

>

> EDITOR'S NOTE -- This is the third installment in a five-part series

> exploring the controversy surrounding breast reconstruction surgeries.

> Names of those who spoke about their surgeries have been changed at the

> women's request.

>

>

> By LAURA TUCKER

>

> FAMILY EDITOR

>

> At the heart of the controversy over breast reconstruction is the issue of

> informed decision. An area plastic surgeon agreed to discuss his own

> methods of informing patients about breast reconstruction surgery, the

> types of reconstruction surgeries available and what they entail. The

> surgeon, like the patients themselves, asked not to be identified.

>

> There are two types of patients who seek information concerning breast

> reconstruction, the doctor said. One is contemplating a mastectomy and

> wants to find out her options before having that done. The other has had a

> mastectomy in the past and is now considering reconstruction.

>

> " I tell both there is no right or wrong choice, " he said. " There are ones

> who have had mastectomies and never considered reconstruction, and that is

> an OK choice also. "

>

> There are other patients who decide they do not want a mastectomy, and it

> is fine for them to seek out their other options. No one should feel

> pressured into making any decision when it comes to surgery, the doctor

> said.

>

> More and more patients are choosing to have reconstruction done at the

> same time as the mastectomy, the doctor said. Much of the timing should

> depend on the patient's general health. Having both surgeries at the same

> time does extend the recovery period, but having the two procedures done

> at once reduces the patient's trips to the operating room by one trip.

> Having the reconstruction done later means undergoing anesthesia again.

> However, the surgeon said any reconstruction regularly requires more than

> one surgery.

>

> Patients considering reconstruction need to keep in mind that no operation

> is without risk.

>

> " People should not be rushed into making a decision. But, sometimes you

> cannot avoid being put under a time crunch if they are going to have an

> immediate reconstruction (with mastectomy), " the doctor said.

>

> Generally, those who delay the reconstruction surgery are more likely to

> be happy with their decision. They have more time to think and to digest

> all the information. And they tend to be better informed about the risks.

> The others are still trying to deal with being told they have breast

> cancer. Adding the decision about reconstruction on top of that can be a

> lot to handle. But the operation can be done safely in either case.

>

> " This is where individual choice comes into play, " he said.

>

> This plastic surgeon said he personally spends 45 minutes to an hour

> talking with a patient and describing the options during the initial

> visit. Then, he said, he gives the patient information to take home and

> tells her to think about it. He encourages her to write down all the

> questions she can think of and then schedule another appointment to

> discuss her options again.

>

> " And I always tell them the decision to not have surgery is OK, too, " he

said.

>

> It is wrong for a plastic surgeon not to give a patient all the

> information he or she can, the doctor said. With the Tram Flap procedure,

> he said he explains to patients that indeed the tissue used to form the

> breast is the same material taken out and thrown away in a tummy tuck

> procedure. However, he said, he makes it clear that along with that tissue

> must come muscle to provide a blood supply to that tissue.

>

> " You do burn bridges in the process, " he said. " If you move it and it

> doesn't work, you can't put it back. "

>

> He said the Tram Flap is probably the best reconstruction surgery option.

> However, it is a major operation and there are many risks involved. People

> with other medical problems are not as good candidates as generally

> healthy people. No operation is always done under perfect conditions, the

> doctor said, so both patient and doctor need to weigh the benefits and the

> risks of the procedure.

>

> " It is the doctor's responsibility to present those risks to the patient, "

> he said.

>

> Before the Tram Flap procedure was identified, the doctor said, many

> patients were choosing the Latissimus Dorsi Flap. Many of those operations

> were done in combination with an implant. But there were complications

> with those procedures and the Tram Flap has nearly completely replaced it.

> The doctor said the Tram Flap does have the risk of hernia, but the

> Latissimus Dorsi Flap was not a good choice for athletic people because it

> removed capabilities for certain movements -- such as those required in

> skiing or rowing.

>

> " This is why there are no black and white answers, " the doctor said,

> noting there are drawbacks and pluses to every operation.

>

>

> EDITOR'S NOTE -- Before the Tram Flap and Latissiums Dorsi Flap procedures

> were developed, women most commonly sought implants, both for cosmetic and

> reconstructive purposes. Implants, however, come with their own potential

> for complications.

>

> Reconstruction options to consider

>

>

> EDITOR'S NOTE: The following information comes from one of several

> Internet websites offering information about breast reconstruction and a

> pamphlet from Mentor, Inc., manufacturers of saline implants.

>

>

> Most mastectomy patients' bodies are medically appropriate for

> reconstruction, many at the same time that the breast is removed. The best

> candidates, however, are women whose cancer, as far as can be determined,

> seems to have been eliminated by mastectomy.

>

> The pamphlet advises that still, there are legitimate reasons to wait.

> Many women aren't comfortable weighing all the options while they're

> struggling to cope with a diagnosis of cancer. Others simply don't want to

> have any more surgery than is absolutely necessary. Some patients may be

> advised by their surgeons to wait, particularly if the breast is being

> rebuilt in a more complicated procedure using flaps of skin and underlying

> tissue. Women with other health conditions, such as obesity, high blood

> pressure, or smoking, may also be advised to wait.

>

> In any case, being informed of your reconstruction options before surgery

> can help you prepare for a mastectomy with a more positive outlook for the

> future.

>

> All surgery carries some uncertainty and risk. Virtually any woman who

> must lose her breast to cancer can have it rebuilt through reconstructive

> surgery. But there are risks associated with any surgery and specific

> complications associated with this procedure.

>

> In general, the usual problems of surgery -- such as bleeding, fluid

> collection, excessive scar tissue, or difficulties with anesthesia -- can

> occur, although they're relatively uncommon. And, as with any surgery,

> smokers should be advised that nicotine can delay healing, resulting in

> conspicuous scars and prolonged recovery. Occasionally, these

> complications are severe enough to require a second operation.

>

> If an implant is used, there is a remote possibility that an infection

> will develop, usually within the first two weeks following surgery. In

> some of these cases, the implant may need to be removed for several months

> until the infection clears. A new implant can later be inserted.

>

> The most common problem, " capsular contracture, " occurs if the scar around

> the capsule of the implant begins to tighten. This squeezing of the soft

> implant can cause the breast to feel hard. Capsular contracture can be

> treated in several ways, and sometimes requires either removal or

> " scoring " of the scar tissue, or perhaps removal or replacement of the

> implant.

>

> Reconstruction has no known effect on the recurrence of disease in the

> breast, nor does it generally interfere with chemotherapy or radiation

> treatment, should cancer recur. Your surgeon may recommend continuation of

> periodic mammograms on both the reconstructed and the remaining normal

> breast. If your reconstruction involves an implant, be sure to go to a

> radiology center where technicians are experienced in the special

> techniques required to get a reliable X-ray of a breast reconstructed with

> an implant.

>

> Women who postpone reconstruction may go through a period of emotional

> readjustment. Just as it took time to get used to the loss of a breast, a

> woman may feel anxious and confused as she begins to think of the

> reconstructed breast as her own.

>

> After evaluating your health, your surgeon will explain which

> reconstructive options are most appropriate for your age, health, anatomy,

> tissues, and goals. Be sure to discuss your expectations frankly with your

> surgeon. He or she should be equally frank with you, describing your

> options and the risks and limitations of each. Post-mastectomy

> reconstruction can improve your appearance and renew your self-confidence

> -- but keep in mind that the desired result is improvement, not

> perfection.

>

> If your surgeon recommends the use of an implant, you'll want to discuss

> what type of implant should be used. A breast implant is a silicone shell

> filled with either silicone gel or a salt-water solution known as saline.

> Because of concerns that there is insufficient information demonstrating

> the safety of silicone gel-filled breast implants, the Food & Drug

> Administration (FDA) has determined that new gel-filled implants should be

> available only to women participating in approved studies. This currently

> includes women who already have tissue expanders (which are implanted into

> the chest with a pump extending outside the skin so they can be gradually

> filled with saline, thus stretching the skin in preparation for a regular

> breast implant), who choose immediate reconstruction after mastectomy, or

> who already have a gel-filled implant and need it replaced for medical

> reasons. Eventually, all patients with appropriate medical indications may

> have similar access to silicone gel-filled implants.

>

> The alternative saline-filled implant, a silicone shell filled with salt

> water, continues to be available on an unrestricted basis, pending further

> FDA review.

>

> As more information becomes available, these FDA guidelines may change. Be

> sure to discuss current options with your surgeon. (The above guidelines

> are current as of July 1992.)

>

> It may take you up to six weeks to recover from a combined mastectomy and

> reconstruction, or from a flap reconstruction alone. If implants are used

> without flaps and reconstruction is done apart from the mastectomy, your

> recovery time may be less.

>

> Surgery cannot provide normal sensation to your reconstructed breast, but

> in time, some feeling may come. Most scars will fade substantially over

> time, though it may take as long as one to two years, but they'll never

> disappear entirely. The better the quality of your overall reconstruction,

> the less distracting you'll find those scars.

>

> Follow your surgeon's advice on when to begin stretching exercises and

> normal activities. As a general rule, you'll want to refrain from any

> overhead lifting, strenuous sports, and sexual activity for three to six

> weeks following reconstruction.

>

> Chances are your reconstructed breast may feel firmer and look rounder or

> flatter than your natural breast. It may not have the same contour as your

> breast before mastectomy, nor will it exactly match your opposite breast.

> But these differences will be apparent only to you. For most mastectomy

> patients, breast reconstruction dramatically improves their appearance and

> quality of life following surgery.

>

>