Under Construction: An Alternate View

Here’s the question: Is breast reconstruction really worth it? How much are we willing to go through to “save” the ‘girls’ while we’re saddled with saving our lives from the ravages of breast cancer?

There’s nothing pretty about surgery

I’ll never forget the first time I observed surgery as a grad student. It was orthopedic surgery for a knee joint replacement. It was like being in a wood-working shop. Sure, all the tools were sterilized and made of titanium, and we were all dressed in scrubs, but still. It was a lot like watching someone repair a piece of furniture. Except it was a person they were sawing and hammering. It was an enlightening experience, because it taught me a little about surgeons and a lot about how my patients were going to feel when I had to treat them afterward.

I wish I had a dollar for every time a post-surgical patient has asked me, “Why does it hurt so much?” And when you’re a physical therapist, you’d better have a good answer, plus a lot of practical advice about how to relieve that hurt, or you’re not going to get very far. So, after I’ve dispensed my instructions about pain meds and ice packs and gentle stretching and assistive devices, and my patient is no longer wincing or groaning, I try to inject a note of reality. Over the years, I’ve taken to using a medieval analogy. “Well, look,” I say. “You’ve just had this person flailing at you with all these sharp implements. It’s like being in a battle in the Middle Ages, and having some dude on a warhorse attack you with an axe. Except you were unconscious at the time. But now you’re awake. And it hurts.” Oddly enough, people find this comforting, even humorous. Gives them a way to understand why they feel like road kill. So, call it professional cynicism. But I sometimes think that a lot of the people who cut people up for a living were probably the sort of children who pulled the wings off flies. Not all of them, I’ll grant you. Some people become surgeons because they actually want to help people. But honestly, it’s a gruesome way to earn a paycheck.

I don’t know. Maybe it’s just that I’ve seen more than my share of post-surgical complications, non-healing wounds, allergic reactions to sutures and tape, infections, edema, cellulitis, wound-vacs, blood clots, oozing drainage, and uncontrolled pain. I’ve seen hundreds of angry, red incisions, held together with staples, that look like something Dr. Frankenstein might have done on a bad day. And not small staples either, but the kind of things you might use if you were reupholstering a leather chair. Why would anyone want to use staples on a human being? Don’t they teach them to sew during their surgical residencies? It’s only been a fairly recent phenomenon that surgeons of all stripes have sought to eschew staples for specialized thread, or even surgical glue, both of which are made to dissolve over time, to close an incision as invisibly as possible. Although I still wonder if some of them could sew a button back on their shirts.

Perhaps this is why, when I was diagnosed with breast cancer, I was not particularly receptive to the idea of reconstructive breast surgery. As far as I was concerned, the less surgery the better. And the more research I did about the options for reconstruction, the more convinced I was that avoiding it altogether was the best option. So, having said all this, here’s my admittedly jaded take on the whole enterprise.

Euphemisms

There are a lot of medical euphemisms about breast cancer surgery. Phrases like “lumpectomy” and “breast conserving surgery.” Maybe I’m too much of a literalist, but I hate these phrases. When you’re told you’re having a lumpectomy, then I think you have every right to expect that you are only going to have a lump excised from your breast. For many of us, however, that is patently untrue. My so-called lumpectomy removed half of my breast. It was, in fact, a partial mastectomy. But my surgeon blithely insisted on referring to it as breast conserving surgery. When I’m getting dressed in the morning and I have to slide my prosthesis into my bra, it doesn’t look much like my breast was conserved.

Perhaps the worst of these surgical euphemisms is “mastectomy with immediate reconstruction.” There is nothing immediate about immediate reconstruction. In general, immediate reconstruction means one of two things: mastectomy followed by the insertion of expanders, or mastectomy followed by some kind of tissue graft.

“Please Pardon Our Appearance — We’re Expanding!”

Expanders are inflatable sacks of saline. After a breast is removed by a mastectomy surgeon, a plastic surgeon has to cut underneath the chest muscle to separate it from the chest wall to make a pocket in which to place the expander. The body doesn’t like having large amounts of tissue removed, and pectoralis muscles don’t like being separated from the chest wall where they belong. Your pectoralis may also not be large enough to cover the expander, which may necessitate adding a tissue matrix to ensure that there is enough tissue to hold it in place. Either way, there is a lot of inflammation — i.e., swelling — afterward. This swelling is fluid composed of white blood cells and other hard-working members of our immune systems that rush to the site of the assault to try to heal the area and fight infection. Our bodies tend to overdo it though, so they send too large a crew to the area, which increases the swelling, which can make things worse by causing more pain and inflammation. In order to mitigate this, surgeons usually also insert a drain in the area to draw off some of this fluid.

And all of this is only the first step. The reconstruction process is far from over. Because after you’ve managed to recover from all this, then you have to go back to the plastic surgeon, several times, to have a certain amount of saline injected by a needle into the expander, in order to gradually increase its size to what you want your finished breast to be. Every time the expander is injected with more saline, your pectoral muscles are stretched more, as is the newly healing skin over them. Your pectoral muscles were not designed to be stretched from underneath. They were designed to lie flat on your chest wall, over your ribs, and exert a lever force on your upper arm and shoulder, which helps your arm lift, hold, carry and push objects. So, it’s no wonder that they resist adjusting to the equivalent of a saline-filled muffin. And that it hurts when you try to lift, hold, carry and push things afterward, or even when you try to do nothing at all.

If all goes according to plan, months after your original surgery, when your expander is filled to the desired size, you have to have another surgery in which the plastic surgeon will remove the expander and replace it with a permanent implant, either filled with silicone or saline. Well, it might be permanent. And it might not. Because our bodies also don’t like having foreign objects shoved into them and left there. And if your body fights this vigorously enough, it will try to isolate it by forming a capsule of scar tissue around this alien being, in an attempt to protect you from it. And if that happens, you will develop something called a capsular contracture. Symptoms may include hardness, tenderness, distortion in the shape of the breast, inflammation, decreased range of motion, and, of course, pain. If you develop these symptoms, you will need to make yet another trip to your plastic surgeon to see if your symptoms can be treated non-invasively, or if the surgeon will have to go back in and surgically excise the capsule of scar tissue.

It has been estimated that capsular contractures occur after breast implant surgery for 15 to 45% of all patients. Other studies have found rates of up to 74%. Various kinds of implants may lessen the incidence, but women with implants are at risk for developing capsular contracture for the rest of their lives. In order to prevent it from occurring, a woman must perform self-massage on a daily basis. This video, developed by Women’s Plastic Surgery, shows how to perform this massage. Even with daily diligence, you still may have problems with your implants, and even with your entire breast or breasts removed, you still may develop breast cancer in the chest wall tissue. In order to check for this, you will have to have a periodic MRI.

Flap, flapper, flappest

And that’s just the first option for “immediate” breast reconstruction. The other main option is an autologous tissue graft, also known as flap surgery. This is a procedure in which a slab of tissue is removed from another part of your body and used to replace the breast tissue that was removed during the mastectomy. It avoids the foreign-object rejection problems associated with implants, but comes with other caveats. The idea is to remove a hunk of your tissue, usually from your abdomen, buttock, or back, that includes muscle, fat, skin and the blood vessels that are attached to them, move it to your chest, and shape it into something that looks like a breast. In some of these procedures, the entire slab of tissue is slid under your skin to your chest area so that the blood vessels that feed this tissue remain intact. In other procedures, the blood vessels won’t reach that far, and have to be severed and reattached to vessels in the chest area by microsurgery.

One obvious problem with all of these procedures is that it means you will have multiple scars — at least one at each breast and one at each site from which your skin and muscle is removed to reconstruct a breast. And if you don’t have enough tissue at one or more of these sites to construct a breast, you may not be able to have one or more of these procedures at all. And even if you do, you may have to augment the flap surgery with an implant to achieve a normal sized breast. And even if the surgery goes well, that transplanted tissue may still die — yes, die — because the blood vessels that keep it alive may not survive the microsurgery. In all but one of these procedures, you are also going to lose muscle tissue from your abdomen or your upper back or your buttock. Which means, to state what should be obvious, that you will have less muscle in the original area to do what that muscle would normally do, and the muscle that’s left there has to heal from the assault and may form scar tissue.

If you’ve ever taken a Pilates class or studied ballet, then you should already know that your abdominal muscles are crucial to stabilizing your torso and spine, which allows the rest of you to do what you do. Like walk upright and carry groceries, for instance. When I worked in outpatient rehab, probably half of my patients at any given time had back problems. And nearly all of those patients with back problems had weak abdominal muscles and/or abdominal scarring from various kinds of surgeries. A successful rehab program to lessen their back pain and improve their function and posture always included exercises to strengthen their abdominal muscles. Patients whose abdominal area has been compromised are at a disadvantage that sometimes cannot be safely overcome without putting them at risk for developing hernias — or tears — in their admoninal wall.

I could go on at some length about flaps taken from the latissimus dorsi, a sheet of muscle that runs from the mid and lower spine to insert on your upper arm, or the gluteus muscles, a group of muscles that attaches the upper end of your leg to your pelvis, but I won’t. The former helps you lift and push stuff; the latter helps you stand up and walk and lift heavier stuff. Suffice it to say that when I consulted with a plastic surgeon about my own options, she confirmed what I suspected. She was a breast reconstruction specialist who had worked with several physical therapists and nurses over the years. “If you need to lift patients and use your body all day at work, I wouldn’t recommend sacrificing any of your muscles for flap surgery. Or dealing with scar tissue across your abdomen.” I agreed. Nor did I want to have to keep seeing doctors, have surgery that required me to be under anaesthesia for several hours, have more surgeries to fix what went wrong with the first surgery, take repeated time out of work, risk infections and blood clots and pain and loss of strength and uneven results from weight changes, and perhaps, in the end, not be able to do my job at all.

As it is, after a partial mastectomy, radiation, and hormone therapy, I still have trouble doing my job. But I have all my muscles, no lymphedema so far, and only one scar.

A lot of women do remarkably well after going through all of the above. A few of them are friends of mine. But a lot of them don’t. As a PT, I suspect that if you are young and/or very fit and have no other significant health problems before you venture into the mire of reconstructive surgery, you’re more likely to do well afterward. Whether you are or not, you’ll likely need the services of someone like me to help you retrain your beleaguered body to function normally. And if it all sounds like way too much trouble just to have fake boobs and no cancer, you are not alone. Me, I’m waiting for instant stick-on replacements. Until then, I’ll stick with my prosthesis.

To view more portraits, visit the photo gallery at The SCAR Project, photographed by David Jay


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This entry was written by Kathi, posted on Wednesday, March 09, 2011 at 05:03 pm, filed under Health & Healthcare, Lymphedema & Cording, Nitty Gritty, Pain & Neuropathy, Surgery & Reconstruction, Survivorship and tagged , , , , , , , . Bookmark the permalink . Post a comment below or leave a trackback: Trackback URL.

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