Breast-cancer reconstruction and the silicone debates
A woman’s body is her temple. As a plastic surgeon, my life’s work is to respect that. I repair faces after unexpected trauma. I make wanted improvements to patients’ appearances, and I boost their self-confidence. To sculpt someone’s face or body and have him or her say, “I like the way I look,” gives me great pride.
But my most rewarding job of all is to work with people who have had their lives altered by all-too-common breast cancer. One in eight women will get this disease during her lifetime. Too many breast-cancer patients are so overwhelmed by the diagnosis and treatment that they have a difficult time discussing their breast-reconstruction options with their physicians.
Today, when breast-cancer treatment is improving, when treatment options are expanding, and when the public’s eye is focused on the controversial silicone breast implants, it is especially important for a patient to consider her plastic surgeon as part of her cancer-treatment team right from the start. Many patients wonder why I have the option to recommend silicone again—they may know it gives a more natural result, but they wonder if it’s really safe.
I’m glad to have the opportunity to educate them—the earlier, the better. To discuss reconstruction at the time of diagnosis is overwhelmingly important, because the body’s final appearance can potentially be affected.
The shape of a woman’s breasts is one of the most distinctive features of the female form. Art history shows us this: from the earliest Paleolithic sculptures and reliefs, to the paintings of the Italian masters Da Vinci and Michaelangelo during the High Renaissance, to the realist Pierre Auguste Renoir in his famous painting The Bathers (1887). Picasso, in his Les Desmoiselles d’Avignon (1907, shown), demonstrates that a woman’s shape is timeless. Art and life traditionally celebrate the female form.
A Woman’s Choice
For a woman, the prospect of having her shape altered at a time when she is faced with a cancer diagnosis can be emotionally and psychologically devastating. Scientific studies show that breast-reconstruction surgery results in numerous physical and psychological benefits for postmastectomy patients.
It is not surprising that breast reconstruction is on the rise. About 63,000 women underwent breast reconstruction in 2004, an increase of 113% from 1992, but down from the late 1990s, after the Women’s Health and Cancer Rights Act of 1998 was passed.1,2
The law, supported by the American Society of Plastic Surgeons (ASPS), mandates insurance coverage for breast reconstruction—and the alteration of the opposite breast for symmetry purposes—for women who have undergone mastectomies. Unfortunately, the law does not apply to women who are enrolled in the Medicare or Medicaid programs.
For many patients, knowing that their insurance covers reconstruction as part of their cancer treatment is reassuring, both financially and emotionally. Patients have told me that they felt guilty for wanting a reconstruction surgery.
“I just survived cancer,” one patient told me. “This should be a small problem to live with,” she said as she grabbed her chest where her shirt was flat.
We discussed her feelings, and as she learned that reconstruction is mainstream, she felt more comfortable with her operation. Her attitude changed from one of, “Why should I want reconstruction?” to, “Why should I live with this just because I had cancer?”
Another patient told me that looking in the mirror each morning served as a daily reminder of her cancer. “I want to forget about it, not have it staring me in the face every day. How can I forget it when I see this every day?”
On a lighter note, one patient expressed to me her joy of having to wear a sports bra again. “I never thought I would see the day,” she said. “I’m back to not being able to exercise without one.”
Choices for Reconstruction
The options for breast-reconstruction surgery are many and growing. One reason why it is increasingly important to include the plastic surgeon from the start is that the options for initial surgery—previously, most cancers were treated with mastectomy—are increasing. General and oncological surgeons often work in conjunction with plastic surgeons to come up with the best plan for each patient.
When possible, the general surgeon can perform a skin-sparing mastectomy or a breast tissue–sparing mastectomy, and the plastic surgeon is “scrubbed in” at the same time to perform immediate reconstruction. For the patient who is a candidate for this combination procedure, the results are often optimized; and for the surgeon, the operative challenges are minimized.
Another reason to include the plastic surgeon at the time of the initial diagnosis is the increased role of radiation in treating breast cancer. Radiation can alter the breast and its surrounding tissue in ways that affect reconstructive surgery. The patient should discuss the radiation-treatment plan with her plastic surgeon and make sure that the surgeon discusses it with her radiation oncologist.
Reconstruction can take place before, during, or after radiation treatment. The decision about the timing is specific to each patient and is made by the patient and the physicians involved.
Besides the timing of the operation—delayed versus immediate—the other subset of options unique to each reconstruction is the type of surgery performed. Some patients are candidates for transverse rectus abdominis muscle (TRAM) flaps. In “flap surgery,” tissue is moved from one part of the body to another to fix a defect or restore a more natural appearance.
Many patients come to me familiar with TRAM-flap breast surgery because they have heard of “the one where you get a tummy tuck.” It is true that flap surgery results in a tighter lower abdomen because it involves taking tissue (skin, fat, blood vessels, and muscle) from the lower abdomen and transferring it to the breast area.
The tissue that is transferred from the abdomen must have a blood supply. This may be either pedicled, so that the original blood supply remains intact, or transfered as a free flap, in which blood vessels supplying the flap are divided and anastomosed to local vessels in the breast. A free flap requires a surgical microscope to reattach the small vessels in the tissue to a new blood supply so that it can survive.
TRAM flaps are definitely not the only type of breast reconstruction available. A patient came up to me a long time after her mastectomy and told me she had waited to see me because she was sure she could not have reconstruction surgery due to her very thin, scarred abdomen. Because her body habitus was not ideal for a TRAM flap, she was a candidate for a different type of surgery—latissimus dorsi flap surgery, which takes muscle and skin from the back to form the new breast.
Some patients are candidates for tissue-expansion surgery and do not even require a flap. There are other, less common types of flap surgeries for breast reconstruction as well, and it is important for a patient to find a surgeon who takes the time to discuss the different options with her.
Implants are often used in breast-reconstruction surgery—saline implants, and, yes, silicone, as well.
The ASPS’s expert panel on breast-implant safety noted in a recent congressional briefing that no medical device in the history of the US Food and Drug Administration (FDA) has ever been subject to such a high degree of scrutiny as silicone gel implants.3 Thirteen years ago, silicone implants were removed from the market because of safety concerns. Since then, physicians and scientists have proven that silicone implants are not dangerous to women’s health.
One published attack against these implants contains the face of a young woman with the words “guinea pig” plastered across her forehead. Sufficient scientific data show that silicone-gel implants are safe and efficacious, so the ASPS and its Plastic Surgery Education Foundation’s Breast Implant Task Force took the opportunity to challenge the “guinea pig” ads.
The task force noted in the congressional briefing that the opponents to silicone implants have failed to produce any peer-reviewed scientific research that correlates these implants with systemic disease or health hazards. At the same time, the task force cited ample scientific literature to support the safety of silicone implants.
Even Thomas Whalen, MD, a surgeon who was instrumental in persuading the FDA to reject silicone-gel implants in 1993, has publicly changed his mind. In May 2005, he was quoted by The Washington Post as saying, “I feel that the time has arrived, and the data is sufficient to approve these devices.”4
On July 28, 2005, the ASPS and the American Society for Aesthetic Plastic Surgery jointly issued a press release announcing that the societies applaud the FDA’s “approvable letter” with conditions to one manufacturer of silicone-gel implants.5
And so it goes. The debate is over; silicone is safe to use. The “guinea pig” ads are as baseless as they are offensive. Who receives the benefit of using silicone-gel implants? The patient. Plastic surgeons are not only scientists, they are also physicians who are concerned about their patients’ well-being. The crux of their Hippocratic Oath is the tenet, “First, do no harm.”
Science has shown that plastic surgeons can present silicone-gel implants as an option to their patients in good faith. Giving patients the option to receive silicone-gel implants is just one more tool for plastic surgeons to use to restore a more normal appearance in their patients. Plastic surgeons have a fortunate role, indeed: to use science and technology to the benefit of those afflicted with cancer—to create, to renew, and to give these patients a fresh start.
Many patients ask me, “Are silicone-gel implants really safe?” And they will keep asking me this, I imagine, for a long time. It’s taken 13 years to be sure, but because of all the rigorous testing to which the implants have been subjected, I can confidently reassure them that, “Yes, they are.” PSP
Jeffrey N. Thaxton, MD, is a plastic surgeon in private practice in Vail, Colo. He also works at the Shaw Regional Cancer Center and is on the medical staff at Vail Valley Medical Center. He can be reached at (970) 476-2777.
1. American Society of Plastic Surgeons. 2004 reconstructive surgery trends. Available at: http://[removed]www.plasticsurgery.org/public[/removed]_education/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=16155 Accessed February 17, 2006.
2. American Society of Plastic Surgeons. ASPS celebrates legislative victory! New law mandates breast reconstruction coverage. PSNews Bulletin. October 22, 1998. Available at: http://[removed]www.plasticsurgery.org/psf/psfhome/comm/psn/psnews/pnb1022[/removed]-98.htm Accessed February 17, 2006.
3. Seward W. ASPS/PSEF Breast Implant Task Force deflects attack, provides Congress with solid evidence. Plast Surg News. June 2005;5.
4. Kaufman, M. Surgeon changes tune on breast implants. The Washington Post. May 11, 2005;A8.
5. American Society of Plastic Surgeons. Plastic surgery societies applaud FDA “approvable with conditions” letter to Mentor Corporation for silicone breast implants. Available at: http://www.plasticsurgery.org/news_room/press_releases/mentor-approval.cfm Accessed February 17, 2006.