Feeling Like A Woman

What happens after major surgery for breast cancer? There is hope for a return to a natural shape and the opportunity for a woman to regain a sense of her feminine self.

Fay Warrilow and Catherine Kalamis report

THE word "cosmetic' describes an improvement in appearance and people often associate it with vanity. But when it comes to breast cancer the way a woman looks can have an important influence upon how she feels. Breast cancer is not only life-threatening, but the disease can also inflict other less-obvious wounds, affecting a woman's sense of identity and self-esteem. But there is hope, through reconstruction surgery. Reconstructive breast surgery is changing, says Dai Davies, a member of the Royal College of Plastic Surgeons.

He visits Guernsey from his base at Charing Cross Hospital in London and although he has not treated any local sufferers, he has extensive experience of breast reconstruction work.

'For most people the initial thought when they're diagnosed (with breast cancer) is that they are going to die - or at the very least have mutilating surgical treatment.

'The quality of life issue - their appearance and family relationships - usually arises later.' As they learn more and more about the illness, women realise that they can often have reconstructive surgery at the same time as a mastectomy.

There are several ways of doing a breast reconstruction, although it is important to note that not every woman is suited to having one. 'If the woman has not had radiotherapy - which is unusual now - an implant can be used, particularly if she is small-breasted.'

The implant is usually silicon, or a bag into which saline solution is gradually injected to stretch the tissue slowly.

But skin which has been subjected to radiotherapy responds differently and

another method has to be used. The blood supply to the skin is damaged in patients who have had radiotherapy and the skin doesn't like to be handled in the same way. So muscle and skin can be taken from her back, from the latissimus dorsi. This leaves a scar on the back, but it is simple and relatively straightforward. 'It doesn't add greatly to the mastectomy, so it can be used as a patch for part of the breast, or to cover a silicon prosthesis.'

The other breast will often need some surgery to achieve symmetry of size and shape. This can also happen after radiotherapy, which sometimes shrinks the breast. The third option is the Rolls-Royce of breast reconstruction, where the skin and fat from the lower tummy, the rectus abdominis, is taken. 'It's a bigger operation and adds a lot to the recovery time of the patient, who may decide against it for that reason. It needs specialist microvascular surgery to join up blood vessels and there often have to be adjustments. 'But on the whole, it's all her tissue, so the fat behaves like the fat in the breast.'

Internal prostheses, on the other hand, leave the breast firmer than it would otherwise be. 'The truth, no one can reconstruct a breast - there will always be scars and no feeling. But for self-esteem and everyday life - wearing a bra, buying clothes, swimming - it can be important. External prostheses are unsatisfactory to many patients. It's part and parcel of recovery.'

"Women who choose breast reconstruction are still in the minority in Guernsey, says Karen Leach, the breast screening specialist nurse. And external prostheses - false breasts - are now free, thanks to the Board of Health and Guernsey Cancer Relief.

Mrs Leach counsels patients during diagnosis, treatment and recovery and helps them to make the decisions necessary for their treatment. 'When people are first diagnosed, their immediate thought is usually that they are going to die - I think we'd all think that. 'So when they recover, a lot of women are just glad to be alive and don't want to put themselves and their family through the trauma of any more surgery.' Reconstruction can now be done at the same time as a mastectomy in some cases, but if women choose not to have any more surgery, they have better options for external prostheses, says Mrs Leach. 'As soon as they've had the operation, they have a temporary lightweight prosthesis. Then, after six to eight weeks, they come back to get a silicon prosthesis.

'It's a good way to see how they've recovered and we try to make it as pleasant as possible - they get new bras and there are prostheses for everyone, in every size, shape and colour, including stick-on ones. 'If necessary, someone could have one made to measure, but we've never had to do that here yet.'

Guernsey Cancer Relief can also help with the cost of adapted swimsuits and lingerie, said Mrs Leach.

The range of bras and swimwear has unproved considerably, probably because the women made a big fuss, and rightly so - they said, "we want to feel safe and secure, but we also want good styles and good colours".

Prosthetic breasts are now designed so that a woman who has not opted for surgery can feel completely comfortable doing any of the things she would have done before. 'It's lovely to see someone who walked in embarrassed come out standing up straight.' Mrs Leach agrees with Mr Davies that it is important for everyone involved in the treatment of a patient to work together as a coherent team. The management of all cancers should be multidisciplinary. The people in Guernsey work well together and that's why we stick to our links with two centres, to make sure that our patients have the best treatment possible.' Most local women who choose to have reconstruction choose the 'back flap' operation (latissimus dorsi). This is a middle way between the complicated 'tram flap' (rectus abdominis) and the basic insertion of a small implant under a mastectomy scar.

But a patient's choice of operation will depend on a variety of factors, said Mrs Leach.

'General fitness comes into account and personal choice. Breast reconstruction works well when it is explained accurately, that it's a process - so that patients don't wake up thinking that they're going to look exactly like they did before.'

The latissimus dorsi procedure a was introduced when Mr Davies was training as a plastic surgeon in 1976 - although it had been described in 1900. 'Research is just that - re-searching. I went to the first breast reconstruction meeting in Europe where it was mentioned and I started to do the operations in Bristol.

There are bad reconstructions, but the methods of doing them and the ability to successfully move tissue are improving all the time.' And the removal surgery is also becoming more and more conservative - partly because of a greater appreciation of the psychological repercussions of mastectomies.

'Many more women are having lumpectomies and radiotherapy. It is recognised that you can't cure breast cancer by cutting it out -once the cells have flown around the body, as it were, it doesn't matter if the breast is removed. 'Chemotherapy has become so important over the last 10 years, treating the whole body. That's true of a lot of cancers, including breast and skin cancer.' (Breast reconstruction surgery is not possible in Guernsey. But 'local breast surgeon Roger Allsopp said the island had close links with three centres of excellence - Salisbury, Southampton and Winchester.

The view is that this highly specialised work should be done by surgeons who regularly perform the procedures. Women do have choices, he said, and it is possible to have either immediate or delayed reconstruction. The operations were performed either by a plastic surgeon or a new type of surgeon who specialises in onco-plastic surgery, he said.

‘It is becoming a much more specialised field. In years to come people will find that reconstruction is a more important part of breast cancer surgeons’ work‘ said Mr Allsopp.

Reconstruction does not cost local patients anything he said. The operations are performed under the island’s reciprocal health agreement with the NHS.

  • Dai Davies’ guide to plastic surgery, ”Plastic Fantastic” has recently been published; the Health Exchange can be contacted for details.

(Reproduced courtesy Guernsey Press and Star)

Article dated 02 October 2002

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