Sculpting a Survivor

“You need to get up.”

Desiree Abele was propped up on pillows with half her torso bandaged from a biopsy on her right breast and couldn’t figure out why her husband cared whether or not she kept resting; she was in pain, and it was only 8 a.m. “You just need to get up,” he repeated.

Abele finally pulled herself out of bed and saw why: It was September 11, 2001. Like most Americans, she and her husband, David, spent the day glued to the television, watching the world crumble before their eyes.

The overwhelming emotions this caused actually made it a little easier for Abele to call the hospital that afternoon and hear the biopsy results: aggressive stage two breast cancer; she felt that her situation was a speck in the midst of a national tragedy.

Of the three lumps biopsied the day before, only one tested malignant, so Abele was a candidate for a lumpectomy, which would have removed only the suspicious lumps from her chest. She decided, however, to be cautious and opted for a full mastectomy of the right breast.

Reconstruction Options
Breast reconstruction became available to patients more than twenty years ago, and the surgeries fall into two categories: implant and autologus, or flap, which transplants tissue from the patient’s stomach or back to the chest.

Because of the stigma associated with silicone implants, many women shied away from the procedure in the early days of reconstruction, says Barbara Bowers, MD, medical director of Fairview Southdale Breast Center. As a result, flap surgery became much more popular. 

Flap reconstructions feel natural because they are developed with fat and blood vessels with a similar texture to breast tissue. Also like natural breasts, they can grow or shrink as body weight fluctuates. Flap surgeries, however, often require several procedures to balance sizes and shapes of breasts and, therefore, carry longer recovery times—at least six weeks for each surgery. And thin, active women and those who have had cesarean sections or appendectomies generally cannot choose flap surgery because they might not have enough extra tissue in their abdomens to remove for the transplant.

According to the American Society of Plastic Surgeons, of the 57,778 patients who had breast reconstruction procedures in 2005, 46,291 of those opted for implants. Implants can be easily removed and offer shorter recovery time and a simpler surgery (even though most require a separate expander surgery to stretch skin from the removed breast before the implant can be placed). Still, they carry a slightly higher risk of infection and need to be replaced within ten to twenty years, in most cases. Choices of reconstruction after breast cancer surgery and radiation should be discussed with a team of surgeons and radiation oncologists, says Doug Yee, MD, professor of medicine, director of the University of Minnesota Cancer Center, and leader of the Breast Cancer Program. In these cases, women can later decide to reconstruct if the tissue is normal enough for surgery after they’re finished with the treatments.

Choosing Wisely
When choosing a procedure, it’s important to pick a plastic surgeon who does a lot of breast reconstructions, Bowers advises, and make sure people talk to their surgeon and plastic surgeon about the timing of the surgery depending on which procedure they pick. “Patients who don’t think through reconstruction may have unrealistic expectations,” she says.

Making breasts more symmetric after a lumpectomy (performed to conserve some breast tissue) is becoming more common, says Evelyn J. Erickson, MD, of Midsota Plastic Surgeons. Even in women who have an entire breast removed, reconstructing the one side will result in “significantly different conditions between the breasts, no matter how skilled the reconstructive surgeon is,” she says. Doctors often include both flaps and implants in a reconstruction to achieve nice results, but it depends on the individual case.

Although reconstruction at the time of mastectomy is common, many patients aren’t ready to choose reconstruction (there’s so much to deal with and decide within a short time period), and they choose to wait. Additionally, some patients are cautioned to wait if they aren’t psychologically or emotionally ready for the change in their bodies or if they have health problems—including those involving weight. For example, a study presented to the American Society of Plastic Surgeons in 2006 found that it’s better for obese patients to lose weight before receiving reconstruction; women with BMIs greater than thirty-five have increased rates of complications, such as fluid collections, infections, and deformity of the abdominal wall (in flap cases).
Jean Pupkes, a clinical nurse specialist for breast and women’s cancers at North Memorial Hubert Humphrey Cancer Center, acts as a sounding board for women deciding whether to reconstruct. She occasionally hears women say, “I think flat is fine,” and opt for no reconstruction following mastectomies, but she also helps many patients during and after their procedures.

Although she encounters some patients disappointed with the results of their reconstructions, Pupkes says the majority is very happy with the outcome. She’s had several women approach her, in fact, and say, “Come and see my breasts,” as they pull her into the bathroom and proudly lift up their shirts.

Surgical nurse and breast cancer survivor Peggy Halvorson also helps many cancer patients through reconstruction and had her own breasts reconstructed in 2003. As is the case with some flap procedures, Halvorson had multiple surgeries, including one to tattoo a nipple and another to place an implant after the doctors removed necrotic (dead) tissue from the initial flap. Through it all, she’s remained optimistic—“It’s been a long haul,” she says with a laugh—but she knows the decision to reconstruct is different for every person. “This is always something that the patient should do for themselves,” she says, mentioning how some women continue struggling to adapt to their new figures even several years after a mastectomy. “It’s a very personal decision.”

Abele and Halvorson, who have worked for the American Cancer Society for the past few years promoting galas and fundraising events and offering support to patients and survivors around them, feel a similar kinship with cancer survivors. They both refer to their bond as a club.

Like many of the “club members,” Abele still struggles with pain and weakness on a regular basis. But she stays positive. When speaking about both her fellow cancer survivors and the added emotion of learning on 9/11 that she had the disease, she says, in a hopeful tone, “I felt connected.”