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Advances in breast reconstruction after cancer

For The Baltimore Sun

When Mary Casterline was diagnosed with invasive carcinoma of the breast in mid-April, she knew she was fortunate. Her cancer was very treatable and she had a lot of options for both treatment and beyond.

Casterline's doctors explained that she had the choice between radiation and lumpectomy (removing just the tumor but preserving the breast) or a mastectomy (complete removal of the breast). If she opted for mastectomy, she could choose to reconstruct the breast, either with an implant or via free tissue transfer (also known as "tissue flap" or "trans flap"), a procedure in which fatty tissue from the patient's stomach is removed and repurposed as the reconstructed breast.

"I had a ton of options," says the 47-year-old Perry Hall resident. "That was actually a little overwhelming."

Breast reconstruction has come a long way over the past several decades, with the development of new and better treatment approaches, such as the tissue flap, that result in better outcomes for post-mastectomy women. Plastic surgeons at hospitals throughout the Baltimore region have embraced these procedures — and. in some cases, become evangelists for their use.

The American Cancer Society reports that in 2014, 232,670 new cases of invasive breast cancer will be diagnosed in women in the United States. An August article in The Journal of the American Medical Association found that of women who have mastectomies, 42 percent opt for breast reconstruction.

Under the guidance of Dr. Sheri Slezak, part of the breast care team at Greater Baltimore Medical Center and chief of plastic surgery and director of breast reconstruction at the University of Maryland School of Medicine, Casterline chose mastectomy, saying she was concerned that a lumpectomy would require further surgery if the initial operation didn't remove enough tissue.

Casterline's reconstruction will be completed later this year, after she finishes chemotherapy. Instead of the tissue flap, she chose to receive a cohesive gel implant. She also had her remaining breast lifted and reduced so that following the implant, her breasts will "match."

The cohesive gel implant, also sometimes called a "gummi bear" implant because its solid gel texture is similar to the candy's, represents an advancement in implant technology, Slezak says.

These implants are relatively new but are now used frequently, she says. "They hold a more natural shape, instead of being a high-riding, '18-year-old' breast."

Just over a year ago, at age 43, Union Bridge resident Lisa Swartzbeck was diagnosed with stage IIIC breast cancer. After chemotherapy and a bilateral mastectomy, she worked with Dr. Gabriel Del Corral at Carroll Hospital Center, having reconstruction via free tissue transfer.

Free tissue transfer, or tissue flap, was originally used during the 1980s but it has been modified since to minimize the impact on the patient. The approach has gained popularity in the Baltimore region over the past several years. Del Corral says the procedure involves "taking tissue from the abdomen — we spare the muscle with microsurgical techniques — and transplant it to the area of the breast to give you a more natural reconstruction."

The tissue flap is popular among patients who like the more natural look and who may be uncomfortable with the thought of a foreign substance being placed in their bodies, says Del Corral. As a bonus, because the tissue is taken from the abdominal area, patients also receive abdominoplasty (a tummy tuck).

The procedure can be done at the same time as the mastectomy; the dual mastectomy and reconstruction takes longer and has a more difficult recovery than mastectomy alone.

"You trade in longer operation and recovery but when you leave the hospital, you're done with reconstruction," says Del Corral. He contrasts this with the implant process, which can involve multiple office visits to stretch the breast area where the implant will be placed, and which typically requires an "update" — new implants — after about a decade.

"I'm very happy with it," says Swartzbeck. "I don't have to go back in 10 years to have my implants redone. It's my own body tissue — no foreign tissue within me and no chemicals. It looks real and feels real, not like an implant, and it moves like normal breast tissue."

From an emotional standpoint, Swartzbeck says, the positive experience was important. "For a breast cancer survivor, I felt like what Dr. Del Corral brought to the table was a silver lining on the awful cloud. Not only did he ensure my dignity as a woman, I got a tummy tuck out of it, too."

Free tissue flap isn't appropriate for all patients, however. Patients who do not have adequate fat deposits on their abdomen often find that they are not candidates for surgery. Janna Freishtat, a patient of Slezak's from West Friendship, discovered that tissue flap was not the best option for her body. "It was less invasive to do implants," she says. "There wasn't enough fat in my stomach area. I know it's a more natural feel and look, but they would have had to take it from my thighs and there would be pretty major scarring."

For those who do receive a tissue flap, doctors carefully connect the blood vessels of the grafted tissue to the existing tissue in the breast area. At Johns Hopkins Hospital, Dr. Gedge Rosson uses three-dimensional CT scans, taken before surgery, to map the blood vessels of the breast, so that even before performing the tissue flap surgery, he knows which blood vessels will be best to connect.

"It's like having a good map," he says. "You find stuff faster. And if you capture the best, you're going to have better blood flow, as well."

Rosson and a team of physicians from the Hopkins department of plastic and reconstructive surgery discovered through research that use of preoperative CT scans leads to several benefits, including fewer breast-site complications and shorter time in surgery.

He also believes that advanced mapping decreases the surgeon's level of stress. "Days or weeks before surgery, I know the plan," he says. "I love that."

Options have also expanded for patients who choose lumpectomy over mastectomy. "The new thing is fat injections," says Slezak. "We can harvest fat cells and stem cells by liposuction from some spots and inject it in the breast — for women who have lumpectomy or who have tissue flap and need some areas filled in."

Another hot topic in post-mastectomy surgery is whether to save the nipples or reconstruct them. For some patients, saving them has a significant psychological impact. "To keep my nipples was to make me feel like I was keeping my body," says Dr. Sandra Sattin, a family physician from Ellicott City, who chose silicone implants after her cancer treatment.

"Surgical oncologists are getting increasingly better with nipple-saving mastectomy," says Rosson. "Now you can do a reconstruction, and from the outside, it just looks like they have a breast implant and their own breast."

For women who choose not to save their nipples, or for whom the procedure is not possible, nipple reconstruction and tattooing are two options. With reconstruction, the surgeon uses skin to form a small mound mimicking the nipple; the patient then has the option to have this area "filled in" with color via tattoo.

Other patients opt for the color tattoo even without the reconstruction. Local tattoo artist Vinnie Myers has recently garnered national attention for his subtle approach to nipple tattooing. "Tattooing has been a part of the reconstruction process all along," he says. "But in the past, the people doing it weren't artists — they're just doing a circle and adding color. We add the fundamentals of art — shadows, light, texture. It looks like a breast. The psychological impact is unbelievable."

Plastic surgeons stress that every woman's treatment and reconstruction choice is individual.

"We have lots of options for every woman. Every woman is different in her goals and anatomy, so it really is an individual process," says Slezak. When she meets with patients, she walks them through the options available to them, given their specific circumstances.

She and her colleagues also suggest that patients do research on their own to make sure they are aware of all types of treatments.

"It's important for patients to know all their options," says Del Corral. "They should ask about longevity of procedures, complications and what kind of recovery to expect. It's important for patients to transmit their wishes — what they want to accomplish at the end of reconstruction."

Plastic surgeons say they want to help patients achieve their goals — and look great for years to come. "The main thing we want to do is get them back to all their activities with complete confidence and forgetting about breast cancer," says Slezak. "The reconstruction is the positive — they're going to be around for a long time, and we want them to look great."

Plus, doctors involved in reconstruction know that a good experience can help a patient not just look good, but feel good about themselves.

"No one's excited to get a mastectomy," says Rosson. "But sometimes, six to 12 months later, after fat grafting, implants and saved nipples, they look great. We really do our best to put people back together and think in an aesthetic way. It's not just some form on their chest. It's important."

Reconstruction decisions

Breast cancer treatment and reconstruction involve a series of complex and often difficult decisions. The list below includes some of the main decisions patients may face during the process:

Lumpectomy vs. unilateral mastectomy vs. bilateral mastectomy One of the biggest decisions patients make is how much tissue to remove; this is largely driven by the size and location of the cancer. With lumpectomy, a surgeon removes the tumor and surrounding tissue. A unilateral mastectomy is the removal of one breast; bilateral mastectomy is the removal of both breasts. Some patients opt for more radical surgery to minimize the likelihood of cancer recurrence. The likelihood of recurrence is related to specific patient characteristics, including genetic makeup.

Free tissue flap vs. implant When patients choose mastectomy and reconstruction, their options include a breast implant or "free tissue flap" surgery that uses the patient's own tissue, typically removed from the abdomen, to replace the breast. The tissue flap surgery takes longer, has a lengthier recovery time, and is not an option for women without enough fatty tissue in their abdomens or elsewhere on their bodies. However, implants may require multiple office visits to stretch the skin prior to implantation and typically must be replaced after a certain number of years. Some patients are also uncomfortable with the notion of foreign objects in their bodies.

Traditional implant vs. cohesive gel Most patients who opt for implants receive cohesive gel implants (also called "gummi bear" implants); they are considered more "natural" by some. However, other patients may prefer the look or feel of traditional silicone implants.

Additional surgery on remaining breast Dr. Sheri Slezak notes that patients who have undergone unilateral mastectomy have the option of a "designer" breast operation, either adding an implant or reducing and lifting the healthy breast as a part of the surgery.

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