Following a breast cancer diagnosis, or confirmation of the breast cancer gene, survival is the number one priority – as it should be. But then what? What happens after the cancer has been eliminated, or after the mastectomy to hopefully avoid the cancer in the first place? At UPMC, Dr. Carolyn De La Cruz specializes in breast reconstruction surgery. She practices at Magee-Womens Hospital of UPMC and the Aesthetic Plastic Surgery Center. She’s also an assistant professor of surgery in the Division of Plastic and Reconstructive Surgery at the UPMC School of Medicine. We talked to her about breast reconstruction, what it entails, what to expect and one of the most important things – is it covered by insurance? Read on.
How do patients that are undergoing reconstructive surgery to breast cancer differ from those who were just undergoing cosmetic surgery, both physically and mentally?
Breast reconstruction differs from those other kinds of cosmetic procedures, because they have breast cancer and it often requires a mastectomy. The more cosmetic procedures – augmentation or a lift – often involve keeping the patient’s breast tissue. And so the major difference is the mastectomy portion of it, which is removing all the breast tissue and leaving behind the skin to do the reconstruction. The way that we reconstruct someone’s breast after it’s been removed often is very different than how we would do cosmetic procedures using their breast tissue.
How do you determine if you are going to do reconstruction during a mastectomy procedure or if you’re going to end up doing a second surgery following the mastectomy?
The timing of the reconstruction can either be done immediately – on the day that they remove the breast tissue, we work together with the breast oncologist and that’s called immediate reconstruction. Delayed reconstruction or situations where we recommend that they wait and complete their treatment and have the patient come back, not usually weeks, but more months or whatever period of time we agreed to. That decision is made sometimes at the patient’s request – some just want to take care of the cancer and separate things, then come back to the reconstruction. So, occasionally it’s a patient request. But most of the time, the decision is made in conjunction with the surgical breast oncologist, based upon the stage of the disease, how anxious they are to start the patient on chemotherapy or if they need radiation. Those are different variables that determine whether or not a patient is a candidate for immediate or delayed.
As technology advances and more and more people are getting tested for the breast cancer gene, are you seeing more patients who have tested positive for the gene – they haven’t been diagnosed with cancer, but they want to go through the mastectomy and reconstructive process?
That’s probably one of the most major shifts that we see today in breast care is the ability to detect from people who have a very high chance of getting breast cancer, and the ability that through removal of the breast tissue or mastectomy to reduce their chances. Oftentimes, it may also have implications for the other breast – if they have breast cancer and have the gene, then they’ll do both sides.
Why do you prefer the free tissue transfer method to using implants, and how did you first become interested in that method?
The free tissue transfer uses tissue that comes from another place in the body – generally the abdomen. I became interested in this when I did my training at M.D. Anderson Surgical Center in Houston, which is one of the major microsurgery centers. For patients that are interested in a more natural reconstruction or in patients that had radiation, those are indications of people who will be good candidates for free tissue transfer. The other way that we rebuild the breast is through implants, and we like to council patients on different options. Free tissue transfers are good for people who are either interested in not using implants or who may have had implant reconstruction the past that didn’t work. It’s generally a lot longer surgery than implant surgery, but the benefit is mostly that you get to use your own tissue.
What should reconstructive surgery patients expect both in terms of recovery and results?
Those are probably two questions spend the majority of my time answering on a daily basis. As far as the recovery process goes, a lot of patients are surprised that breast reconstruction is really a process more than anything – even immediate reconstruction is not really immediate in the sense that it’s surgery all in one day. Most times, it requires a couple of stages and the recovery usually varies depending upon the procedure, it may be a month on average I’d say – which is different than the mastectomy, because usually the recovery is a little bit quicker. So most patients are mostly surprised about the fact that it’s a process, sometimes it requires a couple stages. The operations can be staged, meaning if you’re going with reconstruction, first you put the expander in. In the second stage, you remove expander and put the implant. If they’ve removed your nipple, then maybe the third step is to rebuild the nipple, so there are multiple stages that are involved in the process – it could be nine months or up to a year until it’s all technically completed.
In terms of the results, I think that our goal for patients is primarily to make make them whole again. Years ago, people weren’t offered breast reconstruction and they just removed the breast. They didn’t have a chance to rebuild things. We shoot for symmetry to match the other breast, mostly to avoid using the prosthesis, which really can be a problem for people. So to build symmetrical, comfortable, natural breasts for patients is a reasonable goal – mostly to avoid the reminder of of the mastectomy itself. Sometimes I see patients that have waited for a lot of years and and it’s a constant reminder. In terms of actual results, it really depends upon what kind of reconstruction the patient is getting.
You mentioned the prosthesis – what what exactly does that mean?
For patients who had a mastectomy or were in a place where they didn’t offer reconstruction or didn’t have any kind of reconstruction, a prosthesis is like a custom bra – it’s a custom designed breast form that goes in the bra so, that when you’re in your clothes, people can’t tell that you’re flat. But, lots of patients complained that they’re heavy, that they’re hot, in the summer it’s very sweaty, obviously swimming is an issue. Through breast reconstruction, women can regain their femininity, not have to wear the prosthesis and just feel whole again.
Is this a procedure that is typically covered by insurance?
Insurance is required to cover it, particularly when it’s related to breast cancer – a lot of patients don’t know that, and actually, sometimes people are shy about asking. A lot of times, that’s why they don’t seek reconstruction, because they think like the other plastic surgery procedures, that they’re going to have to pay for it.