From NYTimes:
For many cancer patients undergoing mastectomies, reconstructive breast surgery can seem like a first step to reclaiming their bodies.
But even as promising new operations are gaining traction at academic medical centers, plastic surgeons often fail to tell patients about them. One reason is that not all surgeons have trained to perform the latest procedures. Another reason is money: some complex surgeries are less profitable for doctors and hospitals, so they have less of an incentive to offer them, doctors say.
To raise awareness of breast reconstruction and to market it to patients, the American Society of Plastic Surgeons has adopted the vocabulary of the movement to support a woman’s freedom to choose an abortion, adjusting it for women with breast cancer. Although women “don’t choose their diagnosis, they can choose to go ahead with reconstruction or not, and with the aid of a knowledgeable plastic surgeon they can choose what their options might be,” Dr. Linda G. Phillips, a plastic surgeon in Galveston, Tex., said in a telephone news conference organized by the plastic surgery society to mark Breast Cancer Awareness Month in October. “Then they have that much more power over their lives if they have that power to choose.”
But for many patients, the options may be limited because their doctors are not proficient in the latest procedures. Dr. Michael F. McGuire, the president-elect of the American Society of Plastic Surgeons, said it is not unusual for surgeons to omit telling patients about operations they do not perform.
For many of these women, the operations were more about feeling whole again than about restoring their appearance.
Implant surgery is the most popular reconstruction method in the United States. Often performed immediately after a mastectomy, it initially involves the least surgery — usually a short procedure to insert a temporary balloonlike device called an expander — and the shortest recovery time.
But implants come with the likelihood of future operations. Within four years of implant reconstruction, more than one third of reconstruction patients in clinical studies had undergone a second operation, primarily to fix problems like ruptures and infections, and a few for cosmetic reasons, according to studies submitted by implant makers to the Food and Drug Administration. (Reconstructive patients are more likely to develop complications after implant surgery than cosmetic patients with healthy breast tissue.)
Complication rates for newer flap procedures like the one Ms. Hodges had have not been well studied, though many surgeons say they are less likely to require follow-up operations. The most common flap procedure, named a TRAM flap, for the rectus abdominis muscle, cuts away a portion of abdominal fat, as well as underlying muscle containing blood vessels, and uses the tissue to rebuild a breast. The vessels provide a blood supply for the new breast mound. The procedure promises a more lifelike look and feel, but it carries a risk of a weaker abdominal wall and hernia.
Another flap method, the DIEP free flap, is the newest and most intricate, named for the abdomen’s deep inferior epigastric perforator vessels. It involves moving abdominal fat and blood vessels, but no muscle. The DIEP flap theoretically holds out the promise of a reduced likelihood of abdominal problems. But Dr. Alderman cautioned that researchers have not yet conducted rigorous national studies that would establish a complication rate. Sometimes the flaps fail and need to be surgically removed.
Dr. Martin Jugenburg (www.microsurgeon.ca)(www.plastica.ca)
Martin Jugenburg,MD, FRCSC
Toronto, ON
