AFTER THE REMOVAL OF ONE OR BOTH of the mammary glands due to cancer, women face a number of difficulties. Difficulties in accepting your new appearance, discomfort on the beach or in the locker room are just a few of them. Objective difficulties are added, such as a changed fit of clothes or underwear, back pain or poor posture due to asymmetry, if the mastectomy was only on one side. Breast reconstruction after cancer in many countries is covered by insurance, in Russia it can be done under compulsory medical insurance or for a fee. We understand how to restore the breast after mastectomy and what is important to pay attention to.
Who chooses reconstruction
The websites of large organizations like the American Cancer Society explain in detail why it is normal to want and not want to do reconstruction. Many women find it difficult to accept their body after a mastectomy: they do not want to use removable dentures to fill their underwear, they are uncomfortable to undress and see themselves in the mirror. Scars can remind of a past illness and difficult treatment. Swedish researchers found that younger women who are sexually active and who attach importance to conventional attractiveness are more likely to go for reconstruction.
According to a 2014 study from what appears to be the United States, 56% of mastectomy patients underwent reconstruction; The Canadian Cancer Society cites other figures – 16% in Canada and 38% in the States. The rest refused for various reasons – from health conditions to financial difficulties. At the same time, 70% of women before mastectomy did not know that breast reconstruction is possible.
Who does not do the reconstruction
Many are not ready to go for another operation, especially considering that the result may not meet expectations, and they want to return to an active life as soon as possible: recovery after mastectomy without reconstruction is easier. In addition, life with a serious illness sometimes leads to a reassessment of values, so that the conformity of appearance to typical ideas about it sometimes ceases to play a role for a person. If a woman for one reason or another does not want to use implants, and there is not enough of her own tissue for reconstruction, then it will not be possible to restore the breast. Finally, reconstruction is unlikely to be advised for a patient with a very poor medical prognosis, when life expectancy is too short or the risk of complications associated with the operation is high.
On breastcancer.org, among the options for reconstruction, the rejection of it is also described, and attention is paid , for example, to questions of sexuality and how to dress comfortably – a mastectomy is not a reason to give up beautiful lingerie . One of the important recommendations is open conversations with your partner about feelings and what kind of touch is pleasant or unpleasant. Interestingly, in some cases, after the loss of nipples, the sensitivity of other areas of the skin, for example, on the head, increases. Whether or not to reconstruct is a very personal decision, and the authors recommend seeing another doctor if yours is not attentive enough. And remember, whatever choices you make, you are not alone.
What are the difficulties
The main problem of Russian patients is the lack of information. No attention was paid to the quality of life in Soviet medicine, and in many clinics the attitude remains the same: the tasks do not go beyond the treatment of the disease, and they simply do not consider it necessary to engage in psychological recovery or aesthetics. Vera Kovshikova , who was diagnosed with breast cancer in 2015, visited many surgeons, collecting information about reconstruction, and then created a thematic community for patients. At first it was a chat in WhatsApp, then, when it became clear that new arrivals did not see old messages and asked questions that had already been discussed many times, a future_breast page appeared on Instagram. There they conduct Q&A – not only plastic surgeons are responsible, but also doctors of other specialties, lawyers, psychologists – and photographs of patients appear before and after reconstruction.
Vera says that every time she is surprised by the responsiveness of the experts. She also notes one of the important problems – not all women understand that the possibilities of reconstruction are limited and no matter how good the surgeon is, it is not always possible to achieve complete symmetry or do “as it was before.” On Instagram, topics are also discussed that are not directly related to reconstruction: for example, patients are faced with the fact that even in remission after cancer they cannot continue their care with a beautician – they are told that any procedures are prohibited with this diagnosis. “I find beauticians who work with such patients and arrange the same Q&A days with them,” Vera continues.
There is more information available in English – for example, a detailed description of different types of reconstruction, with illustrations and videos, can be found on the British website Breast Cancer Care . The American Society of Plastic Surgeons is campaigning for awareness of reconstruction and publishes a free magazine on the topic.
How to restore volume with implants
During the reconstruction, implants or their own tissues are used. If the skin is preserved after mastectomy (this happens in the early stages of cancer), then it is, as it were, filled with an implant. Such an operation can be performed simultaneously with the removal of the gland – including during prophylactic mastectomy. In more severe cases, the gland is removed together with the skin and there is no room for the implant. Then they use the so-called expander – a device that is placed under the skin and gradually filled with saline, stretching it. After a few months, there is enough space for the implant and the installation operation can be performed.
In women who have received radiation therapy, the elasticity of the skin may be reduced, making it difficult to stretch it with the expander . If a mastectomy was done on one side, after which a reconstruction with an implant was chosen, then corrective surgery is often performed on the other side to make the breast look symmetrical. At the same time, the appearance may change with age: with weight gain or weight loss, the remaining gland will change differently than a breast with a prosthesis.
Another option is to replace the missing fabrics with your own. A flap of skin, fat, and in some cases muscles is usually taken from the back or abdomen; sometimes tissue from the buttocks or inner thighs is used. Such a tissue transplant is a complex operation, the result of which depends both on the professionalism of the doctor and on how the body reacts to the transplantation. In addition to fixing the layers of tissues themselves in the right place, they need to provide blood supply, therefore, the intervention often includes microsurgery – suturing of blood vessels.
When transplanting a flap from the back (the so-called LD method, from the Latin name for the broadest muscle – latissimus dorsi), the tissues are unfolded, but the vessels and nerves are not completely cut; due to the muscle, the volume of the breast is partially restored, but often an implant is still required. In the future, weakness in the shoulder area may appear, so this reconstruction is not the best option for women climbing or swimming.
When tissues are taken from other departments, microsurgery on the vessels is required, and the result is even more dependent on general health – such transplants are not recommended for people with diabetes and those who smoke. Different types of flaps are usually called abbreviations , depending on which vessels and other tissues are used: DIEP (skin and fat flap with deep vessels), SIEA (also skin and fat flap, but with superficial arteries), TRAM (skin fragment, fat and abdominal muscles). In the latter case, after the operation, you may notice that the press has become weaker, and this may be reflected, for example, in sports. The final decision must always be made in conjunction with the surgeon.
How to restore nipples
To simulate the protruding shape of the nipple, several cuts are made in the skin and shape it in place without transplanting anything. This is done under local anesthesia. After healing, it remains to darken the area of the nipple and areola with tattooing. Of course, a fake nipple will not be particularly sensitive, but it may look almost indistinguishable from a natural one. There are also artificial nipples that are simply glued to the skin.
How much does it cost
In Russia, breast reconstruction after mastectomy refers to high-tech medical care (HMP) and is performed under the compulsory medical insurance. True, as Kovshikova notes , it is important to know your rights and be persistent: sometimes clinics refuse patients or offer to do the operation for a fee. The OMC reconstruction has limitations – if the second gland needs to be operated to achieve symmetry, they will not do it for free. There are also charitable operations – for example, the surgeon Dmitry Melnikov regularly arranges fundraising for the materials necessary for the procedure in order to carry out reconstruction; he does his job for free. These are complex surgeries, and completely at their own expense, they are more expensive than conventional aesthetic mammoplasty: an intervention on the one hand can cost 300-500 thousand rubles.