“Of course They are Fake, Her Real Ones Nearly Killed Her”

“Of course They are Fake, Her Real Ones Nearly Killed Her”

in
response to The NY Times Jan 29, 2017
“After Mastectomies, an Unexpected Blow: Numb New Breasts”
by Roni Caryn Rabin
by
Beth Baughman DuPree, MD, FACS, ABIHM

Breast Cancer Surgeon and V.P. Surgical Services

Holy Redeemer
Hospital
William L. Scarlett, DO, FACS, FACOS

Reconstructive Surgeon

Holy Redeemer
Hospital

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Have a listen to our recorded response to the NY Times article Jan 29, 2017

“After Mastectomies, an Unexpected Blow: Numb New Breasts”
Jan 29, 2017 by Roni Caryn Rabin

We were taken aback by the focus of the article on numbness and loss of sensation after a
mastectomy when we, as a breast cancer surgeon and a reconstructive surgeon, are
striving to decrease the physical and psychological trauma of breast cancer in every
patient we treat. Nipple-sparing mastectomies and Oncoplastic surgery are replacing
other forms of more disfiguring breast cancer operations that were accepted for decades
as “the norm”. Remember, we are not augmenting a breast. We are reconstructing a
diseased breast or one at risk for cancer.
Numbness and loss of normal sensation after breast cancer surgery are just a couple of
the concerns we discuss with our patients before any type of breast cancer operation;
whether it is breast preservation, skin sparing mastectomy, or most recently, nipple sparing mastectomy. For more than one hundred years – until the 1970’s – women didn’t
worry about numbness or loss of nipple sensation in their reconstructed breasts. Women
often had their entire breast, chest wall muscles and lymph nodes removed, often without
their knowledge, for diagnosis of breast cancer. They were simply not offered immediate
reconstruction or breast conservation. It was not an option.
In the thirty years that we have practiced breast surgery, there has been a major shift to
preserve the breast whenever possible, and when a mastectomy is chosen or required, to
try and preserve the nipple areolar complex. Preserving the nipple and skin envelope are
purely for cosmetic reasons and are far more technically challenging cases than the
previously-performed radical mastectomy or skin sparing mastectomy. The prior
reconstructions would require nipple areolar creation with surgery and/or tattooing. There
is no chance of maintaining nipple sensation when the nipple is in the pathology lab.
No one dies of breast cancer in the breast; they die when it spreads to other areas of the
body. Therefore, the “local treatment” (breast and lymph nodes) has made major strides
in working to preserve the physical appearance of the breast while adequately treating the
cancer.
“There’s such a strong cultural gaze at women’s breasts,” Dr. Pitts-Taylor said. “It does
raise the question: Who is breast reconstruction for?” Breast reconstruction is for the
woman who had breast cancer; women who want to look in the mirror in the morning and
feel at peace with their appearance after a traumatic breast cancer experience.
Breast cancer is a diagnosis that is an emotional emergency, not a surgical emergency.
Risk-reduction surgery for women who are identified as carriers of high-risk deleterious
genes is an elective procedure. There is time to gather information, learn about all options
and gain a true understanding of the potential risks, benefits and long-term consequences
of the surgical decisions. We are no longer exclusively performing breast cancer surgery
on individuals with cancer. Genetic testing has come so far that we are identifying
women who have a higher probability of getting cancer, that can then choose to have
their breasts removed and reconstructed.
Let’s reframe the perspective on risk-reduction surgery. Women choose this operation
electively to decrease their risk of getting breast cancer from 50–87 percent to 1–4
percent. In 2008, when data on genetic risk revealed that some deleterious genes carried a
60–70 percent chance of cancers being triple negative (ER-, PR-, Her 2 neu-) the number
of women opting to reduce this chance by removing their breasts sharply increased.
Should we deny women the best aesthetic outcome, which can be achieved with a nipple sparing mastectomy? While we can not police what surgeons do in their practice, we can
educate them about the importance of fully and sincerely informing their patients. We can
empower and educate women to ask the right questions and demand the answers, and for this reason I am thankful that the New York Times has raised the issue.
If you are contemplating risk-reduction surgery, if your cancer requires a mastectomy or
if you are choosing a nipple-sparing mastectomy, remember that your grandchildren will
not care whether they are hugging “fake” reconstructed breasts. They are simply thrilled
to be hugging you.
Here are some of the most important questions to ask before any reconstructive surgery:
• If I choose or need a mastectomy, what are my reconstruction options?
• Can I choose to have implants? Can I use own tissue? If I choose to use my own
tissue, does reconstruction happen immediately or does it need to be delayed?
• How do chemotherapy and radiation therapies affect my reconstruction choices?
• Where will my incision be located?
• Can I preserve my nipple, and if not, why?
• Will my preserved nipple have sensation or contractility?
• Will my chest wall and arm pit have sensation? If so, when?
• If I choose to remove my nipples, can they be reconstructed?
• If I need tissue expanders, what will they feel like and how long will I have them?
• What are the possible complications in reconstruction?

Surgeons can not remove a breast or breast cancer without interrupting nerves, blood
vessels and your body’s lymphatic system. Long-term effects can occur, and no one can
predict the significance of these effects, but to not be fully informed of all possible
outcomes is unacceptable.

If you feel you have not been fully informed by your breast or reconstructive surgeon,
“vote with your feet,” and get a second opinion.