The field has evolved rapidly. Among the techniques available for reconstruction in conjunction with mastectomy are these:
--The tissue-expander implant: This device is like a balloon that is installed under the chest-wall muscle by a plastic surgeon, after the breast tissue is removed in a mastectomy. Over the next few weeks or months, the expander is inflated with salt water until it is about 50% larger than the size of the eventual breast, to allow stretching of the muscle and skin. Once the tissue has been stretched into shape, a permanent implant is installed in a comparatively minor procedure. The expander can be used in both types of reconstruction.
--Immediate installation of the permanent implant: The permanent silicone or saline-filled implant is inserted under the chest muscle during the cancer operation. Women who are small-breasted and whose cancers are not so extensive that mastectomy requires removal of large amounts of skin are candidates for this. The implant can also be inserted months after the surgery.
--Transplanted muscle tissue from other parts of the body: In some women, particularly those who lose a large volume of tissue in the mastectomy, muscle can be transplanted from the abdomen or the back of the shoulder. The advantage of these techniques is that no foreign object is introduced into the body. The disadvantage is that, especially in the abdominal muscle transplant, there may be permanent compromise of the areas from which the transplant muscle is removed. Tissue transplants are usually done on a delayed basis.
--Newer tissue transplants from other areas of the body: The first of these techniques, detailed earlier this year by Dr. William Shaw, a New York City plastic surgeon, relies on transplanting fat, muscle and skin from the buttocks.
--Nipple reconstruction: Rebuilding of the nipple is usually done several months after the initial surgery. This is necessary because swelling at the time of the cancer operation makes placement difficult and could result in the nipples being out of line. Last weekend, plastic surgeons meeting in Toronto heard a report of a new nipple reconstruction technique that uses skin removed from the opposite, undiseased, breast and preserved by freezing. More established techniques include transplanting skin from other parts of the body.
Even for women who had breast cancer surgery many years ago, reconstruction is often possible. Leila Kleiman, a 51-year-old Westside woman, had her surgery in 1973 but it was not until she met Santa Monica plastic surgeon Dr. Harold Clavin that she began to seriously consider reconstruction.
An artist, Kleiman had gained weight after her surgery and had begun to feel her entire personality had changed: "I started thinking of myself rather than as the young, athletic person I had always been, as a middle-aged kind of dowdy person."
Today, she said, with her left breast rebuilt--including creation of a replacement nipple--she has noticed the tone of her work has changed dramatically.
"I'm not so consumed by this constant thought of being lopsided," she said. "The whole coloring of the way I perceive my work is changing. It's amazing. My whole outlook is changed. I lost 40 to 50 pounds. It's as if the clock has been turned back for me 15 years."
Psychologists who have investigated the role of reconstruction in the psychological health and overall recoveries of women who have and have not had the procedure agree the technique can be crucially important.
UCLA psychologist David Wellisch has published a variety of studies on the psychological ramifications of breast reconstruction which found that, among other things:
--Only 25% of women who underwent immediate reconstruction fit a screening profile for "high distress;" 60% of women who delayed reconstruction experienced emotional trauma.
--A reconstituted nipple made a significant difference in one group of research subjects who included 33 women who had the procedure done after their cancers and 26 who did not. Women who had nipple surgery reported that they felt a greater degree of a sexual sensitivity than women who did not have such surgery and that they found their nude appearance pleasing.
"Women say reconstruction makes them feel more whole," Wellisch said. "The cancer experience is not as painfully evident." But Wellisch said the importance of breast restoration as a whole and nipple replacement, in particular, varies among women--even among younger women, some of whom are comfortable without any of the procedures and some who say they could not have faced the cancer diagnosis without knowing their appearances could be restored.
In an article in a recent issue of the Medical Journal of Australia, Dr. Christopher Magarey said reconstructive techniques are increasingly able to make it possible for breast cancer to "be a positive turning point in a person's life."