When cancer invaded Melody Laughbaum’s left breast, she went into survival mode. The busy mother of four opted for a double mastectomy, even though her right breast was fine.
“That was my choice,” she says. “I worried cancer would migrate to my healthy breast. So, I told my doctor, ‘Get rid of them both.’”
Laughbaum, 49, could have selected a less extreme treatment. She could have gone with chemotherapy and radiation, and taken the drug tamoxifen to help slow or stop cancer’s spread. But this regimen would require repeated trips to the hospital, and she’d need to have a biopsy every six months to make sure the treatments were working and her cancer hadn’t spread.
“Those frequent biopsies would carve away my breast tissue over time, like a mastectomy done in installments,” she says. “Eventually I’d need plastic surgery to restore volume to my breast. And all the while, I’d worry the cancer might come back. I decided to have a double mastectomy and end this drama.”
With her decision made, Laughbaum faced another dilemma: how to create new replacement breasts.
Using what you’ve got
Breast reconstruction is performed in one of two ways: by replacing the missing breasts with silicone or saline implants, or by borrowing fat, muscle or skin from another area of the body and sculpting it into a new breast — a technique known as autologous reconstruction.
Like Aretha Franklin’s hit, “(You Make Me Feel Like) A Natural Woman,” Laughbaum wanted to avoid implants and “use what God gave me.”
“I liked the idea of using my own flesh,” she says. “There’s something sensible about it. Once the scars and swelling went away, I’d still feel like me.”
She chose a procedure where skin, fat and blood vessels are removed from the lower abdomen, transferred to the chest, and sculpted into a breast. Taking tissue from the tummy is the most common way to do autologous reconstruction, says Alexander Mericli, M.D., assistant professor of Plastic Surgery.
“Tissue that normally would be discarded during a tummy tuck is instead fashioned into breasts,” he says. “Patients love it. They get new breasts and a flatter tummy.”
The inner thighs, back and buttocks can also supply tissue if a woman doesn’t have enough abdominal fat.
Sculpting a breast from natural tissue tends to create a more natural look and feel than a breast implant, says Mericli, who performed Laughbaum’s surgery. If a patient is having reconstruction on one side only, he notes, it’s easier to match her healthy breast to one made of tissue than to one made from a silicone or saline implant.
Half of all breast implants need replacing every 10 years, according to the American Cancer Society. But Mericli says autologous surgery is typically a one-time procedure.
“There’s no implant,” he explains, “so there’s nothing to replace in the future.”
The downside, according to the surgeon, is that tissue transfer operations are complicated and can take as long as 12 hours to perform, whereas implants are done in only a few hours.
“Autologous surgeries also create more scars, because they require incisions in a second location on the body,” Mericli says. “With implants, surgery is confined to the breast only.”
Still No. 1
The demand for autologous reconstruction is steadily rising, but implants remain the most popular way to build a new breast. Of the almost 92,000 women who had reconstruction last year in the United States, more than 72,000 opted for implants, according to the American Society of Plastic Surgeons. Just over 19,000 women chose autologous tissue transfer.
Implant surgery is usually a two-step process. First, a tissue expander, which is an empty breast implant, is inserted between the skin and chest muscle. Through a valve in the expander, the surgeon periodically injects saline to gradually fill the expander over several weeks or months.
After the skin over the breast area has stretched enough to accommodate a permanent implant, the expander is removed during a second operation and replaced with the silicone or saline implant. A sling or internal bra made of human or animal donor skin is also inserted to support the implant.
Some patients, particularly those with small breasts and pliable skin, may skip the expander step and receive implants immediately after mastectomy.
And some patients are participating in an MD Anderson study that allows them to inflate their expanders at home with carbon dioxide gas.
“They appreciate not having to travel back and forth to the hospital,” Mericli says.
Reconstruction, tattoos and more
After the reconstructed breasts are in place, the plastic surgeon handcrafts new nipples during a separate and final surgery. Snipping, folding and stitching existing breast tissue into a peak, the surgeon creates a nipplesque protrusion for each breast. New nipples can also be crafted using pinkish tissue from the incision scar, the groin, or between the buttocks.
Or, new nipples can be tattooed directly onto reconstructed breasts.
Angela Loveless is one of three MD Anderson nurses trained in this highly specialized technique.
“We use pigments in various hues to create a 3D ‘picture’ of a nipple that has no physical dimension, but it can look quite real,” she says. “Shading makes the nipple appear to stick out. Our results are very realistic.”
Because tattoos are permanent and rarely fade, one session is usually all that’s necessary. Tattoos also are used to add color to tissue-engineered nipples, if needed.
There is such a thing as a nipple- and skin-sparing mastectomy — Laughbaum had one — where the surgeon removes all the breast tissue while preserving the breast’s skin, nipple, and areola – the dark ring of tissue around the nipple.
“It’s like scooping the fleshy fruit out of an orange and leaving the skin intact,” Mericli says.
The surgeon then places the implant or newly constructed breast mound inside this ‘skin envelope.’ However, in some patients the nipple and areola tissue can start to die because of insufficient blood supply.
To spare Laughbaum from this complication, Mericli salvaged her nipples and areolas, then stitched them above her hip bone. The “hipples,” as Laughbaum and her medical team jokingly dubbed them, stayed there for six months, nourished by an ample blood supply while her newly reconstructed breasts healed.
“Looking in the mirror was weird, but kind of funny,” says Laughbaum, who teaches elementary school art. “I felt like a Picasso painting.”
Many options, and they’re all individualized
Reconstruction often can be performed at the same time as the mastectomy, which is called immediate reconstruction. Or it can be performed any time after the initial surgery — even years later. This is called delayed reconstruction.
Laughbaum had immediate reconstruction after her mastectomy.
“Breast tissue came out, then new breasts went in,” she says, “all in one surgery.”
For medical reasons, not all women are good candidates for immediate reconstruction.
“Women with more advanced disease may need chemotherapy, or radiation, which affect the body’s ability to heal,” Mericli says. “It’s best for them to complete their cancer treatment, and then once they’re determined to be doing well, undergo reconstruction at a later stage.”
Not all women who undergo mastectomy have a cancer diagnosis.
“We see many women with high-risk profiles who choose to have a preventive mastectomy,” Mericli says. “The vast majority undergo reconstruction. They’re making an elective decision about removing their breasts, and are quite motivated to consider options to reconstruct their breasts at the same time.”
It’s not about vanity, he says. It’s about something much deeper.
“This is about getting back to where you were before cancer.”
Mericli points out that the choices to be made in breast reconstruction, or whether to have it at all, are highly individualized.
“It’s a very personal decision for each patient, and it’s our responsibility as physicians to help guide them through the process, which can seem overwhelming.”
Robot surgery makes healing quicker and more comfortable
When a healthy woman with natural breasts has breast enlargement surgery, her existing breast tissue and muscle support her implants and keep them in place. But in a woman with cancer who’s had a mastectomy, this breast tissue been removed. And if she’s also undergone radiation treatment, thefatty and connective tissue that lies under the breast is further damaged by radiation and unable to support implants.
To anchor a mastectomy patient’s implants, protect them from infection, and create a better cosmetic outcome, doctors cover the implants in one of two ways: with a manufactured material, or with the latissimus dorsi muscle that is located in the mid and upper back.
Traditionally, the muscle is harvested by a surgical incision that leaves an 8-by-12-inch scar across the back. But Jesse Selber, M.D., professor of Plastic Surgery, has pioneered a minimally invasive, robotic surgery that helps patients heal faster and more comfortably.
Selber’s technique uses the mastectomy incision along with three small incisions, each less than a half-inch in length, made under the patient’s arm. Long, slender robotic arms are inserted through the tiny incisions and operated by a surgeon who sits at a console resembling an airplane cockpit. The robotic arms separate the muscle from the surrounding tissue, then tunnel it under the skin to the breast, where it’s draped securely across the implant.
This procedure is routinely performed only at MD Anderson. The success rate, Selber says, is 100 percent.
“There’s been no loss of muscle viability,” he says, “and we’ve not had to convert to the more invasive technique.”