Rebuilding the Breast

After the removal of her left breast because of cancer in 1970, Mrs. Joan Dawson, 54, of New York City, spent the next three years battling depression and a sense of loss. Then she decided to do something about it. Most women in the same situation turn to a psychiatrist. Mrs. Dawson (not her real name) went to her doctor and asked him to rebuild her missing breast. "I didn't want to be made into a sensational beauty," she explained. "I just wanted to be restored." Her surgeon was able to do just that. In two separate operations, he implanted a silicone-filled sac under the skin where the breast had been removed, then reduced the size of the other breast to make it more nearly resemble the new one. The result is not a duplication of Mrs. Dawson's pre-1970 figure, but she is delighted nevertheless. Says she: "I can finally look at myself in the mirror without wincing."

Since 1969 several hundred American women have undergone plastic surgery similar to Mrs. Dawson's--with increasingly satisfactory results. At a recent meeting at Rutgers Medical School, plastic surgeons predicted that the number of breast reconstructions would continue to rise. Self-examination and mass screening programs are detecting an increasing number of early breast cancers* before they spread; that makes it possible to perform less disfiguring operations than the standard radical mastectomy, in which not only the breast but the lymph nodes under the armpit and the muscles of the chest are removed. As a result, doctors predict that many of the 89,000 women who will undergo breast surgery this year will be able to take advantage of reconstructive surgery.

Surgical Revolution. Doctors have been experimenting since the 1950s with techniques to rebuild amputated breasts with grafts of fatty tissues and implants. Their initial efforts were often unsuccessful. The earlier implants, which consisted of chemically inert plastics, were of a firmer consistency than normal breast tissue and were aesthetic failures; the reconstructed breast was often no more than a hard mound that was usually noticeably smaller than the remaining breast. The plastic, in fact, often shrank and became lumpy after implantation.

But since 1969 there has been a dramatic improvement in the quality of breast reconstruction. One reason was the development by Dr. Thomas Cronin of Houston of an improved implant. Another is the introduction of a newer, though relatively little-used implant that overcomes most of the problems of earlier prostheses. It is divided into three compartments that reduce its tendency to shrink or collapse; the implant also has a fuzzy polyurethane covering that helps hold it in place against the chest wall. "It makes a dramatic difference," says Dr. Randolph Guthrie of New York's Memorial Hospital for Cancer and Allied Diseases.

So does another development, the perfection by Dr. Jon Olaf Strombeck of Stockholm of reduction mammoplasty, a technique for reducing the size of the breast. This can be used in reconstructive surgery to restore a measure of symmetry to the bust.

A third has been the growing acceptance of reconstruction by surgeons themselves. In the past, many doctors dismissed such surgery as frivolous (some major insurance companies still refuse to pay for such "vanity" operations). But now an increasing number of surgeons perform the initial amputation with reconstruction in mind, leaving as much skin as possible. When they can, they often attempt to save the nipple. Some doctors, however, oppose the idea, fearing the nipple may harbor cancer cells. Most agree, however, on the importance of at least making women who are facing surgery for breast cancer aware that reconstruction may be possible. "We don't spend enough time with them," says Dr. Henry Leis, chief of the breast service at New York Medical College. "We have to tell them the truth and give them hope for afterward."

Good Results. When plans have been made in advance, reconstruction can be relatively simple. According to Dr. Reuven Snyderman of Princeton and Dr. Robert Goldwyn of Boston, a woman who has had a simple mastectomy (removal of the breast, but no other tissue) can usually be given a new breast in a single surgical session; all a doctor need do is slip in an implant. Women who have had more radical surgery require more complex procedures and must undergo several operations. Creation of a nipple by "sharing" the one from the intact breast, or the preferred method of building a new aureola (the rosette of tissue surrounding the nipple) out of skin removed from the labia, requires an additional operation or two.

Although reconstructive surgery seems safe, not even its most enthusiastic advocates recommend it for all breast-cancer patients. Only an estimated 20% of all women find it difficult to adjust to the deformity produced by mastectomy; a few even regard their scars as a "badge of courage." Doctors will not attempt reconstruction on women who have undergone excessive doses of radiotherapy after their initial operations: the X rays may scar too much tissue to permit successful reconstruction. They also wait at least six months after a mastectomy before attempting reconstruction: it takes that long for complete healing. But plastic surgeons see no reason to wait longer; cancer specialists say reconstruction need not interfere with the diagnosis of a recurrence--or its treatment.

* When detected and treated by surgery in its earliest stage, breast cancer is nearly 100% curable, according to the American Cancer Society.

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