Tissue-sparing surgery combines tumor removal with breast reconstruction

November 10, 2015 | by Abe Rosenberg

Not that many years ago, a breast cancer diagnosis inflicted a double shock: learning you had a deadly disease, then realizing how disfiguring the “cure” may be.

We've come a very long way since then. Radical mastectomies are rarely performed today.

Surgical oncologists now remove most tumors through much smaller incisions. Cosmetic surgeons have dramatically improved reconstructive techniques. Medical professionals have come to understand  that a patient's mental and spiritual well-being (not to mention her time) matter every bit as much as her physical health.

A new procedure with multiple advantages

This progress has led to what could be a better surgical solution for many women who've been diagnosed with tumors on both sides: bilateral nipple-sparing mastectomies with immediate implant reconstruction.

Instead of routinely removing the nipples and most of the nearby skin (and, months later, trying to rebuild everything in multiple surgeries), doctors now work to save as much natural anatomy as possible, making it easier to restore a patient's appearance right away.

City of Hope is one of only a handful of facilities offering this procedure.

“We have a history of doing less,'” says Laura Kruper, M.D., head of breast surgery service. “We've steadily progressed from radical mastectomies, to lumpectomies, to 'keyhole' incisions, better chemo, to preserving as much skin as possible, and now we work to spare the nipple as well.”

In this new procedure, the cancer surgeon makes a tiny incision just below the areola, through which all the cancerous tissue is removed. This leaves the nipple intact, and creates a “pocket” or “envelope” ideal for accommodating an implant. The plastic surgeon then takes over, sometimes using Alloderm, a natural skin product that strengthens the pocket's foundation, before inserting the implant. The process is repeated on the other side.

When everything works as planned, the patient awakens cancer-free, looking essentially as she did before, with nothing asymmetrical, “lopsided” or out of position.

Another advantage: Uncomfortable, even painful tissue expanders – which were often used to maintain the newly-created pockets for future reconstructive surgeries – are no longer needed.

"Tissue expanders are a relic of the past,” says James Andersen, M.D., chief of City of Hope’s Division of Plastic Surgery. “The use of tissue expanders has continued because many surgeons are just used to them and unwilling to change. Immediate reconstruction with a breast implant is always preferable to delayed reconstruction.”

Kruper admits it's a time-consuming 'struggle' to navigate such a small incision to extract cancerous tissue. Old-style mastectomies took minutes; the nipple-sparing technique takes hours and requires a higher level of surgical skill, because breast cancer typically grows in the ducts, some of which do reach the nipple. However, at least so far, studies have shown no statistical difference in recurrence rates, and, Kruper insists, though there are no absolute guarantees, surgeons take all precautions to make sure no cancer is left behind.

Plus, she says, the end results are worth it. “The patients are so happy. And frankly, I want to do for them what I'd want done for myself.”

Surgical oncologists team up with cosmetic surgeons for “gorgeous” results

Without a doubt, patients want the procedure.

“Word of mouth is incredibly strong,” says Kruper. “Women are asking for this procedure. They've heard about Angelina Jolie (who had both breasts removed and reconstructed because she inherited the BRCA1 genetic mutation, putting her at high risk) and they want similar results for themselves. And the results are amazing. One of my colleagues called it, 'drop dead gorgeous.'”

The “gorgeous” factor is attributed in no small part to City of Hope’s highly-skilled cosmetic surgeons (Kruper calls them “gifted”) who team with the surgical oncologists.

How, exactly, does that work in one operating session? Who goes first? Who's in charge?

“Each of us is in charge of our part,”  says Andersen. “I'll start by taking photos of the patient in my office. I'll draw a few markings before she goes into the operating room. Once she's there, the nipple-sparing incision by the oncologist is usually the same.” The plastic surgeon may begin the implant procedure after the oncologist has finished, or work on one side while the cancer surgeon works on the other.

“The main problem is time,” Andersen says. Adding immediate reconstruction to the already-longer nipple-sparing operation can mean a total of six hours on the table, increasing the risk of infection. “About one in 20 patients may need to return to surgery to clean out the pockets and replace the implants.”

But time can also be an ally.

Doing cancer removal in tandem with reconstruction can dramatically reduce overall recovery time. Because there won't be a second, third or fourth round of surgery months down the road, Andersen says patients can “disappear back into their normal lives” relatively quickly.

“This was far easier than I expected, and so much better than having to come back again and again,” says Susan Sleep, who opted for the all-in-one bilateral surgery after an initial lumpectomy and chemo were found to be insufficient. “My recuperation went remarkably well. I spent one night in the hospital, didn't need a tremendous amount of pain meds, I was back at work in a month's time, and frankly, I could have gone back sooner.”

Removal of healthy breast and tissue raises questions for some

Ethics questions arise, however, when women, like Sleep, request a bilateral procedure, even though only one breast is diseased. Their reasons vary. Some are mainly concerned about overall appearance and “symmetry.” Most insurance will not cover the procedure in that case. Others, like Jolie, may be seeking peace of mind, worried about future tumors. However, no statistics exist yet to suggest this surgery will improve overall survival rates or definitively prevent cancer in the healthy breast.

Still, Andersen says a growing number of women are requesting the procedure anyway.

“Their anxiety is overwhelming,” he says. “I've done thousands of surgeries. Eighty-five percent of my patients want both sides done. I've never had a patient who regretted the bilateral procedure, but I've had plenty who left one side alone and later wished they hadn't.”

Sleep, a physician herself with an internal medicine practice in Los Alamitos, California, understands those feelings.

“I know the science isn't always the best rationale here,” she says. “Yes, they took out some healthy tissue on the other side. But we're talking about how I'll look for the rest of my life. I have to live with the results. At first I didn't think I cared that much. Turns out, I did. They might as well match.”

The all-in-one procedure is not for everyone

Not all women are ideal candidates for the all-in-one procedure. Smokers, with their compromised blood flow, generally don't fare well. Breast cancer patients previously treated with radiation may not be able to tolerate the implants because radiation scars the muscle and skin of the chest wall. The operation is difficult and less effective for women with extra large or elongated breasts. Risk factors such as diabetes and obesity may also rule out the combined surgery. Also worth noting is the reality that although the nipples are spared, they almost always lose sensation because nerves are severed.

For those who do choose the procedure, their peace of mind may well be enhanced by the atmosphere of teamwork and cooperation among the professionals at City of Hope.

“Collaboration is critical,” says Andersen. “We're very good at it. We trust each other, the patients see that and they really appreciate it. It's a big reason why I work here.”

It's also a big reason why Sleep, a medical professional who clearly had a better-than-average understanding of what lay ahead, chose City of Hope for her surgery. She trusted the doctors and believed in the procedure.

“It's value-added,” she says. “It's making lemonade out of lemons. And you know, being able to maintain part of yourself is a very big thing.”


Learn more about breast cancer treatment and research at City of Hope. Read about our unique patient experience, how to make an appointment or get a second opinion at City of Hope. You may also request a new patient appointment online or call 800-826-HOPE (4673) for more information.

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