For about 70 percent of women who have a mastectomy or lumpectomy, breast cancer surgery is the end of the surgical road. Some may be unaware of their options for reconstructing the missing or damaged breast. And some may live too far from a major medical center where reconstruction is performed. And then there are others who decide that enough is enough. But Christy Kessler was determined not to be part of that majority.
“If I was 20 years older, I would probably make a completely different decision, but this is where I am in my life right now. There’s still a lot of active life to live, and it’s part of who I am and what I feel as a woman makes me whole and complete,” says Kessler, a slim, attractive, 41-year-old mother of two who was diagnosed with breast cancer shortly after her 40th birthday.
Yet Kessler’s ongoing journey from mastectomy to breast reconstruction already has been a long one marked by unexpected detours that might have discouraged many women to the point of giving up. Instead, Kessler’s determination became stronger.
When she was diagnosed and her initial surgical plan was formed, Kessler’s decision to reconstruct her breast seemed straightforward: an expander would be placed in the breast following mastectomy, which would stretch the remaining skin. Later, the expander would be replaced by a silicone implant. “Implant reconstruction is the most common way women choose to reconstruct their breasts because it can be done during the mastectomy surgery, it’s quicker, and it offers an easier recovery and less pain,” says Dr. Judith Gurley of Judith Gurley Plastic Surgery.
While this approach does work well for many women, Kessler ran into trouble after her breast implant surgery, which occurred six months after she completed chemotherapy and radiation treatments. The radiation damaged Kessler’s skin, making it thinner and less pliable, preventing adequate wound healing at the incision site. Ultimately, Kessler’s implant had to be removed—a crushing blow.
However, Kessler refused to be daunted, discussing remaining options with her plastic surgeon and researching the topic on her own. It was clear that the only type of viable procedure available would involve using her own tissue to rebuild her breast. She considered a ‘free TRAM (transverse rectus abdominis myocutaneous) flap’ in which skin, fat and abdominal muscle are used for reconstruction. However, Kessler, an active woman who likes to exercise, was uncomfortable with the idea of losing a portion of her abdominal muscle.
Enter Dr. Samer Cabbabe, a plastic and reconstructive surgeon with Cabbabe Plastic Surgery. Cabbabe trained with one of the world’s leading plastic surgeons during his post-doctoral fellowship at the University of Alabama, where he learned to perform a procedure known as a ‘DIEP (deep inferior epigastric perforator) flap.’ This intricate microsurgery spares the abdominal muscle, using skin and fat from the abdomen while calling upon blood supply from the deep inferior epigastric artery, located beneath the wall of abdominal muscles.
“Christy is a classic example of what I see—patients who have radiation, try reconstruction with an implant and find that the reconstruction fails,” Cabbabe says. Not only does DIEP spare abdominal muscle, but “using the microsurgical technique, it’s actually a more robust blood supply to the tissue than the traditional TRAM.” The delicate procedure takes six to 10 hours and requires several weeks of recovery.
Dr. Terry Myckatyn, a plastic and reconstructive surgeon with West County Plastic Surgeons of Washington University, performs one or two DIEP procedures a week. “Both the free TRAM and DIEP flaps are microvascular reconstructions, meaning that the tissues used to reconstruct the breast are separated from the abdomen and then reattached at the breast,” he explains. And both procedures have pros and cons: “The DIEP flap has been associated with less post-operative pain and a lower risk of abdominal wall weakness in some studies compared with TRAM flaps. The free TRAM flap has been associated with less fat necrosis (hard lumps of fat that develop in the reconstructed breast due to poor blood supply) compared with the DIEP flap.”
Myckatyn is quick to point out that breast reconstruction does not significantly alter the ability to detect recurrence or negatively affect subsequent cancer care. “The ability to pick up recurrent cancer with current imaging techniques is the same whether or not you have a reconstruction,” he says. “Worry about recurrence or cancer care should not factor into whether a woman has a reconstruction or not.”
Kessler’s DIEP is scheduled for later this month, and she’s anxious to have the procedure behind her. Based on her experience, Kessler is convinced that knowledge is power. “Research all of your options,” she says. “Get one opinion, two opinions, three opinions—whatever makes you comfortable, because there are a lot of options out there. I wonder, if I’d have done more research, if I would have made a different decision and not gone through a failure the first time around.”
However, Kessler’s not one for regrets. Instead, she looks ahead to her procedure, her recovery and this summer’s family beach vacation where she plans to wear a bikini while she builds sand castles with her kids.