Dr ISABELLE SARFATI – Reconstruction after breast cancer
Interview in July 2018
Most of the time I come in after the battle. That is to say, I see someone who has finished his or her treatments and is coming for reconstruction. At that point, it’s always quite emotional for me at the beginning of the first visit: it’s that in five minutes, someone is going to tell me about their course of treatment but also about the interactions of what happened to them with their life, at what point in their life they found out about their cancer, how it stopped them, what happened, the relationships they formed with the medical profession, how it went… Often they talk about doctors that I know, so I see through what they tell me, I reconstruct a little bit what happened, which in general is not exactly what they tell me, but that’s how they experienced it. And at the same time, they tell me about their difficulties or lack of difficulties, living with small deformities on the breast or a mastectomy, their relationship with their body, their relationship with nudity. This takes place in five or ten minutes, because in fact a consultation lasts between half an hour and three quarters of an hour, and the main part of the consultation for me is to tell them which techniques can be used, which ones exist, which ones are possible on them, which ones they can choose from, and the advantages and disadvantages of the different reconstruction methods. So, we can’t spend too much time on what happened before, but it’s in the way we tell them how they lived through it and how it was integrated into their lives that I will look for what will be the most suitable for them in the reconstruction method.
I also listen to expectations, i.e. not everyone expects the same thing from a reconstruction. There are patients who expect a reconstruction to be like before, which is quite difficult. There are people who did not like their breasts at all before, and who expect a reconstruction to be better than before. Surprisingly, it is often quite simple, because when women have breasts that were ugly before and that they did not like, it is often quite easy to improve both. There are people who expect a reconstruction only to be functional, i.e. to be able to dress without it being noticeable, but who are not ready to undergo several stages of reconstruction in order to have the most perfect result possible. So, it is quite important at the beginning to hear what the person wants from the reconstruction.
In therapeutics, doctors write prescriptions, in practice, we do not give patients the choice of treatments: we tell them, “the ideal in your case is to do such and such a treatment”, that is what we prescribe. Then everything is debatable, but we are guided by the fact that we want to save lives. Here, I am totally optional. I say: here, we have a range of possibilities to offer you, this is how it will happen, I am not the one who prescribes reconstruction, I am at your disposal to reconstruct, this changes the request and the relational mode. I am not in a therapeutic position.
AN ARSENAL OF RECONSTRUCTION
Schematically, there are two possible modes of reconstruction, but in fact, from these two modes of reconstruction, there are many possible hybrids. To reconstruct a breast, one can simply use an implant, which requires that the tissues be sufficiently lax to be able to cover an implant and to fit the shape of the implant correctly. We can also use materials from the patient herself, we can use the belly that is to say in general it is a free flap, we take the skin, the fat of the belly, we take vessels that feed this skin and fat, and we will transfer these tissues to rebuild a breast. Finally, there is the dorsal flap, which means that we take a part of the skin, fat and muscle of the back that we leave attached by a vascular-nervous pedicle in the armpit, so it starts from the back and pivots to go back to the front; and if the person has enough tissue in the back to have a volume equivalent to the breast on the other side, we are not obliged to add an implant. Most often, a combined technique is used, i.e. a prosthesis is used to make part of the volume and the back flap to make the covering tissue and part of the volume.
In addition to this, there is what is known as “lipofillings”, which means that we are now able to take fat from somewhere by liposuction, and to use this fat by reinjecting it elsewhere. The results of reconstructions have been transformed by “fillings”, because when faced with a given reconstruction, the fact of being able to take fat from elsewhere and resculpt on top of it to refine the shape has given us wings, i.e. we are able to obtain a very good result from a mediocre reconstruction thanks to the fat. So between implants, flaps, whether on the back or the stomach, and the fat that can be used by liposuction, we have a therapeutic arsenal that allows us to have reconstructions of fairly good quality.
Reconstruction should be considered as a tailor-made dress. That is to say that we have a first operation that most often makes the shapes, the volumes, the symmetry and then we make appointments of assessment: that is to say we look at the result. Either it is very good and we will only have to do the areola and the nipple, but this is done under local anesthesia, most often at the office. If there are small defects, we can make improvements, and this is where we use a lot of fat, changes of prosthesis, which allow us to go from an acceptable result to a very good result.
AREOLA AND NIPPLE
There are several techniques that can be used to make an areola and a nipple. Schematically, the areola is a round disk, with varying colors from one person to another. There are two techniques to make an areola. Either we use tattoos, and now we are able to make dragons with flowers etc., so we are able to make round areolas by copying more or less the same color as the other side; on light areolas we usually tattoo both sides and not just one side, because dark colors are quite easy to imitate, however it is difficult to have exactly the same color for light colored areolas. We can also use skin grafts that are usually taken from the upper thigh, in the groin.
For the nipple, there are also several possible techniques. Basically, either the nipple on the other side is quite voluminous and we take a small piece of it, we do not see the removal at all and we will make the nipple on the other side by grafting the small piece, it is a graft that works very well and is very easy. Either there is not enough volume on the nipple on the other side, or the person does not want to touch the nipple on the other side, and in this case we do what we call a small local flap, that is to say that we use the skin of the areola, that we roll it on itself to make a nipple, and then we do a skin graft that is taken from the groin to make the areola. And finally, a third technique is possible for the nipple, which is to use a little bit of the labia minora, at the level of the sex, and we will graft them to make a nipple, and this makes nipples that are quite good, that have a good color.
While the first reconstruction operation is a fairly classic operation, with generally 48 hours of hospitalization, it is rare that people stay more than 48 hours in the clinic after a reconstruction, the touch-up time is almost always very light and ambulatory, because everything is done. What is difficult is to make space, contours, volume. Once it is done, the touch-ups are very light surgery, I operate on Fridays in touch-ups, people come in on Friday morning, they leave on Friday afternoon, they are at work on Monday, because it is not aggressive surgery.
ARE THERE ANY RISKS INVOLVED IN RECONSTRUCTION?
It has been shown that reconstruction does not interfere with the detection of recurrence of breast cancer, does not cause recurrence, does not interfere with treatment if it is discovered that there is a recurrence behind it, so it is quite harmless. There is nothing to prevent breast reconstruction in the case of metastatic cancer. And many women do it. However, it is surgery, it takes place in the operating room, there are anaesthetics, it is a little aggressive for the body even if it is a very superficial surgery, it is a journey, appointments, post-op, it is work.
TO REBUILD … OR NOT?
Basically, we know that 30% of women who have had a mastectomy have reconstruction. The majority of women who do not have reconstruction do so for financial reasons. First of all, reconstruction is relatively expensive. Although it is covered by the Social Security, the majority of plastic surgeons charge higher fees, there are very few plastic surgeons in the public service, which means that there is at least a year’s wait to have a reconstruction. There are also reasons of geographical distance, that is to say that there are many oncologists in France and breast cancer specialists, but there are not many plastic surgeons specialized in breast reconstruction, it is essentially in large cities, and doing a reconstruction requires several steps, which means that for someone who lives far from the person who can do the reconstruction, it will take much more energy.
In the choice of plastic and cosmetic surgery, this choice can be lived as a weapon of freedom, that is to say the freedom to reconstruct, and as a form of submission, that is to say to submit to social and cultural norms, which makes that one must have two breasts and that one must reconstruct. It is important to understand that it is not an obligation. And that it is a conscious choice.
A MORE GLOBAL RECONSTRUCTION
I often stay quite close to my patients because breast reconstruction evolves quite a bit over time, for several reasons. First of all, we often have to live with an implant, so there is maintenance on the implant, there is monitoring of the implant which is not very restrictive because it is combined with breast monitoring. But there is also cosmetic monitoring, i.e. when a woman gains ten kilos or loses ten kilos, this will modify the symmetry of the reconstruction, so we will adapt to the new body. In time, because natural breasts fall over time while the reconstructed breast remains quite identical, does not move much over time, we have a symmetry that moves over time and that must be followed. And then there is often a relationship of trust and aesthetics between the patients and the plastic surgeons, which means that breast reconstruction is often the gateway to a number of other small cosmetic procedures. It is quite common for someone who comes in for breast reconstruction to say to me: while you’re at it, wouldn’t you like to do, I don’t know, a little liposuction of the chin, can we do some cosmetic medicine injections? It is a narcissism reconstruction that is much more global than the strict reconstruction of the breast, and it goes further. Its goal is to make you feel as beautiful as before, a pretty woman with hair, a breast and so on. Suddenly, we have aged, we do not recognize ourselves well, we have sometimes lost a breast, and the reconstruction that is done is a more global reconstruction, where finally we do not only take care of the breast but also of the hair, the state of the skin, to find oneself: it helps to find oneself, not only on the breast.