By Anne Levin

Kathy Kowalewski had just stopped breast-feeding her toddler son when she noticed her right breast felt different from her left. With no family history of breast cancer, and at 38 still too young to have begun annual mammograms, the mother of two wasn’t particularly concerned. But she consulted her doctor, who recommended a screening. Seeing the results, the doctor urged Kowalewski to have a biopsy of both breasts right away.

It was cancer in her left breast. But the right side looked suspicious, too. Stunned, Kowalewski was referred to a breast surgical oncologist who recommended she have her left breast removed. After recovering from shock and weighing the options, she made the difficult decision to have both breasts removed and undergo reconstructive surgery.

“The decision process was so fast,” she recalls. “It was like being on a train and going and going and I couldn’t get off. But I had a two-year-old and a four-year-old, and I wanted to make sure I’d be here for them, for a long time.”

Kowalewski dreaded the surgery, a 10-hour process that involved her breast surgeon and a reconstructive surgeon. The recovery wasn’t easy. But a year later, she is swimming almost daily, doing yoga, and running around with her children. Last spring, she biked through Maine’s Acadia National Park while on vacation.

“It was hard in the beginning. It was painful,” Kowalewski says. “But my husband helped me, and step by step, I got back to feeling like myself. Today, I’m so glad I had the surgery at the same time as the mastectomy. I can’t imagine having to wake up from the surgery and not feel anything there, where my breasts had been.”

No one wants to hear that they have breast cancer. While some women with early-stage tumors can be treated with breast-conserving lumpectomy, it isn’t appropriate for everyone. Treatment for a breast tumor depends on the stage, severity, and type of cancer. Mastectomy is often the course of treatment.

Then there are women who don’t have breast cancer, but are at high risk for developing the disease. An increasing number are choosing to undergo prophylactic mastectomy and reconstructive breast surgery. Actress Angelina Jolie’s choice last year to go public with her decision to do just that brought the prevention and treatment of breast cancer into sharp focus. Jolie’s mother had died of cancer, and she had tested positive for a genetic mutation that put her at high risk for breast and ovarian cancer. Her disclosure was praised by some as a courageous move that would inspire women to take action and consider their own family histories.

Prophylactic mastectomy is not without controversy. It is major surgery, and some experts feel the difficulties associated with it are underestimated. “It’s definitely a hot topic,” says Dr. Brian Buinewicz, an experienced plastic surgeon who will be a speaker at the December 6 gathering of the Susan G. Komen Foundation’s annual “Sisters for the Cure” conference at the Philadelphia Marriott Hotel.

“There are recent articles out there saying there isn’t an improvement in survival rates for women who have this surgery. But when you’re dealing with one person at a time, with high risk or difficult breasts, statistics can fly out the window,” he says.

Breast reconstruction is an increasingly common way for women to deal with the effects of the surgery that can save their lives. “The point is, women with breast cancer have choices,” says Dr. Philip Wey, the reconstructive surgeon who treated Kowalewski and is experienced with many different types of plastic surgery such as tear drop breast augmentation, implant-based reconstruction, and flap reconstruction.

“The focus now is beyond survival,” he continues. “It has evolved. It’s about maximizing quality of life. There is always a positive spin on what can be somebody’s worst moment. Not only can you beat this, but you can emerge better than when you started. The goal of reconstruction is not just to rebuild a breast, but to make it as similar to the other as possible. And if women want, we can make their breasts better than they were before.”

Continuing advances and new surgical techniques have created a host of options for women considering reconstruction. Each has its own potential benefits and risks. While some reconstructive techniques may be appropriate for one woman, they may not suit another. The first choice, once a patient decides on reconstruction, is whether to make the new breast from muscle or fat taken from elsewhere in the body, or to have implants. Whether silicone or saline, the implant procedure is less expensive than tissue transfer. But implants can be problematic and do not last a lifetime. “Implants last up to 20 years,” says Dr. Wey. “I tell people, that’s a good problem. There’s nothing I’d rather do than see a patient 20 years down the line because they need a new implant. But using body tissue is best.”

Another option is to not have reconstruction at all. The decision does not have to be made right away. “It depends. It’s a woman’s choice,” says Dr. Doreen Babott, a medical oncologist at the University Medical Center of Princeton. “Obviously, if you’re younger, it may be more important to you. If you’re 80, you probably don’t care. And younger people heal better, too. Prostheses are better today, but it’s just not the same.” Most women today opt for reconstruction, Dr. Babott says, and do it at the time of their mastectomy.

“They don’t want to have more surgery, and it’s easier to just do it at the same time. So you have a breast cancer surgeon and a plastic surgeon involved. The women I see who do it are very satisfied with the results. You don’t wake up without a breast. When you recover from surgery, you have something, and that’s very nice.” Breast surgeon Dr. Rachel Dultz, who also treated Kowalewski and others interviewed for this article, stresses that reconstructive breast surgery does not impact and negatively affect survival. “That’s very important,” she says. “There are enough studies that tell us that. The other thing local patients should know is that in this area, we now have such a wide choice of breast surgeons and plastic surgeons that you don’t have to go elsewhere to have this done.”

Dr. Wey has patients from age 25 to 75. “Treatment is customized,” he says. “All cancers, mastectomies, and reconstructions are different. Sometimes women have too many options. It’s our job as doctors to guide them down the right path for them. We’re constantly reinventing ourselves. The technology and the research is constantly getting better.”

During her recovery from surgery, Kowalewski had physical therapy sessions with Beth Rothman, who was familiar with the process because she went through it herself and changed the focus of her practice to helping women recover from mastectomy and reconstructive surgery.

Now 56, she was 49 when a mammogram revealed a stage one tumor behind one nipple. She went to Dr. Dultz, who told her she had a choice between a lumpectomy and mastectomy. “I knew I just wouldn’t be comfortable having to check every few months,” Rothman says. “I decided to do the mastectomy.”

After consulting with a few plastic surgeons, she chose Dr. Wey. “I saw pictures of the work he had done,” she says. “You want to go to somebody who does the procedure all the time.” He operated on Rothman using latissimus dorsi flap surgery, better known as “lap flap,” taking tissue from her upper back, which is then tunneled under the skin to the breast area, creating a pocket for an implant. The results were “phenomenal,” Rothman says.

“I look better than I did before. The nipples look absolutely real. It’s warmer, it’s softer, they just look real. I was unbelievably grateful to wake up with a breast. I wasn’t going to, but my husband said ‘You’ll be sorry if you don’t.’ And he was right. I look better, I feel better, and I can do absolutely everything I could do before.”

After the surgery, Rothman was advised to be tested for the gene that predisposes a woman to breast and ovarian cancer. When it came back positive, she immediately elected to have a mastectomy on her other breast. “I didn’t expect it, but once I knew I had the gene, I knew I would do it,” she says. “I knew how good it was going to look, because I had already had it on the other breast. It just made sense. So I did it after I finished chemotherapy from the first surgery. I wasn’t scared it was all prophylactic. I went to work with my drains in because I wasn’t worried about it. I think I overdid it because I was kind of cocky, having been through it once already. I hurt my shoulder, but I went for physical therapy and after a week I was fine.”

Laura Martin is the program coordinator for the Breast Cancer Resource Center at the YWCA. The center offers support groups, exercise and wellness programs, and a free wig and prosthesis boutique in an informal setting. “I wish I’d had a place like this when I had surgery,” says Martin, whose “lap flap” reconstruction was in 2007.

Dr. Dultz was Martin’s breast surgeon; Dr. Wey did the reconstruction. “I started on my stomach,” she says matter-of-factly. “He got the muscles out. Then they flipped me over, and Dr. Dultz removed my breasts. She left, he came back, and he put the muscles where he wanted them. Then he put in saline implants. It took about seven hours, so it was all done in one day-one and done.”

A few months later, Martin had her nipples reconstructed. “I went on my lunch hour,” she says. “Three little cuts–not a big deal. Then three months after that, they tatooed them. There’s a color chart, like with Benjamin Moore paints. People’s nipples match their lips, apparently.”

No one denies that reconstructive breast surgery is major, and it carries risks. Infection, bleeding, scarring, ruptures or leaks, muscle weakness-all of these can happen. And if an implant is being put in, it is a multi-step process. “Until things are really, really done, I usually tell patients, it’s a full year from diagnosis to feeling normal and complete again,” says Dr. Buinewicz.

Surgeons agree that the best results are usually when reconstruction is done at the same time as mastectomy. “It’s easier. Everything has been set up,” says Dr. Wey. Then women don’t have to wake up from surgery without a breast. The patient is in control. But you don’t have to do anything. It’s up to you. It’s a very optimistic way of taking on a negative experience.”

Resources:

1. Dr. Philip Wey, Plastic Surgery Arts of New Jersey 60 Mount Lucas Road Princeton, NJ 609. 921.2922

78 Easton Avenue New Brunswick, NJ 732.418.0709 www.psanj.com

2. Breast Cancer Resource Center YWCA Princeton 59 Paul Robeson Place Princeton, NJ 609.497.2100 ext. 349 www.ywcaprinceton.org/bcrc

3. Dr. Rachel Dultz 300B Princeton Hightstown Road East Windsor, NJ 609.688.2729 www.racheldultzmd.com

4. Dr. Doreen Babott Princeton Healthcare 5 Plainsboro Road Ste. 300 Plainsboro, NJ 609.853.7272 www.princetonhcs.org

5. Dr. Gary A. Tuma, Plastic Surgery Associates of NJ Suite 505 2 Capital Way Pennington, NJ 08534 609.537.7000 www.plasticsurgeryofnj.com

6. Dr. Brian Buinewicz Buinewicz Plastic Surgery 3655 U.S. 202 Doylestown, PA 215.230.4013 www.lemedspabucks.com

7. Memorial Sloan Kettering Cancer Center 1275 York Avenue New York, NY and suburban locations 800.525.2225 www.mskcc.org

8. Abington Memorial Hospital Old York Road Abington, PA 215.481.2000 www.abingtonhealth.org

9. Capital Health Center for Comprehensive Breast Care Capital Health Medical Center – Hopewell 1 Capital Way Pennington, NJ 08534 609.537.6767 www.capitalbreast.org

10. Breast Plastic Surgery Center at NYU Langone Medical Center 307 E 33rd Street New York, NY 212.263.5834 www.nyumc.org