Before Breast Cancer Strikes

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Breast cancer is responsible for one of every three cancer diagnoses. According to the American Cancer Society, it is the second leading cause of cancer death in women. Some women who have relatives stricken by breast cancer and other risk factors are surgically removing nature’s own and having new breasts reconstructed by plastic surgeons. Studies on various aspects of preventive mastectomy and breast reconstruction are springing up during October -- Breast Cancer Awareness Month.

Deborah Barnes, a 53-year-old paralegal in Glen Ridge, New Jersey, was terribly worried about the breast cancer in her family. Her grandmother died of cancer in the 1960s and, more recently, her mother and sister both suffered from the dreaded ailment. Eventually, alas, cancer developed in one of Deborah’s breasts.

“The hardest phrase you’ll ever hear is when a doctor says: ‘You have breast cancer,’” Deborah told “Your whole world stops.”

But she did not settle for removing only the cancerous breast. After studying her options and the risks for yet more cancer, she opted for a double mastectomy to rid herself of the breast that showed no symptoms – yet.

While she was still on the table, surgeons rebuilt breasts from tissues in her abdomen and from other areas of her body. It’s known as IBR, or, immediate breast reconstruction.

“I’m now cancer-free and even the clerks in fitting rooms helping with bathing suits don’t realize I have reconstructed breasts,” Deborah says.

Prophylactic mastectomy is not as widely done as breast reconstruction, a procedure performed on some 70,000 women in 2003, according to the American Society of Plastic Surgeons (ASPS.)

But more women are taking a look at the rates of breast cancer among their female relatives and wondering if, or when, the Big C will strike them.

Guidelines for preventative mastectomy aren’t carved into stone, but women with histories of pre-cancerous cells, relatives with breast or ovarian cancer or mutations in several breast cancer genes – revealed through genetic testing – often opt for more counseling, watchful waiting, soul searching and, sometimes, prophylactic mastectomy.

The dagger aimed at the heart of such women seems to be deadliest when several close relatives develop the disease before age 50, if she is a smoker, (especially if she started as a teenager or young adult,) and if she has been on hormone replacement therapy.

“Women whose fathers have had breast cancer are at an even greater risk than if their mothers had it,” says Loren Schecter, M.D., a plastic and reconstructive surgeon near Chicago.

Mourene Tesler in Denver, Colorado, knew her mother had three episodes of breast cancer while her sister suffered two.

“My doctor figured my odds of getting breast cancer again were about 80 percent,” Mourene says. “So the decision was sort of made for me. I had three children at home and the doctor capped his discussion by advising: ‘If you’ve got the guts, have the operation (preventative mastectomy.”)

She had the procedure, received implants right after the double mastectomy and says she has received no complaints from her husband of 40 years during the last 17 years.

However, Mourene’s sister did not have a preventative mastectomy, developed breast cancer in 2000 and died of ovarian cancer shortly afterwards.

“The doctors told us both: ‘By the time we find cancer in your breasts, it will have spread to other organs,’” Mourene recalls.                                        

At the highest risk: the woman who has already lost one breast to cancer and has a female relative with the ailment. That patient stands about a 50 percent chance of developing cancer again. Overall, about one in 500 women carry the gene mutations that usually lead to breast (or ovarian) cancer. The bugbear genes – known as BRAC 1 and 2 -- are present in at least one of every ten breast cancer patients under age 40.

About all the National Cancer Society can say about preventative mastectomy is the procedure lowers chances of developing still more cancer by 90 percent for high risk women. The good news is, plastic surgeons can build bosoms anew, using the body’s muscle and skin.

Surgeons favor rebuilding the breasts immediately after the mastectomy so the patient doesn’t wake and discover missing breasts; the shock can last a lifetime. Moreover, the imbalance created by a missing breast can affect the patient’s spine. In many cases, it is medically necessary to wear prosthesis to make sure the upper torso remains in balance.

In one type reconstruction, known as tissue expansion, the surgeon inserts an implant under the skin and, sometimes, the first layer of chest muscle (pectoralis), after a pocket is created. The doctor then inserts a balloon-like expander under the tissues and periodically injects a solution through the skin into a tiny valve to pump up the device. After several episodes, sufficient space is created for an implant.

“It’s just like pumping up a car tire, little by little,” says Mourene Tesler.

More positive things happened when surgeons found they could leave some muscle. And then later, they found they could leave more skin.

“Many other practitioners and health care specialists will examine a reconstructed breast and not be able to tell it from the real thing,” says Valerie J. Ablaza, M.D., at The Plastic Surgery Group in Montclair, N.J

In another case, a psychologist (who asked not to be identified) knew her mother, her aunt and both grandmothers had breast cancer. At age 36, and with her family complete with three small children, she saw a genetic counselor who found her BRAC 1 gene showed a mutation meaning she, the psychologist, has a 90% chance of developing breast cancer (and an 80% chance of developing ovarian cancer) sometime during her lifetime. Two weeks later, she underwent a double mastectomy, followed by skin expansion and implants.

One type breast reconstruction is known as a TRAM (transverse rectus abdominis myocutaeous) and rebuilds a breast from tissues in the patient’s abdomen. Other flap reconstruction procedures create a breast using skin, fat and muscle from the patient’s back or buttocks. Surgeons say the work includes a rebuilt nipple; the rebuilt breast and nipple are virtually indistinguishable from the real deal.

In some procedures, like the one had by a then 34-year-old Deede (who also asked not to be identified) of Inverness, Illinois, the surgeon – working totally under the skin -- creates a breast under her mastectomy scar by pulling part of her stomach muscle up into the chest.

“When I awoke from anesthesia and found only one breast, my first thought was happiness that it was gone,” says Deede. “I knew I could be there for my little guy -- a 14-month-old son -- for at least the next ten years.”

Some surgeons use a similar technique known as the DIEP (deep inferior epigastric perforator flap,) a procedure that takes tissue from the patient’s abdomen – but without sacrifice to the stomach muscles. Surgeons who use the DIEP process say the operation creates a natural looking breast that results in less pain and allows the woman to return to normal activities more quickly.

Yet another reconstructive procedure, known as EARLi, uses muscle from a woman’s back to rebuild a breast.

“Plastic surgeons have a number of techniques for recreating realistic nipples,” says Richard Lopchinsky, M.D., a clinical associate professor of surgery at Mount Sinai School of Medicine. “Virtually all surgeons feel the nipple is a high risk area for recurring cancer and remove it during the mastectomy.

The EARLi operation harvests the muscle in the rib cage commonly referred to as ‘lats” (latissimus dorsi.) Experts say that muscle is only necessary for those who want to be Olympic class swimmers or those who do many chin-ups. Working under the skin, the surgeon performs, not a mastectomy, but a lumpectomy to remove the tumor while leaving the nipple intact. The latissimus dorsi muscles are then rolled up to fill up the breast pocket.

Nobody seems to be tracking the numbers of patients who opt for preventive mastectomy. But it’s becoming common enough that more experts are studying patient outcomes, and reporting the generally excellent results in professional journals.

But whatever technique is used, more and more women are aware of the danger and use self exams and genetic testing to guard against breast cancer.

For more information visit Staff Report

Medically Reviewed by Dennis J. Hurwitz, M.D., FACS (

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Brent Frank