A Medical Quest

In Which I Talk About Breasts, the Old Ones and the Possible New Ones
Health and medicine explained.
June 21 2004 9:11 AM

A Medical Quest

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Illustration by Robert Neubecker

All of this abstract talk about breasts—other women's breasts, breasts in general—is of limited application when I am trying to think about cutting off my own. So, it's time for full disclosure. For years, other people liked my breasts more than I did. The usual pubescent discomfort with a changing body lasted longer for me than it does for many women: I thought my breasts were too large, and, looking androgynous and liking it, I didn't particularly enjoy having breasts. Over the years, as I got into better shape, they actually got a bit smaller. And I learned to like them—a lot. By the time I was in my late 20s, I had traded in my baggy, breast-concealing shirts for the Wonderbra. Breasts also turned out to be a lot of fun sexually.

At 34, I had a baby. A friend had warned me that breastfeeding was painful, uncomfortable, and inefficient. A male friend cautioned, "That will be the end of those great breasts." I responded that I'd gotten enough mileage out of them. I wanted to be a good mother, so I told myself and others that I'd try to breastfeed until the baby was a year old. She was born tiny, through an emergency Caesarian after her heart had stopped beating during labor, and, almost as soon as I was sewn up, she latched on to my breast and sucked so hard that my milk came in faster than it does for most new mothers. When she was six weeks old, Yael ended up in intensive care, and I spent two days running back and forth from the hospital to my house, where I would pump, and then to the hospital again, to deliver some fresh breast milk. When Yael was out of the woods, I held her on my breast almost constantly for weeks: She would sleep, wake and suck a bit, sleep again, and so on, until she had her strength back. In those weeks, when she was sick, I got mastitis (a blockage and inflammation of the milk ducts) three times; the pain was like nothing before or since, but I kept breastfeeding. So, it really should surprise no one that now, at 2-and-a-half, my daughter is still nursing. It is no longer a source of nourishment, of course, but it is a source of great comfort for both of us. Recently, at a restaurant, when we saw a friend with a five-month-old baby, Yael put her hand on my chest, and asked for reassurance that the baby eats the other lady's breast, not mine.

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This is all part of a bigger story about breasts: When I think of my breasts, I think first of the feelings they have inspired in other people—in my daughter now, in the women and men who touched them before she took possession of them. I suspect most women think similarly. In talking to women over the last few weeks, I have often heard post-mastectomy options stated as a choice between reconstruction and prosthesis. The latter, obviously, provides nothing but the benefit of having a correct silhouette in clothes, yet most women don't even consider going flat-chested.

When I was first thinking about a mastectomy, I figured I would forgo the reconstruction. The pictures of reconstructions I found on the Internet were hideous: blind, nippleless bulges with huge scars. Trading my beautiful breasts for ugly ones seemed like a terrible proposition. Whereas a flat chest was something I could etheticize, perhaps even re-awakening my long-ago desire for androgyny. At least I would have the advantages of not having breasts, which bounce, get in the way, and interfere with running or even driving over speed bumps.

But then friends invited me to a bathhouse. This is not something I do very often, but it's an activity I love, and an important social tradition in Russia, where I usually live. I imagined that if I didn't have breasts, I wouldn't feel comfortable ever going to the baths again. I get in the pool with my daughter during her weekly swimming lessons, and I imagine that every time I did that, I would be reminded of my lack of breasts. Worse, I imagine Yael discovering that I no longer had them. Even though I wouldn't consider a mastectomy until she is weaned, I think it would still be a painful shock for her. On the other hand, she is young enough that I can probably come home one day with changed breasts without traumatizing her.

So, what's a mastectomy, really? First a general surgeon takes out all the breast tissue he/she can get. No one can get all of it, which means some risk of breast cancer always remains. In the old days, a radical mastectomy also meant that the chest muscle was removed; the contemporary standard, a modified radical mastectomy, leaves it in place. The nipples, however, go; they are breast tissue. What is left is the muscle and what surgeons call "the skin brassier"—the empty envelopes of the breast with a hole where the nipple used to be. If a woman isn't doing chemotherapy or radiation, she can have reconstruction done immediately; a plastic surgeon takes over after the general surgeon is done. Plastic surgeons generally prefer this arrangement because it means they won't have to deal with scar tissue.

With each new invention, plastic surgeons make breast reconstruction more appealing, but still, the options for the woman shopping for new breasts aren't encouraging. Implants are the oldest known option. Following the surgery, the surgeon places a balloon expander under the remaining skin. Every few weeks, a doctor injects some saline solution into the expander, which forces the skin to stretch. Once it has reached the desired volume, a new operation is performed, to remove the expander and put in the implant, either silicone or saline-filled. Nipples are done months later, if at all, usually through a skin graft and a tattoo. The good thing about implants is that they look great in clothes. The bad thing is that they feel nothing like breasts to the touch. They also can get infected, puncture, burst, or form bulges. And they usually have to be replaced every 10 years or so. I don't want implants.

Then there are the "flaps," a term that refers to a variety of options for using a woman's own tissue to make new breasts. Surgeons can take the skin, fat tissue, and muscle from the back; they borrow the latissimus dorsi muscle—the long muscle of the back—and rotate it under the skin to the front, forming a pocket. It stays connected to its blood supply in the back. But it doesn't make much of a breast, so this reconstruction is usually combined with an implant. More breast value can be found in the lower belly, where nice, soft, breastlike fat tissue tends to collect. So, a similar procedure can be performed with the transverse rectus abdominus muscle, the lower abdominal muscle; the tissue is cut and slid up to the chest the same way. This is called the TRAM flap, and it is at once a breast reconstruction and a tummy tuck. The problem is, most of the abdominal muscle is removed, which means a woman has less strength in her belly and a seriously increased risk of hernias or bulges. Then there is the "free flap," where tissue, skin, and muscle are removed from the buttocks (most frequently) or the thighs, and reattached to the chest. Because in a free flap the tissue isn't attached to its old blood supply, the surgery is more complicated and the tissue is more likely to die. I don't think I'm a good candidate for the flaps. I love the gym; I travel often and heavy. Not being able to lift or jump or swing myself onto the top bunk on an overnight train seems like too high a price to pay for scarred, imperfect breasts.

Just when I am ready to go back to my original vision of a flat chest, I find out that a surgeon in New Orleans has developed a new flap technique that spares the muscle. The DIEP, or Deep Inferior Epigastric Perforator flap, is a procedure in which the surgeon cuts through the rectus abdominal muscle (the six-pack muscle) to get at the tissue and its blood supply. Then the tissue is slid up to the chest, but the muscle stays in place. There is a free-flap version of this operation too, where tissue is taken from the upper buttocks. The butt fat isn't as breastlike as the tummy fat—it's hard from having been sat on too often—but this is a good option for women who have no fat on their bellies. The rest of us can rejoice in the added benefit of a tummy tuck.

There are still issues, of course. There is the nipple problem. Adam Tobias, the young plastic surgeon who in February started doing DIEP flaps at Boston's Beth Israel Deaconness Hospital, assures me he can make a nipple: He takes a little skin from somewhere—pretty much anywhere—in the body, puts it where the nipple used to be, pulls it up and twists it like a flower or a star in an after-school art project, and lets it heal for some time, during which it usually shrinks by about 30 percent. Then he tattoos it and the surrounding skin the right color. Of course, there is no feeling in these nipples. And there may not be any in the rest of the breast. "The only sensation is what the native skin retains," says Dr. Tobias. "We tell patients not to expect sensation." There is also some risk to the muscle, which has been cut, but Dr. Tobias says virtually all patients can go back to their sports activities after six weeks.

This surgery is complicated, time-consuming, and expensive. Just two days before I went to see him, Dr. Tobias had performed a DIEP flap following a preventive bilateral mastectomy for a 25-year-old woman with a BRCA1 mutation. The plastic surgery lasted 13 hours, which means that, including the mastectomy, the woman must have been under anesthesia for about 16 hours. This patient was fine, but she spent over 24 hours in an intensive care unit. So, the hospital's bill was in the tens of thousands of dollars—and her insurance company may not be footing some or all of the bill for plastic surgery, which means she probably will be.

Plastic surgeons are unique among doctors in that they can be, and usually are, walking advertisements for their craft (it's hard to imagine a general surgeon talking with a twinkle in his eye about spreading the word on appendectomies, or even a heart surgeon hawking bypasses). Dr. Tobias is no exception. He says he is disheartened by the fact that as many as 90 percent of women do not opt for reconstruction following a mastectomy. He also says it's important to know that almost any woman could have the surgery, even if she is obese or suffers from diabetes. Finally, in response to my usual what-would-you-do question, he says that if his wife tested positive for a mutation, he would advise her to have a preventive mastectomy and a DIEP flap reconstruction. But, if she decided she wanted a flat chest, he would respect that too.

I am sold. Taking the pound of fat that has stubbornly camped out on my belly since I gave birth, moving that up to my chest, and winding up with a flat stomach, smaller breasts and a vastly reduced risk of cancer seems worth it. It helps to think of it not as reducing but as enhancing my body. Now I just have to wean Yael.

Masha Gessen is a Russian-American journalist who is the author of Words Will Break Cement: The Passion of Pussy Riot and The Man Without a Face: The Unlikely Rise of Vladimir Putin.

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