Thursday, October 1, 2009

Breast Reconstruction Report: "I wanted to heal my way"

By Lisa Bernhard

I was 29 years old when my gray-haired surgeon looked at me from across his desk and said, "I'd recommend a mastectomy." My dad, seated to my left, exhaled hard. To my right, my mom sat in silence. Family history had repeated itself: My grandmother underwent a mastectomy at age 39. Now it would be me. But in the four days since my diagnosis, I had researched and stumbled upon a choice my grandmother never had.

"It's OK," I said to my dad. "They can rebuild me."

They did. In one nine-hour procedure, a cancer surgeon performed a skin-sparing mastectomy, removing the nipple and tissue inside my right breast but leaving most of the skin intact. Then a plastic surgeon performed a free-flap reconstruction, extracting a portion of my stomach skin and fat and microscopically reconnecting it to my chest. Later, he reconstructed the nipple. The result was a breast that looks and feels breast.

In the 14 years since, my reconstructed chest has seen me through highs and lows: confident in an evening gown while reporting from the Oscars as a TV correspondent; sorrowful, at times, when standing naked under bright bathroom lights, the faint scars tracing my areola reminders of invading disease and scalpels. Yearly screenings send my heart pounding, but my surgery has helped me be hopeful about the future.

Of course, some women don't want any kind of reconstruction, sometimes due to health reasons or as a matter of preference. But women who do choose it report significant, lasting psychological benefits, in a way that transcends physical beauty, according to a study by Amy K. Alderman, M.D., assistant professor of plastic surgery at the University of Michigan Medical School in Ann Arbor. "Women tell me they feel whole again and more able to put cancer behind them," she explains.

Which is why I'm alarmed that many women don't know that options like the one I selected exist. Nearly 70 percent of women eligible for reconstruction aren't informed of their reconstructive options, according to a 2007 study by Dr. Alderman. Almost 65 percent of general surgeons said they believe patients lack interest in reconstruction, and less than one in four consistently refers breast cancer patients to plastic surgeons.

Meanwhile, plastic surgeons often limit the time they devote to cancer patients, because they tend to lose money treating them. Insurance reimbursements—which are roughly based on what Medicare pays—are paltry. In the case of free-flap surgery, plastic surgeons can charge $7,000 to $25,000 per breast; the average Medicare reimbursement in 2007 was $1,737. As a result, some doctors won't accept insurance for reconstructive surgeries, forcing patients to pay out of pocket. Others steer patients toward more profitable types of reconstruction, regardless of what's best medically, says Mark Sultan, M.D., my reconstructive surgeon and chief of the division of plastic surgery at St. Luke's-Roosevelt Hospital Center and Beth Israel Medical Center in New York City. Insurers reimburse implant reconstruction at roughly the same level as a flap, but surgery takes only about an hour. "Doctors may think, Why do a six-hour operation when I am paid the same amount for a one-hour implant?" Dr. Sultan says. "They may convince themselves, consciously or unconsciously, that the patient is a better candidate for an implant."

Comment by Dr C:

I completely agree with Dr Sultan and I strongly encourage all women considering breast reconstruction to research all their reconstructive options. Unfortunately, some patients will have to consider traveling for some of the more advanced procedures. A major consideration for most people is obviously cost. Patients must be aware of the practice of balance billing which can add thousands of dollars to the out-of-pocket expenses.


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