Self Breast Exam - Why it's important and how to do it.

From their 20's onwards, women should know how their breasts look and feel normally and report any breast changes to their doctor as soon as they are found. Finding something new does not necessarily mean there is anything to worry about, but it is important to get any breast changes checked out.

Women are more likely to notice changes by performing a routine (say monthly), step-by-step approach to examining their breasts (see below).

The best time for a woman to examine her breasts is when the breasts are not tender or swollen. Women who examine their breasts should have their technique reviewed during their periodic health exams by their health care professional.

Women with breast implants can still also do BSE. Breast implants can actually push out the breast tissue and make it easier to examine. Women who are pregnant or breast-feeding should also examine their breasts regularly.

Women who have already had mastectomy and breast reconstruction should also consider routinely examining their new breasts for any new changes.  Even though the natural breast tissue and breast cancer has been removed, it is still possible to develop a recurrence of the breast cancer (for example under the breast skin). BSE is often the first thing to alert patients to something new. Again, any new findings must be reported to a doctor straight away.

Women who decide not to do BSE should still be aware of the normal look and feel of their breasts and report any changes to their doctor right away.

How to examine your breasts (from the American Cancer Society's website)

• Lie down and place your right arm behind your head. The exam is done while lying down, not standing up. This is because when lying down the breast tissue spreads evenly over the chest wall and is as thin as possible, making it much easier to feel all the breast tissue.

• Use the finger pads of the 3 middle fingers on your left hand to feel for lumps in the right breast. Use overlapping dime-sized circular motions of the finger pads to feel the breast tissue.

• Use 3 different levels of pressure to feel all the breast tissue. Light pressure is needed to feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel the tissue closest to the chest and ribs. It is normal to feel a firm ridge in the lower curve of each breast, but you should tell your doctor if you feel anything else out of the ordinary. If you're not sure how hard to press, talk with your doctor or nurse. Use each pressure level to feel the breast tissue before moving on to the next spot.

• Move around the breast in an up and down pattern starting at an imaginary line drawn straight down your side from the underarm and moving across the breast to the middle of the chest bone (sternum or breastbone). Be sure to check the entire breast area going down until you feel only ribs and up to the neck or collar bone (clavicle).

• There is some evidence to suggest that the up-and-down pattern (sometimes called the vertical pattern) is the most effective pattern for covering the entire breast, without missing any breast tissue.

• Repeat the exam on your left breast, putting your left arm behind your head and using the finger pads of your right hand to do the exam.

• While standing in front of a mirror with your hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin. (The pressing down on the hips position contracts the chest wall muscles and enhances any breast changes.)

• Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and makes it harder to examine.

• This procedure for doing breast self exam is different from previous recommendations. These changes represent an extensive review of the medical literature and input from an expert advisory group. There is evidence that this position (lying down), the area felt, pattern of coverage of the breast, and use of different amounts of pressure increase a woman's ability to find abnormal areas.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in advanced breast reconstruction. He and his partners are in-network for most US insurance plans. Learn more about your breast reconstruction surgery options and connect with other breast reconstruction patients here. You can also follow Dr C on Twitter!

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How Much Does Breast Reconstruction Cost?

The two most common questions among breast cancer patients considering breast reconstruction are "how much does breast reconstruction cost?" and "will my insurance cover it?". The good news is that even though breast reconstruction is performed by plastic surgeons, it is NOT considered cosmetic surgery.

If the mastectomy is for breast cancer then the law states it must be covered by insurance. If the mastectomy is covered, the reconstruction will be too. The bad news is that even though insurance covers breast reconstruction, there are still some costs that the patient will be responsible for. Patients much research this ahead of time to limit the risk of a nasty financial surprise down the line.

While the degree of coverage varies based on the insurance plan, there are some things that are pretty standard. Effective June 1, 2010 even Medicaid will provide a benefit for breast surgery to the unaffected breast for symmetry, providing certain criteria are met. Breast reconstruction after prophylactic (preventive) mastectomy is usually covered as long as the patient is deemed to be high risk for breast cancer (significant family history or BRCA gene positive).

Even though insurance companies are mandated to cover reconstruction, breast reconstruction insurance laws do vary by state. The amount each insurance pays can also vary a great deal.

It is important to make sure your surgeon is in-network for your insurance plan if at all possible. This will limit your costs to whatever you've agreed to pay under the terms of your insurance plan (such as your deductible, co-pay and out of pocket expense). Using an out-of-network surgeon will likely subject you to other costs such as "balance billing". This is when the surgeon essentially sets his/her price (just to use an example let's say $1,000), receives whatever the insurance plan pays (let's say $600) and then asks the patient to pay the remainder (ie the "balance" of $400). This example is based on relatively small dollar amounts but you can see how this could add up to tens of thousands of dollars of additional bills for a major surgical procedure, and that's just for the first procedure.

Whether or not you can find an in-network, experienced surgeon depends on the procedure you've decided to have. If you've decided to have an implant reconstruction then you may have several doctors to choose from. Implant breast reconstruction is technically not as challenging as other options and most plastic surgeons perform the procedure.

On the other hand, if you're more interested in an advanced reconstructive procedure that not many surgeons offer (like a DIEP flap), you're likely to have a harder time finding an experienced surgeon to perform your surgery who is in-network. Most patients will unfortunately have to travel for their surgery because of this. Even though this may now add the cost of airfare and hotel stays, these costs are typically significantly less than a "balance bill" from an out-of-network surgeon.

Some breast centers even offer special arrangements to traveling patients such as significantly discounted hotel charges to help ease the financial burden.

Find answers to frequently asked breast reconstruction insurance questions here.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in advanced breast reconstruction surgery. He and his partners are in-network for most US insurance plans. Learn more about your breast reconstruction options and connect with other breast reconstruction patients here. You can also follow Dr C on Twitter!

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