Losing a breast as a result of breast cancer can threaten a woman’s sense of wellbeing beyond the disease itself. Eleanor Farmer joins consultant plastic surgeon Pari-Naz Mohanna in the operating room as she reconstructs a breast.
“You’re not on the floor yet?” asks the breast surgeon, aware that I’m an uninitiated observer. The removed breast tissue is bright red. The nipple, still intact, quivers as it rests on the scales to be weighed. It may have assumed many different roles in its lifetime, veering from erogenous zone to udder, but seeing it separated from the body, it is difficult to imagine it was capable of either of these careers. It has been removed because it is cancerous and in all its ugliness it is certainly representative of the disease. According to the latest research carried out by Cancer Research UK, one in every eight women will get breast cancer in her lifetime. 30% of those women will need a mastectomy, the operation to remove the cancerous breast.
In theatre 6, a woman lies anesthetised beneath three giant circular lights, everything but her torso covered in blue sheets. The breast surgeon has been sitting on a stool quietly separating the breast tissue, leaving behind the surrounding skin. Once the weight of the removed breast is calculated, he takes off his gown, collects his briefcase, and leaves the theatre. For some women, at this point the wound would be sutured and the operation complete. But for others there may be the option to have an immediate breast reconstruction. This woman remains in theatre, as a second team of surgeons busily remove tissue from the abdomen, preparing to reconstruct a new breast.
Pari-Naz Mohanna is the consultant plastic surgeon in charge of the breast reconstruction. The majority of her work is carried out within the National Health Service (NHS), treating patients who need reconstructive surgery as a result of cancers, traumas, or tumours. The aim of the reconstructive surgery is visual as well as functional. “Most things we reconstruct are visible to the naked eye,” Mohanna says. “With other types of surgery it’s inside, so you might see your result on an x-ray or by an organ functioning. We see our result at the end of the operation, on the table… I think that’s quite rewarding. Maybe a little self-indulgent because you can stand back and say ‘oh that looks great.’”
Mohanna and her registrar Katie Lancaster perform this type of operation once a week. Before the first incision, Mohanna marks the patient’s skin with a permanent marker pen. Like a tailor marking fabric for a handmade suit, she does not work to a template, but is guided by her knowledge of anatomy and the unique contours of her patient. “A lot of it is subliminal. It’s subconscious, because you do it every day; you do it without thinking” she says. Once the retractors, scalpels and microscopes are in use, the aesthetic side of the operation may seem distant, but her ‘design’ must last a lot longer than a season, so it is considered throughout. “We look at the breast in terms of size, shape, degree of ptosis (droopiness), skin quality, any changes from previous radiotherapy and any scars. We also look at the symmetry of the breasts and consider whether the patient wanted the reconstructed breast to match the other side…we always photograph our patients”, she adds. “People often forget what they looked like before the procedure.”
To someone who has spent more time studying art than science, the surgery seems like brutal sculpture. There are different methods; tunnelling tissue from one part of the body to the breast, inserting a silicone implant which can be expanded to stretch the existing tissue and skin, or lifting tissue from the tummy or back to form a new breast shape. The chosen procedure will depend on many factors specific to the patient and their disease, but all recreate the breast shape, which would otherwise be lost.
I spoke to Pauline Johnson, a patient of Mohanna’s, a week after her operation and we discussed her reasons for choosing reconstructive surgery. “I don’t think I could live with just one breast. I’m 65 and I know I’m getting old, but it’s your body isn’t it? I like to go abroad, I like to wear a swimming costume and I don’t feel I would be able to do that without a breast. I didn’t want to go home without anything. I don’t wear low-cut tops, but even just normal clothes… you would have to wear a high neckline wouldn’t you? You would need different clothes, special bras. It would be a daily reminder of the cancer.”
The National Institute for Health and Clinical Excellence guidelines state that following a mastectomy, every woman should be offered reconstructive surgery to rebuild the breast. Throughout the UK only 21% have immediate reconstruction. “Why don’t more women like Mrs Johnson go for breast reconstruction?” Mohanna asks, rhetorically. “Isn’t it natural that every woman would want to have her breasts reconstructed? Not all women are aware of their options”, she quickly explains. “So many women don’t know what’s available. They don’t think they can even request it because they think it’s a cosmetic procedure, that the cancer is completely different.”
Considering the different options can be difficult at the time of diagnosis. “Delivering the news to a patient that they have breast cancer is enormous” Mohanna says and continues: “How can the patient actually absorb that and take it in?” The current NHS target means that the time from the day of diagnosis to the first day of treatment must be no more than 31 days. “Patients have one month to get their heads around ‘I have cancer, what’s my prognosis? What’s the impact on my family, on treatment? What sort of treatment will I get to cure my cancer? What does it mean? What are the side effects?’ And then you throw another complication into the equation that they have to now consider breast reconstruction. You have to tell them about the options, they also have to select the one that’s right for them. Sometimes it’s too much, they want to just concentrate on one thing at a time. They want to get rid of their cancer.”
Mrs Johnson first found out about the different types of reconstruction on the Internet. “I knew I had to have a mastectomy and I knew I didn’t want to go home without a breast. I wanted something but I didn’t know what.” Having discussed the different procedures with Mohanna, she felt sure of the operation she wanted. “I didn’t want an implant. I wanted part of me. The new breast I have is recreated from my tummy, so there’s nothing false. I know one breast will feel different to the other, but I’ll get used to it. You will get used to it because it’s going to be you, isn’t it? From now on, that’s me. My body is not going to be any different.”
Both mastectomy and breast reconstruction are safe procedures, with a very low incidence of mortality or complications requiring emergency transfer to intensive care. The most recent national audit published in 2010, reported that there is no evidence to suggest that one type of reconstruction is better than another in terms of quality of life or patient safety. Mrs Johnson’s operation is called the DIEP flap. The name refers to the blood vessels called deep inferior epigastric perforators, which are detached when the skin and fat connected to them is removed from the abdomen and transferred to the chest to reconstruct the breast. The operation takes between 6 and 8 hours and involves delicate microsurgery to re-connect the blood vessels.
In theatre, Mohanna asks for the microscope. As a giant apparatus is wheeled over, the beam of light beneath it glides from the floor across the sterile sheets to the patient’s chest cavity. The overhead monitor shows the blood vessels come into focus. Using very fine forceps, Mohanna and another surgeon sitting opposite her begin to tease out an artery. On the monitor, the connection of the vessels looks like two plastic bags being stretched around the rim of a bin, which may make the process sound straightforward but bearing in mind that the vessels are the width of a piece of spaghetti, the reality is rather more impressive.
Not all patients across the UK are offered immediate reconstruction, Mohanna tells me. “In our unit 99% of patients having mastectomies have breast reconstruction, whereas in some units it is 0%. There is a lot of recommendation for this type of surgery to be available to all women undergoing a mastectomy.” Funding limitations mean that there is wide variation between what patients are offered nationally. One argument against including this type of surgery on the NHS is that it doesn’t save lives: “But it’s not just about life-saving procedures,” says Mohanna, “it’s about enhancing the quality of life.”
Mohanna’s own mother was diagnosed with breast cancer six years ago. “When you’re a relative or a patient you see things from a completely different perspective,” she says. “Having seen all the anxieties that my mum had, I didn’t realise patients would be worried or concerned about certain things. I would address all the main aspects of surgery. There might be things that patients worry about that they don’t even want to verbalise because they are embarrassed or scared. My mother’s experience has given me a real insight into the way women think when they are put into this situation and it’s not so much what they say, but what they are not saying.”
Mohanna’s mother had a delayed reconstruction: “For her that was the right thing to do. She said it was too much to consider immediate reconstruction. There are some women who will refuse to have a mastectomy if they aren’t offered reconstruction though. They cannot imagine themselves without a breast.”
“The most important thing to realise,” Mohanna stresses, “is that no two patients are the same in any way. Psychologically, physiologically, and pathologically all patients are different. As a doctor you have to be malleable enough to be able to identify that, address each patient individually and tailor your treatment to them.” The 2010 national audit has identified that patient choice for reconstruction is not the same throughout the country. Whilst no two patients are alike, shouldn’t every woman be offered what for her will be the best possible treatment towards a full recovery, both emotional and physical, no matter where she lives?
Back in the operating room, masked figures dressed in blue flow in and out, as scrub-nurses swap shifts, trainee surgeons come to observe, and the anaesthetic nurses refresh supplies of saline. The whooshing and beeps of equipment mix with an iPod playing Duran Duran and the dialogue of the operating teams. As Mohanna lifts a Doppler to her ear, the music and voices hush. Placing the probe in the centre of the new breast, she listens. Within moments, a pulsing noise fills the theatre, confirming the established blood supply to the new breast tissue.
Towards the end of the operation I watch Mohanna and her team recreate the navel after the abdominal tissue has been removed. The birth-scar that we all carry is retained. “Often patients think that because I am a plastic surgeon I can carry out scar-less surgery”, says Mohanna. For some people having a mastectomy it may not be possible to remove all the emotional and physical scars of the cancer, but offering reconstructive surgery gives many patients the best chance of returning to their normal life. A week later, when I see Mohanna’s patient Mrs Johnson on the ward, she seems remarkably buoyant. “I look like I have been in a fight”, she says. “It will take six months to settle down, but I’m here and I feel well. When I woke up from the operation I still had something there. It’s fantastic…you can’t thank them enough.”
Eleanor Farmer, 2011
“You’re not on the floor yet?” asks the breast surgeon, aware that I’m an uninitiated observer. The removed breast tissue is bright red. The nipple, still intact, quivers as it rests on the scales to be weighed. It may have assumed many different roles in its lifetime, veering from erogenous zone to udder, but seeing it separated from the body, it is difficult to imagine it was capable of either of these careers. It has been removed because it is cancerous and in all its ugliness it is certainly representative of the disease. According to the latest research carried out by Cancer Research UK, one in every eight women will get breast cancer in her lifetime. 30% of those women will need a mastectomy, the operation to remove the cancerous breast.
In theatre 6, a woman lies anesthetised beneath three giant circular lights, everything but her torso covered in blue sheets. The breast surgeon has been sitting on a stool quietly separating the breast tissue, leaving behind the surrounding skin. Once the weight of the removed breast is calculated, he takes off his gown, collects his briefcase, and leaves the theatre. For some women, at this point the wound would be sutured and the operation complete. But for others there may be the option to have an immediate breast reconstruction. This woman remains in theatre, as a second team of surgeons busily remove tissue from the abdomen, preparing to reconstruct a new breast.
Pari-Naz Mohanna is the consultant plastic surgeon in charge of the breast reconstruction. The majority of her work is carried out within the National Health Service (NHS), treating patients who need reconstructive surgery as a result of cancers, traumas, or tumours. The aim of the reconstructive surgery is visual as well as functional. “Most things we reconstruct are visible to the naked eye,” Mohanna says. “With other types of surgery it’s inside, so you might see your result on an x-ray or by an organ functioning. We see our result at the end of the operation, on the table… I think that’s quite rewarding. Maybe a little self-indulgent because you can stand back and say ‘oh that looks great.’”
Mohanna and her registrar Katie Lancaster perform this type of operation once a week. Before the first incision, Mohanna marks the patient’s skin with a permanent marker pen. Like a tailor marking fabric for a handmade suit, she does not work to a template, but is guided by her knowledge of anatomy and the unique contours of her patient. “A lot of it is subliminal. It’s subconscious, because you do it every day; you do it without thinking” she says. Once the retractors, scalpels and microscopes are in use, the aesthetic side of the operation may seem distant, but her ‘design’ must last a lot longer than a season, so it is considered throughout. “We look at the breast in terms of size, shape, degree of ptosis (droopiness), skin quality, any changes from previous radiotherapy and any scars. We also look at the symmetry of the breasts and consider whether the patient wanted the reconstructed breast to match the other side…we always photograph our patients”, she adds. “People often forget what they looked like before the procedure.”
To someone who has spent more time studying art than science, the surgery seems like brutal sculpture. There are different methods; tunnelling tissue from one part of the body to the breast, inserting a silicone implant which can be expanded to stretch the existing tissue and skin, or lifting tissue from the tummy or back to form a new breast shape. The chosen procedure will depend on many factors specific to the patient and their disease, but all recreate the breast shape, which would otherwise be lost.
I spoke to Pauline Johnson, a patient of Mohanna’s, a week after her operation and we discussed her reasons for choosing reconstructive surgery. “I don’t think I could live with just one breast. I’m 65 and I know I’m getting old, but it’s your body isn’t it? I like to go abroad, I like to wear a swimming costume and I don’t feel I would be able to do that without a breast. I didn’t want to go home without anything. I don’t wear low-cut tops, but even just normal clothes… you would have to wear a high neckline wouldn’t you? You would need different clothes, special bras. It would be a daily reminder of the cancer.”
The National Institute for Health and Clinical Excellence guidelines state that following a mastectomy, every woman should be offered reconstructive surgery to rebuild the breast. Throughout the UK only 21% have immediate reconstruction. “Why don’t more women like Mrs Johnson go for breast reconstruction?” Mohanna asks, rhetorically. “Isn’t it natural that every woman would want to have her breasts reconstructed? Not all women are aware of their options”, she quickly explains. “So many women don’t know what’s available. They don’t think they can even request it because they think it’s a cosmetic procedure, that the cancer is completely different.”
Considering the different options can be difficult at the time of diagnosis. “Delivering the news to a patient that they have breast cancer is enormous” Mohanna says and continues: “How can the patient actually absorb that and take it in?” The current NHS target means that the time from the day of diagnosis to the first day of treatment must be no more than 31 days. “Patients have one month to get their heads around ‘I have cancer, what’s my prognosis? What’s the impact on my family, on treatment? What sort of treatment will I get to cure my cancer? What does it mean? What are the side effects?’ And then you throw another complication into the equation that they have to now consider breast reconstruction. You have to tell them about the options, they also have to select the one that’s right for them. Sometimes it’s too much, they want to just concentrate on one thing at a time. They want to get rid of their cancer.”
Mrs Johnson first found out about the different types of reconstruction on the Internet. “I knew I had to have a mastectomy and I knew I didn’t want to go home without a breast. I wanted something but I didn’t know what.” Having discussed the different procedures with Mohanna, she felt sure of the operation she wanted. “I didn’t want an implant. I wanted part of me. The new breast I have is recreated from my tummy, so there’s nothing false. I know one breast will feel different to the other, but I’ll get used to it. You will get used to it because it’s going to be you, isn’t it? From now on, that’s me. My body is not going to be any different.”
Both mastectomy and breast reconstruction are safe procedures, with a very low incidence of mortality or complications requiring emergency transfer to intensive care. The most recent national audit published in 2010, reported that there is no evidence to suggest that one type of reconstruction is better than another in terms of quality of life or patient safety. Mrs Johnson’s operation is called the DIEP flap. The name refers to the blood vessels called deep inferior epigastric perforators, which are detached when the skin and fat connected to them is removed from the abdomen and transferred to the chest to reconstruct the breast. The operation takes between 6 and 8 hours and involves delicate microsurgery to re-connect the blood vessels.
In theatre, Mohanna asks for the microscope. As a giant apparatus is wheeled over, the beam of light beneath it glides from the floor across the sterile sheets to the patient’s chest cavity. The overhead monitor shows the blood vessels come into focus. Using very fine forceps, Mohanna and another surgeon sitting opposite her begin to tease out an artery. On the monitor, the connection of the vessels looks like two plastic bags being stretched around the rim of a bin, which may make the process sound straightforward but bearing in mind that the vessels are the width of a piece of spaghetti, the reality is rather more impressive.
Not all patients across the UK are offered immediate reconstruction, Mohanna tells me. “In our unit 99% of patients having mastectomies have breast reconstruction, whereas in some units it is 0%. There is a lot of recommendation for this type of surgery to be available to all women undergoing a mastectomy.” Funding limitations mean that there is wide variation between what patients are offered nationally. One argument against including this type of surgery on the NHS is that it doesn’t save lives: “But it’s not just about life-saving procedures,” says Mohanna, “it’s about enhancing the quality of life.”
Mohanna’s own mother was diagnosed with breast cancer six years ago. “When you’re a relative or a patient you see things from a completely different perspective,” she says. “Having seen all the anxieties that my mum had, I didn’t realise patients would be worried or concerned about certain things. I would address all the main aspects of surgery. There might be things that patients worry about that they don’t even want to verbalise because they are embarrassed or scared. My mother’s experience has given me a real insight into the way women think when they are put into this situation and it’s not so much what they say, but what they are not saying.”
Mohanna’s mother had a delayed reconstruction: “For her that was the right thing to do. She said it was too much to consider immediate reconstruction. There are some women who will refuse to have a mastectomy if they aren’t offered reconstruction though. They cannot imagine themselves without a breast.”
“The most important thing to realise,” Mohanna stresses, “is that no two patients are the same in any way. Psychologically, physiologically, and pathologically all patients are different. As a doctor you have to be malleable enough to be able to identify that, address each patient individually and tailor your treatment to them.” The 2010 national audit has identified that patient choice for reconstruction is not the same throughout the country. Whilst no two patients are alike, shouldn’t every woman be offered what for her will be the best possible treatment towards a full recovery, both emotional and physical, no matter where she lives?
Back in the operating room, masked figures dressed in blue flow in and out, as scrub-nurses swap shifts, trainee surgeons come to observe, and the anaesthetic nurses refresh supplies of saline. The whooshing and beeps of equipment mix with an iPod playing Duran Duran and the dialogue of the operating teams. As Mohanna lifts a Doppler to her ear, the music and voices hush. Placing the probe in the centre of the new breast, she listens. Within moments, a pulsing noise fills the theatre, confirming the established blood supply to the new breast tissue.
Towards the end of the operation I watch Mohanna and her team recreate the navel after the abdominal tissue has been removed. The birth-scar that we all carry is retained. “Often patients think that because I am a plastic surgeon I can carry out scar-less surgery”, says Mohanna. For some people having a mastectomy it may not be possible to remove all the emotional and physical scars of the cancer, but offering reconstructive surgery gives many patients the best chance of returning to their normal life. A week later, when I see Mohanna’s patient Mrs Johnson on the ward, she seems remarkably buoyant. “I look like I have been in a fight”, she says. “It will take six months to settle down, but I’m here and I feel well. When I woke up from the operation I still had something there. It’s fantastic…you can’t thank them enough.”
Eleanor Farmer, 2011