Who should consider breast reconstruction?

The choice about whether to have breast reconstruction after a mastectomy is a very personal one, and age does not necessarily have to figure into the decision. A lot of older women think reconstruction is not for them, but doctors like plastic surgeon Michael Loffredo, MD, at Cape & Islands Plastic Surgery say that plenty of older patients are great candidates for breast reconstruction.

“I have a lot of breast cancer reconstruction patients in their late 60’s or early 70’s who are just as enthusiastic about the prospects of getting their breasts reconstructed as younger patients. And they are very happy they did afterwards,” he said.

Dr. Loffredo’s experience mirrors a comprehensive study [pdf] done on whether older women enjoy the same benefits from breast reconstruction as younger ones do without a significant risk of complications. The study, published in the Journal of the American College of Surgeons [pdf] in December, included 1,531 women surveyed over two years.

Researchers concluded that there were no higher risks for older patients, but there were significant advantages, such as increased psychological and sexual well-being.

Study participants were broken into the following age groups: younger than 45, 45 to 60 and over 60.

After reading the study, breast cancer specialist Jill Oxley, MD looked at her own patients who have had mastectomies in the past year. She broke them down into the same age categories and discovered that in her practice, every patient under 45 chose reconstruction.

In the age group between 45 to 60, 57 percent had reconstruction. One third of her patients over 60 chose reconstruction.

“It goes to show that when you do offer reconstruction to older women a lot them choose to do it,” Dr. Oxley said. “But when I looked at the numbers more closely, everyone who chose reconstruction over the age of 60 was between 61 and 70. No one over 70 chose reconstruction.”

Dr. Oxley offered several possible explanations for this phenomenon. Older patients are less concerned about body image than younger patients. They are also more apt to be women who are experiencing a recurrence of breast cancer, she said.

“If they’ve already had breast cancer and had a lumpectomy and radiation and now it’s come back, they can’t have an implant reconstruction,” she said. “They have to have a tissue reconstruction. It’s a more involved surgery and a lot of older women don’t want to deal with multiple surgeries.”

Nationwide, there has been a growing trend to educate patients about breast reconstruction, Dr. Loffredo said. The American Society of Plastic Surgeons has made greater awareness about the procedure a goal. There is even a national Breast Reconstruction Awareness Day each year on October 18.

Many patients have the misconception that the procedure will be considered cosmetic and won’t be covered by insurance, Dr. Loffredo said. But, the fact is that the Women’s Health and Cancer Rights Act, passed in 1998 mandates that health insurance companies pay for reconstruction after a mastectomy.

Dr. Loffredo offered the following benefits of reconstruction:

• The ability to wear normal clothing.
• Feeling more comfortable in clothing.
• Feeling more comfortable when not wearing clothing.
• The ability to wear a bathing suit and swim without feeling self-conscious.

There are two kinds of breast reconstructions: immediate and delayed.

“Immediate breast construction, where the construction is done at the time of mastectomy, is ideal for many reasons,” Dr. Loffredo said. “One, we are able to save as much skin as possible, and I think we get a better result. The other reason is from a psychological standpoint. The patient wakes up with a breast, rather than having a time period with no breast.”

Immediate breast construction is done about 95 percent of the time in those who choose the procedure, he said. But some patients are not ready to think about it at the time of their diagnosis and just want to get through their mastectomy and think about whether they want reconstruction at a later time. There is no time limit on when a reconstruction can be done.

When older patients do choose to have breast reconstruction, many times Dr. Loffredo has to do a procedure on the other breast to obtain symmetry. Options include a breast lift, breast reduction, or even putting an implant in on the other side.

“We don’t make an age cut-off for offering breast reconstruction and I don’t think we should do that,” he said. “There are patients who are 65 who aren’t good candidates and there are patients who are 75 who will be good candidates. It depends on their overall health and desires.”