Dr. James Foley is holding up the ends of a large, diamond-shaped flap of skin he has just cut from the abdomen of his patient, 50-year-old Phyllis Arhart.
"Looks like a manta ray, doesn't it?" he says, a lilt in his voice.Foley, a St. Paul plastic surgeon, has been working for more than an hour in a chilly operating room in St. Joseph's Hospital here, and he is happy with his progress. The flap he cut from Arhart is also "happy," to use his term, because it is pink and nicely supplied with blood from one isolated artery.
Carefully replacing the flap, he inserts his hand in Arhart's stomach incision and his fingers extend to her breast incision. "Look, a tunnel", he says, lifting the skin.
Foley's next move is the most stunning of all. He gathers up the abdominal flap--the skin, fat and muscle--and stuffs it through the tunnel. Arhart's navel emerges up by her right arm pit and the tissue that was once her upper abdomen has suddenly become her right breast, replacing the one she lost to cancer.
As a nurse holds up Arhart's new breast with clamps, Foley stands back for a moment and admires his work. "She gets a tummy tuck and a new breast all in one," he says, as the three best violinists in the world play Vivaldi on the operating room tape player.
"This is where the artistry comes in," he says. The skin that was Arhart's navel now looks like a T-shirt with a hole in it. He cuts away some more tissue, trying to match the new right breast with the intact left one. At first, he worried that he would not have enough stomach tissue to form the new breast. Now, he sees that he has more than enough, and he is pleased.
"It's amazing how well that is bleeding," Foley says, gratified that all his careful work to keep the one crucial artery pumping blood to the flap of tissue has paid off. "I am getting personally excited about this case."
When Arhart wakes up three hours later--almost six hours after she went under the anesthesia--Foley and the rest of the surgical team are still there. He asks her what she thinks of her new breast. She looks down, sees a mound where it once was flat and says woozily,"It looks beautiful." A few minutes later, Foley escorts her up to her hospital room and tucks her in.
It is a thoughtful touch, and Phyllis Arhart will never forget it.
Ten years ago, if a woman told her doctor she wanted breast reconstruction following a mastectomy, the response was generally, "Don't be ridiculous. You are lucky to be alive." It was considered erotic or vain for a woman to want to repair her body.
But in the last decade, breast reconstruction has come into its own. Plastic surgeons are offering women more options for repair after cancer surgery, and insurance companies are covering the costs. The number of patients who are having their breasts reconstructed has risen in the United States from 20,000 in 1981 to almost 100,000 per year.
The transverse abdominal flap operation that Arhart had is among the newest advances in breast reconstruction. Foley has done only two others, and it was the first operation of its kind to be performed at St. Joseph's Hospital. Other available methods include:
-A tissue expander implant. A device like a balloon is installed under the chest-wall muscle after a mastectomy. Over a period of months, the expander is inflated with saltwater until it is larger than the size of the eventual breast to allow stretching of the muscles and skin. Then a permanent silicone implant is installed.
-Immediate installation of the implant. After the breast tissue is removed, a permanent silicone implant is inserted under the chest muscle. The implant can also be installed several months after surgery. Sometimes, if a patient's skin is too tight to accommodate the implant, a muscle is taken from the back and tunneled underneath the skin to the chest to provide a pocket for the implant.
-Transplanting buttocks tissue to the breast. This method recently was introduced by a New York City plastic surgeon. But because it leaves the buttocks unequal in size, it has not been performed often.
-Nipple reconstruction. Several months after breast reconstruction, plastic surgeons can take tissue from the high inner thigh and transplant it to the new breast to form an areola. The nipple itself can be formed from half of the nipple of the intact, undiseased breast.
Psychologists who have investigated the role of breast reconstruction in a woman's recovery from cancer surgery have concluded that it plays an important role. The studies say women feel more whole after the operation.
One year ago, the day after her right breast and some lymph tissue were removed in a semi-radical mastectomy, Phyllis Arhart looked at herself in the mirror and thought, "I look like a World War II Nazi experiment." Last week, relaxing in her Minneapolis home, she said, "The only thing that kept me going was the thought that I would have breast reconstruction.
Arhart, a playground director for the city of St. Paul, also knew what kind of reconstruction she wanted. Even before a recent, though inconclusive, study linking silicone implants with cancer in lab animals, Arhart decided she didn't want any foreign tissue implanted in her body.
"To me, silicone is like a microwave," she ways. "A microwave is nice if you are in a hurry, but I would rather have my roast beef cooked in the oven."
She had read a magazine article about doctors who were rebuilding breasts using patient's own abdominal tissue. It was the surgery she wanted.
"Foley was shocked that someone would come in and say this is what they wanted. He had done the surgery twice before, but he said it was better known on the East and West coasts. Well, I'm glad I read because I knew about it."
Arhart prides herself on her take-charge approach to life. If something doesn't work, she fixes it. Without this attitude, her cancer might not have been detected until it was too late.
Her yearlong medical odyssey began last October. "Medical months," she calls it. "That's my time to go in and have a physical exam, an eye exam, get my teeth cleaned and even take my dog to the vet."
When Arhart told her primary-care doctor that she wanted a mammogram, he said she didn'nt need one. He could feel no lumps. But Arhart said she has read in the news and heard on the radio that after a woman was 35, she should have a baseline mammogram-an x-ray technique that detects breast tumors before can be seen or felt. She insisted; he relented.
The following week, after the mammogram, she got a call from her primary care doctor. A small lump had been found in her right breast just beneath the nipple. She was told to see a cancer specialist.
"I was not too worried at that point because I am cystic prone, and I figured it was probably just a cyst," Arhart says. "But it was still hard waiting (for that appointment)."
The first appointment never came. On Nov. 30, 1987, at 10 p. m., she slipped and fell on the ice while locking up the building at a playground. She could hear the bone break near her ankle.
When she finally got to the cancer specialist's office, her broken leg in a cast, she received more bad news. There was a 12-to -1 possibility that her breast lump was cancerous. The doctor recommended a semi-radical mastectomy-removal of the breast and some lymph tissue.
"The two most recent cases (of breast cancer) that I knew were fatal," Arhart says. "I don't want to be dead next week. I will do whatever I can not to be dead next week."
On Dec. 17, 1987, the day after she got her walking cast, her right breast was surgically removed. Fram January to June, she had post-operative chemotherapy.
"You know, the good Lord knew that he was doing when he had me break my leg," she says. "I was so angry with my broken leg, I didn't even think about my breast. Here it was winter, my favorite season, and I love to go snowmobiling, skating, tobogganing and skiing. All of that was taken away when I broke my leg. I had to crawl up and down the stairs, crawl to get coffee from the kitchen."
During last summer's blistering temperatures, Arhart's $180 breast prosthesis was hot and bothersome. She resolved again to inquire about reconstruction surgery. When September came, and things quited down at the playground, Arhart made her first appointment with Foley.
Foley, 46, came to surgery after deciding that the Catholic priesthood wasn't for him. He spent one year in a monastery, but decided to go to medical school instead.
A plastic surgeon for the past 9 and one half years, Foley says he did his first breast reconstruction using the transverse abdominal flap method two years ago. He had never seen it done, but he says he had performed enough tummy tucks and read enough about the operation to feel confident that he could do it.
"Breast reconstruction is a good idea," he says. "It makes a woman whole again. A lot of my patients over age 50 choose not to have it done, but the younger women are very interested in it."
The transverse flap operation typically lasts four to five hours and is the most complex method of breast reconsruction. "There are two challenges," Foley says. "One is to harvest the (abdominal) tissue without injuring the blood supply. The second is modeling the breast--tailoring it to the body. You want symmetry."
Two weeks after the reconstruction, Foley scrutinizes his work in a postoperative checkup. The long abdominal scar and the lighter scars that run across and under Arhart's new breast still hurt, but they are healing. And Foley's goal has been met: In a brassiere, the woman looks "amazingly normal."
In February, Foley will add a nipple to the breast. It's what Arhart wants, and he agrees it's a good option for her.
Then she asks about taking judo lessons.
"No judo," Foley says. "Not this year."