Breast cancer and best reconstructive options uros ahcan by New Breast

There are many misconceptions about plastic surgery and what we do in this speciality. I am grateful for this book because it will further help to create a true picture of a fantastic speciality that can do so much in helping to improve the quality of life for so many people. Per Hedén, Associate Professor in Plastic Surgery Akademikliniken, Stockholm, Sweden

It will be a must have book for every breast centre, and I have no doubts numerous patients and clinicians will benefit from reading this over the years. I look forward to seeing this in print and available for my patients. Venkat V. Ramakrishnan, Consultant Plastic and Reconstructive surgeon, Tutor in Plastic Surgery at the Royal College of Surgeons of England, London

The book is directed for plastic surgeons, general surgeons, general practioner, gynecologists, and oncologists and for anyone else who is looking for a unified source of information for practical and principled surgical management of breast cancer. Prof. Riccardo MAZZOLA, M.D., Consultant Plastic, Reconstructive and Aesthetic surgeon, president of the Italian Association of Plastic, Reconstructive and Aesthetic Surgeons, Milan, Italy

I am confident that this book will answer many of the questions that frequently arise when making choices. This book should be a must read for all patients and health care providers that are involved in the care of women diagnosed with breast cancer. Maurice Y. Nahabedian, MD, Professor and Vice Chairman, Department of Plastic Surgery, Georgetown University Hospital, Washington DC, USA

BREAST CANCER AND THE BEST RECONSTRUCTIVE OPTIONS

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BREAST CANCER AND THE BEST RECONSTRUCTIVE OPTIONS Restore your body and life. Choosing a stateof-the-art approach for modern women

prof. Uroš Ahčan

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prof. Uroš Ahčan

I have frequently wondered how to make the best use of my time. Whether to suture thin vessels under the microscope and give the tissue a new function and form, to reveal the exciting world of surgery to young colleagues, or maybe, to place the final period at the end of a sentence in the last chapter of a book that may be able to give people hope and joy. I am now old enough to know that making good use of oneâ&#x20AC;&#x2122;s time brings meaning to life, but this can only be done if one learns how to use time effectively and bring all the confusion that surrounds life into equilibrium. Doing so brings clarity to reality. Only then can one find wisdom. Life needs balanceâ&#x20AC;&#x201D;the balance between laughter and grief, joy and worry, play and work, success and failure. This is the only way we can grow. When we are old enough, and hopefully wise enough, we realize that we are not alone in this world because the successes we achieve are brought about by the people around us with whom we have shared the adventure of time and place, the places where our mutual interactions have molded us into who we are, and the mentors whose influence has guided our achievements. These experiences are our most valuable possessions, and they come with no price tag. Thank you to Nejka, my wife, and Hana and Ivona, my daughters, for their love and unending understanding and support. Thank you to my parents and teachers who made and molded me into the person that I am. Thank you to my friends who have inspired me and to my colleagues, with whom I have shared the wards of the hospital and the benches of the laboratory, for their dedication in putting aside their personal desires for the advantage of our patients. Thank you to those who have not seen things as I have and who have disagreed with me both openly and quietly for you have brought humility and honesty to my thoughts. And a sincere thank you to all my patients for their courage and inspiration, for their selfless help given to me and to others with whom they shared a similar predicament and for their kind and heartfelt words that fuel my work. Thank you all for allowing me to grow and to help build a better world.

BREAST CANCER AND THE BEST RECONSTRUCTIVE OPTIONS Everything you should know about breast cancer and breast reconstruction 1. edition Written by: Uroš Ahčan and others Edited by: Uroš Ahčan Co-authors: Janez Žgajnar, Maja Klarendić, Manja Leban, Andreja Cirila Škufca Smrdel, Doroteja Diallo-Renko, Tanja Marinko, Simona Borštnar, Barbara Gazič, Alenka Hofferle Felc, Mojca Kobal Petrišič, Lidija Jazbec, Ksenija Burgar, Maja Kern, Maja Potočnik, Elida Berlak Proofread by: Irena Kristan Bradač

BREAST CANCER AND THE BEST RECONSTRUCTIVE OPTIONS

Design and execution: TRIK Studio photography: Aljoša Rebolj Photography: Manuel Hahn, Miha Bernard, Uroš Ahčan Photos edited by: Manuel Hahn, Miha Bernard Illustrations: Urša Florjančič Printed and bound by: Schwarz print Circulation: 1000 copies

Restore your body and life. Choosing a stateof-the-art approach for modern women

Price: --- € Ljubljana, 2014 This book has been published by the author. The English edition of this book has been translated by Gašper Kvartič and reviewed by Charles Durant, MA FRCS (plast), consultant plastic surgeon and Simon Heppell, MB ChB FRCSEd (plast), Consultant Plastic Reconstructive and Aesthetic Microsurgeon Language localization was performed by Zachary Bohannan, MA, at Bohannan Communications.

www.urosahcan.com

CIP - Kataložni zapis o publikaciji Narodna in univerzitetna knjižnica, Ljubljana 618.19-006-089 618.19-006-089.844 AHČAN, Uroš Ko se življenje obrne na glavo : vse, kar bi morali vedeti o raku in rekonstrukciji dojke / Uroš Ahčan [in sodelavci] ; [fotografija Manuel Hahn, Miha Bernard, Uroš Ahčan ; ilustracije Urša Florjančič]. - 1. izd. Ljubljana : samozal., 2013 ISBN 978-961-276-865-2 269960704

Uroš Ahčan

Contents

Foreword

Author

Introduction

The breast as the central part of the female body The focal point of happiness and sorrow

The role of breasts through history

When the breast turns »bizarrely yellow«

Anatomy of the breast

Breast changes in old age

Diseases of the breast

Depictions of breast cancer in art

When a sharp blade just didn't cut it The breast and plastic surgery in the past

As an introduction

Surgical treatment of breast cancer and reconstruction in the past

History of breast reconstruction

Possibilities with one goal in mind: to help people

Historical stories and breast cancer

Breast cancer treatment

Breast reconstruction

Days of fear, anxiety and tears Basic information about the oncological treatment of breast cancer

101 Time cannot conceal every trace Treating the consequences of breast cancer treatment: breast reconstruction 102 The goal of reconstruction 103 Various methods of breast reconstruction 105 When can breast reconstruction be done?

109 In search of symmetry Surgical techniques of breast reconstruction 110 Oncoplastic surgical procedures 111 Reconstruction with the patient’s own tissue (autologous reconstruction) 114 DIEP flap reconstruction 118 Novelties: the use of 3-D technology in autologous breast reconstruction 121 Less common techniques of autologous reconstruction 122 Breast reconstruction with tissue from the back (latisimus dorsi flap) 123 Breast reconstruction using an implant and a tissue expander 130 Methods of breast reconstruction in cases of planned radiotherapy 133 A comprehensive comparison of the three most frequent methods of reconstruction

141 When good is just not good enough Additional operations and touch-up procedures for improving the aesthetic appearance 142 Shaping the nipple and the areola 144 Liposuction and lipofilling

Diagnosis: breast cancer

148 Procedures on the healthy breast

The path to correct diagnosis

153 Additional procedures after implant reconstruction

Determining the stage of the disease

A well-planned treatment is the way to success

Modern surgical treatment of breast cancer

Additional oncological treatment

The so-called “alternative” methods of treatment

Hereditary breast cancer and preventive surgical treatment

The scalpel: once wielded, now meticulously guided Surgical treatment of breast cancer 88

The development of surgical treatment of breast cancer through history

Surgical treatment of breast cancer today

Breast operations

Surgical treatment of regional lymph nodes

Surgical treatment of non-invasive breast cancer

Consequences of the oncological operation

155 Bearing the burden of choice Help with deciding FOR or AGAINST reconstruction 156 Making the decision about the type of operation 157 Research about the influence of the type of operation on the experience of breast cancer patients 158 The operative procedure is only one step on the path to recovery and rehabilitations, one step on the way to life

161 The 7 steps to victory Deciding for a modern, integral treatment of breast cancer 162 Treatment plan 162 The team approach to reach a collective decision 163 Additional help from a psychologist and patients from the breast cancer support groups 163 Getting ready for the operation 164 Surgical treatment: “B”-day - breast day

191 Home at last. Now what? Patient recovery after breast reconstruction 192 Recovery after the discharge from the hospital 199 Taking care of the scars 201 The influence of smoking on the recovery process 202 Weight gain after breast cancer treatment

164 Additional oncological treatment 165 Rehabilitation and reintegration

167 Fearlessly walking into the operation room Preparations for the surgical procedure 168 General anesthesia in breast reconstruction 171 Specialties in anesthesia during microsurgical tissue transfer 171 Individual anesthesia adjustment

205 There are many ways to get you smiling again Examples of reconstruction 207 Breast reconstruction by reshaping - oncoplastic surgery 209 Breast reconstruction using the patient's own tissue (autologous reconstruction) 218 Reconstruction of breasts using a tissue expander and anatomically shaped silicone implants 225 Complex cases of breast reconstruction

233 I only have one question... FAQ (Frequently asked questions from patients)

249 A breaking point … into a better, happier me! Opinions of the patients

173 B-day - Breast Day From hospital admission to discharge 174 Hospital admission

279 Reset or escape »Epilogue«

175 Going into the operation room, the operation 181 Hospital treatment after the operation and the discharge into the home environment 182 Physical rehabilitation 185 Respiratory physiotherapy after breast cancer surgery

291 Sources 292 Text sources 297 Image sources

Foreword

ome diseases can mark people for life, often scarring the body and the soul. Undoubtedly, breast cancer can have horrendous effects: not only can it leave visible marks on the body, it also has the ability to transform a loving wife and mother into a vulnerable victim and to turn what was once a happy family into a distressed husband and a group of terrified children. Today, 464.000 women get breast cancer in the EU every year. And the future of the »developed« world seems to threaten us with the possibility that breast cancer will soon affect the life of every eighth woman, and thus every eighth family out there. In the developed world, we use advanced technology that enables us to communicate effortlessly across large distances, to take a peek at the most remote and hidden places in the world and even to explore the vast and remote regions of outer space. We use nano-technology and mega-constructions, which can bring people close together but also pull them apart. Modern medicine plays an important role in maintaining the privileges of the developed world and common welfare. Less than a century ago, women with breast cancer could only be offered the orderal of an operation with a questionable and often daunting aftermath, but now, we can boast new knowledge in the field of genetics, early disease recognition, advanced imaging diagnostics, novel medication and the new technique of radiotherapy. Modern medicine doesn't just aim for the survival of the patients, but also sets higher goals - a rapid and complete recovery or even an improvement of the patient's previous health condition. All this is possible when surgically removing diseased tissue and, through reconstruction, restoring the shape of the breast and the integrity of the female body as well as the complete well-being of the patient. We physicians strive to make use of our time as efficiently as possible. We are immersed in our work at clinics, in the operating rooms and at highly specialised medical congresses. Alas, we often forget to share our achievements and discoveries with other experts (like family physcians and general practitioners) and the public. This is one of the reasons why too many women who have had breast cancer have been deprived of their former beauty and have been scarred - they are like the Amazon women of our time. People know about their right to vote; they are consumers, stocked with information about new generations of mobile phones, new car models, brand new clothing

collections and all sorts of other material goods, but only a few of them are aware of what modern medicine can do for patients with breast cancer. Despite the increase in breast reconstruction surgeries, nearly 70 percent of women who are eligible for the procedure are not well informed about their options for reconstruction. That is why you are reading this book. It is a book intended to help you when you are faced with a difficult choice, a book that can help you eliminate your fear of the unknown environment and the people in that environment, a book that will walk you through your time in the hospital and the operating room. It is meant to be read by breast cancer patients and by physicians and other members of the medical staff involved in treating breast cancer. Lastly, it is for everyone who hasn't yet been absorbed by the virtual world and wishes to know more about the challenges and the solutions faced by modern society. Modern people strive towards perfection, integrity, freedom, joy of life and a creative existence. Both men and women. Everyone of us - equal. Everyone of us - important. A world without women is an empty one, but a world without happy, cheerful women is a grieving one. Let's make this world a better place! Together. Uroš Ahčan

eing the most common form of cancer in the female body breast cancer concerns everybody. If we have not been affected by it ourselves we have family, relatives or friends that has. It is a disease that most women think of regularly and thus usually search information about. Today the internet is the obvious source of information for us but unfortunately in of the 21st century there is such an overflow of information that it is difficult to find the true and right one. Sadly much of what is found on internet is disinformation and faulty. Thus more objective information is needed. Dr Uros Ahcan has with this publication created a unique book for anybody who seeks objective and honest information about breast cancer and breast reconstructions. In most modern societies of the 21st century it is a woman´s right to be offered a reconstruction of the breast after breast cancer. Only a half decade ago breast reconstructions was basically unheard of. With the introduction of silicon breast implants in 1962 a foundation for a new breast reconstructive era was made. Microsurgical techniques introduced in the late 1970´s resulted in the use of the patients own tissue

(autologous) to rebuild the breast which became state of the art in the end of the 20th century. Today both implant based and autologous tissue reconstruction are widely used based on patients desires and biological conditions and we have also entered into a new era of fat transplantation as a compliment to both implants and autologous tissue transfer but also as a new stand alone procedure. Obviously this all makes it so much more difficult for patents to make informed consent about the reconstructive procedure she is going to go trough and this underlines the importance of this book. A book that can help patients better understand pros and cons of different procedures. Close to 20 years ago I realized the importance of honest and objective objective information about plastic surgery to potential patients and this resulted in the publication of two books, one Swedish and one English (Plastic Surgery and You). I am glad and honoured to see that this has partly inspired Dr Ahcan to write this book. To write a book for the general public on a medical condition is not easy for a physician. Educated and used to reading nonfiction professional book he has to adopt and change the way he usually expresses himself. If not the text would be difficult to digest and boring for non-professional. Dr Ahcan has indeed succeeded in writing an absorbing and engaging text that can be enjoyed by anybody. The book is very objective and covers all different aspects of breast cancer and reconstructions. For women who are unfortunate to be affected by this disease this book will be giving them invaluable information that is difficult to find elsewhere and it will also in this way give them more security in facing their treatment. I am impressed by this book, not only for its objective and fully covering text, but also for it´s very elegant layout. It has been truly delightful to read it but also to see its tasteful illustrations. The historical review underline how much things have changed in medical science and is a very interesting review of this evolution. It is definitely a book that I would recommend to anybody. Even if this book primarily is intended for the general public it is also of great interest for medical practitioners and especially for young plastic surgeons end even for the more experienced ones. There are many misconceptions about plastic surgery and what we do in this speciality. I am grateful for this book because it will further help to create a true picture of a fantastic speciality that can do so much in helping to improve the quality of life for so many people. Per Hedén, MD, Associate Professor in Plastic Surgery Akademikliniken, Stockholm, Sweeden

have known Professor Ahcan as a friend, professional colleague, international teacher, innovator and conscientious doctor, over the years, however, this book has shown me his impeccable skills and passion for writing. This book is an exhaustive compilation of information for not only the patients seeking breast reconstruction. But, it is an essential for all doctors, nurses, therapists, administrators involved in the field of breast reconstruction. This book sets out the ‘project’ of breast reconstruction following mastectomy, as a positive rehabilitative measure for the woman, in the unfortunate situation. It helps the distinction between cosmetic breast surgery and the reconstructive breast surgery, which is often blurred in the minds of patients and healthcare providers at times. The visit into the history is enlightening as well as reassuring to the reader. The chapters on the procedures are beautifully laid out, and offer all the information required to the reader. The final chapters from patients, offers a very personal and direct connection with a real life situation and it will be a great support to women in this difficult times. Attention to detail, excellent illustrations, and easy reading text, are the hallmarks of this effort. It will be a must have book for every breast centre, and I have no doubts numerous patients and clinicians will benefit from reading this over the years. I look forward to seeing this in print and available for my patients. Venkat V Ramakrishnan, MS, FRCS, FRACS, Consultant Plastic and Reconstructive surgeon, Tutor in Plastic Surgery at the Royal College of Surgeons of England, London

ith the many changes in breast surgery during the last two decades and the increasing need for interspecialty collaboration and cooperation, the seeds of “Breast cancer and the best Reconstructive Options” were sown. In order to have the most expertise in as many areas as possible, Uros Ahcan has chosen a multi-authored approach to this subject. The atlas format is intended to provide a “how to” outline for many procedures. The text on the other hand is meant as resource regarding important oncologic, tissue biology, genetics, reconstructive or aesthetic principles or issues. The contributions of and interplay between plastic surgeons and oncologists are presented for mutual benefit.

The female patient dominates the discussion. She is after all the patient at greater risk of or affected by breast cancer and to her the book is dedicated. The key to excellent operative results achieved by Uros Ahcan and his team lies in understanding and communicating with the patient, carefully analyzing her physical and psychological situation identifying her expectations and finding the means to help patients to accept their dramatic mutilation. Some illustrative case studies are self explanatory for demonstrating the outcomes obtained nowadays by the plastic surgery group in Ljubljana. This is a fine textbook about a key procedure, that is management of breast cancer. It has both the needed details and the necessary perspective and information for anyone with a strong interest in breast surgery. Its great strength is its emphasis on the importance of individualizing the appropriate procedure to answer the patient’s needs, not just anatomically but psychologically. The participants into this project – the author, the co-workers and the publisher – deserve praise for producing something that is different from most publications on this subject. But having the text and keeping it on the shelf, does little good for anybody. For the surgeon desiring to add this special field of endeavor to his activities, it represents a unique opportunity for learning. It is a resource of information that has to be read and reread in conjunction with clinical practice. For the patient to benefit, this book has a higher mission. It must serve as a consultant, a sort of guideline, with the admirable advantage of being always available and ever accessible both before and after surgery. The book is directed for plastic surgeons, general surgeons, general practioner, gynecologists, and oncologists and for anyone else who is looking for a unified source of information for practical and principled surgical management of breast cancer. We hope that the well trained general surgeon as well as specialists wishing to possess a volume dedicated to this subject exclusively, will find this text useful for the purposes for which it was written. But also the less experienced surgeon is provided with requisite information to achieve better and more consistent results. Last but not least, the patient will discover the unexpected outcomes of reconstructive procedures.

n the book, Breast Cancer and the Best Reconstructive Options, Uros Achan has beautifully reviewed and illustrated the essential elements that women diagnosed with breast cancer must be aware of. In the world of breast oncology and plastic and reconstructive surgery where the amount of information is continually increasing, it is important for women to have up-to-date information from an expert within the specialty. This resource provides just that and in a style that makes reading or perusing the book fun, enjoyable, and informative. Uros combines elements of antiquity with modern day science and includes beautiful and welldesigned illustrations and photographs that keep the reader engaged throughout the book. There are patient testimonials that women with breast cancer and providers that treat breast cancer will relate to. The options for breast reconstruction ranging from prosthetic devices to autologous tissues to nipple reconstruction are clearly delineated and illustrated. Women will be better able to understand what to expect during the journey as she is taken through the steps of the initial diagnosis, the various consultations, management strategies, and all the way through recovery. I am confident that this book will answer many of the questions that frequently arise when making choices. This book should be a must read for all patients and health care providers that are involved in the care of women diagnosed with breast cancer. Maurice Y. Nahabedian, MD Professor and Vice Chairman, Department of Plastic Surgery, Georgetown University Hospital, Washington DC, USA

Author Prof. Dr. Uroš Ahčan graduated in 1995 from the Faculty of Medicine in Ljubljana. In 1999, he finished his PhD and passed the examination in plastic reconstructive and aesthetic surgery with honours (cum laude). From 2008 onward, he has been the Head of the university clinical department for plastic, reconstructive, aesthetic surgery in the University Clinical Centre of Ljubljana. He is a president of the Slovenian Association of Plastic, Reconstructive and Aesthetic Surgeons. He is a professor at the Faculty of Medicine in Ljubljana and currently teaches plastic, reconstructive and aesthetic surgery. The thorough knowledge and hard work of the Ljubljana school of plastic surgery, as well as a rich tradition in the field, is the basis for numerous internationally known lectures in the area of reconstructive and aesthetic surgery. In the last two years, Dr. Ahčan has visited and lectured at Georgetown University hospital in Washington, Mayo Clinic in Rochester, and other institutions in Las Vegas, Turin, Moscow, Sarajevo, Zagreb, Beograd, Dubai, Barcelona, Prague, Copenhagen, Istanbul and others. He has also presented at international congresses and performed live surgery. He has more than 300 published manuscripts, including numerous articles, papers for conferences, books and manuals.

• Consultant of plastic, reconstructive and aesthetic surgery, dealing intensely with the reconstructive and aesthetic surgery of breasts. • Head of the Clinical Department of Plastic, Reconstructive and Aesthetic Surgery of the University Medical Centre of Ljubljana. • President of the Slovenian Association of Plastic, Reconstructive and Aesthetic surgeons. • Professor and Lecturer at the Faculty of Medicine Ljubljana. • Internationally acclaimed and invited lecturer, author of numerous expert articles and books. • Recipient of the Derganc Award for medical publishing.

»My work is my life. There are only a few minutes a day when my thoughts are not with surgery, medicine, research or patients.«

Prof. Riccardo MAZZOLA, M.D. Consultant Plastic, Reconstructive and Aesthetic surgeon, president of the Italian Association of Plastic, Reconstructive and Aesthetic Surgeons, Milan, Italy

Introduction »Life is like riding a bicycle. To keep your balance, you must keep moving.« (Albert Einstein)

Life is supposed to be beautiful, colorful, and diverse. It is, on its brighter side, full of opportunities, challenges and simple pleasures, while on the other, darker side, it can also be riddled with worry and troubles. Different periods of life confront us with different trials, most of which are predictable and solvable and these can simply be taken as challenges or opportunities for our personal growth. Yet life also has the ability to sometimes lead us to a dead end. We end up being frightened, alone, clueless and lacking the will to live. One word that typically brings us to such a dead end is CANCER. We find ourselves facing a tall barricade and hopelessly wondering: »Why me? Why my family?« Still, after the first few sleepless nights, after days of being anxious and afraid while looking for answers, we must face this question: What is tomorrow going to bring for me and people close to me? Our heads are filled with distracting questions such as these. But rather than finding answers to questions like »Why?« and »Whose fault is it?« is figuring out »How?«. How do I solve this problem? How do I find the right way? How do I return to the sunny side of life? We have to set goals - goals that will be achieved while regaining our previous well-being. Step by step. Battle by battle. All for the cause of a final victory that will leave us stronger, wiser and more experienced. When faced with the diagnosis, patients with breast cancer frequently shut themselves off and become passive, powerless and prone to soaking up all sorts of different advice like a sponge. As though coming to the crossroads of a thousand paths, the majority of people get completely lost and give up. What was once a spirited and creative personality, full of vigor, finding joy in long hours of telephone conversations, taking the pets for a walk, shopping, home decoration, new hairstyles, earrings, fashionable skirts, the achievements of her children, family holidays or a lover's embrace becomes a sorrowful, frightened and helpless being stressing over her own survival and the future of those closest to her.

When a woman is diagnosed with breast cancer, there are several important decisions to make. They have to be rational and based on verifiable, concise, first-hand information. The patient is obliged to take responsibility in finding true, sensible, carefully considered solutions. She needs to know what is in her power to do, what the family can do and what the art of medicine and the physicians are able to do. During treatment, everyone plays a part. Cancer is but one of numerous diseases, so what the patient needs to do first is accept the fact that she is ill - that she has cancer and needs help and medical treatment. When patients are informed that they have been diagnosed with breast cancer, in most cases, their entire world falls apart. They often feel like their life has been turned upside down and that all the issues they have dealt with in the past have lost their meaning and significance. Being under-informed and inexperienced, they find themselves in a situation entirely new to them, and they are at a loss to know how they are supposed to act. Frequently, they are left alone, struggling with numerous serious questions on one hand and a multitude of diverse, often contradictory, answers on the other. A hapless victim of life, they can feel like a mouse surrounded by mousetraps and hungry cats. Those wishing to find more information online are flooded with over 400 million hits when they put in the words »breast cancer«. Decisions based on online information, lay opinions and inexpert advice can have a significant negative impact on the choice and the timeliness of the treatment, adding to the confusion and bringing more sleepless nights. Instead of frantically searching a flood of information for the right answers, she needs to find a proper team to assist her in going through this difficult time of her life. A woman needs the help of a group of qualified professionals: a family doctor, a surgical oncologist and a plastic surgeon, a medical oncologist, a radiotherapist who works with systemic treatment and radiation, a psychologist and other experts. Everyone that is in-

volved in the process of treatment needs to have access to true, up-to-date and professionally verified information. They also need to know everything about cancer treatment, the consequences, the process of restoring a woman’s physical integrity and breast reconstruction. Another group of people who undoubtedly play an important part is the patient’s family and friends. Their understanding and support are a vital part of the treatment, and their presence and encouragement can make it much easier for the patient to think clearly and to make important decisions. Luckily, medical science in the so-called developed world has very high standards and is able to offer breast cancer patients the best forms of cancer treatment as well as address cancer therapy’s side effects. Alongside radiotherapy and the three methods of systemic treatment - hormone treatment, chemotherapy and biological therapy - surgical treatment has also rapidly advanced. Through advanced surgical treatment, which is the domain of surgical oncologists, experts can completely remove a tumor and the affected tissue (the lymph nodes), and reconstructive surgeons can reconstruct breasts using knowledge from the field of plastic surgery. By adequately distributing the tissue of the breast that is left after the excision of the cancer, using anatomically shaped implants of various shapes and sizes and incorporating free tissue transfer and microsurgical techniques, we can fashion a new breast that can come very close to the natural one regarding shape, size and volume. We are able to restore the wholeness of the body and even improve on the appearance and the structure of the body as they were before the disease. We can also help patients regain their self-confidence, creativity and the smile on their face. As you can see, a woman with breast cancer is in no way stuck in a dead end or facing an impassable barricade. She is, however, on a very busy and dangerous road - one that has been crossed many times before by many different patients - one in every eight women (!) for the developed world. It is highly recommended that a breast cancer patient receive some professional psy-

chosocial help. Together, we can walk her back to the sunnier, safer side of life - a supportive and understanding family, a professional medical team and psychosocial help from the patients who have already been there. When faced with the diagnosis, one must make the required preparations for the journey back to health. Every step on its own must be planned. A way out of trouble must be mapped. Treating breast cancer is a “project” that involves a large number of people. If they are in coordination and do their part with dedication and professionalism, the treatment is nothing more than a temporary unpleasant experience that, in the end, brings nothing but joy and relief, complete recovery and a collection of new experience and possibly new friendships as well, all of which undoubtedly improve the quality of life after the disease. And so, patients are advised to have courage, hope and will when embarking on the journey toward the most important goal of all - regaining your health, which will also bring a smile on your face again. And a smile is the most important accessory you can wear! Throughout this book, you will find a variety of good advice and appropriate solutions offered by modern medicine.

• The breast is not an essential organ. It does not have the biological importance of the heart, brain, lungs and liver, but it has been awarded an importance beyond its anatomic and physiologic usefulness. Over time, art and advertising have created a mystique that has made breasts both mysterious and casual. However, regardless of popular perception, breasts are a part of the body that conveys art, sensuality, femininity, and sometimes, identity to the female form. • From the ancient Egyptians onwards, there have been physicians who have tried to help women with breast cancer. They had the idea, courage and will to remove a breast, but many lacked the understanding of the disease nor did they have the technologies and medications that made their efforts safe, comfortable and successful. Sadly, the chance of saving a patient’s life, let alone preserving a woman’s feeling of self, was remote. • In modern times, one will find plastic surgeons who blindly follow the fashionible surgical trends. They are performers; they are neither advisors nor advocates for women. They are not thoughtful creators in the service of womankind. This predicament makes it worth the trouble for a woman in need to seek out a surgeon who understands not only the female anatomy but also the female psyche. Only then will the surgery’s results match the patient’s expectations. • The breast is a simple word, but it is one that, in the mind of a plastic surgeon, conjures a myriad of images. Thoughts of shape and symmetry, contours and size, and beauty and disfigurement all come to mind. • The diseases and the changes of the breast are diverse and numerous. There is, however, one thing they all share: they have to be recognized as quickly as possible and then treated using the best and most complete information available.

The breast as the central part of the female body The focal point of happiness and sorrow

â&#x20AC;˘ In the past, treating breast cancer was like going on an adventure, like wandering in the fog and the dark, or like climbing a steep cliff with no safety measures and no sense of direction. It was an unimaginable test with no chance of reaching the end. â&#x20AC;˘ Today, medical science has much more to offer. It can provide a tiring, but safe, journey with a clearly defined path, a multi-level security system and a clear goal. The journey from disease to health is largely predictable. The team of medical experts, each of them responsible for one of the steps on the journey, is a guarantee for hope, realistic expectations and success.

When a sharp blade just didn't cut it The breast and plastic surgery in the past

12 2

• A diagnosis of breast cancer is a life-changing experience. Any woman, regardless of her age, skin color, education, vocation or religious beliefs, will feel an instant sense of foreboding and mortality once the diagnosis reaches her ears, but it is also a time for courage and learning. Patients now benefit from a century of research and the experiences of those patients who have preceded them. • There is now a defined approach to diagnosis and, based on that analysis, a specific and concise approach to treatment. The only need is to find the medical team who will guide the patient and join her in this journey. This is important because the treatment is unique and individualized for every patient. • Breast cancer, in most cases, is a curable disease. There are several ways to treat the disease, be they surgical, medical or radiation therapy. • Genetic counseling can even define the level of risk for having a breast cancer. If such a risk is found, then the potentially dangerous breast tissue can be surgically removed, and thus, the disease can be avoided.

Days of fear, anxiety and tears Basic information about the oncological treatment of breast cancer

In modern medicine, the patients do not only blindly follow the instructions of the physicians, but cooperate and make decisions together with them. In order to do so, some general understanding about breast cancer treatment and reconstruction can be very helpful. It is wise for the patient to undergo any examinations or investigations advised by her physicians, who should be experienced in the treatment of breast cancer patients. On the basis of all of the examination results, the medical team can diagnose the disease (breast cancer), assess its stage and propose the proper treatment.

Diagnosis: breast cancer Cancer is a disease in which the mutated cells of various tissues start to replicate uncontrollably and can spread to other tissues and organs, where they can grow into healthy tissues (they metastasize and can spread metastases to distant organs through the blood or the lymphatic system). The loss of control over tissue replication is the result of an injury (mutation) in the genetic information (DNA) that cannot be fixed by the cell mechanisms and is therefore spread to all the ensuing cell generations. Mutations can have genetic origins, but in most cases, they are acquired and emerge randomly during the regular process of cell replication, or they are the result of harmful substances in the environment. Breast cancer is the general diagnosis for numerous types of breast cancer, and these can differ from one another quite a lot. When the patient receives her diagnosis, she needs to be informed that, in most cases, there exists an appropriate treatment for her disease and that there is a well-organized team of people who are willing to help her. Breast cancer is the most frequent of female cancers in the developed world. The incidence is on the rise and today, there are more than 330,000 cases per year in the EU, which is close to the average incidence rate in the developed world (1 out of 1000 women). The incidence of breast cancer has been increasing for many years in economically developed countries. Over the thirty year period of 1979-2008, the annual number of new breast cancer cases in women has almost doubled. It is predicted that in the future, every eighth woman will develop breast cancer. The most frequent victims are women between the ages of 50 and 70. But despite the rising incidence, the mortality from this disease is actually decreasing. The reason for this is organized cancer detection in the most vulnerable women (mass screening by mammography and the introduction of new, more efficient methods of treatment). The five-year survival rate without recurrence, which is basically the same as being cured, is 60-

Breast cancer and best reconstructive options

85% in Europe, according to data from various studies conducted during the last decade. Most patients with breast cancer are treated surgically. With about half of the patients, complete mastectomy is the treatment of choice, whereas with other patients, part of the breast is spared. Lately, breast reconstruction has become an integral part of treating breast cancer, and consequently, the oncologist may advise immediate reconstruction and therefore a visit to the oncological-reconstructive team at the very beginning of the patient’s treatment.

The path to correct diagnosis One of the key roles in breast cancer treatment belongs to the team of oncologists, which determines the correct diagnosis and the stage of the disease. There are several different types of breast cancer. Knowing what type of cancer the patient has helps the doctors plan the most appropriate and efficient treatment. Most frequently, breast cancer will emerge from the glandular epithelium - adenocarcinoma (the two most common being ductal carcinoma, where the cancer cells develop in the ducts that carry the milk to the nipple, and lobular carcinoma, developed in the lobules, where the milk is produced). It can be invasive (the cancer cells spread outside the lining of the ducts or lobules into the surrounding breast tissue), or it may be limited to the tissue of origin or in situ (the cancer cells are completely contained within the ducts or lobes). In rare cases, the breast can develop other forms of cancer, lymphoma or sarcoma. The cancer may be palpable and can be discovered through self-examination or clinical examination, or it may be impalpable and thus only detectable by screening techniques such as mammography (nonpalpable lesion). In diagnosing any type of breast cancer (be it palpable or non-palpable), the so-called triple test is of key importance and consists of:

Western Europe

18/89

Australia and New Zealand

15/85

Northern Europe

19/84

North America

14/76

Southern Europe

15/69

Central and Eastern Europe

17/45

South America

13/44

The Caribbean

14 /39

Rest of World

12/39

South Africa

19/38

North Africa

18/33

West Asia

14/33

West Africa

19/32

Southeast Asia

13/31

Central America

10/26

East Asia

6/25

Central-South Asia

12/24

Central Africa

• clinical examination • imaging methods (mammography, ultrasound, and magnetic resonance) • a biopsy to collect cells or tissue for microscopic examination (histopathological or cytopathological needle biopsy; in some cases, surgical biopsy)

13/21

East Africa

11/19

incidence mortality rate

The number of cancer deaths/cancer diagnoses per 100.000 people

80 This graph shows the incidence and the mortality rate of breast cancer throughout the world. Source: GLOBOCAN, IARC, version 1.2. Available at: http://globocan.iarc.fr/

Days of anxiety, fear and tears

• Modern oncological treatment of cancer is based on extensive research. It is constantly being updated, altered and improved, which provides new possibilities for patients. • Cancer cells can be killed in numerous ways. They can be removed surgically, by radiation or by various medications that reach the cancerous cells through the blood system (systemic treatment). • Every cancer is a riddle, an enigma in its own right. It needs to be read carefully (diagnosed) and then solved. In many cases, there is more than one solution. We may even combine several solutions to produce the most efficient one. • Local surgical treatment is based on the proper excision of tissue and the relevant lymph nodes. A rational and safe surgical treatment is only possible with good, multidisciplinary coordination of various experts.

The scalpel: once wielded, now meticulously guided Surgical treatment of breast cancer

Breast operations BREAST CONSERVING SURGERIES IN TREATING BREAST CANCER In the surgical treatment of breast cancer, there are various terms used to define breast conserving surgery techniques. They emerged in the course of the development of breast conserving surgery: quadrantectomy, lumpectomy, tumorectomy, segmental excision, partial mastectomy and wide local excision. In modern surgery, the term wide local excision is used. This is removal of the tumor with a margin of healthy tissue. The width of the margin is a subject of much debate. At the moment, there is a consensus that the width is not of that much importance; the only thing that matters is that, in the case of an invasive cancer, the cancerous tissue does not reach over the surgical margin. If we desire aesthetic results of high quality, the skin excision above the tumor must be planned very precisely. Quadrantectomy, which played a special role in the development of surgical treatment, was introduced by Veronesi in the 1970’s. This surgical technique is relatively aggressive and rarely used today.

105 The most widely used form of conserving surgical treatment of breast cancer today is wide local excision (WLE). The goal of this procedure is to remove the tumor (A) with a 1 cm safety margin of healthy breast tissue (B).

B A

Breast cancer and best reconstructive options

106

Despite the fact that the rate of patient survival after a less radical breast conserving operation is the same compared to mastectomy, the conserving operations have yielded a higher number of local disease recurrences, 0.5-1% a year. Most recurrences emerge in the region of the primary tumor. Although statistics say that the survival rate is basically the same, the recurrence has a significant impact on the psychological health of the patient. Some of the factors that have an impact on local disease recurrence are the width of the excised margin, the patients’ age (the younger the patient, the higher the possibility of a recurrence), additional radiotherapy and systemic treatment, and the properties of the tumor (extensive intraductal component, tumor size, lymph node metastases, malignant stage of the tumor and its expansion into the lymphatic ducts - lymphovascular invasion). With conserving breast cancer treatment, constant vigilance must ensure that local recurrences do not appear more often than 1-2% of patients per year, and must not exceed 15% in ten years. Some research has shown that after breast conserving surgery, 20-30% of patients end up with irregularities in the shape of their breast(s), which calls for an additional surgical procedure. Another study has shown that at least one in three patients is dissatisfied with the aesthetic outcome of a breast conserving operation. In cases when, at the time of diagnosis, the proportion between tumor size and breast size does not allow for a breast conserving operation, the patient can begin her treatment with neoadjuvant systemic treatment. Its goal is to reduce the tumor and make a later conserving operation possible. Every patient with invasive breast cancer needs to be informed about this modern treatment possibility because a breast conserving operation can be performed in every patient with whom a proper excision margin and a good aesthetic result can be ensured. This mostly depends on the proportion between tumor size and breast size; this is more important than tumor size on its own.

When doing a breast conserving procedure, the surgeon performs a wide local excision (WLE), thus removing the tumor with a safety margin. In most cases, it is possible to preserve the areola and the nipple. After removing a part of the breast along with the tumor, all kinds of tissue gaps may appear, and they require several kinds of reconstructive strategies, a good 3D perception and quality pre-operative planning. To perform a successful reconstruction, the surgeon must also take into account the size of the breast, the portion of the removed tissue, the location of the excision, additional radiotherapy and the specific response of individual patients to radiotherapy. All this makes reconstruction more demanding and all the techniques harder to handle, and as a result, the number of failed aesthetic procedures grows. If the histopathological tissue examination shows that the tumor does not have “clear margins” (the edges of the tumor reach into the surgical margin or the margin of the removed tissue), additional tissue excision must be performed at the location of the tumor. Pictured above are various aesthetic disturbances after breast conserving operations on the left breast.

Some attention is given here to the technique for operating on non-palpable changes, which have become very frequent owing to the widespread use of screening mammography. Treating these patients is a complex process that presents a technical difficulty and demands a multidisciplinary approach of various experts. Surgery is usually only a part of the collective treatment process for non-palpable breast cancers. As in palpable tumors, the “triple test” has to be performed: clinical examination, diagnostic imaging and needle biopsy. In this way, we can reduce the number of unnecessary invasive surgical biopsies. Surgical biopsy of a non-palpable breast cancer is advised only when a diagnosis of a non-palpable lesion by diagnostic needle biopsy cannot be obtained.

There have been many descriptions of numerous techniques for localizing non-palpable tumors including injecting blue dye, marking the skin, using a guidewire and using a radioisotopically marked colloid or a titanium seed containing a radioactive isotope. Wire localization was first used in 1960 and is the most widely used technique in the world. In this technique, the wire is inserted into the center of the non-palpable tumor under imaging control, thus marking the tumor. This technique does have its disadvantages: the wire can be displaced, and the surgical technique is quite demanding. Recently, a new technique– the ROLL technique (radioguided occult lesion locali-

107 Despite the preservation of the larger part of the breast after tumor excision, there are many factors which can all worsen the final aesthetic outcome. The removed tissue will make the affected breast smaller than the healthy one, which means that even poor remodeling during the procedure may cause breast asymmetry. The most unpredictable component of the aesthetic part of breast conserving treatment is radiotherapy. This is because its later consequences largely depend on the response of the individual patient and may manifest as discolorations or changes in the shape and size of the breast. Due to irradiation, the affected breast may sag less than the healthy one, or a part of the adipose tissue may change, which causes asymmetry. New techniques in the field of radiotherapy promise fewer side effects in the future. The picture shows the result of treatment after a preservative operation and irradiation of the left and right breast in two patients.

The “less is more” rule does not always apply to the surgical removal of affected breast tissue from an aesthetic point of view. In many cases, it is easier to remove the entire breast and make a reconstructive procedure of the entire breast than to only reconstruct a part of it.

The scalpel: once wielded, now meticulously guided

• Surgery of the breast, regardless of type (breast biopsy, breast augmentation, or breast reduction) always leaves a scar on the breast, but the scars of cancer surgery can be the most distressing. • Changes in breast shape caused by cancer surgery or as the result of radiotherapy may also be a cause of emotional turmoil. Even when these changes are small, they can be a focus of patient dissatisfaction and disappointment. • Depression and even personality changes have ensued in some patients. One might say that the soul is scarred as much as the breast. • Today, there is an array of options available to reconstruct the breast and achieve, once again, the harmony of the body and mind. Reconstruction can be an integral part of the initial treatment of breast cancer, or it can be done at any time thereafter. • A patient only needs to seek out the right surgeon in the right institution in order to restore the fullness of body image that was lost in the cancer operation.

Time cannot conceal every trace Treating the consequences of breast cancer treatment: breast reconstruction

final histopathological diagnosis of the removed tissue, patients have been advised to opt for a delayed primary reconstruction in recent years. This means that the removed affected tissue (which is then sent to be histopathologically examined) is immediately replaced with a filled tissue expander to keep the primary shape of the breast skin. If the histopathological analysis shows that radiotherapy is not necessary, the reconstruction with the chosen technique is performed in the second phase (operation). If radiotherapy is needed, the reconstruction is postponed until after the conclusion of radiotherapy (secondary reconstruction) and is usually

done with autologous tissue due to the possibility of complications with implant-based reconstructions after radiotherapy. Today, breast reconstruction in developed countries is a routine procedure with which we can lessen the consequences of surgical breast cancer treatment and restore the bodily integrity of patients. The word reconstruction itself denotes a variety of methods that are chosen for each patient individually after a holistic consultation (discussion, medical examination and consideration of the patient’s desires, commitments and priorities).

121 In primary (immediate) reconstruction, the plastic surgeon continues with the operation immediately after the surgical excision of breast cancer and forms a new breast in the same procedure. ONCOLOGICAL TREATMENT + PRIMARY RECONSTRUCTION

123

124

Primary reconstruction enables the skin to be preserved and thus makes better sensitivity of the reconstructed breast possible. The scars are located within the areola and on the abdomen. The picture shows the final result of immediate reconstruction of the right breast.

In delayed reconstruction, the scars encircle the breast and are also present on the abdomen. The picture shows the final result of the right breast delayed reconstruction with autologous tissue from the abdomen.

PRIMARY RECONSTRUCTION

SECONDARY RECONSTRUCTION

performed in the same operation as surgical cancer treatment → fewer operations, lower costs, fewer hospital days

the method of choice with planned radiotherapy

positive psychological effect: no period without a breast → an improved self-image, less chance of depression sparing the breast skin (± the nipple and the areola) → a better aesthetic result and skin sensitivity does not affect the plan of chemotherapy ONCOLOGICAL TREATMENT

SECONDARY RECONSTRUCTION

for patients who cannot decide on a primary reconstruction when faced with the diagnosis; they can take their time to think about the reconstructive options may be performed at any time after the surgical cancer treatment in the period between the first operation and the planned reconstruction, the patient can start dealing with some of the factors which may influence the outcome of their reconstruction: lose weight, stop smoking, regulate diabetes

122 Secondary (delayed) reconstruction is chosen by the patient, for various reasons, like correcting physical disorders, several months or years after the removal of the cancer or at any time after the conclusion of the oncological treatment. Thus, cancer treatment and the treatment of its consequences are two separate phases of the process.

106

Breast cancer and best reconstructive options

Time cannot conceal every trace

107

• The question “What will happen to my life?” is always followed by “What will happen to my body?” What does it take to keep your integrity, confidence, attraction and beauty? • There are a myriad of ways to help women restore their physical integrity - or, as we experts like to say - to reconstruct breasts. • Reconstruction is only performed if the patient wants it. It can be included in the breast cancer treatment or it can be done at any later time. It may even be performed in several stages. To form the new breast, we can usually use tissue that is already on the body - adipose tissue - which, under the skilled hand of the surgeon, takes on a new shape, function and meaning. Artificial materials can also be used.

In search of symmetry Surgical techniques of breast reconstruction

Novelties: the use of 3-D technology in autologous breast reconstruction Recreating an aesthetically pleasing breast demands a combination of good measurement, some artistic insight and some level of experience of the surgeon. To counter all the challenges that it brings, the latest technology has helped us develop a technique which enables us to plan the procedure better and to further personalize the whole process and its outcome. Modern technology enables us to scan body parts with a laser and render a 3D model using special computer software. This technology can also be used in autologous breast reconstruction. Before the procedure, we make a laser image of the healthy breast and then, using suitable computer software, render a 3-D model of the healthy breast. The model is then simply mirrored over, and a 3-D mold of the mirrored healthy breast is fashioned. The mold, which is a three-dimensional replica of the healthy breast, is used during the procedure to help us shape the new breast quickly, easily, accurately and reliably. The 3-D model makes it possible to perform the procedure quicker and to increase the

50 Laser scanning of the chest and computer programs make it possible to make a 3D model of the healthy breast..

100

Breast cancer and best reconstructive options

reliability of the result even when less experienced surgeons are performing, and on top of that, it warrants a very high degree of symmetry of both breasts with only one operation needed. This method is especially useful with delayed reconstructions, where there is no information about the weight of the removed breast, or when the anatomical properties of the chest have been altered (the presence of scars, poor quality of the skin, altered submammary fold). These are the least desirable conditions for breast reconstruction. Measurements are usually carried out a few days before the procedure, and then the technicians form a cast from a transparent material that can be sterilized. Immediately before the procedure, the mold is used to draw the incision lines of the operation, with special attention given to the location of the new breast on the chest. Then, the new inframammary fold, the upper edge and the side edges of the new breast (the footprint of the breast) are drawn on the chest. The mold is then sent to be sterilized and is used during the operation after the removal of the flap. The abdominal tissue is then easily, safely, and quickly formed into the new breast in the mold on the table next to the patient, while the abdominal wall (the source area for the flap) is being sutured. It is not necessary to further measure or weigh the tissue, neither to plan how to reshape it. We simply use the mold to shape the new breast, which will in the end be very similar to the healthy one in shape and volume, as it is its exact replica.

In search of simmetry

101

The goal of reconstructing breasts is to remove the aesthetic deficiency, restore bodily harmony and improve the psychological condition of the patient, which allows her to regain her confidence and creative spirit as well as overall quality of life. By using free transfer of autologous tissue and a knowledge of microsurgery or by employing anatomically shaped silicone implants of various sizes, a new breast can be made - one that is as close as possible to the real one regarding shape and size.

166 Autologous reconstruction of the left breast makes it possible to form the breast in any shape, size and degree of sagging as we desire. This is the easiest way to fulfill the wishes of the patient. Pictured here are the results of a primary DIEP flap reconstruction in various patients.

134

Breast cancer and best reconstructive options

In search of symmetry

135

• A good reconstructive surgeon is also a good aesthetic surgeon. Needless to say, he or she should have high ethical standards. Women expect this and deserve this. A patient who has or is about to have a surgical deformity inflicted on her body needs to know that she is under the care of a competent and highly skilled pratictioner who will be sensitive to her concerns. • For the surgeon, the operation is an opportunity to show his or her dexterity and artistry, the technical challenge of sewing small vessels or the precision of choosing the best implant for the patient. • Most importantly, the surgeon must become a colleague with the patient, guiding her through a complex arena of options and helping her understand what has happened and what is yet to come. • Excellence is attained when both the patient and the surgeon understand the three dimensions of cancer: the disease, the reconstruction and the healing. The patient is part of a team.

When good is just not good enough

Additional operations and touch-up procedures for improving the aesthetic appearance

• Even simple, everyday choices may bring stress and difficulty. But decisions about life and death, bodily perfection, and disfigurement can be excruciatingly demanding. Such situations and challenges can break people down. • When dealing with an important decision, one must give oneself enough time. It is also vital to consult professionals and people with a personal experience of the same sort. • A circle of close friends and understanding relatives can be invaluable when treading the path to recovery.

Bearing the burden of choice Help with deciding FOR or AGAINST reconstruction

The operative procedure is only one step on the path to recovery and rehabilitations, one step on the way to life The consequences of breast operations are not the only bodily changes that influence the patients’ experience of their own femininity, attractiveness and bodily image. Some bodily changes are temporary, like hair loss due to chemotherapy. This can be quite a burden because it is visible on the outside, but the hair grows back after the treatment. Other bodily changes are more long-lasting, like those linked to the changes in hormonal balance or hormone treatment, such as an increase in body weight, fever chills, or dry vagina. Some of them can be influenced, reduced or removed but others cannot. The further course of life is not only marked by the changes of the body, but also the patient’s awareness of vulnerability and mortality is increased, which is linked to the realization that the cancer can recur. This fear of recurrence is present in most previous cancer patients. It may surface more strongly even years after the finished treatment, especially in special conditions: during control examinations, when a familiar person develops the illness as well or experiences a recurrence, or when planning for the future.

193 This is a graphical representation of patients’ satisfaction with the results of breast reconstruction using information from a questionnaire answered by patients in Slovenia. The number of patients in the column (partially or completely) agreed with the statement below.

After their cancer experience, many women pay more attention to their bodies; the detection of only a minor disorder or a minor change in appearance may trigger a fear of recurrence. In time, the patients learn about the truly relevant changes, such as those that require a visit to the doctors, and learn how to cope with the renewed fear of recurrence and find support, think positively and find hope. If patient experiences difficulties, she may also seek professional help. Despite the disease and the perceived changes, our body is ours. After the experience of disease, we may perceive the body as unpredictable, less beautiful, or vulnerable, but it is ours, and it needs our care and our attention and a restoration of our trust. This can make us more prepared and more open for shaking the hand of those around us, for embracing the youngest ones, for confirming our partnership with intimacy, and for experiencing all the little joys and delights that make up our lives.

Obstacles are much like mountains; they are not going to move themselves and you have to take action to overcome them. Sometimes disease is just the first mountain you are going to conquer.

I agree completely.

I partially agree.

I do not agree.

87 70

I would advise other patients in a similar situation to have their breast(s) reconstructed.

A reconstructive surgery is a much better option than to be without a breast.

If I needed to decide again, I would choose the same.

I am not sorry for having chosen a reconstructive surgery.

This operation changed my life for the better.

Things turned out exactly as I have planned.

The result is exactly like I was expecting it to be.

194 This is a graphical representation of the psycho-social state of the patients’ health using information from the questionnaire answered by patients in Slovenia. The minimum possible value is 1 and the maximum value is 5.

GajaMaja 4,6

4,6

Average of the average score

Average score

4,6

4,7

4,6

4,6 4,3

192

191 Ferrata Via Della Vita (Path of life) is the hardest ferrata in Julian Alps (2265 m) and in many ways it symbolicaly resembles the content of its Italian name. On the picture is Bojana Bojanič climbing the ferrata one year after her autologous breast reconstruction.

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Breast cancer and best reconstructive options

Ararat, 5137 m. Bojana was standing on the highest Slovenian mountain - Triglav (2864 m) - just five months after her microsurgical breast reconstruction. On its third anniversary she stepped on her first top over 4000 m, soon followed by two mountains over 5000 m.

Is selfconfident in social situations

Is emotionally capable of doing what she likes

Is emotionally healthy

Feels equal to other women

Is confident

Feels feminine when wearing clothes

Got used to her body

Feels that she is normal

Feels like other women

Bearing the burden of choice |

Feels that she is attractive

159

â&#x20AC;˘ It is wise to split every tiresome journey you undertake into stages or steps. After every step, take a break and gather your thoughts as you prepare yourself for the next one. Plan and follow your personal quest. This makes the journey much easier and more predictable and the final destination more attainable.

The 7 steps to victory Deciding for a modern, integral treatment of breast cancer

very suspicious change in the breasts needs to be identified through a clinical examination and various diagnostic procedures (e.g., imaging techniques and fine needle aspiration) and lastly biopsy, a cytological or histopathological examination of a small piece of tissue removed from the lump or abnormal area and examined under a microscope, which accurately determines the type of cancer. On the basis of the ac-

quired information, the oncologist gives the diagnosis and determines the stage of the disease, the grade of the cancer (based on how the cancer cells look under the microscope compared with normal breast cells and the speed of their growth), its size and whether it has spread to the lymph nodes or another part of the body. Next, there are the 7 steps to victory.

Treatment plan A team of various experts talk to the breast cancer patient. The team consists of people who are deeply involved in systemic breast cancer treatment and radiotherapy, surgeons that are skilled in the various surgical techniques (tumor and lymph node removal) and reconstructive surgeons who are qualified to restore the integrity of the body (i.e., perform a breast reconstruction). The treatment plan involves a combination of various possibilities for every individual patient, and the possibilities are dependent the extent of the disease, its type, its size and location, the level of the lymph nodes affected, and various other factors. The plan for the oncological treatment of the cancer is prepared and suggested by the team of oncologists, and the surgical plan is suggested by a team of reconstructive-plastic surgeons.

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Breast cancer and best reconstructive options

The team approach to reach a collective decision A very effective approach is to discuss the patientâ&#x20AC;&#x2122;s case at an oncological-reconstructive council, where the surgical oncologist and the reconstructive surgeon talk to the patient (who plays a central role) individually. At the council, the surgical oncologist then presents the diagnosis and the options for oncological treatment (radiotherapy and/or supplemental systemic treatment before or after the procedure), which is suggested by various specialists involved in breast cancer treatment and is based on the type and stage of the disease. The plastic-reconstructive surgeon presents the options for reconstruction based on clinical factors like the patientâ&#x20AC;&#x2122;s age, body weight, the quality and quantity of tissue, the characteristics of the pectoralis muscle and the glands, breast ptosis, scars, her psycho-physical condition and preferences and the planned oncological treatment. For a better appearance and to achieve the optimal result of the treatment, the reconstructive surgeon may suggest various other aesthetic (symmetrization) procedures on the healthy breast. Based on suitable and integrated information, the patient makes the final decision and accepts her part of the responsibility for the choice that she has made. The final decision regarding the oncologic treatment and the type of breast reconstruction is made by the patient after the consultation.

Additional help from a psychologist and patients from the breast cancer support groups If the patient has difficulties deciding about the treatment on her own, she may also consult a clinical psychologist and/or patients who have already been treated for breast cancer and are happy to draw from their experience and offer their advice to selflessly help other patients. The patient may talk with other women from breast cancer support groups who have had mastectomies or reconstructions about their experiences and how to cope with all the challenges brought by the course of the treatment. Psychological help can be very helpful before the operation, during the hospitalization period and also during the post-operational rehabilitation and reintegration back into familial and social life.

Getting ready for the operation If the patient is familiar with all the therapeutic steps before, during and after the operation, she can avoid surprise and fear of the unknown. An integral part of the preparation process is also an examination and a conversation with the anesthesiologist, who introduces her to the anesthetic procedure, the process of being under anesthesia and waking up, and the care that she will receive immediately after the operation. Before the operation, it is strongly recommended to quit smoking, become psychophysically fit and adhere to a proper diet.

The 7 steps to victory

163

â&#x20AC;˘ After deciding to undergo a surgical procedure, the patient needs to become psychophysically fit and reject habits that may adversely influence the course and the outcome of the procedure. She is co-responsible for everything, which makes her a very important part of the treatment team. â&#x20AC;˘ It is the patientâ&#x20AC;&#x2122;s duty to get well-acquainted with the procedures of general anesthesia and to talk to the anesthesiologist. He will describe in detail the mechanics of the entire course of the anesthetic procedure as well as the various techniques for easing pain.

Fearlessly walking into the operation room Preparations for the surgical procedure

The thought of the surgical procedure filled me with fear, anxiety and worry. At the end, it turned out to be just another day for the surgical team, while for me it was a hopeful new beginning.

I felt like I was on an airplane flight into the unknown. My hands were tingling, I had butterflies fluttering around my stomach, my heart was pounding â&#x20AC;Ś After a few hours, I came back to the real world to discover a bouquet of red roses that had been placed next to me.

188

Breast cancer and best reconstructive options

B-day - Breast Day

189

â&#x20AC;˘ When the doors of the hospital close behind the patient and the doors of her home are opened, she feels happy to be in the familiar environment of her home again. Nevertheless, she is left without the attention and help of the medical team. In the beginning, even the most basic tasks can seem insurmountable and leave her irritated, worried and sleepless. â&#x20AC;˘ It is important that the patient makes everything ready, asks for help with the chores and babysitting even before she leaves for the hospital, and follows the instructions of the physicians after the procedure. â&#x20AC;˘ Trying to reintegrate into a normal life can be a very lengthy and complicated process.

Home at last. Now what? Patient recovery after breast reconstruction

In the beginning, the scars will be reddish and hard to the touch. The process of scar maturation may take up to a year before the scars fade and become softer. Later, the scars can also widen and become darker than the surrounding skin. It is important that the patient does not expose the scars to the sun in the first few months after the operation. Scar maturation can be partially

sped up by daily massage with a neutral greasy cream in the direction of the wound, by wearing compression garments and using silicone gel or silicone pads. Scar massage needs to wait until after the wounds have healed. Later (6-12 months after the operation) a scar correction procedure can be considered in cases of problematic scars.

209 Breast reconstruction with a tissue expander and a silicone implant will only leave one scar on the breast (under the areola, in the inframammary fold or on the outer part of the breast (left)). Reconstructing with the body’s own tissue also leaves additional scars on the area of the source of the tissue - the abdominal area and the area around the navel (right).

210 After the removal of the abdominal tissue, we try to conceal the scar the bikini line in the same way as it is done in aesthetic corrections of the abdominal wall. There will also be a scar around the navel, which is transferred to a suitable location during the procedure. The abdominal wall before (left) and after the breast reconstruction (right). 211 Wound healing is a complex process that can be affected by the surgical technique, the suturing material and possible complications (infection or a gap in the wound). The scar also, and mostly, depends on the properties of the tissue and the patient’s genetic predisposition. Scarring varies among individuals, and scars can even vary in a single patient on different parts of her body. Pictured here is scar variation on a single patient. Normal (A) and hypertrophic (B) scars are visible.

The influence of smoking on the recovery process There have been numerous studies that have proven the adverse effects of smoking. Smoking damages tissues and organs and is the most frequent preventable cause of untimely death. As a general rule, smokers are twice as likely to develop cardiovascular diseases as non-smokers. With female smokers, the risk is about four times as high as that of female non-smokers. The most harmful substances in cigarette smoke are tar, nicotine and carbon monoxide. Nicotine stimulates the brain to release more neurotransmitters, including dopamine, which is responsible for experiencing feelings of pleasure and consequent development of addiction. Nicotine also activates the sympathetic nervous system and stimulates the release of adrenaline. Adrenaline stimulates the body and causes a sudden release of glucose and an increase in blood pressure, respiratory rate and pulse. Nicotine and carbon monoxide damage the vessels. The harm done to the cardiovascular system by smoking can be split into two groups: acute and long-term. The outcome of the operation is mostly influenced by the immediate, direct (acute) effects of smoking. • Acute damage: during smoking, the heart beats faster and the arterial pressure is increased. This also increases the oxygen demands of the heart. At the same time, the arteries constrict, decreasing the blood supply and the delivery of oxygen, nutrients and drugs to the tissues, which can impair wound healing. Nicotine also damages the vascular wall and increases the chances of blood clot formation. • Long-term damage: most likely, smoking influences the conversion of LDL cholesterol into its oxidized form, which promotes the formation of atherosclerotic plaques on the walls of coronary and other arteries - it accelerates atherosclerosis and increases the risk of blood clot formation and thrombosis.

Passive smokers that inhale cigarette smoke, which contains a lot of carbon monoxide and nicotine degradation products, are also at increased risk for developing coronary artery disease. This is a well-known and documented fact. The mechanisms of the effects of tobacco smoke on a person’s health are the same as with active smoking. Even passive smokers inhale fumes with a lot of carbon monoxide and the products of nicotine dissolution. The acute as well as the long-term effects of smoking have a negative impact on wound healing in any type of breast reconstruction. Additionally, in cases of autologous breast reconstruction, smoking increases the risk of thrombosis in micro-vascular anastomoses, which may lead to a failure of the flap. The skin and subcutaneous tissue in abdominal flap reconstruction are sutured together under a great deal of tension, which by itself may compromise blood flow to that area. Because smoking may compromise tissue perfusion even more, smokers are at greater risk of developing wound dehiscence (opening of the surgical wound at the incision sites) and necrosis along the edges of surgical incisions. This is why it is very important for the patients to quit smoking before the operation. The use of nicotine patches is also not recommended. There are several organizations to help people quit smoking. By quitting smoking, patients can make a significant contribution to the final outcome of the operation, the survival of the tissue and successful healing of the wounds. It is not reasonable for the patient to expect excellent results from the surgeon if she herself carries on with habits that are harmful to her health and have a negative effect on the best possible result of the operation, which is what the doctors and the medical team strive to achieve.

A B C D

212 Patients may also be bothered by the different colors of the abdominal tissue and the skin of the breast, when the lighter color makes an “island shape” (A), the nipple tattoo fades (B), the nipple grows smaller (C) or the sides of the long abdominal scar develop “dog ears” (D).

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Home at last. Now what?

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â&#x20AC;˘ Every woman is different. Each of them has a different body; every one of them has a unique perspective on her options and the limitations of medical science. But they all share the same desire: to restore what has been lost. Every one of them carries with them a unique story right from the very beginning to the very end. â&#x20AC;˘ Surgeons that have sufficient experience and knowledge can offer the patient a variety of quality options to consider. This means a bespoke treatment for every woman. Individually. Not only can we replace the lost part of the body, we can restore physical integrity and even improve her bodily appearance as it was before the disease.

There are many ways to get you smiling again Examples of reconstruction

• The success of the treatment can only be achieved if the patient’s questions are properly answered, which allows her to avoid surprises that can be discomforting, fear-inducing, and a cause for worry. Her journey needs to be well planned to help her safely and quickly reach her destination. • It is reasonable for the patient to think about her treatment and write down every question that comes to mind. She is then advised to find the answers with the help of professionals who are working on her case and will be her companions on the journey. • Physicians can forget to mention some of the small details about the treatment because the procedures are a daily routine, but questions are always welcome. None are trivial. All are important and deserve answers.

I only have one question... FAQ (Frequently asked questions from patients)

What is breast reconstruction?

It is a surgical procedure or a set of procedures performed by a plastic surgeon with the purpose of restoring the shape and symmetry of the breasts and the physical harmony of the entire body after the surgical treatment of breast cancer. (More in chapter 5)

Which women can have their breasts reconstructed?

Reconstructive procedures are performed at the request of the patient and are in most countries financed by the medical insurance as part of the general breast cancer treatment scheme. Any patient can opt to have breast reconstruction, regardless of her age and the size and shape of her breasts. This includes patients who undergo preventive mastectomy (the carriers of mutations on the BRCA 1 and 2 genes). The reconstruction must not in any way influence the course of the oncological treatment, and all the factors with a negative influence on the outcome of the reconstruction (e.g., smoking, obesity, poor general health and planned radiotherapy) need to be taken into account.

What is the goal of reconstruction?

The goal of reconstruction is the correction of a visible disorder in the aesthetic appearance of the breast immediately after the surgical removal of affected tissue (cancer) or at any later time after the oncological treatment. A successful reconstruction can prevent or alleviate minor psychological issues left by the mastectomy. After reconstruction, there is no need to hide any aesthetic issues with prostheses. When clothed, the appearance of the breasts is very similar to their appearance before the operation and, in the nude, the new breast feels much more natural than a flat chest with a scar from a partial or complete mastectomy. All of the above can have a significant contribution to the feeling of femininity, attractiveness and confidence.

Does the insurance cover the expenses of the operation or do I have to pay myself?

In many EU countries as well as the USA, the operation is financed by the medical insurance, including the cost of the implants if they are required.

What is the waiting period?

The waiting period varies, depending on the number of patients that have chosen reconstruction. The suitable waiting period for immediate reconstruction, which is a continuation of the oncologistâ&#x20AC;&#x2122;s work in the same operation, is up to 30 days, whereas postponed reconstruction has no time limit. Immediate reconstruction undoubtedly has priority. Cancer treatment is prioritized before all other less dangerous health issues. In patients with immediate reconstruction, the proce-

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dure is a direct continuation of the oncological treatment. The patients that are waiting for a secondary (delayed) reconstruction do not risk any health deterioration because their oncological treatment has already been concluded, which means that they are cancer-free. Unfortunately, the waiting period for secondary reconstruction is getting longer as more and more patients opt for immediate reconstruction.

How do I choose my reconstructive surgeon?

The chosen reconstructive surgeon should be a person with the proper knowledge and experience, one that can be trusted and has a valid license. For large microsurgical operations in first-rate facilities, there are several surgeons who cooperate and simultaneously work on two bodily areas, which can significantly shorten the time of the procedure. The patient is also advised to acquire information about the number of procedures the surgeon has performed and their results. She can also ask the plastic surgeon to show her photographs of the results of his reconstructions.

What can I expect from the reconstruction? What are the results?

It is important to note that despite the hard work of the surgeons, the final result will not be identical to the previous state of the breasts. Only in rare cases can we achieve perfect symmetry with the healthy breast. However, a correct choice of the reconstructive method in the best facilities can yield excellent aesthetic results, a low risk of complications and many satisfied patients. It does need to be emphasized that the new breast does not have the same composition and function. It is, of course, not possible to breastfeed from a reconstructed breast. The sensitivity and the erotic capabilities of the new breast are also diminished. Despite this, most women with reconstructed breasts have a positive attitude toward the procedure and have no regrets. The success of microsurgical operations today is not measured only by the survival rate of the tissue that is transferred from one part of the body to another, but mostly by the satisfaction of patients - from being admitted into the hospital to the years and decades afterward. It is considered a success to use the whole treatment process and the restoration of the aesthetic appearance and symmetry to restore the bodily harmony of the patient and to help her reintegrate into her normal life and cope with further radiotherapy, chemotherapy, hormonal therapies or biological medication. Success also includes the fact that a patient no longer has to wear a prosthesis that reminds her of her disease (more in chapter 12). It is advised to have the breast reconstructed immediately, meaning in the same operative procedure as that in which the surgeon removes the affected tissue and the lymph nodes. Of course, such a procedure needs to be arranged, and an examination by the plastic surgeon is required. This is called immediate or primary reconstruction.

I only have one question...

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• “Patient” should be nothing more than a temporary label in the life of a woman. A patient is a human being, body and soul. She is a person capable of feeling, has good and bad habits and is going through the School of Life. Disease is an opportunity for her to become a better person, a wise person who appreciates her dreams and the beauty of existence. Scarred for life? NOT AT ALL. Instead, richer, happier and more creative, with a new set of values and goals in life.

A breaking point … into a better, happier me! Opinions of the patients

• Many times, I think how simple it would be to just press the big red button that says »RESET« or »ESCAPE«. And then, I receive the letter. It is a letter that warms my heart and fills me with happiness. I am happy to reach out and help someone get back up. I am happy if I can make other people happy as well. Happiness, I feel, is one of the most important things that spice our lives. Let the infectious enthusiasm of happiness spread throughout the world and make it a better place for everyone.

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n the last hundred years, women have climbed the social ladder and have come to prominent positions. They are gaining ground in sports, the arts and the sciences; they have even been to outer space. But what are the options for the 1.700.000 women in the world and the 400.000 in the EU that develop breast cancer each year? Research has shown that the women that have been labeled as “breast cancer patients” or “women without breasts” feel miserable. And a miserable woman brings the misery into her family and the entire society. Society, sadly, has not yet learned to recognize the problem and to provide solutions to all the dilemmas faced by breast cancer patients. After the surgical treatment of breast cancer, the woman leaves the hospital healthy, but with a bodily imperfection - the lack of a breast. The flat scar on her chest follows her around for decades and triggers a flood of negative emotions every time she looks in the mirror. Every time the patient picks up a bra, she recalls the most difficult part of her life journey - the struggle for survival. It is much better for the patient to leave the hospital healthy and with a whole body - with a new, reconstructed breast. This has been proven by numerous authors from around the world, who have unanimously shown through research that breast reconstruction, which is performed to restore the integrity of the body, has a positive effect on the self-image, the confidence, the creativity and the sexual life of the patients and generally improves the quality of their life. The subsequent conclusion that breast reconstruction must become an integral part of breast cancer treatment has also been generally accepted. We would expect that, at least in the developed world, breast cancer patients are being offered equal options and can return from the hospital healthy and physically intact. Sadly, this is not the case either in the developed world or in less developed countries. The newest research has shown that the number of reconstructions after surgical treatment of breast cancer is growing. However, we cannot particularly celebrate the fact that, on average, there is only one breast cancer patient out of five that has had her breast removed and reconstructed as well. Before the year 2000, the rate of reconstructions in the world was at a low average, between 10-20%. Today, it varies in different countries as well as their regions and may range from 0 to 70%. This demonstrates the lack of facilities for integral breast cancer treatment, poor organization and unequal options for women around the world and in the regions of individual countries. Research that included 13 federal states of the USA and 26% of American population has shown that the lowest reconstruction rate is in Alaska (4,5%) and the highest in Atlanta (35%). Between the years 2000 and

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2002, 16,8% of women in the USA got a new breast. In the developed parts of the USA, the rate of immediate reconstructions has been increasing at a rate of 5% yearly and is now close to 38%. The rate of reconstructions also depends on the age of the patients. In young women, the percentage is high (up to 70%), whereas in the group of patient between the ages 60 and 70, it drops below 10%. Even we, the doctors, frequently forget the fact that life expectancy in the EU goes above 83 years and that it makes sense to suggest reconstruction even to a patient over 60 years who is in good physical condition and has more than 20 years of life ahead of her. To account for the low percentage of breast reconstructions, we tend to quickly find some general excuse, like racial, ethical, religious or other differences among women. We argue that it is the women that are making choices about their own bodies. The truth is elsewhere. We first need to ask ourselves: What are the options that society is giving women today? I personally believe that almost every woman that would have the chance to wake up from anesthesia after her breast removal with a new, similar breast, and to do so without health risks, additional costs, lengthy operations and hospital days, a tiring recovery and various complications, would indeed choose reconstruction. It is a fact that modern facilities, which are deeply involved in the holistic treatment of breast cancer, use modern methods of treatment and employ the latest technology, come close to providing such conditions. At institutes like these, 7 out of 10 women decide to have their breast reconstructed simultaneously with its removal and wake up after the mastectomy to behold a new breast on their chest (the percentage of immediate reconstructions is 70%). Sadly, the facilities that could offer modern cancer treatment together with all the methods of reconstruction are few in number; there is also a lack of surgeons with the knowledge of microsurgical techniques that would be able to perform all types of autologous reconstruction. The causes for a low rate of post-mastectomy reconstruction are numerous and various. Too frequently, we see a deficiency in the cooperation of oncologists, radiologists and surgeons of various specializations. A large hindrance is also posed by egocentric individuals as well as inefficient transfer of knowledge to younger surgeons, who are quick to step over to the domain of simple plastic surgery and make good money performing lip filling, injecting Botox, and performing simple cosmetic breast enlargements.

1.700.000 The number of women in the world who develop cancer every year.

38 % 70 %

In the developed parts of the USA, the rate of immediate reconstructions has been increasing by 5% a year and is nearing 38%.

10 %

Nearly ¾ of young women have had their breasts reconstructed. This rate falls down to 10% in women over 60.

< 1:5

It cannot be particularly celebrated that less than one fifth of women with removed breasts have also had reconstructions.

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Another problem is family physicians, who represent one of the most important links in the chain of people responsible for treating breast cancer patients. Every day, the pharmaceutical industry presents these professionals with a variety of new medications and vaccines to prevent and treat a number of diseases. Family physicians are the target of the developers of new technologically advanced diagnostic and therapeutic machinery. Only a few of them fully realize all that modern medicine and plastic surgery has to offer for the breast cancer patient today. The rate or reconstructions also depends heavily on the type of medical insurance that the patient has and the need for additional payments from the patient’s own pocket. In the so-called developed world, preventive mammography examinations are available, which are used to seek and discover breast cancer in its early stage. Thus, we face a growing number of young patients with a much better prognosis. There are also genetic laboratories that help us discover individual women with inherited disorders of the genes responsible for repairing DNA (the carriers of mutations on the tumor suppressor genes BRCA 1 and 2). These women have five times the risk of developing breast cancer, and so they can opt for a prophylactic bilateral mastectomy. Undoubtedly, young patients with many decades of life in front of them would also expect to have their bodies restored besides being treated for breast cancer.

Unfortunately, we as a society are not ready for this. Most health policy planners do not recognize the problem and do not seek suitable solutions. Our perspectives on the female body and on the problem vary. We are aware of the intergenerational, religious, racial and cultural differences as well as the lack of will and money. But despite all this, it is not very productive for the insurance companies, the hospital management and the young surgeon to ask the question “Does it pay off? Is it economically feasible?” time and time again while the patients, who are underinformed about their options, conclude the discussion with question: “Is it even worth it?”. Men and women must come together and support the project “a new breast for every woman” to make the world a better, happier place. They should also do it for the sake of those that have been deprived of such an option in the past. Those patients can also be helped; their integrity and the smiles on their faces can be returned to them. The rate of reconstructions after mastectomy is shamefully low and differs among various countries and their regions. On average, less than 20% of women have a reconstruction after mastectomy. Every year, breast cancer leaves a mark on the bodies of 580.000 women in the world and 130.000 women in the EU.

244 The mastectomy rate was highest in central and eastern Europe at 77%, the USA had the second highest rate of mastectomy with 56%, western and northern Europe averaged 46%, southern Europe 42% and Australia and New Zeland 34% (www.ecco-org.eu). Mastectomy rates and breast reconstruction rates vary tremendously worldwide. Less than 20 % of women with removed breast have also had reconstruction.

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If the taxpayers of Great Britain paid for one less Eurofighter aircraft (valued at 21.000.000 £), this would enable 26.875 breast cancer patients to have their breasts reconstructed. Instead of financing the entire scheme of developing and making the Eurofighter, which is valued at 23 billion pounds, we could have 2.875.625 physically whole, happy and smiling women that have beaten breast cancer. * Taxpayers in the US pay $185.000.000 for their fighter aircraft.

www.theregister.co.uk/2011/03/03/eurofighter_nao_analysis/

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According to the French journal Football magazine, the best soccer players in the world receive a yearly wage that would suffice to restore the physical integrity of at least 4125 women. www.therichest.org/sports/highest-paid-football-players/

According to the latest information from Forbes, the highest paid models could renounce one yearly payment of 45 million dollars and could bring a smile to the faces of at least 5625 women. www.therichest.org/money/highest-paid-models/

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Life can be … … the sum of multiple short sprints in various directions. Running across a room full of artificial sweeteners and dyes and pursuing hidden signposts that are spun around by an invisible hand. … DIFFICULT, if the body and the soul are in discord because of their differing goals. It can be HARD if we continue to view our fellow human beings as adversaries and competitors. … SHORT, if we flee the real world and recede into the cloudy cage of our imagined reality. Surrounded by visual effects and auditory illusions, we are trapped in a fake - albeit ideal world of freedom and hope.

Life can be … … a marathon run with eyes wide open. A rhythmical movement across the infinite stretches of garden paths and concrete roads. Complete with ups and downs as well as stops that we ourselves choose. … EASY, if the body and the soul are allies that can forgive each other and together believe in passion and the power of will and share the same goals. … EASY, if we choose to make people our friends. … LONG, if we consider our ephemeral nature and live every day as though we are nothing but one-day guests of this world, like a flash in the pan.

Disease brings people closer to each other.

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I am honoured and most thankful for the reviews and forewords written by dedicated and highly skilled surgeons, rated among the top international breast reconstructive and aesthetic surgeons: Per HedĂŠn, MD, Associate Professor in Plastic Surgery Akademikliniken (Sweeden), Venkat V Ramakrishnan, MS, FRCS, FRACS, Consultant Plastic and Reconstructive surgeon, Tutor in Plastic Surgery at the Royal College of Surgeons of England, London, Maurice Y. Nahabedian, MD Professor and Vice Chairman, Department of Plastic Surgery, Georgetown University Hospital, Washington DC, USA and Prof. Riccardo MAZZOLA, M.D., Consultant Plastic, Reconstructive and Aesthetic surgeon, president of the Italian Association of Plastic, Reconstructive and Aesthetic Surgeons, Milan, Italy, who inspire my work greatly.