The breast reconstruction journey: What's changed since 1998?
It's hard to believe that the late 1990s were almost 30 years ago. At the time, America was on the precipice of entering a new millennium, and there was excitement about what things would be like as we prepared to enter the future. Y2K fears were real, and cell phones were more like bricks than the pocket-sized computers we use today.
Medical technology and health insurance coverage were also quite different at the time. When a woman received a breast cancer diagnosis, she wasn't always informed about her breast reconstruction options at the start of her journey. Even more disturbing, if she were presented with reconstruction options, her insurance company could classify the breast surgery as "cosmetic." Enter the Women's Health and Cancer Rights Act of 1998.
The was landmark legislation that sought to provide specific protections for individuals who choose to undergo breast reconstruction surgery in connection with a surgical procedure such as a mastectomy. As breast reconstruction techniques and technology have evolved in the ensuing years, critical gaps in coverage have appeared between the letter of the law and modern standards of care.
What's changed in breast reconstruction since the passage of that pivotal legislation, and what more needs to be done to protect reconstruction options for patients?
Understanding the Women's Health and Cancer Rights Act
The Women's Health and Cancer Rights Act, also known as WHCRA, was signed into law on October 21, 1998. The law's spirit requires that group health plans provide coverage for mastectomy patients who choose breast reconstruction after treatment. This can include all stages of reconstruction on the breast where the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses and treatment of physical complications.
Its goal was to expand patient choice and access to breast reconstruction coverage options. Traditionally, insurance providers could classify breast reconstruction procedures as "cosmetic" and not functional.
While the measure was supposed to offer comprehensive and affordable care and reconstruction options to cancer patients, the spirit of the law has not necessarily kept pace with the changing landscape of healthcare and technology.
Looking back to 1998 and breast reconstruction options
The modern world is evolving rapidly, and the "technology" of yesterday is almost unrecognizable when presented to younger generations who stare and shake their heads in disbelief when you talk about how you used to look up phone numbers in a giant yellow book connected to a phone booth by the corner store.
In terms of breast reconstruction options for patients, a lot has changed as well. Even in the 1990s, options were somewhat limited. Warren Ellsworth, IV, MD, can vividly recall the limitations women experienced.
"My mom was diagnosed at the young age of 33 when I was just one year old and had mastectomies with no reconstruction because in 1979, there were not many options that were very palatable, as you can imagine," said Dr. Ellsworth.
As medical advancements evolved, his mother was presented with new options to restore her breasts years after cancer.
"She waited decades until she found the specialty to go through reconstruction, and I saw how breast reconstruction really turned a light on and in her life," said Dr. Ellsworth. "She was single, my dad had passed away from cancer, and she was not dating, raising a family of four alone, and it just brought her confidence back. And so the power of reconstruction is so important for so many reasons."
By the 1990s, medical technology and how doctors and patients viewed breast reconstruction were shifting.
"In the 90s, we really had revolutionized implants and some degree of using tissue," said Dr. Ellsworth.
However, significant advancements in the art of breast reconstruction, such as nipple reconstruction and tissue-sparing surgeries, were still years away. More common procedures of the time involved transverse rectus abdominis myocutaneous (TRAM) flap reconstruction or saline implants. TRAM flap surgery means using tissue from a patient's lower abdomen to create a new breast.
Alicia Billington, MD, PhD, explained what has changed in terms of surgical techniques since the 90s.
"We used to do a lot of pedicle TRAM flaps and now we're doing a lot of microvascular surgery, free flaps, where we dissect out the vessels and we use a microscope and doing more muscle sparing techniques, also using free flaps, so taking tissue from one part of the body and putting it on another part of the body," said Dr. Billington.
The evolution of breast reconstruction since 1998
Another issue many patients faced at the time was the delay between cancer treatment or mastectomy surgery and reconstruction. Plastic surgeons were not always integral members of a patient's care team and were not consulted about breast reconstruction options until much later in a patient's recovery journey. Delayed procedures were more common, leaving patients often struggling with the mental and physical health concerns associated with their post-cancer body.
Dr. Billington noted that one of the most significant shifts in breast reconstruction from the 90s to now is the advancement of technology, which has enabled plastic surgeons to enhance the appearance and feel of a patient's result through new techniques and implant technologies.
"I think one of the biggest things that's changed for most plastic surgeons in the United States is we've switched from going underneath the muscle on a lot of reconstruction to above the muscle," said Dr. Billington. "And what that has allowed us to do is it's really changed the paradigm of what the timeline for breast surgery looks like. Instead of having, you know, two procedures, a lot of times you can do an immediate breast reconstruction where the patient wakes up on the day of the mastectomy and has implants already in."
That shift means more women already have some form of breast restoration when they wake up from their mastectomy.
"It used to be the standard," said Dr. Ellsworth. "You would have mastectomies and then get reconstruction later. Now it is extremely rare that a woman should have to wake up after a mastectomy without some degree of breast mound."
That's because, unlike in the 90s, more plastic surgeons are becoming part of the initial breast cancer team, working with oncologists, patients and other medical team members to develop a comprehensive cancer reconstruction and recovery plan from day one. This shift has enabled today's plastic surgeons to collaborate with other medical professionals, providing patients with more reconstruction options. Paired with newer techniques and innovative tools, breast reconstruction has undergone a significant evolution.
Dr. Billington also said that newer mesh options for breast reconstruction have been game changers for plastic surgeons and patients.
"I do almost all my implants now above the muscle, and there are new products out there like mesh that can help with positioning in the implant pocket," said Dr. Billington. "It's allowed me to help secure that pocket so we can get a really good result on the first try."
Breast implants have been around for decades. However, innovations in today's implants help achieve aesthetic results with fewer complications.
"We used to have a lot more rippling and ruptures, and the newer implants have lower capsular contracture," said Dr. Billington.
It means patients with the newer implants tend to experience less scarring or hardening around the implant, which can affect the shape and feel of the breast. Newer technologies and techniques are also helping plastic surgeons preserve more than the appearance of the breast.
"The real revolution and breast reconstruction has come with advancement and microsurgery, and the microsurgery world has changed, and how we can transfer tissue from different body parts, saving muscles, saving the function of where we take the tissue and rebuilding a breast, and in a very complex microsurgical way that really was not commonplace in the late 90s," said Dr. Ellsworth.
Not only are microsurgical techniques revolutionizing breast reconstruction aesthetics, but these techniques can also help reduce the potential for patients to suffer debilitating and painful complications such as swelling and lymphedema.
"In the same vein, we have had advances in microsurgical reconstruction of lymphatics," said Dr. Ellsworth. "You have probably seen or heard of cases where lymph nodes are removed, which is routine, and radiation is performed, which is also common, and women can get lymphedema or swelling of the chest and arm. We have newer techniques and lymphedema surgery that were simply not around, not even thought of in the late 90s. Now they're commonplace, and we educate all our residents about them, but they're not routinely covered by insurance, which is ridiculous."
What else seems ridiculous? Many insurers still tend to view the breast as purely aesthetic, placing little functional value on the body part, which has given them the ability to deny or delay reconstruction coverage. The breast and breast tissue are functional, and modern advances in medicine recognize that and are helping to preserve feeling and sensation.
"The other technique that I think is certainly new, which wasn't around, is neurotization, or hooking up nerves," said Dr. Ellsworth. "We were just trying to beat the prosthetic in the 80s and 90s, and build something that looks like a breast mound in clothes. But now we're trying to rebuild something that's warm, that looks natural both in clothes and naked, and also trying to make it sensate, which is, you know, next level, or next generation is what I call it. It's the next frontier."
He summed it up best when he explained, "If they can feel the hug of a young one, a little one, that's a big deal."
A lot has changed in 27 years, reshaping the ways patients and doctors approach breast reconstruction. In those 27 years, what has changed to keep pace with these advancements and allow all patients to affordably access the critical care and reconstruction options they need?
What comes next?
Dr. Billington's answer is simple when asked how advances have affected patient care and outcomes.
"Well, they make things better," said Dr. Billington.
Better mental and physical outcomes and fewer complications. WHCRA was groundbreaking at the time. However, it is perhaps not surprising that, with medical advancements in surgical techniques, fat grafting, imaging and pain management, the law and insurance industry have been slow to adapt to the speed of innovation.
"So, when you think about this lobbying, I think it's 27 years old," said Dr. Billington. "You think about, oh my gosh, all the changes that have happened just in technology, apply those to medicine, and we're in a completely different place now than we used to be."
If medicine has come so far in that time, shouldn't the legislation governing breast reconstruction and patient healthcare options reflect this?
WHCRA and the healthcare industry need a refresh in the way it approaches the care and coverage of patients who want to explore their breast reconstruction options without fearing significant financial fallout from their choices. With new advances comes the need for new legislation, legislation designed to put patients first and ensure they continue to have the breast reconstruction options they deserve.
To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.
