Presenting All the Choices: Teaching Women About Breast Prosthetics Carol G. Kiefer, RN, CCM [Medscape Women's Health 6(5), 2001. © 2001 Medscape, Inc.] Abstract It is imperative that women facing breast cancer surgery have all their options for regaining body symmetry presented to them in a nonbiased manner. Today, women are more likely to receive information about breast reconstruction than about external breast prostheses. This may largely be due to the wealth of information available about reconstruction and the comfort level of the medical community in recommending this procedure. Breast prosthetic science is not taught in medical or nursing education programs, and few articles exist on the subject. Although the rate of breast reconstructive surgery is increasing steadily, there are still many women for whom wearing an external breast prosthesis is a comfortable and natural-looking alternative to further surgery. The hard, heavy breast prosthesis of yesterday has given way to a by-product of new technology -- a product designed for comfort and appearance. The breast prosthesis of today comes in many colors, shapes, sizes, and styles. Prostheses can be purchased with a nipple and areola. The higher-end forms are made of silicone, which can emulate the look, feel, and motion of natural breast tissue. Breast prosthesis manufacturers have listened to women who wear their products and have responded with many innovations. Women can now attach their prosthesis directly to the skin to keep it securely in place. Postmastectomy bras have also been modernized and improved to offer support for the prosthesis and comfort for the wearer. Wearing an external breast prosthesis should be presented to the woman facing mastectomy as a viable option after surgery. Introduction Women facing a diagnosis of breast cancer are often presented with many difficult choices. The amount of information they receive can be overwhelming. According to Gospodarowicz and colleagues,[1] the amount and depth of information the patient wishes to obtain is framed by the unique characteristics and values of each patient, and the practice of communicating the prognosis is not applied in the same manner to everyone. All Options for Regaining Body Symmetry Should Be Presented in a Nonbiased Manner. The interval between a diagnosis of breast cancer and surgical intervention is sometimes a matter of days. Often, these women are making a decision they will live with for the rest of their lives. It is essential that these women are presented with all of their options. As reported by Nissen and associates,[2] individual decision making is critical. If breast-conserving surgery and mastectomy with and without reconstruction are available choices for a patient, she should be informed sufficiently as to be able to choose what she believes is most appropriate for her. Women facing a mastectomy are given a great deal of information about reconstructive surgery but very little information about breast prosthetics. It is important that the information given not be biased toward any one choice. Previous research has shown that women who feel they actively participated in their treatment decisions have a more positive adjustment to their breast cancer surgical treatment.[3] The number of breast reconstructive procedures has increased 180% from 1992 to 1999.[4] Surgical techniques today produce aesthetically pleasing results. The option to have a feeling of permanence and fewer physical reminders of losing a breast appeal to women who choose reconstruction.[5] There are women, however, who do not choose reconstruction or who are not surgical candidates. For these women, a prosthesis is a viable option for regaining body symmetry. A recent quality-of-life study comparing women who have had breast-sparing surgery, reconstruction, and mastectomy reveals that of the 3 methods, women who had mastectomy without reconstruction experienced greater feelings of well-being.[2] Dramatically Improved Breast Prostheses Breast prostheses have improved dramatically over the past 25 years. Prosthetic designers study the movement and density of breast tissue in groups of women to develop prostheses that are lifelike in feel and appearance. Women of all ages can find a prosthesis that approximates the shape and drape of their existing breast.[6] Breast prostheses can be purchased in different skin color tones and with or without a nipple and areola. The internal composition of breast prostheses today may consist of water, silicone, glycerin, or latex. The skin of the prosthesis is usually a lightweight, hypoallergenic plastic film or silicone. The weight of the prosthesis is determined by the materials from which it is made. Silicone can be whipped to incorporate air, thereby creating a much lighter prosthesis. The weight of most breast prostheses approximates the weight of the natural breast as opposed to nonweighted temporary or leisure forms. Although there have been no empiric studies done on the physiologic changes experienced by women who wear an under-weighted breast form, anecdotal evidence supports the somatic complaints voiced by women. These complaints range from back, neck, and shoulder pain to "shoulder drop" of the affected side.[7,8] Women for whom the cost of a prosthesis or accessibility to a prosthesis fitter is a consideration have created their own prostheses out of available materials, such as cloth stuffing, socks, rice, and birdseed. There are directions on the Internet today outlining how to make a breast prosthesis out of nylon stockings and millet.[9] In warm humid climates, the organic materials may sprout.[10] They can also harbor fungi or bacteria that could cause infection if introduced to irritated or broken skin. Another problem with these methods is they do not provide enough weight to compensate for missing breast tissue or shape, feel, and contour. Silicone inside a breast prosthesis equally distributes weight over the chest wall. Natural grains do not adhere to each other and tend to sag heavily into the brassiere pocket. Women considering wearing a breast prosthesis may draw conclusions from hearing the complaints of friends and relatives who suffered with less technologically advanced, heavy prostheses and thus dismiss the notion that a prosthesis can be lifelike and comfortable. Women may borrow a prosthesis to save money, but just as with any prescription item, there is little chance that the borrowed prosthesis will be a proper fit. An ill-fitting prosthesis is not comfortable, nor does it give the desired look. A simple trip to an experienced postmastectomy fitter can alleviate many of the problems of wearing a breast prosthesis by ensuring a proper fit. Breast prosthesis manufacturers have listened to the women who wear their products and have made improvements in areas identified. Typical complaints and the improvements made are highlighted below. "Too hot" Women in warm, humid climates complain that their prosthesis is too hot and makes them perspire in their chest and abdominal area. This complaint is more prevalent in women with pendulous breasts that rest on the abdomen. The problem can be overcome by making sure that the brassiere worn with the prosthesis fits properly and holds the prosthesis in the appropriate area. Bra fabric becomes less elastic with use and should be evaluated for continued support at least every 6 months. Bras are being made with new, fast-drying fabrics that allow moisture wicking away from the skin. Pads can be applied between the prosthesis and the skin to absorb perspiration and decrease heat transfer. Silicone forms quickly warm to body temperature. By using the insulator fabric pads between the skin and the form, less thermal mass is stored and the discomfort cycle is broken. Lighter-weight prostheses may also ease the discomfort. "Too heavy" Most manufacturers offer a lighter-weight prosthesis that is more comfortable for women who are weight sensitive. Comorbidities such as osteoporosis of the spine, keloiding of the chest wall, and scoliosis (see Figure 1) often are associated with the inability to tolerate a weighted breast prosthesis. Again, a prosthesis that is properly supported feels lighter. The bra should be evaluated for wear and fit. A prosthesis that is too heavy has also been identified as possibly exacerbating lymphedema, although no empiric studies exist to prove this relationship. "Too artificial" Prostheses are available in many skin tones with a nipple and areola. Silicone forms feel like natural tissue in clothing. Prostheses made today come in many shapes and can approximate almost any breast size and shape. Combining layers of different densities of silicone can mimic the breast tissue of an older woman who has less elastic tissue and pendulous breasts. Firmer silicone gel can mirror the density of a younger woman's breast. The more expensive prostheses can duplicate the motion of natural breast tissue. "It may fall out and embarrass me" Several attachable prostheses are available on the market. The method of attachment varies from hook and latch strips to adhesives that can stick right to a woman's chest wall. These prostheses are appropriate for active women who need their prosthesis to stay put during movement. Women who cannot tolerate bra straps pulling downward over their shoulders also find an attachable form feels lighter and more comfortable as the chest wall helps support the form. Once again, the appropriate bra can help alleviate prosthesis slippage. Mastectomy bras have pockets that hold the prosthesis securely in place. "I am not in the size range" Custom prostheses can be made for the woman who cannot be fitted with a standard prosthesis. These prostheses can be extremely lifelike. They are made by either digitally scanning or casting a mold of the chest wall for the back of the prosthesis. The front of the prosthesis is a mirror image of the woman's remaining breast. In the case of a woman with bilateral mastectomies, she may choose a size that is appropriate for her body size. Custom prostheses are sometimes the only choice for a woman who has experienced extensive surgery to her chest wall and is left with deep concave areas as a result of bone and tissue removal. Custom prostheses are more costly because of the extraordinary amount of time required to make the forms. Many insurance companies cover a custom-made prosthesis. "I only had a lumpectomy, and I don't need a prosthesis" Partial mastectomies or breast-conserving surgeries are being performed more frequently today than total mastectomies largely because of earlier detection of cancers. Partial mastectomies can be anything from a lumpectomy to a segmentectomy. The woman still has her breast, but she has to contend with breast asymmetry. The prosthetic industry has recognized the growing need for partial prostheses. Many products exist that can accommodate the missing breast tissue and give the wearer a smooth breast appearance. Partial prostheses are also used by women who have undergone removal of cysts resulting from fibrocystic disease or who have had unsatisfactory reconstruction. Women with uneven breast development because of congenital syndromes or radiation to the chest wall for treatment of malignancies during childhood can benefit from partial prostheses as well. "I had reconstruction" When women have only 1 breast reconstructed, they run the risk of asymmetry if they gain or lose weight in the future. Natural breast tissue will respond to the change in the subcutaneous fat layer by changing shape. The reconstructed breast has had the fat layer disturbed and will not respond in kind. Implants can migrate, causing unusual fullness in the anterior or lateral chest wall. Some women are opting to have their implants removed completely.[4] They are sometimes left with a small tissue mound for a breast. Prostheses can be used to even out the change in appearance without requiring additional surgery. Immediately after her mastectomy, a woman usually wears a fiber-filled breast form (if allowed by her physician). Such forms add very little pressure to the incision site. The stuffing may be increased or decreased to match the woman's remaining breast. Bras and camisoles have also been designed to be beneficial in the postoperative period. The patient will receive permission from her physician to wear a weighted prosthesis at around 6 weeks postoperatively. Ensuring a Good Experience With Breast Prostheses Breast prostheses may be purchased from durable medical equipment vendors, women's specialty boutiques, pharmacies, catalogs and online vendors. Most of these facilities employ Certified Mastectomy Fitters, who are adept at assessing the patient's needs. It is extremely beneficial for the patient to be professionally fitted to ensure a proper, comfortable fit. Studies estimate that as many as 80% of women wear the wrong size bra.[11] Assessing the fit of the bra is part of the postmastectomy fitting procedure. The bra is an integral part of the successful external prosthesis experience. Assessment and fitting should be repeated at least every 1-2 years as breast tissue density and shape change in response to aging and weight changes. A prescription is required by Medicare and by most private insurance companies for coverage. Summary Women should be given information about all their options for cosmesis after mastectomy. This should include prostheses as well as reconstruction. The science of breast prostheses has advanced and the products available today are very lifelike and comfortable. External breast prostheses should be considered a safe and economical surgical alternative for women facing mastectomy. References 1.Gospodarowicz M, Mackillop W, O'Sullivan B, et al. Prognostic factors in clinical decision making: the future. Cancer. 2001;8:1688-1695. 2.Nissen MJ, Swenson KK, Ritz LJ, Farrell JB, Sladek ML, Lally RM. Quality of life after breast carcinoma surgery: a comparison of three surgical procedures. Cancer. 2001;19:1238-1246. 3.Kraus PL. Body image, decision making, and breast cancer treatment. Cancer Nursing. 1999;22:433-436. American Society of Plastic Surgeons. 1999 Plastic Surgery Procedural Statistics. 4.Rassaby J, Hill D. Patients' perceptions of breast reconstruction after mastectomy. Med J Aust. 1983;2:173-176. 5.Hart S, Meyerowitz BE, Apolone G, Mosconi P, Liberati A. Quality of life among mastectomy patients using external breast prostheses. Tumori. 1997;83:581-586. 6.Wilkins EG, Lowery JC, Kuzon WM, Perkins A. Functional outcomes in postmastectomy breast reconstruction: preliminary results of the Michigan Breast Reconstruction Outcome Study. Surgical Forum. 1997;48:609-612. 7.McGinn KA, Haylock PJ. Women's Cancers: How to Prevent Them, How to Treat Them, How to Beat Them. Alameda, Calif: Hunter House Inc.; 1998. 8.How To Make A Millet Prosthesis. From: About Breast Cancer. Available at: www.bcforum.org. 9.How To Make a Spare Seed Prosthesis. Available at: http://breastcancer.about.com/c/ht/00/07/How_Spare_Seed_Prosthesis0962934723.htm. 10.Choose a Bra That Fits Right. Women's Health Matters. Sunnybrook and Women's College Health Science Centre; 1999. Available at: http://www.womenshealthmatters.ca 11.Carol G. Kiefer, RN, CCM, is a Member of Academy of Certified Case Managers, BOC Certified Mastectomy Fitter. Remember we are NOT Doctors and have NO medical training. This site is like an Encylopedia - there are many pages, many links on many topics. Support our work with any size DONATION - see left side of any page - for how to donate. You can help raise awareness of CAM.