For the estimated 50,000 women a year who have one or both breasts removed through surgery, mastectomy usually means a disfiguring scar or reconstructive surgery to mask it.
Now, a small, but growing, number of surgeons are taking a different approach. They're using smaller, strategically placed incisions that make the scars less visible and leave the breast's skin and nipple intact.
Dr. Charles Cox of the University of South Florida estimates that he's one of about 25 in the country who perform skin sparing, nipple sparing mastectomies. The procedure, pioneered by the Cleveland Clinic, is relatively new; Cox performed his first one five years ago. He has had to special-order tools for it.
The American Cancer Society included the new surgery in an article on its Web site titled "What's New in Breast Cancer Research and Treatment?" The article cautions that further study is needed "to ensure they don't result in an excess risk of cancer developing or returning." That concern, Cox said, is why many surgeons don't perform the procedure.
But early studies offer reasons for optimism. One by the Cleveland Clinic found very low rates of recurrence in 149 nipple sparing mastectomies it performed between 2001 and 2007. Another by the Memorial Sloan-Kettering Cancer Center in New York found similar outcomes, leading researchers there to conclude that the procedure "has the potential to yield excellent results."
For 35-year-old Laura Periord of Sanford, it was a welcome — and unexpected — option after she discovered that she carries a gene known to cause cancer.
"Before I knew this procedure was available, I was resigned to the fact that I would have a scar — which is something I would always remember," said Periord, a divorced mother of two.
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Periord decided to get tested for breast cancer in February, after learning months earlier that her mother tested positive for the BRCA1 gene mutation, linked to hereditary breast and ovarian cancer.
Her mother, Karen Rauch, had had two mastectomies, one in 2002 and the other late last year. Rauch was found to be positive for BRCA1, and then Periord learned she was positive, too.
"I basically from that point had a decision to make," she said.
As a woman balancing a career as a pediatric speech therapist with raising two sons, 9-year-old Noah and 6-year-old Griffin, Periord decided to have a preventative mastectomy of both breasts.
Periord was referred to a number of doctors in the Orlando area. She was aware of the new skin sparing, nipple sparing mastectomy, but none of the doctors she consulted offered it, or even mentioned it.
It was only after she visited an Orlando plastic surgeon, Dr. Richard Klein, who handles breast reconstruction after the mastectomy, that she was referred to Dr. Cox. Klein and Cox had worked together at the Moffitt Cancer Center in Tampa.
"I was not searching for a surgeon who would do it," Periord said of the newer procedure. "I was looking for what my options were."
Cox said Periord was an ideal candidate for the procedure, which is most effective for younger women with smaller breasts. It's also performed more often in patients who want to prevent cancer through a prophylactic mastectomy.
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Cox performed Periord's bilateral mastectomy with another surgeon, Dr. Mary Pernicone, on Wednesday at the University of South Florida's new Carol and Frank Morsani Center for Advanced Health Care.
Working on opposite sides of their patient, Cox and Pernicone made simultaneous 11-centimeter incisions along the lower crease of the breasts. Through those incisions, they removed Periord's sentinel lymph nodes, which would be tested for cancer.
The surgeons then separated the breast tissue from the skin, preserving the nipple. The breast tissue was removed through the incisions, marked and sent for testing. Cox then carefully removed a bit of remaining tissue directly beneath the nipples, an area some doctors say is particularly susceptible to cancer growth. But since the nerves are removed along with the tissue, patients lose feeling in the nipple. Blood supply to the nipple is preserved, however, because it is partially derived from the surrounding skin, Cox explained.
Near the end of the two-hour procedure, the surgeons stitched the incisions and applied a dressing that holds the area in place until Klein inserts implants through the same incisions on Friday in Orlando.
Cox performed the procedure for the first time about five years ago. In those early days, Cox said he felt like TV detective MacGyver, searching for the right tools and methods. Among his tools: plastic surgery scissors.
He has since performed about 200 skin sparing, nipple sparing mastectomies, including in China, where he was the first to do it, he said. The procedure is covered by insurance, and it costs about the same as a standard mastectomy with reconstruction.
Cox estimates that skin sparing, nipple sparing mastectomies constitute about 5 percent of all mastectomies performed, though he thinks 20 percent to 30 percent of patients would be ideal candidates.
Periord said that among the many doctors she consulted in the Central Florida area, Cox is the only one performing the procedure. Cox could think of one or two others in the state, including his brother John, at Tampa Bay Breast Care Specialists.
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Within hours after her surgery, Periord, accompanied by her mother, boyfriend and other family, checked out of Morsani, an outpatient surgery center, and spent the night in a hotel before visiting Cox the next morning.
"I couldn't believe I felt as good as I did," Periord said. "I slept great."
Back home in Sanford two days after surgery, Periord said there was never any question of whether she would have her breasts removed, even if it meant losing her breast skin and nipples.
"As a single mom with two young boys, I knew (a mastectomy) would hopefully save my life," she said. "But this (new procedure) gave me the option to have the mastectomy, and still have a decent cosmetic result that I can look at for the next 50 years."
Richard Martin can be reached at firstname.lastname@example.org or (727) 893-8330.