Source The Associated Press Volume: 107 Number: 2 March 9, 2000

Breast-Rebuilding procedure is less painful, less invasive

WASHINGTON: Cancer stole Jane Culbreath's breast. Two tries at breast implants failed.

And when doctors considered rebuilding her breast using her own tissue, it turned out that at 101 pounds, Culbreath didn't have enough fat to spare. 

Jane Culbreath (left) received tissue from her twin sister, Joan Liddell (center), in breast reconstruction surgery by Dr. Robert J. Allen. There was not enough fat to take from Culbreath's body.

But her otherwise identical twin sister did. So in a medical first, a tummy tuck for one sister provided enough fat and skin to give the other a new breast.

Don't expect fat donations to become common.

But a few doctors have begun rebuilding breasts using only a woman’s own waistline fat without painfully cutting her abdominal muscle the way most surgeons do. The sisters hope their extremely unusual case brings attention to this little-known but gentler form of breast reconstruction.

"There's not a lot of doctors doing this. There's just not a lot of awareness regarding this type of surgery,” said Culbreath’s twin, Joan Liddell of Memphis, Tenn.

"Women need to be aware of this particular procedure, and that it is much easier on the patient," added Culbreath, of Dubach, La.

Women in turmoil after a cancer diagnosis may not realize they have a range of reconstruction options, but experts say it's vital to investigate each thoroughly before deciding.

A saline-filled breast implant is the most common choice. They're fairly quick and inexpensive to perform, and many recipients are very happy.

But they can cause certain problems and over time require repeat surgeries to replace deflated implants or remove painful scar tissue. In one government-mandated study unveiled last week, a surprising 27 percent of implants required reoperations within three years.

Doctors also can reconstruct a cancer patient's breast using her own tissue. Dr. Stephen S. Kroll of the M.D. Anderson Cancer Center says this produces provides a more natural looking breast, without the reoperation problem. But it requires longer, more invasive surgery, and some surgical methods cause their own complications.

That's why Dr. Robert Allen, Louisiana State University plastic surgery chief and twins’ surgeon, is trying to popularize the new, gentler method.

The most common way surgeons rebuild breasts is called a "TRAM flap," in which they slice a section of abdominal fat and muscle, keeping the flesh partially attached to the muscle because its blood vessels nourish the fat. They slide this tethered section under the skin up to the chest, and sculpt a breast.

In a variation called a "free TRAM" doctors sever a smaller piece of abdominal muscle, along with fat, from the body, moving it to the chest, they reattach the tiny blood vessels with meticulous microsurgery. (Occasionally, buttocks or back muscle is used.) 

But this method can cause weakness. Weakness is noticeable mostly to athletes, but after large operations some women lack the muscle for a simple sit-up, Allen said. 

The less muscle cut the better, so "free TRAM’s" cause far less risk. Still, the risk isn't zero and cutting any muscle is painful. 

Allen's alternative: Transplant just skin and fat. He merely dissects one artery and vein from the abdominal muscle, not the muscle itself, to nourish the newly sculpted breast for a few days until new blood vessels begin growing. 

After studying this "DIEP flap" procedure, "there's no question in my mind that it reduces the amount of postoperative pain. I believe it leaves patients with a stronger abdomen," said Kroll at M.D. Anderson, who now uses the fat-only method on 70 percent of his patients. 

The twins hope their unusual experience alerts cancer patient to the little-known option – after all, most women have enough of their own fat to use.

Culbreath twice tried breast implants after her 1998 mastectomy, but infection set in and her radiation-damaged skin couldn't fight it.

Doctors said her 101-pound runner's body was too thin for tissue reconstruction, but Liddell half-jokingly offered a fat transplant - and doctors jumped. Since the 46-year-old twins are identical except for the extra 20 - pounds three pregnancies had left on Liddell, Culbreath could use her fat and skin without fear of rejection. 

Because Liddell's tummy tuck cut no muscle, she was walking pain-free hours later. And Culbreath left the LSU hospital thrilled: "Implants are great, but I feel like this is better. . . . It's actual tissue, it feels just like the other breast.”