By Dina Ingber Stein

After a mastectomy, a woman has several options besides surgical reconstruction. Here, we explore the art of finding (and being fitted for) a good prostheses.

"I'LLWORK WITH ANY OTHER KIND OF PATIENT, BUT JUST DON'T ASK ME TO DO A MASTECTOMY FITTING," TEENA HUNSICKER BEGGED HER BOSS.

Employed by the Nazareth Medical Equipment Company in Nazareth, Pennsylvania, Ms. Hunsicker is a certified prosthetics and orthotics fitter, clearly qualified to handle all sorts of post-surgical conditions. But the one she feared most was fitting the postmastectomy patient.

It wasn't squeamishness over the surgical site that concerned her. "Rooted in my brain was the idea that a breast prosthesis, more than any other, has to look perfect. I was terrified I wouldn't be able to please anyone."

Hunsicker's fears were soon assuaged after handling her first patient. Mastectomy fittings are now her specialty, and she helps close to 200 breast cancer patients a year. The youngest, she says, is 26 years old and the oldest is a 93-year-old woman "who wanted me to make her look good again for her 95-year-old boyfriend." They are among the thousands who find external prostheses to be a viable alternative to surgical reconstruction.

Prostheses are man-made substitutes for body parts that have been removed. These external appliances can be made of silicone, foam or fiber-filled matting. They can adhere directly to the skin or, more commonly, fit into a pocketed bra. They come in a variety of pre-formed shapes, or can be custom-designed to fit a woman’s particular silhouette.

“In the past, women often made prostheses themselves, placing stockings filled with bird seed or some other shapeable substance in their bras,” explains Barbara Ettenger, Senior Product Manager for Women's Healthcare at Camp Healthcare, a Jackson, Michigan-based company that produces breast prostheses and also trains fitters around the country. "The first real commercial form was offered in the early 1960s. It was a liquid-filled soft plastic shell that could fit into a bra. By the 1970s, silicone forms which resemble human tissue in terms of feel, weight and texture, were introduced and they have become the most popular of the prostheses.”

With all the surgical reconstruction options now open to breast cancer patients, why would a woman choose to wear a prosthesis instead? According to Julia Rowland, Ph.D., Director of the National Cancer Institute's Office of Cancer Survivorship, “Our studies indicate that less than half of women who have mastectomies will receive reconstructive surgery, although this type of surgery is more prevalent in big urban settings where women have more access to experienced surgeons, and among younger women and those who are very invested in their appearance.

“Women who consider surgery have to be comfortable with the potential of complications. Those who consider external prostheses, on the other hand, worry about finding a prosthesis, and that the skin-tone and weight may not match the remaining breast,” says Dr. Rowland. It is also important to note that a prosthesis is not necessarily used in place of reconstructive surgery. A woman may want a prosthetic while she is waiting for the surgery, or she may want a small prosthesis that ‘equalizes’ the breast after a lumpectomy or partial mastectomy. Some women use prostheses if significant weight-change or aging causes unevenness between the reconstructed and non-reconstructed breasts.

Dr. William Wolkstein, a plastic surgeon in West Orange, New Jersey, notes that although advances made in surgical techniques draw more women to reconstructive surgery, there are still some cases in which it is inappropriate. “The way reconstruction is today, with implants and the use of the patient's own body tissue to reshape the breast, an increasing number of women do go for the surgery. But there are patients who have an aversion to surgery, or those in the very advanced metastatic stage for whom reconstructive surgery is not an option, or those who postpone reconstruction until after chemotherapy and use prostheses in the interim,” says Dr. Wolkstein.

Indeed, the reasons for choosing the prosthetic option can be as varied as the women themselves. “I had my mastectomy seven years ago, when I was 41,” recalls Marlene Marshak of New York City who volunteers with SHARE, a self-help group for women with breast or ovarian cancer. “I had the option of going for reconstruction but I'm very large breasted. The surgeons were going to remove tissue from my abdomen for the reconstruction, do breast reduction on the remaining breast, and later operate again to put in the implant. I just didn't want to go through anything that complicated. Besides, I was too busy dealing with the cancer at that point. I wanted to deal with the vanity later. I was angry at the plastic surgeons who said I would be sorry when I had to look in the mirror every morning and realize I had a breast removed. I have no regrets. I find the prostheses to be perfectly natural.”

Jeanne Petrek, M.D., a breast surgeon and Director of the Lauder Breast Center at New York’s Sloan-Kettering Cancer Center, discusses the various options with her patients before performing the mastectomy because reconstruction is often done immediately, as part of the same surgery. “If a patient has diabetes or heart problems or is very overweight, the additional surgery may not be advisable,” says Dr. Petrek. “Women with tiny breasts often opt not to have plastic surgery because they feel it would not make much difference. But every woman must decide for herself by picturing what the surgery and recovery would be like, versus getting up every morning and putting on the bra with the prostheses.”

Breast prostheses come in two primary forms: symmetrical (teardrop, triangular or heart-shaped) or asymmetrical. The choice depends on the amount and location of tissue removed during the mastectomy.

“If there is a large void under the arm or on the chest where lymph nodes have been removed, then the tear-drop shape works best because the point of the teardrop can cover the void,” explains Ms. Hunsicker. “An asymmetrical shape can be used to match a drooping or irregularly shaped breast. But for most women, the triangular shape is most appropriate and can be used interchangeably on either the left or right side.”

The silicone can be made softer or firmer to more closely resemble older or younger breast tissue, and comes in dozens of styles and sizes. “There are also some manufacturers that scan the chest wall or take a plaster impression to create a form that exactly matches the chest contour and the remaining breast,” says Ms. Ettenger. “Those are significantly more expensive, though. Our typical silicone form retails for about $200 - 400. The custom-fit variety can cost ten times as much. Not all insurance companies provide coverage.”

The key to a fitting is to get the prostheses to match the woman's natural breast as closely as possible. That process starts with a series of measurements taken by the fitter. Then the bra is chosen. “Getting the bra right is the most important part of the fitting,” says Patrice Sobcznski of the Camp Healthcare Fitter Training Program. “The bra holds the weight of the prosthetic. It has to fit the size, shape and lifestyle of the individual woman. The material, tightness, strap thickness and other variables will depend on such things as how active the woman is, whether she perspires heavily and whether she has other conditions such as arthritis that affect maneuverability.”

The next step is to place the recommended form into the bra and to view it under a clingy hospital-type gown provided by the fitter to make sure that it has the right look and feel. A proper fitting, says Ms. Hunsicker, can take as long as 1 1/2 hours. Even if a woman is not concerned with appearance, having a weighted prosthetic is important for medical reasons. “If you have the weight of a breast on one side and not on the other, you can develop back, shoulder or neck pain from the imbalance,” Ms. Hunsicker explains. “And without a weighted prostheses, the bra has a tendency to slide up when you raise your arms.”

Some women prefer prosthetics with an adhesive strip that attaches directly to the chest wall. These remain in place for various lengths of time – a day, a week or more. “Some women say it feels more like a part of the body. One woman said she wore it to bed when her grandchildren slept over so that when they would cuddle with her, they wouldn't notice anything missing under her night clothes,” says Ms. Sobcznski.

“Fitting is an art, not a science,” says Ms. Ettenger. “Try as many products as you can to get the best look and the most comfortable fit possible. The goal is to walk out of that fitting and feel certain that no one will know which side is the real breast.”

Dina Ingber Stein is an award-winning freelancer who writes frequently on health-related issues for Family Circle, Glamour, Harper's Bazaar, Reader's Digest and Redbook.