The Diep operation to repair breasts after a mastectomy

Getting her cleavage back after a mastectomy was a surprise bonus for one woman
A few days before undergoing a mastectomy to remove her left breast, Helen Williams, a 55-year-old fitness instructor from Surrey, bid an emotional farewell to her favourite lingerie. “Before the operation I said goodbye to all my beautiful underwear and put it away; I didn't believe I would be able to look good in nice clothes again,” says Williams, a mother of two. The former nurse had breast cancer diagnosed in 2005 after a routine mammogram. Doctors told her that the cancer was too widespread for a lumpectomy (the removal of only the tumour and surrounding tissue) and radiotherapy, and that a mastectomy was the best option.

“As an ex-nurse I remembered what mastec-tomies used to be like in the 1970s. It was a pretty grim prospect. I was very nervous beforehand,” she says. Breast cancer is diagnosed in more than 40,000 British women every year and around 14,000 have mastectomies.

Williams's husband Mick took her to hospital the day before her operation, then the following day drove their son Oliver to Sheffield for his first day at university. A friend was at hand to give her support for the eight and a half hour mastectomy and reconstruction operation. “When I woke up from the surgery and looked down, I still had a cleavage and a breast. I never had to go through losing a breast and having to have it reconstructed later on. Emotionally, it helped enormously,” Williams says.

The operation involved a little-known reconstruction technique called deep inferior epigastric perforator, or Diep. This technique is considered by some specialists to be the gold standard and involves reconstruction of the breast using skin and fat from the lower abdomen. Since that surgery she has had nipple reconstruction to enable her to look as natural as possible. “I'm absolutely delighted that I had it done. You wouldn't know that I've had anything done,” Williams says.

Some patients aren't given the option

While Williams's surgeon at the Royal Marsden Hospital, in London, suggested the technique to her, many women are not given the option of the surgery, or told of its existence. A leading surgeon is cautioning that a postcode lottery exists in breast reconstruction treatment. Charles Nduka, a consultant plastic surgeon, says that many breast surgeons are simply not referring patients for the Diep operation, and may not even be offering it as an option.

Nduka works with four other breast reconstruction specialists at Queen Victoria Hospital, in East Grinstead, covering Sussex, Kent and parts of Surrey. He says: “It's very patchy. There are some breast cancer surgeons who will regularly refer patients, but some don't refer any at all, and it would be impossible to think that they don't have suitable candidates. There seem to be pockets where patients are just not even hearing about the operation.”

Given that Diep operations have been happening in the UK for almost ten years, it is surprising that so few women are apparently having them, according to Nduka.

The traditional option for women having a mastectomy is to offer reconstruction with a silicone implant. However, the implants often need to replaced after ten to 15 years because of leakage or hardening. The silicone implants can also lead to asymmetrical breasts, with the implant remaining high in the chest area while the natural breast droops.

A second type of reconstruction, called a latissimus dorsi flap, uses skin and muscle from the back or abdomen to create a more natural breast. However, a recent study in Switzerland of women ten years after surgery showed a 50 per cent failure rate. Patients either were unhappy with the look or feel of the breasts, or needed further surgery.

“Surgery was the first lifeline I was thrown”

After the mammogram results Williams, like most women, had been referred by her GP to a breast cancer surgeon, who advised a mastectomy. But because she had chosen to go to the Royal Marsden, which has a specialist reconstruction plastic surgeon, she was asked if she would consider Diep.

“My surgeon showed me photographs of women who had had the Diep surgery and it was really impressive. It was the first lifeline I had been thrown,” she says. Williams had the operation privately because of her husband's occupational health insurance, but it is available on the NHS.

Nduka argues that the Diep technique has emotional as well as physical benefits. “It gives patients a reconstruction for life. Once it is complete, and symmetry has been achieved, women can forget about breast cancer and close that chapter in their life. And a nice side-effect of the operation is that it gives them a flat tummy too. It's good to be able to give something back to women who have lost so much,” he says.

So why aren't breast cancer surgeons referring patients to plastic surgeons, the only people qualified do the operation? About 100 surgeons have the requisite skills in the UK. It's complicated, Nduka says. “Part of it is feeling that implants are satisfactory, part of it could be the perception that the gold standard is too involved for the patient, part of it could be not being really aware of just how successful these operations are.”

“Women need to know the options”

The Diep operation takes between six to eight hours and it is more intricate than other reconstruction procedures. It also involves an extended in-patient stay, so is more expensive; £14,000 if done privately. But Nduka argues that the cost of secondary operations to replace implants and correct asymmetry would probably make the other procedures just as expensive, if not more.

To tackle lack of awareness, he and other breast reconstruction specialist have been working voluntarily on a DVD, launched to coincide with Breast Cancer Awareness Month in October. It features Williams - who was filmed before, during and after the operation - along with other former patients revealing their experiences of breast reconstruction.

The move has been welcomed by the leading charity Breakthrough Breast Cancer. Its policy manager, Dr Alexis Willett, says: “It's really important to have that information. Women need the options so that they can make an informed decision.”

Williams hopes that the DVD will help others. “Not every woman wants reconstruction and not everyone wants to go through this particular reconstruction, but they need to know the options,” she says.