On a swing in Creighton Park in North Augusta, 3-year-old Marissa Morris mischievously pumps her legs to go higher and nearly hits her mother on the backswing as Dana Morris stood behind to push.
"Marissa don't do that," Mrs. Morris chides her. "If you hit Mama in the port, that would be a mistake."
The port is short for Port-A-Cath, a device that connects to a catheter tube in Mrs. Morris' chest that makes it easier to administer the IV chemotherapy drugs that are helping her battle breast cancer. It is perhaps the only visual reminder of her battle after she underwent a mastectomy and reconstruction of her left breast earlier this year.
Although thousands of women undergo breast reconstruction after mastectomy each year, many newly diagnosed breast cancer patients said they had trouble finding a lot of information on the procedures before making a decision.
That wasn't supposed to happen after Congress passed the Women's Health and Cancer Rights Act in 1998, which required insurance companies to pay for breast reconstruction after mastectomy and was intended to open up access to the procedure to those who needed it.
"It was very interesting, though, that the percentage of reconstructions that were done following the institution of that act really didn't go up much," said Roberta Gartside, a plastic surgeon in Fairfax County, Va., and the incoming vice president for membership and communication for the American Society of Plastic Surgeons.
In fact, the numbers have gone down. According to figures compiled by the plastic surgeon group, the number of breast reconstructions declined from 80,908 in 2000 to 57,102 last year. Part of that might be that more women are getting a breast-sparing lumpectomy instead of a mastectomy, Dr. Gartside said. But some of it could be because women don't know about reconstruction when they get diagnosed, she said.
"Sometimes they're not completely aware of all of the options available," she said.
At Medical College of Georgia Hospital and Clinics, reconstruction is offered to every mastectomy patient and about 65 percent choose to have it, plastic surgeon Edmond Ritter said.
"It's very common here because the patients are offered it and we have really deluxe methods, so a lot of them choose to have it," he said.
For some patients, breast reconstruction is an essential part of being able to cope with the surgery and cancer treatment, said Billy Lynn of Augusta Plastic Surgery Associates, who did Mrs. Morris' reconstruction.
"We still see patients, we will always see patients who will come to you and say, 'If you can't reconstruct me, I'm not sure I can face this,' " he said.
Having the reconstruction seems to help with the other aspects of their cancer care, Dr. Lynn said.
"Patients tolerate those other treatments a little better, too," he said. "They feel whole. And it's a big deal. I don't think men have anything to compare that with."
There is a documented benefit for women who feel better about their outcome after reconstruction, Dr. Ritter said.
"There's a huge psychological benefit," he said.
When patients have a choice, it gives them back a sense of power over their lives, Dr. Gartside said.
"Because so much in the treatment of breast cancer, they're told, 'This is what you need,' " said Dr. Gartside, who has had breast cancer and reconstruction herself. "And a lot of times when they come to see us as plastic surgeons, we can give them back a little control in that they can decide to have reconstruction or not have reconstruction."
There are a number of options for women to choose from. Twenty years ago, when Dr. Gartside started her practice, about 80 percent of women got silicone implants during reconstruction. After concern in the 1990s about systemic health effects from leaking or ruptured implants, concerns that ultimately proved unfounded, the implants are back as an option, usually in conjunction with skin expanders.
Others are using the women's own skin and fat to create a new breast mound after mastectomy. One technique is called a transverse rectus abdominis myocutaneous flap, or a TRAM flap, which involves taking a stomach muscle and its attached blood vessel, plus some fat and skin from the abdomen, and either tunneling it up or detaching and reattaching it on the breast site. One added advantage of this is it essentially results in a tummy tuck. At least that's how Mrs. Morris saw it.
"I tell everybody I'm going to get two for one," she said, laughing. "You have to think of positives through it."
While it might sound funny, it is something women look for, Dr. Lynn said.
"They appreciate that," he said. "They say, 'I want that tummy tuck operation.' "
One of the main drawbacks is that because the surgery removes muscle from the stomach, sitting up can be more difficult, Mrs. Morris said.
"I was told I could never do sit-ups again. I told Dr. Lynn I never did them to start off with," she said, laughing again. "So it wouldn't matter."
A similar technique can be done using skin and fat from the latissimus dorsi area of the back, sometimes in conjunction with a breast implant.
Other reconstructive techniques that Dr. Ritter favors don't take muscle out but do take fat, skin and smaller arteries from the abdomen to rebuild the breast mound.
"We don't really need muscle for the reconstruction, so this is much less destructive this way," he said, and the procedure has been shown to result in fewer hernias and abdominal bulges at the donor site. And less pain, Dr. Ritter said.
"It's much, much less," he said.
The other techniques might have a slightly higher failure rate than the TRAM flap, Dr. Lynn said, which has been around for a couple of decades.
"The failure rate from an (attached) TRAM flap, which is the way I do it, is probably a little bit less, but you're talking small numbers anyway," he said. "I think both techniques are certainly applicable and you get good results."
The results, once a nipple and areola area are redone, can be very close to the original, Dr. Ritter said.
"We want women to look excellent both in clothes as well as naked," he said.
The important thing is to match the kind of reconstruction to the patient and getting the patient the kind of outcome she is seeking, Dr. Gartside said.
"Again, it's their choice," she said. "But you have to match the patient to the procedure."
MRS. MORRIS Might have had one advantage over other women when she was diagnosed in late January: She already knew the man who was delivering her biopsy results, Dr. Randy Cooper.
"He's our Sunday school teacher" at First Baptist of North Augusta, she said. "Never thought I'd see him in the OR, but you know, things happen."
As the mother of two young girls, Marissa and 6-year-old McKayla, she also knew she was going to have her breast rebuilt.
"And I just knew by me being 35, being 36 now, I knew I wanted the reconstruction," Mrs. Morris said.
As she tells her story, it is often punctuated by laughter and jokes, but the real key to her recovery is what links her to Dr. Cooper and what gives her peace.
"I just felt that God was around," Mrs. Morris said. "I just didn't worry about anything. You have it, deal with it. And I told people I think it is actually the reason I got this because it is another testimony that I have, another trial in my life that has just made me a stronger person and who I am."
Reach Tom Corwin at (706) 823-3213 or firstname.lastname@example.org.