The Breast surgeon Heidi Rafferty, MD, and plastic and reconstructive surgeon Saied Asfa, MD, routinely work in tandem treating cancer patients, performing breast surgery and reconstruction during the same procedure. Only about 200 locations in the United States offer breast cancer patients the option of having their surgery and reconstruction at the same time.
The Reverend Laura Minnich Lockey, 50, of Harrisonburg, has always been healthy and on the go. An Episcopal priest, she serves as campus minister at James Madison University
and helps serve the parishioners of Emmanuel Episcopal Church in Harrisonburg. She’s also a wife and the mother of three busy boys.
So when she found a breast lump during a self-exam in June 2010, her first thought was, “What in the heck is that?” She was surprised, she says, because she regularly performed self-examinations.
Taking a deep breath, she reminded herself that 85 percent of breast lumps are benign. However, a diagnostic mammogram revealed additional cause for concern. After reviewing her mammogram, the radiologist told her, “You should have a biopsy today, and you need to see
the surgeon on Monday when she gets back.”
The biopsy, performed the same day as her mammogram, confirmed the lump was not benign; Minnich Lockey had breast cancer. In fact, her mammogram showed several lumps—a larger, 5-centimeter tumor with two smaller tumors in the right breast, and “suspicious scattering” in the left breast.
Although she understood the seriousness of a potential cancer diagnosis—her mother died of lung cancer in 1996—Minnich Lockey chose to delay seeing the surgeon and getting the biopsy by almost two weeks.
“I do this camp for disabled teenagers in the summer, and that was getting ready to start, so I had to be there,” she says. “And there was a weekend parish retreat just before camp started. So I went on my parish retreat and then to camp, and there were moments when I just wanted to scream. But it gave me 10 days of worrying about 70 other people and not about me. So God did a lot of work on me, and I did a lot of work with God, and when I came back, I was in this really peaceful place.”
|The Reverend Laura Minnich Lockey, of Harrisonburg, is a breast cancer survivor. In the summer of 2010, she found a lump that turned out to be cancer. Dr. Rafferty and Dr. Asfa performed tandem surgery in January 2011 to treat her.
Getting the Diagnosis
After returning in early August 2010, Minnich Lockey saw RMH Breast Care surgeon Heidi Rafferty, MD
. Dr. Rafferty advised her that she thought she should have chemotherapy, followed by surgery with immediate reconstruction. Dr. Rafferty explained that she and plastic and reconstructive surgeon Saied Asfa, MD, perform tandem surgery on many of her breast cancer patients.
“Tandem surgery means I begin by performing the appropriate surgery to remove the cancer, and then Dr. Asfa
comes in to do the breast reconstruction,” Dr. Rafferty explains. “It’s the best way to do this type of surgery, if you can, because it means the patient undergoes surgery and anesthesia only once, instead of having the breasts removed and the reconstruction as separate surgeries.”
It’s also better for patients psychologically. “They don’t have to deal with the challenges of seeing themselves without breasts,” Dr. Asfa adds. “When they wake up, that’s it.”
The two surgeons work in tandem in nearly all cases when patients choose to have reconstruction.
Minnich Lockey says she was surprised to find that tandem breast surgery and reconstruction were available locally. “I did lots of reading before my surgery, and I learned there are only about 200 places in the country where you can have breast surgery and reconstruction at the same time,” she says. “And little ole Harrisonburg, my home town, is one of those places.”
Beginning the Journey of a Cancer Survivor
Minnich Lockey began seeing medical oncologist Christine Urbanski, MD
, for chemotherapy at the RMH Hahn Cancer Center
. She says her faith, the prayers and support of her family, friends and parishioners, and her need to appear strong for her boys helped her through the difficult period of chemotherapy treatments.
“I had read Julian of Norwich [a fourteenth-century English spiritual writer and mystic] in seminary, and she has this famous saying, ‘All will be well, all will be well, with God all will be well.’ And that kind of became my mantra,” Minnich Lockey says.
The chemotherapy ended November 30. All three tumors had shrunk significantly, and the suspicious scattering had disappeared. “Dr. Rafferty and Dr. Urbanski explained that by doing chemo before surgery, they could see if the tumors were shrinking, and that would tell them the chemo was the right one, in case the cancer happened to come back,” she says. “Dr. Rafferty also said there would be a better aesthetic outcome if the tumors were smaller when she removed the breast tissue.”
Dr. Rafferty’s office made an appointment for Minnich Lockey to see Dr. Asfa the first week of December 2010. Her surgery was scheduled for Jan. 12.
“You know, there are some days that just stick forever in your brain,” Minnich Lockey says.
Bilateral Mastectomy with Breast Reconstruction
|I did lots of reading before my surgery, and I learned there are only about 200 places in the country where you can have breast surgery and reconstruction at the same time. And little ole Harrisonburg, my hometown, is one of those places."
—Laura Minnich Lockey
Even though the cancer had responded well to chemotherapy, Minnich Lockey decided to have bilateral mastectomies, or removal of both breasts, instead of breast conservation surgery, or lumpectomy, which involves removing just the tumor and a small margin of normal tissue surrounding it, followed by radiation therapy. Removal of the normal tissue and radiation are precautions to ensure that no cancer cells remain, Dr. Rafferty explains.
Minnich Lockey admits her choice may seem extreme. “But those breasts could kill me and they had done their job; they had nursed three babies,” she says. “I really didn’t need them, and my husband, Russell, told me, ‘Do whatever you want to do.’”
The availability of tandem breast surgery also played a significant role in her decision, she adds.
When Dr. Rafferty performs a mastectomy, she can often spare the patient’s skin, removing only the underlying breast tissue, she says. She performed this “skin-sparing mastectomy” on Minnich Lockey.
“I make a small vertical incision and I remove all the breast tissue through that four-inch incision,” Dr. Rafferty explains. “Once I’m finished, there’s just an envelope of skin left. No breast tissue is left behind, although even with the most meticulously performed mastectomy, up to three or four percent of breast tissue may be left behind, and that’s important for patients to understand.”
For his part of the tandem surgery, Dr. Asfa can perform breast reconstruction several ways. The two most common, he says, are implant-based reconstruction using silicone or saline implants, and transverse rectus abdominis myocutaneous flap (TRAM) surgery. With TRAM flap, Dr. Asfa uses the patient’s own tissue—skin, fat and muscle taken from the abdomen—to create the breast mound.
The reconstruction method selected depends on many factors, including the patient’s wishes, the location and type of tumor that was removed and the size of the breast. Implant-based reconstruction was the method he used with Minnich Lockey.
After the surgery, Dr. Asfa explains, he is in charge of the patient’s admission to the hospital, the care of the wound and the tubes that are necessary for draining the fluid that collects in the breasts following surgery.
Recovery and Follow-Up
Minnich Lockey spent three nights in the hospital after her surgery. Then she went home and spent three weeks in bed, she says.
Because the skin around her incision sites was thin and delicate, Minnich Lockey developed skin complications that required revision surgery, which Dr. Asfa performed.
Revision surgery to address complications, touch up a small area of the breast or remove or change an implant is not unusual, Dr. Asfa notes. Nationally the average is about 15 percent. Dr. Asfa’s average is about 10 percent.
“Sometimes during my recovery, I wondered if I should have just gone for the straight mastectomy without reconstruction, and I’d have been done,” Minnich Lockey says. “But then I would see pictures of women who had gone that route, with all the scars, and I’d think, ‘I would not have wanted that.’ Because I did the immediate reconstruction, I never looked down and saw flat.”
Nipple-sparing Breast Reconstruction
After Peggy Shafer, 43, of Mount Jackson, was successfully treated for cervical cancer several years ago, her gynecologist told her that when she turned 40 she should start getting annual mammograms “just to be on the safe side.”
Her first mammogram was normal, but the next year she was told, “You’ve got some activity in your left breast and it needs to be checked.” A biopsy showed she had breast cancer.
After Shafer was diagnosed in March 2010, she saw Dr. Rafferty and Dr. Asfa. They discussed her surgical options, and Shafer chose to have both breasts removed followed by immediate full reconstruction. In June, Dr. Rafferty removed both breasts, performing skin-sparing and nipple-sparing mastectomy. Then Dr. Asfa began her reconstruction, which included “free nipple restoration.”
Free nipple restoration involves removing the nipple, performing the reconstruction and grafting the nipple back on at the end of surgery. “The patient has her own areola and nipple, and it saves having the patient undergo an additional surgery later,” Dr. Asfa explains.
As far as he knows, Dr. Asfa is the only plastic surgeon in the world who performs free nipple restoration. “Maybe some people have done it elsewhere, but so far it has not been reported in the medical literature anywhere,” he says.
Surprisingly, after Shafer had the bilateral mastectomy, the biopsies on her breast tissue showed no cancer. “They told me that apparently the original biopsy had gotten all the cancer, so I had zero cancer,” she says.
She briefly questioned whether she had done the right thing in having bilateral mastectomy. “It took me a while to realize ‘you’re not getting your breasts back,’ and that was very hard,” she says. “But now, looking back, I think I did the right thing. I would always have worried if I still had any breast tissue, especially considering I also had cervical cancer.”
Shafer was off work for six weeks. The hardest part of her recovery, she says, was having the nipple reconstruction. “I stayed indoors for six weeks with the air conditioning running. I didn’t sweat, I didn’t move, I didn’t do anything to make sure the nipple grafts would take and there wouldn’t be any problems,” she says. “And not doing anything for six weeks makes you very weak.”
Today Shafer says, despite her post-surgical “long haul,” she feels very fortunate that she could have her mastectomy with full restoration in one surgical procedure.
“I chose this route because I didn’t think I could handle waking up with nothing being there,” she says.
Prophylactic Breast Surgery
|A strong family history of early onset breast cancer prompted Natalie Bass, of Harrisonburg, to opt for bilateral mastectomy (removal of both breasts) with reconstruction, even though she did not have cancer at the time of her surgery. Dr. Rafferty and Dr. Asfa performed her surgery in November 2010.
Natalie Bass, 38, of Harrisonburg, has a strong family history of breast cancer. Her mother, an aunt and three first cousins all developed breast cancer in their early 40s, she says.
Several years ago, before the RMH Breast Care program got fully underway, Bass began going to the high-risk clinic at UVA, where she was followed closely with medical imaging. In the summer of 2010, she had a biopsy because of “something they found,” she says. The biopsy came back negative, but the findings showed changes that were consistent with a condition that increased her risk for developing breast cancer about two-fold.
“That was enough for me,” Bass says. “I decided to have both breasts removed even though at that point I didn’t have cancer.”
For about two years before the biopsy, Bass says, she had considered that option. “It became nerve wracking getting tested with some kind of imaging every six months,” she says. “I’d have to drive across the mountain, which meant a whole day off from work, have either a mammogram or an MRI, wait to meet with the physician and hopefully get the results while I was there. It was emotionally draining.”
In the end, she says, her decision was not that difficult. “For some cancer, there’s not a lot you can do, but in this case I felt I could do something that I hoped would mean a good outcome.”
Bass talked to her husband, and he supported her decision. Her greatest concern, she says, was when she went to see Dr. Rafferty in August 2010.
“I was afraid she was going to try to talk me out of it,” Bass recalls. “But Dr. Rafferty looked at me and said, ‘I understand one hundred percent why you want to do this,’ and she agreed it was a reasonable next move. She even told me that if the insurance company denied coverage, she would fight them on it.”
However, her insurance company approved the surgery within two hours, she says. Bass then met with Dr. Asfa, who explained the various options for reconstruction. Together, they agreed on silicone implants immediately following the mastectomy. Bass scheduled her surgery in November.
Following surgery, Bass spent one night in the hospital, and then recovered at home for three and a half weeks. She says it was challenging during that time, especially dealing with the drainage tubes and the stretching of her chest muscles because of the implants. She also required some physical therapy to regain full range of motion in her arms. But she says she’s not sorry she had the surgery.
“I’m absolutely happy with my choice, and I’d do it again in a heartbeat,” she says. “Knowing that so many of my relatives developed breast cancer in their 40s, the closer I got to 40 the more panicky I felt. I felt like my own body was the enemy, and I was just waiting for it to turn on me. I thought about it every day.
“I know statistically there’s still a small chance I could develop breast cancer if a few cells were left behind,” she continues. “But they told me my chance of getting breast cancer has been reduced by 90 percent. And those are pretty good odds.”
A Very Special Team
Before moving to Virginia and helping build the Breast Care service at RMH, Dr. Rafferty practiced as a dedicated oncologic breast surgeon in California. She says her background there of working with plastic surgeons was “not very conducive” to creating the kind of dedicated teamwork that she and Dr. Asfa share in Harrisonburg.
|When patients feel the doctors and healthcare providers who are taking care of them are working together and have a mutual respect, it gives them a great feeling of safety and security.
—Teresa Boshart Yoder, Director, RMH Women's Services
“I used to have to beg the plastic surgeons to even consider doing a breast reconstruction, and their reconstruction method was strictly doing whatever was easiest or whatever paid the most, often with outcomes that were not very natural looking,” she says. “But I’ve never experienced that with Dr. Asfa. He truly listens to what patients say they want, and then he gives them what they want in a cosmetically acceptable and aesthetically beautiful way.”
He also shares the primary concern that has always guided her own practice, which is “Cancer first,” she adds.
“I tell patients that whatever Dr. Rafferty needs to do to get rid of their cancer is uppermost,” says Dr. Asfa. “I can fix whatever needs to be fixed afterwards.”
It’s their special teamwork approach to treating breast cancer patients that Dr. Rafferty believes is the primary advantage that RMH Breast Care offers its patients. “It’s the kind of professional relationship that many of the breast surgeons I talk with do not have with their plastic surgeons,” Dr. Rafferty says. “That doesn’t mean it doesn’t exist elsewhere, but it’s certainly not that common.”
Teresa Boshart Yoder, director of RMH Women’s Services
and a breast cancer survivor herself, adds, “When patients feel the doctors and healthcare providers who are taking care of them are working together and have a mutual respect, it gives them a great feeling of safety and security. We’re very proud to offer this level of compassionate, high quality breast care to our community.”
One of the memories that stand out most in her experience with breast surgery and reconstruction, Bass relates, is the personal attention of her surgeons the day of her surgery. “They made a point of telling me I would see both of them in the OR before they started, and that was good,” Bass says. “I knew they were there with me. I’ve had surgeries before—getting my tonsils out and appendicitis—but Dr. Rafferty was the only surgeon I’ve ever had who was there, holding my hand and talking to me while I was going to sleep. That was very calming.”
When Shafer went home following her surgery and first saw herself in the mirror, with the nipple grafts in place, she says she was shocked. “I thought, ‘Oh my god!’ because they didn’t look like what I thought they should,” she recalls. “But Dr. Asfa was so good with me. I called him daily and I’d say, ‘I just saw this.’ And he would always calmly tell me, ‘This is what’s going on. Call me again if you need me. You’re OK … hey, come see me. Maybe you should come see me.’ He was really good about that. And Dr. Rafferty, too; they were both fabulous.”
Three years after her surgery, Minnich Lockey is completely recovered. Like Shafer, she speaks highly of her care. “I had immediate responsiveness and caring, as well as personal service,” she says. “I wasn’t just some number; I was Laura …and Laura who has a job, a husband and children, and other things going on in her life. And that was honored and respected. I know that it was life-threatening, and I know that some of the complications I had were potentially life-threatening. But everyone was calm, responsive and caring. And that was very comforting.”
Editor’s note: October is National Breast Cancer Awareness Month. Is it time for you to schedule your screening mammogram? See the Mammography Van schedule on RMHOnline.com, or call RMH Women’s Services at (540) 689-6800.