When Tami Weeks was diagnosed with breast cancer, survival was the only thing that mattered to the Westminster resident.
"I'm 59 years old, so if she had said we're doing a bilateral mastectomy, it would have been fine," Weeks said of her doctor. Looks "seemed like something that would be important to younger girls. I just wanted to get it over with."
But her surgeon at Carroll Hospital's Center for Breast Health insisted on doing a procedure that hides the incision in the armpit, breast crease or edge of the areola. Such surgeries are the latest frontier in breast cancer surgery aimed at eliminating evidence of the dreaded disease that is diagnosed in one in eight women and can cause lasting body image issues.
While surgeons can remove tumors without removing a whole breast, spare nipples and skin, and begin reconstruction immediately after surgery using an implant or fat from a women's own belly, the scars remain. They are often big, jagged lines women can see every time they look in the mirror.
"They are nothing but a daily reminder to a cancer patient," said Dr. Dona Hobart, a breast surgeon and medical director of the Carroll breast center who has been working to hide the surgical scars from breast cancer for years.
Most of the more than 230,000 women diagnosed with the cancer each year require surgery. It's unclear how many surgeons are working to hide scars, which remains a relatively new approach, Hobart said.
She doesn't think many doctors outside of university affiliated hospitals or specific breast cancer centers like Carroll's likely have learned specific procedures for masking the telltale lines that some women consider a permanent defacement of their physical attractiveness — and their femininity.
That means many women probably don't know it's an option, or like Weeks, don't initially realize that minimizing a scar is important to them, Hobart said.
There is more than one method and tool to hide a scar, but she said the surgery was made far easier when manufacturers began attaching lights to retractors used to separate tissue. The lighting allows doctors to see as they tunnel under the skin from an arm pit through a breast to the site of a tumor.
She uses an instrument from Invuity, which dubbed the related procedure "Hidden Scar surgery" when it launched its tool in 2015. The company reports that eight doctors at seven Maryland hospitals and surgeons in about 40 other states have been trained on the tool.
The Hidden Scar surgery takes a bit longer and is more involved than cutting directly at the point of the tumor. It's not advised for some women, such as older patients with other health issues who shouldn't remain under anesthesia any longer than necessary.
Weeks agreed to the procedure because she trusted Hobart, whom she called after receiving a suspicious mammogram but before she was officially diagnosed. Hobart, who was away on vacation at the time, talked Weeks through options on the phone.
Follow-up imaging and a biopsy confirmed treatment was necessary. Weeks had invasive lobular cancer, which begins in the breast's milk-producing glands and has the potential to spread. There was also a second tumor, an invasive ductal cancer. Weeks had surgery in July, then radiation that was recently completed and hormone therapy that continues.
The physical remnants of the surgery already are diminishing. Week's scar, a semi-circle at the edge of her nipple, looks like a faint pencil line, and she expects it to continue fading.
Hobart has been so pleased with the results of such procedures that she recently began using it to place chemotherapy ports. Typically located in the middle of the chest, such ports deliver chemotherapy drugs to a vein.
Studies going back years say women can develop negative perceptions of themselves because of their altered appearance, including scars, and even become reluctant to look at their own bodies.
The actress Angelina Jolie's widely read 2013 essay in the New York Times about her own breast surgery was credited with not only prompting more women to get tested for what she called "faulty" cancer genes, but also for helping women understand that there were surgical options that would leave them less scarred. The essay describes her decision to have her breast removed and the "beautiful results" of surgery.
"They can see my small scars and that's it," Jolie wrote of her children's reaction. "I do not feel any less of a woman. I feel empowered that I made a strong choice that in no way diminishes my femininity."
Dr. Grant W. Carlson, a reconstruction expert at the Winship Cancer Institute at Emory University, said surgeons have taken notice of the mental health implications of removing women's breasts or parts of them.
As medicine has advanced, he's helped develop some skin-saving techniques, which allow doctors to remove a cancer and then immediately tuck an implant under a women's original breast skin and nipple rather than cut a flap of skin from elsewhere on her body. Carlson is both a cancer and a plastic surgeon and can preform both parts of the procedure — and minimize the scaring.
Women can even choose to get matching breasts that are smaller or larger than the originals, he said. Still he agreed that some surgeons don't seek out methods to minimize scarring.
"A lot of women come in here and they are very well informed and already know what they want," he said. "But a lot of women [who go elsewhere] still have scars. There is progress to be made there. Surgeons need to have someone show them how to do some of this stuff. A number may not be willing to do something new."
Some facilities still can't offer reconstruction at the same time a tumor is removed because a plastic surgeon isn't available, he said. But such efforts are far more than cosmetic given the emotional toll a cancer diagnosis has on women, Carlson said.
He said the next frontier is developing better implants that do not need to be replaced down the road. He said implants should be made of biological material other than fat, which isn't that filling and requires a lot more recovery time.
Sherri Bloom, clinical director at the Pro Bono Counseling Project, which offers free mental health counseling to underinsured people in Maryland, said the needs of women diagnosed with breast and other kinds of cancer vary.
The organization launched a specific unit, called the Jean Steirn Cancer Program, to meet those needs and take referrals from doctors, hospitals and other groups.
Bloom said the first step is helping patients and their families cope with the diagnosis, which nearly always is shocking and distressing and can lead to financial and relationship difficulties and self esteem issues. Part of accepting a breast cancer diagnosis is understanding there will be changes to the body, she said.
She said women may miss the breasts they used to nurse their children, for example, even if breast implants give them the physical look they want. Having reconstruction options, including scar-minimizing surgery, are important steps, Bloom said.
"The procedures are there, doctors are more sensitive, hopefully insurance is covering more," she said. "But we still have to find out how the patient feels, specifically about the body, from the get go."
For Weeks, coming out of treatment looking normal helped her feel more normal. She works as a nurse in a Westminster clinic and planned to tell patients about the possibilities.
"I'm grateful," she said. "After years of seeing other women with very large and choppy incisions, to have one so tiny, it's incredible."