'I just kept thinking that people were staring at my imperfect breast. It was demoralising to have been through all that surgery and still feel lopsided and inadequate,' she said.
Sarah decided to have a nipple reconstruction. Skin was taken from her inner thigh and grafted on to her breast. The operation was successful, but it took her more than a year to recover.
'The wound on my thigh took ages to heal, and my nipple occasionally stuck to the dressing and was very painful,' she says. 'With hindsight, I wouldn't go through that again.'
However, recent developments using a silicone-based substance have resulted in a technique that allows doctors to create realistic stick-on nipples, hugely preferable to the standard 'plastic fried eggs' originally available on the NHS.
Research in the late Eighties at the University of Bradford's plastic surgery and burns unit has given women a genuine alternative to surgery.
Dr Alan Roberts, of the maxillo facial unit at St Luke's Hospital in Bradford, has been at the forefront of the research and implementation of the new nipple-areola prosthesis. 'The design of the old nipples was unsatisfactory, because it didn't take into account the varying size, shape and colour of an individual's nipple and areola,' he says. 'The women who came to see me felt incomplete with just a smooth mound, but they weren't happy with the standard NHS nipple then on offer.'
The material used is silicone based, simulates soft tissue and can be tinted. 'By using the remaining nipple as a template, we can replicate the area and produce a custom-made prosthesis,' he says. The impression of the existing nipple is transferred on to a mould and a computer colour match is made. The mould is filled with silicone elastomer and subjected to heat and pressure.
The finished prosthesis is simply stuck on the breast with a specially formulated, waterproof skin adhesive. The entire procedure, including two appointments, takes two weeks. Each nipple prosthesis lasts about two years, and replacements can be made from the existing mould.
'For many women, nipple reconstruction surgery is out of the question, both for financial reasons and because they have had enough of operations,' says Dr Roberts, who has also used prosthesis to cover unsuccessful nipple surgery.
'There are few problems with a nipple prosthesis. You can swim, bathe, do anything with it. Sometimes the woman doesn't like the result. But, unlike surgery, that's not a problem - she simply doesn't wear it.' He has also used a prosthesis to cover unsuccessful nipple reconstruction surgery.
Dr Roberts has already fitted about 1,200 prostheses and is encouraging colleagues to send staff to St Luke's to learn the procedure. Only three centres in the UK use the method.
Adoption of the technique has been widespread in America and on the Continent but sluggish in Britain. Dr Roberts is critical of the lack of awareness and availability of the procedure here. He believes a lack of advisory groups for women contributes to the problem. St Luke's Hospital works closely with Bosom Friends, a local support group for women with breast cancer.
Brenda Russell, a co-ordinator with Bosom Friends, says information and counselling is essential for women who discover they have cancer. 'My concern is for the patient's welfare,' she says. 'I've seen too many mastectomy patients who feel they didn't get real advice. Bosom Friends aims to restore control to the patient by giving her as much information as possible.'
About one-third of the patients she sees opt for breast reconstruction surgery. 'Mostly they are young women who are concerned about body image. They still want a cleavage, and even the best prosthesis in the world isn't going to give them that,' Ms Russell says. Only then are the problems of replacing a nipple addressed by the patient.
'They all want a fake nipple. I have seen good reconstructions in my life, but I'm not sure how long-lasting the results are,' she says. 'Most of my cases stay with their silicone stick- ons. It makes that all-important difference in a bra.'
Ms Russell hopes the the service will be expanded into other areas. If other health authorities are reluctant to pay for their patients to be sent to Bradford, then, she says, they should set up their own centres.
'At present, if a patient doesn't live within an area that offers such a service, she would have to pay pounds 250 for a nipple prosthesis that is available elsewhere on the NHS. I have no shortage of patients asking about them. But I still feel others don't know enough about the options available. It's a stressful time for a woman, and she needs as much help as she can get.' Irene Grint, a freelance distributor based in Gerrards Cross, Buckinghamshire, has begun supplying 'designer' nipples in a range of shapes and sizes that can be cut and dyed to suit individual clients. These are only obtainable privately, at a cost of about pounds 80 a nipple.
Mrs Grint, a former district nurse, set up Clover Leaf Products to market the nipples, as well as mammary and testicle implants. She travels around the country with boxes of prostheses stacked in the boot of her car, visiting and counselling clients. Most hear of her service through word of mouth.
'Nine out of 10 of my customers find the commercial prostheses satisfactory,' she says. 'The prostheses are realistic, unlike the pathetic pale things that used to be the only product on the market.'
Mrs Grint urges surgeons to keep a stock of nipple prostheses at their surgeries but says her efforts often go unrewarded. 'Surgeons seem to have a mental block on nipples. They just don't offer them. I only know of 10 surgeons nationwide who stock them.
'Too many can't see what a major psychological benefit having a replacement nipple has for a breast-cancer patient. Until the medical profession gets its act together, it looks like only a few who happen to live in the right area, or are lucky enough to hear about the options, are going to benefit,' she says.
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