Reconstruction after Breast Cancer: What you need to know

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features the
00:12 --> 00:13latest information on cancer
00:13 --> 00:15care by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:19of the battle to fight cancer.
00:19 --> 00:21This week, it's a conversation
00:21 --> 00:23about breast reconstruction after
00:23 --> 00:24cancer with Doctor Paris Butler.
00:24 --> 00:26Doctor Butler is an associate professor
00:26 --> 00:28in the division of Plastic Surgery
00:28 --> 00:30at the Yale School of Medicine,
00:30 --> 00:32where Doctor Chagpar is a
00:32 --> 00:33professor of surgical oncology.
00:35 --> 00:37Paris, maybe we can start off by you
00:37 --> 00:39telling us a little bit more about
00:39 --> 00:41yourself and what it is you do.
00:41 --> 00:43The vast majority of my practice as a
00:43 --> 00:45plastic and reconstructive surgery is
00:45 --> 00:48in the breast reconstruction space.
00:48 --> 00:50The other majority of my practice
00:50 --> 00:53really is in in body contouring.
00:53 --> 00:55So I work pretty much from the clavicles
00:55 --> 00:58all the way down when it comes to
00:58 --> 00:59restoration of form and function,
00:59 --> 01:00as we like to say.
01:01 --> 01:04So let's talk a little bit more
01:04 --> 01:05about breast reconstruction,
01:05 --> 01:08particularly after a cancer diagnosis.
01:08 --> 01:10You know, for many women who are
01:10 --> 01:13faced with a breast cancer diagnosis,
01:13 --> 01:15that's always a question that they have.
01:15 --> 01:18Especially if
01:18 --> 01:22they're faced with the loss of a breast,
01:22 --> 01:23what will that look like?
01:23 --> 01:25What will that feel like?
01:25 --> 01:28How will that impact
01:28 --> 01:30their sense of femininity,
01:30 --> 01:32of sexuality, of body image.
01:32 --> 01:34So talk a little bit about the
01:34 --> 01:37options that women have for breast
01:37 --> 01:39reconstruction after a mastectomy.
01:39 --> 01:41It's a great question,
01:41 --> 01:42and it's a broad one and I'll
01:42 --> 01:44probably back up a little bit.
01:44 --> 01:46So the goal of breast
01:46 --> 01:49reconstruction as we say is to kind
01:49 --> 01:51of restore form and function as
01:51 --> 01:53it pertains to the breast mound.
01:53 --> 01:55We as plastic and reconstructive
01:55 --> 01:58surgeons are at least from my purview,
01:58 --> 02:02I love what I do because we get to
02:02 --> 02:04kind of bring some joy hopefully
02:04 --> 02:06to a difficult conversation,
02:06 --> 02:08particularly as it pertains to a recent
02:08 --> 02:10diagnosis of breast cancer.
02:10 --> 02:13So we know in the US about 250,000 new
02:13 --> 02:15breast cancers are diagnosed every year
02:15 --> 02:17that results in about 100,000 mastectomies.
02:17 --> 02:20So when the cancer is of a size
02:20 --> 02:22that it can't be removed locally
02:22 --> 02:24through what we call a lumpectomy,
02:24 --> 02:26then removal of the entire breast
02:26 --> 02:27is indicated or sometimes the
02:27 --> 02:29patient says,
02:29 --> 02:30I've had a cancer in this breast,
02:30 --> 02:33I don't want the chance of a recurrence,
02:36 --> 02:38so I'll have the entire breast removed and a
02:38 --> 02:40prophylactic mastectomy on the other side,
02:40 --> 02:41prophylactic means that there's
02:41 --> 02:43no cancer in that other breast,
02:43 --> 02:45but they're removing it to prevent a
02:45 --> 02:47cancer from ever occurring in the future,
02:47 --> 02:50or at least that's the hope.
02:50 --> 02:51As a plastic and reconstructive surgeon
02:51 --> 02:54that does a lot of breast reconstruction,
02:54 --> 02:56our goal is to reconstruct
02:56 --> 02:59a breast mound. We do about,
02:59 --> 03:01in this country, almost 140,000
03:01 --> 03:03breast reconstruction procedures
03:03 --> 03:05per year.
03:05 --> 03:08That's a big number.
03:08 --> 03:13We think that about 65% of the time in the
03:13 --> 03:14country when a mastectomy is performed,
03:14 --> 03:17a patient will opt for some kind
03:17 --> 03:19of breast reconstruction procedure.
03:19 --> 03:20And that does come,
03:20 --> 03:24as you alluded to, in various forms.
03:24 --> 03:2775% of the time when we perform
03:27 --> 03:28breast reconstruction in the US
03:28 --> 03:31it's an implant based reconstruction
03:31 --> 03:34where we use a prosthetic implant,
03:34 --> 03:36either saline or silicone that we
03:36 --> 03:38implant into the chest wall
03:38 --> 03:39to reconstruct that breast mound.
03:39 --> 03:42And then about 25 to 30% of the
03:42 --> 03:45time we do what we call autologous
03:45 --> 03:47reconstruction where auto is self.
03:47 --> 03:49So we use a different part of the body,
03:49 --> 03:51we remove a part of the body say
03:51 --> 03:52from the abdomen, the thighs,
03:52 --> 03:55the buttocks and we use that tissue
03:55 --> 03:57through microsurgical techniques
03:57 --> 04:00to create a a new breast mound.
04:00 --> 04:02The goal we say is to create a breast
04:02 --> 04:05mound to get patients to look quote unquote,
04:05 --> 04:06normal in clothes.
04:06 --> 04:08I think many of us are proud to
04:08 --> 04:10say that we can get our patients
04:10 --> 04:13to look normal in underwear and
04:13 --> 04:15normal in a bathing suit.
04:15 --> 04:15However,
04:15 --> 04:17as soon as the bathing
04:17 --> 04:19suits is removed or the underwear is removed,
04:19 --> 04:20there's always going to be scars.
04:20 --> 04:22There's no such thing as scarless surgery
04:22 --> 04:25and I don't want to paint a grim picture,
04:25 --> 04:26but I think it's important to
04:26 --> 04:28have that realistic expectation.
04:29 --> 04:31Ao let's dive a little bit
04:31 --> 04:33deeper into these options.
04:33 --> 04:36So what are the things that you consider
04:36 --> 04:39or that patients could consider when
04:39 --> 04:41they're thinking about first of all,
04:41 --> 04:43do I get reconstruction or not?
04:46 --> 04:48It starts with that initial conversation
04:48 --> 04:51with the breast surgeon or the surgical
04:51 --> 04:54oncologist pertaining to what kind of
04:54 --> 04:56cancer surgery they're going to need.
04:56 --> 04:58You know, breast reconstruction
04:58 --> 05:02in my opinion and many others is
05:02 --> 05:04a full continuum of offerings.
05:04 --> 05:05As an example,
05:05 --> 05:08I mentioned the fact that about
05:08 --> 05:0965% of the time a woman will
05:09 --> 05:10opt for breast reconstruction.
05:10 --> 05:13That means 35% of the time in the
05:13 --> 05:15US when a woman has a mastectomy.
05:15 --> 05:17They don't have formal breast
05:17 --> 05:19reconstruction for one reason or another.
05:19 --> 05:20They're either too sick or have
05:20 --> 05:22too many other medical challenges
05:22 --> 05:23that would preclude them from
05:23 --> 05:24getting additional surgery.
05:24 --> 05:26Or they just say, you know what,
05:26 --> 05:28I don't want to go through any additional
05:28 --> 05:31operations to reconstruct breast mounds.
05:31 --> 05:32I'm fine with being closed.
05:33 --> 05:35So our continuum as plastic and
05:35 --> 05:37reconstructive surgeons that work
05:37 --> 05:39and live in this space spans from
05:39 --> 05:42what I call aesthetic flap closures,
05:42 --> 05:43that's for the woman who says,
05:43 --> 05:43listen,
05:43 --> 05:46I don't want reconstructed breast mounds.
05:46 --> 05:47But I don't want to be left behind
05:47 --> 05:49with a lot of redundant skin that
05:49 --> 05:50can get rashes and irritation.
05:50 --> 05:52So can you help the breast surgeon
05:52 --> 05:54in just closing things flat so I can
05:54 --> 05:56either be fitted with an external
05:56 --> 05:58prosthesis or so I can get tattoos
05:58 --> 06:01or no tattoos or just once again to
06:01 --> 06:05avoid that redundancy with excess skin.
06:05 --> 06:07Then you move to more
06:07 --> 06:09formal things like implant based
06:09 --> 06:11reconstruction to flap surgery as we
06:11 --> 06:14like to call it or autologous surgery
06:14 --> 06:16to something that I'm actually
06:16 --> 06:18fairly excited about of late where
06:18 --> 06:21a patient will have a lumpectomy
06:21 --> 06:22and they've always
06:22 --> 06:24had larger breasts and
06:24 --> 06:25they've always wanted a breast
06:25 --> 06:26reduction or breast lift,
06:26 --> 06:28and the silver lining of
06:28 --> 06:29their cancer diagnosis is
06:29 --> 06:31the fact that the breast surgeon
06:31 --> 06:32can do the lumpectomy and then
06:32 --> 06:34I can come in and do a formal
06:34 --> 06:36breast reduction or oncoplastic
06:36 --> 06:38reconstruction and in this circumstance
06:38 --> 06:40actually make their breast maybe
06:40 --> 06:41aesthetically more pleasing than
06:41 --> 06:43they were prior to their diagnosis.
06:43 --> 06:45So the continuum of breast
06:45 --> 06:46reconstruction offerings
06:46 --> 06:49that many of us have in
06:49 --> 06:50our toolkit continues to expand.
06:51 --> 06:53And so as you mentioned,
06:53 --> 06:55you know the discussion about whether
06:55 --> 06:58or not to reconstruct often has to
06:58 --> 07:00do with patients comorbidities,
07:00 --> 07:02it might have to do with their
07:02 --> 07:04cancer with whether or not radiation
07:04 --> 07:06is expected after the mastectomy.
07:06 --> 07:09Can you talk a little bit about
07:09 --> 07:12that interface between
07:12 --> 07:14radiation and reconstruction and how
07:14 --> 07:17that kind of plays into your decision
07:17 --> 07:20to either reconstruct versus not
07:20 --> 07:22reconstruct immediately versus in a
07:22 --> 07:25delayed fashion and or the type of
07:25 --> 07:27reconstruction that you might choose.
07:27 --> 07:30It's a very good question,
07:30 --> 07:32and one that could easily
07:32 --> 07:36go for an hour or more in response.
07:36 --> 07:38I will say, radiation
07:38 --> 07:39does complicate things.
07:39 --> 07:41I tell my patients because I'm very
07:41 --> 07:43also proudly boarded in general surgery
07:43 --> 07:45and speak a lot of the cancer language
07:45 --> 07:47although I'd never overstep
07:47 --> 07:48my surgical oncology colleagues.
07:48 --> 07:51But I understand the magnitude
07:51 --> 07:54of radiation therapy and as a
07:54 --> 07:56plastic and reconstructive surgeon
07:56 --> 07:58I understand the fact that radiation
07:58 --> 08:01is necessary many times for the
08:01 --> 08:03oncologic or the cancer care,
08:03 --> 08:05but it's tough on skin and soft tissue.
08:05 --> 08:06That's just the reality of it.
08:06 --> 08:08But in light of that we still
08:08 --> 08:09move forward.
08:09 --> 08:13So it is my practice that as
08:13 --> 08:15it pertains to radiation needs,
08:15 --> 08:17we still will offer patients
08:17 --> 08:18reconstructive options.
08:18 --> 08:20Now sometimes that will depend upon
08:20 --> 08:23when the radiation needs to be given,
08:23 --> 08:26that impacts the kind of reconstruction
08:26 --> 08:27that we are offering.
08:27 --> 08:29So as an example,
08:29 --> 08:31if a patient has never had
08:31 --> 08:33radiation before but is going
08:33 --> 08:35to need radiation after surgery,
08:35 --> 08:37in my opinion they can still be
08:37 --> 08:39offered either an implant based
08:39 --> 08:40reconstruction or an autologous
08:40 --> 08:41reconstruction.
08:41 --> 08:44And many times we still do that up front,
08:44 --> 08:46we still do that at the time
08:46 --> 08:48of their initial operation.
08:48 --> 08:50There have been an increase in
08:50 --> 08:53amounts of of studies that have
08:53 --> 08:55shown that a woman waking up with
08:55 --> 08:56a breast mound
08:56 --> 08:58has significantly improved psychological,
08:58 --> 08:59social,
08:59 --> 09:00emotional and functional improvement
09:00 --> 09:02rather than being closed flat,
09:02 --> 09:04going through the process and then
09:04 --> 09:06trying to get a delayed reconstruction.
09:06 --> 09:07That being said,
09:07 --> 09:10we do have a subset of patients
09:10 --> 09:13that have to get radiation very
09:13 --> 09:15quickly after their mastectomy and
09:15 --> 09:18in those instances we would almost
09:18 --> 09:20always delay their reconstruction
09:20 --> 09:22until they are have completed
09:22 --> 09:23their oncologic care,
09:23 --> 09:25which would be both chemotherapy
09:25 --> 09:26and radiation therapy.
09:26 --> 09:28We can't do the reconstruction
09:28 --> 09:31until they are at a minimum a year,
09:31 --> 09:33some would say a year and a half
09:33 --> 09:36to two years out from their last
09:36 --> 09:38radiation dose, once again because
09:38 --> 09:40that surrounding area is so
09:40 --> 09:42fibrous and sometimes still so,
09:42 --> 09:44so inflamed and recovering
09:44 --> 09:45from the radiation.
09:45 --> 09:47I hope I somewhat answered,
09:47 --> 09:48it's a complex question.
09:48 --> 09:51Yeah it is a complex question and I
09:51 --> 09:54I wanted our audience to kind of get
09:54 --> 09:57a sense of the nuances that play
09:57 --> 09:59into the decisions that go
09:59 --> 10:01into breast reconstruction.
10:01 --> 10:03The next decision point of course is do
10:03 --> 10:06I do an implant based reconstruction or
10:06 --> 10:09do I do an autologous reconstruction.
10:09 --> 10:11Can you talk us through
10:11 --> 10:13how you talk to patients about
10:13 --> 10:16that in terms of the advantages and
10:16 --> 10:18disadvantages of each and which might be
10:18 --> 10:20best suited for which kind of patient?
10:21 --> 10:23Yes, it's a another very,
10:23 --> 10:24very good question.
10:24 --> 10:26And I'm kind
10:26 --> 10:28of putting a plug in for the
10:28 --> 10:29American Board of Plastic Surgery.
10:29 --> 10:30But I think it's really
10:30 --> 10:32important and it can't be missed.
10:32 --> 10:33And I get these calls from loved
10:33 --> 10:35ones and friends of loved ones
10:35 --> 10:37around the country about finding and
10:37 --> 10:39identifying a plastic surgeon to
10:39 --> 10:41carry out their reconstructive needs.
10:41 --> 10:42And I would say ensuring that
10:42 --> 10:44you have a board certified
10:44 --> 10:46plastic surgeon is really,
10:46 --> 10:49really important and once again
10:49 --> 10:50that cannot be over emphasized.
10:50 --> 10:52Just go to the American Board
10:52 --> 10:53of Plastic Surgery website.
10:53 --> 10:55You can type in the surgeon's name
10:55 --> 10:57just to ensure that they've
10:57 --> 10:58gone through the appropriate
10:58 --> 11:00rather rigorous accreditation
11:00 --> 11:02process to become board certified.
11:02 --> 11:04Next I would say when you meet with
11:04 --> 11:06that plastic and reconstructive surgeon
11:06 --> 11:09making sure he or she is willing to
11:09 --> 11:11have the conversation of the
11:11 --> 11:13full array of reconstructive options.
11:13 --> 11:15If you happen to go into an office and
11:15 --> 11:16the plastic and reconstructive
11:16 --> 11:18surgeon is immediately pointing to
11:18 --> 11:19implant based reconstruction and doesn't
11:19 --> 11:21talk about flap surgery or vice versa,
11:21 --> 11:23just wants to talk about flap
11:23 --> 11:26surgery and not implant based
11:26 --> 11:28reconstruction without giving the full
11:28 --> 11:30menu as I like to say
11:30 --> 11:33and then having a real shared
11:33 --> 11:34decision making experience,
11:34 --> 11:37I think that can be problematic and
11:37 --> 11:40it's likely a time to get a second opinion.
11:40 --> 11:42So when it comes to the different options,
11:42 --> 11:44I've kind of given the two buckets
11:44 --> 11:46of implant based reconstruction
11:46 --> 11:47and flap surgery.
11:47 --> 11:50I give the patients the good,
11:50 --> 11:52the bad and the indifferent on both and
11:52 --> 11:54there are pluses and minuses to both.
11:54 --> 11:56So for implant based reconstruction
11:56 --> 11:59it tends to be a little bit of an
11:59 --> 12:01easier faster recovery for the patient.
12:01 --> 12:04That initial operation with
12:04 --> 12:05implant based reconstruction more
12:05 --> 12:07times than not it's done in two
12:07 --> 12:09stages where the breast surgeon or
12:09 --> 12:11the surgical oncologist performs a
12:11 --> 12:13mastectomy and then we put in this
12:13 --> 12:15device called a tissue expander.
12:15 --> 12:17That tissue expander is a kind of a place holder
12:17 --> 12:19for a couple weeks and then as
12:19 --> 12:22the patient starts to heal in the office,
12:22 --> 12:24the patient returns every other week
12:24 --> 12:26and we slowly start to fill that
12:26 --> 12:28tissue expander to get the patient
12:28 --> 12:30to the size that they desire and
12:30 --> 12:32as surgeons are comfortable with.
12:32 --> 12:34And then about once we've gotten
12:34 --> 12:36them to size about,
12:36 --> 12:38I would say that takes about two
12:38 --> 12:39to three months,
12:39 --> 12:41we go back for a second operation which
12:41 --> 12:43is actually a pretty quick operation,
12:43 --> 12:44maybe an hour and a half,
12:44 --> 12:46two hour operation where we take
12:46 --> 12:47out that tissue expander.
12:47 --> 12:50When we put in the soft implant.
12:50 --> 12:52It's a process.
12:52 --> 12:53It takes two to three months to
12:53 --> 12:54to go through that.
12:54 --> 12:55But once again,
12:55 --> 12:57we've gotten outstanding results
12:57 --> 13:00and we have a lot of control in
13:00 --> 13:02that setting with flap surgery.
13:02 --> 13:04The up front is rather significant.
13:04 --> 13:06So instead of that initial
13:06 --> 13:083 to 4 hour operation,
13:08 --> 13:10this is more like a 8 to 10 hour
13:10 --> 13:12operation if not longer where we take
13:12 --> 13:13tissue frequently from the abdomen
13:13 --> 13:15because that's where most Americans
13:15 --> 13:18have the tissue to donate and we use
13:18 --> 13:21that abdominal tissue and we do microsurgery
13:21 --> 13:22to connect the small little blood
13:22 --> 13:24vessels in order to make that tissue
13:24 --> 13:26live because the tissue couldn't
13:26 --> 13:27live without blood supply.
13:27 --> 13:29So that process of moving tissue
13:29 --> 13:31from the abdomen or the buttocks of
13:31 --> 13:34the gluteal region up to the breast
13:34 --> 13:36once again 8 to to to 10 hours and
13:36 --> 13:38requires about three to four days in
13:38 --> 13:40the hospital just for recovery and
13:40 --> 13:43comes with the risk of, we
13:43 --> 13:45use the term or the phrase
13:45 --> 13:47you're robbing Peter to pay Paul.
13:47 --> 13:49So if we're taking tissue from
13:49 --> 13:51the abdomen we do worry about
13:51 --> 13:53the potential of developing a
13:53 --> 13:55hernia or a bulge at the abdomen
13:55 --> 13:57because we have to take a strip of
13:57 --> 13:59not only the abdominal skin and
13:59 --> 14:01underlying subcutaneous tissue or fat,
14:01 --> 14:03but we're also frequently taking a
14:03 --> 14:04small amount of the muscle
14:04 --> 14:06or the fascia that holds the
14:06 --> 14:08muscle in place in the abdomen.
14:08 --> 14:10So once again it's a longer operation.
14:10 --> 14:13We do worry about the donor site
14:13 --> 14:16when it comes to flap surgery, so
14:16 --> 14:18speaking at length with
14:18 --> 14:20the patient I'm looking at their
14:20 --> 14:22body habitus because if it's a
14:22 --> 14:24fairly thin patient,
14:24 --> 14:26they may not have enough tissue
14:26 --> 14:27to appropriately recreate breast
14:27 --> 14:29mounds and implants is where we
14:29 --> 14:31would kind of do our best to once
14:31 --> 14:33again give them the options but kind
14:33 --> 14:34of steer them in that direction.
14:34 --> 14:37And then patients who
14:37 --> 14:38are more robust, we
14:38 --> 14:40don't have really large implants
14:40 --> 14:43and that's where we kind of steer
14:43 --> 14:45them a little bit more towards
14:45 --> 14:46the flap option.
14:46 --> 14:49I'm doing my best to give you
14:49 --> 14:51a short answer,
14:51 --> 14:53but there's no short answer when it comes
14:53 --> 14:55to the extent of reconstructive options.
14:55 --> 14:57Yeah, no, that was great.
14:57 --> 14:59So we're going to pick up the
14:59 --> 15:00conversation right after we take a
15:00 --> 15:02short break for a medical minute.
15:02 --> 15:04Please stay tuned to learn more
15:04 --> 15:05about reconstruction after
15:05 --> 15:06breast cancer with my guest,
15:06 --> 15:08doctor Paris Butler.
15:08 --> 15:10Funding for Yale Cancer Answers
15:10 --> 15:12comes from Smilow Cancer Hospital,
15:12 --> 15:14where their liver cancer program
15:14 --> 15:16brings together a dedicated group
15:16 --> 15:17of specialists whose focus is
15:17 --> 15:19determining the best personalized
15:19 --> 15:21treatment plan for each patient.
15:21 --> 15:26Learn more at smilowcancerhospital.org.
15:26 --> 15:28Genetic testing can be useful for
15:28 --> 15:30people with certain types of cancer
15:30 --> 15:32that seem to run in their families.
15:32 --> 15:34Genetic counseling is a process
15:34 --> 15:36that includes collecting a detailed
15:36 --> 15:37personal and family history,
15:37 --> 15:39a risk assessment,
15:39 --> 15:42and a discussion of genetic testing options.
15:42 --> 15:44Only about 5 to 10% of all
15:44 --> 15:45cancers are inherited,
15:45 --> 15:48and genetic testing is not recommended
15:48 --> 15:50for everyone. Individuals who have a
15:50 --> 15:53personal and or family history that
15:53 --> 15:55includes cancer at unusually early ages,
15:55 --> 15:56multiple relatives
15:56 --> 15:58on the same side of the
15:58 --> 16:00family with the same cancer,
16:00 --> 16:02more than one diagnosis of
16:02 --> 16:03cancer in the same individual,
16:03 --> 16:04rare cancers,
16:04 --> 16:07or family history of a known altered
16:07 --> 16:10cancer predisposing gene could be
16:10 --> 16:12candidates for genetic testing.
16:12 --> 16:14Resources for genetic counseling and
16:14 --> 16:16testing are available at federally
16:16 --> 16:18designated comprehensive cancer centers,
16:18 --> 16:20such as Yale Cancer Center
16:20 --> 16:21and Smilow Cancer Hospital.
16:21 --> 16:24More information is available
16:24 --> 16:25at yalecancercenter.org.
16:25 --> 16:27You're listening to Connecticut.
16:27 --> 16:27Public radio.
16:28 --> 16:30Welcome back to Yale Cancer Answers.
16:30 --> 16:32This is doctor Anees Chagpar and
16:32 --> 16:34I'm joined tonight by my guest,
16:34 --> 16:35Doctor Paris Butler.
16:35 --> 16:37We are discussing breast
16:37 --> 16:39reconstruction options after
16:39 --> 16:41cancer and right before the break.
16:41 --> 16:44Doctor Butler was telling us about how
16:44 --> 16:45reconstruction might
16:45 --> 16:48not be right for every patient.
16:48 --> 16:50And even for
16:50 --> 16:53the 65% of American women who after
16:53 --> 16:55mastectomy choose to have reconstruction,
16:55 --> 16:57there are options.
16:57 --> 17:00So implant based reconstruction versus
17:00 --> 17:02autologous reconstruction and Paris,
17:02 --> 17:04I was hoping that in this half
17:04 --> 17:06we could delve a little bit
17:06 --> 17:07more deeply into those options.
17:07 --> 17:11So one thing when it comes to
17:11 --> 17:12implant based reconstruction,
17:12 --> 17:14some people have concerns
17:14 --> 17:16about the safety of implants,
17:16 --> 17:18whether they leak,
17:18 --> 17:20whether they need to be
17:20 --> 17:22changed out periodically,
17:22 --> 17:25whether they need to be followed with an MRI,
17:25 --> 17:29whether they can in fact cause cancers.
17:29 --> 17:31Can you speak a little bit to those
17:31 --> 17:33concerns and how you advise your
17:33 --> 17:35patients with regards to that?
17:35 --> 17:37Yes, absolutely it's a great question.
17:37 --> 17:40So a lot of folks don't realize the fact that
17:40 --> 17:43breast implants are one of the most
17:43 --> 17:44studied implantable medical
17:44 --> 17:47devices ever known to human beings.
17:47 --> 17:48They've been studied more than
17:48 --> 17:50pacemakers and hip prostheses and knee
17:50 --> 17:52prosthesis.
17:54 --> 17:56I think the reason for this is because the
17:56 --> 17:57same implants we use for reconstruction
17:57 --> 17:59are the ones that are used for cosmetic
17:59 --> 18:01purposes and anytime you put devices
18:01 --> 18:05into celebrities to enhance their look,
18:05 --> 18:06it comes with a fair amount
18:06 --> 18:07of scrutiny and attention.
18:07 --> 18:09So the interesting thing,
18:09 --> 18:10breast implants have been out for
18:10 --> 18:11a really long time.
18:11 --> 18:13There was a moratorium on them.
18:13 --> 18:15Before even my coming into practice
18:15 --> 18:18to study them to make sure that they
18:18 --> 18:19did not cause additional breast cancers
18:19 --> 18:21or connective tissue disorders and
18:21 --> 18:23they identified the Institute of
18:23 --> 18:25Medicine that they do not and the
18:25 --> 18:28FDA we are now on our fifth
18:28 --> 18:29generation of silicone breast implants.
18:29 --> 18:31The first generation once they ruptured
18:31 --> 18:34I say it's something like
18:34 --> 18:36Ghostbusters eco slime.
18:36 --> 18:37This fifth generation of breast
18:37 --> 18:40implants are much more
18:40 --> 18:42sturdy and stable they're actually
18:42 --> 18:44given the terminology formed
18:44 --> 18:44Stable breast implant.
18:44 --> 18:46So I kind of equate it when I'm
18:46 --> 18:48speaking with the patient that these
18:48 --> 18:50new implants are like a gummy bear.
18:50 --> 18:51And they sometimes are even advertised as
18:51 --> 18:53such that if you cut a gummy bear in half,
18:53 --> 18:54nothing leaks out.
18:54 --> 18:57It kind of stays formed and that's
18:57 --> 18:59what these new silicone implants are like.
18:59 --> 19:02The saline implants have a silicone
19:02 --> 19:05shell and they are filled with saline.
19:05 --> 19:07The silicone implants have a silicone
19:07 --> 19:09shell and then are filled with
19:09 --> 19:11this form stable silicone.
19:11 --> 19:14When it comes to risks of the implants,
19:14 --> 19:15we've proven they do not cause
19:15 --> 19:16connective tissue disorder.
19:16 --> 19:17They do not cause breast cancer,
19:17 --> 19:20but the textured implants,
19:20 --> 19:21which I don't put in patients and
19:21 --> 19:23many of my colleagues don't anymore,
19:23 --> 19:25have been associated with a very
19:25 --> 19:26rare type of lymphoma,
19:26 --> 19:29anaplastic large cell lymphoma.
19:29 --> 19:33It occurred in about 1 in 2700 women.
19:33 --> 19:33For context,
19:33 --> 19:35there are about 10 million women
19:35 --> 19:37in the world that have implants
19:37 --> 19:40and once again a very, very,
19:40 --> 19:42very small percentage of women with
19:42 --> 19:44those textured implants developed
19:44 --> 19:45that rare type of lymphoma.
19:45 --> 19:48The other implants are smooth, round
19:48 --> 19:49implants that the majority of
19:49 --> 19:51us have currently put in.
19:51 --> 19:52Patients are safe.
19:52 --> 19:55I'd put them in a family member if it
19:55 --> 19:57necessitated for reconstructive purposes.
19:57 --> 19:59So they're very good questions.
19:59 --> 20:01I have an in depth conversation
20:01 --> 20:02with my patients about it,
20:02 --> 20:03but that's a little bit of the history.
20:04 --> 20:07What about for autologous reconstruction?
20:07 --> 20:11So you mentioned that these can be very
20:11 --> 20:15long operations, 8 to 10 hours in fact.
20:15 --> 20:18That you're in the hospital for a few days,
20:18 --> 20:21so some patients kind of wonder about the
20:21 --> 20:25risks of the surgery itself. What are the
20:25 --> 20:27complication rates like?
20:27 --> 20:29Can you speak a little bit to that?
20:31 --> 20:33Another very good option is autologous
20:33 --> 20:35surgery or autologous, we'll call
20:35 --> 20:37flap surgery, or taking tissue most
20:37 --> 20:39frequently from the abdomen to
20:39 --> 20:40reconstruct these breast mounds.
20:40 --> 20:42Now it is much more involved
20:42 --> 20:44and I don't sugarcoat it.
20:44 --> 20:46I have a thorough conversation with
20:46 --> 20:48the patient about what it entails.
20:48 --> 20:49As I said before,
20:49 --> 20:51in order for the flap to live,
20:51 --> 20:52it has to have blood flow,
20:52 --> 20:53and that blood flow comes
20:53 --> 20:55from when we take the flap,
20:55 --> 20:57we take it with a blood vessel that goes
20:57 --> 20:59into the top part of the thigh,
20:59 --> 21:00and we actually connect that to blood
21:00 --> 21:02vessels that are deep in the chest.
21:02 --> 21:03Right under the the breastplate.
21:03 --> 21:07And when we do that what we call anastomosis,
21:07 --> 21:08the connection of the small blood
21:08 --> 21:10vessels with our high magnification
21:10 --> 21:12glasses or with our microscope,
21:12 --> 21:14sometimes the connection doesn't
21:14 --> 21:16work and the blood vessels clot
21:16 --> 21:17off and that's a failed flap.
21:17 --> 21:19Now thankfully that doesn't happen that
21:19 --> 21:21often maybe 1 to 2% of the time in
21:21 --> 21:23the country that occurs because we've
21:23 --> 21:26been blessed to get so skilled with it.
21:26 --> 21:27But it is something that we
21:27 --> 21:29talk to patients about.
21:29 --> 21:31The other is the donor site,
21:31 --> 21:32one you're taking tissue
21:32 --> 21:33from another part of the body
21:34 --> 21:36there's sometimes ramifications,
21:36 --> 21:37there can be infections,
21:37 --> 21:41there can be wound separation at the belly.
21:41 --> 21:43We don't perform this operation on
21:43 --> 21:45smokers because of that increased
21:45 --> 21:47risk of wound separation in the
21:47 --> 21:49abdomen because of that increased
21:49 --> 21:51rate of infection in smokers.
21:51 --> 21:53So I would say it's a much
21:53 --> 21:54more involved operation.
21:54 --> 21:57You have to worry about implants
21:57 --> 21:59for the duration of someone's life.
21:59 --> 22:01They have their own tissue,
22:01 --> 22:02but once again it does come
22:02 --> 22:03with a much longer,
22:03 --> 22:05more involved operation,
22:05 --> 22:06a much longer recovery,
22:06 --> 22:09a good four to six weeks and then
22:09 --> 22:11the risk at the donor site.
22:11 --> 22:12One thing I failed to
22:12 --> 22:13mention about the implants.
22:13 --> 22:16Implants are not forever as it
22:16 --> 22:19pertains to the lifespan.
22:19 --> 22:22There are three kinds of main
22:22 --> 22:23implant manufacturers all of
22:23 --> 22:25them say at the 10 year mark,
22:25 --> 22:27we should be proactive rather than
22:27 --> 22:29reactive and have those implants replaced.
22:29 --> 22:32So it's a rather short operation.
22:34 --> 22:35We go through an existing
22:35 --> 22:36incision on the breast.
22:36 --> 22:38We take out the old implants and we
22:38 --> 22:41put in new implants to swap them out
22:41 --> 22:43before the likelihood of rupture,
22:43 --> 22:44spontaneous rupture would happen,
22:44 --> 22:47which is about 1%
22:47 --> 22:48per year for the 1st 10 years.
22:48 --> 22:50After 10 years it goes up to
22:50 --> 22:52about 10 to 15% and then after 15
22:52 --> 22:54years it goes up to about 30-40%.
22:54 --> 22:56So I try to get my patients in that window,
22:56 --> 22:59the 10 to 15 year mark to say, hey,
22:59 --> 23:01when the time is right in your life,
23:01 --> 23:02it's not an urgency,
23:02 --> 23:04but we should have those implants
23:04 --> 23:05replaced.
23:06 --> 23:07Is that covered by insurance?
23:08 --> 23:10It is. And I'm glad you brought that up.
23:10 --> 23:13So I go into the community a fair
23:13 --> 23:15amount to kind of talk about
23:15 --> 23:17and help to help raise awareness regarding
23:17 --> 23:19breast reconstruction options and
23:19 --> 23:21there are two subsets of the community
23:21 --> 23:22that don't tend to get breast
23:22 --> 23:24reconstruction at the same rate as others.
23:24 --> 23:25Those are our ladies of color and
23:25 --> 23:27then our more seasoned ladies.
23:27 --> 23:29I'd say our ladies over 50.
23:29 --> 23:31And one of the things that many
23:31 --> 23:32of these underserved communities tell
23:32 --> 23:34me is that they're concerned that they
23:34 --> 23:36can't afford breast reconstruction.
23:36 --> 23:39And I very quickly inform them the
23:39 --> 23:42fact that our country did a really
23:42 --> 23:45great thing, our legislators in DC
23:45 --> 23:47signed into law back in 1998,
23:47 --> 23:49it's called the Women's Health
23:49 --> 23:51and Cancer Rights Act of 1998,
23:51 --> 23:53where it mandates that if a woman
23:53 --> 23:55has insurance and she is diagnosed
23:55 --> 23:56with a breast cancer,
23:56 --> 23:58that requires a mastectomy
23:58 --> 23:59that insurance company is also
23:59 --> 24:01required to pay for their breast
24:01 --> 24:03reconstruction for their duration of
24:03 --> 24:05their life and that would be either
24:05 --> 24:07implant based reconstruction or flap
24:07 --> 24:10surgery or autologous reconstruction.
24:10 --> 24:11The other very good thing is the
24:11 --> 24:13fact that say a patient has cancer
24:13 --> 24:15on one side and they're only getting
24:15 --> 24:17cancer surgery on that one side.
24:17 --> 24:19The Women's Health and Cancer Rights
24:19 --> 24:21Act of 98' also mandates and allows for
24:21 --> 24:24a plastic surgeon to do a balancing
24:24 --> 24:25operation on that other side.
24:26 --> 24:27So say they have a left sided cancer,
24:27 --> 24:29we do breast reconstruction on the
24:29 --> 24:30left side and then we do a breast lift.
24:30 --> 24:32Or breast reduction
24:32 --> 24:34or augmentation on the opposite
24:34 --> 24:35side to help enhance symmetry.
24:37 --> 24:39And so that pertains to what
24:39 --> 24:41you were talking about earlier
24:41 --> 24:43in terms of oncoplastic surgery
24:43 --> 24:45after lumpectomies, is that right
24:45 --> 24:48that that also pertains to that as well.
24:48 --> 24:50Now some insurance companies
24:50 --> 24:52try to push back and say, well,
24:52 --> 24:53the Women's Health and Cancer
24:53 --> 24:55Rights Act was really only
24:55 --> 24:56intended for mastectomy patients.
24:56 --> 24:58But thankfully with the
24:58 --> 25:01help of our surgical oncology colleagues, we have been
25:01 --> 25:04speaking to insurance companies to say,
25:04 --> 25:06listen these patients who have lumpectomies
25:06 --> 25:09who are left with rather significant
25:09 --> 25:11asymmetries and deficits should be entitled
25:11 --> 25:13to some reconstructive procedures as well.
25:14 --> 25:16Now the other question, you know,
25:16 --> 25:18before the break you were mentioning
25:18 --> 25:21that the prime goal is really the
25:21 --> 25:23reconstruction of the breast mound.
25:23 --> 25:26Many women are concerned about the nipple.
25:26 --> 25:28Can you talk a little bit about
25:28 --> 25:30the options that women have for
25:30 --> 25:32either keeping their own nipple
25:32 --> 25:34versus nipple reconstruction?
25:36 --> 25:38Yeah, so another very good question
25:38 --> 25:40and I would not want to
25:40 --> 25:42overstep my breast oncology or
25:42 --> 25:44my breast surgery contemporaries.
25:44 --> 25:46Nipple sparing mastectomy has been
25:46 --> 25:49in existence for about 25 years.
25:49 --> 25:50The initial mastectomies were
25:50 --> 25:53quite a morbid operation where we
25:53 --> 25:55removed all of the breasts inclusive
25:55 --> 25:57of the skin and even in muscle.
25:57 --> 25:59We have now gone as far as being
25:59 --> 26:01able to remove the entire breast
26:01 --> 26:03but leave all of the skin and
26:03 --> 26:05including the nipple areola complex
26:05 --> 26:08behind and have it just as a
26:11 --> 26:13cancer appropriate and safe operation.
26:13 --> 26:15So they will have a conversation with
26:15 --> 26:17their breast surgeon or the surgical
26:17 --> 26:19colleague regarding whether or not
26:19 --> 26:21they are a nipple sparing candidate.
26:21 --> 26:22If it is,
26:22 --> 26:25then there's no need for us to
26:25 --> 26:26reconstruct a nipple areola complex.
26:26 --> 26:27However,
26:27 --> 26:30certain cancers don't allow for that if
26:30 --> 26:34the cancer is too close to the nipple areola.
26:34 --> 26:36If the cancer is too great in size,
26:36 --> 26:39or the patient is just too large
26:39 --> 26:41breasted or too toxic or saggy,
26:41 --> 26:43then the nipple areola complex must be
26:43 --> 26:45removed as a part of the cancer surgery.
26:45 --> 26:46If that happens,
26:46 --> 26:48we reconstruct that breast mound
26:48 --> 26:51and then six months to a year
26:51 --> 26:52after we're done with their
26:52 --> 26:54breast reconstruction formally,
26:54 --> 26:55we can go back.
26:55 --> 26:57And then we have special techniques
26:57 --> 26:59to reconstruct a niplle areola
26:59 --> 27:01complex using that native tissue.
27:01 --> 27:04Something else that has really
27:04 --> 27:07enhanced our field is the capacity for
27:07 --> 27:11us to perform or to send to an artist a
27:11 --> 27:133D nipple areola tattooing.
27:13 --> 27:17We have a nurse practitioner here at
27:17 --> 27:20Yale plastic surgery that performs
27:20 --> 27:21nipple areola tattooing after
27:21 --> 27:24we've recreated that breast mound.
27:24 --> 27:27So lots of options on that front as well.
27:27 --> 27:28But the conversation really should be
27:28 --> 27:30with the breast surgeon as it pertains
27:30 --> 27:32to whether the nipple can be spared
27:32 --> 27:34or not as a component of their
27:34 --> 27:35cancer surgery.
27:36 --> 27:38And then the other question that
27:38 --> 27:41I think a lot of people have is
27:41 --> 27:43what is their function and their
27:43 --> 27:45sensation after a mastectomy.
27:45 --> 27:48So does the nipple really work?
27:48 --> 27:52Do they lose sensation in the breast area?
27:52 --> 27:54Are there new techniques
27:54 --> 27:55that can address that?
27:55 --> 27:56Can you speak a little bit about that?
27:58 --> 28:00I think that's another good question.
28:00 --> 28:02Once again a lot of this
28:02 --> 28:04is about setting expectations.
28:04 --> 28:07In my experience I've been in practice
28:07 --> 28:09over eight years after training for 12
28:09 --> 28:12and what I have seen is that
28:12 --> 28:15most of my patients say even when they
28:15 --> 28:17aren't nipple sparing candidates
28:17 --> 28:20the sensations not the same and we
28:20 --> 28:22should prepare our patients for that.
28:22 --> 28:24There are some techniques out there
28:24 --> 28:26where we are doing nerve graphs
28:26 --> 28:28but a lot of it's in it's
28:28 --> 28:30infancy, and we're studying to see
28:30 --> 28:32how effective those techniques are.
28:32 --> 28:34Doctor Paris Butler is an associate
28:34 --> 28:36professor in the division of Plastic
28:36 --> 28:38Surgery at the Yale School of Medicine.
28:38 --> 28:40If you have questions,
28:40 --> 28:42the address is canceranswers@yale.edu,
28:42 --> 28:45and past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:56Funding for Yale Cancer
28:56 --> 28:58Answers is provided by Smilow
28:58 --> 29:00Cancer Hospital.

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