“New Year, New You” and Plastic Surgery: Is There Something to This Slogan?
New Year’s resolutions are ubiquitous. We all make them, but most of them are
unfortunately doomed to fail. Most resolutions focus on self-improvement –losing
weight, eating healthier or getting a daunting task completed. Is there
something to this, or is it all just a waste of time?
Many plastic surgeons capitalize on New Year’s resolutions to try to lure
patients into their offices with the slogan “New Year, New YOU!” While this is a
phrase I generally avoid, there may in fact be something to it. Most people do
in fact want to put their best face and body forward, reflecting the healthy
inside on the outside as well, and what better time to do it then at the start
of a new year? Well if that’s the case, how can seeing a board certified plastic
surgeon and ASPS member help? Here are a few procedures available in 2016 that
can help your exterior reflect your very best self and reach those
resolutions:
Surgical Procedures
Liposuction – The most popular body
contouring procedure for both men and women. Permanent removal of unwanted fat
deposits by way of tiny incisions hidden in creases, with a few weeks’ downtime
but permanent results!
Tummy
tuck (abdominoplasty) – A larger procedure but very common
post-pregnancy to remove extra skin, stretch marks and fat, together with
correction of muscle separation (known as “rectus diastasis”).
Breast augmentation/enhancement, lift or reduction – The goal being for a woman to feel
proportional to the rest of her body, with a youthful breast shape and fullness.
The options these days are nearly endless – I call what I offer patients
“designer breast surgery” since “her goals are MY goals”!
Facelift
and neck lift – Both women and men notice aging in their facial
region, in particular the neck. Sometimes a straightforward procedure such as
rejuvenation of the face or neck can make all the difference and create a less
tired and more rested, energetic appearance.
Eyelid surgery (blepharoplasty) – Of the
upper or lower lids removes hooded or baggy eyelid skin and sometime removes
bulging fat pockets, creating a refreshed appearance that permanently refreshes
the eye area.
Mommy Makeovers – A constellation of procedures personalized
to each woman based on how pregnancy changed her body, her anatomy, her specific
wishes and realistic available downtime. A Mommy Makeover traditionally involves
a breast lift, augmentation or reduction, tummy tuck or liposuction;
occasionally additional procedures such as labiaplasty or non-surgical
procedures are included.
Non-Surgical Cosmetic Procedures
CoolSculpting – Who can say no to non-surgical permanent fat
reduction that doesn’t require anesthesia and has no downtime! While the results
are less dramatic when compared to liposuction, work and exercise can resume
immediately, with a 25% reduction of stubborn fat deposits in a single hour
office treatment. CoolSculpting is especially popular with men to banish that
“spare tire” or “muffin top” region.
Botox – The number one popular injectable
treatment is that way for a reason – it works, it’s quick, easy and a great way
to reduce or prevent wrinkles in the forehead and crow’s feet areas. Lasting 3
months or longer and taking just minutes to receive, Botox revolutionized the
cosmetic industry and is still going strong.
Fillers – Dermal fillers are safe, natural
substances injected under the skin or deeper planes (such as immediately over
facial bones) to sculpt the face and fill in lines or hollows resulting from
volume loss with aging or significant weight loss. Some fillers help to
stimulate the body to produce its own additional collagen in the treatment
area.
IPL photo-facials – Intense pulsed light (IPL) is a
non-ablative laser-type machine that targets red or brown pigments in the skin
or deeper water molecules to zap away unwanted pigmentation abnormalities and
cause turnover of skin cells for a refreshed glow to the skin.
LATISSE – An FDA-approved topical medication that grows your
eyelashes longer, fuller and darker (if they are already dark – it will not make
blonde eyelashes darker)! A non-surgical way to help brighten the eyes, many
users work LATISSE into their nighttime beauty regime.
Lastly, medical grade skin care can help rejuvenate and improve the condition
of your skin. In contrast to drugstore or even more expensive brand name
department store serums and creams, “medical grade” means they are generally
only available in a physician’s office and they contain the highest
concentration of active ingredients.
For some, reaching “your best self” might mean a visit to a plastic surgeon’s
office – for others, a change in diet or increased exercise, meditation or yoga
will do the trick!
Either way, be sure to “Do Your Homework” and seek a plastic surgeon who is a
member of the American Society of Plastic Surgeons and who is American Board
Certified in Plastic Surgery. Together we can help determine the most
appropriate and safest way to reaching your personal goals for 2016!
Why the "One and Done" Approach to Breast Reconstruction Can Be Misleading
Recently, a news article circulated with information regarding a new “one and
done” approach to breast reconstruction being available and providing promising
results. Sounds great right? While the procedure can be a great option for some
women, calling it "one and done" can be misleading as over 30% of women will
need further surgery. For this reason, many surgeons refer to the procedure as
"direct-to-implant" instead.
At PRMA we do perform "One-Step" breast reconstruction using implants and Alloderm.
However, we try to limit this procedure to patients who are seeking immediate
reconstruction after prophylactic nipple-sparing mastectomy (eg for BRCA+) since
this group of women have the best chance of needing only one surgery.
For patients undergoing a mastectomy due to cancer, there are some things to
consider before choosing the “one and done” surgery. The final cosmetic results
after implant breast reconstruction depend heavily on the thickness of tissue
covering the implant. Often after mastectomy, the tissues over the implant
aren't thick enough to camouflage the implant completely, even if the implant is
under the pec muscle. Many patients experience visible implant "rippling"
because of this and more surgery is required (usually fat grafting) to add more
tissue over the implant(s) to decrease the visible rippling. This is the most
common reason for needing further surgery after a "one and done" procedure.
The possibility of post-mastectomy radiation also needs to be considered.
Radiation certainly doesn't preclude breast reconstruction, but it does increase
the risk of complications and can impact the final cosmetic results. Radiation
and implants often do not get along very well and patients undergoing radiation
therapy after breast reconstruction often need more surgery for the best
results.
One more factor to consider is the impact of nipple-sparing mastectomy (NSM). Preserving the nipple-areola
significantly improves the cosmetic results after breast reconstruction,
particularly reconstruction with implants. Patients who aren't candidates for
NSM, or prefer not to preserve the nipple-areola, often have results that aren't
as cosmetically appealing after implant-based reconstruction as those who have
NSM.
For patients seeking flap-based reconstruction a single-step approach can be
performed, but consistently superior results are achieved with a staged
approach. Procedures such as the DIEP flap are often performed at the same time as the mastectomy ("immediate reconstruction")
allowing patients to wake up with breasts and avoiding the trauma of a missing
breast. However, the newly reconstructed breast is not considered a finished
product. A second surgery—or revision surgery— is typically needed a
few months later to "fine tune" the reconstructed breast(s) for the best
cosmetic results. This outpatient surgery often includes further breast shaping,
fat grafting, scar revision, and nipple reconstruction.
Although the idea of having everything taken care of in one surgery sounds
great, unfortunately this will not always be in your best interests. Please
discuss your expectations thoroughly with your surgeon prior to proceeding with
"one and done" breast reconstruction to make sure it is the best choice for you.
For more information, including a list of ASPS plastic surgeons in your
community, please use our Find a Surgeon
tool.
Breast Cancer to Reconstruction and Your Healthcare Team
The saying, “It takes a village” seems to resonate repeatedly in my mind when I
think about the group of healthcare clinicians who have been and still are an
integral part of my breast cancer journey team. Some patients may feel that they
don’t have a choice in deciding who their team might be. Perhaps it is because
resources are limited in their area. It could be that some patients are
overwhelmed with the diagnosis and let medical professionals guide them through
the process of choosing or assigning their healthcare team. No matter what the
circumstances you are owed the very best medical team you can find and that will
be covered under your insurance plan. Some with additional financial resources
may even be fortunate enough to choose medical teams not covered by insurance
just for their peace of mind. Either way, here is my story, my process and my
team. I hope you find this helpful in guiding you through the process from
diagnosis to reconstruction.
My team, from the radiologist who found the recurrence of my breast cancer
tumor to my microsurgeon who reconstructed my breasts, was all an integral part
of my healing. The road was not always easy for either of us, as a patient or as
medical professional. At times there was news to deliver that simply left me
devastated and I’m sure was not easy for the individual clinician to convey .
There were ongoing details of treatment and surgery that had to be explained,
sometimes more than once. But in the end, I stuck with this team and have moved
beyond the fateful day that started with my radiologist who had to deliver the
front end of the news; a recurrence of breast cancer as well as a new diagnosis
in a different breast.
My Radiologist
She was a kind and gentle woman. There are those radiologists who I call “the
ghost doctors”, no disrespect intended. They are unseen and spend a great deal
of their time in dark rooms looking at films and then the patient usually hears
the radiology report from the oncologist or breast surgeon. Patients don’t
always speak to them because their main focus is reading films. But, my
radiologist was very interactive with her patients. She came in to tell me as I
held back tears that the lump she detected on my mammogram was likely cancer.
She said it with such affirmation and confidence that I was certain the guided
needle biopsy she performed to confirm that was not going to reveal anything
different. I was correct. She also had to perform one on the opposite breast
after an MRI revealed yet another mass in that breast.
My Advice: If your oncologist, primary care doctor or
surgeon cannot explain your radiological reports to your satisfaction, ask for
clarification and ask to speak to the radiologist. If they aren’t interactive
radiologist like mine, you have a right to speak up and ask to discuss the
results with them. As difficult as that is sometimes, it is your health and you
owe it to yourself to have the best clarification about the findings. That may
necessitate finding a nurse navigator or patient advocate to help you with
that.
My Breast Surgeon
My radiologist, again, was kind enough to ask me if I knew of any breast
surgeons. If not, she would recommend one for me. I immediately told her about a
woman who removed a benign cyst for me a few years prior. When I mentioned her
name she immediately nodded her head in approval, told me that breast surgeon
was in their system, and she thought very highly of her.
Tip: When a trusted and respected doctor that you already
have a good rapport with recommends another doctor, chances are things are going
to go well.
They did go well. My breast surgeon, again another woman, was so easy to talk
to, so compassionate, yet so very thorough and honest with her approach. She
told me upfront that I was likely looking at a double mastectomy but wanted to
do further testing to make sure that was going to be the best course for me.
Additionally, this woman was informed on the latest techniques and knew of the
“gold standard”, as she described it, in breast reconstruction, the DIEP flap.
She gave me other alternatives and information for other types of reconstruction
but when she told me I could be my own tissue donor with the DIEP, I was on
board. She told me what to look for in a DIEP surgeon, how long the surgery
takes and what the recovery time was. In other words, she gave me enough
information to peak my interest and get me going on my own research to find a
board certified microsurgeon.
I was simply amazed that I had my mastectomy on a Wednesday morning at 8am,
was home by noon the next day and walking the neighborhood by the weekend,
albeit short walks. I did go into surgery in very good physical shape but I
attribute her skill and experience as part of the equation in my ease of healing
and recovery.
Tip: Ask how many mastectomies your breast surgeon has
performed. Ask what the healing complications can be and how those are handled
should they arise. Ask how long you will be in hospital and what the recovery
time will be. Ask about your range of motion and if you will need physical
therapy afterward. Ask how quickly your surgical report will come back to find
out about lymph node involvement or if you will need any adjunctive therapy
after surgery. Ask if you are a candidate for nipple sparring mastectomy (NSM)
and what her rate of success is in saving the nipple. Ask, ask, and ask!!
My Oncologist
I was assigned my oncologist by the breast center I would go to. My primary
care doctor was a female and I seemed to be keeping with that pattern because my
oncologist was also female. The best thing she said to me during our first visit
was that she intended to see a cure for cancer in her lifetime, a lofty
statement indeed, but what breast cancer patient doesn’t want to hear that? She
was a young woman and explained everything very thoroughly to me. I wanted extra
time and sometimes things needed to be explained twice or more and she took the
time to do that. She was willing to listen to my needs and my research and what
those findings meant to me. We had to have some intricate discussions about my
care and they weren’t always easy. But, she stuck with me and I stuck with her.
This is what is referred to as shared decision making. This is a process where
you go in as an informed patient, listen to your doctor’s recommendations and
expertise on the diagnosis, share the information you have with your doctor and
together you come up with a plan that you feel is the best decision for your
care.
My Breast Reconstruction Surgeon
Not to diminish any of the relationships I’ve had with any of my health care
team but when a surgeon literally and figuratively puts your life back together
that relationship is forged in a way that is unique and on a completely
different level than with your other cancer care team.
Since I was told about DIEP flap from my breast surgeon, the research for a
qualified plastic surgeon began for me as I was recovering from my mastectomy. I
went to the internet and carefully vetted microsurgeons by reading their
curriculum vitae. I looked at their training, fellowship experiences and combed
the comprehensiveness of their webpage. I looked at before and after photos in
complete amazement at the transformations. I read on line forums from women who
had DIEP flaps and some of their experiences traced back to some of these
doctors I researched on line. I watched YouTube videos and patient testimonials
about their experiences. I connected with other patients who had this same
procedure to ask about their experience, their surgeons. I combined all of this
research with the initial information I was given by my breast surgeon.
I made a comfortable choice with an ASPS board certified, highly-trained,
plastic micro-surgeon named Dr. Minas Chrysopoulo, Dr. C, as he is known by his
patients. He had a high success rate, 99% or more and he also worked with a
team. The practice and team he worked with, all highly qualified ASPS doctors,
dealt mainly with cancer patients and more importantly, their main focus was
autologous flap surgery, particularly DIEP flap. Dr. Chrysopoulo fulfilled my
entire criterion and now it was time to verify my choice.
The day I walked in for my first consult with my board certified plastic
surgeon, my husband and I were both full of anticipation. Dr. C pulled a chair
up right in front of me and said, “You’ve been through a lot haven’t you. But,
you look really great!”
Compassion! Just what a two time cancer survivor needs in a plastic
surgeon.
My husband, who is an engineer, asked my plastic surgeon some pointed and
technical questions about the procedure since he had to trust this man with my
life while I was under the knife and anesthesia for upwards of 8-10 hours. The
responses were straight-forward, honest, and inclusive of everything we should
expect the day of surgery.
Truthful and sincere! Just what a care-giver/husband wants to hear from the
man who is going to put his wife back together after watching her lose the very
body part that defined her femininity. We walked out of his office that day
after the appointment. We felt the first sense of hope since my diagnosis seven
months previous to this consult. My husband looked at me and stated, “That guy
is golden.”
The morning of surgery he walked in and gave me a fair analysis of what he
would be doing that day. During surgery, he had to remove quite a bit of scar
tissue that was left from radiation twelve years previously from my first
diagnosis. When he walked out to report the outcomes to my husband they had a
brief chat. Again, my husband gets straight to the point. After the summation
given by Dr. C, my husband asked him, “Are you happy with the outcome” He
replied, “I am.” That’s exactly what my husband needed to hear.
Unwavering confidence, skill and acknowledgement that my due diligence in
finding a qualified micro-surgeon paid off!
After phase 1and the time leading up to phase 2 of my reconstruction surgery
I became a patient advocate and educator for other women who are seeking
information about breast reconstruction, surgery, healing and recovery. I would
not be doing this outreach had I not had a good experience with my breast cancer
team of doctors from radiologist to plastic surgeon. I will continue this
outreach, education and advocacy because I continue to work with my entire
breast cancer team.
I felt like a team player with all members. Patient empowerment over your
health care should be a given but that is not always the case. Physicians are
individuals just as we all are in every walk and profession of life. Patients do
not always have good experiences but you must be the captain of your own ship.
When a physician treats you like a team member and embraces the shared decision
making process, you forge not only trust but friendships and respect for your
medical team. I applaud each and every doctor who traveled this journey with me.
I will be on this journey a long time as I share it with other patients and the
hope is that other breast cancer patients can navigate the complicated waters of
breast cancer and breast reconstruction with knowledge and shared decision
making with their health care team.
Options and Resources for Breast Reconstruction after Mastectomy
Breast Reconstruction is an option for women and men after
having a mastectomy due to a breast cancer diagnosis. It is also a consideration
for women who have tested positive for a BRCA gene mutation and wish to have a
prophylactic mastectomy to greatly decrease the chances of getting cancer.
Breast reconstruction is a personal choice, a choice that is not for everyone,
but a choice that everyone deserves to know about. So what are the options for
breast reconstruction? There are three types:
- Reconstruction using implants, either saline or silicone gel.
- Reconstruction using your own tissue called autologous reconstruction.
- Reconstruction using a combination of implants and autologous
tissue.
It is important to research all options before deciding on a method to
consider. There are reasons why you may choose one option over the other. There
are still many challenges that individuals face when it comes to considering
their reconstruction preference. They might include the following:
- Your overall health and the stage of your breast cancer. You may have an
advanced breast cancer that requires adjunctive therapy before reconstruction
begins. Radiation can also delay reconstruction. Treating your cancer should
always take precedence over reconstruction. Talk to your plastic surgeon about
this and they should guide you through a shared decision making process to
optimize your health before surgery and decide on the best option of
reconstruction for you.
- Availability of a qualified plastic surgeon and a medical facility that
performs reconstruction that is geographically nearby can be a deterrent to some
due to lack of funds for travel or fear of travel after surgery. Although
medical travel can be claimed as a tax deduction it is an out of pocket expense
for breast reconstruction if there is not a qualified surgeon or facility
nearby. This is a particular challenge for those in rural areas.
- The area of resulting scars from surgery is also of concern to those seeking
reconstruction. There is a difference in scar placement in the three types of
reconstruction and this is an important and personal consideration for
many.
- Support in recovery after surgery. Not all individuals have family, friends
or local support nearby to help them with post-reconstruction recovery and
care.
- Time off work. Women must consider a possible 4-6 weeks off work for
recovery depending on the type of reconstruction they choose. This may vary for
men and again the complexity and type of surgery chosen will depend on the time
needed to be away from work to allow time to fully recover.
- Insurance. Although a 1998 federal
mandate requires reconstruction to be covered by insurance, there are those
still facing barriers with insurance coverage depending on the facility and what
insurance is carried by that facility.
The passage of the Breast Cancer Patient Education Act in December of 2015
hopes to not only educate a larger populous of men and women about their breast
reconstruction options but also speak to many of these challenges that are faced
in making a decision to have reconstructive surgery after breast cancer or for
prophylactic reason due to a BRCA gene mutation. As with any new educational
initiative, this will take time and implementation but there is greater hope
that we can reach a broader audience and continue to educate and inform about
options with the passage of the Breast Cancer Patient Education Act.
There are many resources available to begin research for what choice might be
considered for breast reconstruction. There are survivors and advocates who
write informative blogs about their own breast reconstruction experience and
provide helpful information from how they chose their surgeon and continuing
through to the recovery process.
Travel assistant programs are available for patients but you must call to
find out if you are eligible. There are also 501c3 groups who assist women with
travel in breast reconstruction. Below are just a few of those travel
resources:
- Patient Airlift
Services
- Angel Flight
- Mercy Medical Angels,
Medical Transportation Services
- Alliance in
Reconstructive Surgery Foundation
It is imperative to be your own best advocate. This can be a daunting task
when you are faced with a breast cancer diagnosis. You are inundated with
information about your diagnosis and treatment and sometimes reconstruction is
the last thing on your mind. You just want the cancer to be gone. However, you
may very well want to consider reconstruction at some point in the process. It
is to your benefit to consult with a plastic surgeon soon after your diagnosis
to consider your options and timing.
An important question to ask when you have been told you are facing a
mastectomy is, “What are my reconstruction options if I choose to have my
breasts rebuilt after my mastectomy?” Every women and man diagnosed with breast
cancer has the right to this information to move forward with making an informed
decision. Your radiologist, breast surgeon, or oncologist may just have a
connection or name to a board certified plastic surgeon for you to talk to
The American Society
of Plastic Surgeons has a “surgeon finder” on their website with board
certified plastic surgeons who perform breast reconstruction. If you are
considering autologous reconstruction, the American Society of Reconstructive Microsurgery also has a
“surgeon finder” for patients. When choosing autologous reconstruction it is
important to find a microsurgeon, a specialty in plastic surgery that requires a
specialized fellowship and further training.
Important questions to ask your plastic surgeon, whether for implant based or
autologous reconstruction include but are not limited to the following
questions:
- How many procedures have they performed?
- What is their success rate?
- Do they work with a team? The shared expertise is a factor as well and often
minimizes time for the patient in surgery.
- Do they have before and after photos?
- What aesthetic outcomes can I expect based on my individual health history
and case?
- What type of insurance carriers do they take?
- Will they accept insurance from out of state? These laws are tightening and
it is a good question to ask as many patients travel across state lines to find
the most qualified surgeon.
- Do they balance bill? Balance billing is when a surgeon sets a fee and asks
the patient to pay the remaining amount not covered by insurance. This is not
the case at every facility but it is an important question to ask.
Breast Reconstruction does not involve one surgery in most instances. It can
take two or more surgeries to complete the process and time to heal and recover
in between surgeries. Revision and symmetry phases as well as nipple and areola
rebuilding or tattooing (for those who have not had nipple sparring mastectomy –
NSM) can be part of this process.
There is a lot that goes into the planning process of this surgery but
reaching out for help makes it an attainable goal. Many have had it done
successfully and the hope is that this will continue to be an attainable goal
for more as the science and developments in breast reconstruction continue.
Breast Reconstruction Tweet Chat and the Value of Social Media
Monday evening, February 22, 2016, was a much anticipated #bcsm tweet chat for
me. I reached out to Dr. Deanna Attai in late 2015 when she was requesting
topics to cover for the upcoming year. I asked for an evening of discussion
about breast reconstruction options after mastectomy. I have been diagnosed with
breast cancer twice and had a very successful experience using my own tissue to
reconstruct my breast, DIEP flap surgery. Breast Reconstruction advocacy and
educating other women about the topic is what I do now so I was delighted when
Dr. Attai put us on the schedule. From there I began to “circle the wagons” for
support.
I reached out to the social media specialist at the American Society of
Plastic Surgeons (ASPS) to see if they would be interested in participating and
adding to the discussion. They put their expert plastic surgeon and current
president of ASPS, Dr. David Song, front and center as the specialist on the
topic to partner with me for the evening. The purpose was to provide more
education and information to those who could join us for the tweet chat. We set
up a telecom to plan the topics and went over the basics of the tweet chat. We
strategized about the best way to promote the event and which social media
platforms to use for that.
It was important for me to have them in the discussion because they were an
impressive force behind the passage of the Breast Cancer Patient Education Act.
This was a bill that was passed into law on December 18, 2015, as an education
campaign to inform and educate women and men about their breast reconstruction
options. We promoted the chat as planned and on the evening of February 22nd, we
all sat poised, with fingers in “tweet position” ready to begin discussion.
When the “fastest hour on Twitter” came to an end I admittedly had to ask
myself, “Did I tweet out enough information?” I truly sat back during the
discussion at one point and just let the comments and questions fly and felt
like I could have been doing more. It wasn’t until I looked at the summary of
the conversation provided by Dr. Attai on Symplur the next day that it all fell
into place for me. I realized how much I didn’t see that evening as I was
furiously trying to keep up with the tweets. It gave me a lot of satisfaction to
see what was discussed, what I missed during the actual session and how
multi-faceted the topic of breast reconstruction after mastectomy truly is.
Here is a brief summary of key items covered and some of the comments that
were shared.
Complications of breast reconstruction:
- Smoking! A big no-no when it comes to reconstruction surgery. You’ve just
got to stop before, after and hopefully for good.
- Possible Infection rates: One participant remarked she had 6 surgeries, due
in large part to an infection. Although she was told about outcomes she didn’t
feel fully informed about complications. She said when those complications
popped up, “it was really hard”.
- A Stage IV patient weighed in about the possibility of reconstruction when
you’re faced with metastatic disease. Caution was given from one physician
stating that it is still controversial as it must be evaluated on a patient by
patient level. Hope was given by another physician stating that it is an option
even for patients with mets and offered that studies have been shown to increase
quality of life. It was important that the disease be stabilized and the patient
is in good enough health for the reconstruction.
- Radiation therapy was labeled by one as a “wild card”. It can affect
outcomes both before and after reconstruction whether using implants or
autologous flaps (your own tissue to reconstruct the breast).
- The timing of reconstruction was a hot topic. It was mentioned more than
once that breast cancer is rarely an emergency situation. A majority of the
time, surgery and the research to plan reconstruction is something that can wait
for both women and men. Many stated that patients felt rushed into a decision
because of the stigma, “the cancer needs to come out now”. It is sometimes
perceived as more of a “mental emergency” than a “medical emergency”.
- It was important to note that reconstruction rarely is one procedure.
Revisions and repairs often required more than one surgery and sometimes
multiple surgeries to achieve desired patient outcomes.
- Insurance concerns loom large for many. Some facilities don’t use certain
insurance providers which lead to roadblocks for some patients.
- Travel is often times required to get to a qualified plastic surgeon or to
find one that carries your insurance.
- Some women try to get all necessary surgeries done in one year so that they
do not have to pay their deductibles and meet their out of pocket two years in a
row. It is not possible for some to plan that way due to continued adjunctive
therapy or further tests/scans prescribed for the breast cancer
diagnosis.
Breast Cancer Patient Education Act #BCPEA
- Dr. Song stated that “the goal of the #BCPEA is to inform patients about the
availability of breast reconstructions and other alternatives
post-mastectomy”.
- Quick facts:
- A Majority of women don’t the information.
- There are not enough plastic or micro-surgeons doing reconstruction
especially in rural areas.
- Underserved patients don’t get the advanced options or sometimes any
options.
- One physician mentioned that some surgeons unfortunately are still a little
“old school” for offering or educating about breast reconstruction options.
- The overriding opinion was that the first line of information for
reconstruction options and education should come from the general surgeon or
breast surgeon immediately after the diagnosis.
- And then there was this little nugget from ASPS that I completely missed and
was very happy to come across. “The stories of #BreastReconstruction patients
was a HUGE force behind #BCPEA becoming law last year”. That one made me smile
and I immediately re-tweeted after reading it. It was validation that our voices
do make a difference. Thank you ASPS for that sweet tweet!
Men And Breast Cancer
- Breast Reconstruction is not something men ask about or think about as much
as women.
- Fat grafting and liposuction is used more often than flap surgery in
men.
- One gentleman stated that he had very little fat to use and the response
tweet to that was, “…even very lean people usually have some fat to
harvest”.
- Many men don’t realize that reconstruction/chest wall reshaping is an
option. They have to ask.
- One gentleman was perplexed to know that more women weren’t informed of
their options. His impression was that there was a real push for women to get
reconstruction done.
The Team Approach
- Complications should be discussed with EVERY surgery and for recon, breast
surgeon AND plastic should be discussing them.
- A woman asked how do breast surgeons and plastic surgeons communicate w/
each other about a breast cancer patient's "aesthetic" desire prior to the OR?
Great question!
- Many of the physicians participating agreed that a multi-disciplinary team
was crucial to optimal patient outcomes.
- Shared decision making with the patient as part of this multi-disciplinary
team was important.
- One happy patient stated: “My BS (breast surgeon) & PS (plastic surgeon)
worked very well together. I'm one lucky woman to have landed in their
OR”.
Patients Being Their Own Advocates
- This was a hot topic and many felt that patient or nurse navigators should
be available at cancer facilities to help navigate the complex waters of cancer
care.
- It was stated over and over that patients should be their own
advocates.
- I countered with the fact that many patients don’t have the wherewithal to
do that and that is when the need for a navigator or advocate is paramount.
- Seeking second opinions is in alignment with this topic and it seemed to be
a consensus between physicians, health care coaches and patients that second
opinions are an important part of this equation in breast reconstruction for
clarity and patient desired outcomes.
Opinions And The “Hot Button” For The Evening
- This comment precipitated quite a discussion: “Let's go back to why women
want recon in the first place, possibly too much emphasis on breasts equal
sexuality”.
- Reply from Dr. Song: “I’m glad you brought this up. It’s NOT about vanity.
It’s about restoring what cancer removes!”
- And another follow-up response: “I'm almost 60 so I have one view, probably
diff for young women”.
- I had a great microsurgeon and wonderful experience for my DIEPflap so
admittedly defended my age and position by a rebuttal remark of: “I'm 60 and
have more confidence in my body now than I did when I was 20!”
- One woman weighed in and said, “I think most people want to feel "normal"
just like those who get prosthetics for other areas of the body as well”.
- One of the gentlemen in the chat discussion chimed in with: “I was also
concerned about my appearance in a swim suit, especially soon after surgery.
It's worked out okay.”
- Patients often feel that an explanation for why they are doing
reconstruction is necessary. A reply from a participant on this matter: “Recon
or no recon is a personal choice. The PATIENT's choice. Family/friends don't
have to like her decision, they must respect it”.
It’s not uncommon for Tweet chats to stray from the original topic questions
that are presented for the evening. That is the beauty of tweet chats. They are
spontaneous, organic and full of fast and furious answers and opinions. A
perfect example of this was when two physicians both introduced themselves that
evening by stating they would be “lurking” and tweet when they could. The
reason? They were both tending to their children who were still up. You’ve just
got to admire that dedication!
Did this tweet chat stick exactly to the topics outline? No. Did this tweet
chat serve the function of an open and informative evening about breast
reconstruction? Absolutely; in my humble opinion!
I looked at the data analytics provided and to my amazement there were over
4.5 million impressions, 826 tweets, 74 participants, and the average tweets per
participant was 11. That is a lot of reading, processing and sharing all in one
hour. Social media engagement is important not only for physicians but for
patients and in this instance, it was shared information and stories from both
of those entities. It was an evening of interaction among medical peers,
patients, and healthcare coaches from across the country. Some of those tweets
will be viewed, re-tweeted and liked by those who were not even part of the
chat. That is the positive take home for me from the evening. It is time to rest
the thumbs and digits for the next chat. A big thank you to all who
participated!
Plastic Surgery and Regenerative Medicine
Regenerative
Medicine is a growing new field in medicine that is based on the concept
that physicians can harness the body’s own powers to heal itself rather than
relying exclusively on drugs or invasive surgical procedures. The field deals
with the process of engineering human cells, tissues or organs to replace,
restore or establish normal function . While ‘regenerative medicine’
predominantly includes therapies and devices that use stem cells, the term is
also used to describe therapies that use progenitor cells, as well as other
cellular products such as PRP (platelet-rich plasma).
While both PRP and progenitor cells are widely used in the clinical setting,
stem cells are still in the early clinical trial stages and not commercially
available. PRP is used to treat orthopedic injuries and degenerative joint
disease. Progenitor cells have been used for many decades in the form of bone
marrow transplants.
But stem cells are all the rage now. However, few people are aware that there
are different kinds of stem cells, and that they can be derived from different
tissue sources and with different donor profiles. To help you better understand
the stem cell landscape, let’s review some basic concepts.
Autologous vs. Allogeneic
The most basic premise to understand is that stem cell treatments are largely
divided into two classes:
- Autologous- Stem cells are from your own body, exclusively for your own
use
- Allogeneic – Stem cells come from another person (a donor)
At present there are clinical trials involving both autologous and allogeneic
therapies. These trials include a wide range of disease states (cardiac,
neurologic, auto-immune, orthopedic, etc).
Autologous treatments can be performed in the same operative session and the
procedure uses your own cells. Your cells are extracted from a tissue, and then
reinjected back into your body. It is a one-to-one therapy.
Allogeneic therapies use stem cells from another person , who is referred to
as the donor. Before these cells can be put into another human they must undergo
extensive testing for diseases, and the cells are usually culture expanded in
laboratories to get higher cell counts. Allogeneic therapies are under strict
FDA guidelines as these stem cells will eventually scale up in mass production,
be put in a bottle, and distributed to millions of patients.
Stem Cell Types
Stem cells are derived from various tissue sources, and each tissue source
has different potentials for the cells to differentiate. These tissue sources
and corresponding type of stem cell are as follows:
Embryonic Stem Cells
(ES)
Embryonic stem cells are derived from the embryo of an unborn
baby and were first isolated in mouse embryos in 1981. They have been wrapped in
controversy from the beginning because of ethical and religious issues. They are
currently used mainly for research and understanding how regenerative cells
work.
Adult Stem Cells
(ASC’s)
Only in recent decades have we begun to understand that stem
cells can be found in all our adult tissues. They are called “Adult Stem Cells”.
They cannot differentiate into every type of cell like embryonic stem cells ,
but they can create bone, cartilage and adipose tissue quite readily. The two
most familiar sources of adult stem cells are bone marrow (BM) and adipose
tissue (AT). More than 2000 clinical trials have been conducted worldwide using
the various tissue sources of adult stem cells.
IPS Cells (Induced Pluripotential
Cells)
IPS cells do not come from embryos, but from adult cells. Their
genetic code is manipulated so they become “pluripotent” meaning that they can
differentiate, or become any other type of cell. Because the genetic code of
these cells has been altered, many safety questions remain. IPS cells have a
higher risk profile than both adult stem cells and embryonic stem cells
Types of Adult Stem Cells
Adult stem cells can be isolated from bone marrow, adipose tissue, umbilical
cord blood, peripheral blood, dental pump, and other tissue sources. Recently, a
large number of clinical trials have focused on stem cells derived from bone
marrow and adipose tissue.
Bone Marrow Stem Cells
The
earliest recognized form of adult stem cells in our body were in the bone
marrow. They could be used to help heal bone and to replace different cell types
in the blood. They could also be used after bone marrow destruction by radiation
therapy or chemotherapy. Use of bone marrow stem cells is FDA approved under
certain conditions.
The problem with bone marrow stem cells is that they are hard to extract and
not abundant. In order to be able to treat a patient, these cells must be taken
to a lab and expanded in culture. The FDA places this therapy in the category of
a drug, and requires rigorous oversight and testing. Therapies that use culture
expanded bone marrow cells are not yet commercially available.
Adipose Derived Stem
Cells
In 2001, we become aware that our own fat tissue is a very rich
source of mesenchymal stem cells (MSCs). The finding was made by a group of
researchers and plastic surgeons (Dr. Adam Katz, Dr. William Futrell) from the
University of Pittsburgh and was published in Tissue Engineering Journal. This
was quite a revelation for the scientific community, as up until that time adult
MSCs were predominantly thought of as a bone marrow product.
Adipose tissue offered distinct advantages over bone marrow tissue. Not only
was adipose fat easier to extract than bone marrow, but the stem cell population
found in fat tissue was determined to be an order of magnitude more prolific
than BM cells. One ounce of fat contains 300-500 times as many mesenchymal stem
cells as an ounce of bone marrow. Because of their abundant cell count, most
procedures using autologous adipose stem cells do not require that cells be
expanded offsite in a lab. This means that most adipose therapies can be
performed in the same operative session. This is advantageous compared to most
bone marrow therapies, because BM cells are typically culture expanded for days
in a lab before they can be reinjected back into a patient.
During the past decade, plastic surgeons have developed very safe and
convenient ways to remove fat and isolate the stem cells. Unfortunately, adipose
stem cell therapies are not yet commercially available because the FDA has not
approved them. But there are scores of ongoing clinical trials using adipose
stem cells, many of which have already shown safety and efficacy in the
treatment of many disease states.
Adipose Tissue as a Regenerative Therapy
While adipose tissue is a definitive source of stem cells, what if you don’t
need to isolate or separate the stem cells to get their regenerative power?
Plastic surgeons have known for years that fat grafting itself, without
extracting the stem cells, has regenerative properties. Dr. Sydney Coleman
pioneered safe and predictable techniques for fat grafting and has documented
the regenerative effects of fat grafting in different tissues and disease
states. In addition, Dr. Gino Rigotti documented that fat grafting can reverse
Radiation Tissue damage, something that was considered incurable until recently.
There are currently clinical studies documenting the regenerative effects of fat
grafting in areas we did not even suspect, such as autoimmune diseases and
degenerative joint disease. Unlike bone marrow tissue, adipose tissue is easy to
extract. It is abundant. And it is effective in ways we have only begun to
discover.
Plastic surgeons have decades of experience in harvesting adipose tissue and
refining processing techniques for adipose tissue. Because of this unique
expertise with adipose tissue they now have the leading role in developing its
evolving regenerative applications. The future of regenerative medicine is now
and it belongs to plastic surgery!
Breast Reconstruction Myths Debunked
Myth #1
You'll need to wait until after the mastectomy before having breast
reconstruction.
FALSE! Immediate breast reconstruction can usually be
performed at the same time as the mastectomy and generally leads to the best
cosmetic results. Most women with early breast cancer (stage 1 or 2) are
candidates. Immediate breast reconstruction has the advantages of saving the
natural breast skin and decreasing the amount of scarring. Enabling the patient
to wake up after surgery with breasts and avoiding the experience of a flat
chest is also an added benefit to having reconstruction performed at the same
time as the mastectomy.
Myth #2
Breast reconstruction is not an option for women who have
radiation.
FALSE! Whether a patient is having radiation or not, breast
reconstruction is always an option. For patients who will have/have undergone
radiation, our surgeons recommend flap based breast reconstruction due to the
high complication rates associated with implants in conjunction with radiation.
Reconstruction is usually delayed until after the mastectomy and radiation have
been completed. Unlike radiation, the plan for chemotherapy alone does not
usually delay reconstruction.
Myth #3
Breast implants are the only option for breast reconstruction.
FALSE! When most women think about reconstruction, they
automatically think breast implants. There are many reconstruction options
available to women today. Microsurgical breast reconstruction using perforator
flaps (e.g. DIEP flap, SIEA flap, GAP flap, etc.) represents the state of the
art in reconstructive surgery after mastectomy. Flap surgery uses the patient’s
own tissue from other areas (like the tummy, buttock or thigh) to recreate a
“natural,” warm, soft breast. Flaps also avoid the long term problems associated
with implants - many implant patients require further surgery within ten years
because of implant-related problems like significant hardening (capsular
contracture).