“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:

1. Reconstruction using implants, either saline or silicone gel.
2. Reconstruction using your own tissue called autologous reconstruction.
3. 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:

1. 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.
2. 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.
3. 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.
4. Support in recovery after surgery. Not all individuals have family, friends or local support nearby to help them with post-reconstruction recovery and care.
5. 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.
6. 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.

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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).

Consider Custom Solutions for a Sagging Neckline


Necklines for both men and women can be a focal point of self-consciousness. However, the etiology of an unattractive neckline can be diverse, so treatment options must be tailored to the underlying cause. There is no one solution for everybody. Careful three-dimensional analysis of the soft tissue and underlying bony structure of the midface, lower jaw and neck are imperative to choosing the correct modality to improve your neckline.

Some common underlying causes of poor aesthetic necklines:

Small lower jaw - If you have a deep underbite despite orthodontics and a short chin, this leads to less bone support of the soft tissues of the jawline and submental region. People with this type of lower jaw may have a very obtuse chin-neck angle leading to redundant skin. An ideal treatment for this situation is bony chin advancement (genioplasty).

If your chin is horizontally too short, then an augmentation with a chin implant is an excellent choice. I prefer the Medpore implant, which is carvable, and screw fixated and becomes an extension of the bone.

Both genioplasty and chin implants can easily incorporate the technique of liposuction as a means of sculpting the soft tissues of the neckline by removing unwanted fat. Liposuction induces collagen production and facilities skin shrinkage and redistribution yielding a pleasing result. This combination therapy can produce a wonderful outcome that makes you look more facially balanced. However, if your skin is too loose and hanging, a more formal neck lift may be preferable to liposuction.

Mid face descent of soft tissues - Aging can affect facial fat compartments leading to decreased volume, which results in the midface falling over time. This sagging increases nasolabial folds and causes lower facial soft tissue to drape over the jawline. A crisper jawline can be restored by replacing missing soft tissue volume in the fat compartments of the midface with filler agents like Voluma and Sculptra or via fat grafting. Subtle volume enhancements can create a nice effect on the jawline without looking like you've undergone a surgical procedure.

Gravitational changes to the soft tissue of the neck - Gravity affects all of us. The skin and muscles of the anterior neck begin to pull away over time. The appearance of the platysma muscle medial bellies becomes apparent leading to unsightly banding. In the early stages of gravity-induced changes, treatments such as chemical peels, micro-needling and radio frequency can yield improvements and delay the inevitable soft-tissue sagging.

Ultimately the best treatment option is a face/neck lift. A well performed facelift by an experienced board-certified plastic surgeon will yield excellent results with longevity of up to ten years depending on how well you age forward and take care of your skin, avoiding further sun damage.

Obesity - People with elevated body mass indices will accumulate increased fat throughout the body. The neck is no exception. Very mild amounts of fat excess with firm, good quality skin may realize improved contours with Kithera (an injectable product that dissolves fat in the neck). However, in my experience, few patients I evaluate are ideal candidates for this treatment. The injection results in inflammation, which can cause collagen production and skin remodeling, but most people need bigger guns to fight the battle. The price of several rounds of injections is as much as a true liposuction with less effective results.

If you have significant fat in the submental region and reasonable skin quality, liposuction can be a great treatment option to uncover a more normal neckline without a lot of expense or downtime. However, a face/neck lift with a corset platysmaplasty is the tried and true corrective option that works very predictably.

If you're obese and undergo bariatric surgery or make lifestyle changes to produce massive weight loss, you'll likely develop excess deflated skin that hangs off your face and neck creating an aesthetic deformity. Modifications of standard face and neck lifts must be incorporated to achieve a pleasing result.

The takeaway is that if you're unhappy with your jaw and neckline, you can improve your appearance and boost your self-confidence by seeking out proper consultation with an experienced plastic surgeon. During the consult, a detailed facial analysis should be performed. Treatment options can be formulated to yield the best results by addressing your unique issues as presented during the interview. No need to hide your neck behind scarves and turtlenecks any longer.

Complications and risks
All surgery has risks. Common complications of cosmetic surgery includes hematoma, nerve damage, infection, scarring, implant failure and organ damage. Many women, including famous women Pamela Anderson Lee and Victoria Beckham, who have breast implants have them reversed later, citing many reasons including "health concerns to just wanting a more natural shape". Breast implants can have many complications, including rupture. One in 5 patients who received implants for breast augmentation will need them removed within 10 years of implantation.


Psychological disorders
Though media and advertising do play a large role in influencing many people's lives, researchers believe that plastic surgery obsession is linked to psychological disorders. Body dysmorphic disorder (BDD) is seen as playing a large role in the lives of those who are obsessed with plastic surgery in order to correct a perceived defect in their appearance.

BDD is a disorder resulting in the sufferer becoming “preoccupied with what they regard as defects in their bodies or faces.” Alternatively, where there is a slight physical anomaly, then the person’s concern is markedly excessive. While 2% of people suffer from body dysmorphic disorder in the United States, 15% of patients seeing a dermatologist and cosmetic surgeons have the disorder. Half of the patients with the disorder who have cosmetic surgery performed are not pleased with the aesthetic outcome. BDD can lead to suicide in some of its sufferers. While many with BDD seek cosmetic surgery, the procedures do not treat BDD, and can ultimately worsen the problem. The psychological root of the problem is usually unidentified; therefore causing the treatment to be even more difficult. Some say that the fixation or obsession with correction of the area could be a sub-disorder such as anorexia or muscle dysmorphia.

In some cases, people whose physicians refuse to perform any further surgeries, have turned to "do it yourself" plastic surgery, injecting themselves and running extreme safety risks.

Sub-specialties
Plastic surgery is a broad field, and may be subdivided further. In the United States, plastic surgeons are board certified by American Board of Plastic Surgery. Subdisciplines of plastic surgery may include:

Aesthetic surgery

Aesthetic surgery is an essential component of plastic surgery and includes facial and body aesthetic surgery. Plastic surgeons use cosmetic surgical principles in all reconstructive surgical procedures as well as isolated operations to improve overall appearance.

Burn surgery 

Burn surgery generally takes place in two phases. Acute burn surgery is the treatment immediately after a burn. Reconstructive burn surgery takes place after the burn wounds have healed.

 

 

Craniofacial surgery 

Craniofacial surgery is divided into pediatric and adult craniofacial surgery. Pediatric craniofacial surgery mostly revolves around the treatment of congenital anomalies of the craniofacial skeleton and soft tissues, such as cleft lip and palate, craniosynostosis, and pediatric fractures. Adult craniofacial surgery deals mostly with fractures and secondary surgeries (such as orbital reconstruction) along with orthognathic surgery. Craniofacial surgery is an important part of all plastic surgery training programs, further training and subspecialisation is obtained via a craniofacial fellowship.

 

Hand surgery

Hand surgery is concerned with acute injuries and chronic diseases of the hand and wrist, correction of congenital malformations of the upper extremities, and peripheral nerve problems (such as brachial plexus injuries or carpal tunnel syndrome). Hand surgery is an important part of training in plastic surgery, as well as microsurgery, which is necessary to replant an amputated extremity. The Hand surgery field is also practiced by orthopedic surgeons and general surgeons. Scar tissue formation after surgery can be problematic on the delicate hand, causing loss of dexterity and digit function if severe enough. There have been cases of surgery to women's hands in order to correct perceived flaws to create the perfect engagement ring photo.

Microsurgery 

Microsurgery is generally concerned with the reconstruction of missing tissues by transferring a piece of tissue to the reconstruction site and reconnecting blood vessels. Popular subspecialty areas are breast reconstruction, head and neck reconstruction, hand surgery/replantation, and brachial plexus surgery.

 

 

Pediatric plastic surgery 

Children often face medical issues very different from the experiences of an adult patient. Many birth defects or syndromes present at birth are best treated in childhood, and pediatric plastic surgeons specialize in treating these conditions in children. Conditions commonly treated by pediatric plastic surgeons include craniofacial anomalies, cleft lip and palate and congenital hand deformities.

 

 

 

Evolutionary Advantages of Female Cosmetic Surgery

Women are more likely than men to undergo plastic surgery; in 2014, 92% of cosmetic surgery procedures in the USA were conducted on female patients. The reason for this discrepancy may be explained by current evolutionary theoretical and empirical findings which suggest that differences in male mate preference play a strong role in motivating females to make alterations to their perceived attractiveness.
 
Women are more likely than men to undergo plastic surgery; in 2014, 92% of cosmetic surgery procedures in the USA were conducted on female patients. The reason for this discrepancy may be explained by current evolutionary theoretical and empirical findings which suggest that differences in male mate preference play a strong role in motivating females to make alterations to their perceived attractiveness.

Whereas the common traits found attractive by women tend to be related to resources, men universally rate female beauty as more desirable. In particular, female traits such as youth, fertility and health are deemed most attractive by men These traits appear to have evolved as signals to men of a woman’s fertility.

 Evolutionary psychologists propose that men possess perceptual mechanisms which have evolved to detect these traits as a means of determining whether or not a woman is a desirable potential mate. For example, an ideal waist-to-hip ratio (“WHR”) of 0.7, which corresponds closely to the optimal ratio of health and fertility, is considered to be most beautiful by modern men because their male ancestors identified that ancestral women with that proportion produced more healthy offspring than ancestral women without the proportion.

In this regard, many anatomical features such as breast size and shape, facial symmetry and WHR are reliable indicators of health and fertility in women and are signals to males that one female holds a higher reproductive value over another.

Therefore, a female desiring to promote her reproductive value can manipulate a male’s evaluation of her by manipulating her anatomical features alone. For example, photographs of women who had just undergone micro-fat grafting surgery (in which fat tissue is taken from the waist region and implanted on the buttocks resulting in a lower WHR) were rated by men as being more attractive than the same women’s pre-operative photograph. It is likely that a woman’s decisions to undergo micro-fat grafting surgery are in part mediated by her intention to signal to possible male mates her reproductive potential.

That females outnumber men undergoing plastic surgery procedures is therefore, a reflection of the immense strength of psychological mate preferences. Cosmetic plastic surgery may be seen by women as a means of accentuating the features that are known to be reliable indicators of health and fertility. By undergoing plastic surgery, these desired and admired features of human female beauty can be permanently acquired by women who otherwise would not have access to these signals.

It is no surprise then, that the most common cosmetic surgery procedures for females include liposuction and breast augmentations  in attempts to correct asymmetries and exaggerate traits that are considered to be indicators of health and fertility.

Male cosmetic surgery
Whilst women make up the majority of cosmetic surgery clients, the total number of cosmetic surgery operations for men in the UK have risen from 2,440 in 2005 to 4,614 in 2015 Common cosmetic surgery procedures for men include rhinoplasty, liposuction and breast reduction
One possible motivation for male cosmetic surgery is to get rid of telltale signs of femininity and to achieve a more dominant, attractive masculine face. Intra-male mate competition to appear resourceful. can further explain the motivation for cosmetic surgery. Some research suggests that facial attractiveness in men can signal to different qualities, such as socio-economic success. For example, it has been found that more attractive males are more likely to be hired for jobs. Specifically, an attractive and symmetrical face can signal internal well-being and can act as visual marker for genetic quality.