Reconstructive Surgery Options
October 21, 2019- 00:00Alright good evening. Thank you for coming like doctor, Allison said. My name is Tom Robber, Jamie. I'm a plastic surgeon with specializing in breast reconstruction and I was tasked with talking to you guys about understand the options and breast reconstruction.
- 00:17So just to frame the issue. We discussed earlier breast cancer is quite common as breast reconstruction because surgery is still a mainstay in the treatment of breast cancer. In fact, in 2017. Over 100,000 mastectomy reconstruction were carried out in the United States alone and this actually underestimates the reconstructive issue because there are women that undergo lumpectomy's or partial mastectomies and require reconstruction for their deformities so this is an underestimate.
- 00:47There's been a lot of studies on the impact of breast reconstruction and women and it's been shown to be beneficial in a number of levels improves sense of well. Being improved sense of confidence improve sexual function and well being and most importantly does not impact the ability to treat the cancer.
- 01:03We're not going to Legislate today weather health care is a right or a privilege will leave that to the 2020 candidates. But within our current healthcare system, breast reconstruction is a health care right and this is codified in federal law by the Women's Health cancer and Rights Act of 1998, which states that all mastectomy reconstruction symmetry surgeries and revisions must be covered by commercial insurance is now note that this says, commercial insurances, which doesn't necessarily apply to Medicare and Medicaid. However, I haven't encountered a situation where it's been an issue.
- 01:34Further most cancer centers, including this one generally require the patients that are offered mastectomy at least have the option of meeting with a breast reconstructive surgeon to discuss reconstructive opportunities and again this is law in several states, including in New York state.
- 01:50So where does that leave us we know that breast reconstruction. It's common. It improves quality of life and generally for most patients is iaccessible.
- 01:59But how do we define success? It's really a challenge in plastic surgery in general to define success were not oncologists. We can't look at survival. We can't look at recurrence rates. So how do we define the success of a breast reconstruction? Is it by lack of complications? Is it the way the breast looks looks compared to some supposed ideal breast is that how is the surgeon thinks think thanks turns out and stated slightly differently? What are the characteristics of a successful reconstruction is that the things healed properly?
- 02:30Is that the things look just like they did before surgery? Is it that they look better than before surgery so this brought me back to our subject matter understanding options in breast reconstruction. We talk a lot about patient centered care and what that means is that the patients come first in the patients have to help us dictate the care and I thought that maybe a better way to look at this would be to look at what it is that I've learned about breast reconstruction for my patients and maybe together, we can learn a little bit about the subject.
- 03:00So we'll go through some lessons that I learned and we will have photos of before and after which is pretty standard to understand breast reconstruction, but I just thought this rubric would help us sort of frame. The conversation, so the first lesson I learned is that honesty and mutual trust are really a must you're entrusting your well being to physicians and to a surgeon and you really have to feel comfortable that the person taking care of. You cares about your outcome and invested in your well being not all of our outcomes are ideal and it's our job to listen to you and to believe you when you're uncomfortable with the result.
- 03:34And you're not crazy and we can't make you feel like you're crazy and just because we don't see the same things that you're saying doesn't mean that they're not there. It's important for you guys to realize that I have the reconstructive surgeon. I'm not judging you because you care about how your breasts look or how reconstruction looks. We understand that the main goal of the treatment is to cure your cancer. But that's not mutually exclusive from having a good reconstruction. and I don't really mind when you're nitpicking it's part of my consoles. I sort of make this joke that if a year after we do reconstruction you're torturing me.
- 04:05About a minor cosmetic aspect of your construction consider that a win because we've turned a reconstructive issue into a cosmetic issue and that's where we want to be and the last thing that I really want patients to keep in mind. This is why I don't usually use before and after photos a lot of my consultations is that generally speaking when you're seeing before and after photos you're not seeing typical results. You're seeing the best results and so today with your permission. I'd like to maybe Buck that trend, and it's taking a little bit of courage on my part to do that with you guys, but I'd like to show you a more realistic range of outcomes.
- 04:39The second lesson, I learned is that this is really complicated decision. Making there's a lot of tough decisions to be made, and again. I go through all this in a 45 minutes to an hour consultation. We have 3 minutes to go over this. When I talk to women about breast reconstruction mastectomy. I tell all women that there are 3 basic options. The first option is no reconstruction. You don't need a breast to live and if it's not important to you. Maybe that's the easiest and safest thing to do because it doesn't add any additional surgery. Any additional treatment. Any additional risks. If you do understand decide to undergo reconstruction. We should be able to do that for you in a way that's safe and effective.
- 05:12And there's 2 basic options again. This is an oversimplification there's implants and there's a tissue based reconstruction. We talk about implants again overly simplifying influence or more simple reconstruction. They don't add significant added surgical recovery time. However, there's downsides. Its foreign body. A lot of women are really uncomfortable with the idea of a foreign body. They're not always the most natural looking or feeling reconstruction implant reconstruction is not an implant for breast augmentation and implants may need to be replaced over the course of your lifetime, which means you're buying yourself surgery down the road.
- 05:45And then sometimes we use tissues to reconstruct breasts and most of the commonly will use tissue from lower abdomen and that may be better in some ways, it's natural it ages with you and most importantly studies have shown that in the long run. Patients with tissue reconstruction tend to be more satisfied with the reconstruction implant reconstructions. However, there's downsides. It's a much bigger surgery. It's a much bigger recovery. Anne put succinctly you're making a decision where there's nothing wrong with you woman with breast cancer has to have surgery on her breast, she does not have to have surgery.
- 06:16On her belly.
- 06:17So these decisions are complicated and we look at a lot of different factors. I ask you all about this do you have small children at home, meaning you can't have a significant downtime? Can you miss time from work or if you miss a lot of time from work? Is it going to be a significant financial hardship. Are you an athlete and you don't want to sacrifice any range of motion do you have any major medical problems that preclude you from having a large operation and you have a good support network that will help you through the recovery process an because this is so complicated. It's gotten to the point where the lessons. I've taken is that we shouldn't make these decisions.
- 06:47The first visit sometimes, this is especially true for women that have a fresh cancer diagnosis. Their head is swimming. There's a lot going on. There's thinking about are my going to be OK in my going to need chemotherapy and I'm going to be surgery and there's still digesting so sometimes we need to meet 2 or 3 times before I make a final decision. and I can guide the decisions and but I can't dictate them and again this is something I quote verbatim in my consoles. I take full responsibility and all plastic, surgeons that do are extracted free will take full responsibility for your reconstructive outcome.
- 07:18But the only person that experience is the outcome is the patient so the decision has to come from the patient.
- 07:243rd lesson I want to talk about is the goals of reconstruction. These are all goals that were taught to me by my patients because I didn't know what they were. You know, I'm not a woman and I don't have breasts and so I had to learn from you guys what matters and and this is going to vary from patient to patient. But there are 3 things that I find are very common in the first goal is that in clothing. Women don't want anybody to know that anything happened. They don't want this to be a conversation starter with their coworkers.
- 07:51When a woman takes her clothes off and she's going to go take a shower. I can't have her avoiding looking in the mirror because she's horrified looking at herself that defeats. The purpose of breast reconstruction and the 3rd goal takes some time and that takes work sometimes takes additional surgery. Sometimes it takes psychological work on the patient Spartan that's being comfortable with somebody else seeing your breasts and somebody else touching your breasts and if your breasts are important to you and your intimacy and in your sex life being able to have them be a part of it.
- 08:17And ultimately the biggest lesson is that it doesn't matter how I feel about a womans breast reconstruction. It matters how she feels about it and I'll give you a little bit of an example about that later so getting back to just some specific examples implant reconstruction usually involves 2 operations. The first operation is done at the time of the mastectomy a temporary implant is placed and then a second surgery down the road, which is a smaller operation, but is an operation involves changing it out for the more permanent implant. This is preferred generally in very thin patients who don't have a lot of tissue to give up for.
- 08:50A tissue reconstruction or in patients that have a need for whatever reason for limited recovery time for whatever reason, they can't put in the investment in plants are either a silicone shell. That's filled with sailing, which is salt water or silicone. Shell filled with silicone gel and a key point here to remember his implants or not lifetime devices. What does that mean there's no such thing as a device that's going to last forever. I tell women to expect based on the best literature that we have a problem with an implant that requires it to be replaced every 15 years or so on average.
- 09:22What does that mean a lot of our patients are younger cancer treatment is great, so we fully expect you to be here. In 15 years and that means that when you're 15 years old or you may need more surgery.
- 09:31So let's look at a couple of successful outcomes as defined by how I define them and have patience to find them so young patient underwent a preventative mastectomy nipple sparing mastectomy. Her breasts are not the same. But this is a very good. I think cosmetic result. She was happy with the result, she could fit into clothing while and she was quite satisfied.
- 09:51Another patient young thin had not had breast fed in the past nipple sparing mastectomy thinking very good reconstruction. She was happy with it. We can nitpick it. There's some imperfections there, but ultimately the patient satisfied and that's what matters let's look at us. Some more typical results. I consider those to be excellent results. Let's look at what a more typical result is again a young thin woman. I think this is a very good result. She can as you can see, she's wearing a bathing suit. You can see by the tan lines, but her breasts don't look quite as natural his arrested before.
- 10:22Her nipples are missing and will have to come back and do a nipple reconstruction. Overall, she feels like. This is an OK reconstruction. And why but it's not perfect.
- 10:31And not all women are thin and if not had babies or are in their 30s and so for this woman. This is a result, that she got it. You know, I'm not thrilled with all aspects of it, but ultimately, she feels comfortable that she doesn't want to revision, she feels like. In her clothes. Nobody can tell and she's OK with it.
- 10:50And then sometimes you have poor or unsatisfactory results. This is a patient that was done recently. And you can see, she has her implants in place and there's Reckling thing. There is hollowing at the Top which is going to show when she's wearing clothing and overall. She's not happy and I'm not happy and we're going to offer her revision. Just a little bit of uncertain bias. Note that I showed you 2 excellent results. But I'm only going to show you one bad result because it hurts. My feelings to put it up there and then there's autologous reconstruction.
- 11:21Again usually we talk about tissue from lower belly why lower belly the women. We see tend to be in the 40s fifties and 60s. The majority of them have had children and have had pregnancies so that means they almost all have extra tissue in the lower abdomen. There are other sites that include the thighs in the back. But those are secondary sites and then a bit of disclosure. I have a biased towards this type of reconstruction. I prefer this reconstruction for any number of reasons, but that's my bias. It doesn't have to be the patients bias. There's plenty of women that don't want this and it can get different types of reconstructions.
- 11:53And the way I think about this reconstruction who this is better for it's for women that are willing to undertake the bigger upfront investment in terms of recovery and surgery for? What is a better and longer lasting reconstruction in my mind, so waters. Some successful results. This is a patient you can see, she has a bad cancer in her right breast and she has. I think a very good reconstruction. And she's taken ownership of it with tattoos on her scars and she's quite proud of this reconstruction as an AI.
- 12:23Another patient quite then we managed to get some tissue and this is her after her nipple reconstruction. We just have to do the tattoos for the aerial is and she has a very good result. She's actually very happy with her cosmetic outcome.
- 12:37Lastly, just an example of tissue not from Valley. This is a very, very young woman very thin. Obviously has no belly tissue is never been pregnant and we use tissue from both of her thighs to reconstruct her right breast and this is very gratifying to me. This is a young woman and she came in with tan lines from the same bikini that she wore the year before she had surgery and I consider that a success.
- 13:00And then there's acceptable outcomes that are more typical. Not all women look the same. This isn't it outcomes is pretty good, and close things look OK. Things are reasonably symmetrical, but it doesn't cool, it quite natural and there's revisions that can be done to me in order to make this look better, but again, it's not perfect.
- 13:19In a slightly more in a larger woman and more curvy type of body type again enclosed nobody should be able to tell. She's not horrified looking herself because she's got a deformed breast, but again, it's not perfect. The belly scar is widened. The belly button doesn't look quite right. There's no nipple and this will require work if she wants to optimize the cosmetic result.
- 13:42And then there's poor results again. We don't like these but we have these as well. Unfortunately, this is a patient. We reconstructed her right breast. You can see, there's a lot of scar tissue. The skin doesn't look right. This is firm. It doesn't feel comfortable. She's not happy. I'm not happy and will have to have a discussion to see what it is that we can do to make this better.
- 14:02Another lesson is communication is key. It's really important for me to talk to the patient and be able to be open to the patients concerns and I do the best I can and sometimes I succeed. Sometimes I don't expectation setting is done as a collaborative process and failures in communication can undermine otherwise what would be considered a successful result and this is a patient. I share with doctor. Adelson long-term patient of mine an I think this is when I look at this, I'm pretty proud of what we did on a technical basis. We did uh right breast reconstruction with tissue from the belly and we did a left.
- 14:36A lift excuse me on the left to try to make things more symmetrical and I thought I was pretty happy. But when I saw her. She was really unhappy with me, she felt like I hadn't discussed appropriately with her with things are going to look like well. How much scar. She was going to have and she was really unhappy and I know this woman is not crazy. I've known her for a long time, she's a very rational woman. She's very well adjusted and I think that better communication would have made her feel better and would have made me happier as well.
- 15:02And then finally I think that the most important lesson, here is that it's about getting back to normal. I think what you can gather from these other talks from these experts on cancer. Treatment is that treatment for cancer is a long Rd. The recovery for women, particularly we're going to choir radiation and chemotherapy. Just for the early stages of treatment can take a year before you're feeling yourself and breast reconstruction becomes a big part of it because in some ways, it can set you back. It's additional surgery and you see your breast reconstructive surgery. A lot as a matter of fact in the first year, you might see the.
- 15:34Surgeon more often than you see any of your other providers and ultimately our goal is for you to get back to your life and things that make you happy and these are photos that were sent to me over the past year. I don't know at what stage in life. Women are taught. This particular pose but it's quite fetching and the young woman in red that's her birthday party, 2 months after reconstruction. She got engaged at that party and then the woman. The black dress was at a colleague's wedding and she was very comfortable with what she could wear.
- 16:06And we consider that a success, so just to summarize we feel that breast reconstruction is important part of breast cancer treatment. For many women, it's highly likely that a woman that desires breast reconstruction will have access to it. Care should be patient centered taking into account individual circumstances and goals outcomes of reconstruction really run the gamut. I've shown you some good results and not so good results. I spared you complications, which can be an even worse. But I thought that it would be scary in this form without any context, but there are complications that can.
- 16:39Really impact the outcome and your surgeon should really help. You set realistic goals that keep the best and worst case scenarios in mind. You need to communicate and you need to advocate for yourself. An most importantly, and this is not just true for plastic, surgeons distance for all your physicians find physicians.