Endofound Medical Conference 2017
"Breast, Ovary and Endometriosis"
October 28, 2017 - Lotte New York Palace Hotel
Prophylactic Mastectomy and Breast Reconstruction
Oren Lerman, MD, FACS
Plastic and Reconstructive Surgery, Lenox Hill Hospital
First of all, thank you Dr. Seckin and Endofound for the invitation. It's my honor to be here. Karli, never ask a surgeon how much time he's going to take, because you have to multiply it by three, right?
The first question I was asked multiple times as to why I'm speaking at an endometriosis conference, and the fact is that when we're treating patients with breast cancer, whether that's prophylactic mastectomy or a patient's diagnosed with breast cancer, it really is a team approach. It's interdisciplinary approach, especially in today's day and age, with increasing numbers of prophylactic mastectomies, and patients who are genetically positive for the BRCA mutation.
We get involved very early on. Usually, sometimes even years before they go ahead with surgery, including discussing planning for what type of surgery they want, and the timing. Whether or not they're going to have hysterectomy first, or whether or not to have a mastectomy first. And the patients really need to understand their reconstructive options before they can make those decisions.
So I want to discuss basically the advances that we have in reconstruction, because I think there's a lack of data out there. Actually, two days ago we had our Breast Reconstruction Awareness Night as part of Breast Cancer Awareness Month in October, because probably 95% of what you hear in the social media and the news and PR is all about breast cancer awareness, which is excellent. We like to think that we are trying to close the loop on breast cancer treatment by discussing breast reconstruction options.
One of the major facts that is usually astounding to most people is that up to 70% of women in the United States who get mastectomy do not get breast reconstruction. Now, of course, if you're in Manhattan, or a major metropolitan area, that's probably not going to be the statistics that we encounter, but it is a tremendous number of women.
The classic way that we used to describe as the goal of breast reconstruction was to create a breast mound, to achieve a normal symmetry with your clothing on, and to avoid the need for a prosthesis, but that if you weren't going to be wearing clothing, it would be obvious that you had breast reconstruction. Hopefully, after today, you will see that that is definitely not what we consider to be our goal these days.
When patients come to us for breast reconstruction, what we are really trying to do is to restore normalcy not just so that they don't have to wear a prosthesis, and so that when they're wearing clothing, people won't be able to tell. But also so that when they look at themselves in the mirror, they feel good about their bodies. Maybe even look better than they did before they had surgery. So this is the new gold standard, and this is what I expect from my patients.
In basic, you have two different kinds of breast reconstruction options. You have implant reconstruction, you have natural tissue reconstruction, and I apologize for speaking quickly, but I'm trying to adhere to Karli's rules. So just to review briefly, implant reconstruction is what most people are familiar with. People usually think of breast implants, and breast implants are the tried and true method. We've been doing it for 40 years.
The general way we do implant reconstruction is a two stage operation. You can kind of think of a breast reconstruction and a mastectomy like taking a pillow out of a pillowcase. So what you're left with is the skin around the breast. It doesn't really have any shape, doesn't really have anything to make it look like a breast, but if you replace the pillow, or the breast tissue, with something, you can make it look like a normal breast. Your options are either a breast implant, or natural tissue taken from another part of the body.
In a typical breast reconstruction with implants, it's usually a staged procedure where at the time of mastectomy, we put in a temporary breast implant called a tissue expander. And the tissue expander is basically an empty breast implant. You can think of it like a water balloon. It goes in underneath the skin and the muscle of the chest wall, and the reason why it goes in underneath the muscle is because the implant is a foreign body. It is made in a factory, and it's at risk of infection just like any other implant in your body, whether or not it's a hip replacement, knee replacement.
The skin that's left over after a mastectomy is very, very thin, and usually not healthy enough, or strong enough, or well vascularized enough to protect the breast implant for the rest of your life. So we put the tissue expander in underneath the muscle, but there's no space underneath the muscle to put in a breast implant and have a normal looking breast, so we have to create a pocket by stretching out the muscle and the overlying skin.
And that's what a tissue expander does. It allows the patient to come back to the office, and we inject fluid into it, and we stretch it, and we stretch it, and we stretch it, until the time that they have achieved a breast mound that matches the other side. And this is what most people think of when they think of breast reconstruction, but hopefully today we'll go over newer options, and what's basically the most advanced way of doing it.
These are typical results after implant reconstruction, and when I say "typical," I mean that these are the results that we hope to get. Some of these women are thin, some of them are heavier, some of them are young, some of them are old. Here's a patient where we did a nipple-sparing mastectomy and implant reconstruction, and hopefully, you can't really tell that she had a breast reconstruction.
This is another patient who's a more complicated reconstruction, simply because she doesn't come in with a small breast without ... She's overweight, so she has very large breasts, very ptotic. The left breast had prior lumpectomy, prior radiation. You can see the damage. And she needed to have a completion mastectomy on the left side, and you can see on the right side of the screen the results of the surgery. When you have a patient that has a unilateral mastectomy, or only one side, very often their the most difficult patients to get a good result, because you don't just want to make a breast that looks good, you have to make it look like the other side.
The important thing is that we use the same techniques that we would use for cosmetic surgery in doing breast reconstruction. The two go hand-in-hand. You cannot separate reconstructive surgery and cosmetic surgery. What you can see on the right side, on her right breast, is basically a standard breast reduction. So she had a breast reduction on the right side, a breast reconstruction on the left side, with a nipple reconstruction at a later date.
And these are just more examples of the same procedure.
What's advanced is that we very often nowadays do not need to go through the whole two-stage procedure, where you put a tissue expander in at the time of the mastectomy and then come back a few months later and put in the implant. But rather, we can condense this down into a single stage reconstruction. Now certainly, not all patients are good candidates for single stage reconstruction. There's a lot of different reasons why you would still choose to do two-stage reconstruction. Those include radiation, includes multiple medical co-morbidities, whether or not you're doing a skin-sparing mastectomy, nipple-sparing mastectomy, or a traditional mastectomy, and you really have to stretch out the skin.
But in some patients, we can use biologic mesh or acellular dermal matrix, the most common brand is Alloderm. And the Alloderm acts like an internal sling to expand the soft tissue pocket, so that you could put a breast implant in at the time of the mastectomy and not stretch out that pocket with a tissue expander. And this allows us to condense the entire operation into one stage, so the on the same day they have a mastectomy, they wake up, they're done. And these are the kind of results that you get. Very often, you do this with nipple-sparing mastectomy, because, like I said, you have to preserve that skin envelope. Or if you go back to my original analogy, you're preserving the pillowcase, and you're replacing the pillow.
Again, hopefully these are the kind of results where when we look at these patients, you can't tell that they had a mastectomy, and I have to say, that when my patients come to me, and they say, "Oh, I was at the medical oncologist's office ... I was at my OB/GYN, and it was the first time that they saw me, and they didn't realize I had a mastectomy." And that is probably the thing that makes us feel the best, when we can achieve those kind of results. So she had a mastectomy on the right side, with a single stage, direct-to-implant reconstruction.
And this is a similar patient. She had cosmetic surgery before being diagnosed with BRCA mutation, then elected to undergo bilateral prophylactic nipple-sparing mastectomy. Because she had previous breast implants, she had a little bit of capsule contracture, which is why on the left side, it kind of doesn't look right, and that's because she has fibrosis, or scarring, around the breast implants from her cosmetic surgery. When we did the reconstructive surgery, we were actually able to fix this.
Along the lines of single stage implant reconstruction is something that probably has only become popular over the last year or two, and this is taking the concept of using acellular dermal matrix, or that biologic mesh, to the next level and putting breast implants in front of the pectoralis muscle, underneath that skin. Remember, you have that thin layer of skin, which is really not healthy enough or strong enough to protect the breast implant, but if we wrap the entire breast implant in the acellular dermal matrix, we can get away with not putting the implant underneath the muscle.
The reason why we might not want to put the implant underneath the muscle is because, first of all, it's much more painful to have the implant underneath the muscle at the time of surgery. Second of all, it's a little bit uncomfortable to have the implant underneath the muscle for the rest of your life. Third of all, when you move your arm, you can have very severe, very significant what we call "animation deformity." You can see the muscle moving because there's no breast on top of it.
Now in a breast augmentation for cosmetic surgery, the breast tissue sits on top of the muscle, and if the implant is underneath the muscle, it's camouflaged by the breast. But in a mastectomy patient, there is no breast tissue to camouflage that muscle, and you can see it moving. A lot of people really hate it. So there's reasons why putting it on top of the muscle is better, and these are the pros and cons, like I've just been mentioning.
The cons are usually they need to go back for a second surgery injecting fat to camouflage that tissue, because there's no breast tissue around it. A large piece of ADM, or acellular dermal matrix, costs around $8,000, so if you're doing it on both sides, that's $16,000, to the hospital. I don't know what they charge an insurance company, or what insurance companies pay. And that doesn't include the breast implants, which cost around $1,200 apiece.
The number of techniques and tools that have advanced, just with breast implant reconstruction, in the last seven years is really impressive. One of those things is cohesive gel implants, or what some people call "gummy bear" implants, and they call them gummy bear implants because they feel like a gummy bear. For cosmetic surgery, they're not as popular, because you don't want your breasts to feel firm, you want it to feel soft. And the traditional silicone implants are very soft. They feel much better.
The problem with the traditional silicone implants is that they ripple, and you can see the rippling through the skin. And sometimes that doesn't look good.
So if I press the red button it goes back?
So these are your cohesive gummy bear implants, or what is really the term is form stable, and the reason why they're called form stable is because they keep their form.
You can have an anatomically shaped implant made out of this, and it looks much more natural. You can do a breast reconstruction with an anatomically shaped implant, and get a breast mound that looks like a teardrop instead of a round breast implant. These were really great, and we've been using them a lot in breast reconstruction over the past five years or so. And you can see how, when you cut into them, it really looks like a gummy bear, as opposed to gel which kind of seeps out.
The problem is is that in order to, because they're teardrop shaped, they need to have a texture on the outside that keeps them adherent to the surrounding tissues, so they don't move around, because obviously, if they twist, you'll have an upside-down teardrop shaped breast. They put a texture on it so that it sticks.
Unfortunately, over the last year and a half to two years, there's been increasing public awareness and increasing awareness within the scientific community of breast implant associated anaplastic large cell lymphoma, which is horrible, right? Because in the 1980s, there was a big scare over silicone breast implants and the possible link to breast cancer, autoimmune disease, lupus, arthritis, and all of those links were proven not to be true. Millions of women who had silicone breast implants were proven that, statistically, that there was no link connecting it at all. There was a temporary moratorium on silicone breast implants in the United States, and in 2006 that moratorium was lifted.
They never stopped using silicone breast implants outside the United States, so Canada, South America, Europe. And the NIH and National Institute of Medicine studied breast implants tremendously. As a matter of fact, a little quirk of medical research is that breast implants are the most highly studied implant on the market today. So when they make a pacemaker, it's not studied as much as breast implants.
In 2006, when they put them back on the market, they immediately took over probably 96% of the market, because they just work better. Silicone breast implants work better. The implants with a textured shell, not the cohesive implants per se, have now been demonstrated to be associated with about 400 women worldwide with breast implant associated anaplastic large cell lymphoma.
It's not the same disease as ALCL, which is a very severe form of lymphoma. It can be treated readily. You remove the breast implant. You remove the implant, and maybe or maybe not need some chemotherapy. But it can be treated readily. But obviously, it's a big issue. We've almost taken a big step back, and now a lot of people are just avoiding the textured anatomically shaped silicone breast implants. Now we still have cohesive gummy bear implants that are smooth. They're just round.
Breast implant reconstruction, pre-pectoral implant, Alloderm, gummy bear implants, those are all the things ... Single stage reconstruction, nipple-sparing reconstruction, those are all the things that have advanced breast implant reconstruction, really allowing us to do great work. But the problem with breast implants is that they do not last forever, and when we say that, it means there's no expiration date on breast implants, but the breast implants get hard over time. The breast implants can become asymmetrical over time.
Your body changes. The breast implants don't change. You're going to gain weight. You're going to lose weight. The breast implants can leak. And the capsule contracture, the fibrosis, or hardening of the capsule around the implant, can actually become painful. Okay. And in high grade capsule contracture, women can complain of very severe discomfort and pain. Unfortunately, the natural course of breast implants is that they get worse and worse and worse over time. You can have a breast implant in for 30 years and have no problems. You can have it in for three years and have bad asymmetry or discomfort and pain, and want to have it removed.
On the left side, what you have here is a patient who has a very typical long-term result after an implant, where the implant just kind of stays there, where her right breast, she maybe have gained weight, she maybe got older. Her right breast just looks like a normal breast. But it looks horribly asymmetric. And on the left side, you have very high grade capsule contracture, because the fibrosis and hardening of the implant causes deformity.
So for these reasons, breast implants have their limitations. They still make up about 80% of all reconstructions. The reason why they make up 80% of all reconstructions is because most plastic surgeons don't do autologous tissue reconstructions utilizing their own natural tissue. Most plastic surgeons offer their patients breast implants. So you have to go to a breast reconstruction specialist, you have to go to somebody trained in microsurgery, to do autologous tissue reconstruction.
Autologous reconstruction has been around since the 1980s. It's not new. But what we're going to talk about today is the latest, greatest ways of doing autologous reconstruction. In 1982, Hartrampf described the TRAM flap, and I'm sure you're all familiar with the TRAM flap. We've been doing that for 30 years. The downside to the TRAM flap is that it utilizes the abdominal muscle of your abdomen. It removes the rectus muscle and transplants it up to the chest wall. So everybody, by definition, gets an abdominal wall weakness and/or a bulge. A bulge is what we call a pseudohernia. It's not a hernia because there's no hernia sac, there's no abdominal contents herniating through the abdominal wall, but there's a bulge because the abdomen is missing its muscle.
Now what has advanced in autologous tissue reconstruction is basically a plethora of alternatives to the TRAM flap. Nowadays, we do more and more and more minimally invasive surgeries. So those of us who specialize in breast reconstruction and offer autologous tissue reconstruction and microsurgery can now do flaps where we don't harvest muscle.
The main workhorse of this is the DIEP flap, or the [deep 00:18:11] flap. So the DIEP flap ... And there's a whole alphabet soup of other flaps, so NIH has nothing on plastic surgeons. We've got the DIEP flap, the PAP flap, the GAP flap, the TAP flap, the SIEA flap. They come from all different parts of the body, and they're all based on the name of the blood vessel, so the deep inferior epigastric perforator flap. And that's the way they're named.
The DIEP flap and the PAP flap and the GAP flap are probably the three most common ones. So if most people have extra tissue from their belly, we use the DIEP flap. The benefit of the DIEP flap, and I'll so you right here ... So the blood vessels to the skin and the fat of the breast come from behind the rectus muscle, intra abdominally. And you guys are familiar with these blood vessels all the time, whenever you're going down and dissecting to the pelvis, you push them out of the way.
We love those deep inferior epigastric arteries, and we always get concerned when we hear that somebody may or may not have had an emergency c-section. A c-section is not a contraindication to this operation. It's rare that I've ever seen a patient who had a c-section that has a problem with their blood vessels. We do usually get CT angiogram of the patient, but emergency c-section sometimes raises a little red flags.
When you do a mastectomy, you're removing the breast tissue. The breast is made up of the glandular breast tissue and fat, right? So if we can replace it with fat from another part of the body, not muscle, but just fat, then it'll feel like a natural breast. It'll look like a natural breast. It'll move like a natural breast. And it will be part of you for the rest of your life. So actually, over time, it will only get better. The longer the natural tissue reconstruction is in, the more natural it looks. And when you roll over in bed, and you're lying on your side, it'll just move like a natural breast, and you won't have the sensation of a foreign body in you the entire time.
It's definitely, without a doubt, the gold standard. This is what I describe as a pedicled TRAM flap. And this is where you take the entire rectus muscle. So you can see the rectus muscle's missing. That's why patients get abdominal wall weakness, bulge, or hernia. This is an advance on the standard TRAM flap, where we only take a small piece of muscle from the rectus, and we call that a muscle-sparing TRAM flap, which sounds great. Except that you're still cutting out a big piece of muscle, and you really get a lot of weakness of the rectus muscle. This is an example of a tissue that has been harvested in a muscle-sparing TRAM flap, and you can see the muscle and the pedicle, the blood vessel.
We keep on ... It's like Name that Tune. I can name it in three notes. We kind of push ourselves. "Well, I could take less muscle." Until somebody basically figured out that they can actually do perforator flaps, where you preserve the entire muscle. And that person's a very smart guy, and he decided he's going to rename it, so it's no longer the muscle-sparing TRAM flap, now it's the DIEP flap. So it's a brilliant marketing thing, but it's essentially the next evolution of a TRAM flap.
We don't take the rectus muscle, and you get almost what looks like a tummy tuck, because you don't really incise significantly into the muscle of the abdominal wall, and here you have your tissue and the little blood vessel that is keeping it alive. And that's what we call a perforator flap, and you can have perforator flaps from all different parts of the body, and that's why we have PAP flaps, and GAP flaps, and TAP flaps. But they still all give you this chunk of skin and fat. We transplant it up to the chest wall. We sew it to the blood vessels in the chest wall using a microscope, and we try to recreate the breast mound. We get a CT angiogram beforehand, so that we know where the blood vessels are.
The is the kind of result that we like to get. On the left side, you have a patient pre-op. She actually had a lumpectomy and radiation on her left breast. And that is post-op. Those are not her nipples. That is a nipple reconstruction afterwards. It is very hard to ... And you don't even see scars on her breast, because we hide them all within the nipple in this particular case. So you have basically a scarless breast reconstruction that looks like she never had surgery, plus she gets a free tummy tuck out of it.
Our goal is to improve the patient's overall body appearance. Not just make them feel comfortable when they're wearing clothing, but make them feel comfortable when they're not wearing clothing. Like I like to say, the "drive-by," when you're walking past the bathroom mirror, right? And you see what looks like your normal body.
Here's a patient who had the same operation. Those are not her nipples. That's a nipple reconstruction. You can see the improved contour to her belly. It looks like she had a tummy tuck. These are more examples of the same patients. Hopefully, we look at them and we say, "It's hard to tell."
Here's just the way we do nipple reconstruction, which is kind of cool. We take the little skin from where the nipple used to be. We fold it on itself, kind of like doing origami. And then we rotate it and we make a nipple, and then sometimes we cut the surrounding skin to represent the areola. Here she is before. There she is after her mastectomy and bilateral DIEP flap reconstruction, and there she is after revision surgery and nipple reconstruction and then tattooing to make it look like a real nipple. This is a patient who had nipple reconstruction without a tattoo, and here she is after the tattooing.
So optimizing results ... and one of the biggest complications, one of the biggest difficulties we see is with radiation, and sometimes radiation's our biggest nightmare, and it's good to have a good tattoo artist that can cover up some of your scars, when you can't get that kind of result.
Now radiation ... I'm going to run through this quickly, but one of the new things about radiation treatment is a little bit controversial as to whether or not you should do reconstruction before radiation, or whether or not you should do it after radiation. I will tell you that it's not clear. It's probably 50/50. Half a dozen of one, six of the other.
The last thing I want to discuss real briefly is what I call basically taking the next step, and achieving those cosmetic results. What I said earlier was meshing all of our cosmetic surgery techniques with our reconstructive techniques. So here's a patient after a first-stage reconstruction, so here she is. She's got large breasts. She wanted to do a nipple-sparing mastectomy. When you have ptosis, or droopy nipples, it's hard to do nipple-sparing mastectomy, because the nipple's in the wrong place.
When you do a breast lift, we cut around the nipple, but we leave the nipple attached to the breast. So the vascular supply to the nipple is still intact. When you do a mastectomy, you cut the breast tissue, so the nipple is living off of the skin. How do we move the nipple and do a mastectomy at the same time? Well, with autologous tissue reconstruction, we have the benefit of basically grafting that nipple onto the underlying tissue.
So here she is. If you think of that pillow inside the pillowcase, it looks like somebody put a pillow that's half as big as the original. So we go back, we do a breast lift on her. This is a breast lift after breast reconstruction. After DIEP flap reconstruction. Where the nipple is now going to live on the underlying flap that was transplanted from her abdominal wall, and we give her a breast lift, so she looks like she had a breast lift and a tummy tuck. And there's not a person, plastic surgeon included, that can tell that she had a mastectomy, unless you know that she had a mastectomy. It looks like she had a breast lift and a tummy tuck.
And these are more examples of the cosmetic results that hopefully we can get. Here's a patient who had bilateral nipple-sparing through an inframammary fold, so it's underneath her breast, the scar, so you can't see it. And she wanted to look bigger. She wanted to have a little bit of an augmented look. So we went back and we fat grafted her by doing liposuction and injecting fat. So now she has the result that she wants to achieve.
And here's a patient who has ... Basically, if she came to me for cosmetic surgery, I would say, "You need a breast lift. You need a tummy tuck. Etc., etc." And this is a patient who had breast cancer, and she needed not a nipple-sparing mastectomy. She needed a standard skin-sparing mastectomy, and this is the result we were able to get.
So just briefly, breast reconstruction is also not just for mastectomy patients, right? We also do breast reconstruction at the time of lumpectomy for breast conservation. Breast conservation, doing a lumpectomy plus radiation, very often leaves you with a contour abnormality, asymmetry. And what we can offer these patients is, by bringing the same armamentarium to them at the same time as the lumpectomy, so that we can do like, for example in this patient, you can see the Mediport in the upper right-hand side over here, where she had chemotherapy.
She had cancer on the left. This is the oncoplastic technique, or the reduction she had at the time of lumpectomy, then she had radiation, so her left breast is a little bit smaller, but in general, she looks obviously tremendously better than she did before. It would be very difficult to do if she has lumpectomy and radiation, and go back and then try to make it look like that.
So thank you very much.