Using Your Own Tissue to Rebuild Your Breast

WEBINAR TRANSCRIPT

Breast Reconstruction Series, Part 2: Using Your Own Tissue to Rebuild Your Breast

Karen M. Horton, MD, MSc, FACS, FRCSC February 25, 2015

OPERATOR programs and strategic initiatives at LBBC. I’m very privileged to Greetings, ladies and gentlemen, and welcome to the Living serve as your moderator. Beyond Breast Cancer webinar. At this time, all participants are in a listen-only mode. A brief question-and-answer session will At LBBC, we know that for some women, breast reconstruction follow the formal presentation. plays a very important role in your emotional recovery from breast cancer treatment. We also know that many If anyone should require operator or technical assistance during women have a hard time getting timely, useful and practical the conference, please press “star, 0” on your telephone keypad. information about making what can be very complicated As a reminder, this conference is being recorded. decisions about rebuilding your breast or breasts, whether you’re choosing to do that at the time of your breast cancer It is now my pleasure to introduce your host, Ms. Janine surgery or in the months and years afterward. Our goal today Guglielmino. Thank you. You may begin. is to give you some background to help inform these important and complicated decisions. JANINE E. GUGLIELMINO, MA Thanks, Diego, and hi, everyone. Welcome to part 2 of Living Just to give you a sense of what we’re hoping to cover today, Beyond Breast Cancer’s February webinar series focusing on we’ll talk about rebuilding the breast using your own body breast reconstruction. Today we’ll discuss using your own tissue tissue after mastectomy. This will include things like the DIEP to rebuild your breast. [deep inferior epigastric artery perforator], TRAM [transverse rectus abdominis myocutaneous], latissimus dorsi flap and I want to thank all of you for taking time out of your day to join other free-flap procedures, the impact these surgeries can have us. Again, my name is Janine Guglielmino and I’m director of on your recovery, your long-term physical strength and range of

Connecting you to trusted breast cancer information and a community of support Breast Reconstruction Series, Part 2: Using Your Own Tissue to Rebuild Your Breast

motion, a bit about rebuilding the nipple and areola, and some results, requires an artistic talent of your surgeon — a vision. decision-making tips you can take with you moving forward. They need to be concerned with body image and self-esteem. And they also need to consider what I call the fourth dimension, For those interested in implant reconstruction, I would which are time, gravity, aging and then effects of radiation. So, encourage you to listen to the podcast from the first part of this when we think about breast reconstruction, we really want to series. We won’t be speaking at length today about implants, consider all of those things. but the podcast should answer many of your questions about it. You can find that onLBBC.ORG . Now, I have developed a pamphlet that educates about advanced breast reconstruction techniques. We’re going to So we’ll start our program today with a presentation by our be talking about some of those things today, because, really, speaker, Dr. Karen Horton, followed by time for you to ask all women, either who are facing breast cancer or who are questions by phone or computer. We’ll provide instructions for considering a prophylactic mastectomy for risk reduction, they how to do that after Dr. Horton’s presentation. I’d like to thank deserve the very best results. Mentor and The Plastic Surgery Foundation for the financial support that made this important webinar possible, and [I’d What’s new in breast reconstruction? You may or may not have like to] very much thank Dr. Horton for being with us today, heard a little bit about nipple-sparing mastectomy [during] for sharing her expertise with you and for donating her time as the implant reconstruction section. I’m going to mention it a speaker. just very briefly today. Single-stage implant reconstruction [is something that] hopefully you learned about [during the Just a couple of housekeeping notes before we get started: If first webinar]. And you can always go tomy website as well for you need to leave the program early or are just joining us, please some additional information. visit LBBC.ORG to listen to the full podcast. … But today I’m going to be talking about flap reconstruction. So without further ado, just a couple of words of introduction I’m also going to touch on using your own tissue, meaning if about Dr. Horton: Dr. Horton is internationally board certified you only need a lumpectomy and radiation, we can still do a in plastic surgery with both the American Board of Plastic reconstruction just by rearranging the rest of your tissue. We’ll Surgery and the Royal College of Surgeons of Canada. Her talk a little bit about nipple reconstruction as well and then, private practice specializes in breast cancer reconstruction and again, review talking about aesthetics. cosmetic surgery for women. Her goal is to provide beautiful, natural and long-lasting results using the most advanced So, No. 1: Why do we reconstruct the breast? When the breast is microsurgical techniques that spare major muscles of the body, gone, you can no longer breastfeed and you may lose erogenous nipple preservation and implants in a single stage. sensation. But the breast still serves a function in terms of body image, self-esteem, feeling feminine [and] feeling complete. And So without further delay, I’m honored to welcome Dr. Horton. if you have been going without breast reconstruction, you know that wearing that prosthetic in your bra — it’s heavy, it can be KAREN M. HORTON, MD, MSc, FACS, FRCSC sweaty; if you go swimming you worry about it floating away in Thank you, and thank you, everybody, for listening today. Today the pool. So by using your own tissue, you can throw away that I’m going to be talking [as part of] “Part 2: Using Your Own prosthesis forever, which is another benefit. Tissue to Rebuild Your Breast.” So the goals of breast reconstruction are to recreate the I’m going to start just by mentioning that plastic surgery, and in breast form considering four things. Aesthetics is No. 1 particular breast reconstruction, it really is equal parts art and for me. It has to look good. It should be symmetric. The science. Surgeon[s], of course, [are scientists]. They are critical reconstruction should have longevity — meaning we want thinker[s]. They have analytical mind[s]. They have perfectionist you to be around for a long time; we want your breast attention to detail. But they also really need to be artist[s], reconstruction to look amazing forever —with minimal because breast reconstruction, if it’s going to have beautiful morbidity. Now, morbidity is opposite from mortality. It

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means giving up function. So we don’t want to sacrifice any if you gain weight, or if you lose weight it shrinks a little bit, and major muscles of the body. it ages with you. However, it’s not going to droop like a natural breast because all the suspensory ligaments that go out from When I meet a new patient, I ask, “OK, if we could just wave a the chest wall, out to the skin, and they get stretched out as you magic wand, how would you want your breasts to be? Would age, they’re not there. So you actually don’t even need a bra if you want them to be larger, smaller, fuller, lifted?” Because if you don’t want to wear a bra anymore. And it does last forever, you need to have breast reconstruction, you should really use as opposed to implants, where you might need more surgeries it as an opportunity. And as one of my patients said, “OK. Let’s in your lifetime. And one other thing that’s great about doing make some lemonade out of lemons.” So we consider all of a flap is that if you have had radiation, if you have had implant those things. And I tell patients, “I can really make you look any complications, if you’ve lost skin, if you’ve had trouble with way you want to be.” … And if you goal is to be very full and the healing, when we move new tissue into the area, it brings voluptuous, we can do that. So we really take our patients’ goals a whole new blood supply and new life to the area. And it can in mind in planning their surgery. help to counteract some radiation and infection damage.

I just want to mention that if the reconstruction is only on one The only disadvantage of doing a flap is that we do create side, which is covered by insurance by law, so is a balancing what’s called a donor site. So we have to take the tissue from procedure for the other side. And it’s often done at the same somewhere. And that means additional scars, usually in the time as the reconstruction. And the balancing procedure could belly or sometimes in the thigh area. It is a slightly longer include a breast lift, a breast reduction, an augmentation surgery. It’s usually 4 hours for one side and 6 to 8 hours for a and any other procedures down the road. Say we do a flap double procedure. And that includes the mastectomy if it’s also reconstruction but my patient wishes to be a little bit fuller. We done at the same time, and a slightly longer recovery, usually can put implants underneath the flaps and achieve the effect of about 6 weeks before I let patients exercise and do whatever a breast augmentation, and that’s also covered by insurance. they want. But, in reality, after any major surgery, including an implant reconstruction, it can take about a full year before you So, from a woman and from a woman surgeon’s perspective, feel 100 percent healed. my goal is to find the best fit of the procedure for each patient. And we want to consider what’s their body’s shape, what’s their So, flap reconstruction means using your body’s own tissue. And lifestyle, what are the details of the cancer, and have they had we’ve talked about some of the advantages. The donor site is chemo, do they need chemo, and is radiation on board. I’ve where we take the tissue from. So you can see the lady on the top seen some of the questions come in already. I will talk about — I’m going to back up one second. The lady on the top had some radiation and flaps. tummy tissue and the lady on the bottom had some thigh tissue.

So, you’ve heard a bit of an overview. I’m just going to go Disclaimer: I was supposed to say that before I showed these over this really quickly. Breast reconstruction can either be pictures. But we do have some pictures of naked women. There immediate, meaning at the same time as the mastectomy, are no faces showing, but we have some breasts and we have or delayed. And there’s absolutely no time limit. But if you some tummy areas which may include the pubic region. So if have had radiation, we usually like to wait at least 6 months you’re at work or you need some privacy, just turn the screen from the time that radiation has finished. And the methods of around. If you don’t want to see these photos, maybe you reconstruction can either be an implant or a flap. And a flap could just listen to the presentation. But I will be showing a lot means using the body’s own tissue. Implants you learned about of before and after photos. I’m going to go through them very last time, so I’m going to focus on flaps. quickly. But if you choose to review them later on, they will be on the Living Beyond Breast Cancer website soon. Advantages of using your own tissue are that it’s a permanent reconstruction, it’s warm, it’s soft, it’s living tissue that moves Usually we take the tissue either from the tummy or the thighs with you when you change your body position, it grows with you in my practice, but we can also take it from the buttocks. We can

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take it from the back. And there are some procedures that take So, when we use microsurgery for breast reconstruction, we it from the outer thighs as well. only take the skin and the fat. We leave the muscles alone. And this is a diagram of the flap. And this would be the same skin So, the very first flaps that were used for reconstruction, about and fat as a TRAM flap, but it only takes the tissue based on 30, 35 years ago, always used a muscle to carry the blood blood vessels. And we usually take it on one or two little blood supply. And that’s called a pedicled flap, where the muscle vessels that go into the tissue. It’s time-consuming. It’s not holds the blood supply that brings the tissue to the chest. It’s offered at all the hospitals. But it is currently the best option usually either from the tummy, and that’s called the TRAM flap, that we can offer women. And it is, thankfully, becoming more or from the back, and that’s called the latissimus flap. popular. So, advantages of doing a microvascular transplant, which is called a free flap because we transplant it free in the air, Now, all of these procedures can be performed by any plastic are all the other advantages of a flap, but it avoids sacrificing surgeon. They don’t have to have special training. They don’t muscle. have to be a microsurgeon. And they are good procedures. However, they do permanently sacrifice a muscle from the The best option using your abdominal tissue is called the body. So in my practice, I will take a muscle as a last resort, DIEP flap, and it stands for the deep inferior epigastric artery if there are no other options. And I’m not saying it’s a bad perforator. That’s the blood vessel that supplies the blood option, but there are some better ones that can preserve your supply to that tissue — the same skin and fat as the TRAM, the muscle function. same skin and fat that we throw away in a tummy tuck. But it does not sacrifice any muscle. It’s a much faster recovery than So, the pedicled TRAM flap takes the lower abdominal skin the TRAM. And it’s much less pain than a TRAM. Patients in my and fat. It moves it up to the chest using your rectus abdominis practice are usually in the hospital for 5 to 7 days. They go home muscle as a carrier. That’s the muscle that provides the six- on Tylenol or nothing for pain. And it’s a pretty smooth recovery pack. You can see on the procedure on the right, basically that physically. Emotionally, it can be a big recovery and, again, we woman is missing her whole entire half of her abdominal wall. don’t want patients to exercise for at least 6 weeks afterwards. And even though it provides a nice breast reconstruction, the So, again, using the DIEP flap, we take all the tummy tissue problem is that you can develop weakness, particularly if both away. We only take what we need to make a new breast, but we muscles are taken. You can have a bulge, because if you think still take away as much skin and fat as we can. about it, you’ve lost your resting tone of your core. And you could have a hernia. So these are reasons why this is lower on There is another abdominal option with is called the SIEA my list — because I’m also a microsurgeon — of what I offer to [superficial inferior epigastric artery] flap. It’s the same my patients. But it is a well-described procedure. It is a good abdominal skin and fat, but there is a little superficial artery, procedure. And there are various ways to get around treating a as opposed to the deep artery. And, really, only 30 percent of bulge or a hernia if it does occur. people have a blood vessel which is large enough to use. We always look for it. If we see it, we say, “Great, option No. 1.” But I am a microsurgeon, so I want to talk to you a lot about We usually look at the deep vessel as well. And usually one of microsurgery today. Microsurgery involves using magnification, the two systems is dominant and we will take whichever one either our funny microscope glasses or the operating provides the best blood supply. Again, it does not sacrifice any microscope, to reconnect blood vessels and sometimes nerves muscle or fascia [connective tissue fibers] and it does require a under the microscope. And microsurgery is used, for instance, microvascular transplant. The results are exactly the same and if you cut off your thumb and you need it sewn back on. And the recovery is also the same. it does require special training, so not all plastic surgeons are microsurgeons, but all microsurgeons are plastic surgeons. So, diagrammatically, here is the difference between the DIEP And it requires specialized equipment. It’s usually performed at flap, on the left side, which only takes the skin and fat based on hospitals that do a lot of microsurgery, so either an academic blood vessels, and then the TRAM flap, which uses the entire center or the place where I bring my patients in San Francisco, muscle and usually a layer of the fascia over top of it to carry the which is where microsurgery was born 4 years ago. blood supply. Again, here is the DIEP flap turned upside down.

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This is what we take. And we can usually take — it’s divided into We can make implant reconstructions that don’t look very good zones — we can usually take the zone immediately where the look great. And this lady chose to have her left-sided implant blood vessels are going into it and one zone on each side. We exchanged for a flap, and then she decided to have a preventive usually discard the zone of tissue which is furthest away so that mastectomy on the other side, so she actually has two DIEP we don’t have improper healing of the fat, which is called fat flaps now. Again, you can see how much we can transform a necrosis. We want to only transplant good, healthy tissue. woman’s body. She’s had a lift on the other side. She’s had a flap. So, we can really restore the body; give a really nice result So, once we’ve disconnected the blood supply, like in the and help women move forward. last slide, we bring it up to the chest and then we reconstruct the blood supply under the microscope. And that’s called Here are a few other examples of DIEP flaps: again, changing microvascular anastomosis. We sew the blood vessels together from an implant, which wasn’t great. This was the original tissue under the microscope using microsuture, which is thinner than expander that she had for 13 years. When I met her I was like, your hair. And the diameter of the blood vessels is usually 2 “Why do you still have the tissue expander?” She said, “Well, to 3 millimeters. We do this in a team. There are usually two this is as good as it’s going to be. Why would I want to have any microsurgeons working as a team together. And every single more surgery?” We changed it to a flap. time we do this we go, “Wow. That is so cool.” Usually we do one or two of these a week. … Implants that are not great, like you can see here — we can change implants to flaps. So if you have an implant And here are a few examples: This lady had a breast cancer on reconstruction and you’re not happy, it can certainly be her left breast. You can see her lumpectomy scar. She’s large- modified. Here are a few more examples. breasted. She did not want to be any different. We’ve taken her abdominal tissue. And you can see she has a scar that goes from So, what if you’ve already had a tummy tuck? What if hip to hip. It’s hidden low. It will be hidden in her bathing suit you’ve already had a TRAM or a DIEP and you need a new bottom. She has a scar around her belly button. We’ve redraped reconstruction? Or say you’re just one of those people who her abdominal wall and her tummy looks tauter and leaner. And naturally has a washboard stomach but you’ve got some the scar was actually hidden underneath her breast. She has thighs. Then we take the inner thigh tissue. And that’s called had a nipple-sparing mastectomy. the TUG, which stands for the transverse upper gracilis flap. It is a crescent of skin and fat from the upper inner thigh. It is [Here is] another example of a bilateral — both sides — nipple- also a microvascular transplant. And an advantage of doing this sparing mastectomy. She’s only a month out from surgery. She procedure is that we can make a nipple and an areola at the still has the swelling of her abdominal wall. You can see little kind same time. of corners on the ends of the incision. Those are called dog ears, and they’re usually just related to swelling. They usually shrink So, here’s an ideal candidate — personal trainer [with a] and go away to nothing. But you can see her breasts look almost washboard stomach, but she has good thighs. And this would exactly the same. So using your own tissue can give you the best be for pear habitus rather than sort of apple body type, and cosmetic results, with the benefit of a tuck somewhere else. for women who also don’t want a major muscle sacrificed. Here are a few other candidates: one woman has had multiple This lady had an overabundance of tissue. She chose to have abdominal surgeries. We could have done a DIEP, but we chose a breast lift on the other side. We did a DIEP flap. The breast not to. And all of these women — another lady had a tummy cancer was on her right side. And then we did make her a new tuck — they’re great candidates for the TUG flap. nipple and areola. When we do the TUG flap, we take a crescent of skin and fat So, here are a few other examples: a delayed reconstruction — from the upper inner thigh. And that’s the fat that you can grab I’m just going to go through them quickly. If you want to review and you think, “Oh, if I didn’t have that, I’d have a really nice them, they’ll be on the Living Beyond Breast Cancer website thigh gap.” Well, guess what? This procedure gives you a nice later, and then you can also go to my website. thigh gap. Now, in this procedure, we do take a very small piece

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of the gracilis muscle. And I need to explain why. I have been say it bothers them. If it bothers them, we can do a bit of discouraging use of a major muscle of the body if you can avoid liposuction to even it out. But, again, there’s no loss of function it, like the lat. The latissimus muscle is the biggest muscle in when you take a little bit of gracilis muscle. There have been no your body, and we will use it, for instance, to reconstruct the seromas, which is a fluid collection. There’s been no evidence leg or the scalp if you’ve had a major trauma. But in the breast, of lymphedema, and I’ve done probably about 150 of these. there’s no muscle. And so if you don’t need to sacrifice a major There’s no permanent sensory loss or numbness. And, again, we muscle, don’t do it. give patients the option of donor site contouring on the other side maybe about 6 months later. We would not do it at the With the gracilis flap, we do take a very small piece of the same time, because we want to have a backup flap, just in case. muscle just to ensure that there’s good blood flow to the flap. And there’s no consequence to taking that muscle. And we know So here are some examples: This lady has had a bilateral — that because we transplant the whole gracilis muscle all the [both] sides — nipple-sparing mastectomy and TUG flap. She’s time in other areas of microsurgery, for instance, to reconstruct about 2 months out. You can see the scars are still pink. This the leg or to give motion back to the forearm. And we know lady had skin-sparing mastectomies. We made new nipples. The when we take the whole muscle, it’s not missed, because nipples are made out of her thigh tissue. And we did go ahead to you have your other adductor muscles — adductor magnus, do [a] tattoo. This lady has not had any tattoo. She’s swimming. adductor longus. Gracilis is a teeny little strap muscle. So we do She looks great. And we used all of her own tissue. And this take a small piece, usually what is only under the flap. lady’s had multiple lumpectomies [and] radiation. You can see [her] thighs are no longer touching, and we did both sides using Now, I do have a couple of pictures of surgery. It’s not going to her inner thigh tissue. Here are our washboard abs. We can be gory, so don’t worry about saying, “Ooh, its tissue.” I just use this for a delayed reconstruction as well. And, again, after wanted to show you what the flap looks like. So this is the flap. implant problems, we can do some really great reconstructions It’s been harvested. It’s on the back table. And I want to show just using the thigh tissue. It does provide a little bit smaller flap you what is so great about the TUG flap. You take the crescent than the DIEP, and I’ll mention other things we can do to even and you cone it. And that’s what gives a beautiful breast shape. things out. It gives excellent projection. And on the table, you see — the first time we did this we went, “Oh my God, that looks like a But I want to answer the question I saw already about radiation. nipple.” Well, we decided to use that tissue. The picture on the What if you’ve had radiation? Can you have a flap? Yes, of bottom shows a skin-sparing mastectomy where we’ve removed course. We want to do a flap if you’ve had radiation. But what all the skin of the flap [and] tucked it underneath, but we’ve if you know you need radiation? Can you still do a flap? Well, accentuated that dog ear, which is called the standing cone, to in my practice, I am very comfortable doing a flap and then make a new nipple. So with the TUG flap, we can make a new radiating it. The radiation will not kill the flap. It will shrink nipple and areola at the same time. And what’s also really cool it, usually 5, up to 20 percent, just depending on your body’s is that the inner thigh skin has natural darker coloring. So we response to the radiation. And so we can do a flap. We can don’t always need to do a tattoo, because sometimes it just radiate it, and then it will be fine. So here’s her flap. We’ve made ends up being a little bit darker. it — because we knew she was going to need radiation — about 20 percent bigger than we wanted it to be. Here’s at the end of The donor site is what many women worry about. And I say, “It radiation. It shrinks, and now it’s shrunk to be very good and will be hidden in most of your clothing except your bathing suit symmetric. And this is before we did her nipple and areola. or your underwear.” The scar in the front lies a little bit below your natural groin crease. And the reason for that is we don’t And here’s another example where she’s had radiation. She want to pull the vulva down. And in the back, you can’t even see has a bit of a sunburn as well. But we did her flap. She had it it. It hides in the butt crease. But you will have a nice thigh gap. radiated and we have good symmetry.

Now, if we only do one side, like in this picture, you usually have So, I just want to [talk] really quickly [about] using your own a little bit of asymmetry. And only about 50 percent of patients tissue, but after lumpectomy. And I call that local tissue

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rearrangement. Not everybody needs a mastectomy. Not you can use. And it’s almost like origami. We’re basically everybody wants a mastectomy. And some women naturally creating a box of tissue using your own tissue. Usually we do have large breasts and they wouldn’t mind being smaller the nipple first, we let it heal for at least 2 months, and then we or lifted. So we can do the breast reconstruction either by do the medical tattoo afterwards. There are other options, like a reduction or a lift, either before or after the radiation. We using some cartilage or using earlobe tissue. There are some basically rearrange the rest of your breast tissue to give you a implantable devices that I’ve tried. But, really, the best results reduction or a lift, and we do it on both sides, for symmetry. This are using your body’s own tissue. lady already had a lumpectomy and radiation. She was left with deformity. We basically just rearranged the rest of her breast And I prefer to do a medical tattoo rather than taking a skin graft tissue to give her a nice lift on the cancer side and did a breast because you don’t want to take skin from your groin or your reduction on the other side. labia. And using a medical tattoo, we can really match it up to the other side. And if we’re only doing one side, I usually do a This lady knew that she needed a lumpectomy and radiation. So little bit of tattoo on the other nipple and areola as well, just for we did the procedure and then she proceeded to have radiation the best symmetry. afterwards. Again, this is after a lumpectomy/radiation. We’ve rearranged the tissue. And if you look really closely, you can So here’s step-by-step how we do it — and in this instance, I see the left side is sitting slightly higher. The scars actually actually did the tattoo and made the nipple all at the same look a little bit nicer on the radiated side, because radiation is time. So you see on the top left we’ve drawn the little modified a treatment for scars. And I know there was another question star flap. I’ve pigmented it with the tattoo. We make incisions. about keloid scars [growths of extra scar tissue]. Radiation We rearrange it. And then we do the areola tattoo as well. scars always look better. [Here is] another lady who had a lumpectomy, and she actually had brachytherapy [A type Now, if there’s a normal, healthy tissue on one side, and if it’s of radiation therapy in which radioactive material sealed in big enough to be split into two, then the best way to make a needles, seeds, wires or catheters is placed directly into or near nipple is using what I call nipple sharing, or a nipple free graft, a tumor], which is possible as well. [also called a free nipple graft]. And we just basically take a little piece of the nipple from the other side, usually from the So here are a few other examples I’m going to go through undersurface. It will not affect sensation. The other nipple is quickly. If you’ve already had lumpectomy radiation, we can rearranged. And basically it’s just cut into two. We move it over. even things out and do a balancing procedure on the other side It heals as a graft and [if] it’s [one of the] 99 percent [that are] as well, so lots of examples. successful, then we do a medical tattoo over top of it. And it looks like you’ve had a nipple-sparing mastectomy. So if there is I want to get to nipple and areolar reconstruction because this one nipple left, then that’s what I recommend doing. If you are is something that really is the finishing touch. It puts the icing planning on breastfeeding, I would avoid doing that. Wait until on the cake. And if women do not go on and have nipple and you’ve finished having all of your children, because there is a areolar reconstruction, that usually means that they’re not slight chance that in future breastfeeding, the [milk] might not happy with their result. I just want my patients to move forward be able to get out if there’s scar[ring] there. and to feel normal and natural and not like a Barbie doll with no nipple. I also want to mention some second-stage procedure. After we do the flap reconstruction — we do the flap and that’s not So the traditional way of making a new nipple is using what’s always the end of the story. Flaps can look good, but say a called a local flap. And I also have some diagrams and a few woman’s natural breast size was a D-cup. And say she only had pictures of surgery for you to see. Usually we wait at least 3 to enough tummy tissue or thigh tissue to make her a B-cup. Well, 6 months after the reconstruction is done. And this is the same we can do other things to help get her body image back. And technique we can use either for implant reconstruction or using again, I mentioned they’re covered by insurance. So we can put a flap. We basically lift up three little wings of a star. And it’s implants under a flap. We can do what’s called lipofilling or free called the modified star flap. There are all different techniques fat grafting. It’s very difficult to build a whole breast only using

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fat grafting. But we can fill in little areas or hollows. We can to have a good success rate. But after all that, what’s most do scar revisions. And we can also do donor-site contouring important to you as the patient is the outcome. And for me, as using liposuction. a provider of care, I really want breast reconstruction to be a positive experience. We either want to preserve body image, if Here’s a lady who started off with a lot of asymmetry. She was a woman’s having an immediate reconstruction, or we want to very droopy. She thought she wanted to be smaller. We did help them regain their body image. And it’s also an emotional bilateral DIEP flaps. She lived that way for about a year or two recovery, as I mentioned. The physical recovery, you know, and she said, “You know what? I really miss my volume. I’m not you can have fatigue, you can be tired, [but there’s] not a lot of filling out my bras. I think the bigger breasts fit my body image.” discomfort. I said, “No problem.” We put implants under the flap at the same time as we did nipples and areolas. And she’s back to how And one thing I was supposed to touch on is the impact that she always wanted to be. any type of flap reconstruction will have on your recovery, long- term physical health [and] range of motion. There should be Here’s another example of a woman who had a lumpectomy, zero problems with range of motion. And you should get back radiation [and] implant reconstruction. We ended up doing a to doing all of your regular activities. And I always joke with my DIEP flap only on the cancer side and we put implants in on patients that if their golf swing improves, I want to take credit, both sides. And that enabled her to fill out her bra a little bit although it’s probably not related at all. better. And I really maintain the same aesthetic goals for my breast Here’s a lady who had a lot of implant problems. She basically reconstruction patients as I do for cosmetic procedures. And came to me with an open wound. We did a number of I could look at a DIEP flap donor site, the belly, and not know procedures to prepare her for her final result. We did the TUG whether it’s a tummy tuck or a DIEP flap, because I treat flap on both sides and then we put implants under both TUGs. them exactly the same. So I strive to achieve the best esthetic She’s young, she’s single and now she’s back in action. And she outcome in a single surgery if possible. Breast reconstruction says most of the time she forgets she ever had breast cancer, should be rewarding. And we’ve talked about the emotional which is the best compliment I could ever receive. recovery and body image. It’s a team effort. I’m the surgeon. I have a microsurgical partner, but it really is everybody involved Here’s another example of a woman who had a TUG flap. We in the care of patients who makes it happen. decided not to do the lift at the same time, just because she lived out of town and we wanted to minimize the number of That’s everything I have to say to you. I’m happy to open up trips she needed [to make] back here. We put an implant under to questions. And I’m [on] the phone for at least another 20 the TUG. We did a lift on the other side. minutes or however long that we have. Thank you.

And, again, thinking about donor sites, we always want the scar JANINE E. GUGLIELMINO, MA to be low, low, low — hidden in the underwear. Currently the Thank you so much, Dr. Horton, for that wonderful presentation style is for low-cut jeans, low-cut panties. However, I always ask that was really specific, with photographs that can really help my patients, “What cut bathing suit do you wear?” If you like to people imagine how things might look. And we do have a good wear the high French cut, we can design the scar to fit into your 25 minutes for questions, which is wonderful. Diego, if you could garments. So there’s not a one-size-fits-all. please give the listeners information about how to ask their questions by email and by phone. This lady had a failed implant. We did a DIEP. And then we came back later and did some donor-site contouring. And it really OPERATOR makes her overall body shape that much better. Thank you. We’ll now conduct a question-and-answer session. If you would like to ask a question by phone, press “star, 1” on Considering aesthetics is No. 1 to me. Technically, you have your telephone keypad. A confirmation tone will indicate that to go to a surgeon who knows what they’re doing. They need your line is in the question queue. You may press “star, 2” to

LIVING BEYOND BREAST CANCER LBBC.ORG 08 Breast Reconstruction Series, Part 2: Using Your Own Tissue to Rebuild Your Breast

remove yourself from the queue. Once again, to ask your question OPERATOR over the phone, press “star, 1” on your telephone keypad. Our first question on the phone comes from Chelmsford, Massachusetts. Please state your question. To submit your questions online, use the Ask a Question feature on the left side of your screen. WOMAN Hi. I have had metastatic breast cancer since November of 2007. Thank you. At this point in time, I’ve only had Herceptin [trastuzumab], and radiation in 2007. I still get Herceptin every 3 weeks via my JANINE E. GUGLIELMINO, MA port-a-cath. I feel like I’m going to be living with this as a chronic Thanks, Diego. And I would just ask everyone if possible to try to disease. What is your experience and recommendation for a frame your questions generally so as many people can benefit woman — I’m 50 years old, I’m in good shape. What would your from Dr. Horton’s answers as possible. recommendation be? If you have reconstruction [and you are] metastatic, are you — this is going to sound stupid, because So while we’re polling for questions, I’m going to take one of the I don’t know any better — is it more likely to bring the cancer questions that we got online, Dr. Horton, which is: Are there any back in a more aggressive way? long-term issues with autologous reconstruction that you are aware of? KAREN M. HORTON, MD, MSc, FACS, FRCSC Thank you for that information. And no question is stupid. And KAREN M. HORTON, MD, MSc, FACS, FRCSC that’s a fear. If you have known metastatic disease, should No, there really aren’t, other than you take the tissue from you have reconstruction? It’s a judgment call. I have done one part of the body [and] you move it over to another. It’s reconstruction on quite a few women with metastatic disease. essentially a transplant, but instead of transplanting [from] one And I think you have the right frame of mind. It’s a chronic person to another person, it’s from one part of your body to disease. Maybe think of it like hepatitis. You live with it. What another part of your body. So there’s zero chance of rejection. else are you going to do? As long as it’s healthy tissue it will all heal well. If there’s an area of the fat or the skin that doesn’t get a good blood supply, the So I would offer you reconstruction, definitely. Now, not all skin could die and it could make a scab. When fat dies — it’s surgeons or oncologists might feel the same way. I don’t know called fat necrosis — that can end up with a very large, hard what the answer is. Is it going to create a huge inflammatory lump. Now, no woman who’s either had breast cancer or did response in the body and wake something up? Well, we don’t this because they didn’t want breast cancer wants a lump. So know. But I don’t think it’s a reason not to have surgery. I think if an area of fat necrosis ever occurs, usually what we do is we you need to look at all the options, look at “What do I want to go back to the operating room, we excise it and then we either do? Do I want to go on vacation? Do I want to have surgery?” Is rearrange the rest of the tissue or fill in that gap, either with an at least 6 weeks of initial recovery and then maybe up to a full implant if it’s a large area or a little bit of free fat grafting. year of feeling tired and recovering worth it for you? And if it is, as long as you know what all the pros and cons are and you find But there are no long-range problems, in terms of range of a team that you feel comfortable with, I would say go for it. motion or activity, as long as you don’t sacrifice a major muscle. If you do take the back muscle, you might not be able to do JANINE E. GUGLIELMINO, MA your lat pulldowns or do rock climbing. And if you take both Thanks, Dr. Horton, and thanks so much [to the caller] for your rectus abdominis muscles, for instance in a bilateral TRAM, you really important question. Definitely no question is stupid at all. probably are not going to be able to do a sit-up. So I’m glad we had a chance to address your question.

JANINE E. GUGLIELMINO, MA I’m going to take one of the online questions next. Dr. Horton, OK. Thanks, Dr. Horton. That’s very helpful. one of our listeners is asking: How do you find a microsurgeon that does the forms of breast reconstruction that you’ve been Diego, can we take the first phone question?

LIVING BEYOND BREAST CANCER LBBC.ORG 09 Breast Reconstruction Series, Part 2: Using Your Own Tissue to Rebuild Your Breast

discussing? And then an additional question is: In general, how JANINE E. GUGLIELMINO, MA do you find out more about a breast reconstructive surgeon’s Thanks, Dr. Horton. Diego, let’s take the next phone call please. qualifications? OPERATOR KAREN M. HORTON, MD, MSc, FACS, FRCSC Our next question comes from Lewiston, New York. Please state Great question. Well, back in the olden days, you would just have your question. to ask for a referral and maybe you’d be given one or two names by your breast surgeon and that would be it. Nowadays, thank WOMAN God we have the Internet, although there’s lots of stuff on the If you are unusually thin, is the flap, [the] taking the skin Internet which is good information and then some which is not. method, available?

For microsurgeons who do a lot of breast reconstruction, they KAREN M. HORTON, MD, MSc, FACS, FRCSC usually have a lot of information on their website. There is a So the question is: If you’re very thin — site which is called DIEPSisters.com. … Usually, if a surgeon does a lot of breast reconstruction, they get contacted by that WOMAN site and they’re listed. There’s also the American Society for What are the options available in terms of using your Reconstructive Microsurgery. … You can find surgeons that are own tissue? members. If a microsurgeon does a lot of microsurgery, [he or she is] probably a member of that organization. KAREN M. HORTON, MD, MSc, FACS, FRCSC As long as you can pinch an area of skin and fat between two But it really will take a lot of research, maybe at breastcancer. hands, that’s basically how much tissue you have. I’m also org or the Living Beyond Breast Cancer resources. But do your giving a presentation on this at the Barcelona Breast Meeting homework. Ask how many flaps have they done. If it’s less coming up, on doing flaps in very thin women. We can still do a than 50, they’re either brand new in practice or they don’t do flap, but we might only get you, say, to an A-cup. And if your goal that many. And they should probably do, I would guess, at is to be fuller, as long as we get a little bit of tissue up there, and least 20 a year. Anybody who’s done [a surgery] at least 100 as long as we can close the donor site and the incisions aren’t [times] can be proficient at it. But you want to know what their going to be too tight, we can still do a reconstruction using complication rates are. In the literature, it should be well less your own tissue, get a little bit of padding up there and then than 5 percent for microsurgeons who do a lot of microsurgery. basically we can treat the area as a very small breast. We can Their complication rate should be 1 to 2 percent or less. And it’s put an implant underneath if we needed a little bit more tissue. really important to do your homework. It’s your body and you So you really would need to get an evaluation [by] a breast don’t want to undergo a procedure blind. Do your homework. reconstruction surgeon who has a lot of experience, who’s done Ask around. really thin patients and who can give you their honest opinion.

Unfortunately, not all states have microsurgeons who do a lot So it is possible. However, if doing a flap is not possible, of this procedure. So I have a lot of patients who come from we could do implants or, as I said, as a last resort, we could Hawaii. They come from other local states. And, you know, do something like the latissimus flap and put an implant sometimes it’s worth traveling for [breast reconstruction]. underneath. So we still do have some other options, even if you’re extremely thin. But do your homework and take your time. You’re welcome to go on my website. It’s listed on the screen. You can see it. And, WOMAN you know, say you see a surgeon on consultation and you want Thank you. to know if I know them. Send me an email and I’ll say, “Yeah, I know them. Good guy,” or, “Good girl,” or, “Maybe there are a KAREN M. HORTON, MD, MSc, FACS, FRCSC couple of other names you should see,” if you’re on the other You’re welcome. end of the country.

LIVING BEYOND BREAST CANCER LBBC.ORG 10 Breast Reconstruction Series, Part 2: Using Your Own Tissue to Rebuild Your Breast

JANINE E. GUGLIELMINO, MA KAREN M. HORTON, MD, MSc, FACS, FRCSC Thanks, Dr. Horton, and thanks [to the caller] for your question. Oh, I’m so happy you asked that question. Those are excellent So I’m going to take the next question online. One of our questions. No. 1 — I’ll answer the second question first — there’s listeners is asking: Do you recommend reconstruction at the no age limit. I’ve done a DIEP flap on an 82-year-old who looked same time as breast surgery or after surgery? And I would also like she was 60 and acted like she was 40. Age is just a number. add to that: Are there situations where it would be impossible to It depends on how healthy you are and what you want to do do an immediate breast reconstruction? with your time. If you’re having trouble walking and if you’re not wanting to undergo surgery, well then don’t have surgery. But if KAREN M. HORTON, MD, MSc, FACS, FRCSC you’re a young 70-year-old and you’re vital, of course we can do That is an excellent question. So, my global answer is of course. If it. There’s really no age limit. we can do reconstruction at the same time, we definitely want to. And the reasons for that are that it’s one surgery, it’s one recovery, For the first question — can you remind me what it was? you don’t undergo the period of loss, where you go, “Oh my God, it looks terrible,” and you can get back in action sooner. JANINE E. GUGLIELMINO, MA Oh, lymphedema. However, there are some situations where it’s not recommended. They’re pretty few and far between, and KAREN M. HORTON, MD, MSc, FACS, FRCSC: If it’s usually the breast surgeon who’s planning on doing the you’ve never had lymphedema, doing surgery is not going to mastectomy or the oncologist who says, “No. We need to get to cause lymphedema. Lymphedema is basically like blocked the operating room ASAP, like tomorrow or in two days.” Or, say plumbing. And when we do a DIEP flap, we usually reconnect it’s a patient who has a lot of comorbidities, meaning they have the blood vessels that are closer to the sternum. On occasion diabetes and high blood pressure and they’re really obese and we might hook up an additional blood vessel in the armpit. we’re worried about them having complications. Sometimes But if we dissect into the armpit area, it’s very gentle. We’re not it’s best to do the mastectomy and then maybe treat them with dividing any lymphatics and it will not create lymphedema if chemo, radiation or anything else they might need to do, and you’ve never had it. then do a reconstruction later. JANINE E. GUGLIELMINO, MA So I don’t play a very active role in making that decision, other … than I tell my patients, “Well, if we can, I’d love to do it right away.” But it’s a judgment call and it really depends on the I’m going to take another question from our online queue. There cancer treatment and sometimes on other health-related issues. are a number of listeners who are asking about problems with But I’d say if we’re able to do it, 95 percent of the time we would scarring or stretch marks on the stomach and whether that do it immediately. tissue can be used to do a successful breast reconstruction, [or] whether tissue should be taken from another area of the body JANINE E. GUGLIELMINO, MA because of stretch marks or scarring in the stomach. OK. Thank you, Dr. Horton. KAREN M. HORTON, MD, MSc, FACS, FRCSC Diego, can we take the next phone call please? OK, great. Great question. So, first of all, scars are basically a window to what surgery may have happened underneath. While we’re waiting for Diego, I’ll give another one of the online If you’ve had a C-section, no problem. If you’ve had a questions. We have a couple of questions that are similar. One hysterectomy and it’s just a short scar above the pubic area, of our listeners is saying that she’s 70 years old and she had a no problem. If your abdomen has been opened up for, say, large number of lymph nodes removed along with one breast emergency laparotomy or exploration, then we have to think, 15 years ago. And she’s concerned about getting lymphedema “Oh, maybe the surgeon has injured some of the other blood after surgery. She’s also asking whether she’s too old for breast vessels in the area.” We could do some imaging, something like reconstruction. a CT scan or an MRI sometimes to look at the blood vessels. But

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it really is a judgment call and only in women — for instance, index, BMI, is over 40. She is very obese. Unfortunately, she one of the pictures I showed [was] of a lady who had basically was not offered reconstruction at her other setting. She found train tracks all over her abdomen. We decided not to use me online. And when she came to see me, she said, “Can you [tissue from that area]. But usually having little scars, any type do DIEP flaps?” I said, “Yes, we can, but you have a higher risk of laparoscopy, little incisions, it makes no difference. Again, of complications of healing at the abdominal donor site.” So you would have to see a surgeon who has a lot of experience yes, of course we can do a flap. I usually don’t make patients operating on scarred abdomens. But it doesn’t take it away as lose weight, but I want them to be fit and healthy. This woman an option. power walks. She’s been through Weight Watchers and for some reason that’s the weight at which her body is staying, even The other question — can you tell me what it was again? though she’s fit and she’s healthy and she’s active. Fine. That’s the baseline. JANINE E. GUGLIELMINO, MA So, the other question was about stretch marks. What I do counsel patients is that the more fat you have in the belly — it’s a thicker layer of fat that has blood vessels that KAREN M. HORTON, MD, MSc, FACS, FRCSC have to travel a longer distance to make it up to the skin. And in Oh, the stretch marks. Thank you. women who are morbidly obese — I think that’s a BMI of greater than … 35 — they have about a 50 percent chance of wound- So, a stretch mark is only in the dermis. So you have two layers healing problems down at the abdomen. That means that in of skin. You have your epidermis, which is the skin you can see, about a month or so the incisions might open up. They might and you have the dermis, which is the thick layer underneath. have some areas of fat that liquefies and we might have to pack A stretch mark happens from rapid expansion of skin, usually the incision and get it to heal in on its own. That can take several from pregnancy or sometimes from weight gain. And it’s a little weeks. But there’s no problem with doing the reconstruction, tear in the dermis that gets filled in with scar. It has nothing to and usually their breasts look fabulous. The only potential do with the tissue underneath. So if you have stretch marks problem could be at the donor site. and you don’t want them anymore, I say, “Sure. Let’s use that tissue.” If you are going to have part of your flap which is And as long as they know all that going in and they say, “OK. showing on the outside, say you’ve had a mastectomy already Well, I’m willing to undergo that risk and if I do have some and you don’t have a lot of skin, it’s possible that some of the delayed healing and need to pack my wounds, it’ll eventually stretch marks might end up showing at the bottom part of the heal,” and if they’re OK with it, then it’s fine to proceed. But we breast. But at least you won’t have them on your abdomen did two flaps. One was 1,300 grams, the other one was 1,200 anymore. But it certainly will not take away a flap as an option. grams, and we had an extra, I think, 1,800 grams of tissue that And if you have lots of stretch marks, you probably have lots of we threw away. At 2.2 pounds per kilogram, we were operating good fat to use, so we should use it. on at least 10 to 12 pounds of tissue yesterday. So there’s really no limit, but they have to be healthy enough to undergo surgery. JANINE E. GUGLIELMINO, MA Thanks so much, Dr. Horton. Actually, that’s a good segue JANINE E. GUGLIELMINO, MA to the next question online. One person is asking: Are there OK. Thank you, Dr. Horton. instances where the abdomen is too large to perform a TRAM or a DIEP procedure? Diego, can we take the next phone call please?

KAREN M. HORTON, MD, MSc, FACS, FRCSC OPERATOR Great question. And this brings me to the patient I did yesterday. Yes. Our next question comes from Reidsville, North Carolina. I did a very nice young woman, BRCA [mutation]-positive. Please state your question. She’d already had her mastectomy 2 years ago. Her body mass

LIVING BEYOND BREAST CANCER LBBC.ORG 12 Breast Reconstruction Series, Part 2: Using Your Own Tissue to Rebuild Your Breast

WOMAN prophylactic mastectomy or any type of mastectomy, OK. Thank you so much, Dr. Horton. I’m 70 years old. I’ve had lumpectomy — you’re covered for life. Not all plastic surgeons a partial mastectomy and I went to see a plastic surgeon. want to take insurance. Not all plastic surgeons want to do And he told me that Medicare would not cover — you know, revisions. But, you know, there are some of us out there. And Medicare with my regular AARP insurance — would not cover I tell patients, “Of course. I’m happy to do a touch-up or a [reconstruction] because it was considered cosmetic. You have revision for insurance.” It’s the law. said that it’s covered by insurance by law. Is there a difference between Medicare and regular young people’s insurance? The other question about insurance coverage: Every state is different. It’s really annoying. There are all different plans, and KAREN M. HORTON, MD, MSc, FACS, FRCSC some of the plans cover some things. Some plans don’t cover To my knowledge there is not. And I would go to your insurance others. And not all plastic surgeons take all the insurance plans. company. They usually have a patient advocate. It was actually Let me tell you that as a plastic surgeon who also does cosmetic thanks to California’s governor, Arnold Schwarzenegger — back surgery — about half my practice is breast reconstruction and in 1996, he made a law that spread to the rest of the country, half is cosmetic surgery — I don’t count on the reconstructive [called the Women’s Health and Cancer Rights Act.] … It’s a surgery to bring in any good money. It really does not pay well. document. And I’ve never heard that before [about Medicare So most plastic surgeons who do reconstruction, they do it not covering breast reconstruction]. My only guess is that that because they like it and they think it’s important. But not all surgeon may have been incorrect or maybe they don’t want to plastic surgeons want to do it because the reimbursements are do it for Medicare. terrible and they’re going down all the time. So that’s a reason why many plastic surgeons either go out of network or they WOMAN decide to just be cash only. There are good options of surgeons Yeah, OK. That’s probably — in network. You just have to do some homework.

KAREN M. HORTON, MD, MSc, FACS, FRCSC JANINE E. GUGLIELMINO, MA I’m somebody who will. Thanks, Dr. Horton. Let’s go to our last question, which is a phone question. Diego? WOMAN OK. Well, I’ll have to visit California. OPERATOR This question comes from Chandler, Arizona. Please state your KAREN M. HORTON, MD, MSc, FACS, FRCSC question. You’re welcome to fly out here. I know some great surgeons in South Carolina that I could refer you to if you email me. WOMAN Hello? JANINE E. GUGLIELMINO, MA Thank you for your question. And thank you, Dr. Horton. We JANINE E. GUGLIELMINO, MA actually have quite a few questions from individuals online who Hi [caller]. You’re live. are asking about difficulties with insurance paying. And I’m going to ask one more of [those questions] as a follow-up. For WOMAN people who are not happy with their original reconstruction, if Hi. Thank you. Wow. Dr. Horton, I have a question. I had my DIEP they wanted to go back and have more surgery, do you know if flap surgery on Feb. 9. And I was in and out of the operating room that is covered by insurance? three times. I almost lost my right breast. I had a bilateral. I had had extenders in for over a year. So, my concern is that the scars KAREN M. HORTON, MD, MSc, FACS, FRCSC are very terrible. The right breast still oozes out. I’m still losing Oh yeah. You’re covered for life. Once you have had either blood and fluid in that right breast. Does it seem like I might have the C-word, or if you’ve ever had a procedure, for instance, to have more surgery before I can even have my areola repaired?

LIVING BEYOND BREAST CANCER LBBC.ORG 13 Breast Reconstruction Series, Part 2: Using Your Own Tissue to Rebuild Your Breast

KAREN M. HORTON, MD, MSc, FACS, FRCS joined us late, there will be a recording of this session that you So, when you’ve had some return trips to the operating room can access at LBBC.ORG. So we hope you’ll visit us there. and you’re still healing — early February? We’re not even at the end of February — I say give it time. Give it at least a year for So, in closing, on behalf of Living Beyond Breast Cancer, I really everything to heal. What you see right now, they’re wounds. want to thank Dr. Horton for giving up her time and expertise They’re not even considered scars. It takes at least 3 months for today. Again, I also would like to thank Mentor and The Plastic the body to make a scar. And then it takes at least a full year for Surgery Foundation for the financial support that made this the scars to be mature. webinar possible. …

So are you going to need to have more surgery? We can’t tell. And finally, for peer emotional support at any time, we But I would just put it on the shelf, try to get through your encourage you to call our Breast Cancer Helpline at (888) 753- recovery. Eventually get back to your life and all your regular 5222 to speak with a volunteer. Our volunteers are available activities. And just say, you know what? From the time that all from 9 a.m. to 9 p.m., Monday through Friday to answer your your wounds are healed or your last surgery, whenever that call live. was, give it a year. And then reassess, because even if things look really gory and scary right now, usually they end up looking So thanks again to everyone and have a great day. a lot better. And if you do need any minor touch-ups, they usually are pretty minor outpatient procedures and the recovery [END OF TRANSCRIPT] is pretty easy.

WOMAN Is it normal to already have that necrosis setting up?

KAREN M. HORTON, MD, MSc, FACS, FRCSC If you were going to develop fat necrosis, it probably wouldn’t be evident for several months anyway. So also give it time. And if you do develop fat necrosis, that could certainly be removed and you could have a revision as needed.

WOMAN OK. Thank you so much.

KAREN M. HORTON, MD, MSc, FACS, FRCSC You’re welcome.

JANINE E. GUGLIELMINO, MA Thanks so much for your question.

And with that, we’re going to have to close. I want to thank everyone for your wonderful questions. I’m sorry that we were unable to get to everyone’s questions. Dr. Horton may get back to some of you about your specific questions. And I did want to let all of you know that these slides are going to be available at LBBC.ORG after the presentation. A number of you had asked about that. You should be able to access it. And also, if you

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