Breast Reconstruction/Breast Cancer Blog

Breast Reconstruction with Fat Grafting/Transfer

2012-01-25T11:17:00.003-07:00

One of the newest techniques for breast reconstruction involve utilization of the exciting benefits of fat grafting. Much research has been put forth into plastic surgery for harvesting of fat and its potential as stem cells. Fat grafting and transfer has been utilized both for breast augmentation but also in breast reconstruction for contouring of the breast after implant-based and flap-based reconstruction with excellent results.

After a lumpectomy or mastectomy, an innovative technique which has been implemented is performing this fat grafting and transfer technique to completely reconstruct a breast. This would involve no other scars or incisions, no foreign bodies or implants, and no complex flap procedures. Plus, additional benefits to the breast reconstruction include as close to normal sensation of the breasts along with the benefit of liposuction to harvest the fat from wherever there is spare fat!

Working with your breast surgeon during the oncologic procedure for your breast, some fat is harvested during the same surgery, which in turn is placed back into the breast area. This will give a small breast mound immediately after the procedure. An external expander device is then used for several weeks after the initial procedure while you are sleeping. The expander will have the same befits as the internal tissue expander, owever it is simply worn on the outside as a vest, without having an implanted prosthetic. t has been shown to increase vascualrity, increase blood supply (important for radiated breasts especially), as well as expand the breast framework for which the fat will be placed in the future.

Once adequate expansion has been obtained after several weeks of wearing the external expander vest, a simple outpatient procedure will be performed in which liposuction will be performed from areas where you have excess fat. Instead of wasting this fat, it will be harvested, washed, and then transferred back directly into the breast to give the additional volume to reconstruct the breast. The liposuction may be performed from the abdomen, flanks, hips, thighs, buttocks, etc., until enough fat has been obtained to give adequate volume for your reconstructed breast. Multiple micro-fat grafts will then be placed throughout the expanded breast framework within its well-vascularized bed. Sometimes this will take a few small outpatient procedures, separated by several weeks, to obtain the results. Fat grafting allows precise placement of where the fat should go in order to perfectly contour the breast shape.

The newly-reconstructed breast mound has now been recreated with the use of only your own fat via liposuction with the hopes for a breast mound that looks and feels much like a "normal" breast. The results thus far have been superb and patients have raved about their overall results.

Happy New Year!

2012-01-04T17:20:00.003-07:00

Happy New Year to all!

I hope that much of the information has been helpful to you.

Please continue to follow as I look forward to continually adding information on the subject this coming 2012 and into the future!

To a healthy & happy 2012!!!

Analysis of Sensibility in the DIEP breast reconstruction

2011-10-17T09:54:00.002-07:00

The DIEP flap has been considered by many authors as "the definitive standard in breast reconstruction" due to its "achievable shape and consistency, permanence of static and dynamic symmetry, and aesthetic and functional gain in the donor site". One question regarding this most-innovative type of breast reconstruction such as the DIEP and other free tissue transfer breast reconstructions is the amount of sensation that is restored postoperatively.

Although I, as well as several of the few other surgeons who perform such microsurgical flaps, spare the nerves, there have been no publications to specifically look at the sensibility in breast reconstruction with the non-reinnervated DIEP flap. A recent study followed 30 consecutive women following DIEP flaps and studied the sensation. They found that "for immediate breast reconstruction undergoes satisfactory progressive spontaneous sensitive recovery at 6 and 12 months after surgery" This may significantly save intraoperative time for this already complex procedure and hopefully improve the overall postoperative wellness of the patient with a shorter anesthetic time. Overall, the DIEP flap has become a bright spot in breast reconstruction!

October

2011-09-16T20:38:00.000-07:00

October is National Breast Cancer Awareness month!

Nipple-Areolar Complex Reconstruction

2011-08-16T15:20:00.004-07:00

The final stage of the breast reconstruction is the reconstruction of the nipple-areolar complex (NAC). Usually, this is performed after the nipple reconstruction, however, it may be done without it as well. While some women opt not to have anything further done after the breast reconstruction, as discussed in the last post, these relatively benign procedures are simple and easy to perform, and "complete" the breast reconstruction.

I usually perform a nipple reconstruction first if one decides to proceed with the NAC. If one foregoes the actual nipple reconstruction and only have a NAC recreated, options for such are skin grafts and tattoos. The same techniques are used if a nipple reconstruction is performed as well.

Skin grafts are usually taken from the medial thigh or groin area as the skin is typically darker in color and the donor site is hidden. The skin graft recreates a great appearance to the areola. This procedure is tolerated very well and may be done via local anesthesia or general/sedation. Little recuperation time is required afterwards.

The other popular technique is areolar repigmentation. This is done via tattoo under no or local anesthesia. Often times the NAC area is still insensate from the previous surgery, and the tattoo needle is tolerated very well. As with a tattoo, pigmentation (instead of ink), is injected into the superficial dermis to repigment the area. This, as well, gives a great appearance to the areola. This is my preferred method. I perform this with only topical anesthetic in the office as a short procedure. It also avoids another "surgical procedure".

Both techniques are very simple to perform, benign procedures with little down-time and few complications, and give excellent appearance to a reconstructed NAC.

Nipple Reconstruction

2011-08-01T15:47:00.002-07:00

Many people have asked about what happens with the nipple and areola after the reconstruction. I do have a post on nipple-sparing mastectomy. However, if the nipple-areolar complex (NAC) is removed during the mastectomy, there are several different procedures to reconstruct the NAC to complete the breast reconstruction. I usually wait approximately 6-12 weeks after the implants are placed in order to allow the swelling to subside as well as to allow the implants to settle into their formed pockets.

There are several techniques to reconstruct a nipple. All are very effective, and basically comes down to surgeon preference. The main goal of the nipple reconstruction is to provide the appearance of a nipple as well as give the projection of the nipple. It is a very simple procedure, which usually is performed under local anesthesia alone, often times in the office in less than an hour. Downtime is minimal and local care to the incisions is all that is needed. The biggest problem with nipple reconstruction is loss of projection, usually quoted as about a 30-6-% shrinkage from immediate postoperative appearance. Various things surgeons have tried are to add a filler (e.g., fat, dermis, cartilage, or other material), in order to support the nipple and decrease the amount of postoperative shrinkage. Overall, is is a very safe and easy procedure; most women in my practice opt to undergo NAC reconstruction, as it truly "finishes" the breast reconstruction.

After these incisions are completely healed, there are various techniques to reconstruct the areola, including tattoos and skin grafts. This will be discussed next.

Wellness Center

2011-06-29T10:35:00.002-07:00

Come listen to the presentation on advances in breast cancer and screening/diagnostic technology by the Wellness Center Thursday 6/30 - Phoenix, A. Breast mammographers, breast surgeons, and myself will be there to disucss.

Operation Smile

2011-05-09T08:36:00.002-07:00

Sorry for the absence...

Medical mission in Zhengzhou, China. Looking to screen ~200 children with cleft lips and/or palates and operate on ~170.

Operation Smile

www.operationsmile.org

Back soon :)

Nipple-Sparing Mastectomy and Reconstruction

2011-01-31T16:44:00.004-07:00

Nipple-sparing mastectomy has been a controversial topic in breast cancer and its treatment. Not all women are candidates for this procedure for treatment, and it is necessary to discuss with your general/breast surgeon on your candidacy. In general, women who may fall into this category include those women who do not have cancer at the present time (genetically positive), and low-risk for recurrence of the cancer within the ductal elements (those that lead to the nipple). So, those very early/small tumors that are remote from the central area and do not have a significant ductal component may be candidates. Having said that, it is important to discuss with your general/breast surgeon regarding the oncologic aspect of sparing the nipple, as well as the risks and complications involved with this procedure.

On a reconstructive standpoint, nipple-sparing mastectomies could give an excellent aesthetic appearance, as the natural nipple-areolar complex remains intact, and often times, the incisions are in a remote location from the central area of the breast. Again, it will be important to coordinate the planning with your surgeon and plastic surgeon for optimal treatment, planning, and results. Both immediate implant-based and flap-based procedures have been performed with excellent results. Filling in the volume that is lost during the mastectomy with either an implant or tissue from your own body can produce a superb reconstruction.

Such a procedure is not without its risks, including a significant rate of necrosis of the spared nipple, due to inadequate blood supply to the area. Especially if an implant lies beneath the area, an open wound could potentially seed an infection to the prosthetic device, warranting antibiotic therapy or potential further procedures and/or removal of the threatened implant. Flap-based procedures give the advantage of bringing in a robust blood supply from a remote area that increases the vascularity to the mastectomy flaps. The normal sensation and erectile function of the nipple will be lost, as a nature of the mastectomy. In addition, for women with significant ptosis (sag) of the breast needing repositioning of the nipple-areolar complex to a more appropriate position, a staged procedure may be appropriate to first reposition and then reconstruct the breast, or vice versa. A recent article in the Plastic Surgery Journal reports good results with banking of the complex for use at a later date.

For those who can perform such procedures, the microsurgical flaps (e.g., DIEP, SIEA, TUG, ALT, SGAP, etc) are great ways to reconstruct the breast after a nipple-sparing mastectomy. I have had phenomenal results with these as it recreates the breast with like-tissue as well as having excellent vascularity, thus recreating the most realistic, natural-appearing and feeling reconstructed breast with a real nipple-areolar complex.

DIEP or SIEA Flap Candidate?

2011-01-07T14:49:00.003-07:00

Many women have asked if they are good candidates to undergo such a complex procedure as the DIEP flap for breast reconstruction. Many have been denied by other surgeons for various reasons. I have been asked if I would share some thoughts on who would be the ideal candidate for this type of microsurgical breast reconstruction.

In a nutshell, every woman is a candidate for breast reconstruction. Specifically, there are several types of microsurgical, muscle-sparing, perforator flaps that may be used to obtain an aesthetically pleasing breast reconstruction. Not only is there the DIEP flap and the SIEA flap (which are flaps obtained from tissue from the lower abdomen), but there are also the SGAP/IGAP flap (gluteal tissue), TAP flap (back tissue), ALT flap (lateral thigh tissue), TUG flap (groin tissue), and other donor sites that are continually being found. Certainly these microsurgical, muscle-sparing, perforator flaps are highly complex procedures that usually requires specialized training due to their complexity, and, since they have recently gained in popularity and prowess for their minimal donor site morbidity, decreased complication rate, muscle-sparing nature, robust blood supply, and aesthetic results, very few surgeons have the training and skill to perform such procedures. Many surgeons may not offer, let alone discuss, such types of reconstructive options, which are certainly at the forefront of breast reconstruction today. Certainly there are some risks and potential complications that may occur with such a complex procedure, which should be discussed with your plastic surgeon, but with the advent of these procedures, they should be included in any discussion about breast reconstruction.

You do not have to be overweight to be a candidate for the DIEP flap. This procedure has been successfully performed in women of all Body Mass Indices (BMI's). Gaining weight will not increase the success rate or the result obtained. In fact, sometimes it makes it more difficult. What is known is that the overall risk for surgical complications increases with BMI >35 and significantly increases with BMI >40.

Medical comorbidities, such as heart and lung problems are also a major concern. Your primary physician should medically clear you for the surgical procedure prior to undergoing such a lengthy procedure to maximize your health prior to, and after your surgical procedure. Diabetes also increases the risk of small-vessel disease, wound healing complications, and infection. Great success has been obtained in diabetics after achieving stable glucose control with minimal increased complication rates. Smoking also does the same and cessation should be done at least 6 weeks prior to any surgical procedure. Your overall health will be considered by your plastic surgeon.

Previous abdominal surgery has not significantly increased failure rate, with few exceptions. Women who have previously had an abdominoplasty (tummy-tuck) are not candidates for this procedure. The perforating vessel which would have been used to sustain the flap, have unfortunately been cut already, making this flap unusable. The same holds true for those who have previously had a DIEP/SIEA or TRAM flap procedure in the past. I co-authored a paper while at the Mayo Clinic which looked at success rates of the DIEP flap after laparoscopic gynecologic procedures. There were no increased failure or complication rates to those who did not have ay such procedure performed in the past. Hernias, unless massively large with multiple complex abdominal repairs and/or abdominal wall reconstructions, also have not been shown to preclude one from a DIEP flap. Previous appendectomy, hysterectomy, c-section also are still viable candidates. Another paper through the Mayo Clinic, we looked at obtaining CT angiograms prior to the DIEP flap for evaluation of the vasculature as well as surgical planning. This will certainly help if there is any question regarding viability of the flap for use. We utilize this imaging routinely.

Previous chest irradiation also has not hampered the success rate of any microsurgical breast reconstruction. In fact, it has ameliorated it. Bringing in such a robust blood supply from this microsurgical flap helps the irradiated tissue of the chest. Also, we have not seen any increased damage to the vessels that we utilize in the chest to perform the microsurgery. Several papers have shown this to be true. As discussed before, a flap procedure is the wisest thing to do if previous radiation therapy was done.

Overall, the DIEP/SIEA flap is a great option for breast reconstruction. All women are candidates for breast reconstruction and a thorough conversation with your plastic surgeon should be done to determine WHICH procedure would be the best for YOU...which should include a discussion about microsurgical flap procedures. This should answer many of the questions about candidacy for the DIEP flap or SIEA flap. Even if you may not be a candidate for abdominal tissue procedures, there are other flaps which may be considered as discussed above.

Women have sought the DIEP flap from all over the Phoenix, Scottsdale, Tucson area and Southwest have had great results with our DIEP flap. We have had women travel from throughout the United States to have the DIEP flap, SIEA flap, SGAP flap, and other microsurgical reconstructive procedures.

Additional information

2011-01-07T14:45:00.002-07:00

Happy New Year! Wishes for a happy, healthy, and joyous 2011!!!

Lumpectomy (aka: tylectomy) is a common surgical procedure designed to remove a discrete lump, usually a benign tumor or breast cancer, from an affected man or woman's breast. As the tissue removed is generally quite limited and the procedure relatively non-invasive, compared to a mastectomy, a lumpectomy is considered a viable means of "breast conservation" or "breast preservation" surgery with all the attendant physical and emotional advantages of such an approach.

If you are reading this, you’ve probably already started to consider having breast augmentation or reconstruction surgery. Maybe you are dissatisfied with the size of your breasts, or perhaps one breast is sized differently than the other. Sometimes there is a reduction in breast size after pregnancy to be corrected, or you may need a breast reconstruction after a mastectomy.

Additional information regarding breast reconstruction and augmentation can be viewed on the website and on previous posts. Thank you for visiting!

Preference of Silicone Over Saline Implants Following Mastectomy

2010-11-30T15:09:00.002-07:00

A recent published study in the Journal Cancer reports that women who received silicone implants after her mastectomy were generally happier with her results than women who chose saline implants. This is one of few studies who report on patient preference following reconstructive surgery.

This study looked at 472 women who had breast reconstruction following mastectomy - 176 women stated that they were more pleased with the look and feel of her silicone implants. They also reported that they felt more natural to the touch and preferred the look both in and out of clothing.

Insurance reimbursement is equal for either silicone or saline implants and their is no financial incentive benefit either way.

October

2010-10-05T14:52:00.000-07:00

October - Breast Cancer Awareness Month

Breast Cancer/Reconstruction - New Law Passed!

2010-08-25T09:59:00.002-07:00

A tremendous step forward in breast cancer/breast reconstruction! A recent law was passed in New York state, which requires that women be informed of breast reconstruction options and the Women's Health and Cancer Rights Act (WHCRA) of 1998 prior to her breast cancer surgery.

Even today, only a minority of women are actually informed of breast reconstruction by her surgeon. Although the fight against breast cancer continues, women are still rarely offered a discussion on this topic.

A previous post outlining this topic as well as the WHCRA act was in an earlier post.

The full attached article from the New York Times:

http://www.nytimes.com/2010/08/19/nyregion/19surgery.html?_r=1

Aesthetic outcomes following lumpectomy

2010-07-05T15:28:00.003-07:00

The diagnosis of breast cancer certainly is a traumatic experience, and the management of the disease is just as daunting a decision that must be made, often expeditiously. A lumpectomy, usually followed by radiation therapy, is a treatment modality that has been shown to be safe and effective. Your general surgeon will speak to you about the risks and benefits of this type of treatment for your breast cancer. Women who choose to save their breast by a lumpectomy, with the thought of avoiding any additional reconstructive surgery in the future.

The aesthetic outcome following lumpectomy has been researched heavily. Several reports show that approximately 1/3 of all patients who underwent breast-conserving therapy ) for their cancer are unhappy with their aesthetic result. 28% of these breast cancer patients were dissatisfied with their overall result. Of those polled, 46% felt that their physical appearance was worse, or much worse, following lumpectomy, and were now considering reconstructive surgery. Only 9% of these patients were ultimately satisfied with their outcome, however, would consider reconstruction if it were offered. “I have patients walking into my office saying lumpectomy was supposed to save their breast but what’s left doesn’t look like a breast to them,” said Howard Wang, ASPS Member Surgeon and co-author of the study. “Conservation is believed to be an acceptable way of saving a woman’s breast. But many of these women are coming to plastic surgeons for help, saying it isn’t so.”

An interesting finding was that 26% of these patients were unhappy with their physical appearance after their BCT, but had an improved sense of body image. One thought is that patients are ultimately relieved of treating her cancer above anything else. The oncologic management should precede anything else in importance. There are manners in which to reconstruct partial breast defects following lumpectomy, but especially the radiation changes, which cause much of the breast distortion following lumpectomy. Earlier posts comment on radiation effects to the breast - such treatment often prohibits certain implant-based reconstruction in the future. Overall, many oncoplastic resections may be employed during the lumpectomy, which not only treats the cancer, but brings forth the best aesthetic outcomes following BCT. Otherwise, your plastic surgeons may discuss several treatment options for partial breast defects, which have been shown to obtain excellent results.

Broccoli derivative limits breast cancer growth

2010-05-25T08:32:00.003-07:00

A derivative from the vegetable broccoli has been linked to treatment and the halt of spread of breast cancer stem cells. A recent study from the University of Michigan has associated the component of broccoli, sulforaphane, in preventing the spread of cancer cells and destroying these cells. This has been injected into animal studies with very promising results.

"Sulforaphane has been studied previously for its effects on cancer, but this study shows that its benefit is in inhibiting the breast cancer stem cells. This new insight suggests the potential of sulforaphane or broccoli extract to prevent or treat cancer by targeting the critical cancer stem cells," says study author Duxin Sun, Ph.D., associate professor of pharmaceutical sciences at the U-M College of Pharmacy and a researcher with the U-M Comprehensive Cancer Center.

Thus far, although preliminary results are favorable, it has not been tested in human studies. At this time, there is no recommendation in increasing the amount of broccoli in one's diet. But current research continues.

DIEP flap

2010-05-12T15:29:00.004-07:00

With the advent of microsurgical perforator flaps, this form of reconstruction has revolutionized plastic surgery. Along with them, the application in breast reconstruction has been tremendous. By the replacement of the skin and soft tissue that is removed during the mastectomy with viable, well-vascularized, excess skin and soft tissue from the lower abdomen, a beautiful breast reconstruction may be achieved that is completely your own tissue. This DIEP has gained much notoriety for breast reconstruction today.

The tissue is taken from the lower abdomen, much like that removed during a tummy tuck. Utilizing the excess tissue from this area and hiding the incision low on the abdomen, well-hidden within the panty line, the donor site is an excellent option for borrowing tissue for a breast reconstruction. This skin, fat, and soft tissue, along with its blood supply is taken and moved into the breast area. These small blood vessels are then reattached via assistance of a microscope to vessels in the breast area. This tissue is then shaped and molded to reconstruct an aesthetically pleasing breast reconstruction.

With this new advent of perforator flap techniques, it is the most innovative and state-of-the-art technique used today in breast reconstruction, let alone plastic surgery as a whole. Unlike the traditional way of reconstructing a breast utilizing this tissue (aka TRAM flap), the DIEP spares the muscle of the abdominal wall, by carefully dissecting the blood vessel from within the abdominal musculature and leaving the muscle in place. This muscle-sparing, perforator flap type of reconstruction is beneficial for these reasons. There is less donor site morbidity from the abdomen, since the muscle is left intact. Along with that, there is less postoperative pain. The function of the muscle remains, so abdominal wall integrity remains intact and there is less chance of hernias or bulges, since the muscle remains. These problems are much increased with the conventional TRAM flap, but unlike it, the aforementioned benefits are obtained with the DIEP microsurgical free tissue transfer breast reconstruction.

Unlike conventional TRAM flap reconstructions, use of our refined perforator flap techniques allow for collection of this tissue without sacrifice of underlying abdominal muscles. This tissue is then surgically transformed into a new breast mound. The abdomen is the most common donor site, since excess fat and skin are usually found in this area. In addition to reconstructing the breast the contour of the abdomen is often improved much like a tummy tuck. This well-vascularized flap reconstruction also is also completely your own tissue, and often resembles, moves, looks, and feels more like a natural breast than reconstructions using implants. Other perforator flaps used for breast reconstruction include the SIEA (Superficial Inferior Epigastric Artery), SGAP (Superficial Gluteal Artery Perforator), IGAP (Inferior Gluteal Artery Perforator), and TAP (Thoracodorsal Artery Perforator) flaps, among others.

If you're interested in an advanced reconstructive procedure as such, very few surgeons have been trained to perform these and even fewer offer these procedures due to its complexity and skill involved. It may be difficult to find an experienced surgeon to perform this type of surgery with many patients, unfortunately, having to travel away to obtain such reconstruction. A few helpful resources to find an experienced DIEP microsurgeon are to search websites or listed below is a database of listed surgeons:

www.breastrecon.com

www.diepbreastreconstruction.com

www.diepsisters.com

Quick Breast Reconstruction Info

2010-04-01T15:56:00.002-07:00

For a quick informative of breast reconstruction info/options - visit either our website or The Center for Reconstructive & Plastic Surgery:

http://aaaplasticsurgery.com/

http://www.jcl.com/content/plasticsurgery/default.htm

"After Cancer, Removing a Healthy Breast"

2010-03-17T16:10:00.004-07:00

I read a recent article in the New York Times which I found very interesting, and wanted to share with everybody. In the above article from 3/8/10 by Tara Parker-Pope, she discusses the growing number of women opting for mastectomy on the opposite (presumably unaffected) breast, when cancer is diagnosed in one breast.

The number of women choosing this option has nearly doubled in the past few years alone. Overall in 2006, ~6% of women choose to have this done along with the affected breast, and continuing to grow. Among younger women (less than 40 years of age), statistics show that 1:10 women choose this option in a recent study out of the University of Minnesota. This option is chosen even moreso in women who have the in situ type, as shown in a recent publication in the Journal of Clinical Oncology. It rose dramatically from 2.1% of women in 1998 to 5.2% of women in 2005 alone.

Clearly, women with a genetic risk for breast CA lower her chance of ultimately developing a cancer with this preventative measure. However, studies have shown that performing a mastectomy on an "unaffected" breast does not improve the odds of survival. Several studies have reported this recently. There was a small survival benefit in a certain subgroup of women: less than 50 years of age, early-stage, estrogen-receptor (-) tumors without response to Tamoxifen.

The highest risk to women is not from a future cancer, but from the potential spread of that cancer that is already present. So, removing the opposite breast would not have any effect on changing these odds. Women are certainly opting for the above procedure not because of the statistics, but, for the psychological benefit of not wanting to re-experience the trauma of mammogram/biopsy/diagnosis/etc. The fear has been averted (theoretically) by bilateral mastectomy. This is a reasonable option for every woman, and one which should be discussed with the woman so that she can make an informed decision. Most importantly, it is the individual woman's choice.

Risk Reduction of Breast Cancer with Aspirin

2010-02-18T16:59:00.004-07:00

A recent publication in the Journal of the American Medical Association (JAMA) noted a reduction in the risk of breast cancer in those women who used aspirin - Volume 291(20);2433-89:2010. While not the first to suggest that aspirin can help prevent breast cancer, notably, it is the first to show a significant difference that aspiring protects against certain hormonally-sensitive tumors (hormone-receptor positive breast cancers).

The investigators suspect that aspirin decreases the production of aromatase, which suppresses the production of estrogen, a hormone noted to fuel the growth of breast cancers. Many of the drugs today target decreasing the production of estrogen, and consequently inhibit aromatase. This study looked at about 3000 women on Long Island, NY, half of which with breast CA. They inquired about their use of aspirin, ibuprofen, and acetaminophen as well as risk factors such as hormone use, menopausal status, reproductive history, and family history of breast cancer.

Results showed those that used aspirin had nearly a 30% reduction in their breast cancer risk. Notably, aspiring specifically affected their risk for estrogen and progesterone positive tumors. These cancers have a better prognosis since they respond to hormonal treatments postoperatively. Ibuprofen had a minimal risk reduction and there was no appreciable reduction seen with acetaminophen. The true effect may not be noticed, since there were fewer people who took these latter drugs.

Although early to say definitively, these results show promising results.

Post-Mastectomy Radiation Therapy...and Breast Reconstruction

2010-01-31T21:19:00.009-07:00

Radiation therapy (RT) is a proven and well-accepted modality in treatment (or adjunct treatment) for breast cancer. It is almost always used following lumpectomy, as it significantly reduces the local recurrence rate.

Even following mastectomy, although a definitive procedure for the cancer, may be recommended RT following the mastectomy due to various pathologic findings. Classic indications are:

Certain (aggressive) types of tumors

Tumors 5cm or greater

4 or more positive lymph nodes

Positive (inadequate) margins on specimen

Others, and newer indications, are:

for tumors less than 5cm and 1-3 nodes (+) - include any 3 of the 4: 1-3 nodes (+), LVI, ER (-) tumors, or premenopusal or less than 40 years of age

for tumors less than 5cm and node (-) - include any 3 of the 4: margin less than 2mm, less than 40 years of age

Although a beneficial adjunct for breast cancer in several circumstances, it has also detriments to both the patient as well as plastic surgeon. Above all, treatment for cancer comes before the aesthetics of breast reconstruction, and the proven benefit outweighs the ill-effects of RT. The impact that RT has on the skin, as evidenced by the radiation dermatitis/radiation burn, angiofibrosis, contrcture/fibrosis of the skin, and soft tissue, as well as the healing/infection issues are not favorable.

From the plastic surgery standpoint, these effects are troublesome, especially when dealing with reconstruction. This should be discussed with your plastic surgeon, as it impacts the type of reconstruction you should have. Women undergoing lumpectomy are often told that most of their breast will be preserved and that radiation will be needed postoperatively. However, what is not conveyed, is that the above changes may occur and account for some of the breast asymmetry or contractures. Although a "breast conserving" therapy is performed, many women end up seeking a plastic surgeon to assist with these issues, which often times, include the same procedures as if a mastectomy was performed anyhow.

Implant-based reconstruction is not a recommended reconstructive procedure, as already noted in previous posts. The complication rates are markedly increased with often times, poor aesthetic results, let a lone the wound healing, infection, contracture/asymmetry rates, among others. This type of reconstruction usually fairs poorly following RT. There are several studies showing good results following implant-based reconstruction, however. Many times, RT is not known until final pathology returns several days later. If by chance a tissue expander reconstruction was chosen, and RT is later found to be needed for an indication above, I would opt to keep them in, quickly inflate to maximal expansion, then deflate for the RT. Immediately afterwards, quick expansion would be done (e.g., M.D. Anderson protocol). However, exchange for a flap-based reconstruction is always an option if any complications come about during this process.

Radiation after flap-based procedures are significantly better following RT. After a flap procedure (e.g., latissismus, TRAM, or DIEP flap, recruiting well-vascularized tissue from a remote area negates some of the ill-effects that RT has done. There still is a chance for the reconstructed breast to shrink or contract if followed by radiation, but it resists the effects much better than implants. Usually, performing this in a delayed fashion would allow your plastic surgeon to excise all of the affected tissue, and use the flap to reconstruct the defect. This is my preference after, or for known RT. The flap-based reconstructions (e.g., latissimus, TRAM, or notably the DIEP), are excellent options as discussed in previous posts. You may consider delaying your reconstruction for a later date if you know you will be receiving RT postoperatively.

Silicone Implants

2010-01-13T16:49:00.005-07:00

Several queries regarding silicone implants have been asked recently in regards to breast reconstruction. Basically, silicone implants have always been able to be used for reconstructive purposes. They were taken off the market for a time period for aesthetic reasons, but re-approved in the last few years for this purpose.

The FDA approved Allergan Corp. and Mentor Corp.'s silicone breast implants and have since returned these devices to the U.S. market. 14 years after the FDA restricted access to the silicone implants, they have been placed back on the market after extensive studies for safety concerns. They were off the market for this reason from 1992 until November 2006.

The approval letter stipulated a number of conditions that the manufacturers needed to satisfy in order to receive FDA final approval to market and sell silicone breast implants in the United States. These letters came after an FDA advisory panel hearing in April 2005, in which the panel heard more than 20 hours of data presentations from the manufacturers and public comment.

Breast augmentation is now the most common aesthetic surgical procedure, according to ASAPS and ASPS statistics. About 380,000 and 58,000 women had breast augmentation and reconstruction, respectively, last year, according to ASPS. Both breast augmentation and reconstruction have been proven in numerous studies to have psychological and physical benefits for women who choose these procedures.

Silicone implants have been proven safe for reconstructive and augmentation purposes and the research behind these implants are excellent. Overall, excellent results are obtained from such implants with the health concerns already addressed and complications of such should be discussed with your plastic surgeon.

Implant-Based Breast Reconstruction and Recurrent Cancer

2009-12-09T15:56:00.005-07:00

Many women are fearful, for obvious reasons, that implants may contribute to cancer recurrence or may hinder detection of any recurrent cancer. Implant-based reconstruction is the most common type of breast reconstruction, even today. Recurrence of cancer is always a concern, and thus, studies were performed to evaluate if implants hindered or lengthened the time of diagnosis of recurrence.

The most notable study reviewed two groups of more than 300 women each - women with immediate breast reconstruction with implants and women without any reconstruction. These took into account patient age and stage of the disease. The recurrence rate of reconstructed patients = 6.8% and without reconstruction = 8.1%. There was no statistical difference in detection or recurrence between these groups. Nearly all (~95%) of all recurrences were detected by physical examination alone, with the rest being found via CT scan. Treatment was not affected by the implants. And, generally, did not require removal of the implant. Only 3 of the 21 women who had recurrence had her implant removed, with 2 of 3 requesting to have it removed.

Breast cancer continues to grow in number along with the reconstructive options available. With the growing knowledge of the reconstructive option, more and more women continue to opt for breast reconstruction. Only a few years ago, breast reconstruction was only conducted in approximately 10% of all women with breast cancer. This number has increased over the past few years alone, mostly due to the fact that women are more informed of this option. Overall, immediate breast reconstruction is still a safe procedure with numerous advantages...and as this study shows, has no impact on the identification of a recurrence or any association towards causing a cancer recurrence.

Recent Mammography Recommendations

2009-11-24T21:01:00.013-07:00

Recently, the United States Preventive Services Task Force (USPSTF) has recently released recommendations for screening mammography for women. Their recommendations state that such mammograms should be every other year beginning at age 50yo, instead of the current guidelines of beginning at age 40yo (35yo for high-risk women). Mammography has unquestionably saved many lives, especially in women younger than 50yo. At least 10-20% of all breast cancers are diagnosed in these younger women. Breast cancer in younger women is always a more aggressive tumor, and overall, usually a more deadly tumor, especially when not caught early. When detected early and in its earliest and most treatable stage, the recurrence and survival rate is MUCH lower. Women over 74yo are not given specific guidelines for mammography, as they state that their risk of dying from other medical conditions is far greater than that of breast cancer, despite the fact that breast cancer (1 in every 8 women will develop) clearly increases with age.

The current recommendations by the USPSTF are based on old research from 1992-2001. The medical technology, especially in diagnostics, imaging (including digital mammography and breast MRI, breast cancer research (billions of dollars over the past few years alone, and treatment modalities have made huge advances, which accounts for the massive decrease in mortality rate over these past 8 years from the USPTF quoted studies. Regular mammographic screening began in 1990 - the mortality rate of breast cancer, previously unchanged over the past half century prior, has significantly decreased by mre than 30% since its inception. Clinical breast exams are not recommended prior to mammography, as they state that a clinical exam adds no additional benefit from that given by a mammogram. Lastly, this task force has not made any specific recommendation for monthly self-breast exams. As known, many breast tumors are found by women during self breast exams, prompting earlier medical evaluation, or by an experienced physician who may catch many masses not found by the woman.

The USPSTF has blatantly refused to data and research (and arguably, common sense), when these recommendations were made. No physician of the specialties that should have been involved (breast surgery, radiology, or oncology), had any input on theses recommendations. In fact, the American College of Radiology (ACR) and other Boards still stick to the current guidelines of beginning yearly screening mammograms beginning at age 40yo. Their claims of the "hazzards" of mammograms are unwarranted: discomfort, anxiety from false positives and need for possible surgery/treatment, and radiation exposure. Undoubtedly, a life saved from early detection far outweighs any of these concerns. Discomfort and anxiety is overshadowed by catching a breast cancer in its earliest stage. The radiation exposure from a mammogram is minimal. In fact, the radiation given off from the earth itself is much greater. The money saved by not performing mammograms between ages 40-49 will most likely be the opposite effect - with the more aggressive treatments, surgery, and battling of late-stage breast cancer will cost much more in money, time, and lives lost. This potential money savings in health care does not make sense as evidenced by current research and data/statistics in breast cancer research. My fear is that women that can afford to pay out-of-pocket for mammograms at an earlier age will get them and those who don't have these means will ultimately suffer. Saving women's lives and detecting/treating breast cancer at its earliest stages should be of utmost importance. The ACR still supports monthly self-breast exams, yearly physician breast exams, and annual screening mammograms beginning at age 40yo (age 35yo in high-risk women) - these are the best modalities that we have today.

Acellular dermal matrix - breast reconstruction applications

2009-11-03T10:44:00.005-07:00

The use of the acellular dermal matrix has grown in its applications and use in plastic & reconstructive procedures, and growing. It has truly been a remarkable addition for breast reconstruction.

The acellular dermal matrix is a tissue that is specially-prepared, which comes from cadaveric skin. It has been processed in such a way that the basement membrane and cellular matrix remain intact, while removing all other cellular components that may lead to both rejection and infection. Packages as a sterile tissue product, due to its preparation, the chance of acquiring viruses and such is nearly absent.

Its applications for breast reconstruction alone include its use in tissue expander/implant reconstruction, to act as a "hammock" at the inferior portion of the breast for which the implant lies within. This creates a natural "sling" which mimics the ptosis (sag) of the breast, while supporting it in place. By suturing this matrix to its exact position of the breast margins, the plastic surgeon is able to precisely recreate an excellent contour for your breast, especially at the inferior, medial, and lateral positions. This also minimizes migration of the implant, as sometimes seen with "bottoming out" inferiorly or its displacement into the axilla (armpit). In addition to its increased aesthetic results, the acellular dermal matrix provides additional coverage over your implant. This is especially useful in those instances of dehiscence (your incision opening up), thus protecting the implant from exposure, and threatening its necessity for removal. Furthermore, in cases where the overlying mastectomy flaps are thin or damaged, leading to partial flap necrosis, the tissue matrix again provides a coverage over your implant, which can heal over time or a graft placed over the are or simply closed. Lastly, the additional coverage lessens implant visibility and palpability and is a great adjunct for revisionary breast surgery. The use of this matrix, along with the advantages listed above, has reduced the time of the reconstructive portion of the procedure as well. There is less pectoralis muscle retraction and eliminates the need to raise any other surrounding muscles in order to achieve complete implant coverage.

Additional benefits seen with the acellular dermal matrix are numerous. There has been a significantly decreased incidence (almost none) of capsular contracture around the implant at the area of the tissue matrix. Reasons are unknown as of yet, but contracture has been a huge problem in cases of implants used for reconstruction and augmentation. Also, there are tissue regeneration properties of the matrix in which rather than inciting a scarring response, the dermal matrix begins a regenerative process in which it acts as a biologic scaffold and unbelievably, vessels incorporate into matrix and the surrounding cells differentiate into surrounding tissue that it is incorporated into (an amazing concept).

Overall, the use of the acellular dermal matrix in breast reconstruction has been revolutionary. Its applications for tissue expander reconstruction, possibility to use in immediate implant reconstruction (going directly to implants rather than the use of a tissue expander first), revisionary breast surgery, capsular contracture complications, and nipple reconstruction have been great.

Perforator flaps/Microsurgery

2009-10-20T19:13:00.005-07:00

Flap reconstruction offers an autologous (your own tissue) reconstruction, and gives many of the benefits described in earlier posts, such as a soft and "natural" breast mound. Such flaps also are much better for those with a history of radiation, or those who will ultimately require postoperative radiation therapy following mastectomy. Autologous tissue flaps for breast reconstruction offer the best options for these purposes, until the possibility of reconstruction with stem cells becomes a reality. The conventional autologous flap reconstruction requires sacrificing a muscle to reconstruct the breast, either the latissimus dorsi or rectus abdominis muscle. Although popular and reliable procedures to accomplish the goal of breast reconstruction, some of the expected outcomes that coincide are increased pain and seroma formation, along with functional deficits, weakness, and increased rates of hernias/bulges in the areas where the muscle was taken.

Perforator flaps have come to the forefront of plastic & reconstructive surgery due to their decreased morbidity, decreased recuperation time, and increased aesthetic results. This is due in part since they are muscle-sparing procedures, which subsequently maintain muscle function and do not have any morbidity associated with sacrificing of muscles, such as those described previously. Since these types of flaps are technically challenging and more complex, microsurgical expertise is required and as such, very few plastic surgeons in the United States are skilled enough to perform these perforator flaps successfully. In addition to the elaborate dissection of these flaps, albeit tedious, the flap must be reanastomosed under a microscope to blood vessels in the nearby recipient site.

Although a poplar procedure elsewhere in the world, patients in the U.S. often must travel far to find a surgeon capable of performing these perforator flaps, such as the DIEP, SIEA, SGAP, TUG, or ALT flap (DIEP - abdominal skin/tissue only; SIEA - abdominal skin/tissue only; SGAP - buttock skin/tissue only; TUG - groin skin/tissue only; ALT - lateral thigh skin/tissue only). These flaps spare muscle and are arguably the best reconstructive options that we have today. To find a surgeon near you who perform such free tissue transfer breast reconstructions, see the links provided to the right.

Breast reconstruction does not delay treatment for your cancer, if necessary, such as chemotherapy or radiation therapy. Literature shows no increase in recurrence rate or survival rate nor any decreased ability to diagnose such cancers. n fact, the most recent literature has even shown a decreased recurrence rate with immediate breast reconstruction. With all of this in mind, as well as knowing the the superior aesthetic results that are associated with immediate breast reconstruction (reconstruction performed at the same time as your mastectomy), I recommend discussing all of your breast reconstruction options with a plastic surgeon who specializes in breast reconstruction before your mastectomy procedure...please refer to my earliest posts on breast reconstructive options and understanding all of your options.

Part IV: Flap-based reconstruction - DIEP flap

2009-10-12T14:18:00.005-07:00

DIEP flap

The use of microsurgery and perforator flaps, such as the DIEP flap, is the newest and state of the art technique for plastic & reconstructive surgery today, including breast reconstruction. Very few plastic surgeons perform this technique due to its complexity, time, and skill involved, but such reconstruction arguably provides the best aesthetic outcome with less morbidity, since only perforating vessels are utilized and muscle is not sacrificed for the flap reconstruction, for those women who are candidates for this unique procedure. However, it is a very popular technique elsewhere in the world and by those few surgeons who perform it in the United States. It is a procedure that has been refined through my fellowship training, and one in which women throughout the United States consult for to perform this innovative type of breast reconstruction, such as the DIEP flap.

Like the conventional TRAM flap procedure, the perforator flap DIEP breast reconstruction offers the advantages such as those offered by the TRAM flap, however, without the sacrifice of the rectus abdominis muscle - only the excess skin and fat from your lower abdominal wall is harvested for the flap...the muscle is left intact on your abdominal wall. This gives the distinct advantage of a completely autologous breast reconstruction, without need for an implant. In addition, since it is a muscle sparing procedure where the rectus abdominis muscle is not sacrificed, your abdominal wall integrity is maintained, leaving a much lower chance of bulges or hernias after the procedure than the TRAM flap.

The flap and its blood vessels are then disconnected entirely from the body, and the entire flap is then relocated to its new location in the breast area as a free tissue transfer. Its corresponding blood vessels are then reattached to blood vessels in the nearby area, using microsurgical techniques. Afterwards, the entire flap may be turned, twisted, or inset in the best position possible to contour a new breast for you. The conventional pedicled TRAM flap is limited in its insetting since it remains attached to its muscle insertion and blood supply superiorly.

Much like a tummy tuck, your abdominal incision will be sutured closed, first by repairing the abdominal wall, then by suturing your incision, leaving a single incision at the lower abdomen, hidden within your bikini line. To finish the closure, your umbilicus (belly button) will be brought out through a small incision, and sutured at its normal anatomic location.

General guidelines:

· Hospitalization: 5-7 days

· Advantages: Same as for the TRAM flap, but decreased hernia/bulge risk due to the fact that the muscle is spared and abdominal wall integrity maintained

· Disadvantages: Same as for the TRAM flap; complex procedure; abdominal wall integrity maintained (minimal hernia/bulge risk – much less than conventional TRAM flap)

October

2009-10-04T16:06:00.002-07:00

Proud of the support and awareness of October as Breast Cancer Awareness Month!

Part III: Flap-based reconstruction - TRAM

2009-09-28T15:50:00.007-07:00

TRAM flap (Transverse Rectus Abdominis Myocutaneous) flap

The excess skin, fat, and the rectus abdominis muscle are harvested from the lower abdominal wall. There are two (2) such muscles at the midline of your abdominal wall – one of them will be utilized for the reconstruction. This flap is then raised and tunneled under the upper abdominal skin and soft tissue, to its new location at the breast area. The flap is then trimmed, shaped, and secured into place, once a pleasing breast form is created, to recreate your breast.

The TRAM flap is a completely autologous (your own tissue) reconstruction. Autologous flaps will grow with you - as you gain or lose weight, and become a part of you. Flap-based reconstructions are almost alway preferable to implant-based reconstructions in patients with a history of radiation therapy. A TRAM flap usually provides enough tissue to recreate a breast, avoiding the use of an implant.

Much like a tummy tuck, your abdominal incision will be sutured closed, first by repairing the abdominal wall, then by suturing your incision, leaving a single incision at the lower abdomen, hidden within your bikini line. To finish the closure, your umbilicus (belly button will be brought out through a small incision, and sutured at its normal anatomic location.

General guidelines:

· Hospitalization: 3-5 days

· Advantages: Breast mound is present immediately; implant not needed - only your own tissue is used; your excess abdominal tissue is utilized; has a more natural appearance and feel of a breast

· Disadvantages: Flap complications; slightly weakened abdominal wall integrity; hernia/bulge risk; additional scar on the lower abdomen

Next...microsurgical free tissue transfers (e.g., DIEP, SIEA, GAP, etc.). This new technique for breast reconstruction will be discussed.

Part II: Flap-based reconstruction - latissimus dorsi

2009-09-22T14:14:00.008-07:00

The excess skin, fat, and the latissimus dorsi muscle are harvested from the upper back. This flap is then tunneled under your axilla (armpit) to its new location at the breast area, with its blood vessels attached. The flap is then trimmed, shaped, and secured into place, once we have created a pleasing breast form, to recreate your breast. A tissue expander/implant may be added for additional volume, if needed, to increase the size of the reconstructed breast(s). Your back incision will be sutured closed, leaving a single incision along your back, often being hidden within your bra line.

A unique method of latissimus flap reconstruction that I have learned from one of the world experts in this type of breast reconstruction and which we now perform is the “volume-added” latissimus flap. This adds additional soft tissue when harvesting the latissimus dorsi muscle, increasing the amount of tissue that we use to reconstruct your breast(s). We have seen that using this type of latissimus flap reconstruction provides a more natural-appearing reconstructed breast, due to its additional volume, which optimizes the final aesthetic outcome. In some instances, a “volume-added” latissimus flap reconstruction may avoid using a tissue expander/implant, as this flap may provide adequate volume alone.

In addition, we have seen some excellent results from fat grafting procedures to augment the reconstructed breast. By simply performing some liposuction to harvest fat from unwanted areas of fat elsewhere on your body (e.g., abdomen, thighs, buttocks, etc.), we augment your breast to add additional volume or correct contour deformities. Fat grafting procedures are safe and also avoid the use of implants for the purpose of adding additional volume and create a breast of completely your own tissue. (The fat grafting procedure will be discussed in a separate post). This adjunct procedure is used to augment the volume of the breast, and may avoid the need for an implant - giving you a completely autologous reconstruction.

General guidelines:

· Hospitalization: 2-4 days

· Advantages: Breast mound is present immediately; your own tissue is used

· Disadvantages: Flap complications; minor loss of shoulder range of motion (alleviated with exercise); additional scar on the back; may need implant if additional volume is needed

Insurance Coverage - State Laws

2009-09-14T15:34:00.004-07:00

Insurance Coverage is Required for Post-Mastectomy Breast Reconstruction if Mastectomy is Covered.

Alaska: enacted in 2000; conforms state law to the federal standards. The bill directly refers to the specific federal requirement: (A health care insurer that offers, issues for delivery, delivers, or renews in this state a health care insurance plan providing medical and surgical benefits for mastectomies shall comply with 42 U.S.C. 300gg-6 and 42 U.S.C. 300gg-52 regarding coverage for reconstructive surgery following mastectomies).

Arizona: enacted in 2000; conforms state law to the federal standards. The bill directly refers to the specific federal requirement: (A health care insurer that offers, issues for delivery, delivers, or renews in this state a health care insurance plan providing medical and surgical benefits for mastectomies shall comply with 42 U.S.C. 300gg-6 and 42 U.S.C. 300gg-52 regarding coverage for reconstructive surgery following mastectomies).

Arkansas: enacted in 1997; covers prosthetic devices and reconstructive surgery.

California: enacted in 1978; covers prosthetic devices or reconstructive surgery incident to mastectomy, including restoring symmetry; law was amended in 1991 to include coverage for pre-1980 mastectomies.

Connecticut: enacted in 1987; covers at least a yearly benefit of $500 for reconstructive surgery, $300 for prosthesis, and $300 for surgical removal of each breast due to tumor.

Delaware: enacted 2001; covers all stages of breast reconstruction including surgery and reconstruction of the opposite breast to produce symmetry; includes language stating surgery shall be provided in a manner determined in consultation with the attending physician.

Florida: enacted in 1987; covers initial prosthetic device and reconstructive surgery incident to mastectomy; 1997 amendment states that the surgery must be in a manner chosen by the treating physician, and surgery to reestablish symmetry is covered.

Illinois: initially enacted in 1980; covers initial prosthetic device and reconstructive surgery incident to post-1981 mastectomies. New bill enacted 2001 brings state into Federal compliance with federal requirements of the 1998 Womens' Health and Cancer Rights Act

Indiana: enacted in 1997; covers prosthetic devices and all stages of reconstructive surgery, in the manner determined by the attending physician and patient, including reconstruction of the other breast to produce symmetry. Additional legislation enacted in 2002 requires coverage for post-mastectomy services regardless of whether the individual was covered under the policy at the time of the mastectomy.

Kansas: enacted in 1999; covers breast reconstruction, including surgery of the other breast to produce a symmetrical appearance, prostheses and physical complications, in a manner determined in consultation with the attending physician and the patient.

Kentucky: enacted in 1998; covers all stages of breast reconstruction surgery following a mastectomy that resulted from breast cancer. 2002 amendment conforms statute to federal law

Louisiana: enacted in 1997; covers reconstructive surgery following a mastectomy, including reconstruction of the other breast to produce a symmetrical appearance, as agreed by the patient and attending physician. 1999 amendment conforms statute to federal law.

Maine: enacted in 1995; covers both breast on which surgery was performed and the other breast if patient elects reconstruction, in the manner chosen by the patient and physician.

Maryland: enacted in 1996; requires coverage for reconstructive surgery resulting from a mastectomy, including surgery performed on a non-diseased breast to establish symmetry.

Michigan: enacted in 1989; covers breast cancer rehabilitative services, delivered on an inpatient or outpatient basis, including reconstructive plastic surgery and physical therapy.

Minnesota: enacted in 1980; covers all reconstructive surgery incidental to or following injury, sickness or other diseases of the involved part, or congenital defect for a child. Additional legislation enacted in April 2002 expands language to specifically include benefits for all stages of reconstruction following mastectomy consistent with federal law. Also specifies that limitations on reconstructive surgery do not apply to reconstructive breast surgery following medically necessary mastectomy.

Missouri: enacted in 1997; covers prosthetic devices and reconstructive surgery necessary to achieve symmetry, as recommended by the oncologist or primary care physician.

Montana: enacted in 1997; covers reconstructive surgery following a mastectomy resulting from breast cancer, including all stages of one reconstructive surgery on the non-diseased breast to establish symmetry, and costs of any prostheses.

Nebraska: enacted in March 2000; follows the example of the federal statute by requiring coverage for medical and surgical benefits for mastectomy and for all stages of reconstruction of the breast after a mastectomy has been performed and reconstruction of the other breast to produce a symmetrical appearance. The measure also requires coverage for prostheses and physical complications of mastectomy.

Nevada: enacted in 1983; covers at least two prosthetic devices and reconstructive surgery incident to mastectomy. The law was amended in 1989 to cover surgery to reestablish symmetry.

New Hampshire: enacted in 1997; covers breast reconstruction, including surgery and reconstruction of the other breast to produce a symmetrical appearance, in the manner chosen by the patient and physician.

New Jersey: enacted in 1985; covers reconstructive breast surgery, including cost of prostheses. The law was amended in 1997 to extend coverage to reconstructive surgery to achieve and restore symmetry.

New York: enacted in 1997: covers breast reconstruction following mastectomy, including reconstruction on a healthy breast required to achieve reasonable symmetry, in the manner determined by the attending physician and the patient to be appropriate.

N. Carolina: enacted in 1997; covers for reconstructive breast surgery, including all stages and revisions of surgery performed on a non-diseased breast to establish symmetry, and reconstruction of the nipple/areolar complex without regard to the lapse of time between mastectomy and reconstruction. (1999 amendment conforms statute to federal law: Not Carried Over to 1999 General Assembly Second Session.)

N. Dakota: enacted 2001; specifies that health insurance policies may not be issued or renewed in the state unless they provide the benefit provisions of the 1998 Federal Womens' Health and Cancer Rights Act.

Oklahoma: enacted in 1997; covers reconstructive breast surgery performed as a result of a partial or total mastectomy, including all stages of reconstructive surgery performed within 2 years on a non-diseased breast to establish symmetry.

Pennsylvania: enacted in 1997; covers prosthetic devices and breast reconstruction, including surgery on the opposite breast to achieve symmetry, within six years of the mastectomy date. Additional legislation enacted 2002 adds language consistent with federal law.

Rhode Island: enacted in 1996; covers prosthetic devices and reconstructive surgery to restore and achieve symmetry incident to a mastectomy. Surgery must be performed within 18 months of the original mastectomy.

S. Carolina: enacted in 1998; covers prosthetic devices and breast reconstruction, including the non-diseased breast, if determined medically necessary by the patient and attending physician with the approval of the insurer.

Tennessee: enacted in 1997; covers all stages of reconstruction for the diseased breast, excluding lumpectomy, and procedures to restore and achieve symmetry between the breasts, in the manner chosen by the patient and physician, within 5 years of the reconstructive surgery on the diseased breast.

Texas: enacted in 1997; covers reconstruction of the breast incident to mastectomy, including procedures to restore and achieve symmetry, for contracts delivered, issued for delivery or renewed on or after Jan. 1, 1998. 1999 amendment conforms statute to federal law.

Utah: enacted in 2000; follows the example of the federal statute by requiring coverage for medical and surgical benefits for mastectomy and for all stages of reconstruction of the breast after a mastectomy has been performed and reconstruction of the other breast to produce a symmetrical appearance. The measure also requires coverage for prostheses and physical complications of mastectomy.

Virginia: enacted in 1998; covers reconstructive breast surgery performed coincident with a mastectomy performed for breast cancer or following the mastectomy, and surgery performed to reestablish symmetry between the two breasts.

Washington: enacted in 1985; covers reconstructive breast surgery if mastectomy resulted from disease, illness or injury. The law was amended in 1996 to include surgery to reestablish symmetry.

West Virginia: Enacted 2002, includes coverage for reconstruction of the breast on which mastectomy was performed and the opposite breast for symmetry; also provides coverage for prosthesis and complications all as determined in consultation with attending physician and patient.

Wisconsin: enacted in 1997; covers breast reconstruction of the affected tissue incident to mastectomy and specifies that such surgery is not considered cosmetic.

1998 Federal Breast Reconstruction Law

2009-09-14T15:19:00.006-07:00

Following is the 1998 Federal Breast Reconstruction Law: Signed into Law on October 21, 1998 - ASPS is working with federal regulators as they draft guidance on implementation of the new law.

SEC. 713. REQUIRED COVERAGE FOR RECONSTRUCTIVE SURGERY FOLLOWING MASTECTOMIES.

(a) IN GENERAL.-A group health plan, and a health insurance issuer providing health insurance coverage in connection with a group health plan, that provides medical and surgical benefits with respect to a mastectomy shall provide, in a case of a participant or beneficiary who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, coverage for:

(1) reconstruction of the breast on which the mastectomy has been performed;

(2) surgery and reconstruction of the other breast to produce a symmetrical appearance; and

(3) prostheses and physical complications all stages of mastectomy, including lymphedemas; in a manner determined in consultation with the attending physician and the patient. Such coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the plan or coverage. Written notice of the availability of such coverage shall be delivered to the participant upon enrollment and annually thereafter.

(b) NOTICE.-A group health plan, and a health insurance issuer providing health insurance coverage in connection with a group health plan shall provide notice to each participant and beneficiary under such plan regarding the coverage required by this section in accordance 1078 with regulations promulgated by the Secretary. Such notice shall be in writing and prominently positioned in any literature or correspondence made available or distributed by the plan or issuer and shall be transmitted:

(1) in the next mailing made by the plan or issuer to the participant or beneficiary;

(2) as part of any yearly informational packet sent to the participant or beneficiary; or

(3) not later than January 1, 1999; whichever is earlier.

(c) PROHIBITIONS.-A group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, may not:

(1) deny to a patient eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of this section; and

(2) penalize or otherwise reduce or limit the reimbursement of an attending provider, or provide incentives (monetary or otherwise) to an attending provider, to induce such provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section. 1079

(d) RULE OF CONSTRUCTION.-Nothing in this section shall be construed to prevent a group health plan or a health insurance issuer offering group health insurance coverage from negotiating the level and type of reimbursement with a provider for care provided in accordance with this section.

(e) PREEMPTION, RELATION TO STATE LAWS:

(1) IN GENERAL.-Nothing in this section shall be construed to preempt any State law in effect on the date of enactment of this section with respect to health insurance coverage that requires coverage of at least the coverage of reconstructive breast surgery otherwise required under this section.

(2) ERISA.-Nothing in this section shall be construed to affect or modify the provisions of section 514 with respect to group health plans.''

(f) CLERICAL AMENDMENT.-The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 note) is amended by inserting after the item relating to section 712 the following new item:

SEC. 713. REQUIRED COVERAGE RECONSTRUCTIVE SURGERY FOLLOWING MASTECTOMIES.

(a) EFFECTIVE DATES.-

(1) IN GENERAL.-The amendments made by this section shall apply with respect to plan years beginning on or after the date of enactment of this Act. 1080

(2) SPECIAL RULE FOR COLLECTIVE BARGAINING AGREEMENTS.-In the case of a group health plan maintained pursuant to 1 or more collective bargaining agreements between employee representatives and 1 or more employers, any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement added by this section shall not be treated as a termination of such collective bargaining agreement.

SEC. 903. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.

(a) GROUP MARKET.-Subpart 2 of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-4 et seq.) is amended by adding at the end the following new section:

SEC. 2706. REQUIRED COVERAGE FOR RECONSTRUCTIVE SURGERY FOLLOWING MASTECTOMIES.

(a) ''The provisions of section 713 of the Employee Retirement Income Security Act of 1974 shall apply to group health plans, and health insurance issuers providing health insurance coverage in connection with group health plans, as if included in this subpart.''.

(b) INDIVIDUAL MARKET.-Subpart 3 of part B of title XXVII of the Public Health Service Act (42 U.S.C. 1081 300gg-51 et seq.) is amended by adding at the end the following new section: ''SEC. 2752. REQUIRED COVERAGE FOR RECONSTRUCTIVE SURGERY FOLLOWING MASTECTOMIES. ''The provisions of section 2706 shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as they apply to health insurance coverage offered by a health insurance issuer in connection with a group health plan in the small or large group market.''.

(1) GROUP PLANS.-

(A) IN GENERAL.-The amendment made by subsection (a) shall apply to group health plans for plan years beginning on or after the date of enactment of this Act.

(B) SPECIAL RULE FOR COLLECTIVE BARGAINING AGREEMENTS.-In the case of a group health plan maintained pursuant to 1 or more collective bargaining agreements between employee representatives and 1 or more employers, any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement added by the amendment made by 1082 subsection (a) shall not be treated as a termination of such collective bargaining agreement.

(2) INDIVIDUAL PLANS.-The amendment made by subsection (b) shall apply with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after the date of enactment of this Act

Is Breast Reconstruction Covered?

2009-09-14T14:56:00.006-07:00

I've been asked to comment on the insurance coverage for breast reconstruction. The following posts will detail the following laws on this issue. On October 21, 1998, the Women's Health and Cancer Rights Act of 1998, became effective as part of the 1999 Omnibus Consolidated and Emergency Supplemental Appropriation Act. This new federal law requires group health plans and individual health policies that provide coverage for mastectomies to also provide coverage for breast reconstruction in connection with mastectomy.

In accordance with the Women's Health and Cancer Rights Act of 1998, members receiving mastectomy-related services are entitled to the following benefits:

Reconstruction of the breast on which mastectomy has been performed
Surgery and reconstruction of the other breast to produce a symmetrical appearance
Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas
One home health care visit within 48 hours of hospital discharge
Outpatient care following a mastectomy performed in a health care facility
Inpatient skilled nursing facility care in which the length of stay is determined by the treating physician based upon generally accepted criteria for safe discharge

This coverage will be provided in a manner determined in consultation with the attending physician and patient. These benefits are subject to and deductible or coinsurance requirements that may apply to your coverage.

Part I: Implant-based reconstruction - tissue expander/implant

2009-09-12T20:54:00.011-07:00

A multi-part discussion on the various types of breast reconstructive procedures will be done in the following posts. Each has their own advantages and disadvantages. My hopes will be to thoroughly inform you of the different options and help you decide, along with your plastic surgeon's factoring in of your medical condition and your disease, which of these options would be most suitable for you.

The first part will discuss tissue expander/implant reconstruction...

IMPLANT-BASED RECONSTRUCTION:

Tissue expander / implant

A balloon-like expander is placed under the skin and pectoralis major muscle at the initial procedure. The expander is then slowly filled with saline water over several weeks until the desired breast size is achieved. It is then slightly over-filled, so that adequate skin and soft tissue is available when the tissue expander is exchanged for the permanent implant (either silicone or saline, depending on your preference). This exchange is performed at a separate procedure several weeks after the final volume in the expander is attained. ( Silicone vs. saline implants will also be discusses in a separate post).

As an innovative technique, an acellular dermal matrix may be used as a “sling” or “hammock” for which the expander or implant lies within the lower portion of the breast. In my experience, I have been able to set the margins of your breast perfectly and recreate the natural slope and ptosis (sag) of a normal breast. I have seen that this creates a more aesthetically pleasing breast contour and also adds additional volume and soft tissue coverage over your implant, thus decreasing many of the implant-based complications, such as malposition, capsular contracture, and extrusion.

The acellular dermal matrix has made dramatic advancements in plastic surgery. Especially in breast surgery and breast reconstruction, the dermal matrix has shown excellent aesthetic results, along with much fewer complications. Notably, this dermal matrix has had minimal, if any capsule formation. Also, it provides additional soft tissue between the overlying skin and the underlying implant. Current literature has shown some dramatic results and its popularity, and uses, continues to grow. As such, I will discuss the acellular dermal matrix in a separate posting to discuss it fully.

For some women who are candidates, another new technique that may be offered is immediate implant reconstruction. On certain circumstances, your surgeon may be able to perform a one-stage reconstruction, placing permanent implants at your initial procedure, without the need for a tissue expander. This will spare you from the tissue expander procedure, the subsequent tissue expansions, and the permanent implant exchange in the future. Discuss this option with your plastic surgeon if you are interested.

General guidelines:

Hospitalization: 1-2 days

Advantages: Less pain; no additional scars besides that of the mastectomy; least recuperation time

Disadvantages: May require additional procedures in the future; implant complications (e.g., rupture, contracture, malposition, etc.)

Types of Breast Reconstructive Procedures:

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Breast Reconstructive Procedures:

There are two basic categories for reconstructive procedures used to recreate a breast:

· Implant-based: permanent silicone or saline implants are utilized to recreate a breast mound

o Breast implants are a great option for breast reconstruction and can achieve an excellent result in certain candidates

· Flap-based: your own tissue along with its blood supply from one area of your body is transferred to your breast area to recreate a breast

Utilizing a flap for reconstruction gives the benefit of using your own tissue for reconstruction of a breast. A flap often looks, feels, and moves more naturally than an implant alone. Most importantly, the flap also provides an added advantage of bringing in healthy, well-vascularized tissue to the breast area, which is beneficial for irradiated or compromised areas at the mastectomy defect. Flaps ameliorate some of the healing issues before or after radiation therapy by incorporating a remote source of blood flow, thus avoiding some of the potential complications with implant-based reconstruction.

The next posts will discuss the pros and cons of each of the above procedures as well as a thorough discussion describing the advantages and disadvantages of the above, including timing, effect on recurrence rates, surveillance, etc.

To choose, or not to choose - details to consider

2009-09-01T09:54:00.003-07:00

If you choose reconstruction, there are several details to consider. Reconstruction can be performed at the same time as your mastectomy (immediate reconstruction), or it can be performed at any time in the future following your mastectomy (delayed reconstruction). After any type of breast reconstruction, plans may be made to reconstruct a nipple and areola complex in the future. This may be performed at any time after a few months from your final reconstructive procedure. The breast reconstruction procedures that are offered today include both implant-based and autologous (your own tissue) flap reconstructions, including DIEP, SIEA, TAP, and other free-tissue transfer breast reconstructive procedures. Be aware of all of your options, and again, become involved in the decision of which reconstructive procedure will be the best fit for you.

Women may choose not to undergo surgical reconstruction. For medical or psychological reasons, some women choose to delay their reconstruction. If you choose not to undergo immediate reconstruction, this does not preclude you from undergoing reconstruction at a later date. Some women have had breast reconstruction surgery months to years after their mastectomy. Often times, the same reconstructive options are available to you, and your surgeon will help to determine this for you when you feel ready to proceed with your reconstruction.

During this time, you may consider wearing an external breast prosthesis garment fit to match your remaining breast, or wear prostheses for both breasts. However, a reconstructed breast offers several advantages over breast prostheses. You will not be limited in your clothing options or the activities in which you participate. Psychologically, women reiterate the fact that they feel more confident, attractive, and feminine with a reconstructed breast than without one. The fear of the prosthesis becoming visible or displaced is gone. There is no constant reminder of the previous surgery on your breast or the cancer when placing the prosthesis on and taking it off. Lastly, there is a wholeness that is achieved, as the reconstructed breast becomes part of your own body.

Overall, every woman should be informed of her breast reconstruction options following breast surgery at the time of her diagnosis. Taking into account your cancer type, tumor size, nodal involvement, the need for pre/postoperative chemotherapy or radiation therapy, your overall medical health and comorbidities, along with your own personal preferences, should lead to a meaningful discussion about which reconstructive procedure, if any, you should have. There are several reconstructive options to consider, and not one procedure is right for each person. However, your breast surgeon should discuss the breast reconstruction option and your plastic & reconstructive surgeon should inform you about the pros and cons of every procedure available and assist you in deciding which procedure is most suitable for you.

American Society of Plastic Surgeons statement

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I have been asked by a few people the reason why women are not involved in the discussion of breast reconstruction as discussed on the previous post. The American Society of Plastic Surgeons (ASPS) has issued a statement recently...

"Women need to understand all of their options to make an informed decision," said ASPS President John Canady, MD. "Those who are diagnosed should be immediately referred to a full team of physicians that can provide breast care, and plastic surgeons need to be included as part of that treatment team."

"We know that there are many issues surrounding breast reconstruction and that addressing them all will take time, but this is a very important first step," said Dr. Canady. "Our goal is to make sure that those women who are not getting breast reconstruction are doing so of their own accord and not because they are uneducated or uninformed about their options."

I discussed earlier how every woman should be involved in the discussion of breast reconstruction at the initial diagnosis and should be given all of the options. The ASPS recommends that "primary care, general surgery, radiology, pathology, oncology, gynecology, and plastic surgery be available from the onset of treatment to ensure the greatest possible outcome for the patient." It would be all of our hopes that women are educated in this fact and soon, the ASPS will seek to inform the public of this through a variety of materials - information cards and online videos, ad campaigns featured online and in the waiting-room publication produced by the American College of Obstetricians and Gynecologists.

Knowing your option for breast reconstruction...

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The goal of breast reconstruction is to provide symmetry, and to match, as closely as possible, the appearance and feel of a natural breast.

Breast reconstruction surgery is an option for nearly every woman who has had partial or complete mastectomies for cancer or other reasons, but at the least, every woman should be informed of this option. If you are thinking about having reconstructive surgery, it is a good idea to talk about it with your surgeon and a plastic surgeon experienced in breast reconstruction before your mastectomy. This lets the surgical teams plan the treatment that is best for you, even if you decide to wait and have reconstructive surgery later.

According to a recent report, although there has been a steady increase in the amount of breast reconstructive procedures performed annually, nearly 70% of women who are eligible for reconstruction are not informed of the reconstructive options available to them. Statistics reported by the American Society of Plastic Surgeons (ASPS) shows that >79,000 breast reconstruction procedures were performed in 2008 alone - a 39% increase from the previous year. Unbelievably, current research shows that most breast cancer patients are not even involved in a key discussion that should take place at the time of their initial diagnosis.

Women who choose to undergo breast reconstruction report improved self-esteem, self-confidence, femininity, comfort, and wholeness with their bodies. Your plastic & reconstructive surgeon should personalize your consultation to provide an informed discussion about the procedures that they offer and assist you in determining which procedure would be the most suitable for you. Be sure to discuss the best timing and type of reconstruction for you, taking into account your cancer type, tumor size, nodal involvement, the need for pre/postoperative chemotherapy or radiation therapy, your overall medical health and comorbidities, along with your own personal preferences. The discussion should involve you in the decision-making process, as the final reconstruction will ultimately become part of you.

Welcome

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Welcome to this Breast Reconstruction/Breast Cancer blog. This is the first entry in what I hope will become a primary site for information sharing regarding breast reconstruction, breast cancer, and other resources and information on reconstructive options for women following complete or partial mastectomy for cancer or other reasons. As a plastic & reconstructive surgeon with a particular interest in breast cancer and reconstruction, I look to offer any assistance that I can in regards to this topic.

I look forward to providing and exchanging as much useful information as possible in hopes of helping those searching for answers to gather knowledge and understanding of breast cancer and breast reconstruction options. I encourage everyone with questions, concerns, or information regarding this topic to post on this site. Feel free to browse this site and links/resources and leave comments/questions on topics discussed or future topics that you would like addressed.

Thank you for visiting this site.