Preference of Silicone Over Saline Implants Following Mastectomy

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

October - Breast Cancer Awareness Month

Breast Cancer/Reconstruction - New Law Passed!

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

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

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

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

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Quick Breast Reconstruction Info

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"

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

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

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

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.