Dr. Rogers takes us through the breast reconstruction process. He talks about the importance of having someone with you when you come in for a consultation because breast surgery and reconstruction is such an important part of the puzzle and a personal choice. You will learn about the various forms of breast reconstruction and what is entailed from start to finish, including nipple reconstruction. He discusses pain management and how monitoring your drains are essential to fending off any possible infection. He also talks about the impact breast reconstruction has on sexuality and intimacy.
My name is Leif Rogers. I'm a plastic surgeon. I went to undergrad at the University of Rochester and got a bachelor's in science. Went to Columbia University medical school. Did three years of general surgery there. One year of research at Columbia. One at Carnegie Mellon in Pittsburgh. I did an additional two years of plastic surgery fellowship at Carnegie Mellon.
Initially my PA will go in and talk to them first; get a little bit of background, take some notes, take some history. My PA is an integral part of the care giving system of my team. Once in a while, someone will come on their own without support. And that’s actually unusual. I much prefer they come with support for a couple of reasons. One, it’s good to know there’s someone there to help them. It’s good to have a second set of ears. The patient misses a lot, they’re going through a stressful situation, they’ve just heard they have this diagnosis. They’re going to have to have all of this type of surgery. So a lot of it doesn’t get processed so it’s nice to have a second person. Those patients who don’t come with somebody, I worry that they don’t have a good support system and most of the time it’s true. We can get them through it; it’s not like we can’t do surgery but we have to be extra careful and extra patient with those types of people. And we can usually tell. When you look at somebody you can tell when you look at somebody and tell if they're handling it well or not. And so you can adjust how you address the situation, what kind of information you give up front, whether you go right into it or do you kind of go slowly?
I ask them questions about their life, their lifestyle. I assess whether, you know, what kind of job they have; how much they work; if they're younger or older, and by getting that kind of information it helps me to help them make that decision if they do an implant; do you do a deep flap which is like using tissue from the belly, or some other type of reconstruction. The way most plastic surgeons do it, is we have our before and after books previous patients we've done these similar procedures on, meaning this is more or less the way your body looks before, and this is likely how you're going to look after. And that's true for both reconstruction with tissue or with an implant.
I can tell you the trend, in general, younger patients want implant reconstruction. There's a couple of reasons. It's faster. It gets them back to their life more quickly. It can be a nice result especially if you're doing both sides and it tends to give you that perky look which most women want, anyway. It decreases the likelihood that they'll need incisions anywhere else in their body. Even though they know that likely at some point in their life they'll need another surgery because implants don't last forever, they're okay with that.
My patients can be as young as early twenties but most of the time I see early thirties. By the time they hit their mid-forties to fifties, they start thinking “ok, I don’t want to deal with this in the future, I don’t want to come back to have more work done; I want it done; I want it to feel natural; I don’t necessarily care if I look twenty but I just want it to feel as if it’s as natural as possible. That’s not always true but more so. So I do tend to do more tissue reconstruction in those patients. Those patients often also have had children; they may be a little bit heavier just as natural course of life; they may gain a little bit of weight. They may have extra tissue. They don’t want it; so they get to go and use that little extra tissue. So it’s a win-win in that kid of situation.
The least invasive reconstruction would be to put in a tissue expander. I go underneath the skin now. I raise the chest muscle, the pectorals muscle, up and put the tissue expander under it. I also sew in a piece of, it's called acellular dermal matrix. Now that's a fancy word of saying cadaver skin, okay, so it's human skin that's been treated that only has collagen cells in it. You use it kind of like an internal bra; it holds everything in place while it's healing. Your body heals into it; eventually it gets completely taken over by your own cells and it disappears over probably two years.
Once all that heals we start expanding it; it's a port where you can access it; you stick a needle through the skin, with fluid, and you put in anywhere from 50 to 100 cc's of saline each time. So each time you make it grow until you decide it's big enough. The second surgery, you comet back, you reopen incision, where that scar was. You reopen the pocket. You take out the tissue expander, and you put in an implant, so that implant is already filled with, we call it silicone gel. There's different kinds of implants; there are round ones; there're shaped ones; some are firmer; some are softer. It all depends on your surgeon and what they prefer and what fits you, but that goes in and that's permanent. Those feel pretty nice.
They're much softer. They feel much more like a natural breast than the tissue expander. You may or may not get a drain the second time. The recovery the second time is usually easier significantly. There's just less injury. The pocket is already there. You're just adjusting it.
We're doing either a skin sparing or possibly a nipple sparing. Nipple sparing is great. I mean if you think you can keep the nipples and not have an increased risk of breast cancer, which is possible in many people, you have natural-looking nipples, which is fantastic. I can reconstruct them if necessary, but natural ones are always better. If the nipple has to be removed, usually we make the incision around the nipple; the nipple comes out; and all the breast comes out from the seam incision. The advantage of that is minimal scars. I can usually close that incision and ultimately we put a new nipple on it and I can cover the entire scars; there's no visible scars. So you can have a very nice looking breast with really minimal scars if we go the implant reconstruction technique.
Everyone’s a little different so it kind of depends on your personal pain threshold. There are actually some new methods to control pain which are actually quite good. One is called, On-Q which are pumps; basically it’s like this elastic ball you can fill with local anesthetic. You put a little tiny catheter you can put through the skin where you think is going to be most painful; and it dribbles in local anesthetic over about 3 days. One of the newer ones is the medication called Exparel. Exparel is essentially marcaine. Marcaine is a long-acting local anesthetic, but this is they package it in these micelles, like it's in, how do I say it, it's these little microscopic lipid droplets and the medication is the middle of those.
So it's sustained release, so if you inject into the tissues, it slowly releases the marcaine over about three days. So it's the same idea as a catheter but you get injected everywhere. That stuff is unbelievably good. You put it in the right place, these patients, assuming you have no pain meds, say their pain is a 9, with this stuff, on no pain meds, it's like a 1 if it's done right. So that's unbelievably good. The first few days is where they have the most pain, anyway, so once you get past the first three-day hump, your pain level is usually much, much easier to control.
The recovery for that technique most people are taking it really easy for the first two weeks. I encourage them not to do any heavy lifting with their upper body for six weeks. After six weeks, it's kind of a milestone. Most people are healed well enough where it’s very difficult to cause any problems with their healing process by then; so I let them go to the gym and everything in six weeks. They often have drains. The drains usually last one to maximum three weeks but usually about a week and a half. And nobody likes the drains but unfortunately they're a necessary evil.
For implant reconstruction, usually the tissue expander part, they stay one to two nights. That’s the simplest way to do it. There’s another version of that where instead of putting a tissue expander in, you put the implant in right away. The risk with that one is that one is there's an increased risk of healing problems because you're stretching the skin out to the maximum amount that you want from the get-go, which can have issues of blood flow, especially if the blood flow is to the skin that has already been injured from having a mastectomy. If you have healing problems, you don't have as many ways to fix the situation because everything’s already tight.
It doesn't mean that direct-to implant is bad. It just means you really have to be selective of who you do it on; it's not for every single patient. Frequently, also with direct-to implant, as they're calling it these days, you end up coming back to do a touch-up, anyway, because it's not as perfect as you'd like it to be.
So a pedicle flap, it means you're taking muscle or tissue from another part of the body but you're leaving the blood vessels attached; you just swinging it around so the blood vessels are still flowing. The most common two for best reconstruction is the Opisimus Flap; it's in the back; it's that big muscle when body builders are showing their wings, it's that wing; so that muscle gets raised, usually with skin from the back, but not always, and the blood vessels are in the armpit. You swing the muscle around to cover the defect or to add volume, to take the volume from the back and put it in the front. I still use it but usually to fix a problem that has occurred during the reconstructive process, meaning, like, if the tissues aren't healing because of radiation, which definitely compromises healing; if there's been recurrent infection; and, because when you bring in healthy tissue the blood supply helps clear infection.
So the TRAM Flap now. The TRAM stands for transverse rectus abdominus myocutaneous flap. Basically what it means is that tissue that you normally throw away; when you do a tummy tuck you can grow a breast out of it. It's actually two muscles, two strips of muscles like this and there's blood vessels that flow within the muscle itself. So we keep this tissue attached to this muscle. We tunnel up this way and we literally take this tissue and flip it up underneath and pop it out to where the breast was and use it to fill the defect. It's one of the better techniques for building your own tissues. The negative is you lose one of your core muscles, and if you're doing both sides, you can lose both core muscles. So you don't have muscle anymore, and that's kind of an important muscle, especially as you age and support your back and all these things. Now, people do function. I mean they compensate, but if I can avoid causing an imbalance I’d prefer to avoid that.
The DIEP is the new version of the TRAM. It's similar; you're using the same piece of tissue, the fat in the skin, but instead of taking that muscle, we're separating the muscle, the fibers, and we're taking that blood vessel out completely. Instead of it going this way we're taking the blood vessel from below. So now we disconnect that completely and we bring it up to the chest wall. There are blood vessels under a rib in your chest, one on each side, called internal mammary artery and vein. You actually move a little piece of rib to get to it; you'll never miss that piece of rib; and we sew the blood vessel from the flap to the blood vessel in your chest wall, establishing a novel blood flow; it didn't exist before. It heals together; this piece of tissue survives and will actually heal into place and now you have a new breast. You can do this on both sides. And if you're going to do it, you're going to have to do both sides at the same time. You can't do one side and come back later and do the other side. It's just not technically feasible to do it that way. The DIEP flap, you're in the hospital three to five nights. You're in the ICU one night. You're not in the ICU because you’re critically ill but you really need to have a nurse really watch it because if anything goes wrong with that flap, we need to know immediately so we can come and fix it because if you wait too long, there's no fixing it. Most people don't feel up to really exercising at all for at least four to six weeks. And you won't feel really back to normal, I mean normal energy, for three to six months. I would say most people at six months. Now that doesn't mean you can't do anything. It just means your energy level is going to be a little bit lower.
I can tell you that a reconstructed breast typically does not have much sensation, little to none. In some instances you gain back more than you would think, but for the most part it's so little that it almost doesn't count. And that's something patients are told upfront; they are aware of that. It matters a lot to some patients; other patients couldn't care less. So, again, every individual is different. But it's not just that; it's being like the object of, the visual object of someone's desire, is a big part of feeling good about yourself; I think at least when you're in a relationship. And, if you don't feel comfortable with the way you look, it's hard to even be a part of that. I think having someone else accept the way you look and like the way you look is even extra on top of that. So I do think that performing a nice reconstruction, that aren't just acceptable but actually aesthetically pleasing, is such a huge bonus; it's night and day difference between an acceptable reconstruction versus an aesthetically pleasing reconstruction in terms of your quality of life, especially when it becomes…when you're talking about intimacy.
I don't like the idea of thinking every human being is just one body part. We're not. We're a whole being, made of all these parts, and to be able to understand who we are and how we should look and everything else, it's really about understanding how everything fits into everything else. And it's not just physical. It's emotional and psychological and every thing. So you really need to know the full picture, and to do that you kind of have to be a master of everything or at least try to be.