Information Sessions: Breast Reconstruction

Corporate Speakers:

• Carrie Stern; Memorial Sloan Kettering; Plastic and Reconstructive Surgeon
• Colleen McCarthy; Memorial Sloan Kettering; Reconstructive Surgeon
• Mary Jane Massie; Memorial Sloan Kettering; Psychiatrist
• Emily Clark; Memorial Sloan Kettering; Physician Assistant

PRESENTATION

Carrie Stern:  Welcome to this MSK Information Session.  I am Carrie Stern.  I’m a Plastic and Reconstructive Surgeon with a specific focus in breast reconstruction.  Thank you, all, for joining our call today. 

Firstly, I want to let you know that MSK is working hard to keep you and your loved ones safe when you come in for an appointment or treatment at any of our locations.  As many of you know, October is Breast Cancer Awareness Month.  We wanted to use this opportunity to address your most pressing questions about breast reconstruction. 

Today, with our panel of experts, we’ll answer some of the hundreds of questions you shared with us in advance of this call.  We will try to get to as many of the questions you sent in as possible during our time together. 

I want to remind you that your MSK doctors and care teams are ready and willing to talk to you directly about your concerns.  I strongly encourage you to reach out to them to discuss the next steps in your care and to ask them any questions that you do not get answered here today. 

Breast reconstruction is an incredibly personal choice and lots of factors go into the decision-making around it. 

QUESTIONS AND ANSWERS

Carrie Stern:  I want to start by asking Colleen McCarthy, a reconstructive surgeon here at Memorial to talk about how we counsel women through the different options and what those options are.  Colleen? 

Colleen McCarthy:  Thanks, Carrie.  And firstly, I’m happy to be on this call with you this afternoon and having this discussion.  I think with the first question you, in fact, hit the nail on the head, meaning breast reconstruction is absolutely a personal choice. 

We say reconstructive surgery is elective by nature, which means that women elect or can choose to go through with the process and will do so, of course, based on their different values, preferences, tolerance for risks, and ultimately, their individual goals. 

And really, here, there’s no wrong answer.  In fact, for some women, the right answer may be no reconstruction at all.  But for women who do choose to proceed with breast reconstruction or having their breasts rebuilt after mastectomy, they do have several options for how it can be done. 

And really, we look at those options in sort of two categories.  So, the first being implant reconstruction and the second really being reconstruction using one’s own tissue, and we refer to that as autologous tissue reconstruction. 

So, firstly, again, if we think about implant reconstruction, there are different ways to go about this as well.  The most common way we proceed in reconstructing the breast with an implant is in two stages.  This is called tissue expander implant reconstruction. 

And at the first stage at the time of mastectomy, a temporary implant or tissue expander is placed.  This allows this skin that just had most of its blood supply removed at the time of mastectomy to relax and allow for proper healing. 

And then in a period of weeks or months, patients come back to clinic to have their tissue expander inflated while their tissues are stretched.  And when we reached the desired goal of the ultimate reconstructed breasts, several months down the line, the patient will then return to the operating room to take out her temporary device and place her permanent implant. 

There is another way to proceed with implant reconstruction, and that is in a single stage, which sounds very advantageous for many, but the truth is it’s the rare patient who is a very good candidate for that. 

And that would be someone with a very small breast to start with perhaps an A or B cup breast, and that woman would be looking to go even smaller.  And the reason most are not a candidate for that procedure, as I said, is often, it’s too much for the skin that just, again, has had most of its blood supply removed to take a heavy implant. 

We also know that secondary procedures are very common after a single-stage reconstruction.  So, again, for the overwhelming majority of women who choose implant reconstruction, they will choose a two-stage procedure. 

For some women who are not interested in implant reconstruction or their preference may be to use their own tissues, the most common place we use – or look to take extra tissue is the abdomen. 

We take often the tissue from the belly button to the pubic bone with an artery and vein, and we use that skin and that [set] to reconstruct the breast.  The scar that results is similar to a tummy tuck or abdominoplasty scar. 

This tissue is then transferred with its blood supply as artery and vein, and we find another blood supply in the breast whether it’d be under a small piece of rib or in the underarm and we reestablish the circulation so that transferred tissue has a new blood supply. 

There are other places we can look to take extra tissue, if you will, and those may include the buttock or the thighs.  But again, typically, we look to the abdominal wall or the belly to transfer tissue.  And you may be familiar with those procedures called the TRAM or the DIEP flap, depending on how much muscle or lack of muscle is taken with the donor tissue. 

Each of these options gives a different result.  And again, ultimately, it’s a balance of risk tolerance and weighing of goals for desired breast size and shape and recovery.  And these discussions and decisions will be made ultimately by the patient. 

Carrie Stern:  Thank you, Colleen.  Mary Jane Massie is a Psychiatrist at MSK, who specifically works with breast cancer patients.  Mary Jane, can you talk us a little – through a little bit about some of the emotions surrounding this decision and how you specifically help women work through this part of their treatment journey? 

Mary Jane Massie:  Oh, thank you very much for allowing me to participate today.  I’m happy to be here and I’d happily talk about that.  Women who are considering breast reconstruction fall in, usually, one of two groups.  Women who are considering risk-reducing surgery, prophylactic mastectomy, because they are at high risk of developing breast cancer, or the other group of women or those who have breast cancer and are considering this surgery as the reconstructive follow-up to mastectomy. 

Those are slightly different groups of women.  Let’s talk first about the women who have breast cancer.  The woman who goes to see our plastic surgeons and their staff are worried usually about, “What else am I going to learn about my cancer during – after mastectomy or during mastectomy?” 

So, I think our surgeons would say those women are often very anxious and it’s understandably so and it’s a relief for them to meet our plastic surgeons and hear the discussion we all just heard Colleen gave us about how a plastic surgeon helps each individual woman think through what will be appropriate for her. 

Our plastic surgeons know that this is a surgery.  There’s a lot of worry because, “What else will we learn about the cancer?” So, most of our patients are very relieved to have a discussion like Colleen just went through with you. 

The other group of women who are at high risk of developing cancer who are considering this surgery is this risk-reducing surgery, welcome the opportunity to hear experts like our plastic surgeons describe so nicely what we could do to help them if they make the decision to have surgery that will lessen the likelihood that they will develop cancer. 

So, the opportunity for women to see such caring, intelligent, informed, experienced people who are there to help them go through their rehabilitation after breast surgery is such a rewarding experience for patients and helps relieve an enormous amount of anxiety. 

Carrie Stern:  Thank you very much for that.  I couldn’t agree more.  One listener asked, “What is your opinion of reconstructing during – reconstruction during COVID?  As we all know, we’re still in the midst of a pandemic.  Listeners were wondering whether it’s safe or whether reconstruction should be delayed.  Colleen, can you tell us what MSK is doing to keep our patients safe and when they should come in for a surgery or appointment? 

Colleen McCarthy:  Absolutely.  And I think this is a great question.  Firstly, I think it’s important to note that here at Memorial Sloan Kettering, we are encouraging all of our patients not to delay their care.  And that includes not only their cancer care but their reconstructive care. 

Memorial has put in very strict safety measures to make sure that our expert care can continue well doing all of that in the safest environment possible.  So, some of those things include patient screenings, so all patients are screened the day before any scheduled visit to Memorial.  The same goes for staff, so all staff are screamed – screened, excuse me, for signs of illness and we perform daily health checks before reporting to work. 

We are following social distancing guidelines here again at Memorial at all our sites and limiting the number of people who enter the facilities.  We’ve timed out the space between our patient visits.  We are minimizing the need to be in our waiting rooms.  And we really significantly reduce the number of visitors at all our locations. 

We certainly require all patients and all staff to wear a mask at all times and anyone who enters the building may often see staff also in gowns and face shields and other equipment.  The crews here are disinfecting and sanitizing all high touch and public areas.  And importantly, the COVID-19 testing is operating at full capacity.  So, Memorial Sloan Kettering is able to test the patients and staff as frequently as necessary. 

That all said, I – it is the conversation that I have frequently with my own patients and often, women are concerned about coming in for surgery and/or wish to delay.  And ultimately, they – patients have to make a choice that feels absolutely right for them, but I would encourage anyone to talk to their individual surgeon or their care team to discuss the pros and cons. 

And just a final note maybe, Carrie, is that this has brought in all these new ways of communicating and that for many of us includes telemedicine visits.  So, if there’s something that can be done by telehealth, we are certainly set up to do that and accommodate that.  So, again, a conversation with a care team or with a certain physician’s office is probably good next-step if someone would have specific concerns. 

Carrie Stern:  Absolutely.  I think the comment regarding telemedicine and telehealth is an important one that many patients don’t necessarily realize we have the capacity to do and that we’re doing pretty routinely now for many patients both in long-term follow-up patients, but also newly diagnosed patients that want to get some information but are worried or can’t come in right now for one reason or another.  We definitely do have the capacity to do telemedicine visits and with significant success of [recent]. 

Many of you asked about reconstructive options post-radiation, and I can talk about that briefly.  So, radiation is very effective at killing cancer cells, but in that process, it can cause damage to the surrounding healthy tissue. 

If we know that patients will require radiation as part of their cancer treatment, we sometimes approach their reconstruction a little bit differently.  For example, radiation can increase the risk of developing scar around breast implants called capsular contraction.  Therefore, as Colleen mentioned earlier, we place a temporary implant at the time of mastectomy, and after radiation, we replace that temporary implant for a permanent implant. 

For patients that had mastectomy without breast reconstruction and subsequently had radiation as part of their cancer treatment and wonder if they can have reconstruction now, they most certainly can. 

Options for reconstruction may be different than for those patients that did not require radiation.  But reconstruction is most certainly possible.  For these patients, implants alone may not be possible as their sole method of reconstruction and instead, we may need to use some other tissue, perhaps from their back with an implant or just using their own tissue in flap surgery for breast reconstruction.  But if one has a history of radiation, that does not mean that they cannot have breast reconstruction. 

Satisfaction with outcomes is such an important piece of this puzzle.  Colleen, can you tell us a little bit about how MSK works with their patients to track their outcomes post-surgery? 

Colleen McCarthy:  Yes, another good question, Carrie.  I think I sometimes tease my parents – patients that they never get rid of me.  So, for example, we see our patients annually, whether it’d be 12 or sometimes every 18 months.  We invite them to return for follow-up.  And the goal of those follow-up visits is multifold. 

So, the first thing we do is do a physical exam and have a look and a feel for any lumps or bumps.  And certainly, part of this evaluation is looking for any signs of recurrent cancer albeit extremely rare. 

And then we’re looking to see if there’s any changes in the implant or the autologous tissue reconstruction and to check in how women are feeling and how they’re functioning with the reconstructed breast. 

And one of the exciting things we do as part of that visit as well is have patients fill out something called the breast queue, which is a questionnaire that was developed now about a decade ago with inputs from over 2,000 reconstructive breast patients here at Memorial Sloan Kettering.  And the questionnaire was developed specifically after interviewing these women to find out specifically what was important to them. 

So, for example, the questionnaire asks questions about how do your reconstructive breast feel to the touch, how do they look in clothing, how do you look when you’re undressed, and then even asks about sexual wellbeing and body image and how confident, for example, a woman may feel about her body when she’s with her partner. 

So, all of our patients who come in for a follow-up are invited to fill out the questionnaire.  And we treat this report that we get back almost like a lab value.  And we can review it with our team and with the patient. 

And it also allows us to sort of see if there’s any red flags.  For example, if someone is having more sensory pain then most people at this stage of the game in their reconstructive process, and so, that would be a red flag, or someone’s experiencing more body image issues then most of women who’ve been through a similar process.  So, it really helps us make sure that any problems are addressed down the line and in the survivorship period. 

Carrie Stern:  Great.  Emily Clark is a Physician Assistant and the Manager of the PAs and nurse practitioners on our plastic and reconstructive service.  One of the questions we got from a lot of readers was about nipple tattooing and nipple-sparing surgery.  Emily, can you tell us a bit more about the options out there for women when it comes to nipple reconstruction? 

Emily Clark:  Yes, definitely.  I think that the topic surrounding nipple reconstruction is a great question and is really often something that isn’t covered in much depth at the initial consultation because oftentimes, we don’t want to overwhelm our patients with too much information at that initial visit. 

But firstly, I’ll talk about – a little bit about nipple-sparing surgery.  So, some patients are candidates to have nipple-sparing mastectomies, and that really means that at the time of the mastectomy, the nipple and areola tissue are not removed. 

However, due to things like tumor size or location or really the type of breast cancer that the patient has, many patients are not able to keep their nipple and areola.  So, for those patients, we have many different options for nipple reconstruction. 

So, really starting with the most simple option is that we can do a nipple and areola tattoo.  So, this is something that is not actually 3D, but it is made to look 3D.  And here at MSK, it’s a short procedure that’s done in our outpatient office and really has a minimal recovery.  For patients that ask, “What is the simplest thing that I can do for a type of nipple reconstruction,” I think tattooing is usually what we recommend. 

For our patients – some patients want an actual projected nipple.  And so, for those patients, our surgeons can do a nipple reconstruction, and that is kind of where some incisions are made and the skin of the breast is folded up to make a little projected nipple there.  This is also a pretty short and simple procedure that is done in the office but with some local anesthesia.  We want to make sure that the patients don’t feel any of that procedure. 

Most of our patients that get nipple reconstruction where they have the projected nipple made, additionally, will have a tattoo for some color on top of the nipple reconstruction once it’s healed to make it look as natural as possible. 

Lastly, the third option that we could do is nipple and areola reconstruction, which is a little bit more involved.  That involves picking a little piece of skin from someplace else on the body in order to make the nipple and areola a bit more projective. 

This procedure is done in the operating room and requires a one-week recovery or so.  So, there are really a number of different options that are available for patients from nipple reconstruction after a mastectomy. 

Carrie Stern:  And what are the current trends, meaning do you find more women pursuing tattoos only at this point or more traditional nipple reconstruction? 

Emily Clark:  I think we have seen a bit of a trend in the last few years for more tattooing only.  I think the quality of the tattoos that are being offered now are significantly better than they were 5 or 10 years ago.  And so, we do probably do more tattoos alone now versus a tattoo with nipple reconstruction or other forms of nipple reconstruction, but really, when we meet with the patient, we go through all of the options and see what their – what their preference is. 

Carrie Stern:  Great.  So, I know that we briefly discussed the various types of reconstruction.  There was one listener that asks specifically about flap options or using your own tissue for very thin women, which I wanted to briefly address. 

As was mentioned, the most common place to take – to create a breast – to borrow for breast reconstruction is the patient’s abdomen where there are other – however, there are other areas, which were – which were mentioned before, including the back and inner or outer – the outer thighs. 

But for thinner patients, the question often comes up, “Is it possible for patients to have a breast reconstruction using their own tissue when they have little extra body fat?” And the answer is, for many women, yes.  One may need a stacked flap reconstruction, which uses multiple flaps from more than one donor site, more than one area to form a breast in order to achieve the desired or appropriate size.  So, just something for thinner patients to note if they are interested in pursuing breast reconstruction using their own tissue, there are often other options available. 

Emily, many listeners wanted to know how long the entire reconstructive process takes and what the recovery is like.  Can you take us through the timeline and what women can expect in terms of recovery? 

Emily Clark:  Sure, Carrie.  This is a really common question that we get asked for patients because they are wondering what their time commitment is going to be for reconstruction.  So, usually, the length of the reconstructive process can depend on the need for any additional breast cancer treatment. 

However, for patients that don’t need any chemotherapy or radiation after their surgery, this process can occur in as little as four to six months.  For patients that might need other treatments like chemo and radiation after surgery, this process can lengthen to over a year. 

Additionally, the recovery process and the timeline really vary based on the type of reconstruction.  So, kind of briefly for implant reconstruction, most patients who are out of work for about one to two weeks after their initial mastectomy and reconstruction procedure and then back to their normal activities after about four to six weeks.  The timeline for intent reconstruction can be in a bit of a shorter window. 

However, for reconstruction using your body’s own tissue like the flaps that we’ve mentioned so far, the recovery is a bit longer where patients are usually out of work for about six to eight weeks and then maybe resuming back to their normal activities three to four months later. 

Carrie Stern:  Thank you.  I want to turn specifically to talk about implants, which we got a lot of questions around.  Many of our listeners wanted to know about the safety of implants.  Colleen, can you speak to that? 

Colleen McCarthy:  Absolutely.  And I think to sort of address that question, it may help just to go back in time a little bit.  It was early in the 1960s when the first silicone implant was developed. 

Fast forward 30 years in the early – well, in early 1992, the FDA put a moratorium on silicone implants for cosmetic use.  They were still allowed to be used in the United States for reconstructive purposes and they were still used for both cosmetic and reconstructive purposes in Canada and Europe, for example. 

In 2006, the FDA lifted its restrictions.  It said, “We looked at all the evidence to-date and we don’t think silicone implants can be linked to autoimmune disease, to breast cancer, to other health problems.” And so, they allowed use of a silicone implant, again, in the United States. 

So, fast forward to where we are today, breast implants have been studied.  In fact, they’re one of the most studied medical devices on the market.  On the market today, we think about implants in terms of the shell of the device and then what’s inside. 

So, you can have a smooth shelled or smooth walled implant or a textured shell or a textured wall, a rough surface to the implant.  And within each of those shells, you can have a salient or salt water-filled device or a silicone-filled device.  So, for example, a woman may choose to have a smooth saline or a smooth silicone implant filled. 

There are definitely differences between the look and the feel of a saline versus silicone implant with most women choosing silicone implant because they like the look and the feel of it better.  What can happen to these implants?  They can get a leak or a tear in their shell.  It doesn’t matter what’s inside, saline or silicone, that shell has the same leak rate, but it is – if that implant were to leak, there are differences as to what happens next. 

So, for example, if a saline implant leaks, that saline or salt water gets absorbed by the body, it’s the same fluid that you would have in an IV, for example, and the implant deflates.  We would say, “Okay, we did all this hard work to stretch the skin, we should return to the operating room in a couple of weeks to swap out the device.” The chance of that happening is near 10% to 10 years, meaning 90% chance at 10 years that everything is okay and a woman carries on with her original implant. 

If that same tear or crack in the shell happens with a silicone-filled device, nothing happens looking outward, meaning physical examination wouldn’t detect a leak or tear because that silicone inside is a semi-solid and so the implant typically doesn’t change shape.  So, the FDA is recommending looking long term at implants with MRI or ultrasound to see if we can detect the leak. 

That said, these recommendations are somewhat controversial because there is silicone in the shell, there is silicone on the inside and we’re not – there’s no documented concern or general systemic health issues from a leaking silicone implant per se. 

Carrie Stern:  Thank you.  And that brings up sort of our next follow-up question, which is, should you have regular MRIs to check on implants?  And more specifically, how does MSK follow patients after they’ve had implant reconstruction or reconstruction in general?  Emily? 

Emily Clark:  Yes, I think Dr. McCarthy really covered a lot of why we would – the different types of implants and how we would check on them.  And I think at Memorial, it is usually our recommendation to see the patients every one to two years to follow them clinically.  I think a lot of times, that is even more important than some of the imaging that we get.  But then for our patients that have silicone implants in place, we will get a screening ultrasound or MRI to make sure that their silicone implants are still intact. 

Carrie Stern:  Great.  Recently, a specific type of textured implant has been associated with a type of lymphoma.  Colleen, can you share a bit more on this condition and what women need to know? 

Colleen McCarthy:  Yes, and I’m glad you raised that, Carrie.  So, we just said that you can have a smooth walled implant or an implant with a textured shell or textured wall.  It was about nine years ago when the FDA first released a statement saying they were aware of a link between a textured implant and a type of lymphoma.  This lymphoma has been named breast implant-associated anaplastic large cell lymphoma or nicknamed ALCL for short. 

We now know of about 733 cases worldwide of women who have been diagnosed with a lymphoma due to a textured implant.  Different manufacturers have different texturing processes for their textured implants.  And it appears that there are different risks associated with each different type of texturing. 

It was within the past year that the FDA recalled Allergan, a specific manufacturer of a textured implant, all of their textured devices, so textured devices that had saline inside and textured devices that have silicone inside. 

The FDA did not recommend that women return to the operating room to have their implants removed but they are no – Allergan can no longer sell these devices worldwide.  There are some women who are returning to discuss removal and replacement or even just removal alone of their textured implants.  And that again comes down to that – absolutely a choice that woman can – and that woman can make. 

It is difficult to determine the accurate level of risks for an individual.  We do know that the longer a woman has a textured implant, the slightly higher risk of developing a lymphoma, but the risk estimates currently range from 1 in 500 at 10 years to 1 in 30,000. 

So, what we do know is that it’s a very rare disease and quickly, it presents with a very large amount of swelling, something that a woman would notice.  You don’t – I’d like to say you don’t need a white coat to notice if you have this change, and in rare cases, that presents with a mass or a lump. 

So, it presents itself that it’s readily detectable.  And in short, the treatment is removing the device with the capsule or the scar any area that the textured shell touched, and the success rate of that is extremely high. 

Carrie Stern:  Thank you.  I think that’s great information for lots of patients who are worried about having had textured devices in place.  We also had a lot of questions about breast implant illness, which I can talk about. 

Breast implant illness is a term that some women and doctors use to refer to a wide range of symptoms that can develop in women with breast implants both following breast reconstruction and cosmetic augmentation. 

It can occur with any type of breast implant, silicone gel, saline, smooth textured.  And breast implant illness really impacts individuals in very unique ways.  These wide range – some of these symptoms include things like joint and muscle pain, chronic fatigue, memory and concentration problems, anxiety, depression, sleep disturbances, headaches, gastrointestinal problems. 

And the symptoms that have been reported can appear anytime after implant surgery.  Some people develop symptoms immediately while others develop them years after they’ve had their implants placed. 

There are some women who have breast implant illness also have a diagnosis of a specific autoimmune disease but most do not.  And in some cases but not all cases, surgery to remove the implants improve or resolve these symptoms. 

What’s important to note is that breast implant illness is not currently recognized as an official medical diagnosis and there are no commonly used diagnostic tests or diagnostic criteria specific for breast implant illness. 

So, unfortunately, there isn’t much research on the outcomes after implant removal surgery to-date, and it’s not possible to really predict whether the removal of implants will improve a patient’s specific symptoms.  I hope that there will be more research on this in the future so that we can better educate and counsel our patients.  Mary Jane, how do you help women who have anxieties specifically about implants either post-surgery or as they are making their initial decisions about reconstruction? 

Mary Jane Massie:  Oh, that’s a very good question.  Women who I have a chance to meet before they meet our plastic surgeons often are anxious because they know little about surgery, they may have heard a little bit from other women, they feel there will be thousands of options and, “How on earth am I going to sort through what’s right for me?” 

But once they have a chance to sit down with our plastic surgical team, they get to hear a discussion like we’ve all heard today.  Not every option is the right option or the right pick for any particular patient. 

So, women have a chance to talk through, “What are my goals and what would be my options, what would be best for me?” I think as we’ve heard today, the staff – our surgical staffs talking with women are pros.  We realized for the patient, it’s the first time she’s ever been through this process.  For us, our surgeons have been through this thousands of times.  So, I think patients realize that they’re in the hands working with an expert in this area and that helps calm anxiety significantly. 

Occasionally, a woman says to me, “I’m so nervous.  The night before surgery, I’m not going to sleep.  Could I take some type of a pill just to relax as I’m driving into the hospital that day?” And for those women, of course, we have medication that will help you get through the night before surgery. 

Usually, people after the surgery is over feel wonderful about what they have done.  So, anxiety postoperatively, in my experience, is not a significant problem.  Usually, it’s pretty [obvious] concerns that women have. 

Carrie Stern:  Probably because it’s a lot of the unknowns, right? 

Mary Jane Massie:  Some – absolutely.  And then once they get a chance to go to the surgical center and see the – see the professionals in that center, once they get a chance to see that their surgery has gone beautifully that they looked the way their surgeon said they were going to look, that all helps women feel so much better. 

Carrie Stern:  Colleen, one listener asked, is it possible to remove your implants and have flap reconstruction at that point instead of replacing your implants?  Can you comment on that? 

Colleen McCarthy:  Yes, sure.  And the short answer is absolutely.  So, if a woman has a tissue expander even or an implant and wishes to change course and remove her device, we would simply unzip her same incision, her mastectomy incision, remove the tissue expander or the implant and then look to what best donor site, where is her best extra tissue that we can safely transfer, and we transfer that tissue and fill that pocket or that skin envelope with her own tissue. 

Often, the women who will choose to do that are women who’ve had radiation and, as you described earlier in the conversation, have extra scarring or a capsular contracture around the device.  But certainly, someone can decide to change course simply because they elect to do so or their goals are different or their preferences are different.  So, absolutely, that’s a possibility. 

Carrie Stern:  For women who may not need a mastectomy, one of the areas that have greatly expanded over the last several years is reconstruction after a lumpectomy, which I can explain a bit more about. 

Oncoplastic surgery refers to partial breast reconstruction after lumpectomy.  For many women, lumpectomies cause very little scarring or changes to the breasts.  But still, lumpectomy is more involved and the – and results in a more obvious asymmetry or deformity. 

There are several ways to enhance the appearance of the breasts.  Some of these include a breast lift or breast reduction or even tissue transfer similar to how it’s done with a breast reconstruction following mastectomy. 

And so, if you are considering oncoplastic surgery, particularly good for patients potentially with smaller breasts and larger tumors, for example, where the lumpectomy will cause a significant asymmetry or deformity, breast surgeons and plastic surgeons work together to perform this procedure and plan it too and coordinate your surgery accordingly.  And the purpose of this is truly to improve how your breasts look after lumpectomy.  And it’s important for patients to know that oncoplastic surgery is possible. 

Let’s talk a bit more about the choice not to have reconstruction.  I know we briefly touched on it earlier, but Emily, what does going flat actually mean and what are the considerations for women during this process? 

Emily Clark:  That’s a great question, Carrie, because many patients come to the plastic surgeon’s office thinking that they must have reconstruction because their breast surgeon told them to go to the plastic surgeon when, in fact, really not having any reconstruction is an option for them also. 

And, in fact, if a patient asks, “What is the simplest thing that we can do after a mastectomy,” then that would be no reconstruction for them.  Going flat really means that a patient had a mastectomy where all of their breast tissue was removed and then did not have any form of breast reconstruction. 

So, after the mastectomy, they have an incision on their chest and, as we say, they’re pretty flat there.  Some patients choose this option because they are too overwhelmed at the time of their initial cancer diagnosis to make that decision. 

I think it’s clear from our conversation today that there are many different options even amongst implants and many different options amongst autologous tissue that sometimes for patients at the initial diagnosis time thinking about making one more decision is just too much for them.  And so, oftentimes, that is why a patient might choose to have no reconstruction. 

Other times, patients might choose this option simply because they don’t want to do any other follow-up.  They want to have their mastectomy and not have to worry about coming in for any other visits after that, and so, sometimes patients will choose that because it requires the least maintenance. 

For patients that opt not to have breast reconstruction, they can get fitted for a breast prosthetic to wear inside their bra.  And so, a breast prosthetic is basically a cotton or silicone mold made to look like a breast shape that they can wear inside of their bra to either make them look symmetrical if they’ve had a mastectomy on one side or to kind of fill out a bra and make them feel comfortable in their clothing if they’ve had a bilateral mastectomy.  So, certainly, even if they choose not to have reconstruction, there are still things that can be done to make sure that patients work and feel comfortable in their clothing. 

Carrie Stern:  Absolutely.  And just to add one additional comment, breast reconstruction can be done at the time of mastectomy or at a time at any point after mastectomy.  And so, for women who decide to not have reconstruction and go flat at the time of the mastectomy, they had – still have plenty of options for reconstruction at a later date.  And so, there’s always the opportunity for breast reconstruction in the future if they decide not to have reconstruction at the time of the mastectomy. 

Mary Jane, would you – what would you say to a woman who was contemplating not having reconstruction? 

Mary Jane Massie:  I think our previous speakers have just nicely laid out the options.  Some women are – a small percentage of women, in my experience, are just overwhelmed as you’ve been told and I just can’t think about doing this right now. 

So, it’s nice that those women can be told, “If down the road, you change your mind and you want to have reconstruction, we’re happy to help you.” I think that many of us, women, people like to be in the driver’s seat.  So, knowing that, “This is my choice, I may do this, I don’t have to do this, I will decide if I want to and when I want to,” I think helps women feel better about any decision that they’re making.  So, we’re always the person who gets to decide. 

But I say to women, “Go talk with our plastic surgeons,” and often patients come back and say to me, “That was really helpful.  I got it.  I got what they could do.  I can do this.” So, listen to what a plastic surgeon has to say, let them present your options, and then every woman gets to decide for herself what she’s going to do. 

Carrie Stern:  Great.  Colleen, we got a lot of questions around recurrence.  What do women need to know when it comes to recurrence and reconstruction? 

Colleen McCarthy:  Okay, well, yes, and this is a question that comes up often in my practice.  So, years ago, we did a very big study here at Sloan Kettering where we looked at all women who had been treated for primary breast cancer, and we put them into two groups, one who had reconstruction and one who did not.  And we made sure those groups matched in terms of their risk of recurrent cancer. 

And what we found was, first, the incidence of recurrent cancer is indeed very low.  But there was no difference in the number of women who had a local recurrence or who had local regional recurrence or who ultimately developed metastatic disease. 

And in those small number of women in those two groups, there was no difference in how big the tumor was at the time that we found a recurrence or the stage that the disease was at the time of recurrence. 

This was an important paper and it has been corroborated at different institutions around the world, all the evidence pointing to the important fact that we don’t think breast reconstruction encourages new or recurrent breast cancer. 

Women typically do not go for screening mammography on the reconstructive breast or breasts, but the fastest way to determine if there’s a local recurrence is an examination.  So, thus, again, that we talked about coming back on an annual basis or every 18 months for a look and feel. 

And anything we would need to see or to feel would be in the skin right under where – or right over where that breast gland used to be on top of the reconstruction.  So, things readily present themselves and, again, we don’t think we’re doing anyone a disservice by delaying detection of recurrent disease. 

Carrie Stern:  Mary Jane, I would imagine this is a topic that comes up with all types of cancer.  But how do you counsel women to help them deal with anxiety around recurrence specifically? 

Mary Jane Massie:  Oh, that’s a great question because really, 100% of people who have cancer and go through a cancer treatment, men and women, breast cancer, other cancers worry, “What if my cancer came back?  I’m lucky now, I got great treatment, but what’s going to happen if it comes back?” 

I think we, doctors, realized that everything we know, we learned from the patients we get to work with, and what I’ve learned from patients is anxiety is really high in the first – about recurrence is really high in the first year after treatment. 

But mostly, what I’ve learned from women with breast cancer is as time goes on and as women continue to see their plastic surgeon, their oncologist, radiation oncologist, as they start to get reassurance, the idea of, “I think I’m okay,” starts to sink in. 

And what people tell me is, “I passed the three-year mark, and after that, I was really feeling better again.” I don’t think people ever forget that they had cancer but a lot of my patients say to me, “My biggest worry is the night before my follow-up visit.  I’m able to put it out of my mind, I live my life, I enjoy my life, my work, my family, my hobbies, my career, whatever.  But the night before surgery,” – or I’m sorry, “The night before a follow-up visit, that’s when I start to feel worried again.” 

But the good news is I think most people would say, “I am able to live a good life.” We’ve had a study, a long-term follow-up study of women who had breast cancer for over 20 years who had had a breast cancer treated at least 20 years previously. 

And interestingly, what we found in that study is that women said breast cancer was a thing that had happened in their life, but was not necessarily the most important problem they had had, which I think for those people who are worried about breast cancer treatment, that’s a reassuring note. 

Carrie Stern:  Absolutely.  Several listeners asked about exercise after breast reconstruction and when it’s safe to resume.  Emily, can you answer that for us, please? 

Emily Clark:  Sure.  So, after reconstructive surgery, patients will have some restrictions kind of depending upon what type of reconstruction that they had.  So, generally speaking, after a mastectomy and implant reconstruction, we wouldn't want patients to lift anything heavier than 5 or 10 pounds for a few weeks after surgery.  But rarely, immediately after surgery, they’re able to resume their normal daily activities like brushing their teeth, washing their hair, kind of getting up and moving around. 

For patients that have a more involved type of reconstruction, for example, where we use their own body tissue for their breast reconstruction, they will have more restrictions in addition to the restrictions from their mastectomy in the chest area. 

And that’s mainly because, as we’ve discussed, they will have a secondary surgical site.  So, sometimes for patients, if we use their abdominal tissue, they’ll have some restrictions based on their abdomen.  If we take tissue from their thighs, they would have some restrictions based on that area as well as any restrictions that we would give to their arms from their surgery in their breasts or chest area. 

For all patients post-mastectomy and reconstruction, we actually encourage certain arm exercises or stretches.  And these are really simple things that we have patients do like rolling their shoulders forwards or backwards or slowly crawling their arms up above their shoulder level.  And that information is really information that we give to patients even before they have their mastectomy surgery so that they are well-prepared for what they’re going to be able to do immediately after surgery versus what they’ll be able to do four, six weeks later down the road. 

For patients later on down the road, meaning months to years after their surgery, most patients are really able to get back to all of their normal activities.  And for some people, it takes a little bit longer than others, but most patients, if they were runners before surgery, a few months later, they’re back to their running or skiing or really whatever working out or physical activity that they were doing before surgery.  Most patients once they are well healed are able to get back to their normal activity. 

Carrie Stern:  Definitely reassuring for a lot of patients.  Lastly, Mary Jane, it can be hard for anyone to get back to feeling normal after cancer treatment.  What are your specific guidelines or guidance for women who are having trouble getting back to what feels like their normal selves after breast reconstruction? 

Mary Jane Massie:  I think that what we’ve learned from our patients who attend our breast cancer support groups or women we’ve had a chance to work with in therapy, getting – what helps us get back to normal is women say it’s getting back to normal.  “It’s getting involved in my hobbies, with my family, resuming sexual activities, getting involved in my exercise program, going back to work, answering questions from coworkers like, what have you been through and how are you feeling right now?” 

“But getting my life back the way it used to be and letting myself move forward and see that I have accomplished a tremendous amount in six months, three months, six months, a year of cancer treatment, and as I am able to now be part of the world that I used to love being part of,” most women make a wonderful transition in that area. 

Carrie Stern:  So, we’re coming up on the – on the hour.  I do want to thank everyone who submitted questions and thanks to all of you who made the time to join this call today.  We hope that you found it informative and helpful.  I also want to thank our amazing speakers. 

We plan to host more calls like this in the future and look forward to speaking with you again.  Additionally, a replay of this call will be available soon on our Web site mskcc.org.  We are dedicated to moving your cancer care forward and really want to encourage you again to be in touch with your MSK doctors and care teams.  Make all your necessary appointments and schedule any necessary screenings.  Please don’t delay your care.  Be safe and take care of yourself and your loved ones.  Thank you and have a good evening. 

Operator:  This concludes today’s call.  Thank you for joining Memorial Sloan Kettering’s Information Session for Patients and Caregivers.  Have a good evening.