Welcome back to an introduction to breast cancer, I'm Dr. Anees Chagpar. I am so glad that you're joining us today and I am so excited about our next expert interview. With me today, is Dr. Alex Au, he is a breast reconstructive surgeon and the Director of Breast Reconstructive Surgery at Yale. Thank you so much for joining me. >> Thanks for having me Anees. >> So Alex, in our lectures, we were learning a little bit about different reconstructive techniques. And how really reconstruction can help give a woman back that physical form. And really help her to get kind of over some of the emotional trauma associated with body image that many women can face. Can you talk a little bit about how that is in your practice? >> Sure, so breast reconstruction really is more than just cosmetic. Patients that don't have breast reconstruction or have had surgeries and have a deformity of their breast after surgery. Every morning, every day, they wake up, they see themselves, and it's a reminder of breast cancer. So we're not only trying to restore cosmetically pleasing breast shape, we're also trying to help a woman get past this experience of having breast cancer and move on with their life. And hopefully, every morning they wake up and they look forward to whatever they're going to be doing that day and they're not reminded of that experience of having breast cancer. >> Right, and so we talked a lot in our lectures about different kinds of reconstruction. We talked about tissue expanders and implants. And then we talked about using your own tissue. Tissue from your tummy, tissue from your back, from your buttocks, from your thighs, wherever. Can you talk a little bit about, how you decide with a patient which option is best for them? What are the advantages and disadvantages of each? And how do patients and you, as their plastic surgeon, figure out which way you're going to go? >> Sure, so with each patient it's a very individualized decision. In what I do, during my consultations with them are we go through kind of all the options. So, I review all their history, sometimes their medical history. Such as bleeding disorders, or previous history of blood clots. Those things can affect which type of surgery they're going to have. Additionally, whether or not they've had radiation, and any other treatments that they've had in the past, or could potentially need in the future, affect it. For instance, if someone has had radiation to their breast previously, and had a partial, following a partial mastectomy. They might be a better candidate for autologous reconstruction, using tissue from their belly or somewhere else. Because their own tissue tends to do a little bit better in the setting of having had radiation. So with that in mind it's very individualized. Nationwide, the majority of reconstruction is still expander and implant based. Somewhere probably around 80%, with 20% being autologous or using someone's own tissue. Really, the only time that I steer someone definitively towards using their own tissue is if they've had radiation. So, otherwise it's an open discussion. Expander and implant reconstruction has its risks, like you mentioned. It is a foreign body inside someone, so there's always the risk of infection and that's a life long risk. So 20 years down the road they could have an illness where they became bacteremic or have bacteria in the blood and that could potentially seed, or go to the implant. Other risks of implant reconstruction are capsular contracture, which is thickened scar tissue around an implant. In its most severe case, that scar tissue can become painful, and it can also change the shape of the breast, usually causing the implant to ride higher on the chest and be kind of more full up top. The other main risk that I talk to patients about expander and implant reconstruction, is the fact that implants can rupture. They're man-made, so with time, they do through wear and tear kind of break down. And the risk of having an implant rupture is about 1% per year. Those are the three main complications I discussed for expandure and implant reconstruction. Using someone's own tissue, obviously, that carries different risks. So number one, we're taking that tissue and usually totally separating it from their body. We're bringing it up to the breast and then we're sewing blood vessels back together to restore blood flow, both into and out of that tissue. So these blood vessels we're sewing back together can be very tiny, a millimeter, two millimeters sometimes. There's always the risk of a blood clot or a problem with the blood flow. So that's number one. Number two is, obviously, if we're operating on the belly, to take that tissue, there's the donor site, right? >> Yeah. >> So people can develop abdominal weakness. They can develop a hernia or a bulge, even just a fullness of the abdomen. So every type of reconstruction carries its own risks and I just try and discuss that with each patient. And then kind of fine tune it to what their wishes are and what they think might be acceptable to them and what risks they're willing to take. >> Alex, sometimes patients say, that they want a particular kind of reconstruction. Let's say, they say, we'd really love to have that tummy tuck, here's a two-fer, right? >> [LAUGH] >> Build the breast, take the tummy tuck, but sometimes they might not have enough tissue in their belly. Can you talk about that and how you kind of match their desires with what's feasible in terms of reconstruction? >> Sure, so if someone doesn't have enough tissue from their abdomen, there are other areas where we could potentially look. There's the inner thigh, with what's called a tug flap, or transverse upper gracilis flap. There's the buttock, with gluteal artery perforator flaps, so that's an option. If they don't have enough tissue anywhere and they really want to use their own tissue, it's not impossible, we could still do that. And there's other ways to further augment the fullness of the breast, so we could potentially put an implant later. Although if we're using someone's own tissue we generally prefer to try and avoid implants because of the complications associated with those. And then also we can do some fat grafting, so what that means is after we have transferred the tissue and it's had a chance to heal. We can do some liposuction from somewhere else on their body, harvest fat, prepare that, and then inject it into the breast to help fill up that breast. So those are potential solutions to that issue. >> Okay, so getting back to implants, there's been a lot of talk about saline and silicone. Can you talk about that and the advantages and disadvantages of each? A lot of people are still very scared of silicone implants. Should they be? >> Sure, so 15-20 years ago, there was a concern that silicone could be causing a number of heath problems. Specifically, autoimmune disorders, pain syndromes even cancer. So the FDA holds silicone implants off the market for the most part and then they looked retrospectively at the patient that had received them. And what they found was that they did not identify any true association between silicon implants and those issues. So silicon implants have been re-released for use, to the best of our knowledge, they're just as safe as saline implants. Now, there are differences, so in my experience, I've found that silicone implants tend to feel a little softer than saline implants. So saline tends to feel a little more firm and silicone has a little less risk of rippling. What that means is the breast skin after a mastectomy is fairly thin. Sometimes, you can kind of see the edge of an implant, underneath that skin in the muscle of the chest wall. And specifically with saline, you can kind of see some waviness, that's called rippling. The risk of that is less with silicon. The down side to silicon though, is that there is potentially a higher risk of capsular contracture, at least with the older silicon implants. And if a silicone implant ever ruptures or tears, you may never know it. A lot of the silicone that is filling these implants is generally a little thicker, it's not a liquid, it's more of a gel. And some of it may take a long time to leak out of the implant shell if there's a tear. Additionally, everyone forms some scar tissue around an implant called a capsule and, if a silicone implant ruptures, that silicon can stay within the capsule and you may never know that an implant is ruptured. So they do recommend surveillance for silicone implants after they put in. And usually, they recommend surveying them three years after they're put in and then every couple of years after that. >> With an MRI? >> Generally, with MRI. >> Okay, so let's talk a little bit about, does reconstruction increase a woman's risk of recurrence. A lot of people may still be worried that if they have reconstructions somehow that's going to increase their risk of getting cancer back or that it's going to be harder to find it when they do. >> Sure, so it does not affect the risk of recurrence. So the tissue we're putting there, whether it's from the belly or an expander implant, doesn't affect any of the cells that are potentially still there in the chest, that's number one. Number two, the studies have shown that if there is a recurrence that were still able to detect it and that there's no statistically significant difference. So it is safe and women can have this done immediately at the time of mastectomy and for the most part not have to worry that it's affecting recurrence or detecting a recurrence. >> So that's a really important point. Now the other issue that we talked a little bit in the lectures about was that many times when we do immediate reconstruction, we do that after what's called a skin sparing mastectomy. And at that, we take that nipple areola complex, thinking that the plastic surgeons can always build a nipple areola afterwards. Tell us a little bit about how that's done? >> Sure, so there's multiple different ways to reconstruct the nipple and the areola. For the nipple, in general, what we do is we use tissue that's already present on the breast. Usually, just the skin and subcutaneous tissue. And what I do, is basically I take some of that tissue and I make incisions, I lift it up and I fold it on itself to make a nipple. So it does leave a little additional scar there but I'm just using the skin and the dermis and some fat that's already there to reconstruct the nipple. And then what I do, is after that is healed, we tattoo for the colored portion areola. There are different ways to do that. So there's a number of different flaps, ways that people do basically skin origami to reconstruct the nipple. And then sometimes people are taking a skin graft or skin from somewhere else on the body and using it to help reconstruct the areola. >> So this nipple reconstruction part, happens after the main breast reconstruction part. Is that right? >> For the most part, yes. There are some plastic surgeons who choose to do it at the time of reconstruction usually if someone is using tissue from their belly. But for the most part it's done after the fact, the first part of any breast reconstruction is usually rebuilding the breast mound, or the part of the breast that projects off of the chest, and the nipple and areola come later. >> And so let's suppose a person has the breast mound reconstructed, and the shape isn't quite right. Can they still have things tweaked? >> Definitely, definitely, so we're shooting for the most cosmetically acceptable breast possible. And again, if it doesn't look right, that patient's going to wake up every day and focus on those issues that aren't right. And it's just going to remind them of their battle with breast cancer, so most certainly. I do a lot of scar revisions, making something smoother in a certain area by removing some extra skin and tissue. I also do fat grafting which we talked about earlier, taking fat from somewhere else and injecting it possibly to help fill up an area that has a contour issue. And sometimes with expander and implant reconstruction, someone decides after the fact that they wanted a bigger implant or a smaller implant, and we can always go back and fine tune those issues. >> Great, so the other issue is really how plastic surgery fits into that multi-disciplinary team. And you talked earlier about how, if people have already had radiation, that sometimes that will make you recommend autologous reconstruction. But what if they need radiation after their mastectomy, and they've had reconstruction? How does that play? >> So it can affect the timing of different steps, depending on the type of reconstruction they've had. So if they've had autologous reconstruction, say, using tissue from the abdomen, that tissue can get radiated and it was thought years ago that it would have really detrimental effect, make a lot of fat necrosis, or firm lumpiness, that the incisions could open up and you'd have open wounds. And I think some of that depends on how the radiation is given, whether they're boosting or adding extra fields to the internal memory nodes. But for the most part we found in the data and research in the plastic surgery literature that supported this that autologous tissue generally, tolerates radiation therapy fairly well. It can still tighten the skin and cause the breast to be a little smaller and a little lifted. But we can always do a secondary procedure on the other breast to make it a little smaller or a little higher, or even do some fat grafting to that radiated breast later to try and help soften things up. In the setting of expander and implant reconstruction. If someone has had an expander placed at the time of the mastectomy and then they find out that they need radiation. It's debated and plastic surgery what the right step after that is. Some people would say that you plan on having a radiation and then you take the expander out and then do a reconstruction using their own tissue. A delayed autologous reconstruction, so that's one option. Other options would be to expand while that patient was getting chemotherapy if they needed it and then either exchange for a final implant before radiation or our practice during Yale is to expand during chemotherapy. Let that patient get radiated, and then exchange that expander for an implant, several months after radiation has been completed. >> All right, are there ever situations where you think that immediate reconstruction, so reconstructing at the same time as the mastectomy, shouldn't be something that patients should consider? >> It's a tough question. So for the most part, I think almost every woman is a candidate for immediate reconstruction. If someone had an inflammatory breast cancer, where they were at very high risk despite surgery of having a recurrence. I might say, encourage that patient to discuss it more with their oncologist, their radiation oncologist and consider maybe a delayed reconstruction. Make sure that they're healthy, make sure that they've beat that cancer and then address reconstruction surgery later. >> Yeah, and especially with inflammatory cancers is, we talked about in the class, we want to make sure that we take all of that skin too. >> Yeah, exactly. >> So last question, where do you think breast cancer reconstruction is going in the future? What's new on the horizon that people should be thinking about or looking for talking to their plastic surgeon about? >> Sure, so there's new developments in all the different types of reconstruction. And there are new types of reconstruction on the horizon. I think for expander and implant reconstruction, implant companies are coming out with new types of expanders, shaped expanders, shaped anatomic implants. So changing the traditional shape had been Implant to look more like a breast. Those are all very interesting things that are happening. For using someone's own tissue, there are new flaps being developed. We're also focusing more, a lot of interest at the time when the DIEP flap or muscle-sparing TRAM flap was developed was focused on actually just getting the blood vessels to work properly, making sure it got good blood flow. And we've gotten so good at the micro-surgery part of it that now we're really focusing on the aesthetics of autologous reconstruction. So it's not just worrying about sewing those blood vessels together. It's worrying about getting those blood vessels together, but then making that look really like a fantastic breast. So that's kind of for autologous reconstruction. The latest development is there's this, and I don't know if you spoke about this in your courses, Brava and autologous fat grafting. >> Yeah, we didn't cover it, so please. >> You didn't cover, all right. So, traditionally tissue expansion has always been putting an expander on the inside filling it up and stretching out the skin but pushing it from the inside-out. Brava, is a device created by Roger Khouri who's a plastic surgeon in Florida. And it's basically a suction cup dome that sits over the chest and breast skin and it provides negative pressure. And what it does is it actually sucks that skin up, causing tissue expansion. Now if you just take that dome off, over time that skin will just go back down and the edema or swelling in that tissue disappears. But what we can do is after that skin has been stretched out, we can perform liposuction and we can transfer fat from somewhere else on the body into that stretched out skin and it helps preserve that expanded tissue. So that's a really exciting technique that's kind of being developed. That has been developed over the last couple of years. We're still trying to fine tune it here at Yale, but I think that it has a lot of promise. And it's something that patients should be at least aware of so. >> Excellent, well thank you so much for joining me. >> Thanks for having me Anees, this has been fantastic. >> All right.