It used to be taboo to worry about cosmetic results following breast cancer surgery. Surgeons and patients were focused on one result – removing all of the cancer. How a woman’s breasts looked after surgery was not important.
Fortunately, times have changed, and so have medical advancements. Dedicated breast surgeons and reconstructive surgeons can accomplish both – remove the cancer and restore a woman’s breasts to a cosmetically natural look!
During The Breast of Everything podcast, Eric Brown, MD, Comprehensive Breast Care surgeon, and William Stefani, MD, plastic surgeon, talked about breast reconstructive surgery advancements and what women can expect today.
As surgeons, we ask our patients what is important to them. What do they want their breasts to look like after surgery and treatment? We know their cancer will be treated effectively, but we also want them to have the best cosmetic results. Most women have their whole life ahead of them, and they want to feel good and look good.
This is when oncoplastic surgery merges with breast surgery to achieve the results women are hoping for. The two surgeons have a meeting of the minds prior to the woman’s surgery to determine the best course of treatment for the patient and map out a plan for the best breast conservation possible with the most cosmetically natural looking breasts.
During surgery, the breast surgeon takes out as much breast tissue as possible so the pathologist can have a large specimen. The oncoplastic surgeon sculpts and shapes the remaining tissue of the breast and performs a breast reduction (if needed) and a breast lift. During this one operation, the plastic surgeon also looks at the healthy breast to see if it has any pre-cancerous cells.
Patients report they love the results and love that they only need a single surgery in most cases! That is why it is so important to have dedicated surgeons with specialized training to conduct the surgery. National data shows that if the surgery is conducted by a dedicated breast surgeon, the need for a second surgery is only 15 percent; when an oncoplastic surgeon is involved, the number drops to less than 5 percent.
Dr. Stefani points out that radiation will affect the size of the breast. Radiation doesn’t discriminate, he reports. The breast will shrink over time as a result of radiation, so the surgeon will reduce the size of the healthy breast to match the size of the lumpectomized breast. Patients should also know that, in order to achieve the best cosmetic outcome, traditional radiation will be recommended. This means about 30 to 35 treatments in lower doses over a longer period of time.
One of the most significant issues breast surgeons face is obtaining clear margins. A clear, negative, or clean margin means there are no cancer cells at the outer edge of the tissue that was removed. A positive margin means that cancer cells come right out to the edge of the removed tissue. During a lumpectomy, your surgeon’s goal is to take out all the breast cancer plus a rim of normal tissue around it to make sure all of the cancer has been removed.
If women without breast cancer want voluntary breast reduction, Dr. Stefani notes the three risk factors involved: smoking, diabetes and a high BMI. In the majority of cases, he will not conduct elective breast reduction surgery on these high-risk patients.
During the podcast, Dr. Brown and Dr. Stefani also discussed fat grafting (also sometimes called lipo-filling). The plastic surgeon uses liposuction to harvest fat as a measure to keep as much of the collagen content as possible, which helps restore the breast’s shape and suppleness, helps improve blood supply and helps with wound healing.
Fat grafting has revolutionized medic
Unknown Speaker 0:01
Welcome to the breast of everything podcast your trusted resource for breast health information, support and encouragement. Your host today is Dr. Eric brown of comprehensive breast care. Welcome.
Unknown Speaker 0:13
Welcome to the breast of everything podcast. I'm your host, Dr. Eric Brown. And I remain pleased and excited to be talking to my friend, my colleague, and a fellow resident with me, Dr. William Stephanie, tetra Stephanie is a board certified plastic surgeon. He did an aesthetics fellowship after his plastic surgery fellowship, he does a lot of breast reconstruction. And he and I have worked together for longer than we like to admit, it's been a very, very long time. But it's been great. And he and I work together doing a lot of what we talked about on our previous podcast. And now I'd like to kind of move into aesthetics as it relates to breast conservation. As I mentioned, on our first podcast with Dr. Stephanie, it's really important to us as a breast cancer and breast care providers to really give a good cosmetic outcome. It used to be taboo, to be worried about how it looked, patients had cancer, we needed to treat the cancer and the appearance physically was just kind of friendly fire and you had to deal with it. But now things are totally different. And it's really incumbent upon us as breast surgeons, to really ask our patients the question, what is important to you? And what do you want to look like when this surgery and treatment is over, because the cancer is going to get treated, it's going to get cured. Most women have long lives ahead of them. And you get out of the shower every day, and you're going to look in the mirror, and we want them to be happy with that. As it relates to breast conservation or what's known as lumpectomy or partial mastectomy. One of the most significant issues that we run into as breast surgeons is obtaining clear margins, the margins or the periphery around the tumor that you've removed, there needs to be no tumor going up to the edge. It's always been a battle for us and a frustration when it turns out that microscopically, the margins are not clear. So somebody smarter than me one day had the idea that when you think about a plastic surgeon doing a breast reduction, plastic surgeon is actually doing a lumpectomy, they're just not lumpectomy, anything, they're not taking out any cancer, they're just taking out tissue. So along came the birth of what is referred to as oncoplastic surgery. Now oncoplastic surgery also includes mastectomy and mastectomy based reconstruction that we talked about previously. But let's talk a little bit if you will, about oncoplastic surgery as it relates to lumpectomy and how have you and I've been able to work together to improve cosmesis and in many ways improve our ability to achieve clear margins.
Unknown Speaker 3:14
So oncoplastic is basically a lumpectomy with a breast reduction or a breast lift. And what does that mean? I mean, what we're doing is you and I get together preoperatively, we decide how we're going to outline how I'm going to try to keep blood supply to the nipple. And then you can take out as much tissue as you can in even more to get a very large specimen. And then I can go back and try to rearrange the tissues, make it so that there's no depressions or divots, let's call them and try to keep the breast mound in shape is natural and aesthetically pleasing as we can so and then go to the control of the other breast and make that one smaller, and try to match it to the lump victimized breasts breast and honestly it has changed this lumpectomy for people because now they now as you know if there's a microscopic tumor, or a very small tumor with no lymph nodes, and you do a large lumpectomy, we've got to look at the rest of the breast tissue in that cancer breast. Plus, we get to look at the other side and see if there's any precancerous disease in it. And many times that's the end of the operation which is fantastic for them.
Unknown Speaker 4:45
Yeah, absolutely. From an aesthetic standpoint, you really can leave the operating room knowing that you took care of their cancer and you know that they're going to be happy with that result. And like most cancers that treatment is what we refer to as multidisciplinary. When we map out a treatment plan for somebody, there's a surgical oncologist, a medical oncologist, a radiation oncologist to pathologist will in much the same way. The oncoplastic approach to a lumpectomy is multidisciplinary, the surgical oncologist, the plastic surgeon, the radiologist, the pathologist, kind of work as a team to outline what is the best approach for that particular tumor, we kind of divide the oncoplastic procedures into level one and level two. So even a smaller breasted woman that perhaps might not be a candidate for a big reduction type procedure, when we do the lumpectomies, without a plastic surgeon, we also do some minor tissue rearranging so as to avoid having the dent or the dividend the breast. But when you have a larger breasted woman, that's just a perfect opportunity to at least engage ourselves in the southeastern Michigan area with our dedicated breast reconstructive surgeons to work together with us. Have we ever had a patient that was unhappy following that bill? I don't think I've had any,
Unknown Speaker 6:10
no, I, honestly, the only thing that changes them is a radiation to that breast cancer side. And where it changes that breast and makes it a little firmer, but otherwise, every single one of them is so happy. It's just, it's really changed my approach to to these, at least console consulting with these breast patients to tell them that, listen, we're not compromising your breast surgery, we're making you feel better, your back will feel better, your aesthetically your breasts will probably look better. And you're getting a great cancer operation. I mean, what how can you deny that?
Unknown Speaker 6:51
You know, it's actually kind of interesting, because I talk to women all the time when we introduce this concept. And they almost feel guilty. You know, they feel like I have cancer, but I've kind of always wanted or lift in a reduction. And here, I'm going to use the cancer as a reason to do that. And obviously, it takes a lot of reassurance that that's nothing to be feel guilty about at all.
Unknown Speaker 7:15
Exactly. And as I, as I mentioned previously, they are worried that one, is this going to be an adequate cancer operation? And I try to tell them, Listen, this is more than adequate, this is the best, because we're looking at both breath.
Unknown Speaker 7:31
Now, you mentioned radiation. It's interesting. And I have a question about that, you know, the radiation does cause changes. And it's important that that women know that doing the approach via an ankle plastic reduction, it still does not negate the need for radiation. So we still radiate these women. Do you do anything different one side versus the other, when you know, the one side is going to get radiated?
Unknown Speaker 7:57
Well, I try to make the other breast slightly smaller, because as you know, when they radiate, radiate doesn't discriminate, and it hits the fat cells, the collagen, and it will shrink that breast down over time. And because with weight gain, the other breast will get bigger. And the radiated breast will not change the size very much I try to make it a little bit smaller doesn't always work out that way. But I try to make it a little bit smaller.
Unknown Speaker 8:29
And same question we had in the last segment with smoking and diabetes. How does that come into play in deciding who is a good candidate for these procedures?
Unknown Speaker 8:41
So it's the same smoking and diabetes are for breast reductions. They're high risk, if there's a smoker, and a diabetic, and especially if their BMI is high. Those are three important signs for me to show say, Hey, you know, you better quit smoking. And if you don't, I mean, maybe you should lose weight before. So the three those three, if I have somebody that's coming in for an elective breast reduction, not the cancer ones where they have to have if they're coming in for an elective breast reduction, I will not do them if they have those three. Those three things together with if they say they're a little bit overweight, they're a heavy smoker and they're diabetic. They're they're a setup for wound healing problem.
Unknown Speaker 9:32
Yeah, and we and we stress that as well. In the office with these women. The most important thing obviously, is to stop smoking. I mean, that can't be stressed enough in terms of wound healing, risk of anesthesia. And, you know, it is a challenge, I'm sure for women who have this habit just like it's a challenge for those of us that like, like our pasta to kind of watch our pasta and take two
Unknown Speaker 10:00
So,
Unknown Speaker 10:02
yeah, I mean it it is and you know, you're trying to be more holistic in your approach, you understand that people do have lives that they live in habits that are hard to break. But this has really revolutionized our approach to lumpectomy. And if you look at the data nationally, the risk of women who have a lumpectomy needing a second operation because their margins are not clear, meaning the tumor cells go right up to the edge, that risk is about 25%. If you look at surgeons that are dedicated breast only surgeons, that risk is around 15%. But in the ankle plastic literature, when you're doing these white excisions, the risk of a positive margin which will require another operation is less than 5%. So, needless to say, when you take out more tissue, wider margins, you're certainly likely to clear all of those margins. The radiation changes a little bit only in the sense that nowadays, we've been kind of leaning towards doing a shorter course of radiation for women. But in speaking with many of the radiation oncologists, they're a little uncomfortable doing a shorter course of radiation with the oncoplastic procedures because there's just no data. So women that have the uncle plastic approach usually wind up having more of a traditional 30 to 35 radiation treatments, that's a much slower and lower dose of radiation which I think really helps with cosmesis as well. So, that cosmetic outcome is important to all of us not only the plastic surgeons and the and the breast surgeons
Unknown Speaker 11:47
right in I agree with you that the radiation does change is you know, some of the these people that get lumpectomy with reduction, or just have lumpectomy themselves will go back and will fat graft them. And as you know, when when we fat graft, the radiated breast, we can change the collagen content and the fatty content in there. And it will make it a little bit more supple. It improves the blood supply because it has growth factors and it actually has some vascularity properties to it which will help with wound healing. So a lot of the radiated even the love back demised oncoplastic and just a straight lumpectomy breast will fat graft down to increase the the blood supply and the suppleness and even if they have some contracture, anywhere from the lumpectomy that will help it
Unknown Speaker 12:45
so that's interesting. So what is fat grafting? I like to refer to it to patients as light bulb filling it sounds a lot softer than fat grafting but so what exactly are you doing when you're doing that?
Unknown Speaker 12:57
Well, pretty much that we liposuction areas and harvest the fat and there's multiple ways that we harvest but one of the ways that we like to do is just to harvest the fat wash it slightly try to keep as much of the collagen content that because what we found is that the mesenchymal cell which is like the the collagen cell of the that goes around the fat globules itself, so we get fat globules and we get these mesenchymal cells or fibroblasts in them as ankle cell which are a collagen cell. And we know that radiation changes the collagen and we know that radiation changes to fat globule. So we can put both of those in there, it can reverse some of these and I tell your your listeners to go on to adipose derived stem cells. And there's an there's also stromal stem cells. And those are the two that we think are in fat, and actually fat grafting is now I mean, it is revolutionize everybody's practice from orthopedic surgeons. That graft degenerative joint to get increased. I think it's the collagen mainly but some increase in blood supply. They fat grafted diabetic ulcers in the legs around the periphery with increased wound healing. And, and we use it cosmetically and we've known we've fat grafted almost everything you can imagine cosmetically, I've graphed it from feet to ear lobes. You name it, I've done it, but it does help and there's a lot of literature on how it helps the radiated breast and especially for reconstruction.
Unknown Speaker 14:45
That's great. That's it's it's stem cell transplant at its earliest, right.
Unknown Speaker 14:50
Correct. Correct. And it is, you know, one of the beautiful things talking about radiation again, is that I've even had people that have lost implants don't want to go autologous tissue or using their, their own back flap, or their belly fat graft them, when they've had an infection and lost an implant and they have minimal soft tissue covering over their chest while I'll fat graft that chest, then bring them back in fat graft them again and put an expander in, and then go back and put an implant in. And you'd be amazed at how supple and soft that tissue gets from just the fat grafting when it was almost would hard before that.
Unknown Speaker 15:35
That's interesting. And that's, that's just so terrific. I know that in France, there's some data about using fat grafting almost in and of itself for breast reconstruction. So nice to know that we're doing that same technique, if you will, in the good old US of A
Unknown Speaker 15:54
Yeah, we do we offer it to them, it's just you need, you need mag negative pressure with it, plus fat grafting. So it's it's a lot more of a procedure, and then you need a couple like multiple procedures to get enough fat in the breast.
Unknown Speaker 16:09
One of the other nice things about these oncoplastic procedures as they remain outpatient, right? We don't we don't have to keep these patients overnight, right, Bill?
Unknown Speaker 16:17
No, correct. We do a nice block, and aesthetically, which will last a day or two. And there it's basically our breast reductions have a recovery of roughly 10 days 10 to tend to 14 days. So they're pretty much back to normal in a week and a half to two weeks as an outpatient. Fantastic.
Unknown Speaker 16:38
Yeah, that that's just terrific. And we know from the oncologic side, typically the next step would be radiation or if there is chemotherapy necessary. That doesn't start for a month. So we have plenty of time for healing, for regaining good range of motion in the arm. It's again really revolutionized how we approach breast reconstruction, and how we approach breast conservation. Nowadays, my partner and I Petra gold, Dr. Richardson, we employ oncoplastic in, I'd say 50 60% of the lumpectomies that we do now. It's terrific.
Unknown Speaker 17:15
That's fantastic. That really that is a it's a great idea. And it's It was a long time coming. Well, I
Unknown Speaker 17:22
could talk forever, but I think we should kind of wrap it up for now. This has been fun and really encompassed. I hope for our listeners, some of the questions that I'm sure come up all the time. Bill, I can't thank you enough for taking the time to talk to us for an hour. Look forward to continue working with you. And certainly maybe we'll do another couple podcasts in the future.
Unknown Speaker 17:49
Great. Thank you very much for having me. It was it was wonderful. Terrific. Thanks, Bill.
Unknown Speaker 17:53
I'd like to thank everybody for listening. This is the best of everything podcast. I've been your host for the last two Dr. Eric Brown. And until next time, we wish you good health.
Unknown Speaker 19:30
You've been listening to the breast of everything podcast with your host and board certified breast surgeon Dr. Eric brown of comprehensive breast care if you have a subject you would like the surgeons to discuss. Please email your suggestions online at comp breast care.com that's co MP br e a s t c a r e .COMM The doctors want to hear from you. The views thoughts and opinions shared in this podcast are intended for general education and informational purpose. purposes only, and should not be substituted for medical advice, treatment or care from your physician or healthcare provider. Always consult your healthcare provider first.