Advanced Techniques in Breast Surgery

Transcript

00:00 --> 00:03Funding for Yale Cancer Answers is
00:03 --> 00:06provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:11Yale Cancer Answers features
00:11 --> 00:13the latest information on cancer
00:13 --> 00:15care by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:19of the battle to fight cancer.
00:19 --> 00:21This week it's a conversation
00:21 --> 00:23about advanced techniques in breast
00:23 --> 00:24surgery with Doctor Tristen Park.
00:24 --> 00:26Dr. Park is an assistant professor
00:26 --> 00:29and Doctor Chagpar is a professor
00:29 --> 00:30of surgical oncology at the Yale
00:30 --> 00:32School of Medicine.
00:33 --> 00:35Tristen, maybe we can start off by
00:35 --> 00:37you telling us a little bit more
00:37 --> 00:39about yourself and what it is you do.
00:39 --> 00:42Sure. So I'm an assistant professor
00:42 --> 00:44of surgical oncology specifically
00:44 --> 00:47taking care of breast cancer patients
00:47 --> 00:50and patients with breast disease.
00:50 --> 00:56I teach and help mentor medical
00:56 --> 00:58students and residents at the
00:58 --> 01:01Yale School of Medicine as well as
01:01 --> 01:03the Yale General Surgery program.
01:03 --> 01:06We also have a wonderful
01:06 --> 01:07breast cancer fellowship.
01:07 --> 01:09So we also train fellows.
01:09 --> 01:13and I help in their education and
01:13 --> 01:16clinically I take care of locally
01:16 --> 01:19advanced and early stage breast cancer
01:19 --> 01:23patients as a surgeon and my other
01:23 --> 01:25research interests include the use
01:25 --> 01:28of immunotherapy and the treatment
01:28 --> 01:31of triple negative breast cancers.
01:31 --> 01:35And I'm also involved in some international
01:35 --> 01:39work with collaborations with large
01:39 --> 01:40cancer centers in the East Asia,
01:40 --> 01:41namely South Korea.
01:42 --> 01:46Great. So let's dive into some
01:46 --> 01:48of the work that you've been doing
01:48 --> 01:50and particularly today we wanted
01:50 --> 01:53to find out a little bit more
01:53 --> 01:55about surgical management of breast
01:55 --> 01:58cancers as well as some of the more
01:58 --> 02:00newer techniques that are being used.
02:00 --> 02:03So maybe you could start off by painting
02:03 --> 02:05a landscape of what surgery really
02:05 --> 02:08looks like for breast cancer patients,
02:08 --> 02:10when do they need surgery and
02:10 --> 02:12what kind of surgery are we
02:12 --> 02:13talking about when we think about
02:13 --> 02:15surgery for breast cancers?
02:16 --> 02:20So anyone with early or
02:20 --> 02:23locally advanced breast cancer needs
02:23 --> 02:27surgery, that's part and parcel of
02:27 --> 02:29the multidisciplinary approach to
02:29 --> 02:32treating breast cancer in 2023.
02:32 --> 02:34So anyone that has breast disease
02:34 --> 02:36or breast cancer that's localized
02:36 --> 02:38to the breast or the lymph nodes
02:38 --> 02:41would need a surgery in conjunction
02:41 --> 02:44with local radiation therapy on some
02:44 --> 02:47sort of systemic therapy that may
02:47 --> 02:50be chemotherapy or endocrine therapy
02:50 --> 02:52and now immunotherapy as well,
02:52 --> 02:54something that targets the immune
02:54 --> 02:56system to help decrease the size
02:56 --> 02:58of the cancer if not make it go
02:58 --> 02:59away and prevent recurrences.
02:59 --> 03:02So that's kind of thinking of it
03:02 --> 03:04as a three pronged approach.
03:04 --> 03:06The treatment of breast cancer and surgery
03:06 --> 03:07is definitely a very important part of it.
03:08 --> 03:11Yeah. And so when we think about
03:11 --> 03:13surgery for breast cancer,
03:13 --> 03:16I often think about it kind
03:16 --> 03:18of in two separate buckets.
03:18 --> 03:21So surgery for the breast cancer
03:21 --> 03:24itself within the breast and then
03:24 --> 03:25surgery for the lymph nodes.
03:25 --> 03:27So maybe we could talk a little bit
03:27 --> 03:29about each of those two buckets.
03:29 --> 03:31So when a patient comes to you
03:31 --> 03:34and has say an early stage breast
03:34 --> 03:36cancer and you're thinking about
03:36 --> 03:39how are you going to remove this
03:39 --> 03:41cancer from the breast itself,
03:41 --> 03:42what are the options that
03:42 --> 03:43you lay out for patients?
03:44 --> 03:46Well, a lot of it has to do with the
03:46 --> 03:49subtype of cancer and the tumor
03:49 --> 03:53to breast ratio for the patient.
03:56 --> 04:01So an easy way to think about it is if it's a
04:01 --> 04:03smaller cancer that takes
04:03 --> 04:06up less than 20% of the breast volume
04:09 --> 04:10doing something called a partial
04:10 --> 04:12mastectomy which is just removing the
04:12 --> 04:14tumor with a rim of healthy normal
04:14 --> 04:15tissue and not having to take the
04:15 --> 04:18whole breast or a mastectomy is a
04:18 --> 04:20terrific option in this day and
04:20 --> 04:22age that would be in conjunction with
04:22 --> 04:25whole breast radiation therapy and
04:25 --> 04:28potentially some sort of systemic therapy.
04:28 --> 04:32If the tumor is much larger than
04:32 --> 04:34than that and takes up a significant
04:34 --> 04:35portion of the breast,
04:35 --> 04:39generally 30% or more,
04:39 --> 04:43then removal via mastectomy and with
04:43 --> 04:45some subsequent reconstruction most
04:45 --> 04:48of the time would be
04:48 --> 04:49the recommended course of action.
04:50 --> 04:52And even for those patients
04:52 --> 04:54that do have larger tumors,
04:54 --> 04:55if they came to you and said,
04:55 --> 04:57but Doctor Park, you know,
04:57 --> 04:59I really want to save my breast.
04:59 --> 05:01Are there tricks that
05:01 --> 05:02you have up your sleeve that
05:02 --> 05:04can help patients who want an
05:04 --> 05:06option for breast conservation
05:06 --> 05:08even if they have a larger tumor?
05:09 --> 05:10Well, definitely.
05:10 --> 05:12And now in this day and age,
05:12 --> 05:13with all of our advancements
05:13 --> 05:14in systemic therapy,
05:14 --> 05:17we could do something called neoadjuvant
05:17 --> 05:18systemic therapy to potentially
05:18 --> 05:20shrink the tumor so that they could
05:20 --> 05:22convert them from
05:22 --> 05:23mastectomy to lumpectomy.
05:23 --> 05:25So if it's an estrogen
05:25 --> 05:26receptor positive tumor,
05:26 --> 05:28we could use estrogen blocking
05:28 --> 05:30agents to shrink the tumor.
05:30 --> 05:32And then if it's other subtypes,
05:32 --> 05:35there's other targeted therapies which
05:35 --> 05:39include drugs that target the HER2-Neu
05:39 --> 05:42receptor or if it's a breast subtype,
05:42 --> 05:43breast tumor subtype that
05:43 --> 05:45doesn't express any receptors,
05:45 --> 05:45immunotherapy,
05:45 --> 05:47which targets the immune system
05:47 --> 05:49in conjunction with chemotherapy,
05:49 --> 05:53has had some very clinically
05:53 --> 05:54meaningful shrinkages,
05:54 --> 05:56if not complete responses,
05:56 --> 06:00meaning the tumor shrinks almost completely,
06:00 --> 06:04allowing for the tumor to shrink
06:04 --> 06:06and therefore to fit that criteria
06:06 --> 06:08to do breast conservation therapy.
06:10 --> 06:13A lot of patients when they're faced with
06:13 --> 06:15a cancer diagnosis may understandably
06:15 --> 06:17be very anxious about that diagnosis.
06:17 --> 06:20And may say things like,
06:20 --> 06:22but you know, Doc,
06:22 --> 06:24I'm not married to my breast
06:24 --> 06:25and I just want it out.
06:25 --> 06:27I don't want to have to think
06:27 --> 06:29about this breast cancer anymore.
06:29 --> 06:31I don't want to worry about it anymore.
06:31 --> 06:32What kind of conversation do you
06:32 --> 06:34have with patients like that?
06:35 --> 06:38Well, in in the case where breast
06:38 --> 06:40conservation is a very viable
06:40 --> 06:42option for them and I feel like
06:42 --> 06:45they're speaking more out of anxiety,
06:45 --> 06:48I go over the pros and cons of
06:48 --> 06:51a mastectomy including
06:51 --> 06:53even with the mastectomy
06:53 --> 06:54going absolutely perfectly
06:54 --> 06:57there are longterm kind of sequelae
06:57 --> 06:59or ramifications that one would have
06:59 --> 07:01to deal with which includes
07:01 --> 07:04even if it goes absolutely perfectly,
07:04 --> 07:06like the nerve supply to the breast
07:06 --> 07:08skin is is removed NOTE Confidence: 0.92841864
07:08 --> 07:09as part of the mastectomy.
07:09 --> 07:11So the chest wall will be numb.
07:11 --> 07:13Meaning that you won't be able to
07:13 --> 07:16feel people when they hug you or just
07:16 --> 07:18even kind of practical things like you may
07:19 --> 07:21accidentally burn yourself or
07:21 --> 07:24if you leave a cold pack
07:24 --> 07:26on that part of the body too long.
07:26 --> 07:27It's like things like that
07:27 --> 07:29to be concerned about in addition to,
07:29 --> 07:29you know,
07:29 --> 07:31smaller things like when
07:31 --> 07:32you greet someone and hug them,
07:32 --> 07:34you won't be able to feel that.
07:34 --> 07:35So I talk about that.
07:36 --> 07:39Even if everything went smoothly,
07:39 --> 07:41there's always the risk of complications,
07:41 --> 07:42which include infections
07:42 --> 07:44and wound complications,
07:44 --> 07:47chronic pain and therefore some
07:47 --> 07:49further treatment and potentially
07:49 --> 07:49further operations.
07:49 --> 07:55So it's one thing to take that as
07:55 --> 07:58a necessary cost
07:58 --> 08:00if you have no other choice than
08:00 --> 08:01to do a mastectomy because your
08:01 --> 08:03tumors large and not responding
08:03 --> 08:05to therapy and etcetera.
08:05 --> 08:06But it's another thing to
08:07 --> 08:11have these two perfectly viable options
08:11 --> 08:14and kind of subject yourself to
08:14 --> 08:16something that may have more
08:18 --> 08:20serious sequelae without you
08:20 --> 08:23thinking through it very carefully.
08:23 --> 08:24So I always
08:24 --> 08:25bring that up. And NOTE Confidence: 0.9394707
08:25 --> 08:27sometimes that really gives patients
08:27 --> 08:29pause and helps them
08:31 --> 08:33make a decision not
08:33 --> 08:34completely based on anxiety.
08:35 --> 08:38What about patients who may
08:38 --> 08:41have a genetic mutation and
08:41 --> 08:42they're thinking about people
08:42 --> 08:45like Angelina Jolie who had both
08:45 --> 08:47breasts removed and reconstructed?
08:47 --> 08:48How do you advise them?
08:48 --> 08:51I mean, is that an irrational
08:51 --> 08:53decision that they're making?
08:53 --> 08:54How do you talk to them about that?
08:55 --> 08:58Well, in the setting of a genetic mutation,
08:58 --> 09:02since they do have a higher
09:02 --> 09:05predisposition for 2nd cancers and
09:05 --> 09:07other sporadic cancers,
09:07 --> 09:09that's kind of a different
09:09 --> 09:11population than someone that
09:11 --> 09:13just has an isolated breast cancer.
09:13 --> 09:16So that that definitely is not unreasonable
09:16 --> 09:19and that that is a decent portion of
09:19 --> 09:22the population that requests, you know,
09:22 --> 09:25mastectomy for or or even bilateral
09:25 --> 09:28mastectomy for maximal risk reduction.
09:28 --> 09:29But I kind of consider that as
09:29 --> 09:30as a separate group.
09:32 --> 09:34So for the patients who
09:34 --> 09:37either opt for a mastectomy,
09:37 --> 09:40either because they have cancer
09:40 --> 09:42or because they may have a
09:42 --> 09:44genetic predisposition or they
09:44 --> 09:46may be at increased risk.
09:46 --> 09:49Are there newer techniques that
09:49 --> 09:51you're now using that allow
09:51 --> 09:55patients to have a better cosmetic
09:55 --> 09:57result than what historically was
09:57 --> 10:00done in the past where patients
10:00 --> 10:03were left with a flat chest wall?
10:04 --> 10:06Well, now we have things,
10:06 --> 10:08I mean we definitely have
10:08 --> 10:09reconstruction which is a
10:09 --> 10:11partnership with a plastic surgeon.
10:11 --> 10:14So the plastic surgeon would offer
10:14 --> 10:16some sort of reconstruction that might
10:16 --> 10:19that either may be in the form of
10:19 --> 10:21implant or using their own natural
10:21 --> 10:23tissue like from their belly that's
10:23 --> 10:25called the DIEP flat reconstruction.
10:25 --> 10:27So that that's always definitely
10:27 --> 10:30part of the conversation.
10:30 --> 10:31But from the purely the
10:31 --> 10:32mastectomy standpoint,
10:32 --> 10:36there's the use of something called ******
10:36 --> 10:38sparing mastectomy where the incision
10:38 --> 10:40is hidden in the infra mammary fold,
10:40 --> 10:42kind of like where you would think
10:42 --> 10:44the underwire of your bra would be.
10:44 --> 10:45So it's very hidden.
10:45 --> 10:46So when you're sitting up,
10:46 --> 10:47you can't see it and then all of
10:47 --> 10:49the breast tissue and the surgery
10:49 --> 10:50is done through that incision.
10:50 --> 10:52It's basically like a hidden
10:52 --> 10:55scar and the the entire skin
10:55 --> 10:58and ****** shell is preserved.
10:58 --> 11:02And when the reconstruction is completed,
11:02 --> 11:03you know the outside
11:03 --> 11:04portion of the body looks,
11:04 --> 11:06you know pretty much the same as
11:06 --> 11:07it did before because all of the
11:07 --> 11:09skin and the ****** is intact and
11:09 --> 11:11the the breast tissues removed and
11:11 --> 11:14it has been replaced with either
11:14 --> 11:16on the space has been replaced
11:16 --> 11:18with either an implant or or
11:18 --> 11:20the tissue from your abdomen.
11:21 --> 11:23Are there risks associated with
11:23 --> 11:26a ****** sparing mastectomy that
11:26 --> 11:27you counsel patients about?
11:28 --> 11:31Well, there's definitely risk of practical
11:31 --> 11:34risks that include like skin ****** necrosis,
11:34 --> 11:36meaning the blood supply to the ******
11:36 --> 11:39is compromised due to the to the surgery
11:39 --> 11:41and then over some time then the ******
11:41 --> 11:44may actually die and need to be removed,
11:44 --> 11:46which is definitely not a,
11:46 --> 11:48you know, a pleasant experience.
11:48 --> 11:51So we definitely counsel the patient
11:51 --> 11:54on the you know the potential of that
11:54 --> 11:57happening folks for folks that you know
11:57 --> 11:59are at the most risk of that would be
11:59 --> 12:02generally people with certain anatomy,
12:02 --> 12:06larger breast size, mortosis or droopiness,
12:06 --> 12:07smoking history, diabetes,
12:07 --> 12:10anything that could kind of compromise
12:10 --> 12:12the blood flow to to that area.
12:12 --> 12:15So generally we cut take that into
12:15 --> 12:18consideration when offering that type
12:18 --> 12:20of procedure to patients as well.
12:20 --> 12:23And if the patients are very enthusiastic
12:23 --> 12:25about it despite having some,
12:25 --> 12:27perhaps some some of these risk factors,
12:27 --> 12:28you know,
12:28 --> 12:29we definitely counsel them that
12:29 --> 12:30you know they're at a higher risk
12:30 --> 12:31of ****** necrosis and potentially
12:31 --> 12:34additional surgery to have to remove it.
12:35 --> 12:36Are there other options for
12:36 --> 12:37those kinds of patients?
12:40 --> 12:42Well, there's definitely options
12:42 --> 12:44that include a skin spraying
12:44 --> 12:48mastectomy with ****** reconstruction.
12:48 --> 12:50In this day and age it could look
12:50 --> 12:51extremely realistic with with
12:51 --> 12:53arial or tattooing and a plastic
12:53 --> 12:55surgeon reconstructs the ******.
12:55 --> 12:57And you know, sometimes I can't
12:57 --> 12:58even tell the difference between
12:58 --> 13:00a native ****** area or complex on
13:00 --> 13:02the left side versus a reconstructed
13:02 --> 13:03one on the right side.
13:03 --> 13:04And I always do a double take.
13:04 --> 13:07So it's it's quite realistic and
13:07 --> 13:09advanced in this day and age.
13:09 --> 13:11The other option if for instance
13:11 --> 13:14if the issue is too large of a
13:14 --> 13:15breast size entosis is we could do
13:15 --> 13:17something called a staged ******
13:17 --> 13:19Spearing mastectomy where in
13:19 --> 13:21partnership with a plastic surgeon,
13:21 --> 13:22a ****** reduction,
13:22 --> 13:24a breast reduction is done so that
13:24 --> 13:26their anatomy is more amenable to
13:28 --> 13:29more amenable to a ******
13:29 --> 13:31spraying mastectomy.
13:31 --> 13:33So usually decreasing the amount of
13:33 --> 13:36tosis and decreasing the breast volume.
13:36 --> 13:37And then after that's all
13:37 --> 13:38healed up then we do the actual
13:38 --> 13:39****** spraying mastectomy.
13:39 --> 13:42So in particularly in the case of
13:42 --> 13:43gene mutation positive patients
13:43 --> 13:46that don't have an active cancer,
13:46 --> 13:50that could be a that could be a
13:50 --> 13:51nice kind of compromise like a nice
13:51 --> 13:53stepwise way to get to the the goal,
13:54 --> 13:57terrific. So we have to take a
13:57 --> 13:59quick break for a medical minute.
13:59 --> 14:01Please stay tuned to learn more about
14:01 --> 14:03advanced techniques and breast surgery
14:03 --> 14:05with my guest Dr. Tristen Park.
14:06 --> 14:08Funding for Yale Cancer Answers
14:08 --> 14:10comes from Smilow Cancer Hospital
14:10 --> 14:12where 16 locations across the region
14:12 --> 14:14provide patients with individualized,
14:14 --> 14:16innovative, convenient,
14:16 --> 14:18and comprehensive care.
14:18 --> 14:21Find a Smilow location near you
14:21 --> 14:23at smilowcancerhospital.org.
14:23 --> 14:26There are over 16.9 million
14:26 --> 14:29cancer survivors in the US and
14:29 --> 14:31over 240,000 here in Connecticut.
14:31 --> 14:32Completing treatment for cancer
14:32 --> 14:35is a very exciting milestone,
14:35 --> 14:37but cancer and its treatment can
14:37 --> 14:39be a life changing experience.
14:39 --> 14:41The return to normal activities and
14:41 --> 14:42relationships may be difficult,
14:42 --> 14:45and cancer survivors may face other
14:45 --> 14:47longterm side effects of cancer,
14:47 --> 14:49including heart problems,
14:49 --> 14:51osteoporosis, fertility issues,
14:51 --> 14:54and an increased risk of second cancers.
14:54 --> 14:57Resources for cancer survivors are
14:57 --> 14:59available at federally designated
14:59 --> 15:00comprehensive Cancer centers
15:00 --> 15:02such as Yale Cancer Center
15:02 --> 15:04and Smilow Cancer Hospital.
15:04 --> 15:06To keep cancer survivors well
15:06 --> 15:08and focused on healthy living.
15:08 --> 15:10The Smilow Cancer Hospital Survivorship
15:10 --> 15:13Clinic focuses on providing guidance
15:13 --> 15:15and direction to empower survivors to
15:15 --> 15:17take steps to maximize their health,
15:17 --> 15:19quality of life,
15:19 --> 15:20and longevity.
15:20 --> 15:22More information is available
15:22 --> 15:23at yalecancercenter.org.
15:23 --> 15:27You're listening to Connecticut Public Radio.
15:27 --> 15:27Welcome
15:27 --> 15:29back to Yale Cancer Answers.
15:29 --> 15:30This is Doctor Anees Chagpar,
15:30 --> 15:32and I'm joined tonight by my guest,
15:32 --> 15:34Doctor Tristen Park.
15:34 --> 15:35We're talking about advanced
15:35 --> 15:38techniques in breast cancer surgery.
15:38 --> 15:39And right before the break,
15:39 --> 15:41we were talking about different
15:41 --> 15:43techniques for mastectomy,
15:43 --> 15:45so skin sparing,
15:45 --> 15:47mastectomies, nipple sparing,
15:47 --> 15:49mastectomies, etcetera.
15:49 --> 15:52So before we leave the topic of mastectomies,
15:52 --> 15:54Tristen, I was wondering if you could
15:54 --> 15:56tell us a little bit more about
15:56 --> 15:58different techniques of reconstruction.
15:58 --> 16:01You had mentioned that, you know,
16:01 --> 16:04in this day and age a lot of
16:04 --> 16:06women can have reconstruction as
16:06 --> 16:09opposed to being flat as was the
16:09 --> 16:11case historically when people
16:11 --> 16:13didn't really have a choice.
16:13 --> 16:15So what are the options for
16:15 --> 16:17reconstruction and how do you,
16:17 --> 16:19how do patients make a decision
16:19 --> 16:21about what's right for them?
16:23 --> 16:27Sure. So I always tell my patients there are,
16:27 --> 16:31you know, definitely 2 viable options for
16:31 --> 16:35for reconstruction after after mastectomy.
16:35 --> 16:39One is no reconstruction And then
16:39 --> 16:41and then we discussed the use of
16:41 --> 16:44prosthesis and the pros and cons of
16:44 --> 16:45not have needing additional surgery.
16:47 --> 16:49Then I say the other arm of that branch
16:49 --> 16:51is doing some sort of reconstruction.
16:51 --> 16:54And within reconstruction,
16:54 --> 16:56there's implant based reconstruction
16:56 --> 16:59versus like tissue based reconstruction.
16:59 --> 17:01So I counsel patients that implant based
17:01 --> 17:03reconstruction is like the classical
17:03 --> 17:05thought of the classical implant
17:05 --> 17:11where a implant is used to
17:11 --> 17:15reconstruct and take up the volume of the
17:15 --> 17:17breast tissue that's been removed.
17:17 --> 17:19Generally it's a two staged operation in
17:19 --> 17:22partnership with a plastic surgeon where
17:22 --> 17:24they put something called an expander in
17:24 --> 17:27first which kind of is like a placeholder
17:27 --> 17:29and then as the expander is expanded
17:29 --> 17:32over a period of a few months to the
17:32 --> 17:34ideal size and then that's switched
17:34 --> 17:36out for the final permanent implant.
17:36 --> 17:39So at that point you could get to the
17:39 --> 17:41goal breast size and then the
17:41 --> 17:43final implant is placed afte
17:43 --> 17:46the rest of the tissues have healed
17:46 --> 17:48up well after the index mastectomy.
17:48 --> 17:50The other option is using something
17:50 --> 17:51called tissue based reconstruction
17:52 --> 17:54where, in partnership with a plastic
17:54 --> 17:56surgeon, tissue from the abdomen or
17:56 --> 17:58other parts of the body could be used.
17:58 --> 18:00Although abdomen is the most common.
18:00 --> 18:03That's called the DIEP flap reconstruction.
18:03 --> 18:05Basically in layman's terms we
18:05 --> 18:08describe it as like a tummy tuck
18:08 --> 18:10and the tissues then placed into the
18:10 --> 18:14breast skin capsule to replace the volume.
18:14 --> 18:17So the pluses and minuses is that
18:17 --> 18:20the implant based reconstruction is a
18:20 --> 18:24little bit easier to do regarding time.
18:24 --> 18:26It adds maybe another
18:26 --> 18:28hour to the surgery.
18:28 --> 18:29So that's the pluses of that.
18:29 --> 18:30However,
18:31 --> 18:33some people think it doesn't
18:33 --> 18:35feel very natural and it does have
18:35 --> 18:36to be replaced every 10 years.
18:36 --> 18:38The tissue based reconstruction,
18:38 --> 18:41it definitely feels more natural as
18:41 --> 18:43it is your normal tissue
18:43 --> 18:46but it is a large operation
18:46 --> 18:48that takes an additional,
18:48 --> 18:50sometimes four to six hours
18:50 --> 18:53where in a separate part of your
18:53 --> 18:55body is being operated on and that
18:55 --> 18:58technically doesn't need an operation.
18:58 --> 19:00So there's always complications
19:00 --> 19:02that are associated with that
19:02 --> 19:05as well as kind of more intense
19:05 --> 19:07wound healing and just the recovery
19:07 --> 19:09period because in addition to having
19:09 --> 19:11your breasts operated on,
19:11 --> 19:13you're also having your entire
19:13 --> 19:14abdomen operated on as well.
19:14 --> 19:16So that adds
19:16 --> 19:18to the recovery period and the
19:18 --> 19:19arduousness of the recovery.
19:19 --> 19:20However,
19:20 --> 19:22a lot of people like it
19:22 --> 19:25because it feels very natural.
19:25 --> 19:26It feels like it's part of them,
19:26 --> 19:29there's no foreign body
19:29 --> 19:31in themselves and there is no need for
19:31 --> 19:33switching out an implant every
19:33 --> 19:3410 years.
19:34 --> 19:35Generally patients that
19:35 --> 19:37are on the younger side,
19:37 --> 19:40healthier and could tolerate a much
19:40 --> 19:42longer operation and have this type
19:42 --> 19:43of more complex reconstruction
19:43 --> 19:45would be better candidates,
19:45 --> 19:47although there are plenty of
19:47 --> 19:49more elderly patients that
19:49 --> 19:50could tolerate it just fine.
19:50 --> 19:52As long as they're in
19:52 --> 19:52good health.
19:52 --> 19:55So I can imagine that you know,
19:55 --> 19:56patients may have a number of questions.
19:56 --> 19:59So one of the questions
19:59 --> 20:01that often comes up is,
20:01 --> 20:04are implants safe? There's been
20:04 --> 20:06some horror stories in the
20:06 --> 20:08past of implants rupturing,
20:08 --> 20:12of leakage, even of some cancers
20:12 --> 20:15developing from implants.
20:15 --> 20:17So how do you counsel patients when
20:17 --> 20:19they ask you are implants safe?
20:19 --> 20:21Implants are very safe.
20:21 --> 20:23Regarding the kind of concern
20:23 --> 20:26about the the cancer formation,
20:26 --> 20:29it was a very rare type of lymphoma with
20:29 --> 20:32a very specific type of textured implant
20:32 --> 20:34that had been that particular type of
20:34 --> 20:36implant has been removed from the market.
20:36 --> 20:38So you can't get that anymore.
20:38 --> 20:40And even with that incidence
20:40 --> 20:41was extremely low.
20:41 --> 20:42But that being said,
20:42 --> 20:44it's off the market,
20:44 --> 20:46you can't physically obtain that type
20:46 --> 20:48of implant even if you wanted to.
20:48 --> 20:51So that has definitely been
20:51 --> 20:55addressed quite thoroughly and
20:55 --> 20:57patients have also been recalled,
20:57 --> 20:59the ones that have gotten it
20:59 --> 21:01had them removed and
21:01 --> 21:04replaced with a non textured implant.
21:04 --> 21:06So there's that and then there's
21:06 --> 21:09the more kind of common potential
21:09 --> 21:11complications that may
21:11 --> 21:12include rupture or infection.
21:12 --> 21:15The risks of that are present,
21:15 --> 21:18but overall it's very well
21:18 --> 21:21tolerated and if it does happen,
21:21 --> 21:22it would have to result
21:22 --> 21:24in a surgery to remove it and
21:24 --> 21:26then replace it at a later time.
21:26 --> 21:29But overall it's considered quite
21:29 --> 21:32safe and well tolerated procedure.
21:32 --> 21:34Is everyone a candidate for
21:34 --> 21:35the tummy tuck procedure?
21:35 --> 21:37I can imagine that a lot of patients
21:37 --> 21:39kind of get really excited about that,
21:39 --> 21:44but some might not have enough belly tissue.
21:44 --> 21:46So how do you kind of get around that
21:46 --> 21:48and are there other contraindications
21:48 --> 21:51to having a diep flap?
21:51 --> 21:59Yeah. So for the flap it requires
21:59 --> 22:02a kind of reconnecting these very
22:02 --> 22:04small blood vessels together from
22:07 --> 22:10abdominal tissue to the chest.
22:10 --> 22:12So if there's any compromise to
22:12 --> 22:13those little tiny blood vessels,
22:13 --> 22:17like if you're a smoker or
22:17 --> 22:19have other vascular problems,
22:19 --> 22:21you know you would not be a good
22:21 --> 22:23candidate for that because that
22:23 --> 22:25would mean that the graft would not work.
22:25 --> 22:29And so that's definitely
22:29 --> 22:31a contraindication.
22:31 --> 22:32Morbid obesity would be a contra indication.
22:32 --> 22:34So most of our plastic surgeons
22:34 --> 22:36want the patients to be in a kind of
22:36 --> 22:37more healthy BMI range to
22:37 --> 22:38tolerate that type of surgery and
22:38 --> 22:40the surgery itself is quite long.
22:40 --> 22:43So it's a good extra
22:43 --> 22:466 plus hours of surgery.
22:46 --> 22:48So to just be in good physical
22:48 --> 22:51shape to tolerate that length of
22:51 --> 22:53anesthesia and being in the operating
22:53 --> 22:55room is necessary.
22:55 --> 22:58If you're too thin and do not
22:58 --> 23:00have enough abdominal fat,
23:00 --> 23:01abdominal tissue for this
23:01 --> 23:03type of reconstruction
23:05 --> 23:09we can do some kind of a hybrid approach.
23:09 --> 23:12I've seen that spearheaded bioplastic
23:12 --> 23:14surgeons where they combine both an
23:14 --> 23:16implant with a diep flap or
23:16 --> 23:18tissue from a different area where you
23:18 --> 23:20still have that extra
23:20 --> 23:21tissue coverage to make it feel natural.
23:21 --> 23:24But you have the implant to give it
23:25 --> 23:26some more volume as well.
23:26 --> 23:29So there's some
23:29 --> 23:32tips and tricks that our plastic
23:32 --> 23:34surgeons make use of in patients
23:34 --> 23:36that don't have enough tissue.
23:37 --> 23:41So the other question that can come up is
23:41 --> 23:43after a mastectomy and reconstruction.
23:43 --> 23:46So now people look like they
23:46 --> 23:48have a breast, although their
23:48 --> 23:50breast tissue has been removed.
23:50 --> 23:53Do they still need a mammogram every year?
23:53 --> 23:56They do not need a mammogram every year
23:56 --> 23:58because the definition of a mastectomy
23:58 --> 23:59is removing all of the breast tissue.
23:59 --> 24:02I usually quote like 98-99% of the
24:02 --> 24:04breast tissue is removed by the
24:04 --> 24:05surgeon because we can't remove
24:05 --> 24:07every single last breast cell,
24:07 --> 24:09but everything that's visible by
24:09 --> 24:12the human eye of the surgeon is removed.
24:12 --> 24:15So with 98-99% of the
24:15 --> 24:17breast tissue being removed there
24:17 --> 24:21is no role for mammograms as there
24:21 --> 24:23is no breast tissue left to detect.
24:23 --> 24:25So the main way that one would
24:25 --> 24:27at that point you have maximally
24:27 --> 24:30risk reduced the patient so that their
24:30 --> 24:32future risk of developing any cancer
24:32 --> 24:35is down to you know 1 to 2% maybe.
24:35 --> 24:37And if it does happen,
24:37 --> 24:41it would kind of be discovered on the
24:41 --> 24:44physical exam usually as some sort of
24:44 --> 24:47pea round kind of finding
24:47 --> 24:50usually under the skin somewhere
24:50 --> 24:52and that's how it would manifest.
24:52 --> 24:53If that does happen,
24:53 --> 24:55sometimes we ultrasound that to kind of
24:55 --> 24:57confirm it and then biopsy it.
24:57 --> 24:59But in general the role of screening
24:59 --> 25:01mammograms is obsolete once all or
25:01 --> 25:03most of the breast
25:03 --> 25:04tissue is removed after mastectomy.
25:05 --> 25:08So we've kind of talked about
25:08 --> 25:10the techniques for mastectomy.
25:10 --> 25:12You had mentioned before the
25:12 --> 25:13other option
25:13 --> 25:15is breast conserving surgery,
25:15 --> 25:16partial mastectomies.
25:16 --> 25:18But one of the things that you
25:18 --> 25:21had mentioned in terms of the
25:21 --> 25:22mastectomy side was that for
25:22 --> 25:24patients who have larger breasts,
25:24 --> 25:29this can often be combined with a reduction.
25:29 --> 25:30So if people have larger breasts but
25:30 --> 25:32they want to preserve the breasts,
25:32 --> 25:35they want to have a partial mastectomy,
25:35 --> 25:36can they have a reduction as well?
25:37 --> 25:39Yes. That is a definitely a great
25:42 --> 25:44kind of tool in our pocket
25:44 --> 25:47for both treating the cancer
25:47 --> 25:49and sometimes having
25:52 --> 25:54very large breast size could be
25:54 --> 25:56a detriment to quality of life
25:56 --> 25:58like inability to exercise well,
25:58 --> 26:01back pain, neck pain etcetera.
26:01 --> 26:04So in patients where breast
26:04 --> 26:06reduction could even improve their
26:06 --> 26:08their quality of life at baseline,
26:08 --> 26:09it's definitely a
26:09 --> 26:11wonderful option for patients.
26:11 --> 26:13So in that setting usually it's
26:13 --> 26:15done in partnership with a plastic surgeon.
26:15 --> 26:17The breast tumor is removed.
26:17 --> 26:21The lymph nodes are tested and then
26:21 --> 26:23concomitantly the plastic surgeon
26:23 --> 26:26then with the leftover breast tissue
26:26 --> 26:28does the breast reduction on both
26:28 --> 26:30sides and and then you're
26:30 --> 26:32left with a smaller breast
26:32 --> 26:35size on both sides and
26:35 --> 26:37your breast cancer is removed
26:37 --> 26:39and the lymph nodes are staged.
26:39 --> 26:43And patients generally really,
26:43 --> 26:44really appreciate that because
26:44 --> 26:46not only are you treating
26:46 --> 26:47their breast cancer but
26:47 --> 26:49their quality of life is definitely
26:49 --> 26:51better due to decrease pain and
26:51 --> 26:53you know improved mobility and
26:53 --> 26:54ability to be more active.
26:55 --> 26:57So then the other question
26:57 --> 26:59that might come up is,
26:59 --> 27:00it's really great that
27:00 --> 27:02patients can get a reduction,
27:02 --> 27:05they can get a lift potentially they
27:05 --> 27:09can get maybe even a tummy tuck if they
27:09 --> 27:12have a mastectomy with a diep flap.
27:12 --> 27:13And many of them may say, well,
27:13 --> 27:15geez, that all sounds very
27:15 --> 27:17much like cosmetic surgery.
27:17 --> 27:20Will my insurance cover this?
27:21 --> 27:22So that's definitely a
27:22 --> 27:23question that I get a lot.
27:23 --> 27:26And as long as you have a cancer
27:26 --> 27:28diagnosis and this is done in
27:28 --> 27:29part and parcel with the
27:29 --> 27:30removal of the tumor,
27:30 --> 27:32it will be covered by insurance.
27:32 --> 27:35And actually in the late 90s,
27:35 --> 27:41the US government mandated that all breast
27:41 --> 27:43reconstruction associated with breast
27:43 --> 27:46cancer must be covered by all insurances.
27:46 --> 27:48So that's definitely a
27:48 --> 27:50great thing about
27:50 --> 27:51the system that we have in
27:51 --> 27:52place in this country.
27:52 --> 27:54Including doing the symmetry
27:54 --> 27:56operation on the other side, right.
27:56 --> 27:58If they have a reduction.
27:58 --> 28:01Most of the time, the symmetry
28:01 --> 28:03operations can be done concurrently,
28:03 --> 28:08but sometimes patients opt to wait
28:08 --> 28:10until their complete cancer treatment
28:10 --> 28:12is finished on the cancer side.
28:12 --> 28:13And then after everything's healed
28:13 --> 28:15up and radiation is finished,
28:15 --> 28:17which may alter the size of the
28:17 --> 28:20breast bearing the cancer.
28:20 --> 28:22Then we know what we're dealing
28:22 --> 28:24with in the symmetry procedure
28:24 --> 28:26could kind of replicate exactly
28:26 --> 28:28the end product of the other side.
28:28 --> 28:30And that's called a
28:30 --> 28:31symmetrizing procedure and that's
28:31 --> 28:32definitely covered as well.
28:32 --> 28:35Doctor Tristan Park is an assistant
28:35 --> 28:36professor of surgical oncology
28:36 --> 28:38at the Yale School of Medicine.
28:38 --> 28:40If you have questions, the address
28:40 --> 28:43is Cancer Answers at Yale dot Edu,
28:43 --> 28:45and past editions of the program
28:45 --> 28:47are available in audio and written
28:47 --> 28:48form at yalecancercenter.org.
28:48 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:54cancer here on Connecticut Public Radio.
28:54 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

Advanced Techniques in Breast Surgery with guest Dr. Tristen Park August 20, 2023 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095