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How Will My Surgeons Coordinate Breast Reconstruction? · Healthy Vitals

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  Scott Webb (Host): Today, in part two of our three-part series on
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  breast surgery and reconstruction, I'm again speaking with Dr.
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  Eve Klenotic, specialist in breast surgery and breast surgical
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  oncology, and plastic surgeon, Dr.
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  Mike Tran.
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  And today, we're speaking about surgical approaches and reconstruction
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  choices at Summa Health.
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  This is Healthy Vitals, a podcast from Summa Health.
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  I'm Scott Webb.
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  It's nice to have you both back on the podcast.
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  As I mentioned before, our first one, the last one, where we're doing a three-part
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  series here on basically breast surgery, reconstruction, what folks can expect,
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  you know, every step along the way.
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  And today, in part two, and we do hope folks will listen to part one, but in
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  part two today, we're going to talk surgery and reconstruction specifically.
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  So, Dr.
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  Klenotic, how do you work together during surgery to achieve optimal
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  oncologic and reconstructive outcomes?
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  Dr. Eveline Klenotic:
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  Hi, Scott.
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  It's so good to be back.
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  So before we work together during surgery, actually it's very, very important that
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  we work together before surgery day.
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  So, we would plan how to approach the case beforehand.
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  For example, today we happen to be in the same clinic together so we can
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  discuss our patients, and I would let Dr.
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  Tran know this is where the cancer is, and this is how much tissue
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  I would like to remove to make sure that the cancer is out.
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  And then, Dr.
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  Tran would chime in, "Oh, yeah, I think we can use this part of the breast to reshape
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  and fill in the defect or the dent that is caused by removing the breast tissue."
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  Or there are more complicated cases where someone may have several different spots
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  of cancers in the same breast, and that's termed extreme oncoplasty, for example.
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  And I would consult Dr.
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  Tran to see, is it even possible that my patient would like to still
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  save her breast if she has this many cancer in the same breast?
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  And so on the day of surgery, we often mark the patient together in the
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  preoperative area so that we are in unison in terms of which area to remove and what
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  type of reconstruction would be done.
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  On mastectomy patients, then I would kind of let Dr.
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  Tran know, sometimes the skin needs to be removed, and sometimes we can save the
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  nipple safely, from cancer perspective, and that would be communicated to Dr.
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  Tran prior to surgery to plan together.
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  So back to the day of surgery, we would mark the patient together in preoperative
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  area, and we agree on the plan.
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  And then, we also communicate and work together throughout the case,
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  from making the incision, injecting any blue dye or tracer that we may
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  need to preserve lymphatic and veins to be reconnected for, like, the
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  bigger axillary surgery that, as Dr.
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  Tran mentioned last episode, to reconnect the channels so that the
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  lymphedema risk can be minimized
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  Host: Yeah.
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  Dr.
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  Tran, it really does sound like you guys really work together before, during,
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  after, and makes me wonder how you balance the cancer treatment goals with cosmetic
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  and the quality of life considerations.
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  Dr. Mike Tran:
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  The priority is pretty simple.
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  You treat the cancer safely first, and this part is not negotiable.
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  So, I'm never going to tell the breast surgeon, "Hey, leave that.
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  It'll look better," right?
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  So once breast cancer is treated properly, and then we start to think
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  about the cosmesis and quality of life.
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  So, there used to be an attitude that patients should just be grateful that
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  the cancer was treated, and who cares what the breast looks like afterwards.
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  That's not right, right?
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  We have to consider the appearance, comfort, patient's physical
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  activity, clothing, sexuality, and quality of life, right?
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  These things are important because you still have your entire life to
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  live after the cancer is treated.
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  So in my mind, the goal isn't just to get someone through surgery.
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  We want to treat the cancer and leave the patient with a result
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  that lets her get back to her life.
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  Host: Yeah.
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  And I was thinking about scarring, symmetry, expected outcomes.
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  And from your perspective, what do you really want patients to
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  know about some of those concerns?
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  Dr. Mike Tran:
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  I'm very frank with the patient regarding this.
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  I tell the patient very clearly, "You will have scars.
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  We can improve the shape of your breasts, we can restore volume,
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  we create symmetry, but we cannot make the surgery itself disappear."
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  The second thing I tell the patient is that a reconstructive
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  breast is not a real breast.
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  We cannot make a new breast.
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  It's an organ that has glands, connective tissue, right?
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  We just reconstruct.
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  What we have is a facsimile of a breast.
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  We restore the shape, the volume, and the goal is to create a mound
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  that looks natural in clothing.
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  See, the other thing the patient don't realize is that the
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  reconstruction changes over time.
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  The breast may look high, it's swollen, it's flat, it's bruised,
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  and it may look maybe strange early on, but that's not the final result.
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  I even say that even if the on-table reconstruction looks good,
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  that might not be what you want.
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  We have a pretty good idea how it will change over time from experience, and
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  sometimes we account for those changes.
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  So although you can't predict the changes a hundred percent of the time,
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  and oftentimes you may need smaller procedures later on, like fat grafting
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  or scar revisions to kind of make it look a little more perfect or even
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  in adjusting the opposite breast.
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  But I just personally set the expectation that the reconstruction is a process
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  rather than just one perfect operation.
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  Dr. Eveline Klenotic:
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  I think also, Scott, most people, most women don't realize that most
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  women do not have symmetrical breasts.
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  I often tell my patients, unless it's a Barbie coming out of the
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  store, you know, most women do not have symmetrical breasts.
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  So, that is the normal, you know?
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  So, having said that, it is very, very important to set realistic expectation.
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  The breasts may continue to change over years of time based on radiation changes.
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  And we always say they're sisters, not twins, you know?
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  And I think a lot of people that goes through cancer, they kind
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  of understand and I think they cope with the changes better.
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  Host: Right.
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  Such a perfect analogy, right?
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  We all are familiar with Barbie and how perfect Barbie tends to be.
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  And in, if you weren't Barbie beforehand, you're definitely not
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  going to be Barbie afterwards.
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  Dr.
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  Klenotic, how has breast surgery and the reconstruction techniques
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  evolved in the recent years?
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  Sounds like it's moving pretty fast.
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  Dr. Eveline Klenotic:
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  Yes.
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  You know, it's crazy to think that there was a time when a patient
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  had a breast lump, a radical mastectomy was done that same day.
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  Radical mastectomy is removing the breast tissue, the muscle, all the lymph
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  nodes, and it leaves these women with significant deformity and long-term side
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  effects such as pain and lymphedema.
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  So as we evolved, breast cancer treatment has gotten, we call it less
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  and less—the term is de-escalation.
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  So, we routinely offer, for example, partial mastectomy instead of
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  a full mastectomy because it's a safe option for a patient.
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  For example as well, we are no longer routinely removing axillary lymph nodes
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  or lymph nodes from the armpit, as long as the imaging exam beforehand is normal,
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  especially for women 50 and above.
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  And this way, the risk of lymphedema or the arm swelling would be much less.
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  Dr. Mike Tran:
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  Our implant reconstruction now has become much more refined as well.
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  The implant technology has become so incredible.
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  Gel leak rate is down.
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  The shell on the implants are much stronger.
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  We now routinely use dermal matrix to support the breast and the implant.
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  We've moved from putting the implant underneath the muscle
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  to now above the muscle.
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  We are able to now do the implant reconstruction the same time
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  as a mastectomy rather than previously, where most of the
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  time it's a staged reconstruction.
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  Our ability to use a patient's own tissue now has become much more sophisticated.
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  We're now routinely doing microsurgical reconstruction where we take skin
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  and fat from elsewhere on the body and reconnect the blood supply under
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  the microscope to rebuild the breast.
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  We're also now more focused on doing that without sacrificing
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  the functional muscle or creating significant donor site debilitation.
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  On the horizon, and that actually I think it's already here, we're paying much
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  more attention to things like sensation.
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  We're able to now neurotize the flap and give sensation
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  to the reconstructive breast.
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  And like what Dr.
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  Klenotic was saying is we're also concentrating on lymphatic function,
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  where we're able to do lymphovenous bypass, where we're reconnecting
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  the lymphatics to the veins in order to lower lymphedema rates.
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  We're paying a lot more attention to the quality of life.
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  The standard now is not did the flap survive or did the implant stay in?
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  It's more, "Is this going to be a natural-looking reconstruction
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  five to ten years down the line?"
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  Host: So as we get close to wrapping up episode two, if you will,
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  of this three-part series, Dr.
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  Klenotic, what are the reconstruction decisions made before
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  surgery versus during surgery?
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  Dr. Eveline Klenotic:
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  As we have kind of discussed throughout the podcast today, so prior to
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  surgery, it's important to know if we are saving the breast or not.
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  And then if we're not saving the breast, what type of reconstruction
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  are we pursuing, whether it's implant or tissue-based reconstruction.
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  And when we're talking about implant, there's different type of implants,
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  but there's also tissue expander, because a lot of times for some
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  patient who we know for sure will need radiation, they would not be a
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  candidate for the permanent implant.
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  Although that would be so ideal, right?
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  One and done.
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  However, a lot of times, for this patient who will have radiation, we
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  would put a tissue expander until they're done with the radiation, and then
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  they're reconstructed at a later time.
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  So, an example of reconstruction decision that is made during surgery,
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  a patient who wants to have an implant, and ideally, it would be one and done.
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  However, during surgery, there are multiple factors that would affect how
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  the tissue and the blood flow looks.
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  And Dr.
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  Tran has a special fancy machine that checks the blood flow of
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  this, we call it flap of the skin, after the breast tissue is removed.
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  And if that's healthy enough, then the permanent implant can be placed.
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  But if it's not healthy enough, we want to do the safe thing and put the expander
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  placement and eventually train the skin slowly to stretch so that next time when
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  it's ready, the permanent implant can be placed and the skin would look nice.
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  Host: Right.
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  Dr. Mike Tran:
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  To kind of add on to what Dr.
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  Klenotic is saying, see, it's a major advantage for us to have this discussion
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  before the surgery, and it also allows us to have the patient peek into our
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  thoughts so they can also participate in patient-centric decision-making, right?
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  I always tell patients that the surgery does have some built-in uncertainty.
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  Like, we have a plan coming in, but sometimes, like Dr.
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  Klenotic pointed to, is the skin of the mastectomy, sometimes the skin
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  doesn't look great, or maybe it does.
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  Sometimes it doesn't.
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  Maybe we have to change the plans mid-surgery or intraoperatively, right?
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  And so, I don't really give a patient one rigid plan.
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  I usually tell them, "Look, here's plan A, right?
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  And here's what would make me change to plan B.
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  And here's what plan B looks like."
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  That way, if we make a different decision in the operating
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  room, it's not a surprise.
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  Everyone's involved.
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  Dr. Eveline Klenotic:
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  Yes.
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  Host: Yeah, that's perfect.
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  And, as I mentioned, you know, we're doing this three-part series.
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  This is part two.
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  So talked a lot about surgery and reconstruction today.
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  In part three, when we speak again, we're going to talk more about
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  recovery, prevention, long-term wellness, basically life after surgery.
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  But great having you both on and talk to you soon.
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  Thanks so much
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  Dr. Mike Tran:
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  Thank you.
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  Dr. Eveline Klenotic:
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  Thank you, Scott.
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  Host: And for more information, go to summahealth.org/breast.
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  And if you enjoyed this episode of Healthy Vitals, we'd love
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  it if you'd leave us a review.
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  Your review helps others find our educational content.
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  I'm Scott Webb.
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  Thanks for listening, and we'll talk again next time.