Follow-up to "Building a Better Mousetrap" posted June 2013.

The potential for a much improved method of tissue expansion as a part of breast reconstruction after mastectomy is closer to becoming a reality: interim data from studies of women who used AirXpanders for patient-controlled expansion continue to show promising outcomes compared to traditional saline expanders.

Most implant reconstruction involves the use of temporary expanders that gradually stretch the pectoralis muscle and breast skin to make enough room for an implant. The process typically takes several weeks (2 - 3 months), although some plastic surgeons proceed more conservatively (administering smaller and/or less frequent fills) or more aggressively (administering larger and/or more frequent fills).

AirXpanders introduce a kind of do-it-yourself expansion. They appear to produce similar results in a shorter timeframe, with less discomfort, and offer one big difference: the patient controls when, where and how much she is expanded, without needles or office visits. When the anatomically-shaped expander is in place under the muscle, patients use a wireless remote control to activate release of carbon dioxide from a small reservoir within the expander: up to three doses per day—each dose is 10cc—in their own home and at their own pace.

Study data presented at the annual meeting of the American Society of Plastic Surgeons (ASPS) in October reflect much shorter start-to-finish expansion intervals with AirXpanders. Jeffrey A. Ascherman, MD, FACS of New York-Presbyterian Hospital/Columbia University Medical Center, presented  interim results from the XPAND study in the U.S., which included 138 women with AirXpanders who completed their expansion process in an average of 18.2 days. Women who were randomized to receive traditional saline expanders required 57.4 days on average to complete the process. (Previously published results of a similar trial in Australia found an average completion time of 17 days.)

Enrollment in the EXPAND study has currently reached the target of 138, but AirXpanders is extending the enrollment period.
 
 
If you’re considering breast reconstruction after mastectomy, you’ll find an overwhelming amount of information on the Internet regarding insurance coverage. But be careful what you read, because not all of it is accurate.

You may already know that federal law ensures your right to breast reconstruction. What you may not know is that the law does not guarantee any type of reconstruction performed by any plastic surgeon in any location.

The Women’s Health and Cancer Rights Act (WHCRA) was passed in 1998. For the first time, it required employer and union group health plans that pay for mastectomy (most do) to also cover the cost of breast prostheses and breast reconstruction. The law also applies to individual plans. (Employer group plans are regulated by the federal government; individual plans are governed by each state.) Prior to this law, 84% of plastic surgeons reported having patients who were denied coverage for breast reconstruction. Health insurance carriers often denied breast reconstruction after mastectomy, labeling it as “cosmetic surgery.”

Here’s a summary of what WHCRA does and does not stipulate, and what it means for health insurers and patients:

  • According to the law, health plans that cover breast reconstruction must provide a description of WHCRA benefits to all employees when they enroll in the plan.

  • If your health care policy covers mastectomy, it must also cover the cost of breast breast reconstruction. Certain “church plans” and “government plans” are not subject to the law.

  • Plans must cover the cost of both breast prostheses and reconstruction. So if you decide to forego reconstruction at the time of your mastectomy and use prostheses instead, your plan must pay for the breast forms. If you then decide to have breast reconstruction at some later time, your plan must provide payment for that procedure.

  • Coverage includes payment for all stages of breast reconstruction. If you have unilateral breast reconstruction, this includes surgical procedures (breast augmentation, lift or reduction) on the opposite healthy breast to achieve symmetry.

  • Plans must also cover the cost of treating physical complications, including lymphedema, which may develop as a result of mastectomy.

  • Your payment for reconstruction is limited to deductibles and coinsurance that are consistent with what you pay for other benefits under your healthcare plan.

  • WHCRA allows policies to fulfill these requirements within the tenets of its existing health care policies. That means if your policy requires you to use in-network physicians and hospitals, it may deny approval and payment for reconstruction involving surgeons or medical facilities outside that network. It may also deny certain reconstructive procedures that are not performed by its in-network surgeons. This is a part of the law that is seldom explained, and women are often shocked to find that their HMO will not pay for reconstruction by an out-of-network surgeon who is in another state or across the country.

Visit the Department of Labor’s website (www.dol.gov/ebsa/publications/whcra.html) to access the text of the law and review a set of Q & A.

 
 
Women who face mastectomy have several options to have their breasts recreated. Not all women are candidates for all options, and not all surgeons perform all procedures.

If you’re considering reconstruction, your breasts can be recreated immediately (along with the mastectomy operation), or anytime down the road, even years later. Having immediate reconstruction has cosmetic benefits, however, and you don’t face another series of surgical procedures later.

Mastectomy without breast reconstruction    
  • Single surgery

  • Removes most breast skin
  • Removes nipples and areolae
  • Incisions visibly span chest

  • Flat chest after mastectomy

  • Overnight hospital
  • Relatively short recovery
Mastectomy with immediate breast reconstruction
  • Two surgeries in one visit to the operating room
  • Retains most breast skin
  • May retain nipples and areola (nipple-sparing)
  • Incisions are minimized and may be hidden
  • New breast mounds after mastectomy
  • One or more days in the hospital
  • Extended recovery

Some reasons that women do not have immediate breast reconstruction include:

·      They're unsure about reconstruction at the time of their mastectomy.

·      They don't want to go through any more procedures than are necessary to  
        treat or prevent breast cancer.

·      They want to try breast prostheses (or none at all) before committing to 
        reconstructive surgery.

·      They have a health condition that adds to surgical risk and may impede  
        healing.

·      Their doctor advises them to complete radiation or other treatment before 
        having breast reconstruction.

 
 

Studies show that most women who face mastectomy are uninformed about their post-surgery options, including breast reconstruction. And all too often, those who are told about reconstruction don’t know about all the options that are available to them, or the benefits and limitations of different reconstructive procedures.

National Breast Reconstruction Awareness (BRA) Day was established to educate and create awareness about post-mastectomy options. It’s a coordinated, national effort to provide the answers women need to make informed decisions regarding whether they should or shouldn’t have breast reconstruction, and if they do, what options and patient rights are available to them.

National BRA Day is a collaborative effort between the American Society of Plastic Surgeons, The Plastic Surgery Foundation, plastic surgeons, breast centers, corporate sponsors and breast cancer support groups around the country. These individuals and groups, along with breast cancer patients, coordinate events that include question-and-answer sessions, educational lectures, forums, and other activities and community events in support of breast reconstruction awareness. It’s also a great opportunity to meet and talk with women who have been through mastectomy and breast reconstruction.

This year, National BRA day falls on Saturday, October 15.

Click here to learn more about National BRA Day and find activities in different states (not all activities are listed here, so be sure to check your local breast cancer organizations as well). National BRA day in Canada is also held on October 15. You'll find additional information by searching Facebook for "BRA Day."

 
 
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Image: Facing Our Risk of Cancer Empowered
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An estimated three-quarters of a million Americans live with greatly increased risk of cancer due to an inherited BRCA gene mutation, but most of these individuals are unaware of their risk. So in 2010, Congress designated the last week in September as National Hereditary Breast and Ovarian Cancer (HBOC) Week to raise awareness of hereditary cancer, including genetic counseling and testing. Midpoint during the week is also designated as National Previvor Day.

HBOC week marks the transition between Ovarian Cancer Awareness Month (September) and Breast Cancer Awareness Month (October), symbolizing the genetic link between the two cancers. This year, National HBOC week occurs September 28 to October 4, with October 1 designated as National Previvor Day.

Having a BRCA gene mutation doesn’t guarantee a cancer diagnosis, but it does significantly raise the risk: women with a mutation in BRCA1 or BRCA2 have up to 85% risk for breast cancer and up to 50% risk for ovarian cancer. Men with BRCA mutations face greater risk for male breast cancer and prostate cancer. Having a mutation also slightly increases the risk for other cancers as well, including melanoma and pancreatic cancer. (And individual’s risk may be different depending on whether a mutation is in the BRCA1 gene or the BRCA2 gene.)

Although requests for genetic testing have risen dramatically since Angelina Jolie publicized her genetic status and subsequent preventive double mastectomy, about 90% of cancers are not hereditary, so for most people, genetic testing to determine whether an individual or family carries a BRCA mutation doesn’t make sense. Families who have any of the following red flags, however, should consider talking with a genetic counselor, who can determine whether genetic testing is warranted:

One or more relatives with:
  • ovarian or fallopian tube cancer at any age
  • breast cancer at age 50 or younger
  • breast cancer in both breasts at any age
  • triple-negative breast cancer
  • male breast cancer
  • Ashkenazi Jewish heritage and breast cancer before age 60
  • both breast and ovarian cancer

More than one relative on the same side of the family with any of the following:
  • breast cancer
  • ovarian or fallopian tube cancer
  • prostate cancer
  • pancreatic cancer
  • melanoma

For more information about activities scheduled around the country during National Hereditary Breast and Ovarian Cancer Week and National Previvor Day, and to learn more about hereditary breast and ovarian cancer, visit FORCE.

 
 
Guest Blog

Considering a DIEP or SIEA flap for your breast reconstruction after mastectomy? You probably already know that to do so, you need to have enough tummy fat to construct your new breast. But did you also know that in some cases, previous abdominal surgeries may preclude you from having a  DIEP or SEIA flap? The following guest blog by Dr. Minas Chrysopoulo sheds light on who is and who is not a good candidate for a DIEP/SIEA procedure.

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With more women becoming aware of DIEP flap breast reconstruction as an option, the question of who is and who isn't a good DIEP flap candidate is coming up more often.

As a general rule, women that have had extensive abdominal surgery like a previous TRAM flap, tummy tuck or a complex hernia repair cannot have a DIEP or SIEA flap breast reconstruction. This is because the lower tummy tissue that is needed has usually been removed or moved around, and the necessary blood supply has been disrupted.

Having said that, most of the time previous abdominal surgery isn't an issue in experienced hands.

Many women these days have had at least one previous c-section or another gynecologic procedure like a hysterectomy. It is possible for these procedures to cause damage to the blood vessels needed for DIEP flap surgery, but fortunately this is unusual. A previous C-section, hysterectomy, or tubal ligation is not a contraindication to having a DIEP or SIEA flap. Previous liposuction is not usually a problem either unless this was extensive.

If your surgeon is worried about potential damage from previous surgery, then certain tests can be performed to evaluate your anatomy more closely. This can include a simple Doppler ultrasound exam in the office or a more involved test like a CT angiogram. Unfortunately, the CT scan does involve radiation.

While previous abdominal surgeries may not prevent you from having DIEP flap reconstruction, women that have had multiple previous abdominal procedures are at increased risk of abdominal complications like bulging and hernia after DIEP flap surgery when compared to women that have never had prior abdominal surgery, even though the abdominal muscles are preserved. This is because the fascia (the strong layer of tissue over the muscles) has already been weakened by the previous surgeries.

Some medical issues can make any form of microsurgical breast reconstruction (like the DIEP flap) more difficult and they can also increase the risk of complications like flap loss. These include disorders that make the blood clot more easily (eg Factor V Leiden).

MInas Chrysopoulo, M.D. of The Center for Advanced Breast Reconstruction provides breast reconstruction, including DIEP flaps, in San Antonio, TX.
 
 
Guest Blog

Many women consider grenade-shaped surgical drains to be one of the most annoying aspects of recovery, but drains perform a necessary function. In the following guest blog, Dr. Aldona Spiegel explains why drains are necessary after any type of breast reconstruction.

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Questions about surgery drains are some of the most frequently asked topics about recovery from reconstructive surgery after breast cancer. Patients usually don’t like these pesky appendages which can be cumbersome but ultimately are your friend (hopefully not for too long).

The reason why drains are necessary in some surgical procedures is that the body has a tendency to release lymphatic fluid and a small amount of blood in areas that have been recently operated on during the process of inflammation and healing. When this is a small amount of fluid the body can reabsorb it without any problems, but if this volume of fluid is more than about 25 ml per day the fluid can accumulate and form a seroma. This is why it is important to measure the total amount of fluid that is generated through each drain every day so that we can tell whether the drain is ready to be removed. Remember that the more activity you are doing the more your drains will typically drain as movement increases the amount of fluid that is released.

The drain tube is made of a smooth silicone material that is easily removed in the office. It is sutured in place with a small black stitch and there is a black dot on the drain indicating where it should be in relation to the skin. The dot is generally at the position of the stitch, if the black dot on the drain is more than 2 inches away from the skin that means the drain has been pulled out and needs to be removed.

The color of the liquid collected in the drain bulbs can range between a clear liquid to a pink or a blood tinged one. The drain needs to be stripped approximately 3 to 4 times a day to prevent it from getting clogged. The nurses will have shown you how to do this before you leave the hospital. The fluid is emptied from the drain bulb into a measuring cup and the volume recorded in the drain output sheet. Typically two drains are used per area in order to make sure that if one drain gets clogged the other one is functional. 

The drain bulb has a loop which can be used to put on a loose belt or secure with a safety pin to clothing. We have seen several very inventive ways of securing drains! It is important to be mindful as not to snag the drains because they can be accidentally pulled out, paying specific attention to them when showering to make sure they are secure.

Aldona Spiegel, M.D. of The Center for Breast Restoration provides breast reconstruction, including perforator flaps, in Houston, TX.
 
 
PictureSource: MDAnderson.org
After breast reconstruction, some women opt to forego nipple reconstruction, although many others consider it to be the final step in the process. It’s an optional procedure that can be performed once the new breast has settled in place, or anytime—weeks or months—thereafter.

An older way of creating the nipple and areola involved transferring a small skin graft from the labia or upper thigh, since tissue from these areas is naturally darker than breast skin and doesn’t require tattooing. But the process can be uncomfortable (particularly involving a labial graft), it creates another incision that must heal, and it leaves a scar at the donor site. Labial tissue also tends to grow hair, so new nipples created in this way do as well.

Considering the disadvantages of nipples made with skin grafts, you can see why most surgeons think this procedure is outdated, preferring instead to make the new nipple with a small flap of breast skin. There are many different ways to do this (see illustration), and surgeons typically use the technique they most prefer. Tattooing then darkens the new nipple and simulates the areola around it. Some surgeons like to create the nipple, use a graft of darkened skin for the areola, and then tattoo the nipple to match the natural pigment.

One advantage of nipples/areolas created with skin grafts is that the pigment is permanent, while nipple/areola tattoos tend to fade considerably after a few years.

Done well, tattooed nipples and areolas look quite natural. The trick is to get someone who really knows what they're doing and takes the time to choose a pigment that matches your skin tone and that you’re happy with. Nipple tattooing takes just a few minutes. Tattoos are often applied in-office by the plastic surgeon or a member of the office staff (usually an RN). More surgeons now have tattoo artists provide the service or refer patients to them. This is actually better, because professionals tend to tattoo deeper into the skin, so that fading is less likely.

Many tattoo artists now specialize in reconstructive nipple tattoos, and some offer their services to breast cancer survivors at no charge. (Federal law requires health insurance companies that cover the cost of mastectomy also pay for breast reconstruction, including nipples and tattoos. If your plastic surgeon refers you to a professional tattooist, however, be sure to check with your insurance company to ensure preauthorization and subsequent payment.)

If you want to forego having nipples reconstructed, you might want to consider having just a tattoo—many professional tattoo artists can create beautifully simulated nipples with a 3-D look. Several companies also make adhesive nipples in varying pigments and sizes, which can be worn temporarily.

 
 

All surgical procedures, regardless of their purpose, carry risk to some degree, and breast reconstruction is no exception. Even though most women do not encounter serious problems from surgery, complications can occur, including the following:
  • Infection. Any opening in the skin presents an opportunity for infection to sneak in. Precautionary measures—maintaining sterile operating environments and cleansing the skin with antibacterial wash before incisions are made—are effective. If you are diabetic, obese or you’ve previously had radiation therapy to the breast or you’re currently taking chemotherapy, you’re more susceptible to infection. Infection is particularly worrisome if you have tissue expanders or breast implants, which can be contaminated by bacteria in the bloodstream or infection in the body. Depending on the degree of infection, antibiotics are usually prescribed; debriding (removing unhealthy tissue) may be necessary if large portions of tissue are involved.
  • Seroma. Sometimes clear fluid from blood vessels accumulates in the tissue, despite the use of surgical drains and compression garments. Small pockets of fluid are usually resorbed into the body. Larger seromas may need to be drained with a needle and subjected to several more days with a surgical drain. Treatment is important, because seromas that harden can become infected and require antibiotics or require another trip to the operating room to repair the problem.
  • Bleeding. Most women don’t experience bleeding after their reconstructive surgery, but sometimes a hematoma (a pocket of blood) forms when a blood vessel leaks into the surrounding tissue. As a precaution, for a period before and after your reconstruction, you should stop taking any vitamins, herbs and medications that thin the blood—your plastic surgeon will discuss this with you before your surgery. Like  seromas, many hematomas are resorbed by the body. Hematomas need to be monitored closely; any that are persistent may require additional surgery to reopen the incision and drain the collection of blood.
  • Stubborn wounds. Some people, especially older patients and those who are obese, experience delayed wound healing after surgery. Other factors can also influence how quickly a wound heals. Patients who develop infections, are diabetic or who have other chronic health problems tend to heal more slowly and should be monitored carefully during and after surgery.

  • Necrosis. Tissue that doesn’t receive enough blood dies from lack of oxygen. This necrosis can occur in the breast skin, which tends to be fragile after mastectomy, or in a flap of fat, skin and/or muscle that is used to reconstruct the new breast. If an area of necrosis is large or doesn’t shrink without further attention, it may need to be surgically removed. If an entire flap dies, it must be removed (rebuilding the breast then involves a different type of flap or breast implants). This rarely happens, but it is more likely to occur in patients who smoke, have circulatory problems, or who have had radiation to the breast (radiation compromise blood flow).

Most women have no problem healing after reconstructive surgery, but it is a good idea to be aware of the inherent risks of any surgical procedure before you enter the operating room.

 
 
Guest Blog

One topic that has attracted growing attention in the field of Advanced Breast Reconstruction is autologous fat grafting for total breast reconstruction. (“Autologous” means that the tissue is derived from the patient.) To understand what this procedure is, and how it compares to other procedures that are currently used for breast reconstruction, plastic surgeon Dr. Ergun Kocak explains the important differences between a “graft” and a “flap.”

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  • A flap is a piece of tissue that is transplanted or moved from one part of the body to another, based on a specific blood supply. The flap tissue, therefore, can survive on its own because it has its own, dedicated blood flow, from which it receives oxygen and nutrients. 
  • A graft is still a piece of tissue that is transplanted or moved from one part of the body to another, but it does not have its own blood supply. Instead, it relies on the nearby tissues to derive its oxygen and nutrients. Over time, most grafted tissues will develop their own blood flow as small arteries and veins grow in and out of the tissue. But until this happens, grafts rely completely on their surroundings to survive.

Presently, most of the autologous, or natural tissue options available for breast reconstruction utilize flaps. Examples include DIEP and SIEA flaps from the lower abdomen, GAP flaps from the buttock region, and TUG and PAP flaps from the thighs. All of these techniques are technically demanding and involve specialized training and environments to optimize outcomes. For this reason, there has been ongoing interest to develop methods that utilize natural tissue, without the need for such demanding operative techniques, such as autologous fat grafting.

So where does the fat come from? In most cases, liposuction is performed on parts of the body where fat tends to accumulate, such as the abdomen, flanks, and thighs. The suctioned fat is processed to purify the fat cells while excluding the body’s fluids and oils. The purified fat is then loaded into syringes and it is injected into the desired area. 

Small and large volume fat grafting
Fat grafting can be divided into two main categories: (1) small volume and (2) large volume fat grafting. Smaller volume fat grafting has been used for many years to correct small contour deformities after breast reconstruction using other techniques such as implant or flap reconstruction. For example, it is common to have a small area of volume deficiency at the inner, top part of the breast after implant reconstruction. Fat grafting small volumes (50-100 cc) into this area adds fullness and improves the contour, making many patients much happier with the appearance of their reconstructed breasts.

Smaller volume fat grafts can also be used to improve or correct deformities of the breast which occur after lumpectomy with or without radiation. While the overall goal of lumpectomy is to conserve the breast shape and size, deformities can occur, especially if radiation therapy is added to the treatment regimen. These deformities can be very difficult to repair as there are not many flaps which are small and versatile enough to be custom-tailored to replace the tissue that was taken out with the original lumpectomy. Furthermore, using implants to increase the size might seem like an easy fix, but this approach is generally unsuccessful due to the high rate of complications associated with implants in irradiated tissues. Fortunately, small volume fat grafts can sometimes be used to fill these areas. While it is very difficult to completely correct breast volume or shape, fat grafting can improve symmetry between the two breasts.

Megavolume fat grafting for full breast reconstruction?
Can fat grafting be used to reconstruct an entire breast? Recently, there has been growing interest in this question and methods for transferring large volumes, sometimes called megavolumes, of fat have been described. At the surface, this method has a great deal of appeal. It makes reconstructing the breast with natural tissues possible without the need for highly complex flap operations, such as the DIEP and GAP flaps, which transplant large pieces of intact tissue from other parts of the body.

A closer look at the details, however, reveals several intricacies associated with high volume fat grafting procedures. For example, many of the reports using these methods utilize machines to apply suction to the outside of the breast skin (external expansion). These devices have to be used for extended periods of time and can be quite laborious.

Furthermore, liposuction of very large volumes of fat tissue is needed to harvest the fat that is used for the breast reconstruction. Liposuction has its own associated potential complications which should be carefully considered when exploring reconstructive options:
  • Contour deformities. If an area is aggressively over-suctioned, it can lead to divots in the skin. These can be very difficult to correct.
  • Seromas. These are collections of body fluid in the areas that are suctioned. They can persist as soft contour deformities in the suctioned areas.
  • Fat embolism. During liposuction, small blood vessels can be ruptured or broken, making it possible for small pieces of fat to enter the blood stream and plug vessels in the lungs and/or brain.
  • Visceral perforation. Since liposuction is done through small puncture incisions, the surgeon cannot see the end of the liposuction cannula. This makes it possible for the tip of the cannula to travel deeper than desired, leading to puncture of the internal organs such as the intestines during abdominal liposuction.
Do transplanted stem cells in fat tissue stimulate cancer?
Another potential concern that has been raised by some Medical Oncologists and Surgical Oncologists relates to the effects the grafted fat cells may have on the beds of tissue into which they are grafted. Fat tissue contains several different types of cells. Small parts of these cells are known as stem cells because they have the ability to turn into different types of tissue and to dictate the behavior of the cells nearby. For cases where the reconstruction is taking place after a mastectomy that is done for a breast cancer, this raises the theoretical concern that these stem cells, if grafted into the area where the cancer once was, could influence the behavior of the cells at the recipient site and promote cancer recurrences. Several scientific studies in laboratory and animal models have been carried out to evaluate this concern. Most show that the stem cells that are in fat grafts do not promote tumor growth, but some studies indicate otherwise and no human studies have been done at this time.

In summary, fat grafting is an important part of advanced breast reconstruction and can be used in several different ways to fine-tune other types of reconstruction and possibly even reconstruct entire breasts. While the technique has been around for years, there is a recent revival in interest around fat grafting and several centers are exploring the ways it can be safely used in breast reconstruction.

Dr. Kocak, MD, MS, of
Midwest Breast and Aesthetic Surgery provides breast reconstruction, including perforator flaps, in Columbus and Cleveland, OH.