Removing all cancerous tissue during surgery, and obtaining clear margins—the area of tissue that is free of cancerous cells—is critically important, but it is not always easy or possible.
As archaic as it sounds, a surgeon has no way of knowing precisely where cancerous tissue ends and the margin of healthy tissue begins. Often, when post-surgery pathology shows that cancer cells remain, cancer patients, including those with breast cancer who undergo lumpectomy or mastectomy, need another visit to the operating room to eradicate rogue tissue that may otherwise escape a surgeon’s visual examination. According to Dr. Jim Olson, a pediatric oncologist at Fred Hutchinson Cancer Center who cares for children with brain cancer, “Thirty percent of women who have breast cancer find out that where the surgeon stopped cutting, there are still cancer cells, and that they probably need to have more surgery done. And unfortunately, they get this information 7 to 10 days after they’re out of the operating room.”
Inspired by many of his young patients, Dr. Olson and his creative research team developed Tumor Paint to identify cancerous tissue during surgery so that it can be removed during the initial operation. Simple and effective, injectable Tumor Paint is derived from a peptide in scorpion venom that naturally binds to brain cancer cells. Combining it with a fluorescent molecule that “lights up” cancerous cells and bypasses healthy cells, surgeons can more easily distinguish normal tissue from tissue that needs to be removed and that might otherwise go undetected. (After a tumor is removed, the surgeon uses a special near-infrared camera to make sure no stray cancerous cells have been left behind.)
Initially developed to save healthy brain tissue, in preclinical trials involving animals, Tumor Paint has successfully illuminated prostate, colon, breast and other cancers. If human clinical trials next year are successful, Tumor Paint will become perhaps the most important surgical tool for reducing repeat surgeries, limiting or elminating the amount of normal tissue that is removed, and ultimately, saving lives.
To learn how Dr. Olson was inspired by individual patients that he cared for, and how this inspiration led to a whole new platform of potential cancer drugs that come from violets, sunflowers, spiders, scorpions and other nature-based sources, watch his recent TEDxSeattle talk
. To encourage those who care about breast cancer to spread the word, the Washington Research Foundation (WRF) has offered to donate up to $50,000 ($10 for each view).
Choice can be a wonderful thing, and thanks to long-awaited FDA approval of high-strength cohesive silicone gel breast implants, women have another option for breast reconstruction.
After widespread use in Europe since 1995, in Canada since 2000, and other countries for several years, these fifth-generation semi-solid “gummy bear” implants are now available in the U.S. by three manufacturers: Mentor (MemoryShape), Allergan (Natrelle 410) and Sientra (Silimed).
Gummy bear implants offer several advantages over saline and earlier-generation counterparts:
- New “gummies” mimic natural breasts with gradually-sloped tops and full bottoms, rather than the “half-grapefruit” appearance that often results from round implants. Gummy bears retain their shape over time, a significant advantage over non-cohesive implants that retain no particular shape once they are placed in the chest.
Turned upright, a gummy bear implant (right) retains its form. A non-cohesive silicone implant (left) does not. Source: cohesiveimplants.com
- Cohesive gel does not shift as other implant fillers do, so wrinkles and ripples (more of a problem with saline implants), and folds that often cause implant leaks are less likely to develop. This not only improves appearance, but limits friction and tension that may weaken the outer shell. Some experts expect cohesive silicone gel breast implants to last longer than other types of breast implants.
- Silicone from a ruptured gummy bear breast implant is less likely to leak and migrate to lymph nodes and elsewhere in the body: it holds together in a single mass, like Jello or gummy bear candy.
A gummy bear implant remains intact when it is squished or even cut in half.
- Although long-term data is not yet available, gummy bear breast implants are believed to reduce the rate of capsular contracture (the most common problem and source of reoperation with other breast implants).
Gummy bear breast implants may be an improvement over older models, yet despite a high rate of patient satisfaction and reported lower problem rate, they are still subject to problems that are inherent to all implants:
- Gummy bear breast implants are more expensive.
- Like other types of breast implants, gummy bears are not lifetime devices and need to be replaced soon or later.
- Not all surgeons provide gummy bear implants.
- Semi-solid gummy bear implants cannot be pushed through small incisions as saline and non-cohesive silicone gel breast implants can, and require larger incisions.
- The risk of rupture, although reduced with highly cohesive silicone gel implants, is not eliminated. The FDA recommends MRI screenings beginning three years after the implant is placed and every two years after that to detect “silent” rupture.
- Infection anytime after placement surgery may occur.
- Many women report that highly cohesive silicone gel implants feel firmer and less natural than earlier silicone implants.
- Gummy bear breast implants require a perfectly-sized submuscular pocket to avoid rotation that could lead to breast distortion.
- Women who prefer more projection or fullness at the top of their reconstructed breasts may better served with round implants.
- Long-term study data (10 years or more) is not yet available.
So are highly cohesive silicone breast implants really better? That remains to be seen, and like most things in life, it depends on personal choice. Gummies may not be right for all women, but they do add another choice to the implant menu.
Sometimes the simplest ideas are the best.
Who would have thought that the surgical equivalent of a chef’s pastry bag might reduce infection and capsular contracture from silicone breast implants
? Surgeons are calling the disposable Keller Funnel (see photo below) “innovative,” “revolutionary,” and “exciting.” That’s impressive, because surgeons are a group that is not easily impressed. (The funnel isn’t used with saline implants, which are inserted empty and filled once they are positioned in the chest.)
Capsular contracture is a hardening of the scar surrounding the implant. It is a risk for any woman who has silicone implants for augmentation or reconstruction, and in fact, is the most common reason these women need reoperation. This scar tissue isn’t unusual and it’s not harmful; the body responds in the same way to pacemakers, implanted orthopedic devices and any foreign object within. Many women with breast implants are unaware that they even have capsular contracture, but it can become problematic when it thickens and hardens sufficiently to distort implant shape or position and/or cause pain. Experts use the Baker scale to classify capsular contracture:
Grade I: The breast remains soft and looks normal.
Grade II: The breast appears normal but feels hard.
Grade III: The breast is hard, visibly distorted, and may cause discomfort.
Grade IV: This is similar to Grade III, but the breast is much harder and may be painful.
Grades I and II often require no action; Grades III and IV are sometimes treated with medication, ultrasound, massage or capsulectomy, a surgical procedure to remove the scar tissue surrounding the implant. In most cases, however, the implant and scar tissue are removed, and the implant is replaced (if that’s what the patient wants).
No one knows for sure what triggers capsular contracture, but experts think it might occur when bacteria from a surgeon’s gloves or the chest pocket is transferred to the surface of the implant. The Keller Funnel allows surgeons to follow a “no-touch” procedure, meaning they minimize bacteria by pouring the implant, which has been soaked in antibiotic fluid, into the funnel and then propelling it gently into the pocket; just as you would squeeze frosting from a pastry bag onto a cake. The implant never comes in contact with the surgeon’s hands or the patient’s skin, so any bacteria is minimized. That means less chance of infection, and hopefully, less capsular contracture. Anecdotal evidence shows that the funnel does reduce the incidence of infection and capsular contracture; formal studies aren't yet available for the device that was introduced in 2009.
Using the funnel produces other benefits too. It allows for a smaller incision (that’s always good news) and shaves about 15 minutes from the procedure. It may minimize ruptures as well, because surgeons no longer need to tug and push on the implant with their fingers, which may weaken the implant shell and encourage rupture.
If you’re having surgery involving silicone breast implants—whether it is augmentation or reconstruction—ask if your plastic surgeon uses the Keller Funnel. Or visit http://www.kellerfunnel.com
for a list of surgeons who use it.
Innovations in breast reconstruction
are always welcome, but they tend to be few and far between. That’s why hopes are riding high that clinical trials of a promising next-generation tissue expander
will show that the device is safe and effective. Direct-to-implant
is a faster method of reconstruction because it doesn't require expansion. But not all surgeons offer this procedure, and not all women are candidates (it requires nipple-sparing mastectomy and undamaged, healthy breast skin). Most implant reconstruction involves the use of temporary tissue 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).
AeroForm expanders 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.
Image: AirXpanders Inc.
When the anatomically-shaped AeroForm 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.
Women who used AeroForm expanders in clinical trials in the U.S. (The EXPAND trial) and Australia (The PACE trial) completed their expansion in an average of just 17 days, compared to control participants with traditional saline fills who completed expansion in an average of 51 days. All AeroForm participants said they were highly satisfied with the experience and convenience; 94% said they would recommend the new expanders to other women for breast reconstruction.
Trial locations include select hospitals in California, Florida, Kentucky, Massachussetts, North Carolina, New York and Texas. For more information or to participate in the clinical trial, visit www.clinicaltrials.gov and search "XPAND."
Beauty, like art, is in the eye of the beholder.
Do you find this photo offensive? Probably not, even when you realize that this colorful fashion statement is, in fact, a tattoo. The image recently went viral when it was removed by Facebook due to "offensive nudity." Other post-mastectomy photos of women, with and without custom tattoos, were also removed. Facebook relented when members voiced their outrage and Scorchy Barrington, a woman with stage IV breast cancer, gathered more than 20,000 signatures to demand that the social site stop censoring members' mastectomy photos.
Tattooed nipple and areola
Beyond the issue of Facebook's policy, the brouhaha brings up several important points. First, our bodies are our own, to do with as we please. While many women are comfortable with their mastectomy scars, others (whether or not they have breast reconstruction
) would love not to have such visible reminders of their lost breasts. Among women who have breast reconstruction
, most opt for new nipples and tattoos (right) for a realistic finish to the process. Others prefer not to have nipples or don't feel the need for any type of tattoo, traditional or otherwise.
These days, creative tattoos are an accepted part of our social culture, but like joint bank accounts, pointy shoes and expensive cars, they aren't for everyone. They are, however, one way to celebrate, decorate or camoflauge mastectomy scars whether or not you have reconstructed breasts. And seeing photos like these helps women to know what's available to them.
And that's the great thing about choice: if a tattoo appeals to you, go for it. If not, don't. Do some research if you feel creative: the possibilities are endless.
When Angelina Jolie announced last month that she had bilateral prophylactic mastectomy to reduce her high hereditary risk of breast cancer, newsrooms all over the world scrambled to cover the story.
A local reporter called me to discuss Jolie’s drastic action; when our conversation shifted to breast reconstruction, the reporter asked, “Well of course Jolie had reconstruction, what woman wouldn’t?” This question might seem to be logical (and a foregone conclusion) to those who are unfamiliar or untouched by mastectomy
. We routinely replace worn-out hips, out-of-whack knees and other faulty body parts; why then, wouldn’t it also be a no-brainer for women to opt for reconstruction after losing such an intensely private and personal part of themselves?
While many women consider breast reconstruction to be an option that they can do without, each year tens of thousands of women who lose their breasts to either treat or prevent cancer have post-mastectomy reconstruction. For high-risk women like Jolie, the possibility of returning to a near-normal (or improved) natural feminine profile eases the very difficult decision to have preemptive mastectomy. As one woman explained reconstruction to her child, “It replaces the stuffing in Mommy’s breast.” That might be a bit simplified, but it’s accurate: reconstruction doesn’t restore sensation or the ability to breastfeed, but it does replace breast tissue that is removed during mastectomy with implants
and/or a woman’s own excess fatty tissue
from elsewhere on her body.
Jolie made informed and carefully considered decisions that were right for her, but they are not the only options, and other women, even those with a similar level of risk might prefer a different path.
- Genetic counseling and testing. Based on her family medical history, Jolie consulted with a genetic counselor, who determined that she was indeed a candidate for genetic testing; results showed that Jolie has an inherited mutation in the BRCA1 gene, which greatly elevates the likelihood of developing breast, ovarian and other cancers.
- Preventive bilateral mastectomy. Prophylactic bilateral mastectomy is the most effective way to reduce hereditary risk, but some women who have a BRCA gene mutation prefer to take medication (tamoxifen) to reduce the risk of breast cancer or increase surveillance to detect any breast cancer at an early stage when the odds of successful treatment are increased. Jolie also opted for nipple-sparing mastectomy, which is considered to be quite safe when included as part of preventive mastectomy (during the mastectomy procedure, a small tissue sample from beneath the nipple is tested by a pathologist; if cancer cells are found, the nipple is removed). The good news is that women who keep their nipples retain a small part of their natural breasts, and preserve the natural projection of the breast after reconstruction. The not-so-good news is that sensation is usually decreased, changed or sometimes eliminated after nipple-sparing surgery.
- Immediate reconstruction with tissue expanders. Although all plastic surgeons don’t perform all reconstructive breast procedures, breast tissue can be replaced by implants, a woman’s own tissue, or a combination of both. Jolie chose the most common method of reconstruction: tissue expanders that gradually stretch muscle and skin to make room for implants. Her expansion was completed in just nine weeks: a process that most physicians prefer to complete over a period of several months. A newer method offered by some surgeons places implants immediately, altogether eliminating the need for expansion.
With her double mastectomy and reconstruction now behind her, Jolie, who has been called “the most beautiful woman in the world” wrote, “…I do not feel any less of a woman. I feel empowered that I made a strong choice that in no way diminishes my femininity.” She certainly didn’t have to go public with her story. (Arguably the priority of many in her profession would have been to remain quiet on this intensely personal issue.) By sharing her experience, Jolie opened dialogue about the power of individual choice, while encouraging women to make their own informed decisions.