Is breast reconstruction after a mastectomy right for you?

Transcript

Amanda Wilde (Host): A mastectomy is sometimes the most effective choice, but we all wonder after the surgery, what will your chest look like? Is breast reconstruction right for you? Well, with us today to sort out post mastectomy options is Dr. Jarom Gilstrap, Director of Breast Reconstruction and microvascular surgery at Prisma Health. This is Flourish, a podcast brought to you by Prisma Health. I’m Amanda Wilde. Dr. Gilstrap, thank you so much for being here.

Dr. Jarom Gilstrap: Thanks for having me, Amanda. It’s good to be here.

Amanda Wilde (Host): Now, a mastectomy is a complete removal of breast tissue, and often after that, patients are sent to a plastic surgeon to discuss reconstructive surgery. What happens at that first appointment?

Dr. Jarom Gilstrap: So, a lot of times that first appointment is one of our longer appointments where we have in-depth conversation about what the options are after having the mastectomy. And there’s a wide range of paths that we can take, and it really depends on, not only the clinical scenario, but also what the patient’s desires are. And that’s a conversation that we get into with the patients, and we talk about a lot of things from, what is breast reconstruction? Should I have it? Do I need to have it? What type is best for me? Timing of everything. There’s a lot that goes into that first conversation that we have, and that’s one time where I like to take a lot of time to get to know the patients, get to know what they expect and what they’re looking for and how we can best serve them, in what is a really difficult time for them.

Amanda Wilde (Host): What are the reconstructive options after a mastectomy?

Dr. Jarom Gilstrap: My goal is to help them make the right decisions for them. So, I’m not here to push one thing or another. I always like to make sure that I let my patients know first off, having a reconstruction is not mandatory. They can opt for no reconstruction. But breast reconstruction is considered part of complete cancer care. So that is an option for them if they wish to proceed with that. I would say there are kind of two major camps of breast reconstruction and they’re not at odds with each other. Just one might be better than another for certain patients, and that would be an implant-based reconstruction where we use tissue expanders and implants, or we use a patient’s own tissue in place of an implant material.

And what we’re really doing is we’re replacing that breast tissue with something else, be it with an implant or with the patient’s own tissue. Both of them have their pros and cons. Both of them have really great things about them and not so great things about them. And it’s really a conversation that we like to have with the patient about what might fit best for them and what they’re looking for.

Amanda Wilde (Host): You mentioned no reconstruction. What does that look like?

Dr. Jarom Gilstrap: That’s something that I think a lot of people, when they choose to have no reconstruction, they kind of think of maybe just a flat chest or maybe almost like a male chest where it’s just flat. And, unfortunately, that’s not necessarily what it looks like. The breast tissue on the chest, actually, when it’s removed, there isn’t bit of a concavity or an indention. Sometimes there can be some excess skin that’s a little flabby. And a lot of times in those situations, the nipples are also removed. So, it’s not maybe what people automatically think of.

That being said, you know, some people don’t want to have a breast reconstruction. That’s fine. And we have good people in town that I refer to that do external prosthetics or specialty bras that allow people to maybe wear some of the clothes that they wore before and not feel self-conscious when they’re out in public.

Amanda Wilde (Host): Well, what are the advantages of getting reconstructive surgery? Why might someone choose to have that reconstructive surgery after a mastecomy?

Dr. Jarom Gilstrap: Well, I think, some people think of breast reconstruction as maybe, like, a vanity thing or, I’ve heard people say, Well, I’m done having kids, I don’t need a breast reconstruction. Or I’m divorced. Or they feel like they don’t need it. But really there’s a psychological aspect to it. Restoring one’s body image, being complete, there’s a lot of benefits to it. There are benefits over, say like an external prosthetic because those tend to be heavy. People will get hot underneath and can sweat underneath, and it’s nice to have something that’s a part of you.

And while we’re not, giving somebody back their breasts, we are making a semblance of that and giving something that’s a part of them and restoring that body image and it has been shown to positively affect psychological wellbeing as well.

Amanda Wilde (Host): Is that a longer recovery process then? And once you’ve gotten the mastectomy, you get another surgery for rebuilding. What does that involve in terms of time and how common is it to need adjustments, further surgeries or other complications?

Dr. Jarom Gilstrap: First off, we’re talking about timing. So, you said specifically needing separate surgeries. So, there is something called delayed breast reconstruction where the mastectomy is done and then sometime later, breast reconstruction is performed. That’s delayed reconstruction.

There’s also immediate reconstruction, which is where a breast reconstruction, or at least a stage of breast reconstruction is performed at the same time as the mastectomy. A lot of times that depends on a clinical scenario. But I would say a lot of patients we’re able to offer immediate breast reconstruction too.

As far as adding on to recovery, the recovery from a mastectomy is in the neighborhood of four to six weeks. I would say that the recovery from an implant-based reconstruction is gonna be the same amount of time, and it is overlapping. So, it’s not necessarily adding a whole lot of recovery, per se, to the mastectomy itself.

You asked about, any complications and revisions. Complications. It depends on the type of reconstruction that you have. If we’re doing implant-based reconstruction, the things that I worry about a lot are skin healing and infection, because it is a foreign body that we’re introducing.

So, any sort of infection typically needs to be treated with removal of an implant. And there is a not an insignificant rate, I would say in the neighborhood of, anywhere from two to 10%, of implant removal or failure of reconstruction in an implant-based reconstruction.

In a tissue-based reconstruction, you’re not introducing a foreign body. So that’s not necessarily a worry if there were to be an infection. It can be treated successfully with antibiotics. But there are also cons to your own tissue reconstruction, autogenous or deep flaps, tram flaps, etcetera, where it is a longer surgery and there is a longer recovery time.

As far as revisions are concerned, I would say that it’s more common than not to usually do smaller surgeries to do revisions. Like one thing might be fat grafting. If there’s some contouring, irregularities that we’d like to address, then we can actually perform liposuction where we harvest fat, which not a lot of patients argue with me about wanting to do liposuction that’s insurance covered, you know. But we do liposuction, use that fat to contour the breast reconstruction. Another part of it might be nipple reconstruction. So, there are a lot of aspects to it.

Amanda Wilde (Host): And it can’t always be done in one surgery?

Dr. Jarom Gilstrap: No, it’s typically best to separate things out sometimes because there is an amount of healing and letting swelling and edema resolve before moving on to do more.

Amanda Wilde (Host): So, we’re basically talking about two types of reconstruction. One is using your own body fat to reconstruct, and then there’s implants. So, I have questions about both. Implants have been in the news a lot. How safe are they?

Dr. Jarom Gilstrap: They have been in the news a lot and that’s always an issue in, being physicians, that’s something that we’re always worried about. So, one thing that has been in the news, I would say, for the last several years has been something called ALCL, which is aplastic large cell lymphoma. That specifically has been associated with certain processing techniques for implants. Those techniques and implants are not being used anymore. That being said, the incidence of it was extremely low. I personally have not seen a case of that since I’ve been practicing.

But it is something that I like to talk with patients about and like to make sure that they’re aware. When I say low, I’m speaking at, one in 30,000, might be a good number to throw out there. There’s also, breast implant illness, BII, which is a constellation of more systemic symptoms like fatigue or headaches or things like that, that can’t necessarily be like pinpointed to the breast implant. But we also can’t say that it’s not causing that. Again, that’s rare. I have seen that though, mostly in patients that would like an implant removed and that could be for reconstruction, that could be for cosmetic patients also.

I always make sure that they know I’m happy to do that. I’m happy to remove that. But with the connection where we’re not sure, I also can’t guarantee that removing the implant will relieve those symptoms.

Amanda Wilde (Host): So, with the other surgery we’re talking about, the flap reconstruction that uses your own body. You’re taking fat from other areas and sort of rebuilding the breast mound. Does that feel more part of you than an implant because it’s using your own materials and you have your own blood supply?

Dr. Jarom Gilstrap: It absolutely does. So, it’s very similar to the feeling of breast tissue, the abdominal tissue, which is what we typically use. It doesn’t have temperature differentials that patients feel when they have, say, an implant. It tends to look and feel more natural. When I say feel, I should be careful and specify that. I mean feeling like with your hands from the outside, the kind of consistency of it. When we’re talking about actual sensation, I think that’s an important thing for patients to know that there are nerves that go to the breast that are removed and essentially, I would say, most mastectomies, the skin overlying, regardless of the reconstruction type is numb, is insensate.

That’s from the mastectomy itself, not from what you’re doing with the reconstruction?

Correct.

Amanda Wilde (Host): And we should also say when people are getting these flap reconstructions and you’re doing liposuction and things like that, two things it’s not: It’s not a boob job because a boob job includes using some of your own breast material and with a mastectomy, you don’t have that to work with. And then also when you get the liposuction, my understanding is it’s not like you’re getting this free fat removal because the skin there isn’t going to be all tightened up and things like that, as it would when you’re getting a cosmetic procedure.

Dr. Jarom Gilstrap: It depends on the skin quality. I wanna be very careful to make sure that people know that this is not a cosmetic procedure. But it depends on skin quality if there’s any natural skin tightening that happens afterward.

Amanda Wilde (Host): So, who is a candidate for these surgeries should they want a reconstruction?

Dr. Jarom Gilstrap: I would say that most people are. Things that might disqualify somebody from being a candidate, perhaps? If somebody had very advanced stage breast cancer, I might discourage them from breast reconstruction. But I might encourage them to pursue delayed reconstruction and first focus on completion of cancer treatment before proceeding with the reconstruction.

There are other, serious medical conditions that might preclude you from doing it. There are certain things that preclude people from having one type that’s autologous or implant-based reconstruction. There’s kind of a laundry list and that’s something that I like to go over with people on a case-by-case basis.

Amanda Wilde (Host): Get really specific about that with each individual person.

Dr. Jarom Gilstrap: I could, get really granular with that. I’m not sure if that would be helpful. For example, if somebody had a hypercoagulable disorder, where they formed blood clots, doing a flap or a tissue-based reconstruction might not be the best thing.

If a patient had had breast cancer and a lumpectomy and radiation before and there’s a lot of radiation, skin damage, they might not be a candidate for an implant-based reconstruction. And it really depends on each patient and their specifics of their case.

Amanda Wilde (Host): So, if you’re considering this, at what point might you want to meet with a plastic surgeon if you’re even considering it?

Dr. Jarom Gilstrap: I would say that even if it’s something that the patient thinks that they probably don’t want reconstruction, it would be worthwhile to talk with the plastic surgeon just to hear about details. And I would say ask your breast surgeon to refer you. Regardless of whether you’re interested in reconstruction, whether you think you’re a candidate, just so that you can have all the information. Cause I really think with breast cancer, this is something where it’s best to have as much information as possible.

Amanda Wilde (Host): If you do have reconstruction, what support is needed that you’ve seen either medically or emotionally?

Dr. Jarom Gilstrap: Our breast cancer team has a lot of members. So, we have a nurse coordinator that takes people through a lot of things. We have physical therapists that are very helpful with range of motion, exercise, lymphedema prevention, things like that. I like to think that my team here, myself and my nurses and APPs, are very involved in supporting patients, being there for them, helping them find things that they need and get through what would otherwise be a very difficult time.

Amanda Wilde (Host): So, you really follow up from that very thorough first meeting to team support all the way through recovery?

Dr. Jarom Gilstrap: Absolutely. I tell my patients, you know, when they come here, if they do decide that they want to have breast reconstruction, that they’re gonna get to know the staff here and like them and be friends with them, and feel like they’re part of their family, so to speak.

Amanda Wilde (Host): Well, Dr. Gilstrap, thank you for describing these different approaches to post mastectomy care and for your work helping women decide the right course for each of us individually.

Dr. Jarom Gilstrap: I love my work and I’m happy to be able to serve in that capacity.

Amanda Wilde (Host): You can get in touch with Dr. Gilstrap. For more information and other health podcasts, go to PrismaHealth.org/Flourish. This has been Flourish, A podcast brought to you by Prisma Health. I’m Amanda Wilde. Be well.