Breast Reconstruction 2017 by PlasticSurgeryNews

FALL 2017

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A Supplement to Plastic Surgery News

A patient’s guide to understanding her treatment options

Never Alone Fashion designer helps breast cancer patients find beauty in their scars Page 8

On the Other Side Plastic surgeon shares highs and lows of her unexpected cancer journey Page 12

What Women Really Need to Know 5 breast reconstruction myths debunked Page 15

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New

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Physicians should consider whether or not this procedure is appropriate for patients including patients with poorly vascularized ﬂaps. As with all implant reconstruction, proceed with caution on patients with prior radiotherapy to the breast, a history of smoking, patients with high BMI, and very large breasts. Before use, physicians should review all risk information, which can be found in the Instructions for Use attached to the packaging of each AlloDerm SELECT™ Tissue Matrix. Rx only. CONTRAINDICATIONS: AlloDerm SELECT™ RTM Ready To Use is contraindicated for use in any patient who is sensitive to any of the antibiotics listed on the package or Polysorbate 20. Reference: 1. Sigalove S, et al. Prepectoral Implant-Based Breast Reconstruction: Rationale, Indications, and Preliminary Results. Plast Reconstr Surg. 2017 Feb;139(2):287-294.

Model- not actual patient

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*As compared with saline-filled breast implants † When compared to MemoryGel® Breast Implants. 1. Product Dimensions for MemoryGel® and MemoryGel® Xtra Breast Implants and Mentor R&D Compression Benchtop Testing - July 2017. IMPORTANT SAFETY INFORMATION MENTOR® MemoryGel® Breast Implants are indicated for breast augmentation in women at least 22 years old or for breast reconstruction. Breast implant surgery should not be performed in women with active infection anywhere in their body with existing cancer or pre-cancer of their breast who have not received adequate treatment for those conditions or are pregnant or nursing. Breast implants are not lifetime devices and breast implantation is not necessarily a one-time surgery. The most common complications with the MemoryGel® Breast Implants include reoperation, capsular contracture, asymmetry, and breast pain. A lower risk of complication is rupture. The health consequences of a ruptured silicone gel-ﬁlled breast implant have not been fully established. MRI screenings are recommended three years after initial implant surgery and then every two years after to detect silent rupture. Patients should receive a copy of Important Information for Augmentation Patients about MENTOR® MemoryGel® Silicone Gel-Filled Breast Implants or Important Information for Reconstruction Patients about MENTOR® MemoryGel® Silicone Gel-Filled Breast Implants. Your patient needs to read and understand the information regarding the risks and beneﬁts of breast implants, with an opportunity to consult with you prior to deciding on surgery. For detailed indications, contraindications, warning and precautions associated with the use of MemoryGel® Breast Implants. Please refer to the Product Insert Data Sheet provided with each product, or online at www.mentorwwllc.com. © Mentor Worldwide LLC 2017 079300-170825

Table of

Contents Cover Photo Credit: Tracy Birdsell Photography

FALL 2017

History of Breast Reconstruction Awareness Day .................................... 6 Join the fight against breast cancer ....................................... 7 Never alone: Breast cancer survivor helps women discover beauty and confidence in their battle............ 8 Q&A: When a plastic surgeon becomes a cancer patient .................12 Answers to questions about breast reconstruction ........................14 5 Breast reconstruction myths dispelled ................................. 15 Why breast cancer patients deserve a board-certified plastic surgeon .................................. 16 Checklist: 10 questions to ask your plastic surgeon ...............17 Plastic surgeons share why they perform breast reconstruction ........ 18 Two-time breast cancer survivor advocates for breast reconstruction .......................20 Breast reconstruction words to know.....................................21 Industry support vital to Breast Reconstruction Awareness efforts .............................22 Know your options ............................23 The views expressed in the articles in this supplement are those of the authors and do not necessarily reflect the opinions of ASPS. Acceptance of advertisements is at the sole discretion of ASPS. ASPS does not guarantee, warrant or endorse any product, program or service advertised. ASPS website plasticsurgery.org

Download a free electronic copy of PSN: Breast Reconstruction at plasticsurgery.org/breastreconissue

 PSN: BREAST RECONSTRUCTION 2017

It’s time to close the loop on breast cancer.

elcome to the second edition of Plastic Surgery News: Breast Reconstruction — the Society’s first publication that provides exclusive coverage on all topics related to breast reconstruction to help patients understand their options. Receiving a breast cancer diagnosis is a life-changing event. Recent studies show more than 3 million women have a history of breast cancer in the United States. While nearly one in eight U.S. women will develop invasive breast cancer over the course of her lifetime, only 23 percent of women know the wide range of breast reconstruction options available to them. These statistics show an improvement from previous years, but this is not an ideal situation – far too often, women enter the process overwhelmed, confused and uninformed. The majority do not understand that the timing of their treatment for breast cancer and the timing of their decision to undergo reconstruction can significantly impact their options and results. Yes, we are making progress, but more work needs to be done. As these women begin their courageous battle against this disease, it is essential for them to understand all their treatment options, including their eligibility for breast reconstruction following cancer surgery. We can all do our part to make sure every woman knows her options and has adequate information to make an educated decision. Since 2012, ASPS and The PSF have led the Breast Reconstruction Awareness Day USA campaign, one of the few breast cancer initiatives devoted to raising awareness and educating the public on breast reconstruction options. In celebration of the fifth Breast Reconstruction Awareness Day USA (slated to take place on Oct. 18), we are excited to share stories of hope, courage and innovation from the patients’ and physicians’ perspective in this supplement to PSN. In this issue, we shed light on the common misconceptions of breast reconstruction and highlight why patients need to have a board-certified plastic surgeon on their cancer care team. This edition also features Dana Donofree, a breast cancer survivor who uses her story and fashion-industry experience to empower women all over the world through beautiful lingerie and loungewear. Whether it’s an open letter from plastic surgeons on their personal decision to perform breast reconstruction, a Q&A with a plastic surgeon who unexpectedly found herself on the other side of breast reconstruction as a cancer patient or an article that answers common questions about the procedure, every page is designed to promote patient care, education and research and to highlight the Society’s commitment to raise awareness about breast reconstruction and to “close the loop” on breast cancer. From the moment of diagnosis through recovery, many plastic surgeons use their extensive training and surgical skills to empower breast cancer patients and survivors around the world. As a plastic surgeon, I use my skill to build and restore joy during a challenging moment in a patient’s life. It’s one of the reasons I love what I do. I know I am making a difference. Together, plastic surgeons, patients, breast cancer survivors and all those affected by the disease can join the fight, raise awareness and advocate for breast cancer patients. We hope you enjoy this issue of PSN: Breast Reconstruction and continue to help us close the loop on breast cancer. -Anu Bajaj, MD PSN Chief Medical Editor

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www.airxpanders.com/contact * Ascherman, JA., et al. CO2-based vs. Saline Tissue Expansion for Breast Reconstruction: Results of the XPAND Prospective, Randomized Clinical Trial. Plastic and Reconstructive Surgery. December 2016 – Volume 138, Number 6. The AeroForm Tissue Expander system is used for soft tissue expansion in breast reconstruction following mastectomy, for the treatment of underdeveloped breasts, and for the treatment of soft tissue deformities in the breast. The AeroForm Expander is intended for temporary subcutaneous or submuscular implantation and is not intended for use beyond six months. AeroForm Tissue Expander System, the AeroForm logo and the AirXpanders logo are registered trademarks of AirXpanders, Inc. © 2017. All rights reserved. The products described in the document may be covered by U.S. Patents: 9,526,584; 8,394,118; 8,617,198 and 8,808,322. COL-0053 Rev. A

A BRIEF HISTORY

he numbers say a lot. According to national data, 252,710 new cases of invasive breast cancer are expected to be diagnosed in women throughout the United States in 2017, along with 63,410 new cases of non-invasive breast cancer. As of March 2017, there were more than 3.1 million women in the country who had a history of breast cancer – including those currently being treated and those who had finished treatment. It’s a sobering tally, but there are also strong numbers on the other side. Death rates from the diseases have been decreasing since 1989, and awareness and education of both breast cancer and women’s treatment options continue to grow. Consider the effort that took root just six years ago. ASPS member Mitch Brown, MD, Toronto, launched Breast Reconstruction Awareness Day in 2011 in an effort to “close the loop” on breast cancer and educate patients both on reconstruction options and resources. The first Breast Reconstruction Awareness Day in Canada banded together a team of plastic surgeons, breast surgeons, plastic surgical nurses and women from various breast cancer support groups. ASPS and The PSF joined the effort in 2012, launching Breast Reconstruction Awareness Day USA, and spreading the effort across the United States. In addition to providing patients with a valuable resource, the activism spurred by the event helped secure passage in 2015 of the Breast Cancer Patient Education Act, which informs women of their right to breast reconstruction under federal law and provides women with information about when breast reconstruction or prostheses might be appropriate within their own recovery plan. Today, more than 30 countries celebrate Breast Reconstruction Awareness Day, and the campaign continues its evolution as plastic surgeons, health advocates and patients continue joining together to support the cause and raise awareness about their options in terms of breast reconstruction and insurance coverage. “Despite the clear benefits breast reconstruction provides to women who undergo surgery for breast cancer, it remains an underutilized option,” says ASPS Public Education Committee Chair Ashit Patel, MD. “Efforts over the past several years have helped to increase the overall rate of breast reconstruction, but despite this, inadequate education about reconstructive options remains an unresolved issue. Breast Reconstruction Awareness Day was established to help overcome these educational barriers, and allow women to know about the options they are entitled to. “By participating in Breast Reconstruction Awareness day events, ASPS member surgeons provide crucial outreach and fundraising for their local communities,” Dr. Patel continues. “Past events have taken many forms, but the common thread has been to serve women, and raise awareness of breast reconstruction. Many events have even allowed for fundraising, which in turn is used to assist patients with their care.” There are more than 150 Breast Reconstruction Awareness Day events taking place throughout the United States on Oct. 18. A complete list is available at breastreconusa.org. 6

 PSN: BREAST RECONSTRUCTION 2017

2017 BREAST RECONSTRUCTION AWARENESS EVENTS

Breast Reconstruction Awareness Day 2017 ST. LUKE’S PLASTIC & RECONSTRUCTIVE SURGERY | BETHLEHEM, PA.

Surgeons will be on hand to educate and answer questions. Groups will have the opportunity to design bras for judging and be awarded prizes. There will also be raffles and a silent auction.

BRAs of the Bay PLASTIC SURGERY & SKIN SPECIALISTS BY BAYCARE CLINIC | GREEN BAY, WIS.

The event, which is open to the public, will feature breast cancer survivors, local organizations that volunteer decorated bras, breast reconstruction surgeons and a local celebrity.

Crystal Plastics Pink Runway: Closing the Loop on Breast Cancer CRYSTAL CLINIC PLASTIC SURGEONS | AKRON, OHIO

Patients who have undergone breast reconstruction will have the option of having their hair and makeup done and will wear an outfit – donated by local boutiques – for the day and walk down the runway. During their runway walk, a short bio prepared by them will be read describing their journey with breast cancer and breast reconstruction. Members of the community who are interested in breast reconstruction are encouraged to attend the event.

A Day of Health and Healing PALI MOMI WOMEN’S CENTER | AIEA, HAWAII

Patients will be invited to an evening of yoga, healing touch and health screenings to include lymphedema measurements. Helen Hui-Chou, MD, and breast surgeons at Pali Momi Medical Center invite their patients to an evening of pampering, promoting good health and overall well-being.

Everything You Ever Wanted to Know About Breast Reconstruction BREAST CARE PARTNERS, LLC | CENTRAL NEW YORK

A public education seminar featuring local breast surgeons and plastic surgeons, as well as patients who have undergone breast reconstruction.

First Annual Whole-in-One Golf Tournament RALEIGH PLASTIC SURGERY CENTER | RALEIGH, N.C.

The first annual Whole-in-One Golf Tournament event benefits Breast Reconstruction Awareness Day 2017 and the journey women take to become whole again.

High SocieTEA GOOD SAMARITAN HOSPITAL CANCER SERVICES CENTER | LOS ANGELES

An afternoon tea party for women to enjoy an afternoon with others and learn more about breast reconstruction. A post operative decorating contest will be included.

Get Involved: How you can join the fight

ASPS member practices across the countries, along with breast cancer patients, their families and friends participated in last year’s Breast Reconstruction Awareness Day USA to honor courageous cancer patients, promote patient care and educate their local communities on women’s health and breast reconstruction. Sponsored by ASPS and The Plastic Surgery Foundation –with generous support from Mentor (Diamond-level), Allergan (Silver-level), AirXpanders, The Mary Kay Foundation, CareCredit and ViOptix (Bronze-level), the celebration of Breast Reconstruction Awareness Day USA continues this year on Oct. 18 as individuals, breast cancer support groups, plastic surgeons, patients and organizations join the movement to honor and advocate for cancer patients and close the loop on breast cancer. Become an affiliate Individuals and organizations are encouraged to become a Breast Reconstruction Awareness affiliate and host a Breast Reconstruction Awareness Day event in their area. There is no fee to participate, and ASPS offers a free starter guide to help plan the activities. Affiliates hosting a fundraising event also receive a free marketing and public relations toolkit to assist in advertising. Affiliates from across the country share their events with ASPS and are all posted to the Breast Reconstruction Awareness Day events page and all social media platforms. Previous Breast Reconstruction Awareness Day events have included fundraising parties, art contests, spa days, patient appreciation lunches, community outings, fashion shows, educational seminars and more. Be on the lookout for the Breast Reconstruction Awareness Day campaign in your community and join women in the fight against cancer.

For questions or more information to become an affiliate and receive your free Event Starter Guide, please email breastrecon@plasticsurgery.org. PSN: BREAST RECONSTRUCTION 2017 

In fashion: A breast cancer survivor helps remind women they are never alone By Kendra Y. Mims

ana Donofree had an unexpected hiccup to her wedding planning at age 27. The bride-to-be showed no signs of illness when she discovered a lump in her breast while taking a shower. Upon having the lump examined, Dana was diagnosed with infiltrative ductal carcinoma – the most common type of breast cancer. She received the news from her doctor the night before her birthday and two months before her wedding day.

 PSN: BREAST RECONSTRUCTION 2017

Overwhelmed with questions and uncertainty about the diagnosis, Dana sought advice from ASPS member Michael Bateman, MD, Denver, and her oncologist, who informed her of treatment and reconstruction options. Dana was urged to postpone her wedding to focus on her health. “We all agreed it was best to wait, so I wouldn’t get married and then turn right back around to start chemo,” says Dana, who had spent months preparing for her wedding. “I told my plastic surgeon and oncologist I wanted to get married at the same time the following year. They both told me, ‘It’s going to be really tough, but if you can do it, then we can do it with you.’ ” Dana, now 35, credits her cancer-care team for their ongoing support in helping her achieve her goal of walking down the aisle one year after her diagnosis. She underwent a bilateral mastectomy with implant reconstruction in 2010, followed by six months of chemotherapy and one year of Herceptin. “My plastic surgeon made sure I had my breast reconstruction surgery completed and that I was healed in time,” she says. “My port was removed 30 days before our wedding. It was right up to the tail end, but we made it happen. Dr. Bateman and the physician assistant were always supportive and encouraging. They gave me exercises to make sure my range of motion was coming back, and to ensure I strengthened myself appropriately and adequately after the surgery. They helped me through the tissue expansion process, which was really difficult for me.” NAVIGATING THE UNEXPECTED Dana’s chemotherapy treatment caused a drop in her platelet count, which led to two platelet transfusions. Dr. Bateman performed her reconstruction surgery after she recovered from the transfusions. “That was probably the most crucial time,” Dana recalls. “Had I not done the (tissue expander to implants) exchange surgery in time, I would have really screwed up the dates for my wedding. Dr. Bateman was incredibly helpful throughout the entire process.” Dana concedes she expected a recovery equivalent to that of her friends who underwent breast augmentation. She was unprepared for the physical challenges she experienced after reconstruction. “As a young woman, I thought I would just jump back into my old life, because I had friends who had done that after getting breast implants,” she says. “But I learned that breast reconstruction is not a boob job. I wasn’t prepared for the pain, lack of movement or how much I needed to rebuild my strength post-surgery.” Dana says she had limited knowledge of breast reconstruction prior to her diagnosis, and adds that her plastic surgeon was instrumental in helping her understand how the procedure would rebuild and reshape the breasts

she would lose due to the mastectomy. After many discussions with her surgeon about her options, Dana chose breast reconstruction because she wanted to feel whole. “I wanted to look and feel the way I did before cancer,” she says. “I was 27 years old, and I figured and hoped I had a lot of life to live. I had a wedding the following year and a beautiful strapless dress. The thought of not having breasts and wearing this beautiful dress I already bought was really emotional. To know that I had an option to rebuild my breast was very encouraging.” SOMETHING NEW After cancer treatment and surgery, Dana struggled to adjust to her new body image. Her beautiful bras no longer fit her reconstructed breasts, which limited her options to sports bras and camisoles. She missed shopping for bras and intimate apparel that made her feel pretty, feminine and sexy. “Once I got my expanders, which I called my LEGO boobs because they felt like building blocks on my chest, I understood why I couldn’t wear my beautiful lace and satin underwire bras, so I started wearing layered tank tops, sports bra and things that suppressed me,” she says. “Even though that made me feel comfortable, I was tired of it. When I went to the store to try on bras, I found that underwires are just extremely uncomfortable I learned that breast and painful. I thought, ‘What am I reconstruction is supposed to do next?” not a boob job. I Having worked for more wasn’t prepared than a decade in the fashion for the pain, lack of industry and a desire to feel sexy and beautiful again after cancer, movement or how Dana started designing her own much I needed to rebuild my strength stylish and beautiful bras without underwire that fit her body post-surgery. without causing any pain. She wanted to do the same for other women to help them feel like themselves again. After moving to Philadelphia shortly after her wedding, Dana discussed her vision with her new plastic surgeon, ASPS member Brannon Claytor, MD, who provided her with insight on breast implant sizes and specifications. Dr. Claytor and Dana have collaborated at various events to educate breast cancer patients in the Philadelphia region and beyond. Dr. Claytor describes Dana as selfless in her desire to provide compassion and confidence for women struggling with their breast cancer journey. “This started as a way for her to deal with her personal challenge, yet she has gone above and beyond that in what she’s done for others,” he says. “It’s more than simply trying to make a business. Dana is a crusader for women’s comfort with themselves.” PSN: BREAST RECONSTRUCTION 2017 

NEVER ALONE Dana interviewed numerous women and doctors over a period of three years to get insight and feedback as she created her designs. She left her full-time corporate job and launched her lingerie and loungewear company, AnaOno, in 2014 with the mission to design specifically for those who’ve had breast reconstruction, breast surgery, mastectomy or are living with other conditions that cause pain or discomfort. Dana aims to help women feel beautiful, confident and comfortable, and alleviate the frustrations she experienced while readjusting to life after breast cancer and reconstruction. AnaOno’s tagline, “You are never alone,” reflects Dana’s belief in joining others in the fight against breast cancer. She made history in February 2017 when she partnered with the #Cancerland organization to raise awareness about breast cancer and reconstruction during New York Fashion Week. For the first time since the event’s inception in 1943, 16 breast cancer survivors of diverse backgrounds strutted the runway in AnaOno’s designs and bared their scars to show the physical effects of the disease in Dana’s groundbreaking “Exposed” show.

“What I realized while dressing women with reconstructive surgery is that many people don’t know what reconstructive surgery is,” she notes. “We talk

Women who underwent mastectomies, breast surgery or breast reconstruction displayed their scars for #Cancerland and AnaOno during New York Fashion Week.

about reconstruction if you have breast cancer, but no one really talks about it if the disease doesn’t impact them. They don’t really understand that a woman’s breast tissue is getting completely removed to rebuild and reconstruct a new breast. “We had 16 individuals all affected by breast cancer, and almost half battling metastatic cancer, on display to expose what reconstruction, empowerment and this side of the disease looks like,” Dana says. “We’re excited to say several of our models will be in O magazine in October. Hopefully, we’re bringing awareness to women who don’t know breast reconstruction is an option after their disease.” Dr. Claytor brought two of his reconstruction patients to attend Dana’s fashion show and says the event helped raise awareness on a global scale. He notes that two breast cancer models succumbed to the disease a few months after the fashion show – including the founder of #Cancerland, Champagne Joy – which increases the urgency for continued awareness, global research and patient support. “This is an ongoing process, and the pain and angst Dana feels from losing the women who participated means so much more to the entire mission,” Dr. Claytor says. “These are women who know they are staring at an uncertain future, and yet they are willing to celebrate it in a way that’s unbelievably bold and expressive by wearing intimate apparel in front of the world.” STRONGER TOGETHER After the fashion show, Dana received support and praise from women all over the world. One patient who watched the fashion show reached out for support after her doctor disqualified her as a candidate for reconstructive surgery. “She said, ‘All these beautiful women have their breasts, but I can’t rebuild my breast,’” Dana recalls. “I told her she had to find another doctor. She didn’t know where to look, so we recommended 10 different doctors in the area. She talked to all of them, and now she has undergone reconstruction and feels amazing.” Dana says breast cancer patients and survivors must band together and support one another – especially during challenging moments. “When her doctor told her she wasn’t a candidate, she believed it even though she qualified,” Dana explains. “Breast reconstruction is really important to her and her recovery, and she should have the right to explore it without being shunned. Not everybody feels as strong as the next person, and it takes time to get to the space. We just try to help women feel as good as they can when they can, and encourage them to find that place in their heart.”

Sixteen breast cancer survivors strutted the runway wearing Dana’s RAISING AWARENESS AnaOno lingerie in her groundbreaking “Exposed” show. AnaOno isn’t slowing down. Dana plans to continue raising awareness through fashion shows, photo campaigns and “I got a lot of my information through my plastic surgeon. sharing women’s stories of the beauty and raw truth of their He showed me beautiful pictures and results from prior cancer battle. She also has plans to launch a swimwear line procedures. I was really excited about his technique and and a plus-size collection. Dana wants to ensure the company results. You want an expert for the surgery you want. Make continues to respond to the special needs of women who sure you have a good relationship with your surgeon because need alternative products to the traditional bra market. you’re going to see them a lot and they’re in your life forever.” “We want women to feel confident and proud of the Dana wants breast cancer patients to remember that war they’ve gone up against in battling breast cancer and their choices belong to them. Although some women choose altering their bodies,” Dana says. “We’ll keep putting real nipple reconstruction, she says she opted out of the procedure women with real stories and real bodies in all our campaigns and nipple/areola tattoos, and chose a mastectomy tattoo so we can expose people to the real side of breast cancer. instead. She continues to use her story We’re not covering it up with a pink and experience to empower women to feel ribbon. We want future generations Make sure you have comfortable with their decisions during their of women to feel empowered and a good relationship cancer journey. encouraged to see their mothers or “I felt encouraged to make a decision sisters go through such a body- and lifewith your surgeon based on what I wanted and what would be altering disease.” because you’re going to see them a right for me,” she explains. “I feel like you’re in such a rush to get your treatment complete, WHAT’S BEST FOR YOU lot and they’re in but it’s okay to slow down, take a breath and Dana encourages breast cancer your life forever. think about the decision you’re about to make. patients to have an open and honest You might want to wait six months to see if conversation with their plastic surgeon you want to get your nipples reconstructed. You may want to on expectations and their ideal outcome of the surgical see if you want breast reconstruction. You may just want to procedure. She also recommends that patients request to see heal for a little bit, and that’s okay too. It’s still your body and pictures of their surgeon’s previous work. your mind, and that’s what you have to live with for the rest “In 2010, we didn’t have as much access as we do today, of your life.” and there weren’t a lot of photos I could research,” she notes.

PSN: BREAST RECONSTRUCTION 2017 

On the

Other Plastic surgeon’s cancer diagnosis Side gave her more than it took away By Kendra Y. Mims

ASPS member Emily McLaughlin, MD, received her cancer diagnosis while performing a tummy tuck procedure. Her biopsy results revealed she had a high grade noninvasive breast cancer, also known as ductal carcinoma in situ (DCIS). That phone call changed everything, even if she concedes her reaction was a little delayed. “The beauty of your radiologist calling you with a cancer diagnosis in the middle of a procedure is you have to focus on that tummy tuck, and you don’t have to think about it,” she says. “That might have been one of the biggest gifts ever.” Dr. McLaughlin recalls the technician’s look of concern during her routine screening mammogram in May 2016. She received a follow-up call the next day recommending additional mammogram views. “I always tell my patients not to worry, but when it’s you, it’s different,” Dr. McLaughlin says. “I had no idea this was coming. I was 47 years old at the time of diagnosis. I had no health problems or masses in my breasts. My paternal grandmother had breast cancer, but no other family members. Cancer was never on my radar.” Dr. McLaughlin underwent a bilateral nipple-sparing mastectomy with a direct-to-implant reconstruction one month after her diagnosis. In this procedure, all breast tissue is removed (the nipple is left alone), and the breast implant is placed immediately following mastectomy. Dr. McLaughlin took time to discuss with us her reconstruction experience, why she decided on an aggressive approach and how cancer gave her more than it took away.

ever enough. That’s just my opinion. If you do breast conservation treatment and radiation, you don’t know if the cancer is going to come back. I know my personality. I can’t live with that. I took the aggressive route for peace of mind because I needed it gone. My lymph nodes did not contain cancer, so I didn’t need chemo or radiation. I am stage zero and I’m cured, which is another reason to consider the aggressive approach.

PSN: How has your cancer diagnosis and breast reconstruction procedure impacted your life? Dr. McLaughlin: I am one of the few people who can say with conviction that cancer gave me more than it took away. This has been an eye-opener. I’ve learned that policies aren’t necessarily in place to protect the patient during this difficult time. I never saw this coming, but it’s become my passion to see changes. I’m an advocate for this. I’ve started a nonprofit. I live very much out loud about my experience. This wasn’t, ‘Hush hush, I have cancer.’ It was, ‘Oh hell, I have cancer.’ I shared my experience on social media, and I am very open with my patients. I’ve shown patients my scars when they’ve asked if it will help them process their reality.

PSN: You say cancer gave you more than it took away. How did your experience inspire you to start your nonprofit? Dr. McLaughlin: Last year, we put together a breast cancer fundraiser called BoobieQue in six weeks and

PSN: How did you choose the type of reconstruction you received? Dr. McLaughlin: Patients always ask female surgeons what we would do if we had cancer. Although I’ve avoided leading the witness, so to speak, in the past, I always knew the reconstruction option I would choose. I called a colleague and one of my best friends, Danielle LeBlanc, MD, one of the best reconstructive surgeons in Fort Worth, Texas, and made plans for the procedure. I don’t think reconstruction with breast conserving surgery (i.e., only removing part of the breast) is 12

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Dr. McLaughlin and her husband Jeff Knipper at their 2016 BoobieQue event in Texas.

So many friends and patients of mine have endured so raised $85,000 on a Sunday afternoon. We donated it to much more than me. They don’t get to have this seemingly the National Breast Cancer foundation and the Cancer light-hearted, ‘I’m lucky it gave me more than it took away’ Care services, a local nonprofit for cancer. The joy of that story. If I could go back in time, I don’t think I would erase experience transcends anything I’ve ever known. It whet it. This defines me now, and it’s become a part of my story. my appetite to do more. We have another BoobieQue I’m blessed it happened to me on such a microscopic level. scheduled for this October, and thanks to its success, I am I’m a better surgeon and a better person because of it. now the president of a nonprofit called “Fighting Right.” The purpose of our nonprofit is to fight for women’s issues, including all types of female cancers, PSN: What words of wisdom health issues, domestic violence issues, do you have for breast cancer My advice is to get etc. We’ll fight for the rights of women, patients who are unaware of their as many opinions whatever it takes. It’s all about knowing reconstruction options or have as they can. what you can do when you know what reservations about the procedure? Cosmetic and you’re capable of. Dr. McLaughlin: My advice is to get reconstructive patients as many opinions as they can. Cosmetic sometimes apologize and reconstructive patients sometimes PSN: How has your experience for getting apologize for getting other surgeons’ changed the way you approach other surgeons’ opinions. opinions. Don’t apologize. You should talk and interact with breast cancer Don’t apologize. to others. I knew without a doubt that I patients today? You should talk would choose Dr. LeBlanc, because she’s Dr. McLaughlin: My practice is to others. amazing. You must find a surgeon you predominately cosmetic, but I do a know and trust. lot of reconstruction. However, if any I also advise patients to educate themselves. In my of my cosmetic patients are breast cancer survivors, they practice, women who come in have already been told what automatically receive discounted cosmetic services because to do. Maybe their breast surgeon, family or other cancer it’s a sisterhood. We’ve been through it. I know what it patients and survivors recommended lumpectomy and feels like as a patient now. When my patients needed radiation. That may be right for some patients, but not a biopsy on a mammogram, I used to tell them not to every patient. Some women tell me not to do anything to worry, and I believed they should not worry until there the other breast, and I always remember thinking, what are was something to worry about. Now I call and tell them, you holding on to? ‘Listen, I’ve been there.’ I’ve waited for my biopsy and In the past, I tried not to tell patients what I would it’s terrifying. There’s so much merit if a patient knows do. Today, there’s no way I could tell them, “I don’t know.” you’ve been where they are, and I must look at it from that I absolutely would not recommend breast conservation perspective. I can talk to a patient and tell him/her I’m not treatment given the personal experience with this diagnosis immune from any of these things. This happened to me, and treatment that I now have. I would not change my too, and here’s how I’ve dealt with it. Biopsies are no fun. reconstruction choice because I’m cured. My decision to When I send patients for stereotactic biopsies now, I go take this aggressive approach means this incident is in my down to the hospital with them and hold their hand if they rear-view mirror, and that’s priceless to me. want me to. Knowledge is power. Don’t be afraid to ask questions. Just because someone tells you something, you don’t have to PSN: How has your knowledge as a plastic take it at face value. You can respect their opinion, but you surgeon played a role throughout the process? must educate yourself and find out what your options are. Dr. McLaughlin: Being a female plastic surgeon with breast cancer is a crazy thing, but it happens. It’s a blessing I did not need chemo or radiation, but I’ve been through it. I have had five surgeries in the past year; that takes a toll Emily McLaughlin, MD, FACS, is a board-certified plastic surgeon in on you personally and professionally as you have to be out Fort Worth, Texas. As a breast cancer survivor and a plastic surgeon of the office, out of the operating room to recover. I have who performs breast reconstruction, Dr. McLaughlin is passionate scars from incisions and drains, but it’s still given me so about making a difference in the lives of patients facing breast cancer. much more than it has taken from me. I had to hear, ‘You To learn more about Dr. McLaughlin’s Fighting Right organization, have breast cancer.’ I still processed it differently, because as visit fightingright.org. For more information on this year’s BoobieQue a surgeon, you think, ‘This can’t happen to me.’ event, visit www.boobieque.org. PSN: BREAST RECONSTRUCTION 2017 

Answers to questions about breast reconstruction By Margo Herron, MD

here are a lot of uncertainties and questions that run through a patient’s mind after a breast cancer diagnosis and discussion of breast reconstruction options. Margo Herron, MD, Ashland, Ore., provides some insight on some of the questions that patients might consider before undergoing breast reconstruction.

Will my insurance cover breast reconstruction? When my mother got breast cancer prior to 1998, breast reconstruction was considered a cosmetic procedure by most insurance companies – has that changed? This is a very a common question. Yes, breast reconstruction is covered, and became law almost 20 years ago. Determining whether or not to undergo breast reconstruction is a huge decision in a woman’s life who either has been diagnosed with breast cancer or possibly tested positive for the genetic mutation for breast cancer. Those who have tested positive for BRCA (genetic mutation) are more likely to go to their mothers or aunts for information to help them determine how best (or if ) to proceed with breast reconstruction. However, much has changed in the past 20 years. Most importantly, in October 1998, the Women’s Health and Cancer Rights Act (WHCRA) became law. This law helps protect women with breast cancer who choose to have their breasts reconstructed after a mastectomy. It requires insurance companies to pay for reconstruction of the affected breast and reconstruction of the other breast to make the breasts look symmetrical or balanced. The most recent change is in insurance coverage; women can no longer be dropped from their insurance plan due to the preexisting condition of breast cancer. 14

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Women now have more access to genetic testing, and this often guides their decisions on whether to undergo prophylactic mastectomy. Testing now often occurs at a younger age. If a woman tests positive, she is likely to consider how reconstruction will affect her family, work and travel. We strongly recommend patients contact their plastic surgeon’s office and ask to speak with a patient coordinator regarding financial commitments. It’s important to consider breast reconstruction as part of your breast cancer treatment.

What are the risks? Will I have a complication? The benefits, risks and complications are all important factors to weigh when considering breast reconstruction. As with any surgery, there are inherent risks and complications do occur, which is why it’s important to have a discussion with your plastic surgeon. There are many variables with respect to surgery technique, breast tissue viability, patient health and prior surgeries performed. Breast reconstruction can consist of one surgery or many more. For example, tissue expander reconstruction (the most common type of reconstruction that plastic surgeons perform) can take anywhere from three months to two years depending on variables such as chemotherapy and/or radiation. Some complications are minor and can be resolved with a quick trip to your plastic surgeon’s office. Others will require repeat surgery. If your plastic surgeon performs breast reconstruction surgery as a part of his or her practice, he/she will have experience with complications and know how to handle them. Make sure you have all information prior to deciding on a path for your reconstruction. Will I be able to keep my nipples? Yes, in some cases. Breast reconstruction techniques have advanced significantly in the past 20 years, resulting in better outcomes and higher patient satisfaction. Some techniques utilize the expander option, allowing a patient to keep her nipples if other determining factors allow for nipple-sparing breast reconstruction. This is another discussion to have with your plastic surgeon. Some options now allow patients to undergo what we call “straight to implant,” which places a permanent breast implant at the same time as the mastectomy, instead of a tissue expander. If you are not a candidate for nipple sparing, your plastic surgeon can make you one. What will my new breast feel like? New or reconstructed breasts are not your original breasts. continued on page 21

MYTH #1:

Breast reconstruction can only be performed after a mastectomy.

FACT: Breast reconstruction can be performed at the same time as a mastectomy (immediate reconstruction) or any time after (delayed reconstruction). Whenever possible, immediate reconstruction should be considered; patients can avoid the experience of a flat chest and enjoy better cosmetic results with fewer scars. Studies show undergoing immediate reconstruction does not impact or delay cancer treatments such as chemotherapy. However, in cases where radiation is anticipated following the mastectomy, many surgeons advocate delaying reconstruction until all breast cancer treatment has been completed to decrease the risk of complications. Much depends on the patient’s specific situation, the type of reconstruction and the radiation oncologist’s experience in treating breast reconstruction patients.

a second surgery to fine-tune the reconstructed breast(s). Even patients undergoing “one step” or “single stage” implant reconstruction must be prepared for a second surgery to achieve the desired results. Typical procedures included in the second stage include fat grafting, scar revision and nipple reconstruction for patients who did not undergo nipple-sparing mastectomy.

MYTH #4:

Breast reconstruction is not an option when radiation is part of breast cancer treatment.

Breast Reconstruction Myths Dispelled

MYTH #2:

Breast implants are the only option for breast reconstruction.

FACT:

By Courtney Floyd and Minas Chrysopoulo, MD

For many women, breast reconstruction is an important part of healing after breast cancer. Sadly, there are many misconceptions keeping women who desire reconstruction from making informed decisions based on their individual needs.

Only seven out of 10 women are informed of all of their breast reconstruction options before a mastectomy. Implants are not the only choice. Perforator flap breast reconstruction, for instance, is a state of the art procedure in reconstructive breast surgery. The tissue removed by the mastectomy is replaced with the patient’s own living tissue from the abdomen, buttock or thigh. The tissue is transplanted to the chest and reconnected using microsurgery to recreate a “natural,” warm, soft breast, which is permanent and unlike implants, won’t harden over time, leak or rupture. The DIEP flap uses the patient’s lower tummy tissue similar to a “tummy tuck” and represents today’s gold standard in breast reconstruction.

MYTH #3:

Breast reconstruction only requires one surgery.

FACT: Breast reconstruction, regardless of the type

of procedure performed, typically requires more than one surgery for the best cosmetic results. Most patients need

FACT: Radiation should not prevent anyone from considering breast reconstruction, but it can certainly influence the timing and choice of procedure. When radiation treatment is recommended, delaying the reconstruction is often preferred to decrease the risk of complications. After radiation, about one in three implant reconstructions fail. Breast hardening, tightness and pain are common complications when implant reconstruction is performed in conjunction with radiation, and these can require multiple surgeries to correct. Procedures that use the patient’s own tissue are strongly preferred if the patient has had radiation, as they are associated with much higher success rates.

MYTH #5:

Reconstructed breasts look unnatural.

FACT: This can be the case with some implant reconstructions, and for some women, the “augmented breast” is the desired look. In contrast, perforator flap procedures such as the DIEP flap not only look natural— they are natural. Because the reconstructed breast is created using the patient’s own living tissue, the new breast will be warm to the touch, change with weight fluctuation and look like a natural breast. DIEP flap patients may also be candidates for sensory nerve reconstruction that can help restore feeling after a mastectomy. This additional procedure repairs the nerves cut by the mastectomy and significantly improves the return of sensation so the reconstructed breast also “feels” more natural to the patient.

For more information on breast reconstruction procedures and options, visit plasticsurgery.org or breastreconusa.org. PSN: BREAST RECONSTRUCTION 2017 

Why patients deserve to have a board-certified plastic surgeon on their cancer care team By Daniel Z. Liu, MD

PATIENTS RECENTLY DIAGNOSED WITH BREAST CANCER FACE A MOUNTAIN OF QUESTIONS AND DECISIONS. The American Society of Plastic Surgeons (ASPS) urges breast cancer patients and their physicians to advocate for inclusion of a board-certified plastic surgeon on their cancer treatment team. The team approach to breast-cancer care brings together an interdisciplinary group of key medical professionals who work together at the inception of a patient’s breast cancer diagnosis to develop and implement a tailored treatment plan based on each patient’s unique needs. This medical team could include a medical oncologist, radiologist, pathologist, radiation oncologist, breast oncologic surgeon, gynecologist, physical therapist, dietician, genetic counselor and plastic surgeon. Each step of the breast-cancer care journey requires specific medical expertise. Patient outcomes vastly improve when each member of the multidisciplinary team works together to examine every opportunity to provide a unified treatment approach. The majority of breast cancer patients miss out on a critical conversation that should take place at the time of diagnosis: options for breast reconstruction following partial or total mastectomy. 16

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As treatment modalities and evolving technologies advance our ability to successfully treat breast cancer, breast reconstruction outcomes have also vastly improved. A boardcertified plastic surgeon possesses training and expertise in breast reconstruction, ranging from cutting-edge implant/regenerative medicine technologies to advanced techniques in reconstructive microsurgery. More importantly, an experienced plastic surgeon within a team setting will respectfully communicate with other medical professionals about how the reconstruction plan may affect overall cancer treatment and vice versa: Breast surgeon – Critical oncologic decisions about the type of mastectomy (skinsparing versus nipple-sparing) and incision placement influence aesthetic outcomes and ameliorate potential complications. In cases of partial mastectomy (lumpectomy), a board-certified plastic surgeon may work simultaneously with a breast oncologic surgeon to maximize aesthetic results while safely removing a breast tumor. It cannot be underemphasized that a skilled plastic surgeonbreast surgeon team is paramount to achieving successful surgical outcomes, as the quality of the mastectomy directly influences the ability to safely proceed with immediate reconstruction. Medical oncologist – Oncologists provide expert recommendations and oversee the delivery of neoadjuvant chemotherapy, adjuvant chemotherapy, hormonal therapy and targeted treatments. Important conversations about how these drugs influence wound healing help determine the safest timing for breast reconstruction. For certain patients, a plastic surgeon may recommend delaying reconstruction until cancer-fighting therapies are completed. A medical oncologist and plastic surgeon may also work together to determine when it would be appropriate to perform breast reconstruction in patients with metastatic breast cancer. Radiation oncologist – Perhaps the most important factor affecting long-term breast reconstruction outcomes may be determined by the inclusion of adjuvant radiation therapy following mastectomy or lumpectomy. The need for radiation must be balanced with the timing of each reconstructive step. In appropriate candidates, a board-certified plastic surgeon will often recommend autologous (flap-based)

reconstruction in women who need or have received radiation. Physical therapist – Physical therapy improves mobility, strength, range of motion and comfort following breast cancer surgery and breast reconstruction. Breast cancer treatment that involves surgical removal of axillary lymph nodes or radiation to the lymph nodes can result in transient or permanent lymphedema of the arm. Therapists provide vital education and prevention of lymphedema, as well as make appropriate referrals for surgical intervention by a boardcertified plastic surgeon. Genetic counselor – Some patients may be diagnosed with a genetic mutation that significantly elevates the risk of developing breast cancer. Genetic counselors can aid patients and their families to decide if and when to pursue risk reduction surgeries, such as prophylactic mastectomies. A board-certified plastic surgeon should be involved early to provide recommendations for immediate breast reconstruction in these patients. Gynecologist – Removal of the ovaries (oophorectomy) may be indicated in women with certain genetic mutations that predispose to the development of ovarian cancer and in certain women diagnosed with hormonally-driven breast tumors. Oophorectomy can often be combined with a step of breast reconstruction when properly coordinated with a plastic surgeon. The multidisciplinary treatment team benefits patients who encounter a complex and serious disease such as breast cancer. When this team consists of a variety of specialists that includes a board-certified plastic surgeon, it is more likely that these professionals will be knowledgeable on the latest multimodal treatment options. Patients deserve to be fully informed about their treatment choices that include breast reconstruction, and medical professionals should guide patients in a balanced, shared decisionmaking process. Breast cancer treatment can be quite stressful, but thorough communication and informed involvement from all team members can ease the journey. ASPS member Daniel Liu, MD, is a board-certified plastic and reconstructive surgeon at Cancer Treatment Centers of America® in northern Illinois. Dr. Liu specializes in all forms of breast reconstruction and is passionate about promoting public education on breast reconstruction and plastic surgery.

Questions to ask your breast reconstruction surgeon Use this checklist as a guide during your breast reconstruction consultation: Are you certified by the American Board of Plastic Surgery? Were you trained specifically in the field of plastic surgery? How many years of plastic surgery training have you had? Do you have hospital privileges to perform this procedure? If so, at which hospitals? Is the office-based surgical facility accredited by a nationally- or state-recognized accrediting agency, or is it state-licensed or Medicare-certified? Am I a good candidate for this procedure? What will be expected of me to get the best results? Where and how will you perform my procedure? What surgical technique is recommended for me? How long of a recovery period can I expect, and what kind of help will I need during my recovery? What are the risks and complications associated with my procedure? How are complications handled? What are my options if I am dissatisfied with the outcome? Do you have before-and-after photos I can look at for this procedure, and what results are reasonable for me?

DONATE A PHOTO TO HELP BREAST RECONSTRUCTION AWARENESS By sharing a photo now through Jan. 15, 2018, will help raise as much as $40,000 for The PSF Breast Reconstruction Awareness Campaign thanks to the “Donate a Photo” initiative by Johnson & Johnson. To participate, get the free Donate a Photo app and upload a photo – any photo – and the company will donate $1 for each. Johnson & Johnson is the parent company of Mentor, a Diamond sponsor of The PSF’s Breast Reconstruction Awareness campaign – which will have a photo booth for Donate a Photo at Plastic Surgery The Meeting in Orlando. PSN: BREAST RECONSTRUCTION 2017 

By Minas Chrysopoulo, MD, FACS

 I KNOW WHAT I DON’T LIKE ABOU T being a breast reconstruction surgeon. I don’t like witnessing the difficult place in which patients find themselves when they come to see me for their initial consult – especially soon after a breast cancer diagnosis. Going to see a plastic surgeon is supposed to be an exciting event, a chance to talk to someone about options for improving or enhancing your appearance. Breast cancer has nothing to do with selfimprovement or cosmetic enhancement. There’s no excitement. It can be a dark and lonely place. It’s about surviving. It’s about not knowing what the future holds and feeling overwhelmed with information. Thanks to increasing awareness, both among patients and the medical community, breast reconstruction is now part of the multidisciplinary breast cancer conversation. More patients are finding their way to come in and discuss their reconstruction options. Their final choice is so very personal and there is no “best” reconstruction procedure for everyone. What matters most is that patients are offered the choice, and, preferably, the full array of reconstructive options. Discussing potential results and showing patients their possible outcomes can be a huge help and often provides much-needed hope. I love seeing how far breast reconstruction has come and the results we can achieve. Much more importantly, I love seeing what it means to them. That’s what makes everything worthwhile. Seeing patients complete their journey is wonderful. Thanks to Reaching the end of something is often a sad event but in increasing this case, it’s very positive. It signifies moving on. awareness, both I work with a team of surgeons, nurses and many folks among patients behind the scenes. I love the shared passion we all have, and the medical clinical and non-clinical staff alike. It’s absolutely selfless. community, breast The people here have an endless passion for serving our reconstruction is patients, and that enthusiasm only continues to grow. It’s an now part of the honor to be part of something so much bigger than myself, multidisciplinary and I love being able to serve our patients with this worldbreast cancer renowned team. conversation.

Why I perform breast reconstruction

"Dr. C" is a board-certified plastic surgeon, breast reconstruction surgeon and microsurgeon at PRMA Plastic Surgery in San Antonio. His areas of special interest include state-of-the art breast reconstruction techniques, short scar breast surgery, cosmetic surgery of the breast and body, and scar healing. He has dedicated his professional life to advocating for breast cancer patients. He strongly believes that shared decision-making between the physician and patient is crucial in achieving the best results, and he has built his practice on this philosophy.

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By Aisha Baron, MD

 I PERFORM BREAST RECONSTRUCTION BECAUSE it is extremely gratifying for me as a surgeon. It is more than physically restoring a breast. A mastectomy or deformity from a lumpectomy or radiation can damage a woman’s sense of self-confidence, femininity and/or sexuality. The ability to take a patient through the steps of a successful reconstruction to completion and see her walk into my office exuding confidence – and feeling restored – is the ultimate reward as a plastic surgeon.

Medicine in Houston, I was diagnosed with Stage 4 NonHodgkin’s Lymphoma. I was fortunate to have been placed in a program that was supportive of my health as well as my education. Like many of my breast reconstruction patients, I know what it’s like to have the power and control over your life taken from you. You are no longer in charge of your schedule, and told when and where to be and what you can no longer do. You could be given chemotherapy, which might result in any number of side effects and cause discomfort you never knew possible. I lost all my hair and hid under a wig at work to avoid questions.

I perform breast reconstruction because I am a survivor. Like many of my breast reconstruction patients, I know what it’s like to have the power and control over your life taken from you. I form lasting relationships with my breast reconstruction patients thanks to the time spent with them during their reconstructive process, and they are such a joy. I truly feel that providing breast reconstruction is a duty that I’ve been called to fulfill. It really doesn’t get any better than that. I also provide comprehensive breast reconstruction. I believe that if a patient is a good candidate, she should be educated about and potentially offered all types of breast reconstruction (implant, tissue with implant, free tissue). I’m fortunate to have trained under and learned from leaders in the field. My favorite operation is the DIEP flap for breast reconstruction, which is a microsurgical operation that transfers skin and fat from the abdomen to the breast area, but leaves the abdominal muscles intact. It’s a fun operation that provides a durable option for many patients who have extra abdominal tissue. I also provide implant-based reconstruction and other tissue and muscle flaps when appropriate for patients. I perform breast reconstruction because I am a survivor. During my residency training at Baylor College of

It was very humbling and defeating at times – particularly when I had trouble focusing on the big picture. It’s neither glamorous, nor a badge I chose to wear at the time, but one that I now hold up with pride as a survivor. I often trade tips and pearls of wisdom with my patients to help them deal with managing hair loss or dry skin and optimizing their nutrition. Sometimes we simply talk about how much cancer sucks. Having been a patient myself provides me with a uniquely sensitive perspective when considering what my patient is going through. I’ve trained my staff to be compassionate, understanding and considerate of our patients’ feelings, time and scheduling concerns, as they are often running from one appointment to another. Most doctors sympathize with their patients, but because of my experience, I can empathize because I’ve been there. It’s an honor to consult with and treat these patients. These women just want to be normal again, and being able to restore and improve the feminine physique is pure satisfaction.

Dr. Aisha Baron is an ASPS member and board-certified plastic and reconstructive surgeon practicing at Breast Body Beauty Plastic & Reconstructive Surgery in the metro Atlanta area. She has authored multiple peer-reviewed medical articles and presentations, and is known as the “BreastNBodyDoc” in local media. Dr. Baron was also on the nationwide hit reality television show “Atlanta Plastic” on Lifetime to share her talents as a plastic surgeon with the country.

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Why I advocate for breast reconstruction By Terri Coutee

 I AM A DAUGHTER, SISTER, EDUCATOR, ADVOCATE, WIFE AND MOTHER. I am not made of steel, but I think I have some rather resilient genes in my DNA. I had a horse fall on my right hip and leg when I was 18 years old while working on a ranch. I crashed and burned on the ski slopes twice in my early 40s. I was the one-armed-teacher in a sling. I broke my tibial plateau when I was 55, crashing and burning again while riding my bike (that incident put me in a locking brace for three and-a-half months). I AM ALSO A TWO-TIME BREAST CANCER SURVIVOR. After my first diagnosis at age 47, I had a lumpectomy combined with a difficult regimen of chemotherapy, followed by radiation. Breast cancer seemed to be in my rear-view mirror, a fading memory of a difficult situation as each year passed. January of 2014 brought great promise. I was headed back to school after 36 long years to attain my Master of Education degree in teacher leadership. There was the possibility of a two-year overseas assignment, which made my online degree even more purposeful. Then April 2, 2014, arrived. I went for my routine mammography to hear those dreaded words for the second time in my life: “I see a mass and I’m highly suspicious that it is cancer.” Tears, shock and disbelief followed. Twelve years after my first diagnosis, I had to face it head-on again – this time undergoing a double mastectomy. The day I walked into my breast surgeon’s office to begin planning that surgery, she told me my options for breast reconstruction. Breast reconstruction? Wasn’t I supposed to be here to talk about getting rid of the cancer and the next steps once all labs and surgical reports were completed? The information I was given about options for breast reconstruction were life-changing – unexpectedly so. She

gave me options for implants and autologous (using your own tissue) breast reconstruction. When she described DIEP flap surgery and called it the “gold standard” in breast reconstruction, a feeling of warmth and relief – combined with absolute amazement – lifted my spirits. In that very moment, I began advocating for breast reconstruction of all kinds even though I chose a DIEP flap. What started as researching studies, finding a boardcertified plastic surgeon and learning as much as I could about planning, surgery and recovery transformed into full-time advocacy for others. As a long-time educator, I know that without information, patients cannot make an informed decision about what should come after breast cancer and a mastectomy. The thought of anyone being told they have breast cancer and that they must have a mastectomy without having a conversation about reconstructive options did not settle well with me. I wanted others to have the chance that I did. I also wanted them to have quality information – not hearsay or opinions, but evidence-based information and experience from someone who had successful breast reconstruction. I had an obligation to be that patient-advocate for breast reconstruction, and I was honored to accept it. I do not simply tell all who are faced with mastectomy to have reconstruction. It is a personal choice and not for everyone. Nevertheless, that choice cannot be made without appropriate information, and I provide tools to make that decision. By engaging with breast surgeons, plastic surgeons, microsurgeons and other patients, I gather and share information necessary to engage fully with a patient’s health-care team, family members and care providers about what the process will look like for them. We have yet to find a cure for breast cancer. Until we find that cure and mastectomies are no longer needed to rid the body of the disease, there needs to be an advocate for options in breast reconstruction.

Terri Coutee writes a blog about her experience at diepcjourney.com. She is the founder and director of the nonprofit diepcfoundation.org, advocating for all options in breast reconstruction after mastectomy.

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ANSWERS TO QUESTIONS ABOUT BREAST RECONSTRUCTION / continued from page 14

Sensation and feeling depends on several factors, including prior cancer treatments and other breast-related surgeries. If a mastectomy is performed, you might feel limited sensation, as opposed to lumpectomy surgeries, which will likely regain most of the sensation of the breast. Radiation also has an adverse effect on sensation of the breast. Although breast reconstruction can improve the shape, size and aesthetic appearance of the breast, it will not improve sensation. Many women say the breast doesn’t feel like part of their body for the first year after reconstruction, but then they become more comfortable with their reconstructed breast. If implants are used, there are different shapes, sizes and levels of firmness to discuss with your plastic surgeon.

What do I wish I would have known before I underwent breast reconstruction? We asked a select group of patients who underwent breast reconstruction, including women of different ages, some who had radiation and chemotherapy, some who had complications, and some who barely missed any time off work because recovery was so smooth. A few patients said they wished they had more information regarding risks and complications. One of our patients even mentioned doing a delayed reconstruction. A couple of patients wish they would have spent more time thinking about how the implants feel and how the implants don’t move as naturally with their bodies. One of our patients told us she wishes she would have known that her implants would get “ice cold” from time to time, especially when submersed in water. Although the majority of our patients told us they felt well informed about the process, the time commitment, types of reconstruction, risks and expected outcomes, the bottom line is you should find a boardcertified plastic surgeon who specializes in breast reconstruction to discuss all options. *For more information on breast reconstruction options or to find a board-certified plastic surgeon, visit plasticsurgery.org. ASPS member Margo Herron, MD, is a board-certified plastic surgeon in Ashland, Ore. Dr. Herron’s desire is to help patients feel whole again through cosmetic, hand and reconstructive procedures that enhance the way they feel about themselves and improve their quality of life.

Breast reconstruction words to know Areola > Pigmented skin surrounding the nipple. Breast augmentation > Also known as augmentation mammaplasty; breast enlargement by surgery. Breast lift > Also known as mastopexy; surgery to lift the breasts. Breast reduction > Reduction of breast size and breast lift by surgery. Capsular contracture > A complication of breast implant surgery which occurs when scar tissue that normally forms around the implant tightens and squeezes the implant and becomes firm. DIEP flap > Deep Inferior Epigastric Perforator flap, which transfers skin and fat from the abdomen. Donor site > An area of your body where the surgeon harvests skin, fat and muscle to reconstruct your breast – commonly located in less exposed areas of the body such as the back, abdomen or buttocks. Fat grafting > A surgical technique that transfers fat obtained by liposuction to enhance breast reconstruction by adding volume under the skin. Flap (autologous) techniques > Surgical techniques used to reposition your own skin, fat and muscle to reconstruct or cover your breast. General anesthesia > Drugs and/or gases used during an operation to relieve pain and alter consciousness. Hematoma > Blood pooling beneath the skin. Intravenous sedation > Sedatives administered by injection into a vein to help you relax. Latissimus dorsi flap > A surgical technique that uses muscle, fat and skin tunneled under the skin and tissue of a woman’s back to the reconstructed breast and remains attached to its donor site, leaving blood supply intact. Local anesthesia > A drug injected directly to the site of an incision during an operation to relieve pain. Mastectomy > The removal of the whole breast, typically to rid the body of cancer. PAP flap > Profunda Artery Perforator flap, which transfers skin and fat from the upper thigh. SGAP flap > Superior Gluteal Artery Perforator flap, which transfers skin and fat from the buttock. SIEA flap > Superficial Inferior Epigastric Artery flap, which transfers skin and fat from the abdomen. Tissue expansion > A surgical technique to stretch your own healthy tissue and create new skin to provide coverage for a breast implant. TRAM flap > Transverse Rectus Abdominis Musculocutaneous flap, a surgical technique that uses muscle, fat and skin from your own abdomen to reconstruct the breast. TUG flap > Transverse Upper Gracilis flap, which transfers skin, fat and muscle from the inner thigh. PSN: BREAST RECONSTRUCTION 2017 

CORPORATE SPONSORS SUPPORT EFFORTS By Kendra Y. Mims RESEARCH SHOWS that far too many women diagnosed

with breast cancer remain in the dark about their reconstruction options following a mastectomy. Launched by ASPS and The PSF in 2012, the Breast Reconstruction Awareness USA Campaign is instrumental in providing these courageous women with education and information about their reconstructive options as they endure treatment for breast cancer. Breast reconstruction can help women rebuild their self-esteem and improve their quality of life after undergoing breast cancer surgery. Plastic surgeons play an important role in a breast cancer patient’s recovery process. The annual Breast Reconstruction Awareness Day movement gives plastic surgeons an opportunity to empower cancer patients, celebrate survivors and help women make an informed decision at the time of diagnosis. The Breast Reconstruction Awareness Campaign would not be possible without the generous support of our dedicated corporate sponsors. Because of their commitment to the cause, the campaign can provide education and invaluable information about reconstructive surgery and raise awareness to close the loop on breast cancer on Breast Reconstruction Awareness Day and throughout the year. 2017 Campaign Sponsors Six companies have generously provided support to the 2017 Breast Reconstruction Awareness Day campaign. The Diamond Sponsor of this year’s Breast Reconstruction Awareness Day DIAMOND SPONSOR Mentor is Mentor, a leading supplier of SILVER SPONSOR medical products for the global Allergan aesthetic medicine market. The BRONZE SPONSORS company has made breast implant The Mary Kay Foundation devices for more than 30 years. AirXpanders ViOptix Mentor Worldwide LLC became Care Credit a Diamond Sponsor of the Breast Reconstruction Awareness Campaign in 2015. As a leader in breast reconstruction, Mentor has launched multiple reconstruction solutions and is committed to continued innovation that will provide surgeons with the tools to improve patient outcomes in breast reconstruction. To help spread awareness around breast reconstruction, Mentor supports several patient advocacy groups including, Living Beyond Breast Cancer, Young Survivors Coalition and Facing Our Risk of Cancer Empowered (FORCE). In addition, Mentor has worked to create platforms such as YourBreastOptions.com to provide women with helpful educational resources as they consider breast reconstruction. “Improving patients’ lives through breast reconstruction is ASPS and The PSF sincerely thank the 2017 Breast Reconstruction Awareness campaign’s generous sponsors for their dedication to women’s health and patient education.

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a key part of Mentor’s mission, and we are highlighting this through our Johnson & Johnson Donate A Photo fundraising campaign at the Plastic Surgery The Meeting 2017 in Orlando,” says Warren Foust, vice president of U.S. sales and marketing for Mentor. “At Johnson & Johnson and Mentor, we’re working to make the world a better, more caring place by supporting causes that help people live longer, healthier, happier lives. Donate A Photo is an example of how we live into that mission. Since our launch in 2013, we’ve expanded to regions all over the world to make a greater impact – more than 2.6 million photos have been donated, helping 139 causes. We are thrilled to partner with ASPS and The PSF as the Diamond sponsor of Breast Reconstruction Awareness Day on Oct. 18, and our sales representatives are looking forward to supporting events in local practices in their territories. “Educating patients and potential patients about breast reconstruction is incredibly important, and continues to be an area that needs focus and attention from industry and providers alike,” Foust continues. “It is important we all play a role in empowering women to be informed about breast reconstruction following a mastectomy or lumpectomy so they can make the best decision for their physical and mental well-being, and the well-being of their families and those they care about.” The Mary Kay Foundation℠ joins the Breast Reconstruction Awareness Day campaign this year as a Bronze sponsor. The foundation’s mission is to fund research and awareness of cancers affecting women and prevention of domestic violence. “The Mary Kay Foundation is honored to be one of the sponsors of Breast Reconstruction Awareness Day, continuing to supporting breast reconstruction research and providing financial help to women seeking reconstruction,” says Michael Lunceford, Mary Kay’s senior vice president of public affairs and chairman of the board for The Mary Kay Foundation. “Fighting cancers against women is a top priority of The Mary Kay Foundation, and by supporting initiatives like Breast Reconstruction Awareness Day, we know we are continuing Mary Kay’s mission of enriching women’s lives.” Additional corporate support for the campaign comes from Allergan at the Silver level; and AirXpanders, ViOptix and CareCredit, each at the Bronze level. Every corporate partner contributes to the campaign’s success annually and continues to make a difference in empowering women facing a breast cancer diagnosis, and providing them with reconstructive education. Donations from sponsors are applied directly to programs that support related research, awareness efforts, and provide charitable care. For more information on the Breast Reconstruction Awareness Campaign corporate sponsors, visit breastreconUSA.org.

KNOW YOUR OPTIONS

“I have just been diagnosed…” YOUR OPTIONS: Mastectomy: If you have just been diagnosed with breast cancer and are considering mastectomy, here are some things to know. There are many different types of mastectomy. The latest technique, known as a nipple-sparing mastectomy, preserves all the breast skin and the nipple-areola complex. This provides the best cosmetic results without compromising cancer care. Regardless of the type of mastectomy, breast reconstruction can be performed at the same time or many years later. Breast Reconstruction Options Using Your Own Tissue > DIEP Flap: Fat and skin from the lower tummy are used. Does not use abdominal muscle. > SIEA Flap: Fat and skin from the lower tummy are used. Does not use abdominal muscles and is less invasive the DIEP. > TRAM Flap: Fat and skin from the lower tunny along with abdominal muscle are used. > LAT/TDAP Flap: Fat, skin +/- muscle from back are used. > GAP Flap: Fat and skin from the upper or lower buttock area is used. > TUG Flap: Fat, skin and muscle from the upper inner thigh are used. Breast Reconstruction Options Using Tissue Expanders and Implants > Tissue Expanders: Used to expand the breast skin. Replaced by a permanent silicone or saline implant. > Direct to Implant: Permanent silicone or saline implant placed at time of mastectomy. Avoids expansion process. Lumpectomy: Lumpectomy, or breast conservation surgery, is the most common type of breast cancer surgery currently performed. The surgery removes only the part of the breast affected by the cancer. Unfortunately, this can significantly change the appearance of the breast and even deform the breast in smaller-breasted women. In the majority of cases, the lumpectomy will be followed by radiation therapy to decrease the risk of the breast cancer returning, known as a "recurrence". Radiation often causes tissue fibrosis (toughening, tightening and shrinking), and skin color changes are also common. The change in skin color can be permanent. Radiation therapy has improved significantly over the years, but unfortunately it can still be associated with significant side effects, including damage to underlying organs such as the lungs and heart. Anyone who is facing radiation therapy must discuss all the potential risks with their radiation oncologist beforehand.

“I have had a lumpectomy” LUMPECTOMY RECONSTRUCTION OPTIONS: Oncoplastic Surgery: Oncoplastic surgery is breast reconstruction performed at the same time as a lumpectomy. In many cases, a lumpectomy can leave a significant breast deformity. This deformity is often made worse by the radiation therapy that typically follows a lumpectomy. During an oncoplastic procedure, the lumpectomy tissue is removed in a way that allows the plastic surgeon to perform a simultaneous breast reduction. This avoids unwanted cosmetic deformities and simultaneously creates the most cosmetic result possible. Completion Mastectomy: Some patients will be left with a significant breast deformity following breast conservation therapy (lumpectomy and radiation). In many cases, completion mastectomy with immediate breast reconstruction can provide a much better cosmetic result and improved breast symmetry. For some patients, removing the remaining breast tissue and avoiding the need for continued screening are added benefits of this approach. A completion mastectomy removes the remaining breast tissue. In patients interested in breast reconstruction, the completion mastectomy is performed in a way that preserves as much of the overlying breast skin as possible, and can be combined with a variety of breast reconstruction techniques. Breast Symmetry Surgery: One common concern for breast cancer patients is how the other breast will look compared to the lumpectomy breast, and whether their final breast symmetry will be normal. Legislation passed in 1998 by President Clinton mandates that health insurance companies provide coverage for symmetry procedures following breast cancer surgery. This means that if a person has a lumpectomy on one side, insurance companies must cover the cost of surgery on the other breast if it is needed for the best symmetry. Some of the most common procedures to improve breast symmetry include: breast augmentation to create a larger breast to match the reconstructed breast, implant exchange, breast reduction, breast lift or fat grafting to add volume to a reconstructed breast. Fat Grafting: This has become a widely-used technique in breast surgery and is the most commonly used technique to address deformity caused by a lumpectomy. Fat is liposuctioned from one part of the patient’s body, purified and then injected into the breast to “fill in” the contour defect created by the lumpectomy. There are several fat-grafting techniques used by plastic surgeons. *This content is provided by PRMA Plastic Surgery

PSN: BREAST RECONSTRUCTION 2017 

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Sientra breast tissue expanders are indicated for breast reconstruction. They are temporary expanders and are not intended for long-term or permanent implantation. Sientra breast tissue expanders are contraindicated in patients with active infection or existing carcinoma at the intended expansion site. Tissue Expanders with integral magnetic ports should not be used in patients who already have implanted devices subject to magnetic field interference or in patients where an MRI may be needed. Prior to use, plastic surgeons should review the Instructions for Use and detailed information regarding the risks and benefits of Sientra breast tissue expanders, located at sientra.com.