Breast Reconstruction 2018 by PlasticSurgeryNews

FALL 2018

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A Supplement to Plastic Surgery News

A patient’s guide to understanding her treatment options

Life after breast cancer Survivors help women rebuild their lives PAGE 6

Beauty on display Women bare their surgical scars in art exhibition | 20 Pros and cons of breast reconstruction procedures | 13 Bringing awareness to underserved communities | 15

YOUR CHOICE—

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THERE ARE MANY REASONS YOU KEEP CHOOSING ALLODERM™— more than 550,000 implantations for tissue reinforcement in breast reconstruction, more than 20 years of experience in tissue processing, and an ongoing commitment to product innovation.1

ALLODERM™ IS THE MOST-USED AND MOST-STUDIED ADM, TRUSTED BY MORE PLASTIC SURGEONS.2,3 Not actual patients. Individual results may vary.

Learn more at the Allergan booth at Plastic Surgery The Meeting 2018.

INDICATIONS ALLODERM SELECT™ Regenerative Tissue Matrix (ALLODERM SELECT™ RTM refers to both ALLODERM SELECT™ RTM and ALLODERM SELECT RESTORE™ RTM products) is intended to be used for repair or replacement of damaged or inadequate integumental tissue or for other homologous uses of human integument. This product is intended for single patient one-time use only. ALLODERM SELECT™ RTM is not indicated for use as a dural substitute or intended for use in veterinary applications. IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS ALLODERM SELECT™ RTM should not be used in patients with a known sensitivity to any of the antibiotics listed on the package and/or Polysorbate 20. WARNINGS Processing of the tissue, laboratory testing, and careful donor screening minimize the risk of the donor tissue transmitting disease to the recipient patient. As with any processed donor tissue, ALLODERM SELECT™ RTM is not guaranteed to be free of all pathogens. No long-term studies have been conducted to evaluate the carcinogenic or mutagenic potential or reproductive impact of the clinical application of ALLODERM SELECT™ RTM. DO NOT re-sterilize ALLODERM SELECT™ RTM. DO NOT reuse once the tissue graft has been removed from the packaging and/or is in contact with a patient. Discard all open and unused portions of the product in accordance with standard medical practice and institutional protocols for disposal of human tissue. Once a package or container seal has been compromised, the tissue shall be either transplanted, if appropriate, or otherwise discarded. DO NOT use if the foil pouch is opened or damaged. DO NOT use if the seal is broken or compromised. DO NOT use if the temperature monitoring device does not display “OK.” DO NOT use after the expiration date noted on the label. Transfer ALLODERM SELECT™ RTM from the foil pouch aseptically. DO NOT place the foil pouch in the sterile field. PRECAUTIONS Poor general medical condition or any pathology that would limit the blood supply and compromise healing should be considered when selecting patients for implanting ALLODERM SELECT™ RTM as such conditions may compromise successful clinical outcome. Whenever clinical circumstances

require implantation in a site that is contaminated or infected, appropriate local and/or systemic anti-infective measures should be taken. ALLODERM SELECT™ RTM has a distinct basement membrane (upper) and dermal surface (lower). When applied as an implant, it is recommended that the dermal side be placed against the most vascular tissue. Soak the tissue for a minimum of 2 minutes using a sterile basin and room temperature sterile saline or room temperature sterile lactated Ringer’s solution to cover the tissue. If any hair is visible, remove using aseptic technique before implantation. ALLODERM SELECT™ RTM should be hydrated and moist when the package is opened. DO NOT use if this product is dry. Use of this product is limited to specific health professionals (e.g., physicians, dentists, and/or podiatrists). Certain considerations should be made to reduce the risk of adverse events when performing surgical procedures using a tissue graft. Please see the Instructions for Use (IFU) for more information on patient/product selection and surgical procedures involving tissue implantation before using ALLODERM SELECT™ RTM. ADVERSE EVENTS The most commonly reported adverse events associated with the implant of a tissue graft include, but are not limited to the following: wound or systemic infection; seroma; dehiscence; hypersensitive, allergic or other immune response; and sloughing or failure of the graft. ALLODERM SELECT™ RTM is available by prescription only. For more information, please see the Instructions for Use (IFU) for ALLODERM SELECT™ RTM available at www.allergan.com/AlloDermIFU or call 1.800.678.1605. To report an adverse reaction, please call Allergan at 1.800.433.8871. References: 1. Data on file, Allergan. 2018. Sales Data. 2. Data on file, Allergan. March 12, 2018. Breast Reconstruction Market Metrics. 3. Data on file, Allergan. PubMed search performed in January 2018. Tissue Reinforcement: Breast Reconstruction Entries. Allergan® and its design are trademarks of Allergan, Inc. ALLODERM™ and its design and ALLODERM SELECT™ are trademarks of LifeCell Corporation, an Allergan affiliate. © 2018 Allergan. All rights reserved. ALS116515 08/18

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Introducing

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References: 1. Worth It Ratings Data - November 2017. 2. In-person consumer survey with 452 respondents. Mentor Consumer Preference Market Research Report - July 2017. 3. When compared to MemoryGel® Breast Implants. 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 2018 079300-180206

TABLE OF CONTENTS Cover Photo: Jennifer Lee Photography Graphic Designer: Anna Abbinante

Get involved: Breast Reconstruction Awareness Day ........................................... 5 By Kim Kubiak

FALL 2018

Power of sisterhood: Survivors help women rebuild their lives after breast cancer................... 6

Breast reconstruction changes lives…

By Kendra Y. Mims Patient Education

Understanding your options after preventative mastectomy ........................ 11 By Jay Orringer, MD

What you need to know about breast reconstruction ...............................13 By Christopher Tokin, MD, and Kye Higdon, MD Patient Perspective

A joint effort: Cancer survivor and plastic surgeon bring awareness to underserved communities...................15 By Kendra Y. Mims

Emmy-winning journalist shares her story of survivorship ..........................18 By Adam Kivel Reconstructed

Art exhibition shows the beauty of women’s scars after breast reconstruction ..............................20 By Kendra Y. Mims Physician Perspective

Coping with cancer: Plastic surgeon shares her reality ...................................... 26 By Emily McLaughlin, MD

Beauty for Good Gala champions awareness ............................. 27 By Paul Snyder Wellness

Navigating sexuality and intimacy after treatment.......................................... 28 By Cheri A. Ong, MD

Yoga moves to restore vitality ................ 29 By Natalie Holland Team Effort

Industry support vital to Breast Reconstruction efforts .................31 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.

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

 PSN: BREAST RECONSTRUCTION 2018

chose to become a plastic surgeon because of my passion for reconstructive surgery. As a medical student, I always thought that the best part about plastic surgery was having the opportunity to help fill a “hole” or help put the pieces back together after an accident or cancer. With these ideals in mind, breast reconstruction still forms a significant part of my practice. Every day, I hear stories from women about how breast reconstruction has changed their lives. Patients tell me, “I didn’t feel like a woman before,” “I feel whole now” or “Now I can take my kids to the pool.” I have had patients who have told me they never allowed their husbands to see them naked after their mastectomies or others who are brought to tears after seeing the results of their reconstruction. One of my patients showed the results of her reconstruction in my waiting room by raising her shirt. She and her husband say that breast reconstruction changed her life. However, I am also aware that the vast majority of American women who undergo a mastectomy will not have a breast reconstruction. Breast reconstruction may not be the right option for every woman, but for many, it is a life-changing procedure. This year, an estimated 266,000 women will be diagnosed with breast cancer. Only 23 percent of those women know the wide range of reconstructive options available to them. In other words, the focus will be on cutting out the cancer – not surviving it, not healing from it and certainly not rebuilding after the cancer is gone. Since 2012, ASPS and The PSF have led the Breast Reconstruction Awareness USA Day Campaign, one of the few breast cancer campaigns devoted to raising awareness and educating the public on breast reconstruction options. In my practice, I have found that my patients want to talk to other women who have had reconstruction, which leads total strangers to meet, discuss and share their experiences. Breast Reconstruction Awareness Day is another opportunity to share those experiences with the world. In celebration of the seventh Breast Reconstruction Awareness Day USA (slated to take place on Oct. 17), we are excited to release the third edition of Plastic Surgery News: Breast Reconstruction – a publication dedicated to providing exclusive coverage on breast reconstruction to help patients understand their treatment options. Within these pages, we highlight survivors and physicians who are raising awareness and making a difference in the lives of breast cancer patients in their communities. From photographic essays that put women’s scars on display to organizations devoted to encouraging survivors and their families, these stories reflect hope, healing, courage and awareness, and empower breast cancer patients to embrace their beauty and reclaim their victory over the disease. I encourage everyone – plastic surgeons, patients, survivors – to get involved and discuss breast reconstruction because it is an integral part of the recovery process after cancer for many women. As we try to raise awareness about both breast cancer and breast reconstruction, we need to share our experiences and tell our stories. We hope you enjoy the third edition of PSN: Breast Reconstruction and join our efforts to educate and advocate for breast cancer patients to ensure all women know their options after a breast cancer diagnosis. Together, we can do our part to make a difference and close the loop on breast cancer. Anu Bajaj, MD Oklahoma City, OK

GET INVOLVED:

Breast Reconstruction Awareness Day By Kim Kubiak The American Society of Plastic Surgeons and The Plastic Surgery Foundation believe every woman should be made aware of her breast reconstruction options. Sponsored by ASPS and The PSF, the celebration of Breast Reconstruction Awareness Day USA continues this year on Oct. 17 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. It’s important to inform women of their breast reconstruction options and legal right to health-care coverage. Start planning now to become an affiliate and host a fundraising event in your community to show your support. BreastReconUSA.org has all the resources you need to get started, including a free marketing and PR toolkit to assist in promoting Breast Reconstruction Awareness Day activities. Every event, large or small, plays an important role in raising awareness. You can be a leader in “closing the loop” for women who remain unaware of their surgical reconstruction options post mastectomy. Here are some ways you can help: • Work with a local support group to host a reconstruction Q&A panel. Invite plastic surgeons, breast cancer survivors and patients who have undergone mastectomy and breast reconstruction to participate in a panel discussion that allows people to ask questions about the process. • Plan a fundraising event in your hometown. Recruit a local salon to support a day of spa services for breast cancer patients to generate awareness for their business and breast reconstruction. • Gather friends and survivors for a bold flash-mob event. Organize a group to dance, sing, parade or run in a public place. • Educate your friends about Breast Reconstruction Awareness Day on Instagram, Facebook and Twitter. Use hashtags such as #BreastReconDay, #BreastReconstruction, #CloseTheLoop, #BreastReconAwareness, #RaiseAwareness and #BreastReconRibbon. • Take a photo, make an impact. For every photo you share through the Johnson & Johnson Donate A Photo initiative, Johnson & Johnson gives $1 to the Breast Reconstruction Awareness Campaign. Download the app or share your photos at donateaphoto.com. • Show your support by wearing the Breast Reconstruction Awareness ribbon. The 3-inch dark pink

ribbon symbolizes “closing the loop on breast cancer.” All proceeds will benefit the Breast Reconstruction Awareness Fund of The Plastic Surgery Foundation. Order yours at breastreconusa.org/ribbons. Oct. 17 is just the beginning. You can use your voice and help make a difference. The opportunities are endless, and any effort will contribute to the ongoing campaign to support women physically, mentally and emotionally as they survive and thrive after breast cancer. For more information to become an affiliate and receive your free Starter Guide, please email breastrecon@plasticsurgery.org.

Funds generated from the new Close the Loop 5K will be awarded to Chicagoland organizations through the Breast Reconstruction Awareness Campaign of The PSF.

The Close the Loop 5K race will take place from 6 a.m. to 9 a.m., Sunday Sept. 30, where runners/walkers can enjoy a great view of Lincoln Park Zoo. If you can't join us in person, become a 5K Virtual Participant or gift someone's registration fee. Packets will be available for pick-up starting at 6 a.m. The race starts at 7 a.m. at the west end of the Chicago Park District's South Field House in Lincoln Park. Register now ! https://raceroster.com/events/2018/15651/close-the-loop-5k

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SISTERHOOD OF OVERCOMERS

Every leader in Overcomers is a breast cancer survivor.

 PSN: BREAST RECONSTRUCTION 2018

Help Women Rebuild Their Lives After Breast Cancer By Kendra Y. Mims

enny Small did not expect a cancer diagnosis during the third trimester of her eighth pregnancy. She and her doctor presumed the sudden lump above her right breast was a clogged milk duct until further testing revealed triple-negative breast cancer. Genny was induced at 38 weeks and started chemotherapy after the birth of her son. The mother of eight says hearing the “C” word at age 39 felt surreal. PSN: BREAST RECONSTRUCTION 2018 

{ SISTERHOOD OF OVERCOMERS }

Called to serve Serving breast cancer survivors is a communal effort for the Small family. Genny's husband, Paul, teaches the men’s workshop to help spouses process their emotions and support their wives as a co-survivor, and their children, who range from ages 4 to 16, also volunteer. Genny hopes these charitable efforts and community outreach inspire them to follow in her footsteps. “All of our children are involved, whether it’s helping me stuff envelopes for the gala, working behind the scenes with the organization or updating the organization’s website,” Genny says. “They all see the positive part of joining together as a family. I hope they’ll find a way to give back no matter what challenges come their way. That’s what life is about. It’s not about us. It’s about giving back in whatever season we’re in. If someone has a need, and we can meet it, why not be a blessing to someone else?” Genny and Jessica hope to expand their reach to help women beyond the San Antonio area find their new normal after breast cancer and remind them they are not alone. “I want to be a voice to let them know it’s OK to be vulnerable, and it’s OK to have these scars,” Genny says. “My breasts represented nurturing, so it was hard to lose that part of me. But having reconstruction helps me look in the mirror and say, ‘We’ve been through some stuff together.’ I’m thankful. If you can look at yourself in the mirror and say, ‘This is the new me – I’m stronger, I’m more resilient,’ that’s powerful. “Reconstruction has helped me feel whole again,” she continues. “We have scars, but I think scars are amazing. They represent a battlefield and remind me that I am a warrior.”

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The Small family enjoy time together at Roszell Gardens (from left) Andrew, Alizabeth, Anastasia, Addington, Aaron, Genny, Paul, Alexander, Andersonn and Aiden.

“I thought about my husband and children, and my initial response was, ‘What do we need to do to get rid of it?’ ” Genny says. “Because of my age, I didn’t want to worry about cancer or getting scans. I wanted to do what I needed to survive.” Instead of worrying, she immediately went into battle mode. Genny underwent a double mastectomy and implant-based reconstruction in 2014 after completing chemotherapy. Unfortunately, she contracted a mycobacterial infection shortly after her reconstructive surgery and experienced numerous complications, which required six months of oral antibiotics, a wound VAC, a PICC line to administer her IV antibiotics and removal of her implants. “We thought we could clear it with antibiotics, but the infections just kept coming back,” she recalls. “The bacteria kept forming a growth and traveled between my right and left breast. I went from never being sick to having cancer and all these infections.” Genny faced a long and arduous recovery. She underwent seven surgeries to remove the infected tissue. While dealing with her failed implant reconstruction, Genny also struggled to find support groups that addressed her personal questions. Faced with an unmet need to help women navigate through the physical, mental, emotional and spiritual challenges they encounter upon a cancer

diagnosis, she used her experience in homeschooling her children to develop and write a faith-based workshop curriculum for cancer survivors. “My first plan was to get chemo, expanders, implants and be done,” says Genny, who completed a successful DIEP flap surgery in 2016. “This was definitely plan B, but plan B is OK. Had I not gone through this struggle, how could I encourage someone when reconstruction doesn’t go as planned? I couldn’t find anyone to help me process things or tackle the hard questions when I went through all those surgeries. I want women to be hopeful and truly know there is a new normal and that it’s going to be OK.” NEVER THE SAME

Jessica Meyers, a hairdresser in San Antonio, Texas, first learned about breast reconstruction while servicing a client who had recently completed radiation therapy. Jessica says although she listened to her client’s DIEP flap reconstruction experience in awe, she never thought cancer and reconstruction would become a part of her story. When Jessica received a Stage 2 invasive breast cancer diagnosis several months later, she was adamant about using her own tissue for breast reconstruction. Jessica, now 50, underwent a bilateral mastectomy with immediate DIEP flap breast reconstruction six weeks after her

chemotherapy treatment in 2015. After experiencing a seamless recovery with minimal pain, Jessica says the real struggle began in the aftermath. “There are ways to live a new normal after breast-cancer, but providing support for survivors is where people fall short – especially in our community,” she says. “You get all the support when you have cancer, but there aren’t a lot of options for support after.” Jessica and Genny crossed paths at the end of their breast-cancer journeys. They discovered a shared passion to help survivors rebuild their lives after cancer and joined together to create Overcomers: Daughters of the King of Kings, a nonprofit organization and sisterhood to encourage, equip and empower breast cancer survivors and their families. “Right after I was cancer-free, I made a vow to help as many people as I could, so when Genny first approached me about her idea, it was a definite yes,” says Jessica, Overcomers co-founder and vice president. “We dove into it together without any hesitation. As survivors, we try to focus on the things we experienced and spread awareness to let people know about our services, so

they won’t feel alone. We have a huge sisterhood. We take these women under our wings, and they become family.” The partners ran a pilot program in 2015 with 10 attendees at Methodist Hospital in San Antonio. Three years later, their organization has expanded to provide a nine-week biannual workshop that helps breast cancer survivors transition into survivorship, one-day workshops for spouses of survivors, annual retreats, charity events and financial assistance to help the survivors’ families during the holidays. Volunteers help run the organization and facilitate workshops. To date, more than 60 women have completed the program, and Genny says participants are changed for the better. “We help people process tough topics they don’t want to talk about but need to address during their breast cancer journey,” Genny says. “No one is going to fully arrive, but we give them the tools they need to process losing relationships, sexuality issues or grieving the loss of who they were before cancer. When they’re done with the workshop, they have a sense of the new normal. The woman who walks in the class is not the same woman who

walks out nine weeks later. You see hope return to her eyes.” Since being diagnosed with Stage 3 ductal carcinoma in 2017, Overcomers volunteer leader Jennifer Smith has undergone a double mastectomy, 16 rounds of chemotherapy and radiation therapy. She says she can’t overstate what Overcomers did for her. “It’s a challenge to cope with cancer – mind, body and spirit,” Jennifer says. “This organization has provided the support and tools I so desperately needed to ease my pain and to move forward in a positive direction with my life. I have been so inspired, I’ve chosen to go into Overcomers leadership to help others through their struggles. I would recommend Overcomers to anyone on their journey through cancer. My life will never be the same.” Genny and Jessica both said that they could not help others without the support of their leadership team of 10 women. “My experience led me to be the founder and president of Overcomers,” Genny says. “Through my struggles and those of my pink sisters, Jessica, the Overcomers team and myself can help others navigate life after a breast cancer diagnosis. All of these women have gone through our workshop and have decided that they want to teach and mentor others. We are surrounded by great women, and all of us working together is what makes this organization who we are as pink sisters.” MAKING A DIFFERENCE

ASPS findings show that less than a quarter of women know the wide range of breast reconstruction options available, and only 22 percent of women are familiar with the quality of outcomes that can be expected. Jessica notes Overcomers’ mission includes raising awareness in their local community on breast cancer initiatives and reconstruction options. Overcomers founder Genny Small (right) and cofounder Jessica Meyers (left) share their stories to help other breast cancer survivors.

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{ SISTERHOOD OF OVERCOMERS }

“Genny and I both have a passion to help people, so being involved in the community and spreading awareness to other cancer patients is huge for us,” Jessica says. “We try to incorporate education and awareness into our workshops. We’re really big on letting women know all their options for breast reconstruction, self-care and other aspects of being a survivor.” Genny and Jessica express gratitude for their plastic surgeons, ASPS members Peter Ledoux, MD, and Minas Chrysopoulo, MD, of PRMA Plastic Surgery, who played an instrumental role in their recovery and healing process. They encourage women to find a board-certified plastic surgeon who will fight with them and promote shared-decision making. “If you’re seeing a doctor who says you don’t have any options, you need to go find somebody else because that’s just not true,” Genny says. “I’ve had friends who’ve been told there’s nothing they can do, and then they see a board-certified ASPS surgeon and undergo reconstruction. There’s always hope. Keep searching if you don’t get the answers you want. You have a voice. Find a board-certified plastic surgeon who will listen to your needs and become your partner because you’re going to be with them for a long time. I don’t think people get that at first.” Genny adds that Dr. Chrysopoulo has become like family to her over the past four years and commends his positive reinforcement during challenging times. “Dr. Chrysopoulo constantly told me, ‘We’ll get through this,’ ” she says. “He gives you the peace and calmness you need in the middle of your storm to let you know it’s going to be OK. It’s been an amazing experience for me. “We’re very fortunate here in San Antonio that we have PRMA,” Genny continues. “They have breast reconstruction awareness events where you can get an actual visualization of what reconstruction will look like. They 10

 PSN: BREAST RECONSTRUCTION 2018

really make sure their patients know what they are getting themselves into. I’m thankful because I know a lot of people don’t have that.” Jessica credits Dr. Ledoux for helping her reclaim the active lifestyle she enjoyed before cancer. Because of his encouragement, Jessica ran a half marathon four weeks after her breast cancer revision surgery. “I ran to prove to myself that cancer wasn’t going to hold me back from doing what I loved to do before I was diagnosed,” she says. “Dr. Ledoux and his team always encouraged me to stay active. I jumped back into exercising with his permission and guidance. That helped with my recovery.” THE POWER OF STORY

Overcomers held its first Men in Pink Gala fundraiser this spring to honor men in the breast cancer medical community who are making a difference in the lives of breast cancer patients. The runway show featured plastic surgeons and other doctors, nurses and health professionals who were nominated by their patients. Dr. Chrysopoulo and Dr. Ledoux both walked the runway and say they are privileged to witness the impact Genny and Jessica have made in the lives of breast cancer survivors in their community.

“Overcomers is truly an invaluable resource for patients seeking coping skills and support for life after breast cancer,” Dr. Chrysopoulo says. “Genny has touched the lives of countless women and men in the San Antonio community. She is never shy to share her story or to lend a helping hand for a fellow breast cancer sister and their family.” Dr. Ledoux says the same can be said about Jessica. “Jessica and Genny continue to bless others by providing emotional and educational support to the breast cancer community,” Dr. Ledoux adds. “Jessica is committed to living a healthy lifestyle and encouraging others to do the same. Her lifechanging experience with breast cancer and breast reconstruction helped guide Jessica to discover her calling to support others through Overcomers.” Jessica says she will continue to share her story with her fellow breast cancer survivors. “We’re very fortunate to have such a wonderful medical community here,” she says through tears. “We’re thankful we’re able to provide a service to our own breast cancer survivors, and we’ll continue to do that for as long as we can and for as long as we’re here.”

ASPS members Minas Chrysopoulo, MD (left), and Peter Ledoux, MD (right), walk the runway as honorees at the Men in Pink Gala. Funds raised sponsored Overcomers first “Beauty in Brokenness retreat.”

{ PATIENT EDUCATION }

ANGELINA JOLIE’S SURGEON SPEAKS...

UNDERSTANDING YOUR OPTIONS

after preventative mastectomy By Jay S. Orringer, MD FIVE YEARS AGO, actress and humanitarian Angelina Jolie elected to proceed with prophylactic (preventative) double mastectomy after undergoing genetic screening and learning that she had a significantly elevated risk of developing breast cancer due to a mutation of the BRCA1 gene. As a member of her surgical team, I was deeply moved by her courage and benevolence, as Ms. Jolie shared with the world her journey through mastectomy, breast reconstruction and recovery. Our knowledge of genetic breast cancer risk and gene testing has significantly increased in recent years. Today, we understand BRCA1 and 2 mutations are only two of many mutations that significantly elevate breast cancer risk. Multi-gene panels now assess for a variety of mutations, including those affecting CHEK2, PALB2, PTEN and TP53 genes, as well as many others. Identification of these gene mutations helps to assess breast cancer lifetime risk. In addition, women who have undergone radiation therapy to the chest for childhood Hodgkin’s or nonHodgkin’s lymphoma have a greatly elevated lifetime risk of developing breast cancer. If genetic counseling or other risk assessment suggests a high risk for the development of breast cancer, a woman

might choose close surveillance or prophylactic mastectomies – depending upon her unique situation, including her actual estimated risk, family history, age and any other health issues that may exist. Although twice yearly surveillance might detect early breast cancer, neither MRI, mammogram nor ultrasound will always do so, and serious, life-threatening tumors can still be missed. Currently, prophylactic mastectomies are estimated to decrease breast cancer risk by approximately 9097 percent. However, it is important to consider both the major and very personal nature of this decision. Undergoing a preventative mastectomy isn’t right for every high-risk woman. Factors such as estimated lifetime breast cancer risk, willingness to tolerate that risk and overall health must be considered.

Preventative mastectomy and reconstruction Today, women choosing risk reduction through prophylactic mastectomy have a variety of ever-improving reconstructive options. As a plastic surgeon, I believe it is important to address with the patient various approaches that include the use of implants, as well as one’s own tissues, to create the new breast. In most instances, modifications of standard cosmetic surgical breast incisions can be used. In the setting of ptotic (droopy) breasts, I often PSN: BREAST RECONSTRUCTION 2018 

{ PATIENT EDUCATION }

factors that might make genetic testing advisable: Personal history of breast cancer, including bilateral breast cancer or diagnosis of triple-negative breast cancer by age 60 Personal history of ovarian cancer Family history of breast cancer before age 50 in two or more close relatives, including a mother, sister or daughter Close relatives of Eastern European Jewish ancestry who have a history of breast, ovarian or pancreatic cancer A close male relative with breast cancer

use breast lift-type mastectomy incisions. These current incisional approaches may allow for elevation of the new breast and a more youthful appearance of the breast. In the last decade, nipple-sparing mastectomy has become much more common. A number of studies have demonstrated excellent risk reduction and improved cosmetic outcomes with this approach. Nipple-sparing mastectomy and reconstruction is also now often done in the setting of breast cancer, but this depends upon the nature of the tumor, its size and location. Newer techniques might allow for nipple preservation – even in the setting of considerable “droop.” Attempted nipple preservation in this setting, however, will depend upon a variety of considerations, such as the actual nipple position, smoking history, prior radiation injury and prior scarring around the nipple. Although these risk factors do not necessarily preclude preservation of the nipple, other techniques might be recommended prior to mastectomy to try to enhance nipple survival. In addition to more cosmetic incisions, newer implants and reconstructive materials along with innovative techniques often allow for more natural and aesthetic breast reconstruction results. Breast reconstruction options include use of implants and use of one’s own tissues. Each approach has distinct advantages and disadvantages. Implant reconstructions are often associated with a shorter hospital stay and recuperative period. However,

unlike use of one’s own tissues, implants require maintenance over time. Reconstructions that use the patient’s own tissues provide the potentially most natural and durable long-term results. Once successfully transferred, the tissue used to make the breast does not need to be replaced. Unlike implants, which might become firmer or less natural in appearance over time, breasts reconstructed with tissue tend to act more like natural breasts. This approach might be appropriate for a woman who has considered a tummy tuck and for whom the tummy tuck-like scar would be an acceptable trade-off for improved abdominal contour. Buttock (gluteal) tissue can also be used in women who have had a previous tummy tuck or have limited abdominal tissue. This scar mimics that of a buttock lift. Use of your own tissue might be an excellent choice in the setting of very thin or radiated tissues for individuals who have failed implant reconstructions, or in women who simply prefer reconstruction without implants. If you are considering prophylactic mastectomy and reconstruction, take the time to gain an understanding of your estimated risk and options. Once you have decided this course is right for you, select your general surgeon and board-certified plastic surgeon after lengthy discussion with each. Feel comfortable that they offer a wide variety of current options and consider it a privilege to serve on the team of which you are captain.

Jay Orringer, MD, is Adjunct Clinical Faculty at the John Wayne Cancer Institute in Santa Monica, Calif. He has been in private practice, specializing in plastic surgery in Beverly Hills, Calif., for 28 years. Dr. Orringer served his general surgery residency at the University of Michigan Affiliated Hospitals, plastic surgery residency at the UCLA Hospitals, and microsurgery fellowship at the New York University Affiliated Hospitals. He is a diplomate of both the American Board of Plastic Surgery and the American Board of Surgery.

 PSN: BREAST RECONSTRUCTION 2018

WHAT YOU NEED TO KNOW ABOUT

Breast Reconstruction By Christopher Tokin, MD, and Kye Higdon, MD

Breast reconstruction basics Twenty years ago, the majority of women having mastectomy for breast cancer treatment were not undergoing reconstruction. With improvements in patient education, implant technology and microvascular technique, most women today choose to have their breasts recreated. All patients should be offered the option to discuss breast reconstruction with a board-certified plastic surgeon. PROS:

BREAST RECONSTRUCTION refers to the operation to restore breast shape after cancer surgery. Traditionally, when we talk about breast reconstruction, we are often referring to reconstruction after mastectomy (or removal of the whole breast) for breast cancer. The benefits of breast reconstruction include improved body image, self-esteem, sexuality and quality of life. Just as breast cancer treatment has become more individualized, the approach to breast reconstruction is truly an individualized endeavor, as the goals and expectations for one patient may be very different from another. Even with the widespread use of Internet searches and online communities – which serve as invaluable sources of knowledge and shared experiences – it is more common than not for patients to present with little to no knowledge of their reconstructive options or the timing of reconstruction as it relates to therapy and recovery. In 2018, plastic surgeons are helping patients after all types of breast cancer surgery, not just mastectomy. It is our goal to help you better understand your reconstructive options after breast cancer surgery and the pros and cons of each approach, as well as address some common questions and misconceptions about different reconstructive techniques.

• Ability to recreate the breast mound and the nipple shape • Improved body image, self-esteem, feelings of sexuality and quality of life CONS:

• Often requires secondary procedures • Unable to restore full breast function (i.e., milk production, normal sensation)

Implant-based reconstruction Most patients choose to have implant-based reconstruction. In 2002, implants surpassed autologous tissue as the more common reconstructive approach. While both saline-filled and silicone-filled breast implants are options, new-generation silicone implants are superior in both natural shape and feel and can give excellent aesthetic results. This approach usually, but not exclusively, starts with placement of a tissue expander partially or fully under the chest muscle and occurs in stages. The tissue expander allows the tissues to heal and soften, while at the same time allowing the pocket to expand to a breast size the patient finds desirable. Another option for well-selected patients includes placement of a tissue expander or final implant above the muscle (prepectoral), in conjunction with acellular dermal matrix. In general, the expansion occurs in the office over a period of weeks to months, followed by a second procedure where expanders are exchanged for permanent implants. This is often combined with fat grafting, a procedure where liposuction is used to harvest fat for transplant to the breast for improved natural symmetry and volume. PROS:

• • • •

Ability to achieve excellent aesthetic results Quick recovery Flexibility with final breast volume Does not delay adjuvant treatment (common misconception)

CONS:

• Often requires staged approach (several operations) • Inability to re-create normal tissue (can feel hard or cold) • Implants may need to be replaced in the future (if rupture or contracture occurs) PSN: BREAST RECONSTRUCTION 2018 

{ PATIENT EDUCATION }

Autologous tissue reconstruction

• Often feels more natural (real body tissue) • Removes implant-associated risk factors (rupture, contracture, etc.) • Secondary/revisionary procedures less common • Does not delay adjuvant treatment

Oncoplastic breast surgery

PROS:

Up to 80 percent of all breast cancers are treated with breast conservation therapy (lumpectomy +/- radiation). Although this approach allows for conservation of breast tissue, subsequent lumpectomy defects can be deforming. In cosmetic breast surgery, we have a variety of techniques to reconfigure the breast into the ideal shape and position. This can include volume reduction, lifting and tightening procedures. Using these skills and procedures to plan cancer excision in the setting of breast conservation is often referred to as oncoplastic surgery and can allow for resection of the cancer and reshaping of the breast at the same time. The approach is individualized to the patient and the cancer and can involve either volume replacement with tissue rearrangement to restore symmetry, or volume-displacement techniques used in conjunction with contralateral breast lifts to restore ideal shape and nipple position.

CONS:

Remember, breast reconstruction is an option after nearly all breast cancer surgery, and board-certified plastic surgeons can help guide you through the decision-making process and create an individualized reconstruction plan based on your goals and wishes. Christopher Tokin, MD, is a breast oncology fellow and plastic surgeon practicing at UC San Diego in San Diego, Calif. He completed his plastic surgery training at Vanderbilt University. His practice focuses on breast cancer, breast reconstruction and oncoplastic surgery. Kye Higdon, MD, is a plastic surgeon who practices at Vanderbilt University Medical Center in Nashville, Tenn. He is an associate professor of plastic surgery there, and also serves as program director for the residency training program in plastic surgery at Vanderbilt. His practice focuses on aesthetic and breast reconstruction surgery.

PROS:

Autologous tissue-based reconstruction uses one’s own tissue for breast reconstruction. This traditionally meant taking the back muscle (latissimus) or the abdominal muscle (TRAM) and rotating it with skin and fat onto the chest to recreate the breast mound. With improvements in microsurgical technique, tissue from nearly every part of the body can now be used for autologous reconstruction. The principle behind all microsurgical breast reconstruction is similar; the tissue to be used for breast reconstruction is isolated on its blood supply, and with the assistance of a microscope, reconnected to blood vessels in the chest. The most common donor site is the abdomen, referred to as DIEP (deep inferior epigastric perforator) breast reconstruction. This technique can be useful in obtaining a more natural look – especially in scenarios where the breast is larger, or the nipple is lower hanging (ptotic). This technique often obviates the need to use an implant at all, and patients often refer to it as a “natural” reconstruction, in both feel and appearance. Sometimes, we even reconnect nerves to give sensation to the reconstructed breast with this method. It is also the preferred modality in the setting of radiation, although many patients who undergo reconstruction with an implant in that setting have a good result.

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CONS:

• Longer/more involved initial operation and recovery (a few days in the hospital as opposed to overnight with implant-based surgery) • Requires donor site (additional scar and possible loss of function if muscle is recruited) • Can be delayed by adjuvant radiation treatment

• Breast conservation often accomplished in single surgery • Can allow for increased tissue removal at time of cancer operation (wider margins) • Not an option for very large or advanced tumors • May require procedure on unaffected breast for best cosmetic results

{ PATIENT PERSPECTIVE }

A joint effort:

Cancer survivor and plastic surgeon bring awareness to underserved communities By Kendra Y. Mims

TRACI SMITH WANTED TO FEEL BEAU TIF UL AGAIN.

After losing her left breast to cancer and mastectomy, she struggled to look at her body in the mirror. The disease took a toll on her confidence, and she felt undesirable. At the end of her nine-month treatment process, she decided to undergo free flap reconstructive surgery. Traci says choosing breast reconstruction was a no-brainer. She needed the constant reminder of cancer to disappear. “I didn’t like how I couldn’t look at myself in the mirror for those nine months,” Traci says. “I just felt disfigured, and the longer I waited, the more depressed I became because I was reminded that I had breast cancer every single day. I wanted to feel like the normal Traci prior to breast cancer. I didn’t want to wake up with the reminder that cancer invaded my body and took my breast, so I elected to have reconstructive surgery. I also elected to remove my right breast as a precaution.” Traci, 50, learned about breast reconstruction long before her stage 3 diagnosis. Her mother underwent breast cancer treatment more than 30 years ago, and although she opted not to undergo reconstruction, Traci says her mother’s diagnosis made her aware of treatment options. As a survivor and advocate for plastic and reconstructive surgery, Traci

strives to raise awareness about breast cancer and reconstruction in the African-American community. In 2014, she founded Traci’s BIO (Beautiful Inside Out), a nonprofit organization that helps women maintain a level of normalcy while going through cancer and provides education, resources, beauty services, emotional support and sisterhood. She is also the author and publisher of “The Pink Sister Chronicles,” a compilation series featuring stories of survivorship. “I wanted to inspire ladies to feel beautiful both inside and out,” she says. “We help women feel attractive and beautiful while they’re going through this crazy process. You lose your eyelashes, eyebrows and hair during treatment. You don’t feel attractive. We provide makeovers and create wigs for the ladies, so they feel somewhat back to normal.” Traci also became a life coach to assist women in coping with the stressful disease. “My doctors were wonderful, but I needed someone to talk to at 2 a.m. when

everyone in my house was asleep and I was scared, or when I needed someone to pray with me,” she says. “When I was going through my treatment, I had an excellent support system, but I would see women who didn’t have that support. “I visit women during their chemo and radiation treatments,” she continues. “I’m there for their families. I can answer questions they may not want to ask their loved ones. Oftentimes, we don’t want to burden our families with our fears, so I can be a soundboard to answer those questions.” While coaching women through their treatment process, Traci noticed that many women of color – particularly in the African-American community – chose not to undergo reconstruction after cancer treatment. Some were unaware of their options; others simply had no desire to reconstruct their breasts. Traci believes a lack of knowledge and stigma about plastic surgery in the African-American community both play a role in the women’s decision-making process. “I’m finding that it’s so taboo to get plastic surgery within our community because many say, ‘You should be satisfied with how God made you and keep it moving,’ ” Traci says. “We don’t talk enough about cancer, let Traci Smith, breast cancer advocate and founder of Traci’s BIO

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{ PATIENT PERSPECTIVE }

Traci’s BIO provides education to empower women and raise breast cancer awareness in the AfricanAmerican community.

alone having reconstruction. Through coaching these ladies, I’ve discovered they just want to get the cancer out, and that’s it. A young woman told me she’s been through enough and doesn’t want to consider reconstruction even when I tell her the benefits. I also have older women say they’re too old for reconstruction and their husbands love them the way they are. I don’t know why it’s so taboo.” Traci says she first discovered the benefits of plastic surgery after undergoing breast reduction surgery in her 30s. She has no qualms about sharing her breast reduction or reconstruction experience with women, including the difficulties she faced after her free flap procedure. “I’m open about my dissatisfaction with my first reconstructive surgery, which is why I went back,” says Traci, adding she underwent four revision surgeries to achieve her desired outcome. “I knew I could resemble who I was before cancer with reconstruction. I want to encourage women to be comfortable with their bodies and new lives. My first order of business is to get women comfortable enough to get a mammogram and help them through the process of beating cancer if diagnosed. Then, the conversation informs them of their options. It’s not an easy conversation, but it lets them know they can take control of their healing process.”

Improving health literacy ASPS member Paris Butler, 16

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MD, MPH, met Traci after one of his attendings performed her reconstructive surgery at Penn Medicine. Through their conversation about her diagnosis and decision to undergo reconstruction, Dr. Butler and Traci discovered a mutual interest to improve health literacy among underserved populations.

Some studies in the early 2000s described the disparity and stated African-American women were getting reconstruction at half the rate as Caucasian women. Since their first encounter in 2014, Dr. Butler and Traci have collaborated at multiple outreach events in Philadelphia’s underprivileged communities to provide education on breast health, including detection and reconstruction. Dr. Butler commends Traci’s efforts to raise awareness and help women find their new normal after breast cancer. “There are not a whole lot of services out there for women who are diagnosed with breast cancer in these communities, so it is very necessary work, and she is doing a fantastic job,” Dr. Butler says. “I was still in training when I met Traci. Because

of my understanding that women of color undergo breast reconstruction at a lower rate than the majority of the community, I asked her how she was informed about her breast reconstruction options, and that has led to a multiyear relationship of collaborative outreach efforts and support of her organization.” Dr. Butler, now a faculty member at Penn Medicine, has authored several studies on racial disparities in post-mastectomy breast reconstruction. Based on his findings, he strongly advocates that all women requiring a mastectomy after a breast cancer diagnosis be referred to a board-certified plastic surgeon – regardless of their race or ethnicity. “Some studies in the early 2000s described the disparity and stated African-American women were getting reconstruction at half the rate as Caucasian women,” Dr. Butler recalls. “I needed to know if that was still the case. We looked at it three years ago based on our experience in Philadelphia, and then we looked at it nationwide and confirmed this was still happening.” The reasons racial disparities still exist are multifactorial, ranging from insurance coverage to lack of referrals from breast and general surgeons, he adds. “I don’t know if it’s just negative stigma as much as the lack of education within the community,” Dr. Butler says. Dr. Butler attempts to reduce racial disparities through educational symposiums held at large churches in the Philadelphia region that target women of color. African-American women comprise most of the audience. He concedes it’s surprising that many attendees don’t realize their insurance is mandated to pay for their breast reconstruction after paying for their mastectomy, as well as surgery of the other breast to produce symmetry. He and his peers educate attendees on breast health, Penn’s free mammogram program, breast surgery and reconstruction options.

“I am trying to help arm our community with information as it pertains to their breast reconstruction options and improve the health literacy of our women of color in the community,” Dr. Butler says. “More family members also attended the event to get information or provide support to their loved ones who were diagnosed. That’s how we are really making strides because we are educating people outside of those personally impacted by breast cancer. That’s how you really expand the knowledge base of the community.” Dr. Butler adds his goal is to also demystify the myth that minority women are not as interested in breast reconstruction as Caucasian women. “We know that is also completely inaccurate, so we have to educate within our primary care and breast

surgeons that every woman who needs a mastectomy deserves a referral to a plastic surgeon to have a conversation about her reconstruction options,” he says, adding that fewer plastic surgeons are also accepting insurance, which plays a factor. “If a woman is referred to a plastic surgeon who doesn’t accept any insurance, then she is unlikely to get breast reconstruction,” he continues. “In my opinion, the etiology of the disparity is three-fold (patient education, breast surgeons’ referral patterns and plastic surgeons’ interest in caring for these patients) and I am trying to do my best to work on it from all three ends. It’s a big undertaking, but if we look at patient health literacy in addition to further education of providers more strategically, we can make a difference.”

Sisterhood Traci speaks candidly about the newfound confidence she gained after her breast reconstruction surgery. She has shared her story and reconstruction patient testimonial with Dr. Butler’s audience at several educational symposiums. Traci says she is transparent about her cancer journey and fights hard to raise awareness because she doesn’t want women to hide in fear. She also wants to be a role model to her daughter. “My mother hid her breast cancer from me,” she remembers. “There is someone out there who is hiding cancer from their family. My daughter is 19, and it’s important for me to speak about it because I want her to stay on top of her health. I want family members to understand it’s not a hidden disease. If you treat it early, you can minimize some of the stages you go through.” As she pays it forward through her organization, Traci hopes BIO continues to comfort, spiritually enlighten and remind women they are not alone. You have a sister who will do whatever it takes to get you through your survivorship, she adds. “It’s not a sisterhood I wanted to be in,” Traci says. “Fortunately, I’ve come across an array of people, and I’m proud to say I’m part of this sisterhood now. I hope we can make the process a little easier for others. I’m just a woman who saw there was a mental and spiritual need when I was going through it, and I will do whatever I can to assist people in this fight.” “I’ll never be the Traci I was before, but given my new life and where I am now, I am perfectly imperfect.”

Traci (third from left), and Paris Butler, MD, raise awareness about breast health and reconstruction at Penn Medicine’s 5th Breast Reconstruction Awareness Day event.

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{ PATIENT PERSPECTIVE }

“I’ll tell anyone that I’m a

who had faced various types of breast cancer so that Sambolin could ask questions and learn about their experiences. The women spanned various stages in their cancer and each differed in their responses. Some, for example, had opted for double mastectomies, while others hadn’t; in addition, some had chosen reconstruction, while others had decided to have no reconstruction at all. Sambolin received answers to any question she asked and at the end of the interviews, the women extended their willingness to share further. “I asked them if I could really see what the reality was like, and they all instantly took off their tops and allowed me to be able to really see and feel, and ask more specific questions,” Sambolin says. “That was one of the greatest gifts they all gave me.” Having all of that

cancer survivor.” Emmy-winning journalist shares her story of survivorship By Adam Kivel GROWING UP BETWEEN

Chicago and Puerto Rico, Zoraida Sambolin didn’t expect to have a career as a thriving television journalist. The path to that kind of success wasn’t always easy, but she quickly learned that she had a passion for storytelling and sharing with others – traits that led Sambolin to anchor roles at CNN and NBC Chicago, where she can connect with thousands of viewers every morning. More importantly, when Sambolin received a breast cancer diagnosis in 2013, those same traits proved to not only help her find the best path to facing the disease, but also to spreading awareness and empowerment with countless others. “I would get a call from the doctor after every mammogram saying to come in six months later,” Sambolin recalls. “But this time, she started by asking how I was, and I just thought to myself, ‘Oh my God, I have cancer.’ ” She was living a healthy life with her husband and two kids, returning to Chicago for mammograms and ultrasounds like clockwork, but just that hint of the unexpected signaled something new and terrifying on the horizon. Memories of a past biopsy that returned as noncancerous suddenly seemed like an uncaught 18

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warning sign, and the excitement stemming from a recent engagement and a move to Atlanta for an anchor job on CNN’s “Early Start” seemed farther away. “I started processing a lot of doubt,” Sambolin says.

Into action However, she quickly displaced that doubt with a new urgency bolstered by her storytelling and investigative skills. As a first step, Sambolin reached out to a medical correspondent at CNN she’d met in the previous year at a banquet. “I didn’t know her very well, but I just told her I’d been diagnosed and needed help researching and understanding my options,” she says. “That woman was on a plane about to take off, being told to hang up, and she insisted she needed one more minute to talk to me. She really jumped into action.” That wasn’t the only help Sambolin received in those early stages. Together, the two put together a panel of women

information and variety of perspectives was essential, but Sambolin wanted to take it one step further: she wanted to share her own experience and the knowledge she gained with others who might be facing similar concerns. “I wanted others to have the same information that I had so they could make better-informed decisions too,” she says. “It was important for me to have women see that it doesn’t have to look weird or feel different. You may always worry about cancer again, but having that network and sisterhood is a beautiful gift. There’s nothing I wouldn’t do for another woman struggling, and I know that there’s nothing she wouldn’t do for me.” As a newscaster, Sambolin’s platform was there, but she just wanted to broach the subject – both with her coworkers and her audience – at the right moment. When she first received her diagnosis, Sambolin was certain she wanted a double mastectomy. “My first inclination was that I wanted the cancer gone – take everything,” she recalls. Meeting with the panel of other women helped her shape that decision in a more real way. When Angelina Jolie’s double mastectomy was slated to be the lead on CNN one morning in 2013, Sambolin took the opportunity to share her own experience alongside the story, to give even more perspective to her audience and to women everywhere. Before that taping, Sambolin had told only one person at CNN of her diagnosis – a manager who was also a cancer survivor. When that executive producer saw the news about Jolie, he chatted with CNN president Jeff Zucker and got the go-ahead to allow Sambolin to handle the news however she would feel comfortable. “There were so many people already weighing-in, but I knew she was trying to save her life and make sure that she was there for her

children,” she says. “I had chosen to see it that way, too. I needed to send that message because I was living it in that moment.” That morning, Sambolin decided to tell Helping women in the Hispanic community gain access to health care is her colleagues. one of Zoraida’s priorities. She had other turned out, I did have cancer in both tough discussions about her diagnosis breasts. I wanted people to see what already and organized a group of six I was looking at, why I made the sisters and cousins on a conference decision that I did.” call to tell them, to avoid having to Since then, Sambolin has taken have individual conversations with every opportunity she can to raise individual fears and questions. She breast cancer awareness. She’s had to tell her fiancée and two young spoken at fundraisers, conferences children. When she and reporter and appeared on several radio and Nischelle Turner discussed the Jolie television programs. While at NBC, story, Sambolin felt safe and ready she put a lot of effort into the to share her experience with her organization’s breast cancer awareness audience. projects every October. Perhaps most importantly, through CNN, she became the spokesperson for Susan G. Women in the Komen in the Hispanic community. Hispanic community “Women in the Hispanic community often don’t get the kind often don’t get the kind of of health care that they need, so I’m health care that they need, proud to help make that a priority,” so I’m proud to help she says. “All of this outreach – it’s who I am now.” make that a priority. She calls the outpouring of support All of this outreach – she received on social media based on it’s who I am now.” those stories “unbelievable.” When she would share an update on her progress, to tell her followers that she was heading in for surgery, she “I felt safe sharing that information had thousands of fans rooting for her with her in that type of a way,” alongside her family. Sambolin recalls. “I felt really great once I started She followed up that story with telling my story because I could reports that had radiologists showing immerse myself in it the way I would in her own imaging. anybody else’s story,” Sambolin says. “In “There was pushback from others the past, I would have normally kept – even a doctor asking why I wanted my mouth shut, but now I’ll tell anyone to ‘chop off my breasts’ – about my that I’m a cancer survivor – and you're decision to have a double mastectomy going to get some advice on getting because I hadn’t been diagnosed in your mammogram on time.” both breasts,” Sambolin says. “As it PSN: BREAST RECONSTRUCTION 2018 

CONSTRU

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UCTED

Art exhibition puts cancer survivors’ scars on display By Kendra Y. Mims

“There is beauty in imperfection.” ASPS member Jonathan Bank, MD, is on a mission to help women wear their scars with pride. After watching a video his breast reconstruction patient sent him on kintsugi – the Japanese art of repairing broken pottery with gold and highlighting the cracks – Dr. Bank felt inspired to create an art project that glorified the beauty of breast cancer survivors’ scars. The kintsugi philosophy underscores beauty in broken things; objects that suffer damage become more beautiful. Taking inspiration from this, Dr. Bank teamed up with leading fashion photographer Erez Sabag and creative Jonathan Bank, MD director David Warren, and they set out to capture women’s personal victories over cancer through photo essays that interlaced their scars with gold. Warren says he and Sabag relished the idea of helping cancer survivors feel more beautiful and less ashamed of their bodies. “There’s some shame in our Western culture around imperfection and scarring,” Warren says. PSN: BREAST RECONSTRUCTION 2018 

CONSTRUCTED:

WHAT BREAST CANCER TAUGHT ME… LIVING THE ALTERNATIVE

Name: Elaine Ngai Age: 49 Location: Fresh Meadows, N.Y. Year of diagnosis: 2017 Cancer diagnosis: DCIS, left breast, Stage 0 What breast reconstruction procedure did you choose: DIEP flap What did you enjoy the most about the project? I didn’t like the idea of being naked, but I agreed because of my devotion to Dr. Bank. He is the best doctor I’ve ever known in terms of skills and compassion. My favorite part of the project was getting to work with Erez Sabag’s entire team. They are all wonderful people who put me at ease and helped bring out a part of me that was needed for the project. What do you want other women to take away from this project? I want other breast cancer patients to know there’s an alternative to implants or a mastectomy alone. I want them to see other women living the alternative, DIEP. When Dr. Bank first mentioned DIEP, I had no way of understanding what the surgery entailed. I couldn't process it. It wasn’t until he put me in touch with a previous patient of his who had DIEP flap reconstruction done that I decided to go ahead with it. I want other women to garner courage seeing all different kinds of women going through different stages of breast cancer. I told anyone who would listen to go get themselves checked, because breast cancer can happen to any woman at any age. I’m hoping this project clarifies the DIEP process and helps other women seeking alternatives. How has Reconstructed impacted your life? I’m so happy with the results. I have returned to my previous life – including Muay Thai martial arts. My self-esteem about my body is even better than it was before the surgery. I feel very grateful to have met Dr. Bank. He was my second opinion. The first opinion did not offer DIEP and instead offered double mastectomy with implants. I did not want implants and almost went with mastectomy alone, which would have been devastating to my self-esteem. One thing breast cancer can’t take away: My sense of humor or my will to be strong for my family and those who have been there for me.

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“These women have gone through such physical, emotional and mental trauma during their treatment. They’re often heavily scarred at the end of it, and perhaps feel embarrassed. We wanted to photograph the beauty of their scars as symbols of the battle they fought, not only the suffering they endured.” Dr. Bank and his creative team presented the concept to 19 breast cancer survivors. Every patient supported their idea, and 16 women agreed to participate in the project. With participants ready, Reconstructed came to life. “Beyond the obvious commonality, they all crumbled in tears upon viewing the kintsugi video, and all felt empowered after seeing our proposition for Reconstructed,” Dr. Bank says. “Moreover, they all share the same determination to use this opportunity not only to help themselves come full circle, but to help other women who are faced with the diagnosis and give them hope and fortitude on their journey to survivorship.” DIPPED IN GOLD

Reconstructed is a series of photographs about women of differing ages, races, professions and socioeconomic backgrounds who have undergone various types of breast reconstruction surgery – and have the scars to prove it. The raw and emotional images depict women reclaiming their identity and femininity after going through cancer treatment. Sought-after hair stylists and makeup artists in the beauty industry volunteered their time for the project’s photo and video shoots. Warren says every woman showed enormous bravery as they bared their scars and naked bodies on camera. Some women were completely covered in gold glitter, while others had their entire bodies splattered in gold paint. Warren notes every gold-painted scar was photographed precisely. “It’s not just a random picture of

a tummy with a scar on it,” Warren explains. “We tried to create in true kintsugi spirit to represent the beauty because of their journey. We used the personality of each woman. We pushed them, but we were respectable about not pushing them too far. It takes a brave soul to disrobe in front of a team of people they’ve never met before who want to throw gold all over them. It was definitely a journey to have them become more comfortable with us and for us to get them out of their comfort zone to do something extraordinary they wouldn’t do in their daily lives.” Reconstructed walks a fine line between exposing the harsh reality about breast cancer and treatment, and alarming people with the truth, and Dr. Bank says finding the balance between the two was a challenge. “We are trying to make this impactful to educate women at large about their options for breast reconstruction without sugarcoating breast cancer treatment – whether that includes breast reconstruction or not,” he explains. “I don’t want to say it’s a walk in the park and beautiful. The scars are there – and they come from something – but it’s a story that must be told. “These women are doing this to help themselves and other women through this battle and to encourage women not to be afraid to get a mammogram,” Dr. Bank continues. “We want to show that it’s scary, but you can survive and have the option of reconstruction if you get diagnosed and treated early. There are ways to overcome it.” Dr. Bank says the project changed his perspective as a plastic surgeon and how he approaches his work. "There's an expression in surgery that says 'better is the enemy of good,' yet sometimes good is great," he explains. “I constantly scrutinized my post-op photos and beat myself up for little or large imperfections in my outcomes, but then you look at these pictures from Reconstructed, and they are much more dynamic. None of

Name: Donna LoNigro Age: 43 Location: Long Island, N.Y. Year of diagnosis: First diagnosis, 2010; second diagnosis, 2014 Cancer diagnosis: In 2010, I was diagnosed with cancer in my right breast, and in 2014, they found abnormalities in my left breast that they said were precancerous. They told me I would continue dealing with it if I didn’t do something. I underwent a double mastectomy and reconstruction right after. Reconstruction procedure: DIEP flap after failed implant reconstruction What inspired you to participate in Reconstructed? When Dr. Bank proposed the project, I was hesitant because I didn’t want people to see my scars. My mother is also a breast cancer survivor, and she told me the scar is not horrible. It’s a scar. My sister and husband told me the same. It was overwhelming, exciting and scary. I feel so much better that I did it. How has Reconstructed impacted your life? I’m no longer insecure with my body. I don’t hide my scars anymore. It’s the new me. What do you want other women to take away? I want women to know that they’re beautiful no matter what their body looks like. It’s you and that’s what makes you unique. I don’t think I would be who I am now unless I went through what I went through. I want women to know getting a breast cancer diagnosis is not the end. It’s not a death notice. There’s so much more they can do for you. These surgeons did so much for me. I’m cut up, but I’m whole. I had to be stitched up to be me again. Everyone is beautiful in their own way. One thing breast cancer can’t take away: My life. It’s not going to take me away. I have to be here for my family – for my husband and my boys. I will fight tooth and nail for them. I won’t let cancer win.

WHAT BREAST CANCER TAUGHT ME… WON’T LET CANCER WIN

CONSTRUCTED:

WHAT BREAST CANCER TAUGHT ME… Name: Margaret Donohue CELEBRATION OF LIFE Age: 39 Location: Queens, N.Y. Year of diagnosis: 2015 Cancer diagnosis: Lobular carcinoma in situ (LCIS) Reconstruction procedure: Direct-to-implant post-mastectomy reconstruction and nipple reconstruction. I chose this procedure instead of DIEP flap because I still wanted to have a baby. Why did you participate in Reconstructed? I wanted to raise awareness about breast cancer and breast reconstruction. I think people tend to focus on the negative part of reconstruction, but breast reconstruction really helped me physically and emotionally. My mom had a mastectomy when I was younger and died from breast cancer. She didn’t have the chance to have reconstruction – in the early 1980s, it wasn’t covered by insurance or really talked about. I felt very lucky to have the opportunity. When making the decision about the mastectomy, I knew insurance would cover my reconstruction and that helped with my decision. The concept of the project is very beautiful. What do you want other women to take away from this project? Hopefully, other women who are contemplating on having a mastectomy – whether by choice or necessity – will feel a little less scared. I hope it helps them feel beautiful. I also hope younger women become more aware of breast cancer. Even with my family history, I didn’t think it would be an issue at this age. I have friends who put off their mammograms, but it’s important to keep up with your screenings because you can prevent things if you catch it earlier. The only reason they caught mine is because I went in for a fertility treatment and they ran a test. I feel lucky they caught it early and I could choose what I wanted to do for my future. What have you learned during your cancer journey? Dealing with infertility and breast cancer can make it difficult to decide what to do. I was going through fertility treatments when they discovered I had cancer, and they put them on hold until my cancer treatment ended. It took a while, but I eventually got pregnant after my reconstruction and it was a celebration. It’s important for younger women who are dealing with infertility issues and cancer to know it is still possible to have a baby after cancer. One thing breast cancer can’t take away: Love. The entire process shows you the people in your life who love you and care for you. It puts things in perspective, and you realize what’s important. Even during the bad times after the surgery, love is what got me through all of it.

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them are perfectly symmetrical, and they’re all beautiful in their own way. The women in them feel alive again, beautiful again and wanted again.” “Taking these women who have been through a lot and making them feel like top models for a day was really transformative for them,” he adds. “More people should embrace imperfections. Whether a surgeon or a patient, we shouldn’t beat ourselves up for not being perfect.” BEAUTY ON DISPLAY

Although Warren and Sabag have collaborated on numerous beauty campaigns for more than 20 years, Warren says Reconstructed is unlike anything they’ve done before. “A lot of the campaigns we photograph don’t have such compassionate beginnings,” he says. “We created a beautifully designed coffee-table book with extraordinary images that we’re immensely proud of, but it’s bigger than that. If a woman picks up this book in a doctor’s office and thinks, ‘Wow, these women did this, and I can be OK,’ that would be fantastic. Even though women may fear how their bodies will look after breast reconstruction, we want to show they are beautiful and there is nothing to be ashamed of.” Reconstructed has expanded into 18 video interviews of the survivors, a 120-page, high-quality coffee-table book and an art exhibition in multiple venues. The website and app (currently under construction at press time) will feature the project’s video interviews with plans to expand the platform and give other breast cancer survivors an opportunity to share their stories. Reconstructed is slated to appear at a New York Fashion Week event in September. International exhibits are scheduled for November at the Tel Aviv Museum during the 44th Convention of the Israeli Society of Plastic and Aesthetic Surgery, followed by a two-week gallery exhibit

Name: Katica Ulysse

WHAT BREAST CANCER TAUGHT ME… NEVER GIVING UP

Age: 56 Location: Hempstead, N.Y. Year of diagnosis: 2017 Cancer diagnosis: Left-sided breast cancer Reconstruction procedure: Left mastectomy with immediate autologous tissue reconstruction What inspired you to participate in Reconstructed? I joined because everyone treated me like I mattered. From the first day I met Dr. Bank, he didn’t have pity for me. He had compassion and understanding, and he explained everything to me. He also told my husband he wasn’t alone, and he was going to be there for any questions or concerns we had. You don’t find that these days. When I go to the office, Dr. Bank always has a smile on his face and a kind word of encouragement. I was blessed that God sent me there. He’s a great plastic surgeon. He has a good heart. I love the job he did. What do you want other women to take away from Reconstructed? It’s not always bad. I want them to see they can still look beautiful after all the tragedy and be the women they were before cancer. That’s what I thought about when I had my breast removed. One thing breast cancer can’t take away: My faith in God. It also can’t take away my strength and love for life. I have been through so much and giving up was never God’s plan for me before cancer and certainly not now. I believe I have a mission in this life to do something great. I’m not done yet. God is not finished with me yet, and with His grace, I will continue to be grateful for every day and happy for big and small favors.

in Tel Aviv. Reconstructed will also appear at Plastic Surgery The Meeting 2018 in Chicago in September. Dr. Bank says limited edition gold-treated prints and high-quality coffee-table books will be sold at the annual meeting and upcoming gallery events. “We have an opportunity to make this project impactful – and not just for the one in eight women who are touched by breast cancer,” Dr. Bank says. “We can take inspiration from the kintsugi philosophy and push what it means to paint women in gold; some filled with fine lines, some with huge brush strokes, dripping and splashing body paint, and gold light projections. “Ultimately, Reconstructed is not about breast cancer, but about love,

compassion, hope and understanding,” he adds. “The images glorify the beauty of the inspiring women who wear the scars that connect and strengthen all of us.” Dr. Bank works with New York Breast Reconstruction Associates, a group of ASPS member surgeons committed to optimizing breast reconstruction outcomes and quality of care for women facing mastectomy.

Reconstructed's photographer Erez Sabag (left) and creative director David Warren (right) bring Dr. Bank’s vision to life.

To purchase your copy of Reconstructed, visit shopasps.org or projectreconstructed.org. Proceeds will be directed to The PSF and the American Cancer Society for breast cancer research. PSN: BREAST RECONSTRUCTION 2018 

{ PHYSICIAN PERSPECTIVE }

Coping with cancer: Plastic surgeon shares her reality of cancer diagnosis By Emily McLaughlin, MD

“ You have cancer.”

These are words that my patients hear from someone else before coming to me to discuss plans for reconstruction. These are also words I heard for the first time in May 2016, while I was in the middle of performing a tummy tuck. It would seem that it’s impossible to separate the surgeon and the patient in my world. Of course, it’s absurd to imagine that a female plastic surgeon is immune to breast cancer – or any cancer, for that matter. Almost every time I meet a breast cancer patient and tell her my experience, she says, ‘You had breast cancer?!’ Yes, I am one of the ‘one in eight women’ to develop breast cancer in their lifetime. So, what have I done with this reality? The first thing I did was rid the awful monster that is cancer. I was diagnosed with high grade DCIS, or ductal carcinoma in situ, in my left breast. I had stage 0 cancer and I did not require chemotherapy or radiation. I have had six operations in two years to address specific situations with my reconstruction; my last surgery was March 30 of this year. My style is to share my reality. I have posted pictures of scars and drains on Facebook, uploaded photos heading into each surgery on Instagram and blogged about it on my website. Thanks to this visibility and my role as a plastic surgeon, I am approached almost every day by someone recently diagnosed with breast cancer or with an abnormal mammogram or a palpable mass in 26

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degree of animation deformity exhibited when I flexed the muscles over the implants. With an implant beneath the muscle, the effect is flattening of the implants to a very unnatural degree. Ultimately my reconstruction was converted to pre-pectoral, or over the muscle. No more animation – much more natural. I am thrilled and now a vocal advocate for this technique of reconstruction. Research your options – mastectomy techniques, reconstruction over or under the muscle, expanders and implants versus flaps. You are entitled to know what is going on. Some options may not be right for you, but you can ask and then understand why or why not. Knowledge is power.

her breast seeking advice on what to do. As a surgeon who performs breast reconstruction and a breast cancer thriver, here is what I have to offer anyone facing this reality:

Breathe. I have had more patients than I can recall with an abnormal mammogram who needed a biopsy. I have always reassured them not to worry until there is something to worry about. As a patient, I now realize you cannot control the worry. My reassurance comes from a place of awareness you can only find when you have been there. Until you have something definitive to worry about, do not let your mind take you where you don’t want to go. Deal with facts.

Do not delay getting a mammogram if you’re due or if you feel a mass in your breast. Patients tell me they don’t have time, they are afraid of what it might reveal, or it might be painful. Get your mammograms!

Ask your surgeons questions. My initial reconstruction was standard in the eyes of plastic surgeons: double mastectomy with implant reconstruction. The implants were placed beneath the muscle on the chest wall because after a mastectomy with removal of all breast tissues, coverage of the implants or expanders is not sufficient. Within months of surgery, I was terrorized by the

Allow yourself time to heal, physically and emotionally. My plastic surgeon would readily agree that having a plastic surgeon as a breast reconstruction patient is the worst thing you could ever imagine. Rather than waiting for my surgeon to explain something to me or discover it’s not “normal” at a routine follow up, I called her at least once a week. Your surgeons’ instructions are not suggestions; be compliant with drains, incision care, garments. Your regular routine will wait for you. Give yourself some grace.

I am one of very few women who can say with conviction that breast cancer gave me more than it took away. I embrace my reality of this side of this awful disease. If this is part of your story, I wish you peace and happy healing from every perspective – and I am here if you need me.

Emily McLaughlin, MD, is a board-certified plastic surgeon in Fort Worth, Texas. As a breast cancer survivor and a plastic surgeon who performs breast reconstruction, Dr. McLaughlin is passionate about making a difference in the lives of patients facing breast cancer. To learn more about Dr. McLaughlin’s Fighting Right organization, visit fightingright.org.

Beauty For Good gala champions breast reconstruction awareness By Paul Snyder

THE PSF’S BREAST RECONSTRUCTION AWARENESS FUND was the beneficiary of the second annual Beauty For Good Gala and the philanthropic efforts of Mosharrafa Plastic Surgery in Phoenix. Beauty For Good, which serves as a fundraising foundation for medically based charities, was established by ASPS members Tamir Mosharrafa,MD, (who spoke to PSN about the event) and Ali Mosharrafa, MD.

The foundation partners with several organizations to raise funds and awareness for various local charities, but the Breast Reconstruction Awareness Fund is an annual anchor and the only national charity. This year’s gala – a “Great Gatsby” – themed event held in mid-April – raised more than $2,000 for the Breast Reconstruction Awareness Fund. “Breast reconstruction is why my brother and I went into practice in the beginning,” Dr. Mosharrafa says. “We underwent a lot of training, and then we built a practice based largely on caring for women with breast cancer. It’s why we come to work everyday.” It’s also why the Phoenix practice’s charitable giving goes beyond a once-a-year event. “We give $100 from every cosmetic procedure we perform to Beauty For Good, and each donation subsequently is redistributed to our five charitable partners,” Dr. Mosharrafa says. “That’s good, but that’s also kind of a limited amount of resources. We began thinking, ‘Why don’t we get other people involved as well?’ So we also allow donations to be made from our website – from patients who want to give beyond contributions for surgery.”

Although the Breast Reconstruction Awareness Fund will always be one of the benefactors of Beauty For Good’s donations, Dr. Mosharrafa says the other charities can change, and he adds that they are selected based on their missions and the work they do in the community. Some of the other charities to receive donations through Beauty For Good include Prevent Child Abuse Arizona and the Phoenix Dream Center, for which Dr. Mosharrafa has volunteered for a decade, removing tattoos from girls who were victims of sex trafficking. “When I saw what was being demanded of these girls, it wrecked me and I knew I had to get involved,” he says. “We want to use this opportunity to raise awareness of things that people might not realize are happening in their own backyard.” To that end, Dr. Mosharrafa says that during a recent meeting, it was decided that the charities with which Beauty For Good partners must be willing to work on fundraising efforts throughout the year. “We want the community to be involved – and not just for one night,” he says. As far as boosting donations to the Breast Reconstruction Awareness Fund, Dr. Mosharrafa says he’s also looking for more plastic surgeons to become involved. Whether that’s mirroring what’s done at his practice – donating a certain percentage or dollar amount from cosmetic procedures to the fund – or something else, is up for discussion. He says he wants to spur more involvement. “We have big plans for this charity,” he says. “A couple of plastic surgeons attended our gala and saw what can be done. Eventually, I want to be writing checks that are in the hundreds of thousands of dollars, not just thousands, to these charities. I want to be able to say, ‘You’re funded for the year.’ “The charities will always have more work to do, and whatever we can do to help them do that work, we will,” Dr. Mosharrafa adds. “Beauty For Good is not separate from our practice – it’s core to what we do.”

Left to Right: Tamir Mosharrafa MD, Co-Founder, Brandie Barclay, Creative Director, Kara Schell, Executive Director, Ali Mosharrafa, MD, Co-Founder

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{ WELLNESS }

Navigating sexuality intimacy after breast reconstruction By Cheri A. Ong, MD Are you struggling with intimacy after breast reconstruction? You are not alone! Many women share intimacy challenges after cancer treatment. A study published in the Journal of Sexual Medicine reported that 70 percent of the 994 cancertreated patients who were sexually active at the time of diagnosis still experienced sexual difficulties two years after their cancer treatment ended (“Sexual Function After Breast Cancer,” 2011). Unfortunately, the topic of sexuality and intimacy may be one of the least-discussed side effects of cancer treatment. A breast cancer patient’s decreased sex drive – a side effect of antihormonal treatment – is commonly misinterpreted as, “I am not interested in you” or “I don’t love you anymore.” This misconception can cause severe and long-term emotional pain. If you are

experiencing sexual difficulties, do not blame yourself. This is not your fault.

Intimacy challenges Breast cancer treatment, unfortunately, affects the core of what makes a woman a woman and can lead to a negative body image as a direct result of surgery or indirect changes, such as weight gain or hair loss. As a plastic surgeon, I see a huge need for education and support to assist women through their sexuality and intimacy struggles. One of my patients told me it took time to resume sexual activity with her husband after surgery because he feared he would hurt her. She had to convince him it was OK to touch her breast. Her experience is not uncommon. If you have undergone breast cancer treatment, you may experience a perceived loss of sexuality and unattractiveness in your own mind, perceived loss of sexuality by your partner and side effects of treatment, such as a decrease in sex drive, vaginal dryness and painful intercourse. Maintaining intimacy is difficult when fear and pain are involved. Remember, intimacy issues are a common result of treatment. Take the following steps to regain normalcy: 1. Get your hormones in balance. Hormones play a major role in a woman’s emotional and functional needs. Targeted hormone therapy is one of the important aspects of breast cancer treatment. Taking vitamins and supplements to assist with estrogen detoxification pathways and supporting your thyroid and adrenals are extremely important and can help with sleep problems, night sweats and hot flashes. A functional medicine or naturopathic doctor and dietitian can point you in the right direction. 2. Get your weight and energy back. Fatigue and weight gain are common as a direct result of treatment and an

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overall decrease in physical activity and movement. Slowly transition back into a healthy lifestyle. This will help you gain more energy, lose weight and improve your physical self-confidence. 3. Address some of the side effects of therapy. Estrogen is such a powerful hormone for women, and antiestrogen therapy such as Tamoxifen can cause significant changes to tissues that rely on it, including bone density and heart health; vaginal dryness and painful intercourse; vaginal looseness and urinary incontinence; hair loss; and brain fog.

Treatment options • Topical treatments such as lowdose estrogen cream or DHEA can help improve the health of the tissues. Always have a discussion with your medical oncologist if you are planning to introduce hormones back into your body. I also use non-hormonal topical growth-factor treatments options in my practice for patients seeking to avoid the estrogen concern. • Regenerative treatments such as platelet-rich-plasma (PRP) and placental-based products can also make a difference in improving lubrication, tightening tissue (including bladder support) and balancing the healthy bacteria in your vagina. One final thought, and perhaps the most important, is maintaining open communication with your partner. Together, open communication and these treatment options can help you take the first steps to regain normalcy and improve your confidence to achieve better intimacy. Cheri A. Ong, MD, is an ASPS member and board-certified plastic surgeon practicing in Scottsdale, Arizona. Her practice is focused on female and functional health. She created the XX™ Revolution as a platform for women to elevate their self-confidence and give them the freedom to be the best version of themselves.

6 Yoga moves to restore vitality

after breast cancer treatment By Natalie Holland

WHEN I WAS DIAGNOSED with

breast cancer at 36, I was in the middle of a career shift from a high school science teacher to Pilates instructor. On top of all the other concerns and complications that come with a cancer diagnosis, I also worried that breast surgery would render me ill-equipped to teach Pilates. So, I decided early on that I simply would not let that happen. Cancer was not going to take away something I passionately wanted to do. In hindsight, it seems so serendipitous that I discovered Pilates before my diagnosis. It gave me a toolbox full of resources for restoring my physical body. After each operation, I used Pilates exercises to restore my strength and range of motion. While Pilates was extremely beneficial in helping me piece myself back together physically, something was still missing. Cancer treatment left my body wrecked. I endured eight operations (i.e., bilateral mastectomy, reconstruction, which eventually failed,

capsulotomy and more reconstruction, hysterectomy), chemotherapy, infections, hormone therapy and more. My body had been invaded by cancer. Treatment came with both physical and emotional pain along with lots of poking and prodding by numerous medical personnel. To distance myself from that pain, I checked out of my body. I made it to the other side of treatment, but everything had changed. I felt like a stranger in my own skin, and my spirit needed mending. I desperately needed a way to quiet my racing anxieties and build a new trust in my body. I needed to know my body in a new way – to make peace with it and to feel at home in it once again. Enter yoga. As I began to deepen my yoga practice (both on and off the mat) with asana (yoga postures); pranayama (breathing exercises); gentle-self massage and thoughtful observation, my body began to feel better. A sense of peace eased back

into my life. I began to feel at home in my own body again. Yoga is an ongoing and vital piece of my wellness protocol. My self-care routine is a balance of both rhythm and rest, because both are important for sustainable wellness. The following exercises combine both Pilates and yoga principles, and they are designed to help restore both strength and range of motion following breast surgery and encourage a sense of coming home to you. I practiced these exercises after mastectomy and every additional reconstructive surgery. Perform them in a comfortable seated (crisscross) position or seated on the edge of a sturdy chair. (Remember to consult with your doctor before beginning any exercise program.) EXERCISES BREATH OF LIFE • Left hand to heart; right hand to belly. Breathe deeply, slowly and rhythmically. Set an intention here. Return to this intention every time PSN: BREAST RECONSTRUCTION 2018 

{ WELLNESS }

you practice. (Examples: “I heal because I am alive.” “My body is in a constant state of healing and regeneration.” “I am restoring strength and range of motion.” “I forgive my body”). Your intention can be anything on which you’d like to place your focus. • Umbrella rib breath: Rest your hands on the lower part of your rib cage. With each inhale, feel the ribcage expand to its full capacity, from the front of the chest all the way to the spine. Imagine an umbrella opening. Repeat 10 times. • Belly breath: Place your hands on your belly so that you can feel its rise and fall. With each inhale, allow the belly to balloon and fill all the way to the pelvic floor. With each exhale, draw the pelvic floor up and the navel in. Repeat 10 times.

SHOULDER SLIDES Root down through your sit bones and grow tall through your spine; crown of the head reaching toward the ceiling. Align knees with hips; ankles with knees (if seated in a chair). Center shoulders over hips; ears over shoulders. Gently scoop the belly to stabilize the core. Extend arms straight in front of your shoulders; parallel with the ground. Keeping your torso still, inhale to draw the shoulder blades closer together thus sliding the arms back. Exhale and return the shoulder blades and arms to the start position. Inhale and slide your arms forward, this time feeling the space 30

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created between your shoulder blades. Repeat five times in each direction. Be sure to keep your shoulders low and away from your ears. PEEKABOO Maintain the same start position as your shoulder slides. Keeping the shoulders low, extend your arms straight out in front of your shoulders. Turn your palms up to face the ceiling, and then bend your elbows 90 degrees. Keeping the elbows bent and the ribcage still, inhale and open the arms as wide as possible. Exhale, return to start. Repeat five to 10 times.

PUPPET From peekaboo, keep the elbows bent, arms wide and shoulders low. Rotate your palms to face away from you. Take a deep breath in and on the exhale, rotate your right arm down while the left remains stable and still. Inhale, return to start; exhale, rotate your left arm down. Continue for five rounds. OVERHEAD LIFT Arms slightly in front and slightly wider than shoulder width; hands grasping the stretch band. Inhale and gently pull the band

until you feel resistance. Keeping your shoulders low, lift your arms overhead with an exhale. Inhale, lower arms to start position. Repeat five to 10 times, continuously drawing your shoulder blades down your back.

LOTUS TO PRAYER Bend your elbows and bring your palms together at heart center. Keeping your thumbs and pinkies together, part your middle fingers so that your hands resemble a lotus flower. Close your eyes and breathe here, remembering that you have the ability to rise from the mud, bloom out of the darkness and radiate into the world. At your own pace, inhale and reach your arms wide and overhead; exhale and bring your palms together. Inhale and hold; exhale and bring your palms to heart center. Pressing your palms together and keeping your shoulder blades low, continue breathing here for two or three breath cycles. Then inhale, reach your arms wide and overhead again, and repeat the whole process three to four times, reconnecting with your intention from the beginning of your practice. My yoga practice gives me time and space to sort my thoughts to gain clarity, perspective and peace. It moves my body in challenging and soothing ways, serving as a tool for healing. Happy healing, sister! Natalie Holland teaches Pilates and is a registered yoga teacher. She specializes in scientifically based holistic health practices and education, and works to help others improve their quality of life by utilizing wellness education, adaptive yoga, and Pilates. She holds a B.S. in Nutrition and Dietetics and an MSEd in Science Education. She is the author of “Scarred but Smarter: A Cancer Memoir and Get Healthy Manifesto” and runs YourHouseOfHealing.com.

CORPORATE SPONSORS SUPPORT DAY EFFORTS

BRA

this through our Johnson & Johnson Donate A Photo esearch shows that far too many women diagnosed with fundraising campaign at Plastic Surgery The Meeting 2018 breast cancer still don’t know about their reconstruction in Chicago,” says Warren Foust, Worldwide President. “At options following a mastectomy. Launched by ASPS and Johnson & Johnson and Mentor, we’re working to make the The PSF in 2012, the Breast Reconstruction Awareness USA world a better, more caring place by supporting causes that Campaign is instrumental in providing these women with both help people live longer, healthier, happier lives. Donate A education and information about their reconstructive options Photo is an example of how we live into that mission. Since as they undergo breast cancer treatment. our launch in 2013, we’ve expanded to regions all over the Breast reconstruction can help women rebuild their world to make a greater impact – more than 2.6 million self-esteem and improve their quality of life following breast photos have been donated, helping 139 causes. We are cancer surgery. Plastic surgeons play an important role in thrilled to partner with ASPS and The PSF as the Diamond a breast cancer patient’s recovery process, and the annual sponsor of Breast Reconstruction Awareness Day on Oct. Breast Reconstruction Awareness Day movement gives 17, and our sales representatives are looking forward to those surgeons an opportunity to empower cancer patients, supporting events in local practices in their territories. celebrate survivors and help women make an informed “Educating patients and potential patients decision at the time of diagnosis. about breast reconstruction is incredibly The Breast Reconstruction Awareness ASPS and The PSF important and continues to be an area that Campaign would not be possible without the sincerely thank the needs focus and attention from industry generous support of our dedicated corporate 2018 Breast Reconstruction Awareness and providers alike,” Foust continues. “At sponsors. Thanks to their commitment, the campaign’s Mentor we are deeply moved by the stories campaign continues to provide education and generous sponsors for their dedication to we hear every day of brave women and their resources about reconstructive surgery and women’s health families overcoming adversity and rising to raise awareness to close the loop on breast and patient education. fight breast cancer. We’re proud to honor cancer – both on Breast Reconstruction DIAMOND SPONSOR women and their fearlessness during Breast Awareness Day and throughout the year. Mentor Reconstruction Awareness Day, and in fact, GOLD SPONSOR every single day.” 2018 sponsors Allergan CareCredit joins the Breast Four companies have generously lent their BRONZE SPONSORS Reconstruction Awareness campaign this support to the 2018 Breast Reconstruction CareCredit Integra year as a Bronze sponsor. Awareness campaign. This year’s Diamond “Supporting Breast Reconstruction Sponsor is Mentor, a leading supplier of Awareness Day is an important part medical products for the global aesthetic of our company’s ongoing commitment to the Breast medicine market. The company has made breast implant Reconstruction Awareness Fund,” says CareCredit CEO devices for more than 30 years. Mentor Worldwide LLC Dave Fasoli. “Donations to the Breast Reconstruction became a Diamond Sponsor of the BRA Campaign in 2015. Awareness Fund truly help educate and empower women so As a leader in breast reconstruction, Mentor has launched they are informed of all their options.” multiple reconstruction solutions and is committed to Additional corporate support for the campaign comes from continued innovation that will provide surgeons with the Allergan, at the Gold level, and Integra joins the campaign as tools to improve patient outcomes in breast reconstruction. a Bronze sponsor. Every corporate partner contributes to the To help spread awareness around breast reconstruction, campaign’s success annually and continues to make a difference Mentor supports several patient advocacy groups, including in empowering women facing a breast cancer diagnosis and Living Beyond Breast Cancer, Young Survivors Coalition providing them with reconstruction education. Donations from and Facing Our Risk of Cancer Empowered (FORCE). sponsors are applied directly to programs that support related “Improving patients’ lives through breast reconstruction research and awareness efforts, and provide charitable care. is a key part of Mentor’s mission, and we are highlighting

For more information on the Breast Reconstruction Awareness Campaign corporate sponsors, visit breastreconUSA.org. PSN: BREAST RECONSTRUCTION 2018 