Breast Reconstruction 2019 by PlasticSurgeryNews

FALL 2019

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A Supplement to Plastic Surgery News

A patient’s guide to understanding her treatment options

The

Breast Goddesses: Survivor group helps cancer warriors cross the finish line PAGE 6

Plastic surgeon shares lessons learned after diagnosis | 17

ACTRESS CAPTURES BREAST CANCER JOURNEY THROUGH A PHOTO SERIES | 20

Reducing racial disparities in breast cancer care | 13 Life after reconstruction: Tips for a healthy recovery | 25

The tissue expander with over 30 years of clinical experience is available in a smooth surface1 PAIRED FOR PRECISION 100% match to the Natrelle INSPIRA® Collection2 SECURE PLACEMENT 360° tab orientation for greater placement support

SMOOTH SURFACE Less surface area and less tissue adherence3,*

FASTER FILL 4X faster fill with the FOURTÉ® Expander Fill System4,† (included with all Natrelle® 133S Tissue Expanders)

For more information, visit NatrelleSurgeon.com *Clinical significance has not been established. † Based on a comparison to a 21-gauge needle infusion set. Clinical significance has not been established. Natrelle ® 133S Smooth Tissue Expanders With MAGNA-SITE® Injection Sites Important Information INDICATIONS Natrelle ® 133S Smooth Tissue Expanders are indicated for: • Breast reconstruction following mastectomy. • Treatment of underdeveloped breasts. • Treatment of soft tissue deformities. IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS Natrelle ® 133S Smooth Tissue Expanders SHOULD NOT be used in patients: • Who already have implanted devices that would be affected by a magnetic field (eg, pacemakers, drug infusion devices, artificial sensing devices). • Whose tissue at the expansion site is determined to be unsuitable. • Who have an active infection or a residual gross tumor at the expansion site. • Undergoing adjuvant radiation therapy. • Whose physiological condition (eg, sensitive over- or underlying anatomy, obesity, smoking, diabetes, autoimmune disease, hypertension, chronic lung or severe cardiovascular disease, or osteogenesis imperfecta) or use of certain drugs (including those that interfere with blood clotting or affect tissue viability) poses an unduly high risk of surgical and/or postoperative complications. • Who are psychologically unsuitable. WARNINGS • DO NOT use Natrelle ® 133S Smooth Tissue Expanders in patients who already have implanted devices that would be affected by a magnetic field (see Contraindications) because the MAGNA-SITE® integrated injection site contains a strong rare-earth, permanent magnet. Diagnostic testing with Magnetic Resonance Imaging (MRI) is contraindicated in patients with Natrelle ® 133S Smooth Tissue Expanders in place. • DO NOT alter the tissue expander or use adulterated fill. Fill only with sterile saline for injection as described in INSTRUCTIONS FOR USE. DO NOT expose to contaminants.

Natrelle ® 133S Smooth Tissue Expanders IMPORTANT SAFETY INFORMATION (continued) WARNINGS (continued) • DO NOT expand if the pressure will compromise wound healing or vasculature of overlying tissue, or beyond patient or tissue tolerance. Stop filling immediately if tissue damage, wound dehiscence, abnormal skin pallor, erythema, edema, pain, or tenderness are observed. • DO NOT reuse explanted products. • Active infection anywhere may increase risk of periprosthetic infection. DO NOT expose the tissue expander or injection needles to contaminants. Postoperative infections should be treated aggressively. • Adverse reactions may require premature explantation. • When using suturing tabs be careful to avoid piercing the shell. Use a new one if damage occurs. • Natrelle ®_133S Smooth Tissue Expanders are temporary devices and are not to be used for permanent implantation or beyond 6 months. Tissue expansion in breast reconstruction typically requires 4 months to 6 months. PRECAUTIONS Active infections may need to be treated and resolved before surgery. Allergan relies on the surgeon to know and follow proper surgical procedures and carefully evaluate patient suitability using standard practice and individual experience. Avoid damage to the tissue expander and use a sterile backup in case of damage. Pay careful attention to tissue tolerance and hemostasis during surgery. Expansion should proceed moderately and never beyond patient or tissue tolerance. Avoid contamination in any postoperative procedure. ADVERSE REACTIONS Deflation, tissue damage, infection, extrusion, hematoma/seroma, capsular contracture, premature explantation, displacement, effects on bone, pain, sensation, distortion, inadequate tissue flap, and inflammatory reaction. For more information, please visit www.allergan.com/labeling /usa.htm. To report a problem with Natrelle ®, please call Allergan at 1-800-433-8871. Natrelle ® 133S Smooth Tissue Expanders are available by prescription only.

Natrelle ® Breast Implants Important Information INDICATIONS Natrelle ® Breast Implants are indicated for women for the following: Breast reconstruction. Breast reconstruction includes primary reconstruction to replace breast tissue that has been removed due to cancer or trauma or that has failed to develop properly due to a severe breast abnormality. It also includes revision surgery to correct or improve the result of primary breast reconstruction. IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS Not for women with active infection anywhere in their body, with existing cancer or precancer of their breast who have not received adequate treatment for those conditions, and women who are currently pregnant or nursing. WARNINGS Breast implants are not lifetime devices and breast implantation may not be a one-time surgery. Avoid damage during surgery: Avoid excessive force, minimize handling of the implant, and use care when using surgical instruments near the breast implant. For more information, please see the full Directions for Use. PRECAUTIONS Safety and effectiveness have not been established in patients with the following: autoimmune diseases, a compromised immune system, planned radiation therapy to the breast or planned chemotherapy following breast implant placement, conditions/medications that interfere with wound healing and blood clotting, reduced blood supply to breast tissue, or a clinical diagnosis of depression, other mental health disorders, body dysmorphic disorder, or eating disorders. ADVERSE EVENTS Key adverse events are reoperation, implant removal with or without replacement, implant rupture with silicone-filled implants, implant deflation with saline-filled implants, and capsular contracture Baker Grade III/IV. For more information see the full Directions for Use at www.allergan.com/labeling/usa.htm. To report a problem with Natrelle ® Breast Implants, please call Allergan at 1-800-433-8871. Natrelle ® Breast Implants are available by prescription only.

References: 1. Data on file, Allergan, July 14, 1986; FDA Section 510(k) marketing approval letter. 2. Data on file, Allergan, January 6, 2017; Study Report MD16076-DV. 3. O’Shaughnessy K. Evolution and update on current devices for prosthetic breast reconstruction. Gland Surgery. 2015;4(2):97-110. 4. Data on file, Allergan, January 4, 2016; Protocol MM-1225-FR.

Inspired and deeply moved by their stories, we honor the fearlessness of women and proudly stand alongside you and the millions of women who choose Mentor.

Mentor Worldwide LLC 33 Technology Drive Irvine, CA 92618 www.mentorwwllc.com Intended for use by or under the direction of a physician, it is important to read the Instructions for Use and to understand the contraindications, warnings and precautions. All rights reserved. © Mentor Worldwide LLC 2018 097018-180815

TABLE OF CONTENTS Cover Photo Credit: Rick Egan Graphic Designer: Elena Bragg

Get involved: Breast Reconstruction Awareness Day By Kim Kubiak

The Breast Goddesses: Survivors help cancer warriors cross the finish line By Kendra Y. Mims

11 Working toward global education for a universal theme By Andrea Pusic, MD, MHS

12 National Breast Implant Registry to improve patient safety By Paul Snyder 13 Reducing racial disparities in breast cancer care By Olatomide Familusi, MD, MS, and Paris Butler, MD, MPH

15 Community breast care advocates awarded for raising awareness By Kendra Y. Mims

17 Dual perspective: Plastic surgeon shares lessons learned after her diagnosis By Kendra Y. Mims 20 Actress channels her breast cancer journey through storytelling By Adam Kivel

24 Helping women rebuild their lives and breasts after breast cancer By Karen M. Horton, MD, MSc

25 Life after reconstruction: Tips for a healthy recovery By Karen M. Horton, MD, MSc

27 Implementing a patient-centered approach to breast cancer care By Daniel Z. Liu, MD

28 Beauty For Good gala’s growing success helps medically based charities By Paul Snyder 29 5 questions to consider before undergoing breast reconstruction By Cristiane Ueno, MD

30 Industry support vital for Breast Reconstruction Awareness efforts 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

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FALL 2019

Breast reconstruction rebuilds more than the breast…

hether to undergo breast reconstruction and which method of reconstruction to choose are uniquely personal decisions. Each year, more than 260,000 women will be diagnosed with breast cancer – the majority of whom will not be aware that breast reconstruction is an option. Since 2012, The Plastic Surgery Foundation (PSF) and American Society of Plastic Surgeons (ASPS) have supported the Breast Reconstruction Awareness USA campaign to promote education and awareness of options for breast reconstruction. This is the only public campaign that I am aware of that focuses the breast cancer discussion on reconstruction. Rates of mastectomy continue to rise; however, the rate of breast reconstruction continues to be less than half of those diagnosed. On top of that, less than a quarter of women who are diagnosed even know of the options that are available for reconstruction. Every woman is entitled to a conversation about breast reconstruction, to have the opportunity to restore what cancer has taken away. I care for patients at a very vulnerable time in their breast cancer treatment and my surgical skills allow me the opportunity to help rebuild more than just the breast. As a reconstructive microsurgeon, I love what I do. I see firsthand the effect that cancer treatment, with or without reconstruction, can have on one’s quality of life and survivorship. I am excited about the innovations in reconstruction that have had a significant impact on my practice and patients. For example, building on our understanding of anatomy and nerve repair, plastic surgeons are able to aid the body in nerve regeneration with a goal of restoring sensation. Treatment of post-mastectomy lymphedema syndrome continues to expand with physiologic surgeries such as lymph-node transfers and lymphovenous bypass to reduce congestion and improve volume overload in the affected extremity. As always, patient safety is paramount in any reconstruction, and The PSF has two major initiatives tracking outcomes of reconstruction by our board-certified plastic surgeons – the National Breast Implant Registry (NBIR) and the General Reconstruction Autologous Fat Transfer (GRAFT) registry. In celebration of Breast Reconstruction Awareness Day USA – slated for Oct. 16, 2019 – Plastic Surgery News releases another special edition dedicated to breast reconstruction education and advocacy. Within these pages are stories to promote patient care, education, advocacy and research. You will read personal narratives from breast cancer survivors. We’ll tell the story of a survivor’s group on a mission to help women regain their strength and cross the finish line after a breast cancer diagnosis. We feature key things to know when considering breast reconstruction. We share stories from the plastic surgeon’s perspective, from raising awareness in medically underserved communities to helping women rebuild their lives and navigating through breast cancer on the other side of the table as a patient. We hope you enjoy this fourth edition of PSN: Breast Reconstruction and join our efforts in closing the loop on breast cancer. Summer E. Hanson, MD, PhD PSN Associate Editor

GET INVOLVED:

Breast Reconstruction Awareness Day By Kim Kubiak The American Society of Plastic Surgeons (ASPS) and The Plastic Surgery Foundation (PSF) 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. 16 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 beast reconstruction options and legal right to healthcare 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 with plastic surgeons, breast cancer survivors and patients who have undergone mastectomy and breast reconstruction. • 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. • Help raise awareness about breast reconstruction options. No gift is too small. Your donation will help us close the loop on breast cancer. To donate, please contact Rochelle Jerry at (847) 228-7597 or visit thepsf.org.

• 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. 16 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.

Run or Walk the Close the Loop 5K in San Diego

The Close the Loop 5K race will take place from 7:30–9:30 a.m., Sunday, Sept. 22, 2019, where runners/walkers can enjoy a great view of San Diego Bay.

Packets will be available for pick-up before the race start time. The course starts and ends at the Hilton Bayfront Hotel. Participants will be able to enjoy the panoramic view of San Diego's vibrant waterfront in Embarcadero, where there is something for everyone. You can register for the Close the Loop 5K or gift someone else’s registration. If you can’t join us in person, create a virtual fundraising team and raise money for the Breast Reconstruction Awareness Campaign. You can also register as a member of a team (no limit on team size), team captain or create a new team. Teams can be runners or walkers. Join our Facebook community for Breast Reconstruction Awareness to post times, photos and more. It's a great place to connect with fellow participants if you are participating virtually or raising money for your team. Help us bring awareness to the Close the Loop Breast Reconstruction Awareness 5K. Share and encourage your family and friends to join you in this fundraising effort. Funds generated from the Close the Loop 5K will benefit the Breast Reconstruction Awareness Campaign of The PSF. Register and start your team today! https://www.athlinks.com/event/305595 PSN: BREAST RECONSTRUCTION 2019 l

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Goddesses: Finding new strength after surviving breast cancer By Kendra Y. Mims

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group of breast cancer survivors and their supporters will gather at Zuma Beach in California on Sept. 14 to participate in the Nautica Malibu Triathlon Relay and pay tribute to women pushing through chemotherapy, surgery and radiation. Team TBG, which is short for “The Breast Goddesses,” is composed of breast cancer patients, survivors and previvors who aspire to rebuild and embrace their new bodies. They also want to prove how strong they are after undergoing cancer treatment. As the founder and chair of Team TBG, Tiffany Grunwald, MD, is committed to helping women discover both their beauty and warrior spirit during their cancer journey. The plastic and reconstructive surgeon from Santa Monica, Tiffany Grunwald, MD Calif., formed the survivor’s group in 2011 with a mission to restore women to wellness after reconstruction and make a difference in the fight against breast cancer. Team TBG empowers and instills self-confidence in women who want to overcome their physical and emotional challenges through a supportive community and physical activities, including triathlons, paddling events, charity walks and fun runs. Dr. Grunwald credits her patientcare coordinator Sheila Young, a triathlete and co-chair of Team TBG, for encouraging her to run their team’s first relay eight years ago to honor their patients. Sheila also suggested they invite breast cancer patients to join them the following year. That marked the start of Team TBG, Dr. Grunwald recalls. “We started talking about the 8

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triathlon event with patients, and they would be in awe of the training,” she says. “Still, you look at them and realize they’ve already done their own triathlon with chemotherapy, surgery and radiation, so you know they can do this. Some of my patients have been with us for six years now.” Since its formation, Team TBG and its supporters have participated in the Nautica Malibu Triathlon Relay event to swim, bike and run. The first relay team consisted of Dr. Grunwald and two staff members, but the group has organically grown to 30 teams with 90 athletes, including cancer patients, family members and medical professionals. “Unfortunately, I see many new breast cancer patients every year,” Dr. Grunwald says, adding her breast cancer patients account for nearly half of Team TBG. “I hope to keep adding people, so we can continue to raise awareness. My goal is to turn this into a group that not only includes my patients, but other breast cancer survivors as well. I love when people from other states reach out and compete with us. It’s an incredible credit to all the patients who participate and share their story.”

Embracing the new normal

Dr. Grunwald says she introduces patients to Team TBG’s mission early on in their cancer treatment, often starting with their consultation. “When a breast cancer patient comes into my office, she feels vulnerable and knows her life is going to change,” she says. “There is so much fear about how her body will feel or what she will be capable of doing after surgery and radiation. We have picture books of what Team TBG does. We tell them they can regain

health and wellness regardless of their reconstruction decision. We show them how women who have gone through exactly what they are about to go through are training with us and competing in the Malibu triathlon. We work with their physical therapist and set goals for them from the beginning.” Dr. Grunwald says her goal as a reconstructive surgeon is not only about building breasts, but also rebuilding strength and confidence through exercise and a community that makes these women feel like they belong. “Their bodies no longer feel the same,” she says. “I’ve altered their anatomy. For me, it’s about getting them back out there and helping them feel healthy, strong and beautiful. It’s an important part of my whole process. The biggest thing I hope to accomplish through Team TBG is to give my patients a place where they can learn to love their new normal and their bodies again. That’s the core of what drives me.”

Training for champions

When Lauren Raissen discovered her lobular carcinoma in situ diagnosis increased her risk of developing invasive breast cancer, she underwent a double mastectomy and breast reconstruction. After performing her reconstruction, Dr. Grunwald encouraged Lauren to join Team TBG, and she started paddle boarding with the group in 2013. “I was in the hospital for a few days, so she caught me at a vulnerable moment,” Lauren jokes, adding she ran her first triathlon with Team TBG one year after her surgery. “I supported them from the sidelines the first time, but I’ve done the run portion of the triathlon every year since then.” Lauren credits Dr. Grunwald and the group for helping her to rebuild her strength. “I had several surgeries, and they were really extensive,” she says. “Team TBG got me back on my feet. The more I trained, the stronger I became.

Getting involved with Dr. Grunwald’s training program with fellow survivors was totally motivating. “There’s something to be said about training and participating with women who are going through the same thing as you,” she adds. “You can identify and feel each other’s pain and help each other move through it. I’m in better shape now than before I had my surgery.” Team TBG’s training program for the annual triathlon event begins every March. Team members meet at Venice Pier every Saturday and split into groups to walk, swim, run or bike. Dr. Grunwald says the training program is suitable for any fitness level and notes many participants never trained for a marathon or competed prior to their diagnosis. Team TBG also hosts a monthly Champion Paddle event, where women participate in stand-up paddle boarding to recognize their own strength and honor other champions battling the disease. Dr. Grunwald says watching the women transform mentally and physically during the triathlon training and Champion Paddle reminds her of why she started Team TBG, adding she experienced her own evolution as an athlete in the process. “Their transformation is the motivation to keep it going,” she says. “A lot of people are at that stage in their life where they’ve let things go, and breast cancer can certainly be a wakeup call. My patients want to make positive changes in their lives, and this is a great opportunity for them to become healthy, strong and better for their second chapter. Many women take that opportunity and really embrace it. They train with us and go on to do other things, even beyond what our group PSN: BREAST RECONSTRUCTION 2019 l

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does. That makes me so happy.” Their two-hour training sessions often end with coffee and conversation on the beach. The weekly meetups provide women with an outlet and a safe haven to discuss their cancer experience, and she notes that many look forward to the camaraderie and sisterhood. “There are always new women to the group who are in the middle of treatment and radiation, and other women will share their tips and challenges,” Dr. Grunwald says. “It’s a beautiful and different aspect for a support group in a survivor community. It’s incredible to listen to them talk to each other about the sequelae they have from chemotherapy or how their implants look in their sports bra.” Although Dr. Grunwald concedes she is nervous about competing in the swim portion for the first time, she says watching her patients train for the event pushed her to step out of her comfort zone this year. “Sheila once told me she gets through the triathlon by thinking about our patients and what they go through during treatment, and that pushes her to keep going whenever she struggles with a run or swim,” Dr. Grunwald recalls. “It’s a little nervewracking for me, but I’m excited. I just look at my patients during the triathlon, and I’m so inspired. It gives me empathy for patients who have to do things they don’t want to do, like surgery. Yet they show up anyway with a smile on their face and they get through it.”

Finishing strong

After being diagnosed with stagetwo breast cancer six months after giving birth, Candice Witek opted for a bilateral mastectomy and underwent breast reconstruction with Dr. Grunwald. She found out about 10

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Team TBG during an office visit. In 2013, Candice joined at the end of her seven-month chemotherapy treatment and completed the triathlon’s 10K in 55 minutes. “I cried so hard when I crossed the finish line because it meant a lot more to me than just running,” says Candice, who has competed with Team TBG nearly every year. “I was athletic before my diagnosis, and it was a powerful feeling to know that I could get my body to do that after cancer. When you run across the finish line, it’s telling cancer you haven’t stopped me. You haven’t changed who I want to be. You’ve haven’t ruined me. It’s a mutual feeling we all share.” The mother of three says Dr. Grunwald and Team TBG members provided her with the support and positivity she needed to get through her recurrence four years ago and adds she looks forward to joining them at this year’s triathlon event along with her husband. “It’s a club you never want to

be in, but it’s also a really beautiful, supportive group of women,” she says. “Crossing the finish line marks an anniversary and another year of us making it. You get really beaten down by the surgeries and chemo, and you’re trapped in your bed for months on end. To get out there and push yourself just makes you feel alive and healthy. I cry every time.” Dr. Grunwald anticipates the moment she will see all 90 Team TBG athletes on the beach dressed in their fluorescent pink shirts. The Breast Goddesses will put their six-month training to use as they transition from swimming to cycling to running, passing their timing chip to other teammates after completing their race portion. Dr. Grunwald describes the event as a celebration and says they are unapologetically loud in their cheering. “These women are out there rocking their scars and showing newly diagnosed women and everyone else that cancer is not the end of their health and wellness,” she says. “I love seeing patients who never thought their body could do this come into the transition area, where everyone’s hugging and high fiving them. For me, that is the last step of breast reconstruction – to see them feel so proud of their body and what it’s done.” Dr. Grunwald says the joy she experiences watching patients cross the finish line is one of her favorite moments. She says she is grateful to be a part of their journey. “I get to see their grit and determination up close,” she says. “They come in scared and vulnerable. Yet, you see the warrior spirit rise as they go from vulnerability to a sense of pride and appreciation for a body that not only survived cancer treatment but can also perform as a strong athlete. It grounds me every day.”

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WORKING TOWARD

GLOBAL EDUCATION FOR A UNIVERSAL THEME By Andrea Pusic, MD, MHS The PSF President

Having traveled around the world and performed breast reconstruction in several countries, I know there’s a

universal theme for women at the time of a breast-cancer diagnosis. No matter where she might live, a woman who receives the diagnosis typically has this initial thought: “I don’t want to die of this.” The second thought is: “I don’t want to lose my breast.” Survival is paramount, but there are benefits to being able to offer options that make a breast-cancer diagnosis a little less frightening. Through various organizations, I’ve traveled to help teach breast reconstruction and other reconstructive procedures in India and Bangladesh for more than 10 years, and in East Africa for about five years now. In fact, as I write this piece, I’m preparing to board a flight for a surgical effort in Dar es Salaam in Tanzania. Although these trips reinforce the fact that there are many areas throughout the world where women struggle to get basic healthcare, there is a global desire for more advanced reconstructive surgery techniques, such as breast reconstruction. Offering breast reconstruction in low- and middleincome countries has some important benefits that may not be immediately obvious. We know, for instance, that women in Africa typically present with breast cancer at a later, more advanced stage. That can be for a variety of factors: It could be related to financial means, poor physician access or, in many cases, fear. They know that if they go to the doctor and it’s cancer, the breast will be amputated and there’s no recourse beyond that. It’s the end of the story from a body-image perspective. Additionally, there’s the social factor in terms of women feeling that their role in their marriage, family or society is a little less secure as a result of mastectomy. It could mean the loss of a husband or other concerns about abandonment. We did a study recently and interviewed women in Tanzania and there was a strong sense that fear of mastectomy was an important factor behind delaying treatment – these women knew that mastectomy would be recommended and sought to delay as long as possible. Offering breast reconstruction in East Africa or India isn’t about being able to offer it to every single woman. It probably isn’t the right choice for everyone, and from a

Dr. Pusic (right) operating in Tanzania. Photo courtesy of Aga Khan Development Network

resource perspective, it’s probably impossible. Nevertheless, we can raise awareness that breast reconstruction is a possibility. Yes, a breast cancer diagnosis may mean mastectomy initially, but it could also lead to reconstruction. Our efforts center on educating the local community with the hope that those who might not otherwise seek treatment might feel more comfortable coming forward. Beyond helping an individual woman, these efforts all help skill-building efforts in East Africa and India so that plastic surgery capacity grows locally. As an example, for a woman in Dar es Salaam who had a mastectomy five years ago, I performed a reduction of the breast. In her situation, she was literally listing to one side because the remaining breast was so heavy. She’d developed neck and back pain from being so off-kilter. That simple breast reduction is the kind of short-case procedure that can be easily taught to a local general surgeon and it has a very significant quality-oflife benefit. While I wouldn’t say the change over the years has been sweeping, you can see our efforts taking root. Year after year, we’ve held press conferences and you can see the level of discussion is growing. Nevertheless, there’s a long way to go. Keep in mind that a woman who has early-stage breast cancer in the United States would likely be a candidate for keeping her breasts, followed by lumpectomy and radiation. Many of these other countries don’t have access to radiation, so breast cancer automatically equals mastectomy. Nevertheless, these trips keep me conscious of the solidarity among women globally. We have common emotions and common concerns. Personally, it’s incredibly PSN: BREAST RECONSTRUCTION 2019 l

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affirming to me when I see the women in my practice in Boston, who have similarities in what they think about, worry about and the things that make them happy. It’s with this in mind that the plastic surgery community needs to continue to be there for women who are going through their own breastcancer journeys. We can continue global education when it comes to capacity building, techniques and know-how – how to do procedures safely in their own environment. How we measure that is difficult, but there are things we can look out for from community and patient perspectives. Although I made a recent trip to Dar es Salaam, there’s a special reason I’m returning right now. While the Aga Khan hospital our program works with typically helps to finance these trips, the local community recently established its own fundraiser and donated money so that our surgeons could return and provide procedures for more patients this summer. The community sees the value of reconstructive surgery capacity-building and the education we can provide. We think about metrics differently in the United States in terms of measurements and figures that we can count, but to me, this local effort is just as significant. A community in Tanzania is saying, “Come back and expand this program.” As an example of this, I’ve been working for several years with a young surgeon at the public hospital there. Although he hasn’t had plastic surgery training, he is skilled in plastic surgery and he and I have worked together multiple times, building his skill set in reconstructive breast surgery. On this trip, I’ll be assisting him. As I said earlier, the little things are adding up. We need to continue building upon that so that we can be there for as many women as we can. 12

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Registry is a vital step toward patient safety By Paul Snyder

In collaboration with the FDA and breast implant manufacturers, The PSF developed the National Breast Implant Registry (NBIR) to strengthen national surveillance for these devices in the United States. The NBIR, more than six years in the making, debuted in 2018 and is available to any site performing breast implant procedures. The registry is a prospective, non-interventional, populationbased, outcomes- and safety-surveillance registry and quality-improvement initiative. The NBIR collects clinical, procedural and outcomes data at the time of operation and any subsequent reoperations. Data collection is anticipated to continue as long as breast implants are being manufactured. “This is an important mechanism by which we can continue to ensure the safety of breast implant surgery,” says The PSF President Andrea Pusic, MD, MHS, who is also the NBIR Subcommittee cochair and helped steer the registry’s creation. The registry enables both plastic surgeons and breast implant manufacturers to identify trends and other information that can be used to improve the safety of implants for both current and future patients. Patient demographic, risk/co-morbidity, procedural, adverse and complication/adverse event data related to breast implants are all types of information that can be collected through the registry. The FDA has been pushing the development of registries for several specialties based on the quality of information they can get on medical devices. Although there have been several papers and journal articles written about breast implants and various issues surrounding them – Charles Verheyden, MD, PhD, past president of The PSF and co-chair of the registry, notes a literary review on the devices that Tufts University did for Annals of Internal Medicine that included nearly 6,000 published works – the data has not produced hard numbers for plastic surgeons or their patients. The NBIR looks to change that. “I’m excited about having good data,” he says. “Even though we’ve been using breast implants for more than half a century, we still don’t have the hard numbers on capsule contracture rate, rupture rate, how many reoperations these patients have or how long an implant lasts. It will be good to have numbers you can hang your hat on.” The registry is supported by Allergan, Mentor, Sientra and Ideal Implant.

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Reducing racial disparities in breast cancer care Plastic surgeons’ efforts empower medically underserved areas By Olatomide Familusi, MD, MS, and Paris Butler, MD, MPH

Shortly after the introduction of the Women’s Health and Cancer Rights Act (WHCRA) in 1998,

several studies brought to light the glaring disparity in the rates of breast reconstruction between Caucasian women and women of color. These differences remained regardless of a woman’s insurance status, socioeconomic status or geographic access to a plastic surgeon. One study from MD Anderson Cancer Center found that African-American women received breast reconstruction at half the rate of their Caucasian counterparts. Another study revealed that African-American women were less likely to be offered referrals for breast reconstruction, less likely to accept referrals if offered, less likely to be offered reconstruction and less likely to choose reconstruction if offered. We now understand that the cause of the observed disparity is multifactorial, but awareness and health literacy appear to play a significant role. In the wake of the 21st anniversary of the WHCRA, we would like to reflect on some of the strides taken at the University of Pennsylvania Health System (UPHS) to improve breast reconstruction awareness among women of color, what we have learned in doing so and how we plan to continue this work. PSN: BREAST RECONSTRUCTION 2019 l

Dr. Butler's awareness event.

Community empowerment

In collaboration with The PSF, the Abramson Cancer Center at the University of Pennsylvania, breast surgeons within the UPHS Department of Surgery and a dedicated group of residents, medical students and research fellows, our plastic and reconstructive surgery division organizes an annual symposium focused on educating local, underserved communities about breast reconstruction. To build stronger community ties and reach as many Philadelphians as possible, the symposium is held at a church in a different section of the city each year. Participants spend an afternoon learning about breast health, breast cancer screening, treatment modalities and breast reconstruction options. Attendees have the opportunity to listen to patient testimonials and participate in a panel-based Q&A session. One of the many highlights of the day is the exhibitor fair, during which samples of implant devices, wigs, bras and prostheses are available for patients to experience. To date, more than 200 community members have participated, with many returning each year, bringing friends and family members with them. The pre- and post-symposium surveys administered in the past three years brought to light some of the knowledge gaps and misconceptions about breast reconstruction among our participants, which we focus on in subsequent symposia. Less than half of the attendees at our second annual symposium were aware that breast reconstruction was covered by insurance, and even fewer knew that contralateral balancing procedures – performed to create symmetry with the opposite breast – were similarly covered. We also noted that although half of our program participants were college educated, many demonstrated poor baseline knowledge about breast health, breast cancer and breast reconstruction. This emphasizes the fact that higher education does not necessarily translate directly to health literacy. Most importantly, we witnessed the Philadelphia community demonstrate a remarkable desire to be engaged and empowered. Year after year, we receive positive feedback and encouragement to repeat the symposium, and we 14

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truly believe that the key to raising awareness about breast reconstruction among women of color in a sustainable way is to focus on community engagement and empowerment. Naturally, not all women who undergo a mastectomy for breast cancer will go on to have breast reconstruction. It remains a very personal choice. One attendee told us she frequently wondered what a reconstructed breast looked like and never seriously considered reconstruction for herself. Nevertheless, with the information she received at our symposium, she scheduled an appointment to learn more. Plastic surgeons must exercise our due diligence in raising awareness about breast reconstruction. It is incumbent on us to help ensure that every woman – regardless of her age or race/ethnicity – has the opportunity to make an educated decision about what is best for them. We plan to continue these symposiums annually at new locations across Philadelphia with the hope that our success can serve as a template for other institutions and practices across the country. ASPS member Paris D. Butler, MD, MPH is an assistant professor in the Division of Plastic Surgery at the University of Pennsylvania. His clinical interests reside in both reconstructive and cosmetic plastic surgery. He is board-certified by both the American Board of Surgery and the American Board of Plastic Surgery. Additionally, Dr. Butler has a MPH in health policy and management with a special certificate in minority health. He currently serves on the American College of Surgeons’ (ACS) Committee on Surgical Health Care Disparities as well as the ASPS Diversity Task Force. Olatomide (Tomi) Familusi, MD, MS, is a fourth-year plastic surgery integrated resident at the University of Pennsylvania. She completed her medical training at Albert Einstein College of Medicine in New York, where she also attained a master’s degree in Clinical Research Methods. Her clinical interests thus far include body contouring, microsurgical reconstruction and aesthetic plastic surgery. Her research interests focus on patient education and health care disparities.

{ COMMUNITY AWARENESS }

And the grant award goes to… Two breast cancer advocates empower women in their communities

By Kendra Y. Mims

The Plastic Surgery Foundation (The PSF), the philanthropic arm of ASPS, is committed to supporting organizations that focus on increasing breast reconstruction surgery awareness and education to women and their families. Through The PSF's Breast Reconstruction Awareness Fund, the Charitable Care Grant and the Public Awareness Grant provide financial assistance to organizations supporting uninsured or underinsured women who choose to have their breast(s) reconstructed following a lumpectomy or mastectomy (as a result of a breast cancer diagnosis). This issue highlights 2019 grant recipients Salem Baptist Church Ministries of Chicago, which provides educational and financial support to women of color who undergo mastectomies, and ALAS-Wings, a Latina association dedicated to empowering Hispanic women about breast reconstruction awareness. The PSF honored these organizations during the 2019 Chicago Breast Reconstruction Awareness Dinner, the second annual fundraising event of its kind. The program will expand to the Bay Area next year. Show your support and help raise awareness about breast reconstruction options. Donations are applied directly to qualified programs that support breast reconstruction-related research and awareness, and to help non-profit medical organizations providing charitable care to breast reconstruction patients. To donate, please contact Rochelle Jerry at (847) 228-7597 or visit thepsf.org.

WOMEN’S MINISTRY WALKS ALONGSIDE PATIENTS TO RAISE COMMUNITY AWARENESS In 2006, Salem Baptist Church launched its first walkathon to raise funds for breast cancer, HIV/ AIDS and domestic violence under the leadership of First Lady Jamell Meeks, director of the church's women’s ministries. In subsequent years, Meeks noticed an increase in phone calls and requests for assistance from women newly diagnosed with breast cancer in the community. “After the third year, we realized we needed something ongoing for these women, and it wasn’t enough to do something once a year,” she says. “We started our Heart 2 Heart meetings where we come together quarterly to offer seminars and educational events to help women facing breast cancer. We also bring in professionals to talk to them.” Meeks discovered most of the women who attended Heart 2 Heart were not undergoing breast reconstruction at the time of their mastectomy. Some felt it was too vain to consider reconstruction after breast cancer, while others declined

First Lady Jamell Meeks accepts the Public Awareness grant from The PSF immediatepast President Arun Gosain, MD.

the option due to their religious beliefs – not an uncommon decision for African-American women in the church, she notes. “We had to talk them through it to help them understand it’s not vanity; it’s part of their healing,” Meeks says. “So, part of our mission is to help women – especially women in church – understand it’s OK to have breast reconstruction.” Beyond simply raising awareness about breast reconstruction, Meeks saw a need to inform women of their options. “Sometimes they are shocked and just want the process over

without considering the latter,” she says. “They may wonder why no one told them about reconstruction or helped them understand the process or benefits. “This is why everyone needs an advocate,” she continues. “You can’t see the full picture if you’re in the frame. While you’re going through it, you need someone on the outside to tell you it’s going to be OK and this is something you’ll want later on. These women need to know all of the information upfront and understand all the details.” To date, the women’s ministry of Salem Baptist Church has raised more than $150,000 through fundraising efforts to help women of color diagnosed with breast cancer in underserved communities receive treatment. Women are not required to join the church to receive financial support or participate in Heart 2 Heart events. Meeks notes some women in their meetings concede they often have to choose between paying for their medication or rent. The ministry walks alongside PSN: BREAST RECONSTRUCTION 2019 l

them to provide them the help they need, she adds. “With the funds we raise during the walk, we buy medication,” she says. “We provide at least 10 free mammograms every year at local hospitals within our community. We rent a bus and take them on Gilda’s Club trips, so they can get out instead of sitting at home. We

offer free Zumba classes. We try to target every area of their life to make it better for them.” Meeks says The PSF public awareness grant of $9,000 will help their ministry empower and educate women on a bigger scale and further their outreach in the community. As a breast cancer advocate, she says she feels honored

and grateful to receive the grant. “It gives you a boost when you realize people you don’t know are supporting you and believe in what you’re doing,” she says. “It’s definitely an emotional and spiritual lift to the group.” For more information about Salem Baptist Church’s Heart 2 Heart Ministry, visit salemchicago.org.

ALAS-WINGS HELPING LATINA WOMEN SOAR ABOVE BREAST CANCER Two-time breast cancer survivor Judith Guitelman founded ALASWings in 2011 with a mission to provide breast health awareness, education and emotional-support programs for underserved and uninsured Latinas diagnosed with breast cancer. Guitelman noticed a shortage of educational and financial resources for the Latino community while volunteering at a breast cancer organization after her first diagnosis in 2005. Her experience engendered a passion to educate and empower Hispanic women facing the same battle. Over the past eight years, ALASWings expanded to offer a variety of free programs to breast cancer patients and their families, including seven support groups (all facilitated in Spanish), educational programs, yoga sessions and the ALAS on Wheels: The Mobile Salon™ program, which provides prosthetic bras, wigs and prostheses at no cost to breast cancer patients who have limited financial resources. The organization sees several hundred women each year and recently launched its first Spanishspeaking support group for younger survivors, ages 30 to 45. When her breast cancer returned 10 years later, Guitelman discovered the Latino community also lacked information about breast reconstruction. Although she chose a lumpectomy without reconstruction 16

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ALAS-Wings Executive Director Judith Guitelman accepts the Charitable Care grant from The PSF immediate-past President Arun Gosain, MD.

after her first diagnosis, she decided to have a double mastectomy and bilateral reconstruction the second time around. She says her experience taught her the importance of breast reconstruction awareness. “We were barely talking about reconstruction with Latina women, and we had no information to offer in our support groups,” she says. “Many of the Latina women we see don’t even realize they can have reconstruction after a partial or double mastectomy – or they’re unclear about the different types. I knew I needed to provide resources about reconstruction that we were not offering at that time. As a survivor, I felt it was important to educate women about reconstruction before going through it.” Guitelman says they’ve witnessed an increase in the number of women undergoing reconstruction since they started raising awareness through their support groups, particularly among their young survivors. Most of the ALAS-Wings survivors are uninsured and ineligible to undergo breast

reconstruction. The PSF Charitable Care Grant of $10,000 will allow the organization to establish a breast reconstruction fund for uninsured Latina breast cancer survivors. The fund will cover medical expenses, including 3-D nipple tattooing, implants, childcare and transportation. “A lot of women who come to us can’t afford to pay someone to watch their children while they go to their procedure, and they don’t have money to see a doctor,” Guitelman explains. “As an organization, we’re grateful to receive the support so that we have the funding to help. Many of our younger survivors are finishing their reconstruction and we can help them complete the process.” Guitelman says most women in African-American and Latino communities typically don’t consider reconstruction after hearing they have breast cancer, but she believes raising awareness will help them understand the benefits, so they can make the right choice for them. “You just want the cancer out of your body,” she says. “I just wanted to be cancer-free. I didn’t think much about reconstruction, but after I had it, my quality of life and selfesteem improved. I started liking my body again, and that’s the feeling I want other women going through this to find.” For more information about ALAS-Wings, visit alas-wings.org.

{ DUAL PERSPECTIVE }

Plastic surgeon shares lessons learned after her cancer diagnosis

By Kendra Y. Mims

When Anne Peled, MD, a San Francisco-based plastic and breast cancer surgeon, discovered a lump in her breast during a routine selfexam at age 37, she never suspected

breast cancer. Dr. Peled had no family history of the disease. She lived a healthy lifestyle and exercised often. She presumed the lump was a cyst until a biopsy revealed stage 1 breast cancer. Although Dr. Peled frequently informed women of their diagnosis and treatment options, she found herself unexpectedly facing breast cancer through the lens of a patient. Dr. Peled weighed her options carefully. The cancer had not spread, and she didn’t need chemotherapy. After receiving negative genetictesting results for breast cancer gene mutations, she reached out to a trusted plastic surgeon and colleague in Vancouver, Wash., to schedule a lumpectomy with oncoplastic reconstruction, a breast-conserving technique that only removes a portion of the breast and reshapes a woman’s breast using her own tissue. Dr. Peled credits her surgical team for her optimal aesthetic outcome by using the hidden-scar approach she performs on her patients. “I felt very strongly about not wanting a visible reminder of cancer every day, so I’m grateful to my surgeon for his surgical scar management,” she says. “As a plastic surgeon, I’m always thinking about what recovery looks like and how we can get people back to their lives quickly and safely –

Left: Anne Peled, MD, before surgery. Above: Dr. Peled and husband Ziv Peled, MD, in the operating room.

whether it’s cosmetic or reconstructive surgery. I thought about that for my own recovery, and I had a team that helped me think through my options and supported my decision. I was comfortable with my treatment plan and felt it would be less invasive and obtrusive to my life.” A year after the initial diagnosis, Dr. Peled says she will need alternating mammograms and MRIs every six months for most of her life. She is also required to take estrogen-blocking medication for five years, but she has no regrets about her decision. As an avid runner and triathlete, Dr. Peled says choosing a procedure that preserved most of the appearance and sensation of her breast weighed heavily in the decision-making process. “Women tend to lose all sensation

in their chest area after a mastectomy, which can really negatively impact their lives,” she says, recalling her friend’s inability to feel anything while trying on bras after a mastectomy. “When weighing my options, I had to consider how each surgery would impact my ability to exercise and get back into my active work and home life,” she says. One of the main benefits of oncoplastic reconstruction done at the time of lumpectomy is using your own tissue to reshape your breast, which maintains sensation and a natural feel to your breast tissue. “We can make some women’s breasts look better than they did before surgery with a breast lift or reduction done in conjunction with lumpectomy,” she adds. “This option PSN: BREAST RECONSTRUCTION 2019 l

{ DUAL PERSPECTIVE }

could be less invasive than a full mastectomy and reconstruction. We have a full spectrum of choices, so women can find what option is best for them. Every woman is different.”

Building deeper connections

Even though I do breast cancer surgery and reconstruction day in and day out, I still had a hard time figuring out the best choice for me in terms of surgical options. I try to help women weigh different options and identify what’s going to be the right choice for them in a much more involved way than I did before.

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Dr. Peled’s practice in the Bay Area specializes in reconstructive and breast cancer surgery. As a dual-trained plastic surgeon and breast cancer surgeon, she is involved in her patients’ breast cancer care from diagnosis to surgical treatment. She says her own diagnosis changed her interaction with patients, allowing her to connect with them on a much deeper level – and she believes she’s a better plastic surgeon for it. “Being able to know what it feels like to hear you have breast cancer firsthand really changes your ability to empathize and help women think through their treatment options,” she says. “Even though I do breast cancer surgery and reconstruction day in and day out, I still had a hard time figuring out the best choice for me in terms of surgical options. I try to help women weigh different options and identify

what’s going to be the right choice for them in a much more involved way than I did before.” After being on the receiving end of waiting for test results, Dr. Peled now prioritizes getting patients their results quickly to avoid the waiting game, even if it means calling after hours or during the weekend. She also notes her new understanding of the family’s vital role throughout treatment. “I didn’t realize the depth of this until I went through it, and now I’m much more attuned to think about how women talk to their significant others and children about their diagnosis and how they can assemble their support system,” Dr. Peled says. “That’s been an extremely valuable part of this, because I feel the relationships with my patients are so much richer and stronger than they were before I was diagnosed myself.”

It takes a village

Dr. Peled attributes her passion for treating breast cancer patients to her family of physicians. Her parents and sister are all oncologists specializing in breast cancer, and they stayed by The Peled Family

her side during treatment. Dr. Peled says her family’s medical expertise and support were instrumental in helping her through recovery. “They were so helpful in getting me different resources,” she says, adding her parents’ work inspired her to become involved in cancer research in high school. “For a long time, I’ve witnessed how rewarding it’s been for my parents to help people navigate through the incredibly disruptive and scary time around a cancer diagnosis and get them to the other side where they can feel back to themselves and return to their lives. I feel so incredibly grateful to be a part of my patients’ lives in the same way.” Although Dr. Peled maintained an open dialogue about her cancer journey with her family, she chose not to discuss her diagnosis with her then 6-year-old son and 3-year-old twin daughters. She maintained her regular routine, so they didn’t suspect anything. “My kids were so little, and I didn’t want to worry them,” she says. “Fortunately, I recovered quickly from my surgery. I worked the entire time, so my kids didn’t know any different. In their eyes, I was just their mom doing all the things I had done before, so their lives weren’t too impacted. I was grateful for that.” Dr. Peled also had a tremendous amount of support from her husband, Ziv Peled, MD, who is also a plastic surgeon. Dr. Peled, who now operates alongside her husband to perform sensation-preserving mastectomies with nerve grafting to improve sensation for women after mastectomy, notes that being married to a plastic surgeon required a balancing act of discussing and involving him in her treatment without being overwhelming. “My husband specializes in migraine headache surgery, but he’s done enough breast reconstruction over the years to

a recurrence, and it’s something I prescribe to my patients as well.”

Words of wisdom

Exercising after radiation treatments kept Dr. Peled feeling mentally strong through her journey.

be understandably concerned,” she says. “Trying to figure out how to share my expertise and knowledge about breast cancer so that he felt involved without worrying him was a real balance we both had to work on.”

Healing benefits of exercise

Dr. Peled wore running clothes to radiation therapy and ran after every treatment. She also ran a 10K several weeks after completing radiation. She credits exercise for keeping her mentally strong, and she strongly advises women to see a physical therapist and begin an exercise program after their breast cancer surgery. “Exercise often gets overlooked for many women as part of their healing, but it plays a huge role in breast cancer treatment, most importantly in decreasing the chance of cancer returning,” Dr. Peled says. “Working out has so many psychological benefits, as well as managing side effects after surgery and other treatments including hormone blocking therapy, chemotherapy and radiation. Running helped me feel more like myself instead of someone going through cancer treatment. Exercise is part of my treatment now to help prevent

Dr. Peled currently travels the country throughout the year to teach surgeons how to perform oncoplastic surgery on their patients. Although this procedure was the best option for her, she urges women to do their homework to find the right procedure and board-certified plastic surgeon for them and to talk to other women about their experience. Dr. Peled implemented a buddy system in her practice that pairs women who have undergone breast cancer surgery with women considering it. She says it helps for them to hear about the procedure’s impact on their job, exercise or family and adds that patients are pleasantly surprised to learn that most breast cancer today is survivable, and the recovery is less extensive than they expected. “Researching your options and talking to others will help you make a much more informed decision,” Dr. Peled says. “Often, women hear they have cancer and just want to get it out without really considering their options, which is understandable. Sometimes I bring up the idea of breast reconstruction or hiding scars and women think of it as cosmetic, but it’s not. It’s really about not thinking of yourself as a cancer patient every day once you’ve gotten through all of your treatment and have settled back into your pre-cancer life. “I tell my patients, ‘My hope is you're going to have these breasts for a very long time, and I want them to be something you are happy with,’ ” she continues. “I don’t want them to have the reminder of cancer. It’s a big deal when a woman can look in the mirror after breast cancer and feel like herself again or even better than when she started her journey.” PSN: BREAST RECONSTRUCTION 2019 l

cancer

A two-time

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{ PATIENT STORY }

journey Actress Aniela McGuinness and breast cancer activist channels her experience through storytelling By Adam Kivel

survivor’s

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{ PATIENT STORY }

acing both cancer and its treatment requires immense strength.

Actor/model/activist Aniela McGuinness, however, took that bold attitude one step further. “Aniela cracked jokes while on the table, and then she went and had glamour shots taken at each stage of her reconstructive surgery process,” recalls ASPS member Shashidhar Kusuma, MD, one of the plastic surgeons on her care team. “Being an actress, she already had a stage presence and an ability to take this experience and share it with others.” That might sound lighthearted, but McGuinness’ says her journey has also been full of pain and difficulty. However, by channeling her experience through the art of storytelling, she has been able to inspire others – and herself. McGuinness’ history with cancer is tragically long and varied. After her mother’s ovarian cancer diagnosis, McGuinness took a large role in her care. It was only a year after her mother’s passing that she would face cancer herself. When she first learned of her mother’s diagnosis, McGuinness initially considered a prophylactic double mastectomy. “I knew that I had the BRCA1 mutation for breast cancer,” she says. “I had found the reconstructive surgeon. I had found the breast surgeon for oncology. Everyone was already on board.” Nevertheless, when she was scheduled for the MRI and ultrasound prior to the mastectomy, she learned that she herself had already developed

breast cancer. Even that early in the process, McGuinness knew she’d want to be able to tell and potentially share the story. “I actually filmed it when I got the phone call, and it’s now on my YouTube channel,” she says. Even though she’d already planned on having a double mastectomy, the reality of the diagnosis hit hard. “I was 31, very healthy, in great shape,” she remembers. “From the outside, it looked like I had all of the statistics proving that I would not get cancer. It was a horrible experience, but it pushed me from 80 percent certainty to 100 percent certainty that the mastectomy had been the right plan to begin with. To electively remove healthy body parts and go through the mental part of having your breasts removed – I would have questioned if I had made the right decision probably for the rest of my life.”

Stories of healing

Having come to the reconstruction process from a semi-proactive angle, McGuinness was able to consider her options and meet with potential doctors, an advantage she knows is rare and for which she is incredibly grateful. Although other women are “shot out of a cannon” at the time of their diagnosis, as she puts it – needing to make decisions immediately to begin treatment – McGuinness had already built a plan by the time of diagnosis. “I had the genetic counseling done, which allowed me access to a lot of these doctors already,” she explains. “I had been able to take that time to figure out who I liked the best, gather

McGuinness worked with Blast ‘Em Photography for her #MyBreastChoice photo series to capture her emotions during each stage of the mastectomy, chemo and reconstruction process and change the images women saw of mastectomies. Photos courtesy of: Blast 'Em Photography

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Rosie the Riveter

Bride of Frankenstein

Mannequin

Cancer-free shot two months after her reconstruction

{ PATIENT STORY }

“I don’t shy away from people looking at my scars, to look and find curiosity and beauty - and with that comes a level of comfort. After a while it becomes normal.” recommendations from women, see whose breast I liked and see what work I liked.” In addition to the benefit of time and that adjusted perspective, McGuinness had a rare opportunity to share her experience with others. Cancer and treatments may have curtailed her ability to book acting gigs, but she channeled her storytelling ability elsewhere. “I ended up doing a one-woman show that I cowrote with a friend - and then performed it while on chemo,” she says. “I was able to play the role of ‘Cancer’ in it. It gave me something to look forward to.” That’s something that McGuinness stresses: People can see the reality of the physical recovery that comes with breast cancer, but they aren’t often privy to the emotional recovery that’s equally important. “The idea of your body betraying you in a way takes time to come to terms with,” she says. Just when things were beginning to look like they were turning around, McGuinness went to see a dermatologist to check on a spot she’d noticed on her forehead. A resident of Florida, McGuinness knew that skin cancer was a risk, but was certain that a quick visit would be the end of the concern. Unfortunately, she was wrong, and a skin cancer diagnosis led to extensive facial reconstruction surgery. Once again, she teamed with a friend who was a fashion photographer to document every stage of the process. Although she shared the photographs of her breast reconstruction, McGuinness has yet to share her facial reconstruction photos.

“They were really beautiful, and yet my face is, in essence, mangled,” she says. “I wanted to use art to help myself through this; it became a private experience. The people I have showed have said it looks like the scarring is photoshopped on because the juxtaposition is so strange. But again, it was my way of looking forward to every step, as I would get to meet up with this friend and we’d get to photograph it.” While going through the facial reconstruction surgery, McGuinness found another way to find light in the midst of the darkness. “I was really depressed but I would joke around, and then the nurses would joke back,” she says. “That helped to lift my spirits back up.” After undergoing multiple sessions, McGuinness came out of the facial reconstruction with a four-inch scar on her forehead - something she hasn’t let stand in her way as an actor and model. She recently booked commercial work, as well as a speaking role on an Emmy-nominated television show. Turning her experience into stories that she could share helped McGuinness heal, and she continues to make a difference for countless women inspired by her journey. “I still get emails from women saying the photo series helped them feel more comfortable with their own scars,” she says. “It gave them an opportunity to share their experience with their family and friends through each step of this process. I don’t shy away from people looking at my scars, to look and find curiosity and beauty and with that comes a level of comfort. After a while it becomes normal.”

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{ PHYSICIAN PERSPECTIVE }

Helping women rebuild their lives ( breasts) after breast cancer By Karen M. Horton, MD, MSc

Breast reconstruction is so incredibly rewarding. Why?

Because we truly are “saving lives, one breast at a time” – albeit figuratively, and not literally! Reconstructing the breast form helps women facing breast cancer feel more whole and regain a sense of normalcy, and it also helps them move forward after a loss of all or part of their breast(s). Breast reconstruction, as a career, is not lucrative for plastic surgeons. Most insurance reimbursements for breast reconstruction are embarrassingly poor and not reflective of the skill and experience needed for a successful and beautiful aesthetic outcome. The plastic surgeons who dedicate their time and expertise to breast reconstruction believe that reconstruction is important, valuable and a rewarding professional challenge. Performing breast reconstruction enables us to help women facing cancer regain their body image, self-esteem, femininity and confidence in moving forward in their fight. The most significant reward is probably hearing my patients say they no longer think about their cancer when they are in the shower, getting dressed or with their partner in an intimate situation. They express that we are the doctor they actually look forward to seeing, and that we 24

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help them to see reconstruction as a positive light in the overwhelming sea of negatives of breast cancer. For many patients, immediate reconstruction can help mitigate their sense of loss by removing the

experience of their mastectomy defect. I encourage women to participate in the planning of their surgical results and to consider their reconstruction as an opportunity to have breasts that are lifted, smaller, fuller or rejuvenated. Preserving chest muscles, saving nipples and holding reconstruction results to the same standard as cosmetic surgery helps facilitate the best aesthetic outcome in breast reconstruction. Delayed reconstruction recreates a female form after a period of complete loss. Whether reconstruction uses implants or the body’s own tissue, patients universally express gratitude when we help them take a step forward in their breast cancer recovery.

Tips for a healthy recovery after breast reconstruction As with planning for any elective plastic surgery procedure, planning for breast reconstruction involves the following principles:

Before and after bilateral delayed DIEP flap breast reconstruction.

PHOTOS COURTESY OF DOCTOR HORTON PLASTIC SURGERY

Before and after bilateral immediate prophylactic nipple sparing mastectomies and implant reconstruction.

Breast reconstruction often requires a future revision, and that surgery is equally gratifying and essential to help women achieve improved symmetry of their breasts, balance with the rest of their body and the very best aesthetics after reconstruction. ASPS member Karen Horton, MD, MSc, is internationally board certified in plastic surgery by both the American Board of Plastic Surgery and the Royal College of Surgeons of Canada, specializing in cosmetic and reconstructive surgery for women. Based in San Francisco, Dr. Horton’s private practice focuses on providing personalized care with meticulous attention to detail in a warm and welcoming environment. Her practice is centered on providing beautiful, natural and long-lasting results for breast cancer survivors using microsurgery or prepectoral implants in a single stage.

Be as healthy as possible – in mind, body and spirit. The best time for breast reconstruction is when you are at your best. There might not be a ton of time to take up an intense fitness program or strict, clean diet prior to surgery, but you should ideally have stable weight, good nutrition and moderate physical fitness going into surgery. Consume whole, fresh food rather than packaged products – you must “feed your wounds” while you heal from surgery. Vegetables, fruit, protein and increased hydration are key before and after reconstruction. A simple way to boost physical fitness is to power walk so you are out of breath. Practice this three times a week and consider it “training for surgery” as you would train for a marathon. Every little bit helps!

Plan to take more time off than you expect after breast reconstruction. Surgery is an injury to the body, and it takes a long time to fully heal. You will feel fatigued, emotional, completely out of your comfort zone and experience “a loss” – even though your breast form has been reconstructed. You are losing part of what makes you a woman, often including the ability to breastfeed and erogenous sensation.

Surround yourself with supporters who give you what you need, unconditionally. Following breast reconstruction, mental and emotional recovery are often greater than the physical recovery. Surround yourself with supportive loved ones and keep individuals or situations that create additional stress or drama far away. Bring those supporters with you to your consultation, preoperative and follow-up visits. Allow them to be an active member of your recovery team and to help advocate for you.

Understand that breast reconstruction is a “journey.” Recovering from breast reconstruction has different phases, including emotional trauma and body image changes, wound healing, nerve recovery, return to normalcy, scar maturation and acceptance of a “new normal.” Having breast cancer and reconstruction changes you. Accept that you will be different, and that time not only heals wounds and encourages scar maturation but allows you to reflect on your journey. In time, hopefully your experience will allow you to pay it forward and help other women who are facing breast cancer. Giving back and sharing your journey with others is a rewarding experience that helps you move forward.

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{ PHYSICIAN PERSPECTIVE }

Implementing a patient-centered approach to your breast cancer care By Daniel Z. Liu, MD

ASPS urges breast cancer patients and their physicians to advocate for inclusion of a board-certified plastic surgeon on their breast cancer treatment team.

The multidisciplinary team approach to breast cancer care brings together a group of key medical professionals who work together at the inception of a patient’s breast cancer diagnosis to develop and implement a tailored treatment plan based on each patient’s unique needs. The conventional medical team may include a medical oncologist, radiologist, pathologist, radiation oncologist, breast oncologic surgeon, genetic counselor, gynecologist and plastic surgeon. Integrative cancer care then plays a simultaneous role to help patients combat treatment-related side effects. Supportive therapies include oncology rehabilitation (physical therapy), nutritional support, pain management, acupuncture, mind-body practices and spiritual support. Each step of the breast cancer care journey requires specific medical expertise. Patient outcomes vastly improve when each member of the multidisciplinary team works together to examine every opportunity to provide a unified treatment approach. Breast cancer patients might miss out on a critical conversation that should take place at the time of diagnosis: options for breast reconstruction following partial or total mastectomy. A board-certified plastic surgeon possesses training and expertise in

breast reconstruction, ranging from cutting-edge implant/regenerative medicine technologies to advanced techniques in reconstructive microsurgery. More importantly, an experienced plastic surgeon within a team setting will respectfully communicate with other medical professionals about how the reconstruction plan may affect overall cancer treatment and vice versa. The multidisciplinary treatment team benefits patients who encounter a complex and serious disease such as breast cancer. When this team includes a variety of specialists – including a board-certified plastic surgeon – it is more likely that these professionals will be knowledgeable on the latest multi-modal treatment options. Patients deserve to be fully informed about their treatment choices including breast reconstruction, and medical professionals should guide patients in a balanced, shared decision-making process. For instance, the three major decisions for women considering a mastectomy with reconstruction involve whether to have reconstruction at all, when to undergo reconstruction and which type of reconstruction to consider.

Shared decision-making

The Institute of Medicine defines patient-centered care as “care that is respectful and responsive to individual patient preferences, needs, and values and [ensures] that patient values guide all clinical decisions.” Shared decisionmaking is a mutual and respectful exchange of information between the physician and patient to reach agreement about a health decision.

There is often no “best” option for a health condition, and the choice depends on a patient’s values and preferences. Although this is important for all aspects of breast cancer care, patient preferences and expectations are especially crucial for informed decisions around breast reconstruction, an area where the patient’s satisfaction is central. In the field of breast reconstruction, the surgeon’s goal is directed toward a restoration or improvement in the appearance and feel of the breasts as perceived by the patient. Beyond a surgeon’s technical proficiency, shared decision-making requires a physician’s commitment to listen to patients and adapt recommendations to medical conditions, personalities, fears, perception of outcomes, family member engagement and cultural differences.

Establishing trust

By understanding patient expectations and assimilating surgical expertise, the physician and patient become equal team players in designing the optimal path for breast reconstruction. The patient learns about the benefits and possible complications of each procedural step, including the expected healing process, and provides input on their personal goals and preferences. The physician is responsible for delivering pertinent technical information to a level of detail that is comfortable for each patient and recommending procedures that minimize morbidity and mortality. The patient is responsible for disclosing all aspects of their medical health including habits (e.g., smoking) and honestly describing their optimal aesthetic outcomes. An experienced plastic surgeon will be able to provide realistic expectations (including photographs representing a range of outcomes) for breast reconstruction based on the patient’s body type and reconstructive modality. Patients might have preexisting notions to expect higher satisfaction with specific types PSN: BREAST RECONSTRUCTION 2019 l

{ PHYSICIAN PERSPECTIVE }

of reconstruction, but it is important for physicians and patients alike to put them in context of the impact of other treatment variables for breast cancer such as adjuvant chemotherapy and radiotherapy. This interactive discussion establishes the trusted relationship between surgeon and patient that may continue for years due to the longitudinal nature of breast reconstruction. Improved patientcentered communication of information promotes a strong patient-surgeon relationship, which has been shown to positively impact satisfaction with breast reconstruction and overall patient outcomes. Patients should feel that their plastic surgeon is competent, reassuring and thorough.

Above all, the physician must nurture an environment where the patient feels comfortable sharing intimate concerns and asking questions to meet her information needs. Disagreements about treatment decisions are inevitable, but physicians engaged in shared decision-making during disagreements often end up with more satisfied patients. Fortunately, the culture of physicians has transformed from their roles characterized by authority to goals of partnership and collaboration. Breast cancer treatment can be quite stressful, but thorough communication and informed involvement from all team members can ease this journey. The patient-surgeon relationship in

breast reconstruction begins with providing information, empathy and comfort to patients; demonstrating competence; and encouraging ample opportunities for patients to ask questions. Supplemental resources outside of the patient-physician conversation can be useful to increase engagement in shared decision-making. Visit plasticsurgery.org or breastreconusa. org for more information. ASPS member Daniel Liu, MD, is a boardcertified plastic and reconstructive surgeon at Cancer Treatment Centers of America® in northern Illinois. Dr. Liu specializes in all forms of breast reconstruction and is passionate about promoting public education on breast reconstruction and plastic surgery.

As gala’s success grows, surgeons eye potential for future By Paul Snyder

osharaffa Plastic Surgery of Phoenix turned back the clock 30 years for a 1980s theme with its third annual Beauty For Good gala earlier this year. Beauty For Good serves as a fundraising foundation for medically based charities and was established by ASPS members Tamir Mosharrafa, MD, and Ali Mosharrafa, MD. The foundation partners with several organizations to raise funds and awareness for various local and national charities, including the Breast Reconstruction Awareness Fund. This year’s gala, which boasted a 1980s theme, raised nearly $50,000 for Beauty For Good’s partners. With fun costumes, dancing and a cover band playing an array of hits from the 1980s, Dr. Tamir Mosharrafa says the night was a tremendous success and is continuing its pace of growth in terms of local awareness and attendance. Nevertheless, he says he’s not yet convinced that the event – or the foundation – has realized its full potential yet. “We’re still not where we really want to be,” Dr. Mosharaffa says. “We’re still dreaming really big for this charity and for this opportunity to serve our charitable partners in the community. We want to continue to write bigger checks to our partners and provide more support.” For each cosmetic procedure that Mosharaffa Plastic Surgery performs, $100 goes to Beauty For Good and the donation is subsequently redistributed to the foundation’s charitable partners. Contributions can also be made through 28

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the practice’s website. Next year, Dr. Mosharaffa says he hopes to increase the corporate contributions to the fund. “I hope there will be different tiers of sponsorship and participation that will not only attract corporate sponsors, but also local businesses,” he says. “I want all of our attendees to be aware of how they participate in the entire process.” The focus on breast reconstruction in particular, Dr. Mosharaffa says, is something that is never far from his or his brother’s mind. The procedure is why the two went into practice in the beginning, and he says caring for women with breast cancer is why they Tamir Mosharrafa, MD, and Ali Mosharrafa, MD, in their 1980s attire. come to work every day. “Breast reconstruction has always been and will always be the core of what we do here,” he says. “Beauty For Good, being an extension of our practice and our outreach to the community is, by nature, focused on breast reconstruction because that’s what we do. Our partners are centered around taking care of women dealing with cancer and how they can help them move to their next phase of life. It’s an important mission to take part in.”

questions to consider before undergoing breast reconstruction

By Cristiane Ueno, MD

What is your primary motivation? I’ve had patients tell me, “Since I have cancer, I should gain something out of it and get bigger breasts after the mastectomy,” or “I am too old, and I should not think about looking pretty.” Other patients just want to feel normal again, and they don’t want to undergo further surgery – they are just happy to be alive. Breast reconstruction can help you feel like you didn’t lose everything and improve your self-esteem, sexuality, quality of life and body image depending on your motivation. If restoring your breast to near normal shape will help you feel like yourself again, find a board-certified plastic surgeon. Our goal is to give you a breast shape that allows you to feel whole again.

Getting a breast cancer diagnosis is scary and overwhelming. There is a

lot to process and you may find yourself wondering the following:

• Should I have a mastectomy or double mastectomy? • Should I have breast-conserving surgery (also known as a partial mastectomy)? • Should I undergo chemotherapy or radiation therapy? • What will happen to me after the diagnosis? Breast reconstruction itself can be an overwhelming prospect to consider in terms of what the procedure entails. Your initial thought might be to get a double mastectomy and remove both breasts to avoid dealing with breast cancer ever again. As board-certified plastic surgeons, our goal is to make you aware of every option, so you feel empowered to make an informed decision. Here are five questions to consider before undergoing the procedure. ASPS member Cristiane Ueno, MD, FACS, practices at Kaiser Permanente Washington. Dr. Ueno came to the United States from Brazil where she had completed her plastic surgery residency. She has specialized in treating breast cancer patients since her early years in Brazil and is board certified in surgery and plastic surgery (both in Brazil and the United States).

Which type of reconstruction is best for you? There are many different types of breast reconstruction. You and your plastic surgeon will discuss all options available for treatment based on your breast cancer, expectations, associated medical conditions, emotional health and the decision that makes you most comfortable. You can use your own tissue, an implant or even a combination of your own tissue and an implant. Talk to your breast surgeon and plastic surgeon, discuss your options and take time to consider the pros and cons of each procedure before deciding which type of reconstruction is best for you. Review expectations, risks and complications carefully with your plastic surgeon to assure you are speaking the same language. Ask questions if you don’t understand certain words or if the information is not clear to you.

How is your health? A medical condition can limit your options and prevent you from undergoing the procedure. Consider your physical health. Will cancer and/or other associated medical conditions affect your ability to heal or withstand further treatment after reconstruction? Be sure to discuss your health concerns and all medical conditions with your plastic surgeon. Ultimately, it is your decision, in conjunction with your physician, to determine if you are a candidate for breast reconstruction.

What is your preferred timing for breast reconstruction? Don’t worry if you had a mastectomy days, weeks, months or even years ago. There is no specific timeline. You can always consult a plastic surgeon and discuss breast reconstruction before or after your mastectomy, and in some cases, before or after breast-conserving surgery. You can undergo immediate reconstruction – which reduces the number of anesthetics required to complete reconstruction – or postpone it to focus on your cancer treatment. You are entitled to choose your priorities and change your mind on when you want to have it done.

What is covered by your insurance plan? The Women’s Health and Cancer Rights Act (WHCRA), signed into law in October 1998, provides protections to women who choose to have breast reconstruction after a mastectomy and includes all stages of breast reconstruction, surgery of the other breast to produce a symmetrical appearance, any external breast prostheses needed before or during reconstruction and treatment of physical complications of all stages of mastectomy – including lymphedema. In most cases, WHCRA will protect you and help you with breast reconstruction coverage. Be sure to ask your team about it. PSN: BREAST RECONSTRUCTION 2019 l

CORPORATE SPONSORS SUPPORT

BRA Day Efforts

esearch shows that far too many women diagnosed with breast cancer still don’t know about their reconstruction options following a mastectomy. Launched by ASPS and The PSF in 2012, the Breast Reconstruction Awareness USA Campaign is instrumental in providing these women with both education and information about their reconstructive options as they undergo breast cancer treatment. Breast reconstruction can help women rebuild their self-esteem and improve their quality of life following breast cancer surgery. Plastic surgeons play an ASPS and The PSF sincerely thank the important role in a breast cancer patient’s recovery process and the annual Breast 2019 Breast Reconstruction Awareness Day movement gives those surgeons an opportunity Reconstruction Awareness Campaign's to empower cancer patients, celebrate survivors and help women make an generous sponsors informed decision at the time of diagnosis. for their dedication to women’s health The eighth annual Breast Reconstruction Awareness Day will take place and patient education. on Oct. 16, 2019. The Breast Reconstruction Awareness Campaign would not DIAMOND SPONSORS be possible without the generous support of our dedicated corporate sponsors. Thanks to their commitment, the campaign continues to provide education and Mentor Allergan resources about reconstructive surgery and raise awareness to close the loop on breast cancer – both on Breast Reconstruction Awareness Day and throughout BRONZE SPONSORS the year. CareCredit

2019 SPONSORS

Beauty for Good GEM

Five companies have generously lent their support to the 2019 Breast Reconstruction Awareness Campaign. This year’s Diamond Sponsors are Mentor and Allergan, two of the country’s leading supplier of medical products for the global aesthetic medicine market. Mentor Worldwide LLC became a Diamond Sponsor of the Breast Reconstruction Awareness Campaign in 2015. Both companies have launched multiple reconstruction solutions and are committed to continued innovation that will provide surgeons with the tools to improve patient outcomes in breast reconstruction. CareCredit, Beauty for Good and GEM each join the Breast Reconstruction Awareness Campaign this year as Bronze sponsors. Every corporate partner contributes to the campaign’s success annually and continues to make a difference in empowering women facing a breast cancer diagnosis and providing them with reconstructive education. Donations from sponsors are applied directly to programs that support related research and awareness efforts, and provide charitable care.

For more information on the Breast Reconstruction Awareness Campaign corporate sponsors, visit breastreconUSA.org.

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Breast Reconstruction 2019

Articles inside

Industry support vital for Breast Reconstruction Awareness efforts

Life after reconstruction: Tips for a healthy recovery

Beauty For Good gala’s growing success helps medically based

5 questions to consider before undergoing breast reconstruction

Implementing a patient-centered approach to breast cancer care

Helping women rebuild their lives and breasts after breast cancer

Community breast care advocates awarded for raising awareness

Dual perspective: Plastic surgeon shares lessons learned after her

Actress channels her breast cancer journey through storytelling

The Breast Goddesses: Survivors help cancer warriors cross the finish line

Reducing racial disparities in breast

Working toward global education for a universal theme

National Breast Implant Registry to improve patient safety By Paul Snyder

Get involved: Breast Reconstruction Awareness Day By Kim Kubiak