Breast Reconstruction Q&A Panel with Joshua Levine, MD; Constance Chen, MD; and Andrew Salzberg, MD

Transcription of above presentation:

Breast Reconstruction Q&A Panel with Joshua Levine, MD; Constance Chen, MD; and Andrew Salzberg, MD

Joshua Levine, MD: Welcome, everybody! To the breast reconstruction panel, this is going to be a 45-minute discussion of all things related to breast reconstruction, and we have some distinguished guests and panelists and I will introduce them, allow them to introduce themselves momentarily. But first, let me read to you the welcome from the FORCE organization.

“The topics that will be covered today are paramount to our community. As many as 90% of the millions of people who have an inherited mutation that causes or predisposes them to cancer are unaware of their risk. FORCE improves the lives of millions of individuals and families facing hereditary breast, ovarian, pancreatic, prostate, colorectal, and endometrial cancers. Our community includes people with BRCA, ATM, PALB2, CHEK2, and other inherited gene mutations, and those diagnosed with Lynch syndrome. The FORCE mission is accomplished through education, support, advocacy, and research efforts. Visit FORCE website for expert-reviewed information and access to support programs including virtual Zoom meetings, peer navigation matching program, and online message boards.”

Again, welcome to the breast reconstruction panel. My name is Joshua Levine, MD. I’m a breast reconstructive microsurgeon in New York City and I have moderated this panel for many years now, and what we have learned through feedback from our participants is that rather than having expert panelists present to everyone what they do, most participants get most of the information and the value from this conference by the question-and-answer session. So, the meeting organizers this year have had the wisdom to eliminate the presentation section of this and just go straight to the question and answer. So, what we’re going to be doing is we’re going to be asking and answering many questions that we’ve compiled directly from patients who are participating in this meeting, and then we’ll open it up to questions that can be tested in via the chat.

So, let me introduce our panel. We have, also from New York, Dr. Constance Chen and Dr. Andy Salzberg. These are two of the foremost breast reconstructive surgeons in the field. We all happen to be in New York City, but we are going to field questions from all over the country and all over the world, and hopefully what we tell you is applicable to your situation. So, I’m going to first introduce Constance Chen and I’d like for Connie to say a few words about herself, and then we’ll say hello to Andy Salzberg. Hello, Connie! 

Constance Chen, MD: Hi, Josh! So, I specialize in microsurgical breast reconstruction. I do do implants as well. I’m in private practice. I operate primarily out of Lenox Hill Hospital and I’m happy to be here. 

Joshua Levine, MD: Excellent. Hello, Andy.

Andrew Salzberg, MD: Hi, Josh. Happy to be here also. I am based in New York City. I am currently the Chief Of Plastic Surgery at Mount Sinai Hospital System, which encompasses seven hospitals in the city, and do—probably most of my practice—breast reconstruction, both implant- and autologous-based reconstruction, but I’m known obviously for implant-based reconstruction, mostly direct to implant, but we obviously do everything.

Joshua Levine, MD: Terrific, and the audience should know also that you’re looking at three plastic surgeons who really focused their practices on breast reconstruction, and three of us offer some of the most advanced techniques in breast reconstruction – but we’re really here to answer questions about anything related to breast reconstruction. So, we’re going to get started with our first question.

The first question is that the plastic surgeon had recommended to a patient that she lose weight. She said the plastic surgeon said, “You have to lose weight before reconstruction.” “But, I’m not obese,” says the patient. “I’m 30 pounds over my ideal body weight and I’m relatively fit. Should I find another surgeon?” I’ll start that question for Dr. Chen. What do you think?

Constance Chen, MD: Well, there are a number of studies that look at body mass index and other issues when it comes to surgery in general, and with a BMI greater than 30 you are at high risk of surgical issues such as delayed wound healing and infection, and I think that if you’re going to go into something such as breast reconstruction it behooves you to prepare yourself and try to optimize your surgical experience. So, do you think it’s a good idea to get your BMI under 30 if at all possible? 

Joshua Levine, MD: Andy, anything to add?

Andrew Salzberg, MD: Yeah. I think I would probably take the other tact and I think that it really depends on the patient and the situation. Obviously, we’re dealing with both breast cancer patients who may or may not be genetically positive, and if a patient needs to have a mastectomy or a breast surgery in general the only thing that we really worry about is the diabetic patient out of control, but a high BMI is a not a contraindication in my practice to do either autologous- or implant-based reconstruction. Obviously, if it’s an elective procedure and we’re doing something on a really elective basis, I would prefer the patient lose weight, but I’d never insist on the patient having to lose weight if it’s indicated. And the patient is in good health – I think we can deal with both of those issues.

Joshua Levine, MD: Excellent. Alright, well, let’s jump right into a COVID question. We were talking about this before the panel started, and it’s on everybody’s mind. The question is: “I would like to travel out of state for the type of surgery that I want. Is that considered risky during COVID? How about recovery? Once I’m home, would I have to travel back if I had a complication?” So, this covers a lot of different areas, and so why don’t we ask Andy. What do you think about travel in the time of COVID? 

Andrew Salzberg, MD: Well, obviously, as we all know for the past year and a half, traveling in the time of COVID is fraught for anyone. Whether it be a patient or a surgeon or whoever, there are some risks. Obviously, sitting amongst if you’re taking a plane, there are risks for everyone to develop COVID. I would think at this point the patients and the people who are wanting these procedures should be able to control those environments. Wearing a mask obviously is going to help. But, I don’t think there’s a big contraindication. We have patients flying in from all over the country and the world to have these procedures now during COVID, and as we talked before the panel started, either having a negative COVID test or being fully vaccinated and also having a test which is negative would probably be indicated for any of the hospitals that you’re going to have surgery in.

Joshua Levine, MD: Right. The other part of that question, Connie, involves a patient who’s wondering what happens if they travel for surgery and then have a complication once they return home. How do you handle that in your practice?

Constance Chen, MD: So, if someone has some sort of complication once they return home and, surely, that’s going to be something like delayed would healing or something of that nature, I usually try to partner with a plastic surgeon in their home community or some other physician in their home community to help them along with that whether it’s, you know, sometimes another surgeon can help them [00:08:28 with drains] or help them with wound care and things like that. I’m always happy to see somebody if they’re able to come back, but that’s not always possible for all patients. 

Joshua Levine, MD: Is there any circumstance in which you would insist that a patient return to New York because of a complication that you think everything can be handled remotely?

Constance Chen, MD: Well, there may be situations where it would nice that they could return back whether it’s, I mean, if you’re going to have a significant medical issue—they may not be in a condition to travel. I haven’t actually had that situation myself, but I’m trying to imagine a situation where I would have to insist that somebody come back. I mean, if someone is going to come back for something, for example, to make something look better [00:09:16 that I thought only] I could do—I don’t know, I try to work with a patient on a case-by-case basis, I would say, because it also depends on how far away they might be. Are we talking two hours away? Are we talking across the country and you have to take a six-hour plane flight? 

Joshua Levine, MD: Alright, Connie, can you speak to the overall satisfaction rate in women after different types of breast reconstruction surgeries?

Constance Chen, MD: Well, again, that’s highly individual. I think that there have been studies where using the BREAST-Q and other quality-of-life management tools where it seems that women either after implant or autologous tissue reconstruction have a pretty high patient satisfaction in the short term, either type of breast reconstruction. After about the eight-year mark, it does fall off a bit for people who have implant reconstruction probably because of things like [00:10:18 inaudible] and rupture and things like that that can happen with implants, whereas with autologous tissue it appears, according to these studies at least, that the patient satisfaction seems to remain higher. 

Joshua Levine, MD: Well, I would add to that in regard to the longevity, certainly because autologous tissue, once it works out, there’s really no possibility of failure, whereas implants do in the long-term have a failure rate. Andy, what is the failure rate of implants in General? 

Andrew Salzberg, MD: So, over time, the failure rate goes up for sure. The studies really document that implants are not a lifetime device, and we tell patients that probably in their lifetime depending on their age, obviously when they go in, that they should expect to have to change them for another implant. There’s a common misconception I think on the Internet and [00:11:20 throughout] patient education that every 10 years you need to change your implants, which is not necessarily true, certainly promulgated by the companies that develop the implants and sell them. But, there are some good studies during the 1980s and ‘90s that show that the failure rate of implants after 10 years was definitely higher. That being said, the technology has definitely improved, the implants themselves have improved, and patients now can consider that they can keep their implants for a lifetime if they are fine. So, there’s no question that autologous reconstruction in and of itself is a better concept, and if we could give everyone their own tissue it would be wonderful but some patients are not candidates to have their own tissue reconstruction. But, they are long-lasting, and it’s really based on the patient and we individualize the patient based on what their needs are, what they want, what their body habitus on surgery is. So, they’re both great ways to reconstruct patients, and you have to choose the right one for the right patient.

Joshua Levine, MD: Now, when you say that it’s better in general and you’d like to do it in every patient if possible, are referring to what you would consider to be overall satisfaction rate? 

Andrew Salzberg, MD: No, I mean, ultimately, if we had to protect the future 50 years from now, we will probably be not using breast implants at some point, that we would either develop some mechanism to grow the patient’s own tissue or scaffold that incorporates patients’ tissue. Ideally, the best thing for the patient would be their own or some type of tissue which maybe we grew in a laboratory. But, that’s not available at this point and implants do serve a wonderful role for breast reconstruction, and most of the patients as Connie said are very happy with their implant-based reconstruction. But, it’s to each his own. Everyone is a little bit different, and the surgeon that they interview should be able to give them the pros and cons for both of these options.

Joshua Levine, MD: That’s a great point. But, you know, we’ve been talking exclusively about breast reconstruction, and that’s what we do and that’s what we love to talk about, but there are some questions out there about going flat after mastectomy. I’m sure you’re aware—there was an article about it in the New York Times a few years ago, there is a session about it in the FORCE meeting. I’d love to get your opinion, Connie, on going flat if you have one. 

Constance Chen, MD: I always give it as a viable option to every patient who comes to see me for breast reconstruction. I actually start out with that. I tell them, obviously, what I do is breast reconstruction but going flat is a viable option for every patient and, at the end of the day, I think you need to know yourself and what’s important to you. There are some types of breast cancer such as inflammatory breast cancer or [00:14:22 inaudible] breast cancer, or you may want to conserve your body’s energy and go flat either permanently or delay your breast reconstruction until you finish your oncologic treatment. For the FORCE population where many people are looking for prophylactic mastectomies, I’ve actually come across people undergoing prophylactic mastectomies who want to go flat as well. But, most people who are undergoing prophylactic mastectomies, because they have no disease, want to come out of it looking and feeling more or less like they did before or either like they did before or better. So, many of those people think that going flat is not for them, but it should be mentioned and considered as a viable option in my opinion [00:15:05 inaudible]. 

Joshua Levine, MD: Well, talking about the FORCE population and prophylactic mastectomy is a perfect lead-in to the next question which has to do with nipple preservation. I think everybody is comfortable at this point, and nipple preservation is very, very safe from an oncological point of view particularly as it relates to prophylactic mastectomy and actually most cancers as well, and it’s something that we all offer and we all work with breast surgeons who offer that. So, from an oncological point it’s pretty well settled, but this question has more to do with one of the issues of nipple preservation from a reconstructive point of view. Andy, what do you think about that? 

Andrew Salzberg, MD: Well, first of all, I think that the statement that you made about nipple preservation is right on. I think that nipple preservation should be offered to patients. I think that the breast surgeons are on board with this in most of the country, especially New York City I would say, and most of the patients if they can would like to do that. So, it actually helps the overall reconstruction. We actually looked at patients who had their nipple removed and then reconstructed versus the normal regular nipple that they have and preserving it. Most patients who have fairly aesthetic nipple-areolar complexes would be much happier with their own nipple preservation. We did our study on our own patients of about 2,000 breasts and showed that 60% of our patients did have nipple sensation, not necessarily the same sensation they had preoperatively but they did have touch and feeling, and sometimes even more so after five or six years.

So, I think that that’s a positive thing for the patients. Even in those patients when we looked at it, only about four patients have ever developed a cancer after prophylactic mastectomy and none at the nipple-areolar complex. So, I think it’s safe. I think it’s a procedure that should be offered to patients. I think that it’s silly for patients to believe that if they remove the nipple complex that their rate of removal, all the breast tissue, goes up, because we performed many mastectomies with patients who removed the nipple and leave breast tissue on the skin flap. So, I think it’s a viable option and I think everyone should be offered [00:17:29 it if] capable.

Joshua Levine, MD: Okay, I want to pursue that a minute, but I want you to get back to the original question, which was, what are the plastic surgical issues related to nipple preservation, and what are some maybe contraindications or difficult situations regarding that? But, before you get to that, let me ask you something about something you said, which was you have 60% nipple sensation and nipple preservation. Were you talking about implant reconstruction or autologous reconstruction or both? 

Andrew Salzberg, MD: Both.

Joshua Levine, MD: So, you didn’t distinguish in your study whether it was autologous or implant? 

Andrew Salzberg, MD: Correct.

Joshua Levine, MD: So, you’re saying that with implant reconstruction you would expect 60% of them to have nipple sensation? 

Andrew Salzberg, MD: Yes. I mean, that’s what was reported by the patients and tested by the physicians who did it.

Joshua Levine, MD: Okay, I work like to just say that that’s surprising to me, and I think that that is significantly related to the type of mastectomy, the quality of the mastectomy, and I think that it’s not necessarily what most patients would find in the world out there… 

Andrew Salzberg, MD: [00:18:44 inaudible] the variability of the sensation went from 0 to 100. So, that bell-shaped curve and the amount of sensation varied vastly, but 60% of the patients reported sensation. On the implant side, all the patients had MRIs followup to this study, had 0% breast remaining and the breast itself. So, hopefully, it’s going to be published in a paper coming out, but I was also shocked because we tell patients that, “We expect that you’re not going to have nipple sensation.” But, this is many years out. This is up to 10 years out. So, patients seem to get more and more sensation with time, which I’d never told patients. I said it two years, “If you don’t have any sensation, you’re probably not going to get it,” but I was obviously not right on that.

Joshua Levine, MD: Connie, I’m going to ask you about sensation and nerve coaptation in a minute, but I wanted to pursue to this. What are the contraindications, Andy, to nipple preservation? We decided that oncology is probably not usually a contraindication [00:19:58 inaudible] from an oncological point. What about from a reconstructive point of view?

Andrew Salzberg, MD: Well, if technically nipple preservation can be performed, the biggest issue is where the nipple complex lies on the chest and on the breast. So, if you have a nipple that is way below the inframammary fold, it’s going to be much more difficult to preserve the nipple and get it in the right position. We also may be able to preserve it, but it also has to be in the right position once you finish the reconstruction. So, the biggest challenge in nipple preservation and reconstruction is getting the nipple in the proper position and keeping it there, because many times a nipple tends to drift. Especially depending on the mastectomy incision, it can be lateralized or medialized or down because of the implant position or implant reconstruction and it becomes a difficult situation. So, the amount of ptosis or hanging of the breast will definitely affect whether it can be preserved. A lot of patients are now electing to have a breast lift or reduction beforehand to get the nipple into the correct position, maybe reducing the areola and doing that as a two-stage procedure so they preserve the nipple later.

Joshua Levine, MD: Right. Great answer. Thank you for that. 

Andrew Salzberg, MD: Pleasure.

Joshua Levine, MD: Connie, Andy had mentioned that somewhere around 60% of patients with nipple preservation maintain some degree of sensibility. Now, I know that you’ve done some work and are offering nerve coaptation and flap innervation in some patients. Do you feel that that is very important in light of what Andy just said?

Constance Chen, MD: Actually, too, I think that, also as a woman, if I were to have a mastectomy I would  ideally like sensation back and do everything I can to restore the breast to as close as possible to some kind of [00:22:00 inaudible] stage, and when you have living tissue and you’re recreating a breast with living tissue, you can dissect out a nerve. I use a nerve graft and connect the nerve graft to a nerve on the chest wall to restore sensation to the living tissue so you have something that is alive and feeling. There is a woman in San Francisco who does implant reconstruction and is exploring nerve grafting and that sort of thing. I did speak with a patient who saw her and she did say that one way that she preserves sensation is that she said about 10% of the tissue is there to preserve the sensation, and I think that if you don’t have something that’s alive underneath, the only way you can have sensation to the nipple is through the subdermal plexus right below the skin, which of course you don’t want violated because you also don’t want the skin to die. But, I think when you preserve that, then I can see how you might be able to preserve some sensation.

Joshua Levine, MD: Let’s suppose a patient that for whatever reason she doesn’t want or maybe she’s not a candidate for nipple preservation. So, in those circumstances, we call that skin-sparing mastectomy, and this is an operation that basically replaces the modified radical and the radical mastectomy, the skin-sparing mastectomy. So, what do you do, Connie, for patients who don’t preserve the nipple, they end up with a reconstructed nipple? How do you do a reconstruction?

Constance Chen, MD: So, I actually have fairly strong—my idea of a skin-sparing mastectomy I think is a little bit different from some breast surgeons’ idea. So, if someone say has bloody nipple discharge or their tumor is very close to the nipple and it’s just not oncologically safe to preserve the nipple, then I would like to work with a breast surgeon if I’m there at the time of mastectomy to try to preserve as much as of the breast envelope as possible. And so, whether they’re having implant reconstruction or flap reconstruction, I like for them to make an incision, a circular incision, around the areola, and then usually something like a vertical incision down, so that you preserve that round shape of the breast. And then, if it’s an implant you can do a pursestring closure or, if it’s a flap, you have the flap skin hollow where the areola used to be.

So, that I think is in contrast to what some breast surgeons think of as a skin-sparing mastectomy, which is basically like a regular transverse mastectomy [00:24:40 that just] maybe you’re not as aggressive in removing skin. I don’t really like that because it does change the shape of the breast and… 

Joshua Levine, MD: Tell us how you make a nipple. Do you do nipple reconstruction?

Constance Chen, MD: I do. I do a CV flap, which is I take tissue from the either breast skin or the underlying flap and I kind of do an origami thing and make a nipple out of that. 

Joshua Levine, MD: Okay. So, the alternative to nipple reconstruction is also something that a lot of patients are electing to do lately, which is 3D tattooing, and if your nipple and areola are plate-replaced with skin from your donor area in a flap procedure, you have basically a circle of skin, and if it’s tattooed to look like a nipple you might not even need nipple reconstruction, which is another option. 

Andy, what do you recommend to say patients who say, “I don’t know if I want an implant reconstruction or a flap reconstruction using my own body tissue, and I don’t really know how to even begin to make that decision?” What do you recommend to patients who are in that quandary? 

Andrew Salzberg, MD: Well, first of all, it entails an encounter with the patient of at least 45 minutes to an hour consultation. This is not a quick discussion. This is really exploring the patient’s options and deciding what’s best for each patient, and it takes a long time. We do on every patient preoperatively a 3D image of the patient, we show them before-and-after photographs, and we’re trying to give the patient an idea of what they might look like postoperatively with both procedures. Obviously, while we explain the procedures, we explain the benefits and the risks of both since we do both, and I think that it’s really patient feeling versus surgeon’s feeling. I think that if you’re a candidate for both, it’s one of the hardest things to be a candidate for both because they have to make a decision.

So, I think that talking with other patients is extraordinarily important. Coming to this conference and participating in this panel is extraordinarily important. I think that it’s a personalized decision and every patient should be treated individually, and I’m sure you do and Connie does exactly the same mechanism. We try to figure out what’s best for patient because, at the end of the day, we want the patient to be happy. It’s not about us, more about the patient and, well, what’s going to be best for them for the long run.

Joshua Levine, MD: So, Connie, if you were to say, “What are the big differences between implant reconstruction and flap reconstruction?” and let me just be clear because we didn’t have a presentation. We all agreed that there are two main ways of making a new breast for breast reconstruction. You can have implant reconstruction on one hand or your own body tissue on the other hand. We also call that autologous reconstruction, and the other word that we use to describe that is a flap procedure. Now, there are lots of different types of flaps which we may get into, but Connie, break it down for us: What are the big differences between implant reconstruction and using your own body tissue?

Constance Chen, MD: Well, in the United States about 80% of people who undergo breast reconstruction undergo some kind of tissue expander implant reconstruction. Some people do direct implants such as Andy does. Many people have a tissue expander as well as an implant. The biggest difference is that with implant reconstruction you’re only operating on one surgical site and that is her chest. There is not another surgical site that you need to heal from, there is not another scar, and because of that it’s a simple operation. It’s easier for the patient and it’s also easier for the surgeon to be quite honest. Another big difference is when you have autologous tissue reconstruction or a flap procedure or a natural tissue reconstruction, when you reconstruct the breast your breasts are alive. When you have an implant, your breasts are clearly not alive. And so, because they’re alive, if you have for example an infection or if you have any sort of anything, there’s a blood supply to your breasts after natural tissue breast reconstruction so [00:28:58 you gain and lose weight.] Your breasts will [00:29:01 gain and lose weight.] If you get your teeth cleaned or you have a colonoscopy and you have a low-grade bacteremia, you don’t worry that it’s going to land on your breast implants and get infected. You don’t have to worry about it in the same way that you would with a heart valve or a knee replacement or any other kind of device that is a foreign body in your body. So, those are probably the two most simple differences between implant reconstruction and flap reconstruction. 

Joshua Levine, MD: What would you say is the biggest drawback to flap reconstruction, the biggest in your opinion?

Constance Chen, MD: I would say that it’s a bigger operation where you have a permanent scar on another part of your body. Some people always wanted a tummy tuck, and so to them it’s a bonus, it’s not a downside, but at the same time it is a bigger operation. It’s a greater burden of surgery on the patient’s body. And so, that’s just something you need to know: You will have drains and surgery and whatnot at a different site of your body that does not include the chest where you had disease previously [00:30:06 inaudible]. 

Joshua Levine, MD: Andy, what do you think is the biggest drawback to implant reconstruction?

Constance Chen, MD: So, implants are great in the short term… 

Joshua Levine, MD: Let’s let Andy answer that question.

Constance Chen, MD: Okay, sure. 

Joshua Levine, MD: Yeah. 

Andrew Salzberg, MD: The biggest drawback is having an implant, basically. So, obviously, the decision is either autologous, which is using our own tissues, which Connie went through nicely, versus an implant. An implant is a foreign object. It’s placed into the and has been placed since the 1960s for both augmentation and reconstruction. Most plastic surgeons think that they’re very safe to have in your body. There are millions and millions of women who have them and are comfortable with them. But, the biggest downside is that you have to live with an implant. Most people are very comfortable with their decisions and I would say most people are comfortable without complications if they have breast-implant-based reconstruction.

Joshua Levine, MD: Could you tell us a little bit about recovery? Walk us through, how long does it take – the surgery, how long does it take in the hospital, how long is the recovery, what’s the followup like?

Andrew Salzberg, MD: I’m sure things have gone better for all of our practices because of the pain control methods, but… So, an implant-based reconstruction that you do a direct implant, mastectomy reconstruction is probably three to four hours from both the breast surgeon and the plastic surgeon, and once the implant is placed, and that can be placed either above or below the pectoralis muscle, it’s basically pain level – not too bad. We now use long-acting pain medicine, which is called Exparel, and most of that is used on both reconstructions. So, in the autologous- and implant-based reconstruction, we now have the ability to extend the patient’s analgesia for three to four days before they go home. So, most patients are now leaving the hospital 24 hours for implant-based reconstruction. During COVID times, we were sending them home the same day.

Joshua Levine, MD: How long is the recovery?

Andrew Salzberg, MD: The recovery is, drains, usually one to two drains in each breast. Drains usually come out to seven to 10 days, I would, and the patient’s back, doing their activities within two weeks – two to three weeks.

Joshua Levine, MD: Connie, how long does it take to recover from a flap surgery?

Constance Chen, MD: So, I would say it varies for me widely. I do have patients who are very fit and go back to work after two weeks. But, I tell people for both implants and for flap surgery the natural process of wound healing is such that even if you feel fine it takes six to eight weeks in a normal healthy person for complete wound healing to happen. So, I would most people will feel pretty normal at about a month, but I’m still going to encourage them whether they had implants or flaps to take it easy, not do heavy lifting, not start kickboxing or horseback-riding or doing anything like that. But, depending on the patient, I’ve had people go back to work as early as two weeks after flap reconstruction and then some people take longer.

Joshua Levine, MD: Connie, if there’s a patient right now sitting out there and listening to this and thinking to themselves, “I think I want flap surgery but I’m afraid I might not be a candidate,” how can they evaluate that prior to getting a consultation? How should they be thinking about themselves, “Am I a candidate?” 

Constance Chen, MD: Well, I’m not sure that I have met somebody in person who has not been a candidate. I think people are often told that they are not candidates for flap surgery. Most commonly, they’re told they’re not candidates because they are too thin, and I have actually never met somebody who was too thin to have flap surgery, and I have reconstructed people using their own tissue who are very thin, BMI 18 or so. Sometimes if you don’t have abdominal tissue to use to reconstruct your breast, you can go to other sites such as the upper inner thighs or the flanks or the back area or all sorts of places.

Joshua Levine, MD: Let me put it this way then. What is a contraindication? What would be something that would say to you, “I can’t do a flap on this patient?”

Constance Chen, MD: So, every surgeon will have their own litmus test of who they will operate, who they will not. We discussed earlier BMI. Over the years I have really tried to get people to get their BMI under 30 if at all possible. I just find that people have an easier recovery when their BMI’s under 30. Andy mentioned uncontrolled diabetes. That, again, is another setup for wound healing problems and flap problems and whatnot. And then, smoking, I personally do not do flaps on people who are current smokers, and this is because the nicotine takes the place on a red blood cell where the oxygen is supposed to be. So, your tissue oxygenation is going to be poor. In addition, the nicotine causes vasoconstriction, which prevents the blood flow to the flap. And finally, nicotine causes platelet clotting, which means that your flaps are more likely to clot. And so, why would you undergo a big surgery where you have to heal wounds in your chest and in the donor site if you’re setting yourself up for failure by…

Joshua Levine, MD: So, uncontrolled diabetes and smoking, okay.

Constance Chen, MD: Yes. 

Joshua Levine, MD: So, Andy, you mentioned before that you could do a one-step procedure. Now, many people probably don’t know what that is, but Connie had said that the traditional implant reconstruction involves the placement of an expander, which typically would go underneath the muscle and is expanded over one to three months, and then there is another operation which is the exchange, and typically there may be even yet another operation which would be nipple reconstruction and some type of shaping. When you say one step, do you really mean one step? 

Andrew Salzberg, MD: Yes, I mean one step. So, the procedure, because of the availability of the tissues that we can use for the reconstruction, [00:36:23 inaudible] the patient to have an implant at the time of the mastectomy. I think that it’s enough coverage for almost anyone. There are very few people who are not candidates to do direct-to-implant [00:36:39 preoperative…]

Joshua Levine, MD: Why don’t you tell us what is the difference? 

Andrew Salzberg, MD: Okay.

Joshua Levine, MD: Now, because most people, correct me if I’m wrong but most surgeons who do implant reconstruction, still do the expander and the exchange, right?

Andrew Salzberg, MD: Yup.

Joshua Levine, MD: Direct-to-implant is not offered in most parts of the country. And so, tell us briefly what that is because I think you’re one of the few people who offers it, and then tell us the truth about how many surgeries a direct-to-implant patients should expect.

Andrew Salzberg, MD: Okay. So, the difference of the procedure is that instead of putting an expander in, most patients have enough skin and/or muscle to allow the implant device to go in at the same time. So, rather than put an expander, which is now largely done either above or below the muscle, a lot of patients are getting expanded above the muscle and then replaced with an implant later [00:37:34 inaudible] second stage. So, in 2001 I developed a procedure to do this direct-to-implant because there is no reason to expand patients who have enough skin, and the viability of the skin is really the question.

So, preoperatively, there is almost no one who is not a candidate. It really depends on the mastectomy skin quality at the time of surgery, and we test that by injecting a dye into the vascular system to make sure the blood is flowing adequately to the skin, and once that happens the patient can have one operation.

Joshua Levine, MD: How available is that operation in the country or in the world today?

Andrew Salzberg, MD: So, Connie mentioned that about 80% of the patients get tissue expander reconstruction. About 8 to 10% of the rest of the country get direct-to-implant reconstruction. So, 15 or 20 years ago, it was not common. The downside is that doctors get paid less, unfortunately, to do a direct-to-implant reconstruction. So, it’s an economic advantage for the surgeons to be doing two operations. And, it takes a little bit more time and effort to make it the way you want it on the first operation and never come back again.

Joshua Levine, MD: So, it’s not that available, in other words? 

Andrew Salzberg, MD: It’s not available through the country because…

Joshua Levine, MD: Okay, so I need to understand that. This is something that’s relatively at the forefront of plastic surgery. Let me ask you both this question: If a patient’s sitting there thinking, “Well, that sounds great. I want direct-to-implant,” but they go to their local plastic surgeon, the local plastic surgeon says, “Well, I’ve never done that before,” what should that patient then do? Should the patient ask the surgeon to try it on her? Connie, what do you think?

Constance Chen, MD: In general, I don’t know that I want to be the first patient who has a—I mean, someone has to be the first person, but I don’t know if it were me I would feel comfortable being the first person someone was trying a new technique on. 

Joshua Levine, MD: Let me ask you this. Now, the patient says, “I want direct-to-implant but I don’t want this surgeon to do it, and I’m not able to travel. I’m just not. I have kids. I have responsibilities. I have to stay local.” Is it okay for that patient then to say, “I’ll go to my local surgeon and trust him to do the right thing for me?”

Constance Chen, MD: [00:39:56 What do you mean,] force the surgeon to do a procedure…? 

Joshua Levine, MD: No, I’m not saying ask the surgeon that they are not comfortable doing. I’m saying go ahead down the traditional route of [00:40:07 inaudible] expansion, because I think most people are probably sitting here thinking, “Well, that sounds great, but it’s not an option for me. What am I supposed to do?”

Constance Chen, MD: Well, I mean, that’s going to be a tough call for that patient. I mean, you basically painted a picture where they’re not going to be able to go somewhere else and what they want is there, so I guess they’re going to have to make a decision on what they want to do. 

Joshua Levine, MD: Here’s the bottom line: Is it safe to go ahead and have a traditional plastic surgical approach in a local community? That’s the bottom line, because I honestly think that most women watching this today are in that situation.

Constance Chen, MD: Yeah, of course. I think that, for example, say you want flap reconstruction and nobody does flaps, you can always have implant reconstruction where you are. If you want above the muscle and nobody does that, I mean, personally, I would probably go somewhere else to get above the muscle, but is it safe to have below the muscle? Obviously, people do it all the time. If you want direct-to-implant and you can’t get it, well, unfortunately, if you can’t travel you probably won’t get it. So, I don’t know what to say about that.

Andrew Salzberg, MD: So, I think the answer to, or at least in my mind, the answer to your question really is, yes, it’s absolutely safe. Safe is a good word because there’s no reason that having two operations is not safe theoretically, and you can go that traditional old technique route, which we developed tissue expanders back in the seventies. When patients had a lack of tissue after the mastectomy, we’d take wide areas of skin out and they really required expansion of the skin. Nowadays, we’re leaving skin and we don’t need to expand that skin anymore. So, we have the ability not to do that. For whatever reasons surgeons feel more comfortable doing an expander, it is absolutely safe to have an expansion procedure and then come back and put an implant in later or come back and do a flap, as Connie said. That’s commonly done.

Joshua Levine, MD: I think that’s a really important point. You know, you have great surgeons all over the country, they don’t all offer the latest and greatest operations that people in the forefront are doing. It’s perfectly safe to go to a reliable board-certified plastic surgeon who has a good reputation provided that you talk to patients who she has operated on and feel comfortable in that situation. You are not burning bridges by going [00:42:45 inaudible]. 

Andrew Salzberg, MD: [00:42:45 inaudible]

Joshua Levine, MD: You can always go back and, if you have the time in the future, maybe the resources to travel, you can always go a different direction, but… 

Andrew Salzberg, MD: And there are people who get very nice results by having expander placed, going through the expansion process, and then replacing with an implant, and there’s nothing wrong with that. It’s just not necessary, and I think as a woman, almost anyone on this call would say, “I’d rather have one operation than two,” which is basically…

Joshua Levine, MD: Get back to that now because I want to push you on that point. 

Andrew Salzberg, MD: Yes.

Joshua Levine, MD: When you say one step, how many of those patients do you actually revise in the future? 

Andrew Salzberg, MD: So, the paper was published a number of years ago. We looked at all of our patients who had one-stage operations direct-to-implant and 9.4% of the patients had a secondary revision operation. Most of them were patients who wanted to have a size change, but it varied and many of the patients needed a secondary revision. Some patients wanted some fat transferred. So, it’s about let’s say 10% of the patients required a revisional surgery.

Joshua Levine, MD: Will you say a couple of words about ALCL? 

Andrew Salzberg, MD: Sure. So, this is a condition that’s an associated condition with breast implants that are textured. It has only occurred in anyone with textured devices. These implants [00:44:17 were these shaped,] anatomically shaped implants that were developed many years ago. 

Joshua Levine, MD: What is ALCL? What are we talking about? 

Andrew Salzberg, MD: This is a lymphomatous condition associated with texturing of the implants and it happens not only in breast implants, it happens in gluteal implants and I think other implants that may be textured. It’s not reported as much in non-breast-related procedures but it can happen.

Joshua Levine, MD: Alright, let me just interrupt you because it’s almost over. I want to say What You Should Know About Breast Implants is a session by Liza Wu tomorrow at 1:30 p.m. and I think that she’s going to be covering this in a little bit more detail, but it’s an important thing for patients to understand. 

Andrew Salzberg, MD: It’s terrific and everyone should attend that.

Joshua Levine, MD: Alright, I think we’re almost finished…

Constance Chen, MD: Yeah, one thing I’d like to say is you mentioned you traveling to get the procedure you want, I would say that if you want for example flap reconstruction or above-the-muscle breast implant or something like that that you can’t get locally, if you can find a breast surgeon who can do nipple-sparing mastectomy on you whether you get reconstruction or not, you at least are setting yourself up for an optimal breast reconstruction even if you have to travel later on to get the breast reconstruction you want. Again, nipple-sparing is also not always available locally, [00:45:44 a few other] things aren’t, but if you can get at least get that I think that you’re at least putting yourself in good shape. 

Joshua Levine, MD: Connie, Andy, thank you guys so much. This was a really enlightening and really enjoyable discussion. It’s great to see you both. It’s been a long time because of COVID. I hope we can meet up in person soon and share some of these stories in person. I want to thank everybody for attending.