1. Holt, Chuck

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After a mastectomy resulting from breast cancer, women who choose to undergo breast reconstruction with their own tissues using one of the commonly known techniques for the procedure usually face a hospital stay of about 1 week, followed by an extensive recovery at home.

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Determined to find a better way to help his patients facing this scenario, Western Connecticut Health Network (WCHN) plastic surgeon, Boris Goldman, MD, teamed with colleagues, notably Zandra Cheng, MD, to develop a new, less-invasive technique for reconstructing the breast. They focused on using a patient's own tissues and skin-reducing the surgery from 6-12 hours for a one-sided procedure to about 90 minutes, plus the time it takes to complete the mastectomy-and a far less difficult recovery, which begins with patients only needing one overnight stay in the hospital for monitoring.


Goldman, Cheng, Jeanne Capasse, MD, and Valerie Staradub, MD, all WCHN surgeons and coauthors of the article on the new technique, entitled "Autologous Immediate and Delayed Breast Reconstruction Utilizing Micro Fat Grafting With and Without Dermatocutaneous Flaps," recently earned an Excellence in Oncology award for their work from the Oncology Times.


Below, without getting too far into the mechanics of the new breast reconstruction technique, which the team details in depth in a soon-to-be-released manuscript, Goldman shares insights into the impetus for developing the new breast reconstruction technique, and why the outcomes thus far have been universally satisfying for patients.


What inspired you to investigate this new breast cancer reconstruction technique?

Boris Goldman, MD: Many women prefer to reconstruct their breasts with their own tissue, because some think that it feels more natural, that it looks better, and because there is no maintenance of their own tissue, if you will, unlike implants, which may need to be replaced at different intervals. But the problem with the currently available techniques for reconstructing a breast with your own tissue is that they tend to be very invasive. They tend to involve large incisions across the lower abdomen, for instance, for an abdominal flap procedure, or incisions in the back for back flap procedures. And I wanted something that was better for my patients.


Has anything about the results of the new breast cancer technique surprised you so far?

Goldman: Yes, both in a good way, and in a not so good way. The good thing that surprised me is that everybody who has had the procedure done thus far has been universally pleased with it. We have had patients who have had the procedure done, and then their first-degree relatives, like mothers or siblings who have had reconstruction done with other techniques get referred to me to evaluate them to see if there is anything that we can do with our technique, even though they have already been reconstructed. And certainly, when our patients compare their recovery experience to that of their siblings or their first-degree relatives like mothers, their recovery experience was much easier.


We do anesthetic blocks, and we do use medications to help minimize postop pain that are not narcotic. But many of our patients will just take an acetaminophen after their initial procedure. Now, not everybody does, some will need to take a narcotic for a couple of days, but what surprises me is that their recovery was really well-tolerated and the patients themselves felt that that they did very well.


On the flipside, one of the things that we didn't expect was that the technique may not be for everybody. We have applied it to radiated patients, but the results are not consistent, so we have told them all before we begin that they may have to consider a different method of reconstruction if our technique is not successful. And that's because in some patients with radiation after mastectomy, the skin tightens down and there is no longer breast tissue underneath keeping it expanded.


If they have a very thin skin flap after mastectomy, or if they have had a more aggressive type of radiation, sometimes those patients really get quite a bit of scarring and it is difficult to expand them out to a full breast with our technique. Although, I will tell you that, despite the fact that there is more scar tissue in radiated patients, everyone who has started the procedure has continued with it. And even the radiated patients have actually been happy with their outcomes thus far.


What are some of the clinical implications of the new breast reconstruction technique?

Goldman: First of all, in the operating room, the standard technique to transfer your own fatty tissue will take anywhere from 6 to 12 hours for one-sided reconstruction, and in a bilateral case, it can take quite a bit longer, and that's with two surgeons. With our procedure, we add about an hour to an hour and a half to the mastectomy time. So, for a bilateral reconstruction, our patients are usually done within 3-4 hours. We also use an oncologic breast surgeon and a breast reconstruction surgeon, me, so there are two surgeons present. With the typical bilateral reconstruction using one's own tissue, most patients will stay in the hospital for 5-7 days, and many of those patients need to be on a special unit, like a step-down unit where they can monitor the flap very carefully to look for vascular compromise issues. And if there is a failure of the blood flow to the flap, they have to go back to the operating room to have it explored.


Our patients go home the next day by and large. They have the surgery, stay in the hospital that night, and then they go home the next day. They have a drainage tube in the breast when the reconstruction is done, but the drainage tube is for the mastectomy, not so much for the reconstruction. Whereas, there could be a drain left in the abdominal region as well with the typical reconstruction, and sometimes there is mesh that has to be used to reconstruct the abdominal wall. Even if they spare the abdominal muscle when they take the fat to make the breast, the problem is that, often times, the muscle doesn't function well because the nerves that sit beside it have been harmed during the procedure, and so patients can come back with abdominal bulges.


The big advantage of the technique that we have, where we're making the breast for the patient from their own fatty tissue and their own breast skin, is that there is no additional foreign material placed, and so the procedure itself is non-invasive in the sense that there is not a lot of scarring left on the body.


To harvest fat for our procedure, we make 3 mm incisions, compared with the large abdominal incision with the older technique. Obtaining fat via a 3 mm incision is as non-invasive as you get for transferring fatty tissue for breast reconstruction. Again, we didn't invent fat graft reconstruction for breasts. What we have done is we have combined different known procedures that have been used to make breasts to allow patients to have immediate reconstruction using their own skin and fat with minimal downtime and a minimally invasive procedure. At this point, friends of relatives cannot donate fat, although many have asked. Patients must have enough of their own fat to complete the reconstruction.


What further research, if any, needs to be conducted about the new breast reconstruction technique?

Goldman: The preliminary research is done. We are utilizing two techniques that are known and that have been used separately in the past, so we pretty much know what to expect that each one individually does. Combined together, we have a series, but ultimately we want more patients and longer follow-up. The longest patient we have now is about 2 years out. So we need longer-term follow-up. But all of the studies to date looking at fat graft breast reconstruction-fat graft is an important part of our technique-have documented that it doesn't increase the risk of breast cancer recurrence, but it is still something that we monitor.


So how do you follow these patients? We have been following them clinically, and very often they will get additional imaging as recommended by their breast surgeon and oncologist. And these are things that need to be fleshed out over time. Do we need to be doing MRIs on these patients? Do we need to be doing mammograms on these patients?


There have been studies done showing that for fat graft patients, mammograms are as effective as MRI scans at finding areas of fat necrosis. But, what we have to decide is what recommendations to give these patients long-term. Do we need imaging every other year like breast implant patients? What we are going to do is recommend the oncologic breast surgeon recommend follow-up and imaging as appropriate for their patient (i.e., type of breast cancer, stage of breast cancer, etc.). In comparison, silicone breast implants are advised to get an MRI scan 3 years after placement and every 2 years thereafter. And then we have the skin component to monitor over the long-term as well.


The last thing that we still need to work on is helping radiated patients. We know for a fact those patients who are not radiated can complete the breast reconstruction within two outpatient sessions usually, although some patients may need three sessions and some patients may need more. We have one patient who had been radiated, had one fat graft session after her mastectomy, and is done. She is happy. She doesn't want anything else done.


We have other radiated patients that have had two sessions and still aren't done because of the tightness and the scarring. So, if we are going to expand the technique to radiated patients, which is a very special subset of patients, additional work needs to be done to decide how many sessions these patients are going to need to complete their breast reconstruction. We think it is going to be anywhere from one to three sessions, but that number can change as we get up to speed with these radiated patients.


Is there anything else that you would like to share with Oncology Times readers?

Goldman: I will tell you that this is a team effort. It's one of those things for which you have to have collaboration between the breast surgeon and the plastic surgeon. And it has to work well, because success of this reconstruction technique, more so than with any other technique, really depends on how the breast surgeon does the mastectomy.


We are very lucky that we have first-rate breast surgeons at Danbury Hospital and Norwalk Hospital, which are part of the Western Connecticut Health Network, but also that we have very close collaboration between the breast surgeons and me, the plastic surgeon. Also, our anesthesiologists administer block anesthesia so that our patients don't really need to take narcotics after the procedure. All of that adds up to a very satisfying experience for these breast cancer patients.


Chuck Holt is a contributing writer.