You have options: Breast reconstruction decisions

During this free, 75-minute webinar hear from a panel of women sharing their breast reconstruction choices. Panelists include Amy Battaglia, Sylvia Morrison, and Ginny Shudlick. Plastic and reconstructive surgeon Joseph M. Serletti, MD, FACS shares how he helps patients understand their options, including when to have the surgery – immediate or delayed, as well as aesthetic flat closure.

ASL interpreting was offered during the live webinar.

Transcript

Jean A. Sachs, MSS, MLSP:

I want to say a few words about the three women that will be joining me in a few minutes.

• Sylvia was first diagnosed with breast cancer in 2010. She was 48 at the time. She had a lumpectomy, and then she experienced a second diagnosis of breast cancer in 2019, and she decided to have a bilateral mastectomy followed by reconstruction.
• Ginny was diagnosed in 2019 at the age of 41. She had a bilateral mastectomy and decided to forego breast reconstruction, and she's excited to share how she made that decision and how she feels about it.
• Amy was diagnosed in 2021, so very recently, just a few weeks shy of her 45th birthday. She had a bilateral mastectomy and implant reconstruction.

Thank you to all of these women for being with us and for sharing their stories. Once we're finished that discussion with them, Dr. Joseph Serletti, who is the chief of Penn Plastic Surgery and a plastic and reconstructive surgeon with an expertise in breast reconstruction, will join us. Feel free to go to our website, LBBC.org, to see the full bios of all of our panelists.

I'm going to ask each of you one question. And Sylvia, I'm going to start with you. If you could, tell us one line about who you are, when you were diagnosed, your treatment, and what reconstruction you had.

Sylvia Morrison:

I am a two-time breast cancer survivor. I was diagnosed 2010 and in 2019. I am an author, I'm a mother, a grandmother. The first time I decided to have the lumpectomy. They removed the knot. Then the second time, in 2019, after the double mastectomy, I decide to have the flap versus the implant.

Jean A. Sachs, MSS, MLSP:

Great. Thank you. Amy, why don't we go to you next?

Amy Battaglia:

I'm Amy. Nice to meet everyone. I am a wife, I'm a mom of three, and I'm a breast cancer survivor. I was diagnosed in December of 2021. I had eight rounds of chemo, a double mastectomy, implant exchange, and 25 rounds of proton therapy post-implant exchange. I finished all treatments in October of 2022.

Jean A. Sachs, MSS, MLSP:

Congratulations. It's great to have you with us. Finally, Ginny.

Ginny Shudlick:

Hi everybody, my name's Ginny. I am a breast cancer survivor. I'm also a mom, a wife, an advocate, a snark queen, an aspiring artist, and a flat fashionista. Essentially, I like to think that I'm all of those things. I was diagnosed in 2019, at 41 years old, with stage I hormone-positive, HER2-negative breast cancer. I had a bilateral mastectomy, chemotherapy, radiation, and then had a salpingo-oophorectomy after that. That's when you have your ovaries and your fallopian tubes removed as well. After all of that, I opted not to have any reconstruction.

Jean A. Sachs, MSS, MLSP:

Great.

We're going to go right to the questions. Ginny, I'm going to stick with you. The first question is, are you happy with your choice, and why or why not?

Ginny Shudlick:

I am very, very happy with my choice. My story is a little bit unique. When I was initially diagnosed, the plan was to have a mastectomy straight to implant. But as we went through additional testing, we discovered that the cancer had spread to my lymph nodes, so I was going to need radiation. And the plastic surgeons at the time, in that practice, recommended that we not do any kind of reconstruction, expanders, nothing until after I had finished the radiation treatment. So it was over a year later, after I had all the surgeries and all of the treatment, before it was time to go back to the plastic surgeon and have that conversation about whether I wanted to go ahead and do implants or attempt some kind of flap surgery.

But I'd been living that whole time as a flat person. I had tried all the clothes on in my closet and thinned it out and determined what worked for me and what didn't work for me. I had started to embrace my body and my scars, and I really didn't want to go under the knife again. It just was not for me. My breasts were not part of my identity anymore. My flatness is what's part of my identity now, and part of what makes me unique. I'm not going to say that every single day I don't wish that I had boobs because sometimes you see somebody that looks really good in that outfit and I just know that I could never wear that, that wouldn't work for me because of my body type. But those are pretty fleeting thoughts in the grand scheme of things. I do think it's important to acknowledge that it's okay, no matter what decision you make, to sometimes think about what might have been.

Jean A. Sachs, MSS, MLSP:

Right. Thank you. And thank you for sharing that so openly and for knowing what you want and doing it.

Sylvia, how about you? Are you happy with your choice, and why or why not?

Sylvia Morrison:

I am happy now, but that has not always been the case. It was because I did go through quite a bit. I went in expecting to do the flap and be done, but the left side did not work and though I didn't want an implant, I ended up with one anyway. So right now, I have my tissue on the right side, and on the left side I ended up with the implant. And sometimes when I look at myself, I can see the differences. So, with that, I'm just a little iffy about it. But overall I'm okay with it. If I had it to do all over again, I would just go with the implants and be done.

Jean A. Sachs, MSS, MLSP:

I hear you.

How about you, Amy? I know you're the newest to this. How are you feeling about your choices?

Amy Battaglia:

I feel very happy with the choice that I made. At first, when you're given all of the information, it seems so overwhelming because you're in a spot that you never wanted to be in. And then you're faced with all these decisions you have to make. Luckily, I had a great team and I was able to talk to my nurse and we went over all the different choices that were laid out. I wasn't a candidate for the flap surgery, but I was for implants, so I did go with the implant. I didn't know when they did the mastectomy, they did find cancer in my lymph nodes. So, they did have to go ahead and remove those. I was supposed to just do regular radiation on the right side, but then it changed to my whole chest wall and my underarms and my neck. It was proton therapy got switched to it.

So, they had to take out the expanders and put an implant in, and they went over the risks that I might have to get another procedure after that because I had to get the proton therapy for the entire chest wall and it can destroy tissue and an implant. But luckily that didn't happen for me. So, I don't have to get a second surgery to get these implants removed. They're fine, they're all intact, and it's all great. I didn't have any complications with any of the surgeries. My scars are healing. I'm kind of putting this all in my rearview mirror. I just wish my hair would grow as quickly as everything else. But, I'm happy with the decision I made. I wanted to get some sort of normalcy back, my body back to what it was. I know it'll never be what it was. But moving forward, I am happy with the decision I made and I’m ready just to put this in my rearview mirror.

Jean A. Sachs, MSS, MLSP:

Thank you. Ginny, let's go back to you. You talked a little bit about the factors that went into you making this decision, but I'm wondering, were your doctors supportive? What kind of roadblocks did you run into as you made this decision?

Ginny Shudlick:

I was very fortunate. Since, I’ve found out that other people haven't had the same experience. The first consultation I had with the plastic surgeon, before any kind of treatment had started, flat was presented as an option. It was presented at the end, after all the other options. But I specifically remember the doctor saying to me that, sometimes, women come in here, even younger women like yourself, and this is the first and only time I ever see them because, ultimately, they decide that they want to go flat. Just having him verbalize that, I think, put it in my brain because it wasn't something that really had occurred to me prior to him saying that – like, oh, I guess that could be an option. I didn't really think about that. I had only been thinking about implants, for example. Having that from the plastic surgeon and having that in my brain from the get-go really helped me solidify that decision. I was also really fortunate that my oncology team was supportive of my decision. My family has been really supportive of my decision, as well, and it was always my decision to make. It wasn't anybody else’s. There wasn't a lot of noise that I had to deal with when I was going through all of that, which was great.

Jean A. Sachs, MSS, MLSP:

Sylvia, you talked about some regrets. What do you wish you had known prior to making your decision? What would've helped you make a decision that maybe you would've been happier with?

Sylvia Morrison:

I will say my surgeon was very good and he did tell me that there was a possibility that it would not work, and if it didn't, he would have to put the expander back in. But I went into the hospital thinking I'm going to get this surgery, he's going to do the tissue transfer, and I'm going to be okay. I knew I was going to have to go in ICU for a little bit.

Well, I ended up with the original operation, then I went in and the left side didn't take, and I had to go back and have emergency surgery, not once, but twice. So that was three times I end up in the OR for this one surgery. I ended up with three different surgeries. Then on the back end, about a month later, my expander that had to be put back in got infected. So, that was a fourth surgery. I have some pretty extensive scarring from hip-to-hip on my back where they used tissue the second time, and then of course my breast is scarred. That's a lot of scarring, that's a lot of surgery. For that reason alone, had I known, I definitely would not have chosen that route, because that was a lot for my body to go through.

Jean A. Sachs, MSS, MLSP:

Right. And do you feel like you knew this was a possibility, but you didn't know the extent of what it would be like?

Sylvia Morrison:

Right, right. He told me there was a possibility, but I should have asked more questions as far as if this does not work, what does it entail to correct it? That may have changed my thinking about going forward with it.

Ginny Shudlick:

I just want to jump in here with what Sylvia said because I waited as well, I was able to talk to a lot of other survivors that made all of these other decisions about whether they wanted to stay flat or get reconstruction. And talking to them and hearing their stories also really helped me solidify my decision. I didn't want the additional surgeries because it's generally not a one-and-done type of thing. But I wouldn't have known that until I was talking to some of my peers.

Jean A. Sachs, MSS, MLSP:

Yes. We know that the community's so important. Ginny, while I have you, there is a question in the chat. She has heard that for some women who decide not to reconstruct that your chest can become concave. Has that happened to you?

Ginny Shudlick:

Yes. Okay. I am slightly concave. If I wanted to, I could go in and get some fat transferred, but again, I don't want to do anymore surgery if I don't have to. I'm happy with how I look aesthetically.
I had my surgery in 2019 and I had small breasts to begin with, so I did not have a lot of extra skin even though we thought maybe we were going to do implants or something later on. So, my situation is a little bit unique there. I think women with larger breasts, there would be more skin around and you wouldn't necessarily have that aesthetic effect unless you went in and specifically asked for aesthetic flat closure. That terminology didn't exist until 2020. So, now you have language to go in and ask for that.

Jean A. Sachs, MSS, MLSP:

Yes, I'm really glad you mentioned that. That is really important. Thank you.

Amy, since you're the closest to going through this, how did you your doctors explain the timing and your recovery from breast reconstruction, and how well did that match what you experienced?

Amy Battaglia:

You have to wait a little bit of time in between your mastectomy, when you have expanders in and when they do the implant exchange surgery. I felt like after the mastectomy I could do anything now. The implant exchange, it's outpatient. The recovery was like nothing. I don't know if any of you had a port put in, but I compare it to my port surgery. You're sore for a couple days but you're back at it. I was walking out and about. I have a young son and I was out with him. You wear kind of like a brace. I'm losing the word. That's another fun thing with my brain after chemo. You wear a compression garment over the area and you're good to go. I wasn't down and out, maybe a day in bed the day that I came home from surgery, but it was very easy. It was a lot easier than I had anticipated. They told me it was going to be much easier, but I didn't believe them. But it was quick and easy and I'm glad that I chose to do it.

Jean A. Sachs, MSS, MLSP:

Okay, thank you. We understand chemobrain, so you're doing great.

There are a lot of questions, and not surprisingly, they're mostly medical. So, I'm going to start because we want to focus on decision-making.

Let me start with a question for you, Dr. Serletti, which is, what are the major issues doctors and women should discuss when they're thinking about breast reconstruction options?

Joseph M. Serletti, MD, FACS:

I think that, as a surgeon seeing a new patient, you have to evaluate the patient, evaluate what things are going to happen after their cancer surgery in terms of radiation chemotherapy. You have to see the patient look at their body habitus and then discuss with them what all the options are in breast reconstruction. So, implant-based, two-stage implant-based, direct-to-implant autogenous reconstruction from the abdominal donor site, other donor sites. And, once you've gone through that full menu, see what direction the patient is interested in moving in.

Jean A. Sachs, MSS, MLSP:

And how do you talk to your patients about potential complications? I mean, I know it's a scary time. These women have been diagnosed with breast cancer, so how do you set them up so they know complications might happen?

Joseph M. Serletti, MD, FACS:

Basically, there's two ways to reconstruct a breast: implant-based and autogenous-based. Certainly autogenous is a more complex surgical operation. It's a longer operation, but the success rate is actually much higher than with implant reconstruction. So, we tell every patient, look, whatever we set out to do in the beginning, may not work. Obviously, this happened to Sylvia. It may not work. The one thing we always tell the patient is, if it doesn't work, you will end up with a successful breast reconstruction. It may take us a couple of operations, but it's going to happen. But I tell patients in this general discussion of implant-based versus autogenous-based, that the implant reconstruction fails 3-to-4 percent of the time, and it's based on infection.

If an implant gets infected, we try to treat it with antibiotics. A lot of times we're successful. But if the infection will not be treated, if it's not treated successfully with antibiotics, you have to remove the implant. That doesn't mean it's the end of implant reconstruction. We typically wait 8 weeks, 10 weeks, and then go back to either putting a tissue expander or an implant in again. I will say that with basically every implant infection that we've had and lost the implant, we ultimately got a successful implant reconstruction in our patients.

With autogenous reconstruction where we're taking tissue from the abdomen, separating it from the body with the artery and vein, bringing up to the chest, hooking it up to an artery and vein in the chest…at Penn Plastic Surgery, where we do more of this than any place in the world, frankly, our failure rate is 0.6 percent. Our success rate is 99.4 percent. So, it's rare that we lose a flap, but it happens, and you have to let the patient know it because it can happen.

Jean A. Sachs, MSS, MLSP:

Well, that's good. It's good that that information is shared. Can someone go from deciding not to reconstruct, to “Oh, I do want to reconstruct” a couple years later? Is that possible?

Joseph M. Serletti, MD, FACS:

Sure. Oh, yes. We've said this for many years. There's two ways to reconstruct. There are two timing mechanisms for breast reconstruction: immediate, which is either initiated, or done completely, at the time that the mastectomy's done; and delayed, so that the patient has a mastectomy and comes for a reconstruction at another point in time. Whether implant-based or autogenous-based, there's no time limit to delayed reconstruction. We can do it 6 months after the mastectomy, we can do it 20 years after the mastectomy.

Jean A. Sachs, MSS, MLSP:

So, women should know you have options, right?

Joseph M. Serletti, MD, FACS:

Yeah, always options. Always.

Jean A. Sachs, MSS, MLSP:

Can you explain the difference between saline or silicone implants?

Joseph M. Serletti, MD, FACS:

Sure. I would say 95 plus percent of the time we use gel implants. There's been a lot of research done on negative effects of having silicone gel implants and it's called breast implant-related disease. Nobody has been able to prove, no scientific organization has been able to prove that there is a link between silicone gel implants and breast implant-related disease. But I believe it exists. I believe there's a very small percentage of patients who definitely have some negative reaction to implants, but it's very small. We tell patients that there is this potential. And when we see someone like that, we remove their implants and their symptoms usually get very promptly better. So, other than a very, very small group of people, we have gel implants and we have saline implants. If some patient is really averse to the potential of this rare breast implant-related disease, we'll offer saline implants. When I see a patient in the office and they ask me, what is your opinion about saline versus gel implants? I always say this – and I mean it, from the bottom of my heart – if my wife was in this situation and she asked me should I have gel implants or saline implants, I would tell her, have gel implants. Because the gel is just much more natural. The gel under the breast skin feels a lot more like a breast than the saline implant.

Jean A. Sachs, MSS, MLSP:

Thank you. There are a lot of questions about radiation and implants. Can you talk about that?

Joseph M. Serletti, MD, FACS:

Absolutely. I deal with it on a weekly basis. In the past, if we knew someone was going to have radiation, we would put in a tissue expander underneath the muscle, expand them prior to radiation, let them have the radiation, and then after radiation, take out the expander and put in an implant. And most of the time you did that, you got a very unsatisfactory result, meaning that the implant had significant firmness. It's called capsular contracture. And it's very, very hard to get a decent result in implant reconstruction with that situation.

Over the last couple of years, we've been doing direct-to-implant, where we've put the implant in right away, or a tissue expander in. We've been putting it on top of the muscle, and we've been putting some acellular dermal matrix on top of that. And what we have found is that those people who need to go on to radiation, they don't seem to get the same firmness that we saw when either the expander or the implant was underneath the muscle. We believe that it's the radiated pectoralis muscle that is really contributing to the capsular contracture. So, that's radiation in the implant scenario. If I know someone wants implant reconstruction, whether it's two-stage with expanders or direct-to-implant, and we know they're going to be radiated for sure, we're going to put it in what's called a prepectoral position. We put it on top of the muscle, and underneath the skin. And this has worked out, so far, pretty well.

If someone's going to have the flap, we just go ahead and do the flap. The flap tolerates radiation reasonably well. I'm not going to share this publicly, but we work with several radiation oncologists who are outstanding at radiating a breast that has had a reconstruction, and they understand how to do it so that the cancer is treated, but there's minimal impact on the reconstruction.

Hopefully I answered it reasonably clearly for everybody.

Jean A. Sachs, MSS, MLSP:

Yeah, there's always a lot of questions on that. Here’s another question: if you have breast cancer in one breast, will insurance pay for a reduction in the breast that has not been impacted by cancer to get better symmetry?

Joseph M. Serletti, MD, FACS:

Yes, so, everybody should know: There's a thing called the Federal Breast Act, which was sponsored by Senator Alfonse D’Amato from New York. I was at the University of Rochester before I was at the University of Pennsylvania, and that's where we really started doing, in the early 90s, free-flap breast reconstruction. Senator D’Amato came to visit us at the University of Rochester as he was putting this Federal Breast Act together. One of the things that we talked about, which he had already figured out, was that it was going to mandate that all insurance companies cover balancing procedures on the opposite breast. Prior to this, if someone wanted a reduction, they had to pay for it themselves. If they wanted an augmentation, they had to pay for themselves. If they wanted a breast lift, had to pay for it themselves.

Every patient on this webinar should understand there is a federal law that mandates that balancing procedures are covered by your health insurance company. So if you get denied, I would call your local congressman, because they can't deny it.

Jean A. Sachs, MSS, MLSP:

There are some questions about tightness after having expanders in and, after several years, still having a lot of tightness under the arm. Is that common, and what causes that? Is there any way to avoid it?

Joseph M. Serletti, MD, FACS:

It's not common, but we see it. It's not an easy thing to treat, a lot of times. A lot of times what patients are having is post-mastectomy pain syndrome, which is sort of like – if someone has a leg amputation and they have phantom limb pain, it's the same thing. There are a lot of nerves that go into the breast and they're cut as the breast tissue is removed. And these nerves, which usually settle down in most patients, can remain very active and they cause this sort of chronic pain. People describe it as a vice across their chest, or a band across their chest. When we see a patient with this, one option is to remove the implants. I tell them we can remove them. There's no guarantee that this pain can get better. I've been down this road with a number of patients, and in the end, if we can't solve it surgically, they really need to enter a pain management program.

Jean A. Sachs, MSS, MLSP:

There's another attendee saying she just had her exchange surgery very recently and she's not happy with the results. Do things change over time? Is what it's like at the beginning the way it's always going to be? What can she expect?

Joseph M. Serletti, MD, FACS:

I would say that in general, an implant-based breast reconstruction looks its best the day you do it, and it tends to change to the negative over time. So, if it's not looking good right now, it's probably going to need some revision. I'm just being totally upfront and honest. With an autogenous reconstruction, when we use the patient's own tissue, it can look very surgical, meaning it doesn't look much like a breast. But by doing nothing over time, your own tissue tends to soften itself out and it definitely gets better over time. I've always referred to this as the realities, the late realities of breast reconstruction: that in implant reconstruction, it can look great at 6 months or a year. And if you look at it 5 or 10 years later, it doesn't look anywhere as good as it looked then. And that's okay. Unfortunately, if you have implant reconstruction, you're probably going to have one or two revisions over your lifetime, which is fine. Autogenous reconstruction is just what I said: it can look very surgical, irregular, a little depressed here and there. And if you wait, over time, by doing nothing, your own body and your own tissue has a way of smoothing itself out.

Jean A. Sachs, MSS, MLSP:

Right. When you talk to patients who choose implants, do you tell them ahead of time that you probably will need to have these replaced? What information do you share with women upfront about what to expect?

Joseph M. Serletti, MD, FACS:

What I say is that the current recommendation is that we get an MRI every 5 years. I say, we'll do it every 5 years. A lot of people come and say, “I've heard I have to have these replaced at 10 years.” That's not true at all. We get an MRI at 5, if the implant looks good and the patient is happy, you don't have to do anything. Same at 10, same at 15 years. My feeling is when you get to 20 years, we should probably replace the implants. Why? Because when I replace implants that are younger than 20 years, they're almost always intact. And I see this both for cosmetic surgery and for breast reconstruction. When we see someone who comes in with implants that are over 20 years, one side's intact, the other side is ruptured, and it's an asymptomatic rupture. So, I think my personal feeling is these things can last for 20 years, but at 20 you should come in and have an implant exchange.

Jean A. Sachs, MSS, MLSP:

And would a woman know that her implant had ruptured? How?

Joseph M. Serletti, MD, FACS:

Usually not. It's usually asymptomatic.

Jean A. Sachs, MSS, MLSP:

Okay. So, that's why the MRI is important?

Joseph M. Serletti, MD, FACS:

Yes. Yes.

Jean A. Sachs, MSS, MLSP:

Okay. So, back to surgery. We have a couple of questions about who's a candidate for nipple-sparing surgery, and does that work? Is that a good option for women who've had breast cancer?

Joseph M. Serletti, MD, FACS:

Yeah. We do it all the time. I would say you can't have an overly droopy breast and you can't have a D to DD, or beyond, breast cup. So, if you have an A, B, or C breast with not a lot of droop and you have a breast surgeon who is comfortable doing this operation, and the tumor is not near the nipple. Again, this is a decision between the patient and the breast surgeon, because the tumor cannot be near the nipple. But we do nipple-sparing all the time, and we do it for both implant-based reconstruction and autogenous reconstruction, either one.

Jean A. Sachs, MSS, MLSP:

So, there are a couple of questions. This is really back to decision-making. Some women are now considering getting areola or nipple tattooing. Is that something you talk to your patients about? Is there a certain time that it's good to do that? How do you talk to patients about that?

Joseph M. Serletti, MD, FACS:

We won't do it before 6 months after completing implant reconstruction or 6 months after autogenous reconstruction. And it's usually later than that. There are two ways to reconstruct the nipple. There's a two-step process and a one-step process. The two-step process makes the most realistic-appearing nipple. Whether a patient has implant or autogenous reconstruction, and if all they're having done is a nipple, we can do this in the office under local anesthesia so that they can drive themselves to the office, we can do this, and they can drive themselves home. The two-step process is under Novocain. We make a nipple projection in the office. You let that heal, and about 6 or 8 weeks later, we have a tattoo person in our office who's very skilled, and she will then put the color in. So, that combination of the nipple projections made surgically and the tattoo, it makes a very realistic nipple. A lot of patients do not want the two-step. They don't want the projection of the nipple. So, the alternative is just come in for the tattoo person to do a three-dimensional tattoo, which again, is an office visit. They drive in, it takes about, I think 20 or so minutes per side, and they have a three-dimensional tattoo, which looks good. It doesn't look as realistic as the two-step method.

Jean A. Sachs, MSS, MLSP:

Thank you. For our national audience, if you want to find out where you can get this done in your location, you can contact us and we can help you figure that out.

Some people are asking, is it better to see a reconstruction surgeon or a plastic surgeon? Are they really one and the same?

Joseph M. Serletti, MD, FACS:

It's one and the same. One and the same. No question.

Jean A. Sachs, MSS, MLSP:

Okay, great. That's an easy one to answer. I love this next question. We have someone who says, “I'm 86 years old, so how old is too old for reconstruction?”

Joseph M. Serletti, MD, FACS:

There's no age limit. We have definitely reconstructed people in their eighties. I've seen people who come in with an old implant and they want it changed. We've written at least two papers about age and autogenous reconstruction, which is the more complex method of reconstruction. And we looked at our experience in patients 60 to 80, and then patients age 59 to 20-something. And there were no differences in the medical or surgical complications between the older group and the younger group. If you're 86 and you're pretty healthy, there's no reason you can't have breast reconstruction. There's a thing called the ASA class, it's the American Society of Anesthesiologists, and it gives you a risk assessment for having surgery. An 86-year-old who either takes no medications or maybe just has some high blood pressure, they're ASA of two. Most people are an ASA of two. There's no reason why that person can't go ahead and safely have breast reconstruction. It's not age, it's your overall medical health.

Jean A. Sachs, MSS, MLSP:

That's great. Thank you. Another person is asking…she met with a surgeon and this surgeon advised against a DIEP flap procedure if she intends to get pregnant in the future. What kind of complications could happen if a woman does get pregnant after doing that procedure?

Joseph M. Serletti, MD, FACS:

So, same thing. Again, we sit in a very fortunate position where we've done more DIEP flaps than any place in the world. So, we've written almost everything about it. And we looked at our patients a few years ago, people who got pregnant after DIEP flap surgery. I can't remember if there were 20 or 25 people. They all had successful pregnancies. There were a couple of twin pregnancies and one triplet, which is crazy. We looked at it from our Rochester group as well. And the thing that we learned is most of these patients delivered by C-section. I think because of the scarring and the lower abdomen, it just doesn't distend like it does in a normal person. And so, a lot of these people had C-sections, but a few were able to deliver vaginally. So, we don't really consider it because our experience has been so positive that patients clearly can get pregnant. And I'll never forget, I had one patient in Rochester, a youngish woman, who had a unilateral mastectomy, free flap breast reconstruction about 6 or 8 weeks after surgery, or maybe it was a couple of months. She got pregnant in the postoperative period and she was our earliest patient after surgery, she did fine.

Jean A. Sachs, MSS, MLSP:

And for the DIEP flap, you can get the fat from your thighs as well, like there's other places in your body [other than the abdomen], right?

Joseph M. Serletti, MD, FACS:

Yeah. Our No. 2 go-to place for other tissue is the thigh. It used to be the buttock, but that leaves a pretty significant donor defect. In other words, there's a significant loss of tissue from the buttock, and it doesn't give the best tissue. So, our second go-to place is the thigh, which actually works reasonably well.

Jean A. Sachs, MSS, MLSP:

And is the healing process easier?

Joseph M. Serletti, MD, FACS:

I think they seem to recover a little more quickly than the abdominal patients. Definitely.

Jean A. Sachs, MSS, MLSP:

I've been hearing a lot recently about over-the-muscle, under-the-muscle implants. If you've had them under the muscle, can you switch them to over-the-muscle? Is it true that they're more comfortable? What are your thoughts about over or under?

Joseph M. Serletti, MD, FACS:

Today we mostly put them on top of the muscle. It's a lot less uncomfortable in the immediate surgical post-operative period because putting it underneath the muscle is painful. It gives you an overall softer result, definitely a higher rate of rippling. Rippling is where you see the creases on top of the implant. But that can be treated with a secondary operation. Definitely, if you're going to be radiated, definitely putting it on top of the muscle is good. We have had more wound complications putting it on top of the muscle, so putting it underneath the muscle gives it some additional soft tissue protection. But I think all things considered, going on top of the muscle is the better way to go.

Jean A. Sachs, MSS, MLSP:

Okay, thank you. I have the question of how small of an implant can you get? This woman is an A cup and so she wants to know, could she still get an implant to match?

Joseph M. Serletti, MD, FACS:

The answer is yeah, the implants go down to about 100 CCs, which would be an A cup. So, yes.

Jean A. Sachs, MSS, MLSP:

This is an important one. You need a surgeon trained in microsurgery for a DIEP flap. Is that correct?

Joseph M. Serletti, MD, FACS:

Yes.

Jean A. Sachs, MSS, MLSP:

And is that easy to find around the country? I know we're in Philadelphia, we have a lot of great hospitals, but is this something people can find pretty easily?

Joseph M. Serletti, MD, FACS:

Well, I think yes, it should be. When we started this back in 1991, I was probably the only person in New York State doing DIEP flaps. They weren't even being done in New York City. Now they're being done all over the place. We've trained so many people to do this.

Whatever city you're in, you should be able to find somebody who's experienced in doing this.

Jean A. Sachs, MSS, MLSP:

Great. All right, let's bring Ginny, Sylvia, and Amy back.

In listening to this conversation, is there anything you want to add, or something you thought about?

Ginny Shudlick:

I just wanted to kind of add on to what was mentioned earlier about the Federal Breast Act. I believe that's the same one that that means that insurance has to cover prosthetics, to cover lymphedema sleeves. So anybody that's recently diagnosed or goes through a mastectomy, even if you're flat temporarily or whatever, your insurance has to pay for a certain number of prosthetics. And you can get fitted at places like Nordstrom's pretty easily. And I think LBBC has some good resources as well that you can go through for that.

Jean A. Sachs, MSS, MLSP:

Absolutely. I think what we're learning from all the questions is that this is a really big decision and it's a hard one to make. There can be big surgeries, lots of decisions, and complications down the road. What advice would you give? I'll go to you first, Ginny. What advice would you give a woman who is trying to figure out how to sort through what's best for her? Because in the end it's what's best for you, right? Not what your neighbor did.

Ginny Shudlick:

As Dr. Serletti said, it depends on your body type, as well. You have to have a conversation with your surgeon. You have to find a surgeon that you're comfortable with to be able to discuss all the options and what is going to work for you. I would say my advice, and this is hard, is know that you can take your time and delay reconstruction if you want to. The most important thing is saving your life. And I really appreciated that. My medical team and my plastic surgeon, when I spoke to him, put a lot of emphasis on that. This is about saving your life. Now that we've got the plan for saving your life, let's talk about saving you, or what's going to help you mentally, and how we get you back to a physical place that you want to be. But, first and foremost, know that you don't have to be rushed to make those decisions, which ultimately aren't aesthetic.

Jean A. Sachs, MSS, MLSP:

Right. I want to make sure Amy's perspective comes in because she has young kids. Tell us why, for you, it was important to do it right away.

Amy Battaglia:

For me it was just trying to have some control over a situation where you have no control. So much is changing, you're getting hit with so much. It was like one choice that I had in all this. I have to say when I lost my hair, my young son, he's still asking, “when are you getting your hair back?” So, I think all these changes to us physically, it's a lot for them. It was a lot for him. It's a lot for you to handle. So, whatever you can take control of, that's what I did. That's why it really meant a lot to me to have that back, just to have some semblance of who I was prior to all this.

Just to let other people know, it's a personal decision. You have to think about what it is that you want at the end of this, because you're going to go from being a patient to a survivor, and patient mode is different than survivor mode. You will come out of it. You are going to be on that other side. It's hard to think about when you're in treatment mode and you're in patient mode. So, take your time. I think you have to just take your time, don't be rushed. You can always reconstruct later if you want, but if it's something that you know you want to do, maybe get it done while you're in the mix of being in the hospital. It might make it easier for you.

Jean A. Sachs, MSS, MLSP:

How about you Sylvia? What would you tell people? What was important to you in making these decisions?

Sylvia Morrison:

Something that I didn't do was connect with the breast cancer community and talk with women that had gone down that road, had been through those type things. I didn't do that. I would tell anybody now, talk to someone who's gone down that path and get their perspective. That way you'll have some idea of what it feels like, what you're looking at, and then you get that support as well. I would just suggest, get more information. I should have gathered more information before I made my final decision.

Jean A. Sachs, MSS, MLSP:

That's helpful. We know it's hard to do. You're diagnosed with breast cancer, you're making a lot of treatment decisions, it's overwhelming. So no blame for anybody, but I do think that's where connecting with people who can help you think about things and make the choice that’s best to for you. Because again, there's no right way.

Dr. Serletti, before we do closing remarks, anything you want to add after being part of this?

Joseph M. Serletti, MD, FACS:

I think that the most important thing is, if a patient is diagnosed with breast cancer and is interested in breast reconstruction, please make sure that you see a surgeon who does everything. We here at Penn, we do everything. We do lumpectomy, reconstruction, we do two-stage implant reconstruction, we do direct implant reconstruction, we do DIEP flap, we do thigh-based. There's nothing we don't do. But we're not the only people. There are a lot of people out there like us who do everything. The majority of my colleagues in plastic surgery do not do everything. They may give you all these options, but they're going to steer you towards, more likely, implant reconstruction because most people are very comfortable doing that. So, if you really want to get a fair assessment of what your options are and what may really be best for you, please see somebody who is an expert in this, who offers everything, so that they can give you all of the options and you can make an informed decision.

Jean A. Sachs, MSS, MLSP:

Yeah, that's a good point. We've definitely heard from a lot of women over the years that they go to a plastic surgeon and they have a favorite procedure and that's what they're steered towards. I think this is another area where getting a second opinion or even a third opinion is really worth it. We know some people live in areas where that's harder to do, but if you can, or you're able to travel or delay it because it is something you're going to live with for the rest of your life as, as you all can attest to.

I want to thank Ginny and Sylvia and Amy for being with us this evening and for sharing your stories, for being so open. I'm sure everyone got a lot out of that. I want to thank Dr. Serletti for his expertise. And I want to just thank the audience. I have not had time to look at what's going on in the chat, but there is a lot of interaction. I can tell a lot of you are exchanging email addresses and phone numbers and connecting with each other, which is something we really value when we can't do these programs in person. We used to be able to do these programs in person and women would run into the ladies room and they would lift their shirt up and they would show what they look like. And that was great. That's what people want to see. So, thank you everybody for participating and for spending your evening getting better informed and building community.

I want to also thank again our sponsors, our signature sponsor Natrelle and our benefactor sponsor Penn Medicine Plastic Surgery. Please remember, we're always here for you. We have a Helpline, we have programs throughout the year and this is why we exist. Thank you so much and everybody have a good night.