Breast reconstruction: Revision options and solutions for post-mastectomy pain

LBBC welcomes medical advisory board members Jonathan Bank, MD, FACS, and Ron Israeli, MD, FACS, and former board member and founder of AnaOno Dana Donofree to discuss the reasons to consider a revision surgery, common and complex problems, and how to find solutions to improve quality of life. Moderated by Ashley Dedmon, MPH, CHES®, LSS, our speakers share their knowledge and help you understand insurance coverage and the importance of finding a skilled and qualified plastic surgeon.

Webinar transcript

Ashley Dedmon, MPH, CHES®, LSS [00:00:00]:

I’m Ashley Dedmon. I serve as the vice president of mission delivery at Living Beyond Breast Cancer.

I am honored to be your moderator for this important session, and, I would like to share, I am a high-risk undiagnosed woman. And I am intimately connected to the cancer experience as a caregiver to both my parents who experienced prostate and metastatic breast cancer. I can relate to the complexity and challenges that accompany surgery and recovery as I had a double preventative mastectomy in 2016 at the age of 31.

Although I don’t fully understand the experience of someone who has been diagnosed with breast cancer, I carry a deep empathy and a shared commitment to find comfort and hope through our conversation this evening and providing trusted information for our LBBC community.

Tonight we have gathered to explore critical options and solutions for those who may be experiencing discomfort or pain following a mastectomy and breast reconstruction. This is a topic that impacts many in our community and we are here to provide clarity, hope, and practical guidance. I’m thrilled to introduce our distinguished panel of speakers.

Dr. Jonathan Bank, a board-certified plastic surgeon specializing in microsurgery, breast and body contouring, and breast reconstruction.

Dr. Ron Israeli, a board-certified plastic surgeon who is a nationally recognized expert in breast reconstruction.

And finally, Dana Donofree, a true inspiration to many. Diagnosed with early-stage breast cancer, Dana turned her experience into empowerment by founding AnaOno.

For more information on our very impressive panel, please go to LBBC.org.

Tonight’s session will begin with an introduction to the topic, where Dr. Bank will set the stage by discussing the potential need and options for revision surgery. This will be followed by a case presentation and a detailed discussion on available solutions. With that, let’s dive in.

Dr. Bank, take it away.

Jonathan Bank, MD, FACS [00:02:38]:

Thank you, Ashley, and welcome, everybody, wherever you are. I’m seeing the people sign in on the chat from all corners of the globe, it seems, which makes me just want to start by saying that as a physician, I take care of the person in front of me, in the room with me, and it’s a very individual way of practicing medicine. And in this day and age where we can get on things like webinars with LBBC and others, it’s occurring to me that we’re practicing medicine in a different way, and we can pass the experience on to people from all over the world, which is kind of mind-blowing.

But back to the basics of options after mastectomy. I’m going to start by sharing a little presentation showing the general options for people that are facing a mastectomy, and their choices.

I always start by showing the option of what we call now aesthetic flat closure. This is a patient of mine that came to me after she had an aesthetic flat closure. This is one of the choices that is available to women these days. There are many permutations of all these options, combinations of them, but these are the basics.

Option number one is what we call no formal breast mound reconstruction. A few years ago was actually coined aesthetic flat closure, and we support that. This is another choice where women have what we call implant-based reconstruction. In this case, on the squares above, you see the patient before a bilateral mastectomy done through an incision underneath the breast fold. And in the images below are results essentially after one operation in which we do the reconstruction in an immediate fashion with the implant and something called acellular dermal matrix, which is a mesh that wraps around the implant.

This is a little schematic, a computer-generated image that we created to show what this is. My talk will have some images of, obviously, women that have had breast reconstruction and some other intraoperative things. So this is the mesh that goes basically cradling the implant and through an incision, in this case, underneath the breast fold.

In some women that are very small breast and would like to be larger. We do this in a couple stages. In this case, it’s a woman that initially had tissue expanders placed that help grow the skin ot stretch the skin until we get to the volume that we want to achieve, and then we swap out the expanders, the temporary ones, for the permanent implants.

Another option is what we call natural tissue reconstruction or the flaps reconstruction. In this case, transplanting tissue from the lower belly to the breasts. This is done at the time of the mastectomy, typically. That’s called an immediate reconstruction, but it typically requires more than one phase to get to the final result. I’m not going to show all the phases here. I will show an example of the schematics of how this procedure takes place. Again, computer generated, so no blood, but just so you have a concept.

We basically make an incision in the lower abdomen and take out this shape of skin and fat. In this case, we were showing an example of how we save the skin but then go to reconstruct the nipple later. There’ll be a patch of skin that then turns into the nipple. All this is hinged on blood vessels, an artery that brings the blood in and a vein that drains the blood out; those are disconnected from the groin area.

In this case, we’re also talking about nerve reconstruction. So there’s a nerve that used to go to the belly, it’s connected to a nerve graft, and then after the mastectomy or at the time of the mastectomy, we can identify that cut nerve edge. The mastectomy is performed. I’m sorry for that weird animation, but there it is. And then we transplant the tissue from the lower abdomen to the chest area. And now we have something that we can mold into almost any shape we want, in this case, the breast or something that looks like a breast mound.

Then we reconnect the blood vessels to blood vessels between the ribs and the chest. And in a similar fashion, we connect nerves that over time can grow back. And remember that point that nerves can grow back. There’s a question, what happens to nerves that can’t grow back, if there is some issue with them? And we’ll talk about that later when we talk about post-mastectomy pain syndrome.

And that’s frequently done in immediate fashion. At the time of mastectomies, we do the reconstruction, but there’s also an option to do these types of reconstruction in what we call the delayed fashion, or in a subsequent stage. For instance, this lady that initially made one choice and then later selected to do something different. So we transplanted skin and fat from her lower belly and in several stages reconstructed her breast mounds.

I’m going to turn it over now to Dr. Israeli who will talk about what happens when those things don’t go according to everybody’s desires. And that can be for all different kinds of reasons, and some of them are beyond everyone’s control. It’s not to say that somebody had an error or a mistake during surgery. Sometimes that’s just how the cookie crumbles.

Ron Israeli, MD, FACS [00:08:08]:

Good evening, everyone. I’m glad to be here and happy to see people also from all over the world. It is amazing how we’re able to do this now in a way that we never have before.

Jonathan spoke about options for reconstruction, but we know that breast reconstruction by its nature is staged. He kind of touched on that. It typically takes more than one stage of surgery or more than one operation to get the best possible outcome, and those second stages we call revision surgery. It’s not always because somebody has an unfavorable outcome, it’s a typical part of how we do this type of surgery. I’m just going to share my screen and just show you a couple of slides as well. And I’ll go through those to explain some of the general concepts in revision breast reconstruction.

This is an example of somebody that presented to me having had surgery elsewhere. You can see that after having bilateral mastectomies and implant-based reconstruction with incisions underneath the breast, there’s asymmetry. The implants are malpositioned, too low, too lateral, and she wasn’t really given good options for revision or corrective surgery.

What I do when I examine patients beforehand, it’s very important to understand what the expectations are and what the problem is. And it’s an algorithmic approach. We want to make sure that the reconstructed breast mound is in the right place, right position, on the chest wall. That’s the footprint of the breast. And we always think about that in revision surgery. Here, clearly, the footprint is not. It’s too low, it’s too far to the side.

The other components we think about are the skin, the tissue under the skin, the fat, and the implant itself. And we can control all of those variables when we do revision surgery. Here in the operating room, you can see on one side is the before, you could see the implants are way too far to the side, the footprint is wrong. And then after the corrective surgery, the footprint is right. Postoperatively, you can see that after one operation, she has the implants better positioned with a much improved contour than it was before.

Implant revision surgery is a routine part of what we do as breast plastic surgeons, and it’s most commonly to address issues like malposition of the implant. We’re going to talk a little bit later about other issues including post-mastectomy pain related to reconstruction.

Just to shift gears, this is a patient who had flap reconstruction, and you can see her beforehand. I’m going to talk about what are the typical stages, what is revision surgery with a flap operation. Before, Dr. Bank showed you a before-and-after but didn’t show you the in-between, so I’m going to do that now so you get a feel for what revision surgery is with flap reconstruction.

You can see what she looks like beforehand. The tissue from the belly is going to be transferred as a DIEP flap with a breast reduction pattern for the mastectomy. And this is what she looks like after one stage. And this is not bad. This is what we expect. We know that when we do these procedures, frequently with a flap, that the intermediate stage is not going to be the final shape, and it may not be a pretty breast shape. That’s the expectation. We know that a revision procedure will be required. So this is an interim phase for a period of a couple of months where you can see on the lower breast on each side a little island of skin from the belly, that skin from the belly that was used to monitor the tissue. And then she was brought back for a second operation. And you can see on one side, you can see the image of what it looks like on the left side after that first revision procedure. That skin island was removed, the tissue is lifted, and we have a pretty breast shape. And then at a second stage, and you can see the final outcome after the second revision procedure — so third stage, three operations in total — she had a nipple reconstruction and then a nipple tattoo.

The way that we think about revision reconstruction, a little bit different for flaps and for implants, but conceptually, we want to control every layer of the breast that’s reconstructed and we want to make sure that we create a pretty breast shape that’s properly positioned on the chest wall.

I’m going to go directly to our cases now. We have three specific cases that we’re going to discuss, and the first one is a case of mine of prepectoral conversion. When we focus on these cases, we will be able to answer questions as well.

This is a woman that came to see me, initially with a problem of severe animation. She was 59 years old. She had a history of left breast cancer. She was treated with bilateral mastectomies and had subpectoral expander reconstruction underneath the muscle in 2006.

When she came to see me just last year, she had pretty significant residual deformity, we call this implant animation, and chest wall deformity associated with that animation. And really a lot of pain. She complained that her bra felt like it was always too tight. When you look at this image, this is an image of her flexing her chest muscles. But this is an image of what it looks like relaxed, and this too has some residual deformity and areas of concavity. What I’d like to do is I’d like to show a video now, if I can. The video is going to show her actually animating, when she brings her hands together and flexes her pec.

Kind of bring your hands in front of your belly, put them together. Now flex your chest muscles tight, tight, tight, tight. Relax. Flex again, very tight. And relax.

OK, I think you can see from that that it’s a pretty significant residual deformity that she had. And I was able to repair the problem that she had with the animation by moving the implant, which was underneath the muscle, moving it so that it’s over the muscle.

I’m just going to draw that out just so that people understand it. And I just set this up beforehand. This shows a drawing of a natural breast, and underneath the breast is a layer of fatty tissue and the ducts drain into the nipple.

In the normal anatomy, the pectoralis major muscle is on the chest wall itself. This is normal anatomy. It’s a cross section of the breast. What we know is that on top of the pectoralis major muscle, and I’m just going to draw it in yellow, is the breast tissue, the breast glandular tissue. This is normal anatomy and this is the ideal, this is what we want to achieve when we do breast reconstruction or when we do breast revision reconstruction. When we do a DIEP flap, for example, that Dr. Bank showed earlier, the flap is placed underneath the skin over the muscle. So that’s the ideal.

If we look at what my patient had after her mastectomy and implant reconstruction, first of all, the nipple was removed. So this tends to be, it’s a little flatter in the front of the breast after that surgery. She still has a thin layer of fatty tissue underneath that skin, but her reconstruction was accomplished in a way where the pectoralis major muscle was placed directly under her skin. So that muscle, which used to be here, that muscle was moved and is now adherent to, it’s directly underneath, the skin. And her breast, instead of breast gland, she has an implant, which I’ll draw also in yellow.

This implant, which is her breast now, the implant is positioned underneath the muscle. So every time she moves that muscle it pushes down on the implant and it creates that deformity and it can create pain. When we do this kind of revision surgery, what we call a prepectoral conversion, what we want to achieve — again, I’ll draw the layer of fat right underneath the skin. What we want to achieve is we want to go back to the normal anatomy, we want the pectoralis muscle back on the chest wall. And we can reposition the pectoralis muscle back on the chest wall with stitches securing it to the chest wall so that it becomes functional again. Then we place the implant on top of that muscle in a more natural position, and we secure that implant in place with a dermal matrix. Dr. Bank had mentioned that earlier, what we call AlloDerm, sort of a mesh. And you saw that in the diagram earlier. So the muscle is back where it belongs in this cross section, the implant is on top, secured in place with AlloDerm.

If you look at her normal anatomy before any surgery, pectoralis where it belongs, then the breast and then the skin, this is going to mimic that. It’s the same general anatomy. That’s the concept of this type of revision surgery, which is to revise the breast so that it’s back to a normal anatomic scenario where the muscle is back where it belongs.

I’m just going to show you again what she looked like after surgery. This is what she looked like after surgery, and you can see here she’s flexing her pectoralis muscle and we don’t see any animation at all. On the oblique view and on the side view, a much prettier contour.

What I’d like to do now is I’m going to stop sharing my screen and we’ll go to a couple of post-op videos that show that better. A post-op video with her again, actively flexing her muscles.

Let’s do it one more time. Hands together. OK, now flex. Super tight, tight, tight, tight. No animation, nothing. Relax. You’re relaxed, right?

Patient [00:18:55]: 

I think so.

Ron Israeli, MD, FACS [00:18:56]:

Yeah, I just can’t tell the difference.

Patient [00:18:58]:

I can’t, can’t.

Ron Israeli, MD, FACS [00:18:59]:

Flex again.

Patient [00:19:00]:

No you can’t! Because it’s not moving!

Ron Israeli, MD, FACS [00:19:03]:

That’s it. So that was a clear-cut, radical difference for her. And you can imagine she doesn’t have that tightness. The muscle is back home where it belongs. She doesn’t have the muscle pushing on the implant and causing spasm and discomfort.

I’d like to show one other video, the last video. And this is the patient, this is her explaining what she felt. And it’s best to hear it directly from her because she can explain the discomfort, the pain that she felt.

Ron Israeli, MD, FACS [00:19:34]:

You had implants that were under the muscle.

Patient [00:19:37]:

Yes, they were placed under the muscle 20 years ago.

Ron Israeli, MD, FACS [00:19:41]:

OK, so tell me, since then, about what happened and how you decided to have revision surgery. What prompted that?

Patient [00:19:50]:

I had horrible pain, and what happened was I consulted with my original surgeon who said there was nothing he could do. Until I researched and got over myself and realized that I needed to do something different.

Ron Israeli, MD, FACS [00:19:34]:

Let’s talk about that. When you say you had pain, describe that a little bit more.

Patient [00:20:06]:

Oh my god, I couldn’t raise my arms. I had no range of motion. It looked like I had two boobs and I can’t even explain, no matter what I did, no matter if I would reach for something, because you use your pectoral muscle for anything. I didn’t realize that 20 years ago they only did under the muscle, and I never realized that over the muscle was an option. So when I flexed my pecs, what happened was it like pulled and tightened and I was in pain.

Ron Israeli, MD, FACS [00:20:46]:

What did you feel after? Just explain after the surgery; describe after the surgery what you felt.

Patient [00:20:51]:

Oh my god. The first thing I remember feeling after the surgery was that I thought it was going to be awful because of the work on the muscle and the whole thing. The thing I realized was that I didn’t have that deformity, and I had no pain. And it was like less than 24 hours. And when I came back for my one-week post-op visit, I was like, “Look! I have no pain. I have no deformities.” And the rest is history.

Ron Israeli, MD, FACS [00:21:23]:

I think that says it all, that speaks volumes.

I just wanted to give this particular case as an example of something that we see fairly commonly, which is patients that present with discomfort, pain, animation with implants that are placed under the muscle. And there’s nothing wrong that a plastic surgeon had done by putting them under the muscle. That’s the technique that we were doing for many, many, many years. But now we know that you don’t need to do that with implants, and we can revise those patients by placing them over the muscle the way we would do DIEP flap reconstruction, for example. We always did flap reconstruction over the muscle. It wouldn’t make sense to do a flap reconstruction under the muscle.

Ashley Dedmon, MPH, CHES®, LSS [00:22:07]:

Thank you Dr. Bank, Dr. Israeli.

Continue to put your questions in the chat. I know a couple of questions have already been answered. We’re going to bring our speakers and our panelists back on screen.

A couple of questions to kick us off. Should implants be placed over or under the muscle? And I think we definitely touched on this, but just where we are today, is there a standard of where they should be placed or is that up to the patient to discuss with their doctor?

Ron Israeli, MD, FACS [00:22:52]:

I think as a general rule, we want to place the implants on top of the muscle in the prepectoral position if we can. And that of course depends on the quality of the breast skin. If there’s a good quality mastectomy and the skin looks healthy at the time of surgery, then you should be able to put the device, whether it’s a tissue expander or an implant, in the prepectoral position. And that’s in the majority of the cases that I do.

Jonathan Bank, MD, FACS [00:23:28]:

Yeah, that’s definitely the scenario for us. The last time I did an under-the-muscle, old-school type of reconstruction was 7 or 8 years ago, and that’s been the general trend across the country and abroad as well. But it’s not the absolute rule. I still know many doctors that do it the old-fashioned way. It’s not to say one way is better or worse. I think one way is better, but it’s always a matter of weighing the pros and cons of each technique.

There are pros and cons of anything in life, and specifically breast reconstruction, it’s always figuring out what is best for that patient and that specific scenario. The patient’s anatomy goes into it, their medical comorbidities go into it. Knowing what the future plan is for that patient may affect it. Knowing how surgical outcomes from mastectomy may be in one patient versus another with one technique of mastectomy versus another.

There are many variables and that the choice of what to do is always going to be with the patient and discussing the pros and cons with them. It’s definitely not the case where this is how it should be done in this day and age. It’s these are the options, let’s discuss why and choose together.

Ashley Dedmon, MPH, CHES®, LSS [00:24:59]:

I love that. And Dana, I’m going to bring you in. You and I have two different experiences. I know I decided to go under the muscle. Can you share with us what decision did you make, and what were some of the factors that went into making your decision for your reconstruction?

Dana Donofree [00:25:19]:

Yeah, it’s been so informative to kind of like do this overview of all of the reconstruction options. To understand a little bit about my experience and background, I was diagnosed 14 years ago at the age of 27. So when Dr. Bank references old school, I technically had one of those old-school reconstructions that needed to have a revision surgery with both Dr. Israeli and Dr. Bank as my physicians to help take me from under the muscle to over the muscle.

Ashley, you and I got a little bit of time to talk about the differences in our experience, and relying on what your physicians are sharing with you is super important as you’re making this decision because everybody’s body types and anatomies are very different. It might rely on their expertise, but it might also rely on your body anatomy as well.

For me, you know, one of our big concerns when I was under the muscle to go over the muscle was because my mastectomy was done so long ago, my skin was actually quite thin, and we knew that there might be a challenge going over the muscle because of my thin skin.

I personally was willing to take that risk to help curb some of the pain and the discomfort I had from my implants being under the muscle. I think that animation is obviously a huge part of that pain and discomfort as well as that awkward inner feeling when you can see your implants moving around your chest. It kind of just like makes your stomach twist just a little bit. And for me, although that bothered me, what bothered me the most was my chronic neck and back pain that I was suffering from for nearly a decade before I even really understood that this revision was an opportunity for me.

You really as a patient have to understand what’s bothering you the most. It might be your aesthetics and if it’s your aesthetics that’s also OK. It’s fully something that you can embrace to go and talk to a physician to make a revision. Mine was pain, and that’s really what I was trying to fix in my correction from under the muscle to over the muscle. But it was also a little bit of aesthetics. I really felt like I had two round bulbs that were stuck to my chest that didn’t move, they didn’t go anywhere. I had pretty severe animation as well, and all of those things stacked up for me to take the opportunity of that 10-, 11-, 12-year mark postrecon and think about what does my future revision look like.

But Ashley, I’ll toss that back over to you because I think your experience is equally as valid and is very different than mine. And this kind of just shows how you can have two very different experiences with two different types of similar surgeries.

Ashley Dedmon, MPH, CHES®, LSS [00:28:04]:

Absolutely, Dana.

As I shared, I’m undiagnosed, so I had a mastectomy preventatively because I carry the BRCA2 gene mutation, which makes me at a higher risk. Very similar to one of the photos that the doctors showed, I was a very small-chested woman, and so I had to go through the expansion process. I like how you described your breasts as balls, I called them my teacups because they look like teacups. It just took getting used to. I have my implants behind the muscle and I do experience the contraction that happens when I work out and in just different positions. I’ve had to have two revisions just from the rippling and then also from having my second child and what happens during pregnancy. I have a doctor who shared all of this information with me, and we have those check-ins where I go visit him. To your point, he’s just asking like, how do you feel, how are you feeling about your image. And he takes that very, very seriously as a part of our process. And so I think that’s so important and it’s kind of kicking us into our next question.

We know that complications can happen and so, Dr. Bank, Dr. Israeli, we would love to hear what are some of the common complications and what are those corrections that can be considered in helping to address those complications. And then Dana, I’m going to kick it to you to see if you had any.

Ron Israeli, MD, FACS [00:29:53]:

We’re focusing on, I guess, implant at this point, and the issues with implant complications relate to, first of all, pain and animation, which we’ve already touched on, but also the aesthetic appearance. Malposition is a complication, if it’s too low or too lateral; thin skin, which can contribute to rippling; and more and more recently with prepectoral reconstruction, we’re seeing flipping of the implant, the flipped implant. Any of these things they can be addressed surgically if they bother the patient enough. There’s a conversation between patient and plastic surgeon about realistic goals and surgical options. When each of you, Ashley and Dana, were speaking before, it occurred to me, I have patients that I see — I’ve been in practice for 27 years — that I’ve done the subpectoral reconstruction, as I used to do routinely, that come to see me for follow-up visits, as they frequently do. Nowadays one of the first things I ask them to do is, you know, flex your pec muscles, does that bother you. And some of them now that I’ve seen several times since I’ve started doing prepectoral conversion, they’re like, “You asked me that last time, leave me alone already!” Because it doesn’t bother them. So if it doesn’t bother them, it’s not painful, and the animation is not something that visually bothers them, then you don’t do anything. There’s no reason to do that.

Any of these, you know, complications if you will, for some patients it’s a complication, for other patients it’s not. And as Dr. Bank suggested earlier, it’s a shared decision between doctor and patient as to whether or not it’s worth doing a revision procedure. What is involved in the revision procedure, what’s involved in the recovery, and will it meet the expectations of the patient and the doctor, in which case, OK, we do it.

Jonathan Bank, MD, FACS [00:32:00]:

The main complications that occur after an implant reconstruction are implant opposition. So the implant can shift a little bit too low or a little bit to the side, not as common but to middle. Almost creating something called a symmastia, or like a single mound across the chest. All those are addressable by essentially reinforcing or reestablishing an appropriate pocket. Sometimes the implant is too narrow or too wide and can cause an appearance that’s not favorable.

The second one, Dr. Israeli mentioned it, is capsular contracture. There’s a question in the chat, can that happen to anyone or is it just after radiation. It can definitely happen to anyone. But, I’d say the study show that long-term risks of that are around 10% to 15%. Double, triple or quadruple that whenever radiation is involved.

Other things that can cause capsular contracture is around any implant, the body, because it’s a foreign object, the body wants to shell it away, it creates scar tissue. A lot of times the scar tissue is flimsy like tissue paper and sometimes it hardens almost like a cardboard box or an eggshell in some cases of radiation, or after long-term effects. The treatment for that is to remove the hard capsule and then usually replace that with that dermal matrix, with that mesh. And a lot of times that can help minimize recurrence of that capsule contracture but not necessarily. Other things that can cause capture contracture at a higher rate are infections or bleeding, things like that. Or other trauma that could precipitate those.

Another scenario that is very common is something called rippling. Because the implants are designed to feel like normal tissue, they never will be normal tissue, but they’re designed to feel that way. They come in different grades of what we call cohesivity or how firm the implants are. You can imagine if the implant would be very, very firm and hard, there’d be no rippling. The rippling is like think of a bag of water that you just hold up and you can see the ripples or the pleats almost of a bag.

A saline implant, we rarely use in breast reconstruction because it’s so fluid you’ll see a lot of those ripples. Now the very hard implants, on the other side of the spectrum, will be so uncomfortable, would not be pleasant to have in one’s body. So we use ones that are somewhere in between, more towards the cohesive or firmer ones. But even those it’s essentially a gel of silicone within a shell of a different manufacturing process of silicone. And in certain positions you can see that rippling. In people that are very slender and don’t have a lot of cushioning above the implant, between the skin and the implant, that’s going to be more noticeable. That’s a big trade off of doing a prepectoral reconstruction, essentially like Dr. Israeli drew, the skin, then subcutaneous tissue or fat underneath the skin, and then that bone matrix, and then the implant. If the cushioning underneath the skin is very thick, then you won’t see the rippling as much. But if people are very, very slender, then you will see that more. The trade-off is the whole animation situation and the other things that go along with it.

Another complication, particularly with a subpectoral reconstruction, but can be really with any breast or chest surgery is chronic pain after a breast or chest procedure, a post-mastectomy pain issue. And that I think is mainly related to nerves that are cut during the surgery. And that’ll be the next thing that I’ll discuss.

Ron Israeli, MD, FACS [00:33:44]:

I was going to say that’s a good segue into the next case because radiation is going to increase any of these complications. And if you have a complication with an implant in the setting of radiation — and this came up in a couple of questions in the chat — if you have an implant that’s been radiated and there’s a complication or loss of that device, the likelihood of being able to salvage the reconstruction with an implant alone is very low.

That’s where we come into thinking about the sort of gold standard in the setting of radiation, which without a doubt is a flap. And if it’s some somebody thin, you can take a flap from the back in combination from an implant, the latissimus dorsi flap, or you can take a flap from the abdomen, the DIEP flap, which is the ideal donor site, or the inner thigh. There’s a lot of options, but as soon as you have a complication with radiation and an implant, they don’t mix well, that’s when you’re going to start thinking about including a flap in the algorithm to solve the patient’s problem. And I think that’s the next case Dr. Bank is going to speak about.

Jonathan Bank, MD, FACS [00:36:55]:

I’m going to take the next few minutes to talk about a topic that’s near and dear to my heart. The short term for it is post-mastectomy pain syndrome, but that’s really only a subset of what I think the true term should be, which is post-breast surgery pain syndrome. Because these issues can occur after almost any operation on the breast or chest. It could be with a regular breast reduction, a breast augmentation, a lumpectomy, a mastectomy with or without reconstruction of any type. And we see a whole range of scenarios. It can also happen in what we call top surgeries in gender affirmation surgeries where the breast tissue is removed to create a more masculine appearance of the chest.

The hallmarks of those are all related to nerves that are cut during the mastectomy. There are nerves that travel underneath the breast skin that wrap around from the outer part of the rib cage and then ones that come from the inner part and they meet together. The larger of them provide the nipple areola complex, and that’s one of the reasons that that area is quite sensitive. There are nerves that pierce through the breast tissue itself, and those can be affected by the mastectomy because they have to be cut to do a safe oncological procedure. Additional ones, the ones that sort of wrap around, some of them can be during a mastectomy, if it’s a mastectomy that took care to note where those nerves are and save at least the larger ones. Some will be cut one way or the other, and those are the ones that can be a problem.

Remember when I showed that animation earlier on when I showed how we reconstruct nerves at the time of the mastectomy? Nerve reconstruction only works because nerves, what we call peripheral nerves or nerves outside of the brain and spinal cord, want to sprout back. They sprout back at about a pace of a millimeter a day. So it could take a long time for them to grow back and regain some sensation to the breast. We think it occurs better and faster if we actually reconnect those nerves at the time of the mastectomy.

There was a question, can we do it in a later stage. And the short answer is yes, it’s possible, but the results are much, much more variable in recurrence of sensation.

The issue that we’re going to talk about now is not so much reconstructing those nerves but thinking about how to address problematic spots that cause pain or this post-mastectomy pain issue.

The hallmarks, as I mentioned before, are related to those nerves wanting to grow back. Anatomically, physiologically, we want to have an indication that they are in a region where we understand the nerves to be, typically in the outer part of the chest, sometimes in the inner part of the chest. Not as common, but that can be. And it can also be in other parts deep inside the chest or in the upper part, under the clavicle area.

That’s typically because those nerves are cut and they want to grow back. Because they’re still connected to the spinal cord and the brain, the body thinks that they’re there. So the pain feels like it’s shooting along where it used to be. It radiates to the front, sometimes to the back. The typical complaints that people have is it’s burning, electric, sharp, stabbing pains. And it has to last more than 3 to 6 months from after mastectomy because almost everyone has some kind of what we call acute pain or immediate post-surgical pain. But if it lasts a long time, then that’s defined as post mastectomy pain syndrome and it can be addressed.

It’s much more common than what we would like to believe. There are several, quite large studies ranging from 500 to 5,000 participants from four different continents showing that the prevalence of those scenarios ranges from 10% to 50% or even more of women that have had mastectomies. Fortunately only a small percentage, somewhere between 2% and 10%, the pain is significant enough to really be debilitating to their daily living and requires some kind of additional treatment.

What treatments are possible? Standard pain medications, not everybody wants to be on those. If they don’t work, you don’t want to be on them for a long period of time. Some people find relief with numbing medicine injected into those areas and sometimes steroids. Those are procedures that can be done by pain specialists. There are ways to ablate the nerve so you can completely basically take out the nerve that was affected. And those are ablation procedures also done by people that specialize in in pain treatment.

We send almost all of our patients after mastectomy to a physical therapy group that specializes in post-mastectomy therapy. We think that that can reduce a lot of symptoms that are related to this post-mastectomy pain. Sometimes it can help release scar tissue that builds up and can be a cause of the post-mastectomy pain.

I get involved when all those have failed or they aren’t working to the degree that the patient would like to achieve. If the physical exam and the history corresponds to the diagnosis of post-mastectomy pain that’s not related to a stretched out muscle or radiation, which can also affect it; that there are no other medical issues like a cancer recurrence that can sometimes present as pain; and there are findings on physical exam that really pinpoint that pain. That gives me a target as a surgeon to go and explore.

Frequently what we will find are nerves that were cut during the mastectomy. Sometimes they’re just stuck in scar tissue, sometimes they’re stuck in suture material or clips that we use during surgery to proceed through surgery safely and stop bleeding. But sometimes they get intertwined and entangled with those nerves. And sometimes the nerves that want to sprout back grow things that we call neuromas. Neuromas are benign growths, just the normal sprouting of those nerves, but because they don’t have anywhere to go, they start causing a problem. It’s almost like a live wire that was cut. You can imagine what that would be if you touch that area, patients often jump to the ceiling, and I know that I have a target.

I’m going to show one example and then another example where Dr. Israeli and I worked together to address a couple of these postoperative issues, and we’ll get to that later. This is a patient that actually has a bunch of the hallmarks of the complications of implant reconstruction done elsewhere through incisions that are across her chest. Overall, it’s not a bad reconstruction, not by a far stretch, but she complained of tightness in the chest, her implants were underneath her chest muscles. And more importantly, specific to this conversation, where that X marks, I would touch her there and she would absolutely jump to the ceiling with pain that’s radiating both forward and backwards towards her back.

In this scenario, we did a couple things. We removed the implants from the subpectoral position. We reestablished the normal pectoralis muscle, or the chest muscle position, back on the chest wall so it wasn’t stretched out abnormally. She had radiation on the left side, which probably contributed to her pain. You can sort of see that the left side is a little bit more tight than the right and the shape isn’t as nice as the right side. And then we use the tissue from her lower belly, doing the DIEP flaps, and reconnected the nerves to nerves that we found during surgery.

This is a very closeup view. On the screen left, you can see my cursor, her natural skin, that’s towards the inner part of her body, and this, where those yellow backgrounds are, it’s towards the outer part of her chest. And if you can make out, these little strands here are about a millimeter, a millimeter and a half thickness, almost like a wet spaghetti. Those were nerves and you can see this ball in the middle of it, that’s an abnormal nerve growth. This nerve on the lower field was cut. We found the nerve edges on either side. And then to provide them a natural pathway to grow back, we use what we call a nerve graft, similar to what we’ll frequently use in breast reconstruction. The mesh is essentially skin from a donor devoid of all the cells. These things that look like little noodles are actually nerves from a donor as well, devoid of all the cells. So it’s just a natural channel for the nerves to grow back and then we’ll use something to connect those nerves so there’s no tension and they can just grow free and find the other side.

This is her later on after some other revisions done, making her nipples and so on. And this is her description.

Patient [00:46:51]:

We are probably, I would say three to four weeks, absolutely no pain whatsoever. None. Completely gone.

Jonathan Bank, MD, FACS [00:46:59]:

That’s the area that I used to touch and she used to [jump].

OK range of motion?

Patient [00:47:03]:

I can move everything. Yep.

Jonathan Bank, MD, FACS [00:47:05]:

We achieved natural looking breasts. [This is] before her areola tattoo, but more importantly back to full functioning life.

This is again, something that I think is very important to, number one, be aware of. That that scenario is very, very common, and more importantly that there are solutions for that. And that’s something that I focus a lot on in my practice, in combination with everything else.

It’s really affected how we do surgeries all over the body, being mindful of those nerves. It really affects the interaction that I have with the breast surgeons that I work with. Make sure that they’re not putting the patient at risk for no need. And we work together as a team to preemptively avoid these issues. And if those issues arise, we don’t just say, oh, that can happen and we’re not going to do anything about it. We really say let’s tackle this problem together and find a way to if not cure it, at least help.

Ron Israeli, MD, FACS [00:48:10]:

The next case is in many ways similar but different. It might make sense to actually present this next case that Dr. Bank and I worked on together, helping this patient, because I think it’ll bring up some questions that may apply to both of the cases.

This is a DIEP flap revision case. This is a patient who, unlike Dr. Bank’s previous case, presented to us having had mastectomy on the left side with reconstruction elsewhere. She’s 42 years old. She had a history of left breast DCIS that was treated with a left mastectomy and a DIEP flap reconstruction. At that time they also did a breast reduction on the opposite breast.

The surgery that she had was complicated with, or complicated by a skin necrosis on the left lower reconstructed breast. And you can see that in this image, the left lower breast skin itself did not heal. She developed an open wound, the unhealthy tissue had to be removed surgically. They applied a vacuum-assisted closure dressing that required frequent dressing changes until that healed. But then she developed a hardness of that lower breast flap. And I know that there were some questions about that in the chat earlier. People that have had DIEP flaps and now have areas that are firm or hard and that could be painful or not, but that’s what she had, areas of fat necrosis, firm regions underneath the skin within the flap itself that were tender.

She also specifically complained to me about a terrible sensitivity, very, very severe pain along the upper inner aspect of her left reconstructed breast. This is her with the markings just prior to surgery. I had marked the circle that’s around the areolar skin island and the markings on the lower breast to revise the reconstructed breast to expose the tissue so that I can remove the areas of fat necrosis that were hard, firm, painful.

I asked Dr. Bank to participate in her surgery as well, given his experience with the nerve repairs, as I’ve learned a tremendous amount from him in how to manage these patients. We examined her together, prior to surgery in the office and focused on this terrible sensitivity that she had to the point where she was complaining that she can’t even hug her children because anybody even touches lightly on that skin and it’s just a terrible shock, that pain that she develops.

That X is Dr. Bank’s handwriting. It shows the spot where she had the pain marked just prior to surgery before we took her to the operating room. So I exposed everything and began the revision procedure. And I’m going to let Dr. Bank explain what we’re looking at here.

Jonathan Bank, MD, FACS [00:51:41]:

Where the green background is, that’s towards the inner part of the chest. Behind the retractors, the big black one, and that’s again, towards the inner part of her chest. And then the flap that was previously done is on the other side.

Here again, it’s not that common a scenario to have the nerves on the inner part of the chest really be the problematic one, but that was the case in this patient and we went in, as we term it, a surgical exploration. You don’t really know what you’re going to find. You have to be prepared for all the kinds of scenarios. Specifically in this case, because it was a DIEP flap, right underneath that green mat is where the blood vessels that supply the whole tissue that comprise her reconstructed breast exist. We needed to be very mindful of those, not to damage those. You have to have that understanding of the anatomy and ability to manipulate the tissues in a cautious way as to not do further harm.

Fortunately we were able to find nerves right in those areas. They travel right next to the blood vessels and the ribs that are in that region. In this case it actually did something that was a little bit different. On the bottom part of that green mat is the nerve, that’s part of her chest, and then on the top part you see a very, very tiny nerve ending that actually goes into her breast skin. Essentially we reconnected the nerve that was cut during the mastectomy from the chest to the skin envelope, and potentially that may grow and meet together, theoretically providing some return of sensation. I don’t think she’s far enough out yet to determine if that’s the case, but she definitely has almost no pain or no pain whatsoever at this point.

And then Dr. Israeli completed the reconstruction in her and obviously she has a much nicer shape just at this point. At a subsequent phase she had nipple areola reconstruction and tattoo. So here we achieved the perfect diad of plastic surgery, which is restoration of form and function. The form is clear and beautiful, and the function of having a chest that enables one to hug one’s loved ones is really a win in this case.

Ron Israeli, MD, FACS [00:54:34]:

Yeah, that’s the biggest win. She is a bit too early to tell if she’s going to regain sensation necessarily, but the key is that she doesn’t have that chronic, unremitting, terrible sensitivity, and of course a pretty breast shape. The left side, her left breast, is a mastectomy with a DIEP flap, nipple reconstruction, and tattoo. Her right breast is a breast reduction, and her abdominal scars are still immature scars. They’re still, you can see them, are dark in color and a little firm. This photograph was taken in the office very recently as she’s presenting for management of the scars with microneedling. We don’t consider that as necessarily a breast revision operation, but management of scars and adjunct procedures that help us improve scars is something that we do with not only breast reconstruction patients but all of our patients. And that’s an important tool for us.

So I think that this case, a little different than the previous one does bring up a lot of very similar issues and I think we’ll be able to kind of focus on answering questions now perhaps related to both of these cases.

Ashley Dedmon, MPH, CHES®, LSS [00:56:11]:

Thank you, Dr. Bank and Dr. Israeli. We’re going to bring all of our panelists back on for Q&A. We have some great questions in the chat. We have participants that have shared about your artistry, your work, beautiful, for both Dr. Bank and Dr. Israeli.

A couple of questions. Can sensory nerve reconstruction be done during a revision if this option was not discussed before having a DIEP procedure?

Jonathan Bank, MD, FACS [00:56:48]:

Yeah, that’s a very common question. The short answer is yes. The nerves that are cut, they don’t vanish, they don’t go away. But the tricky part is finding those stumps of nerves, and the question is how functional are those nerves at this point. If you cut a nerve and then reconnect it, it has the best chance of growing back. If you cut a nerve and leave it for a year or 2 or 10, there is some degeneration of the nerve from the cut edge to a variable amount of distance backwards.

Whenever we do these operations, we’ll find the cut nerve edge and then we’ll trim it back to what appears to be healthy nerves. There are ways to identify what looks healthy, but it’s still hard to say what is actually functionally going to regrow. I would say that there’s a large variability in that.

If you think about it, if you have chronic pain in one spot, that tells me that that nerve is actually functioning. It’s hurting, but it’s alive. So that gives me more hope that if I find that and reconnect it, that it will grow back. Maybe restore some sensation.

I do have more than a few patients that have had revision surgeries just with implants. And we find those nerves and then we shift them and direct them to grow into the skin. I can’t fully explain it, but I have had people that have regained a lot of their sensation after. I don’t have a good explanation for how that works; I have all kinds of theories. I never ever guarantee, but I have seen it happen. I think that the downsides are fairly low particularly if there’s a pain situation that you’re potentially helping. And if you’re reconstructing something that doesn’t go anywhere, then I don’t think you’re doing much damage in that scenario and you are giving some hope. That can be done both in the implant scenario, in the no reconstruction, in an implant or a flap reconstruction, and that’s it. I’d say just keep challenging us because that’s the only way we grow as a profession.

Ron Israeli, MD, FACS [00:59:04]:

I think the risk-benefit or downside, if you will, if you don’t have a specific neuroma, like the cases that we presented where you know where to chase and find those nerves, is that — if you happen to find a random nerve, OK — but to take things apart and chase nerves where there’s no known pain issue is more of a difficult thing to do. Wouldn’t you agree with that, Jonathan?

Jonathan Bank, MD, FACS [00:59:41]:

Yeah, if you find nerves that are intact, again, the first tenet of medicine is first to do no harm. So you don’t want to disrupt something for no reason. But if you find nerves that are in regions that you identify were affected by surgery and there’s a problem, go after them. Or if there’s nerves that were cut but they’re not causing a problem and we want to maybe try to restore some sensation, then again you think a hundred times before you take that action. But I think with the correct plan, the risks are fairly minimal.

Ashley Dedmon, MPH, CHES®, LSS [01:00:17]:

I was going to kick a question to Dana as we’re talking about nerve and sensory.

Dana with founding AnaOno, in your experience, how important was that when creating your line, taking into consideration nerve sensitivity, loss of sensitivity from your own experience and even just hearing feedback from persons who are looking for comfort undergarments to be able to wear on their body. How was that? And this is more of exploratory, I was wondering is that something that was a factor?

Dana Donofree [01:00:58]:

Thank you, Ashley. I’m reading the chat and absorbing all of the information that so many patients are here sharing, and it seems there is a lot of pain associated with these surgical procedures. Some people are lucky and have no pain at all. But with my own experience and also the experiences that we hear every day, I will say the number one complaint and the number one challenge that we work with is overall body pain. Whether it’s coming from the nerves, if it’s coming from where the implants or the reconstruction is sitting on somebody’s body, maybe it’s too high, maybe it’s too low, maybe it’s under their armpit, it causes them discomfort throughout the day. We hear a lot of pain around the torso and around the rib cage. Somebody referenced earlier that it feels like they’re wearing a tight underwire bra on their body all day, and that’s when they’re wearing no bra at all.

As a patient and somebody who hears thousands upon thousands of stories that this, I hate to say it, is normal. But so much of it can be addressed. So don’t feel like you’re alone if you’re really facing a lot of these painful issues. I’m also seeing a lot of people are talking to their doctors about it, but not getting the advice and input that Dr. Bank and Dr. Israeli are providing today. Just keep advocating for yourself. I know it gets hard, I know it gets exhausting, but it’s important.

And know too, some of this pain may be because what you are wearing on your body. Something that is not necessarily spoken about and something that we’re not really told, because it’s not something we learn inside the doctor’s office, is that if we are trying to fit ourselves back into the bras that we were wearing before our surgeries, some of this pain can be caused if you are wearing an ill-fitting underwire bra. The pain in the body is not necessarily sensitized inside the chest area. So if you have an underwire digging into your armpit all day, eventually your shoulder, your elbow, your hip, or your neck can sort of scream that pain back at you at the end of the day.

Something that I did when I was creating AnaOno was I could not wear an underwire bra at all. To this day, even if I put one on, my ribs scream at me. There’s no tissue left. It feels like bone on bone. It’s really uncomfortable.

It doesn’t have to be an AnaOno, of course we make chest inclusive lingerie for all body types. Two boobs, one boob, no boobs, or new boobs, We are here to support you. But if you’re out and about and you need something and you want something, look for something that doesn’t have underwires, really soft cups that will mold to your body, stuff that doesn’t have itchy materials. because a lot of these nerve sensitivities can feel like your skin is crawling. You want to make sure things are really sensitive against your skin. We have different types of pads and different types of inserts that can smooth out your reconstruction or can help build up asymmetry from your natural breast to your reconstructed side, because not everybody has a bilateral, so there’s going to be differences of side to side.

Different types of nipple reconstruction. If you have an older reconstructive surgery, we always hear, you never really know where the headlights are pointing. They can be pointing in multiple different directions. That doesn’t always give you the most confident feeling underneath your clothes. If you feel like people can see your nipples and can see your scars and things like that.

Anything that you want to check out on AnaOno, we present all chest decisions. So if you have no breasts, you see the bras on people with no breasts. If you have one breast, you see them on one breast. Flap surgeries, implant surgeries. But also we have dozens of models on our website. If you’re contemplating or considering a surgery, you can also use this for research because all of the different body types have different outcomes depending on what reconstructive surgery or what mastectomy surgery was chosen as a part of their treatment.

Ashley Dedmon, MPH, CHES®, LSS [01:05:12]:

Thank you for sharing. And I see one good question that I want to bring back to Dr. Israeli and Dr. Bank.

We know that there are options, and we have some persons who choose to not have an implant or not do any form of reconstruction through fat grafting or through a DIEP. Can you talk a little bit more about the flat closure option or even the Goldilocks option as well?

Jonathan Bank, MD, FACS [01:05:48]:

When I gave that little primer, I said that there are many, many permutations of all these things and it’s impossible to touch on all of them. We’re focusing today on revision situations.

The Goldilocks procedure, for instance, somewhere between here and there. It’s not exactly a flat closure, but it’s not generating a formal breast mound. It’s usually best suited for women that have very large or long breasts. It’s almost like an extreme version of a breast reduction where all the tissue is removed and we just have the skin left. It’s almost as if you had a sock within a sock, you remove the internal sock and you just have the outer sock that you can roll up onto itself to make something that looks like a small breast. You can give it the shape of the breast, but nothing is really tenting up the skin. It’s good if there’s extra skin to use to tent it up a little bit. But we’re somewhat limited because we don’t necessarily know how the skin layers will scar down. So that’s something that in my experience would frequently require some kind of revision to address.

Another option that was brought up is breast reconstruction with fat grafting only. That’s when we liposuction fat. So we suck it out of other parts of the body like the belly or the thighs or the back. And then the fat, which is almost gelatinous, turns into almost a fluid material. And then we can inject that into something. And that’s the caveat, it has to have a field to go into. It’s like putting water into a sponge versus into a bowl. You have to have a sponge to retain it, to create some kind of a shape.

There’s a limit at how much fat you can transfer at one go. And once you inject some fat, you’re creating a little sponge and then you have more of a sponge to inject into more. And the sponge grows and grows and grows until you get to the size you want. So that operation would take more than one, usually more than two, sometimes more than three steps to it. And it’s a little bit more difficult to create a projection to really give the three dimensions to the breast. And for some people that’s just fine. They just want something and they’re willing to go through several steps to get to the size that they want without having an implant, without having a scar elsewhere.

The advantage of the flaps is that you can really mold it. because it has the whole structure that the body creates. We can shape that, and we’ll sculpt it to whatever we want. With the semi-solid fluid stuff, it’s trickier.

Ron Israeli, MD, FACS [01:08:47]:

And it does take many stages. That’s the multiple-stage procedures. If you can avoid that with a single flap operation, that’s the obvious benefit.

Ashley Dedmon, MPH, CHES®, LSS [01:09:00]:

I have a question for the larger group, and I know we discussed this during our prep call. We talked about fat grafting, removing fat from one part of the body and replacing it in another part of the body. And Dana, feel free to share your experience. How important is it to be able to share or for patients to be able to ask, not just with fat grafting but with any procedure, what will other aspects of their body look like, that’s involving a second location? And how can they prepare for that mentally, physically, and emotionally when fat grafting or when having a DIEP?

Any feedback? Dana, Dr. Bank, Dr. Israeli?

Ron Israeli, MD, FACS [01:09:51]:

It’s a very important part of the discussion and we want the donor site, whether it’s a flap or a fatty tissue that we remove from the thigh or the abdomen or the hip or wherever it is, we want to have a favorable outcome at the donor site. So it’s very, very much a part of the conversation. Again, whether it’s a flap or fat grafting.

I know this is also a special area of interest of Dr. Bank. And Dana, when we did your surgery, that was certainly a focus in that conversation. Where are we taking this fat from and we want to make this area look better. It’s an obvious thing for us to do as plastic surgeons is to take advantage of that opportunity.

Dana Donofree [01:10:45]:

I will say, from the patient experience — and I only had fat grafting, I did not have a flap — but I can tell you all it is painful. I don’t know if there’s a special reason as to why or what the procedure is. But know that if that’s something that you are considering, there are other points of pain in the recovery process. I’m not sure how people opt into this as an elective, but it did help smooth out a lot of my rippling and little bits that were concaved and whatnot. But from a patient perspective and the recovery of the revision surgery, I think that my fat grafting sections were more painful than my chest. But it also maybe because I can’t feel my chest, so it might not entirely be fair.

Ron Israeli, MD, FACS [01:11:34]:

Some patients tell us that it just feels sore, like somebody punched them in their arm, that kind of soreness where you harvest the fat. Other patients will have more significant pain, and we can’t always predict that.

But I guess the point is it’s an operation even if it’s minor, it’s still surgery and that’s it. Typically fat grafting is part of the of the equation, as we touched on earlier, we consider all of the layers of the reconstructed breast, especially with an implant scenario. So the skin, we can make the skin tighter. Cut the skin, tighten the skin, put sutures to secure the skin where we want it. The layer underneath the skin, the fatty tissue, that’s where fat grafting comes in. We can augment that, we can reduce it — reduce it with liposuction, augment it with fat grafting. The layer underneath that, the capsule or the AlloDerm layer, can be tightened and repaired to reinforce or change the pocket shape. And then the implant, we can make a bigger implant, smaller implant, more projecting implant, less projecting implant. All of these factors are taken into consideration whenever we do a reconstruction or a revision reconstruction, with fat grafting a very, very important part of that in our practice.

Jonathan Bank, MD, FACS [01:13:03]:

Can I just add that fat grafting is a prescribed treatment for post-mastectomy pain. Some people feel that injecting the fat somehow helps with that. I think if there’s a structural nerve issue, it may not, but sometimes in radiated cases where if there’s a lot of scar tissue then there are cells, we call stem cells, that exist in and around the fat that may help alleviate some of that.

I think in this day and age we don’t just want to reconstruct a beautiful breast, we want to take the whole body into consideration. Because this is done in stages, I think there’s an opportunity to do that. Yes, there’s a little bit more, hopefully temporary, discomfort, but I think the long-term benefits are important. And that goes for everything from planning the incision on the belly to keep it nice and low in the bikini line. I’m very obsessed with the belly buttons these days and trying to reconstruct them in the most beautiful way and minimize risks of wound dealing issues. And then the fat grafting that we do, we don’t just take fat from somewhere, we take it in a way that highlights the contours that we want to in the body.

I put in the chat of the webinar, maybe we can share that to the rest of the group, an article that we wrote a couple of years ago titled “Thinking Beyond the Breasts” and thinking about body contouring in the context of breast reconstruction. It’s an open journal that everybody can read and see our approach to that.

Ashley Dedmon, MPH, CHES®, LSS [01:14:47]:

I have a couple more questions and I’m going to try to summarize this question. Are there any types of preexisting conditions that would prohibit any form or any type of reconstruction? One question was around does your A1C level have to be at a certain level in order to have reconstruction. There were also questions about autoimmune disease.

Any insight? And I definitely know that’s a definitely a personalized question with each and every patient and their provider. But any insight, Dr. Bank, Dr. Israeli?

Ron Israeli, MD, FACS [01:15:29]:

I think any medical comorbidities, we have to take into consideration. In general the things that we worry about the most, as far as wound healing is concerned after a mastectomy: We worry about smoking. Smoking will negatively affect the blood supply to the skin. And nicotine and the breakdown product of nicotine, cotinine, which can stay in the blood for 3, 4 weeks after you quit smoking is just as bad as nicotine itself. So an active smoker, we worry about doing an implant-based reconstruction in particular, unless they’re able to quit smoking for a few weeks prior to surgery.

You mentioned the hemoglobin, A1C, that’s of course diabetes is something that can increase the risk of infection and increase the risk of wound healing problems. And in general, hemoglobin A1C less than 7 is what we think of before I would do a DIEP flap for example, because we worry about not just the breast or the mastectomy healing, we worry about the abdominal donor site healing. We don’t want to create a problem increasing the risk of wound healing at the abdomen or increasing the risk of hernia developing, for example, in the abdomen.

Same thing with autoimmune issues. Every patient is different and frequently we have to collaborate with the medical team to decide approach to reconstruction. So that’s definitely an individualized situation, when we decide on how to proceed with any given patient and approach

Jonathan Bank, MD, FACS [01:17:18]:

Specifically with autoimmune situations, a lot of people feel that silicone or something in the manufacturing process of implants can trigger one’s autoimmune system. We call that breast implant illness. It’s not completely clear to the plastic surgery society what is the culprit, but it’s something that we bring up as part of our obligation for informed consent for any patients receiving an implant. We will do surgeries that would remove those implants — that’s the explant procedures — and then different types of reconstruction following that.

On the other side, people that have severe autoimmune issues are at higher risk in some cases for blood clotting. And that can be in veins and arteries unrelated to surgeries, but those are blood vessels that really need not to clot. Not to clot in the flap operations because everything hinges on those blood vessels. So if that is the case, we’ll approach it with the medical team and we can do those operations in those scenarios. But there are additional measures that we take to ensure that that risk is reduced. It’s not going to be to zero, but it’s definitely something we need to take into account.

Ashley Dedmon, MPH, CHES®, LSS [01:18:48]:

Thank you both.

We tried to make sure we answered a potpourri of questions. We have time for one last question. I’ve seen this one a couple of times in the chat. Can you remove the middle mastectomy scar with a revision?

Ron Israeli, MD, FACS [01:19:06]:

Any revision can address scars, whether it’s, let’s say in a DIEP flap, the skin island may be not properly positioned or maybe too large, for example. Or in an implant procedure the scar is unfavorable. You may be able to revise it, but to entirely remove a scar would be difficult to do. I’m not sure if I’m fully understanding that question.

Dana Donofree [01:19:37]:

I think, Dr. Israeli, because it’s popped up a few times, the center line scar across the mastectomy, sort of like how I have, are there options to make any revisions to that if you undergo a revision surgery? Where I opted to go in through my same scar, to not have an additional scar, I think they’re asking what are their options for that. Maybe tattooing or nipple tattooing, et cetera, is often something that we see a lot of.

I have a mastectomy tattoo across my entire chest, which helped me mask that center scar because I didn’t like looking at it every day. Also, a lot of people opt in for these incredible 3D nipple-areola tattoos. It’s an amazing option. But I don’t know if you guys have any other concepts or ideas that people are actually addressing those center line scars.

Jonathan Bank, MD, FACS [01:20:26]:

Once the scar is created in the skin, by definition it will never go away. You can camouflage it with decorative tattoos, portions of it with nipple-areola tattoos. In the example that I showed that had the implants and the pain, we actually removed probably half or so of that central part of her scar to bring skin from the belly to create a patch that then we use to create a nipple and areola. But the remainder of the scar remains.

There are good modalities with the microdermabrasion, lasers, and other ways to treat scars to help minimize it, but by definition it never fully goes away. Unfortunately.

That’s one of the reasons that I try to avoid that scar altogether. Not just having that horizontal reminder, but also the sort of the thickness of the skin above and below can sometimes be an issue. So it’s a tricky one to address for sure.

Ron Israeli, MD, FACS [01:21:34]:

We try to teach our breast surgeons to avoid that too.

Jonathan Bank, MD, FACS [01:21:37]:

Yeah, things evolve both on both sides of the surgical table.

Ashley Dedmon, MPH, CHES®, LSS [01:25:45]:

Thank you so much, Drs. Bank and Israeli and Dana, for sharing your expertise, your experience, and the great conversation.