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The Breast: From Reduction and Augmentation to Reconstruction, Lymphoma and Beyond
Victor Stams M.D discusses a range of breast surgeries from reduction and augmentation to reconstruction and he shares information about breast implant associated anaplastic large cell lymphoma (BIA-ALCL). He talks about the goals, benefits and some common surgical approaches.
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Learn more about Victor Stams, MD
Victor Stams, MD
Victor Stams, MD is a plastic surgeon.Learn more about Victor Stams, MD
Transcription:
Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit, please click on the link and complete the episode’s posttest.
Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I’m Melanie Cole and today, we’re discussing breast reduction, augmentation, reconstruction and lymphoma. Joining me is Dr. Victor Stams, he’s a Plastic Surgeon with the Carle Foundation Hospital. Dr. Stams, it’s a pleasure to have you with us today. We’re covering a large gamut of topics in this segment today, but let’s start off with breast implant associated lymphoma. Tell us a little bit about what it is and is it very common?
Victor Stams, MD (Guest): Well but before we get into that, I do want to point out that it’s exceedingly rare for patients to develop breast implant associated lymphoma. In fact, some of the more recent data suggests that there have only been less than 600 cases worldwide that have been identified and only 33 deaths from those cases. So, this is an exceedingly rare diagnosis. But what we’re understanding is that in about the early 2010-2011 range, we identified these first cases of breast implant associated lymphoma and over time, we’ve understood that it typically appears to be associated with textured type of implants. There appears to be sort of a local inflammatory reaction from the texturing process of the implant that leads to sort of a ramping up in production of a whole host of cells but specifically, the lymphocyte and that lymphocyte predominates leading to this specific type of lymphoma.
So, that’s sort of in a nutshell what breast implant associated lymphoma is. It’s a local inflammatory response to a textured implant.
Host: Well thank you for that explanation and for the reassurance that this is pretty rare. So, before we move on, what should patients considering implant and reconstruction discuss with their physician as far as the benefits and the risks of these different types of implants?
Dr. Stams: Well because our understanding of breast implant associated lymphoma has evolved, there has been a push nationwide and dare I say, worldwide for plastic surgeons to no longer use textured implants. And when I say implants, not only am I referring to permanent implants but also tissue expanders which is sort of one of the foundations of breast reconstruction. And so there’s been a big push to sort of do away with these textured devices and so that’s first and foremost.
Beyond that, specifically with the use of silicon implants; there are recommendations for patients to undergo routine screening every two to three years with MRI to evaluate both the integrity of the implant but also any recurrence of any type of lymphoma or cancer. That in conjunction with physical examinations by your plastic surgeon should serve most women fairly well at addressing any sort of irregularities or abnormalities that may come up.
Host: So interesting. So, then let’s back up and talk about breast reduction surgery. Tell us about this type of surgery, why would someone need it, what are the main goals when you’re discussing this with your patients?
Dr. Stams: Well breast reduction surgery in plastic surgical terms we term it reduction mammoplasty, it’s a procedure that’s designed to remove not only excess fat but also glandular breast parenchyma in addition to skin in an effort to achieve abreast size that’s more proportionate with a patient’s body. That, in addition to alleviating discomfort that could be associated with excessively large breasts, what we call macromastia.
Host: So, then tell us a little bit about what’s involved and really is the timing of the surgery important? Are there risks associated? Tell us a little bit about some of the options that women have.
Dr. Stams: Sure. And so, the timing of the surgery, I encourage most patients to hold off on breast reduction until the breast is completely developed. Beyond that, I try to talk to patients and counsel them about future pregnancies as we know any manipulation of the breast whether it’s reduction or a simple biopsy, can impact negatively the ability of patients to breastfeed and so for my patients who have larger breasts, who are considering future pregnancies; I do counsel them that the breast can enlarge with future pregnancy as breast tissue is hormonally responsive. And so I try to counsel those patients to consider holding off on breast reduction surgery until they are complete with childbirth. But the surgery in and of itself, is a relatively involved surgery.
It involves a series of measurements and drawings to effectively understand and decide where the breast tissue will be removed from. Now in doing so, while this is considered largely an insurance based procedure; one of the benefits and I think it’s a great benefit for my patients, is that in reducing the breast itself, we also lift the breast to a more youthful position. That includes the nipple areolar complex and so for some of my patients, in which the majority of the breast tissue is sitting lower in the chest wall or even for some patients, on the abdomen; this is a way to not only reduce the size of the volume but also restore the breast to sort of it’s normal position when those patients were much younger.
Host: Well thank you for that very comprehensive answer. Dr. Stams, so now on the other side of the coin, is breast augmentation. Tell us a little bit about what that means, why somebody would choose this option? Tell us what you do?
Dr. Stams: Well breast augmentation itself involves typically the use of an implant and we touched upon this earlier, either silicon or saline implants and even more recently, the use of fat to increase the size of a patient’s breasts. This procedure can also restore breast volume which can be lost after weight reduction or pregnancy. And it’s whole goal is to achieve a more rounded breast shape or improve the natural breast size and any asymmetries that may go along with that. In doing so, this increases the fullness and the projection of the breast, balancing sort of the shape of the breast with the remainder of the body including the hip contour and even the abdomen. And this can also enhance the self-image and self-confidence of our patients.
Some things that breast surgery cannot do and this is important for patients to understand and speak with their physicians about. Breast surgery cannot address drooping of the breast and this classically happens with age and with heavier breasts is that the breast tissue begins to descend, descend to lower portion of the chest wall and even the abdomen. Now with placing an implant, while it can add volume; the simple physics of it dictates that the heavier implant will not raise the breast back to its normal position on the chest wall. And so oftentimes, for patients who have drooping breasts; they may need breast augmentation combined with a breast lift, what’s called a mastopexy. So, it’s important for those patients to speak with their plastic surgeon to undergo a thorough evaluation to determine if a simple augmentation is best for them or if it should be combined with a mastopexy or breast lift.
Host: What a good point that you make Dr. Stams. So, now if a woman has breast cancer and she is looking at her options, surgical options, breast reconstruction, after mastectomy. Tell us a little bit about how that works. Can it happen during the mastectomy? Can they happen concurrently? Tell us how that works.
Dr. Stams: Absolutely. So, in 1998, the Women’s Health and Cancer Rights Act was enacted. This is an act that allows women who have undergone mastectomy or treatment for breast cancer to at the time of their choosing either at the time of their mastectomy or at a later date, sometimes a much later date, to undergo reconstruction to address any defects or asymmetries as a result of their breast cancer treatment. Classically, the reconstruction for many of my patients takes place at the time of mastectomy. This gives the patient the benefit of undergoing one anesthetic instead of having to come back for multiple rounds of anesthesia and surgery.
And so the goal of breast reconstruction is to restore one or both breasts to a near normal shape, appearance, size and symmetry. Again, following mastectomy, lumpectomy or even for congenital deformities. Now this topic can really sort of go on in perpetuity, but breast reconstruction generally falls into two categories. One is an implant based reconstruction and the other one is what we call autologous or using the patient’s own tissue for reconstruction. The implant reconstruction relies on breast implants to help restore the normal mound of the breast. With the autologous or the patient’s own tissue approach, this uses the patient’s own tissue from a different part of the body, oftentimes that’s the abdomen or even the gluteal region to mold and shape the breast into a new mound.
It's important though because this is a more complex operation. It’s important that patients be evaluated thoroughly and a number of factors to be taken into account in choosing which option is best for patients including the type of mastectomy they are going to undergo, potential other cancer treatments that they may have in addition to a history of any surgical operations that those patients have had in the past. These all help us understand what the best approach is and what the best treatment option is in reconstructing a breast for those patients.
Host: That’s fascinating Dr. Stams. As we wrap up, I know this was a lot we covered today. but kind of summarize as a plastic surgeon and for issues that really surround the breast, what would you like other providers to know when they are taking forward to their patients to counsel them on whatever the situation is what you want them to know from a plastic surgeon’s viewpoint.
Dr. Stams: Well I think first and foremost, I think to double back for breast implant associated lymphoma, this has again garnered nationwide attention, but I want primary care physicians and other physicians to counsel their patients to help them understand and know that again, this is an exceedingly rare diagnosis. The treatment is not to have patients come in and sort of just haphazardly request their implants to be removed. That’s not the current recommendation. The best course of action is routine screening and evaluation by a plastic surgeon on a frequent basis to ensure that those patients are being closely followed. So again, if there are any changes or abnormalities we can intervene early.
Likewise, in discussing breast reduction surgery, again, this is oftentimes a procedure that’s covered by insurance. Again, patients with neck pain, back pain, bra strap grooving; these are patients that may benefit from breast reduction surgery. It’s important for those patients to consider consultation with a plastic surgeon to see if breast reduction surgery can help them.
Likewise, again breast augmentation surgery is one that can not only help restore the physical appearance of the breast but also help improve the confidence of a patient moving forward. So, again, patients should be encouraged to speak with their plastic surgeon to see what type of breast augmentation is best for them, what type of implant is best for them and whether or not a mastopexy would help in addition to the augmentation.
Lastly, breast reconstruction is a very complex topic. It’s best handled in a multidisciplinary fashion. Not only with a breast surgeon but a medical oncologist and oftentimes a radiation oncologist in addition to a plastic surgeon. Together, in a team approach, we can best identify what approach is best to reconstruct the patient’s breast.
Host: Wow, that was an excellent summary. You’re a great guest Dr. Stams. Thank you so much for joining us and really showing us the gamut and sharing your incredible expertise with us today. and that concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at www.carleconnect.com for more information and to get connected with one of our providers. We hope the information gained will be applicable to your work and life. If you found this podcast informative, please share on your social media and be sure to check out all the other interesting podcasts in our library. I’m Melanie Cole.
Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit, please click on the link and complete the episode’s posttest.
Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I’m Melanie Cole and today, we’re discussing breast reduction, augmentation, reconstruction and lymphoma. Joining me is Dr. Victor Stams, he’s a Plastic Surgeon with the Carle Foundation Hospital. Dr. Stams, it’s a pleasure to have you with us today. We’re covering a large gamut of topics in this segment today, but let’s start off with breast implant associated lymphoma. Tell us a little bit about what it is and is it very common?
Victor Stams, MD (Guest): Well but before we get into that, I do want to point out that it’s exceedingly rare for patients to develop breast implant associated lymphoma. In fact, some of the more recent data suggests that there have only been less than 600 cases worldwide that have been identified and only 33 deaths from those cases. So, this is an exceedingly rare diagnosis. But what we’re understanding is that in about the early 2010-2011 range, we identified these first cases of breast implant associated lymphoma and over time, we’ve understood that it typically appears to be associated with textured type of implants. There appears to be sort of a local inflammatory reaction from the texturing process of the implant that leads to sort of a ramping up in production of a whole host of cells but specifically, the lymphocyte and that lymphocyte predominates leading to this specific type of lymphoma.
So, that’s sort of in a nutshell what breast implant associated lymphoma is. It’s a local inflammatory response to a textured implant.
Host: Well thank you for that explanation and for the reassurance that this is pretty rare. So, before we move on, what should patients considering implant and reconstruction discuss with their physician as far as the benefits and the risks of these different types of implants?
Dr. Stams: Well because our understanding of breast implant associated lymphoma has evolved, there has been a push nationwide and dare I say, worldwide for plastic surgeons to no longer use textured implants. And when I say implants, not only am I referring to permanent implants but also tissue expanders which is sort of one of the foundations of breast reconstruction. And so there’s been a big push to sort of do away with these textured devices and so that’s first and foremost.
Beyond that, specifically with the use of silicon implants; there are recommendations for patients to undergo routine screening every two to three years with MRI to evaluate both the integrity of the implant but also any recurrence of any type of lymphoma or cancer. That in conjunction with physical examinations by your plastic surgeon should serve most women fairly well at addressing any sort of irregularities or abnormalities that may come up.
Host: So interesting. So, then let’s back up and talk about breast reduction surgery. Tell us about this type of surgery, why would someone need it, what are the main goals when you’re discussing this with your patients?
Dr. Stams: Well breast reduction surgery in plastic surgical terms we term it reduction mammoplasty, it’s a procedure that’s designed to remove not only excess fat but also glandular breast parenchyma in addition to skin in an effort to achieve abreast size that’s more proportionate with a patient’s body. That, in addition to alleviating discomfort that could be associated with excessively large breasts, what we call macromastia.
Host: So, then tell us a little bit about what’s involved and really is the timing of the surgery important? Are there risks associated? Tell us a little bit about some of the options that women have.
Dr. Stams: Sure. And so, the timing of the surgery, I encourage most patients to hold off on breast reduction until the breast is completely developed. Beyond that, I try to talk to patients and counsel them about future pregnancies as we know any manipulation of the breast whether it’s reduction or a simple biopsy, can impact negatively the ability of patients to breastfeed and so for my patients who have larger breasts, who are considering future pregnancies; I do counsel them that the breast can enlarge with future pregnancy as breast tissue is hormonally responsive. And so I try to counsel those patients to consider holding off on breast reduction surgery until they are complete with childbirth. But the surgery in and of itself, is a relatively involved surgery.
It involves a series of measurements and drawings to effectively understand and decide where the breast tissue will be removed from. Now in doing so, while this is considered largely an insurance based procedure; one of the benefits and I think it’s a great benefit for my patients, is that in reducing the breast itself, we also lift the breast to a more youthful position. That includes the nipple areolar complex and so for some of my patients, in which the majority of the breast tissue is sitting lower in the chest wall or even for some patients, on the abdomen; this is a way to not only reduce the size of the volume but also restore the breast to sort of it’s normal position when those patients were much younger.
Host: Well thank you for that very comprehensive answer. Dr. Stams, so now on the other side of the coin, is breast augmentation. Tell us a little bit about what that means, why somebody would choose this option? Tell us what you do?
Dr. Stams: Well breast augmentation itself involves typically the use of an implant and we touched upon this earlier, either silicon or saline implants and even more recently, the use of fat to increase the size of a patient’s breasts. This procedure can also restore breast volume which can be lost after weight reduction or pregnancy. And it’s whole goal is to achieve a more rounded breast shape or improve the natural breast size and any asymmetries that may go along with that. In doing so, this increases the fullness and the projection of the breast, balancing sort of the shape of the breast with the remainder of the body including the hip contour and even the abdomen. And this can also enhance the self-image and self-confidence of our patients.
Some things that breast surgery cannot do and this is important for patients to understand and speak with their physicians about. Breast surgery cannot address drooping of the breast and this classically happens with age and with heavier breasts is that the breast tissue begins to descend, descend to lower portion of the chest wall and even the abdomen. Now with placing an implant, while it can add volume; the simple physics of it dictates that the heavier implant will not raise the breast back to its normal position on the chest wall. And so oftentimes, for patients who have drooping breasts; they may need breast augmentation combined with a breast lift, what’s called a mastopexy. So, it’s important for those patients to speak with their plastic surgeon to undergo a thorough evaluation to determine if a simple augmentation is best for them or if it should be combined with a mastopexy or breast lift.
Host: What a good point that you make Dr. Stams. So, now if a woman has breast cancer and she is looking at her options, surgical options, breast reconstruction, after mastectomy. Tell us a little bit about how that works. Can it happen during the mastectomy? Can they happen concurrently? Tell us how that works.
Dr. Stams: Absolutely. So, in 1998, the Women’s Health and Cancer Rights Act was enacted. This is an act that allows women who have undergone mastectomy or treatment for breast cancer to at the time of their choosing either at the time of their mastectomy or at a later date, sometimes a much later date, to undergo reconstruction to address any defects or asymmetries as a result of their breast cancer treatment. Classically, the reconstruction for many of my patients takes place at the time of mastectomy. This gives the patient the benefit of undergoing one anesthetic instead of having to come back for multiple rounds of anesthesia and surgery.
And so the goal of breast reconstruction is to restore one or both breasts to a near normal shape, appearance, size and symmetry. Again, following mastectomy, lumpectomy or even for congenital deformities. Now this topic can really sort of go on in perpetuity, but breast reconstruction generally falls into two categories. One is an implant based reconstruction and the other one is what we call autologous or using the patient’s own tissue for reconstruction. The implant reconstruction relies on breast implants to help restore the normal mound of the breast. With the autologous or the patient’s own tissue approach, this uses the patient’s own tissue from a different part of the body, oftentimes that’s the abdomen or even the gluteal region to mold and shape the breast into a new mound.
It's important though because this is a more complex operation. It’s important that patients be evaluated thoroughly and a number of factors to be taken into account in choosing which option is best for patients including the type of mastectomy they are going to undergo, potential other cancer treatments that they may have in addition to a history of any surgical operations that those patients have had in the past. These all help us understand what the best approach is and what the best treatment option is in reconstructing a breast for those patients.
Host: That’s fascinating Dr. Stams. As we wrap up, I know this was a lot we covered today. but kind of summarize as a plastic surgeon and for issues that really surround the breast, what would you like other providers to know when they are taking forward to their patients to counsel them on whatever the situation is what you want them to know from a plastic surgeon’s viewpoint.
Dr. Stams: Well I think first and foremost, I think to double back for breast implant associated lymphoma, this has again garnered nationwide attention, but I want primary care physicians and other physicians to counsel their patients to help them understand and know that again, this is an exceedingly rare diagnosis. The treatment is not to have patients come in and sort of just haphazardly request their implants to be removed. That’s not the current recommendation. The best course of action is routine screening and evaluation by a plastic surgeon on a frequent basis to ensure that those patients are being closely followed. So again, if there are any changes or abnormalities we can intervene early.
Likewise, in discussing breast reduction surgery, again, this is oftentimes a procedure that’s covered by insurance. Again, patients with neck pain, back pain, bra strap grooving; these are patients that may benefit from breast reduction surgery. It’s important for those patients to consider consultation with a plastic surgeon to see if breast reduction surgery can help them.
Likewise, again breast augmentation surgery is one that can not only help restore the physical appearance of the breast but also help improve the confidence of a patient moving forward. So, again, patients should be encouraged to speak with their plastic surgeon to see what type of breast augmentation is best for them, what type of implant is best for them and whether or not a mastopexy would help in addition to the augmentation.
Lastly, breast reconstruction is a very complex topic. It’s best handled in a multidisciplinary fashion. Not only with a breast surgeon but a medical oncologist and oftentimes a radiation oncologist in addition to a plastic surgeon. Together, in a team approach, we can best identify what approach is best to reconstruct the patient’s breast.
Host: Wow, that was an excellent summary. You’re a great guest Dr. Stams. Thank you so much for joining us and really showing us the gamut and sharing your incredible expertise with us today. and that concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at www.carleconnect.com for more information and to get connected with one of our providers. We hope the information gained will be applicable to your work and life. If you found this podcast informative, please share on your social media and be sure to check out all the other interesting podcasts in our library. I’m Melanie Cole.