Jaime Lewis (Host): Meaningful Medicine is a Novant Health podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. Today, I'm sitting down with Dr. Tripp Holton, a Plastic Surgeon specializing in breast reconstruction, to discuss surgical options following breast cancer treatment.

Before we get started, Dr. Holton, what inspired you to specialize in plastic and reconstructive surgery?

Dr. Luther "Tripp" Holton: I would say for me plastic surgery, I came by it, I would say through serendipity, like all amazing things in life. I was in medical school thinking that I wanted to do one thing, and I zigged and zagged a million times but ultimately figured out that I wanted to be a surgeon, and I, then I had my heart set on being either a trauma surgeon or a transplant surgeon, and during my training I loved both of them.

But I accidentally ended up in a research lab with a very smart plastic surgeon who was doing just truly spectacular research. And so I spent two years doing that and almost immediately, I felt this like, sense of relief. Because many of the things in general surgery, they're just doing amazing surgeries, but things are very by the book.

And the minute that I walked into a plastic surgery environment, we would be posed with a problem, and if there were 10 plastic surgeons in the room discussing it, there would be 7 or 8 different ways to solve the problem, and for me, the ability to be sort of extemporaneous and creative really resonated and I have really enjoyed that throughout my career. I, definitely think that my mind was cut out to be more contemplative and creative than reactive.

Host: That's such a great answer. A problem solver and creative. That's a wonderful reason to go into that field.

Dr. Luther "Tripp" Holton: We're just really in that problem solving business and it works for some personalities really well.

Host: Well, today we're talking about breast reconstruction surgery. Breast cancer treatment, it involves radiation, it can involve radiation, chemotherapy, immunotherapy, and surgery, and often in a combination of all of them. When do you enter the picture in a patient's cancer journey?

Dr. Luther "Tripp" Holton: Yeah, so that is an amazing question. And it's honestly one that I struggle with on a weekly basis. I can spend a lot of time with the patient and their family teaching them about breast cancer options, I want to catch them early because I think that my counseling and my explanation of what the options are and how they relate to all of those therapies that you're talking about, I think it's really critical. It helps them make decisions.

But if I catch them too early, the discussion is too nebulous, and that's confusing to patients. So it's, I would say a fine line. I do think I'm really one of the only people in that very multidisciplinary team that is not actually a cancer doctor. You know, when you think about the team of people taking care of the breast cancer patient, there's a medical oncologist, that's cancer. There's a radiation oncologist, that's cancer. There's a surgical oncologist or breast surgeon, and that's cancer. And then the plastic surgeon shows up and I am not a cancer doctor. So I really sort of bridge the gap between all of those things. And I think sometimes help them understand how all of those things fit together.

And I think that that's a problem our country. We are rich in resources. I mean, I think our patients are very lucky to have as many specialists at their disposal, as they have, but yet, chronically, we know from research in plastic surgery that we probably under counsel, probably too low of a percentage of people diagnosed with breast cancer are ever sent to a plastic surgeon.

Plastic surgeons are not the gatekeepers of reconstruction. It turns out, in the case of breast cancer, it's usually the breast surgeon, the person responsible for cutting out the cancer, makes the decision about whether or not someone's time would be well served by taking the additional hour or two to meet with the plastic surgeon.

And In many regions of the country, there just aren't enough plastic surgeons to go around and that's the reason. But we also know from looking carefully at the data that quite honestly, people just don't think to include us. And I would say, again, I'm not making cancer decisions, but I feel like I have a huge impact on people's decision about what path they're going to follow.

So, we don't want to see every single patient because that would be a waste of resource, but we want to see more patients. We think it matters.

Host: As you mentioned that path, I mean, obviously patients are focused on successful cancer treatment. How do you help guide them through the reconstructive decision making process?

Dr. Luther "Tripp" Holton: Well, again, I keep on using the term, it's a fine line. One of the reasons that we afford ourselves as a culture and a society that we afford ourselves the expense of doing breast reconstruction, is I think we want to inject into this journey, this often fraught journey; we want to inject a sense of hope, and we want to give people a very positive pathway. We want them to feel whole at the end of the process. We don't want them to wake up on a daily basis and feel like cancer got the better of them and keeping their body looking as close to original as possible is certainly one way that we can do that.

But it is very easy sometimes, and it's understandable for some patients to all of a sudden get focused on what they want their reconstruction to be. And they, in some ways, have to be reminded that the primary focus is curing the cancer. I describe to my patients that a successful reconstructive journey should be a silver lining in the cloud.

The problem is when we overstep our bounds and patients have complications with the reconstruction, it becomes a cloud in a cloud. So, you have to be very careful, I think, with reconstruction to make sure that it doesn't complicate their journey.

Host: Well, that touches on the fact that a lot of individuals who undergo surgery opt against reconstruction. For those who prefer reconstruction, what are the main options available to them?

Dr. Luther "Tripp" Holton: Let me segue back to the way you introduced that question because I think that's like one of the seminal issues in plastic surgery, in my opinion. I think we under counsel people on the fact that a very reasonable and safe option for reconstruction is to do no reconstruction at all.

So if a patient needs a mastectomy and they choose to simply have a mastectomy and not have a reconstruction, the breast surgeons are actually a specialty trained to close the breast, to close the incision and have it look as good and sort of flat as possible. In fact, we call that process going flat. 

 I actually start by sort of explaining the options for breast reconstruction like a menu. And I always try to always tell people that the first thing on the menu is to simply do nothing at all. It's the least co pays, the least visits, the least pain, the least time on the operating table, the least downstream maintenance, the least confusion, the least everything. And so that is an option I really want people to consider. We want people choosing to go flat instead of simply never being offered reconstruction. So once you get beyond that in the discussion once, you know, and I would say it's probably a selection issue.

Most people for whom going flat resonates, honestly, they probably don't ever take the time to come see the plastic surgeon. They already know that that's what they want. And so they don't end up in my office. So it seems like a very high percentage of people who meet with me end up doing some form of reconstruction or another.

And the reality is that that menu moving beyond going flat, the menu is unbelievably diverse, but there are three general things that people can do. And I sort of three silos. I think if the uninitiated know about these three things, they know more than honestly many physicians. And that is when we cut out a tumor, when the breast surgeon cuts out a tumor, if they don't need to remove the entire breast, and that's a growing percentage of patients, especially because we now have chemotherapies that they get ahead of time, that will shrink tumors. If we can get a patient at that stage of their cancer and not have to remove the entire breast, they become eligible for a mode of care called breast conservation, and breast conservation means removing the area of the breast with the tumor, and then any chemo and typically also radiation at the end.

Oncoplastic surgery is when a breast surgeon and a plastic surgeon work together so that when the breast surgeon is cutting out the area of the tumor, I'm there in the operating room and they work through a pattern that I create on the breast that would otherwise be a breast lift or a mastopexy, a cosmetic breast lift.

And that is a powerful way to address cancer because it gives the breast surgeon tremendous access to get in and find the tumor easily and then remove as sort of as large chunk as they want, and then I'm there to close it and it's very seamless. The likelihood that we cured the cancer in the first operation is higher because the breast surgeon has better access. And then I'm there to lift the other breast in the same way, that's called asymmetry surgery. And so quite honestly, that's one of my favorite ways to address breast cancers. And that's, again, called oncoplastic surgery of breast. It's part of breast conservation.

If a patient needs a mastectomy where all of the breast tissue is removed, some, maybe, or even none of the skin, including the nipple, is removed; then to make a breast, you just need to find something that replaces the tissue that gave the breast the shape. And so the thing that most people know about is implant based reconstruction. You remove the breast tissue and you put it in a breast implant, and that is a proxy for the breast. And that is a spectacular and powerful way to make a breast, and over the, I would say over the last decade, our techniques for doing that, have evolved to the point where I would say 90 percent of my patients can get a mastectomy and I can usually put in their final implant at the very same time. So they get the breast cancer cut out, they get their implant placed and they get sent home on the same day. So that's spectacular.

And then the final arguably the most complex way to reconstruct a breast is with a process called autologous tissue reconstruction. And that's just a fancy medical word for taking tissue from somewhere else on a person's body and repurposing it to the area of the breast. And so we in plastic surgery, we informally call that sort of robbing Peter to pay Paul. So an example of that would be for someone who's never had a tummy tuck, if they have extra skin and fat of the lower abdomen, and I would say most patients in the breast cancer age have gained and lost weight, they maybe have had a child or two. And so many, many patients have a little bit of extra tissue they would not mind donating to the process of making a breast. So that's a situation where I would go to the lower abdomen and remove the same tissue that might get removed in a tummy tuck. Instead, we spend extra time finding the tiny little blood vessels that keep it alive. And then I connect it to blood vessels right over the heart using an operating room microscope. And so I do a live tissue transplant, where I turn unnecessary lower abdominal fat into a living, if you will, breast implant. So that's a great example of autologous tissue. So it's basically taking tissue to make a breast instead of an implant.

And they're all amazing. They're all powerful options. And I would say one of the most important jobs that I have is helping a patient figure out which of those they need. And which of those really resonates with their sort of life goals and what they want for quality of life.

Host: Well, this is a lot of information. I mean, I'm not a patient, but I can feel what it would be like to hear all these choices, you know, depending on what my situation was. But I would imagine you get a lot of questions, and I would also imagine you get some misconceptions. What kinds of misconceptions do you encounter about reconstructive surgery?

Dr. Luther "Tripp" Holton: I mean, I think the single most disheartening misconception is that implants are somehow making people sick. And I, think we can all admit that we are to some extent victims of unfettered access to unverified information. I can't make it through a single day where I don't open my phone and find out information.

For me, the pitfall is, you know, thinking that I can read a little bit about the stock market and know how to pick my own stocks. And certainly, I see a lot of patients who come into my office and they already have preconceived notions about implants. I would have no reservations about my daughter, my wife, my mother, or my sister having a breast implant in their body if they needed it for breast reconstruction. I see it as a replacement to much more involved surgeries that can, in theory, cause harm. When I talk think I make it sound easy when I say I can go to the lower abdomen and harvest tissue and do a transplant and then connect it to blood vessels right over the beating heart under a microscope.

I mean, it's just like, oh yeah, you take it from here and you put it there. But the reality is that while they're not common, there can be complications at the abdomen where I take the tissue from. And these operations are longer and they're more complicated. So the ability to simply open a box and put a beautiful, sterile breast implant that will likely last the rest of the patient's life into their body and do it in an hour, as opposed to sometimes six to 10 hours, and send them home on the same day, rather than a three to five day recovery in the hospital; it's magic. The problem is technology. And so when breast implants were first introduced in America I believe it was the early 1960s, they were um, a great first pass at design, but they were certainly not what we have today. And so what we have today is they're great.

You know, they're incredibly well made, they're long lived. And so I think, debunking myths about breast implants is one of the things that I can really do. Now, there are issues, of course, with implants. They are more likely to get infected than the tissue from your body. But even in the last decade, not only do we have techniques for getting them into the body, but I also have amazing techniques for battling infection if we see one.

I mean, I used to be concerned in the beginning of my career, what do we do if someone gets an infected implant? Now, I don't want an implant to ever get infected. On the rare occasion they do, I actually have methods for addressing that. And so I just, I would say that's the big thing. Spending time, getting people to understand what the actual facts are about breast implants and trying to demystify and de, not making them the villain. I think that's the major thing.

Host: Yeah, fantastic. Is there anything else that you think potential patients should know about breast reconstruction that you feel it's important to share with viewers?

Dr. Luther "Tripp" Holton: Yeah, I mean, again, going back to what we talked about initially, I think anyone listening to this, whether they are a patient or a health care provider for a patient with breast cancer or a family member; is just knowing that it's absolutely appropriate to ask if spending time with a plastic surgeon would be an appropriate use of time.

I think simply asking would probably get more people to us. And again, the goal is not to convert every patient that I see into a reconstructive case. That's actually not my goal. My goal is making sure that people really don't have any regret and they know their options because breast reconstruction is one of those things, it tends to be very simple to do if you are organized and have a plan from the beginning. Breast reconstruction, years down the road after someone's had a mastectomy and their skin has scarred down to their chest wall, that's an entirely different process. And so I think it's way better for everyone in our community to understand that when someone's given a breast cancer diagnosis, reconstruction can actually be an integral part of that.

And meeting with a plastic surgeon can really just be another way of hearing the information. I have a lot of people, I think, walk out of my office with an actually a better understanding of what their diagnosis is and what their options are because they're not in the same room where they're being told for the first time that they have cancer and they're not hearing about things like the deleterious effects of chemotherapy and radiation.

They're hearing about what their journey could be in a little bit more of a hopeful environment. I actually think that it matters. It's like anything in life, if you hear it more than once, it starts to sink in a little bit better. So I think that's a big thing.

Host: Yeah, I agree, and I really appreciate the time you've spent explaining all of this, and it does give people hope, so thank you.

Dr. Luther "Tripp" Holton: Yeah. No, thanks for inviting me and giving me a chance to speak with you. Hopefully it will help some people.

Host: Once again, that was Dr. Tripp Holton, Plastic Surgeon at Novant Health. To learn more about surgical options, visit nh.team/surgical. And for more health and wellness information from our experts, visit healthyheadlines.org. Thank you for joining us.