Michael Smith, MD (Host): Welcome to Southwest General Health Talk, the podcast from the specialist at Southwest General Health Center. I'm Dr. Mike. And with me is Dr. Ayesha Punjabi, a plastic and reconstructive surgeon. And today, we're going to be talking about breast reconstruction surgery after cancer. Thank you so much for joining me today.

Very important topic. And I wanted to start off with, you know, for someone who's newly diagnosed with breast cancer, when does the conversation actually begin about reconstruction surgery if needed?

Ayesha Punjabi, MD: Yeah. Thank you so much for having me. Honestly, the conversation about breast reconstruction should happen before the surgery for the cancer, before the mastectomy or the lumpectomy.

Host: So very early on conversation, I guess you're almost seen like as part of the whole treatment team.

Ayesha Punjabi, MD: Absolutely. And the reason to involve a plastic surgeon as early as that is that no matter what the patient chooses, they know what their options are early. And, you know, the patient and I have established a relationship that they can fall back on at any point through their surgery, recovery, cancer treatment, all of that.

Host: And what are the main types of breast reconstruction surgery that we see today?

Ayesha Punjabi, MD: For total mastectomy reconstruction, the two main options are either with an implant or with the patient's own tissue called a flap. So, those are the two main types for total mastectomy. If people are getting partial mastectomies or lumpectomies, the options are tissue rearrangement where we perform essentially a breast reduction if the patient has enough breast tissue to rearrange so that they heal optimally from removing a piece of the breast versus, again, flap reconstruction, bringing in some of the patient's own tissue to fill the defect from the lumpectomy.

Host: I have to just imagine that this is really tough on the patient, right? They just got a cancer diagnosis and they're working through that. So, how do you help patients make this decision?

Ayesha Punjabi, MD: The first thing, and the thing that I love about breast reconstruction is that I want patients to see breast reconstruction as the silver lining of this whole terrible thing that they're going through honestly. My goal with breast reconstruction is to potentially give the patient a result that they're even happier with than they were happy with their breasts before the breast cancer treatment. So number one, silver lining.

Number two, I want patients to understand that everything about the breast reconstruction. It is completely elective. There is no urgency to choose breast reconstruction. They have all the time in the world. We could do breast reconstruction at any time, and I never want a patient to feel pressured to get breast reconstruction.

I think those are the two things, because it is a lot of information. You know, if we're doing breast reconstruction, that adds surgery to the patient's treatment. I never want the patient to feel pressured to go through that, but I want them to know their options.

Host: How many patients choose to wait. You know, so they're going to go through their basic cancer treatment first, and maybe they wait a year, or how many women take that route versus let's just get it all done at once if we can.

Ayesha Punjabi, MD: In the United States for patients with breast cancer, I would say half choose breast reconstruction kind of at all, versus just having a little bit of asymmetry from the lumpectomy or going flat from the mastectomy. In terms of for the folks who go through breast reconstruction, it is usually favored to start the process in the immediate setting at the time of the mastectomy or lumpectomy, just because then the patient wakes up from their first surgery with some of the reconstruction done. That being said, there can be very good reasons to delay the reconstruction.

Host: So, the two broad categories here are immediate versus delayed, but immediate does have its clinical benefit.

Ayesha Punjabi, MD: The concept is that it's better for patients psychologically to wake up with some of their breast reconstructed. And automatically, the other advantage is that it decreases the number of surgeries because you're, for example, combining the mastectomy with implant placement instead of having a mastectomy and a separate surgery for implant placement. So, those are the advantages of immediate.

The advantages of delaying the reconstruction are essentially that we can make sure the patient's cancer treatment is complete—and that's all. There's no uncertainty about whether they need radiation or whether they need further surgery for their cancer. The cancer treatment is completely done, and we can focus on reconstructing the patient.

Host: Now, what are some of the biggest concerns or fears patients have when considering reconstruction surgery? You know, kind of the common ones that you deal with a lot.

Ayesha Punjabi, MD: I think, number one, patients are overwhelmed by having additional surgery. Number two, I think there's a lot of concern, especially if you poke around online. There's concern about kind of being stuck with a bad reconstructive outcome. So, asymmetries or just, you know, suboptimal breast shapes or really bad scarring.

 What I talk to patients about is if they want reconstruction and they're willing to go through some additional surgery to get breast reconstruction, any kind of outcome with reconstruction that's asymmetric or excessively scarred is correctable with usually an outpatient surgery. So, no one has to kind of live with a bad outcome.

Host: Let's talk about recovery. What does that typically look like with reconstruction. Do most patients say it does feel natural, and they're happy with outcome?

Ayesha Punjabi, MD: Number one, for recovery, I would start with, say, that a patient is simply getting a mastectomy with no reconstruction, they can usually expect an overnight stay in the hospital. I would give it a couple of months until they're running, jumping, working out completely back to themselves. Reconstruction doesn't really add too much to that. So, if we add some implants during the mastectomy, it really is a similar recovery.

For some of the bigger flap surgeries where we're making big incisions on the abdomen and all that, it can add a few weeks to the recovery, especially to the level of being completely unrestricted activity-wise. So, maybe three months instead of two months.

And then, for partial breast, if someone gets a lumpectomy alone, it's probably four to six weeks of recovery, again, until they're completely unrestricted. If, for example, we do a oncoplastic breast reduction instead, maybe it adds a couple of weeks. It's about eight weeks until full unrestricted activity because. We might be operating on both breasts. It might be more incisions, but it's pretty similar to the surgery the patient is receiving for their breast cancer anyway.

Host: And when you say in eight weeks to recover from reconstruction, it's important I think for patients to understand—and aplease correct me if I'm wrong—that that doesn't mean it takes eight weeks to start feeling better. You're talking about full-blown activity. You know, people feel better way earlier than that, right?

Ayesha Punjabi, MD: People start to feel better after about three days, the pain and swelling start to decrease and they start feeling more and more like themselves. And I always tell people, just for a baseline, you can walk around the night of surgery. Kind of gentle walking around, you're able to do right after surgery. But yes, you know, I talk to patients about, like, until you're completely full steam ahead, working out, heavy lifting, running all of that.

Host: Right. Gotcha. Now, what about patients who they just don't want to do reconstruction? How do you support them in that decision?

Ayesha Punjabi, MD: Yeah. So first of all, I really support that choice. I think that, absolutely, I would want no one to feel pressured to go through breast reconstruction. So, what I can offer those folks as a plastic surgeon is I can offer skin rearrangements, for example, if they're getting a mastectomy and going flat, oftentimes when I can fold their breast skin on itself, in a way that prevents their scar from sticking right to their pec muscle and gives them kind of a smooth result and a smooth closure, which is what people want.

Host: I want to summarize with having you tell us, is there one thing you want patients to know about reconstruction that maybe they don't realize?

Ayesha Punjabi, MD: I would like patients to know that breast reconstruction is not just cosmetic. So, I mean that in a few different ways. Number one, kind of the scarring after a mastectomy can inhibit patient's range of motion. And so, sometimes breast reconstruction is actually helping patients move their arms more smoothly and be in less pain throughout their day-to-day life.

Second of all, fitting clothing is something that patients have to do every day, and honestly, sometimes that's just a little trickier without breasts. And so, fitting clothing is another like very functional activity that breast reconstruction can help patients with. Second of all, I mean that breast reconstruction is not cosmetic in the very pragmatic sense of insurance coverage. By law, insurance companies are required to cover breast reconstruction.

All of that being said, even if breast reconstruction is just cosmetic, I think, that's the patient's choice and patients should get to choose that for themselves after breast cancer.

Host: This has been fantastic. I really appreciate all the information that you have shared. If you would like to schedule an appointment or talk with Dr. Ayesha Punjabi, you can go to swgeneral.com. That's swgeneral.com. If you found this episode to be helpful, please share it and check out our full podcast library for topics of interest to you. This has been another episode of Southwest General Health Talk. Thanks for listening.