Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals. Providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And joining me today to discuss updates in breast reconstruction is Dr. Maria Helena Lima. She's an Associate Professor in the Division of Plastic Surgery, specializing in aesthetic and reconstructive plastic surgery of the breast, facial reconstruction, and body contouring at UAB Medicine.

Dr. Lima, thank you so much for joining us today. Tell us a little bit about some of the types of breast reconstruction that are available today.

Dr Maria Helena Lima: Hi, Melanie. Good morning. Thank you so much for having me here. Well, there are different types of breast reconstruction available today. We have breast reconstruction with implants and we have breast reconstruction with autologous tissue, which is also called flaps. The flaps can be pedicle flaps, and can be microsurgical flaps, which are also called free flaps. And there's also reconstruction which we call oncoplastic reconstruction in case, let's say, the patient has a lumpectomy instead of a mastectomy. When we rearrange the tissue of the breast. Let's say we do a breast lift on one side in if the patient has a lumpectomy, we will rearrange the tissue in a breast lift, for example, in one side, and then we will do a symmetrization surgery on the other side with another breast lift, for example. We call that an oncoplastic breast plastic surgery. And then, of course, some minor procedures, such as just rearranging tissue, or sometimes we will just place some local flaps if it's another lumpectomy done, and it's not necessarily just a breast lift.

Melanie Cole, MS: What an exciting time in your field. There are so many options nowadays and tools in your toolbox. Dr. Lima, as you're speaking to other providers, what kind of procedures are you doing the most at UAB?

Dr Maria Helena Lima: I would do mainly oncoplastic procedures and implant-based reconstruction which are reconstruction with implants and reconstruction with tissue expanders.

Melanie Cole, MS: Well, then tell us about patient selection, because I imagine that that is a very important part of this. So, who is a candidate for breast reconstruction?

Dr Maria Helena Lima: The main important thing for the patient to be a candidate is if the patient is a non-smoker, especially if they're undergoing implant-based reconstruction. They can have comorbidities, but if their comorbidities are well controlled, such as diabetes, hypertension, and, if they have obesity, it has to be BMI ideally under 30, but between BMI 30 and 35. We have to really consider risks and benefits of the surgery. So, for example, if it's an implant-based reconstruction, we may delay the reconstruction. It may not be immediate reconstruction, they may not be a candidate for immediate reconstruction. We may have to do a delayed reconstruction in some cases. We will have to weigh the risks and benefits depending on the number of the comorbidities of the patient.

So, it all depends on the patient's medical conditions, and also, of course, the desire of the patient of having a reconstruction. So, it all comes like in a package. And when we see the patient for the first time, and when they're referred by the breast surgeon, we will talk to the patient about their expectations of the reconstruction, and then also their medical history. And then, we'll come to a conclusion if they are a good candidate for reconstruction.

Melanie Cole, MS: It's really shared decision-making these days. Now, speak about the different options for reconstruction. As far as implants, we hear about saline, silicone. Tell us which kind is better.

Dr Maria Helena Lima: Yeah, absolutely. It's decision-sharing nowadays. It's past the time when, you know, the doctor would tell the patients what to do. We really have to consider the patient's decision nowadays. The silicone implants nowadays are much, I would say, "safer" than they used to be because nowadays we use the cohesive gel type of silicone. In the past, you know, the silicone implants used to be more liquid. Let's say, if they would leak or rupture, the silicone inside basically could go anywhere in your body. Now, the new type, which the population called gummy bear implants, it's much more cohesive gel. So if the implant gets ruptured, they stay in the breast pocket. So, they don't just go everywhere in your body. They stay in the breast pocket. So, there's not such a risk of that silicone going into lymph nodes or in the mediastinum and other places in your body. So, there's still of course the risk of getting ruptured. But if that happens, since they stay there, the worst thing that can happen is a capsule contracture, which can be detected by an MRI. So if you have a silicone implant, the FDA suggests that you have an MRI, in the first one after five, six years. And then after that, the surveillance would be every two to three years to detect for rupture. But the risk is basically just a capsule contracture, which is a hard scar from your body. There's no major damage from the silicone. And the saline implant doesn't have such a natural feel. And plus, if it gets ruptured, your breast goes flat right away because your body will absorb the saline. So, we recommend the silicone implant nowadays over the saline, because it feels more natural and it's much better to have this type of silicone in your body than it used to have with the other type of silicone in the past. Plus, you know, if you're really afraid of a silicone inside of your body, the saline type of silicone implants, they also have silicone, because the shell is also made of silicone, so you wouldn't escape from that either.

Melanie Cole, MS: Are there any other risks you wanted to mention with silicone implants? You mentioned the leak and that's now changed. Are there any other risks that you alert patients to?

Dr Maria Helena Lima: So, people are afraid of the breast implant illness. They hear a lot about that in the media. There's some patients that report they have more than 40 type of symptoms related to having silicone implants inside of them. There's some reports in the literature about that. There's been a lot of research done about it, but none of those research found any conclusion related to causality. You know, there's been association, but we can't prove that the silicone implants are actually the cause of those symptoms. And there's been a lot of other symptoms and other medical problems found in these patients as well. But we still have to tell patients that there's this entity called breast implant illness.

There's also the BIA-ALCL, which is the breast implant-associated lymphoma, but those have been associated to the textured shell of the breast implant, and we don't use this type of implants here at UAB. Actually, most of the United States plastic surgeons don't use that type of implant anymore. They've been recalled from the market several years ago. So, all the reports in the literature have been associated to this type of shell, you know, which is a textured shell. We only use the smooth shell silicone implant. Basically, those are the risks that we find.

Melanie Cole, MS: Well, thank you for going over those. Do you place immediate implants? Tell us a little bit about reconstruction after mastectomy. How many surgeries does a patient need if they don't do it at the same time?

Dr Maria Helena Lima: Yeah, the average patient usually, I wouldn't say require, because none of these is a requirement. Everything about breast reconstruction is what you usually want to do, but the average patient usually tends to have two to three stages after reconstruction. So, immediate implants, it's an option for some patients. It's just a minority. I would say maybe 15-20% of patients are candidates for placement of immediate implants. And those patients are maybe the few patients that can have less surgeries.

So, it's a good option for the ones that are candidates. Not everybody's a candidate. Like I'm saying, it's maybe for some patients that have like smaller breasts and are a candidate for a nipple-sparing mastectomy, which the tumor is not so close to the nipple. So depending on the situation, the breast surgeon and I will discuss the situation. And when it's a good indication, of course, you know, the patient will be included in that discussion. We can try to place immediate implants. And in some cases, these patients can just go with one surgery, and that's a good option for them. Yes, I do place immediate implants. And I think that's a good option, but it's not for everyone.

Melanie Cole, MS: Dr. Lima, as we wrap up, please explain the importance of collaboration with other healthcare professionals such as oncologists and reconstructive surgeons to ensure that comprehensive care for breast cancer patients seeking reconstruction.

Dr Maria Helena Lima: We all work together very well as a team. We all communicate via our electronic chart, via our confidential messenger system. So, we all make sure we always communicate about our patients as soon as possible, as soon as patients messenges us when anything important is happening. So, we are always working together for the benefit of the patient. We have definitely a patient-centered team approach. We have a nurse navigator. We have a lot of nurses and nurse practitioners, and I think we work very well as a team.

Melanie Cole, MS: Thank you so much, Dr. Lima, for joining us today and sharing your incredible expertise. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. Thanks so much for joining us today.