Amanda Wilde (Host): For patients contemplating breast reconstruction, techniques and procedures have evolved. So we're exploring what you need to know about breast reconstruction with plastic surgeon, Dr. David A. Sterling. This is UAMS Health Talk, a podcast from the University of Arkansas for Medical Sciences. I'm Amanda Wilde.

Dr. Sterling, welcome and thank you so much for being here.

David A. Sterling, M.D.: Thank you for having me on the show.

Amanda Wilde (Host): I know there've been huge advances in breast reconstruction, so can you start us off by talking about what breast reconstruction entails?

David A. Sterling, M.D.: Sure. Breast reconstruction is recreating the breasts following surgery for cancer. And the most common indication is breast reconstruction in an individual who has had either a mastectomy or a lumpectomy. And the goals for a patient, it varies for everyone. In general it seems to be to feel whole or complete following surgery for cancer and to achieve this, the things that I focus on are recreating volume and shape for the breasts, and in certain circumstances may be reconstructing the nipple and aerola.

Host: So you, I think, touched on this, what are the most common reasons patients might consider breast reconstruction? You said it might make people feel more whole after cancer?

David A. Sterling, M.D.: Yeah. A common reason a patient, at least my patients might be seeking out breast reconstruction, were to feel some sort of completeness following surgery for this cancer. So after the cancer is removed, which is a significant event in their life, to recreate their breasts and give them a sense of wholeness.

Host: Who is typically a good candidate for breast reconstruction surgery, or are all women in this position candidates?

David A. Sterling, M.D.: Luckily, one of the best things about breast reconstruction is that it doesn't have to happen immediately. It can be delayed, which gives us time if a patient wasn't upfront a good candidate, which I'll define in a second, to become potentially a better candidate. So we can always have that conversation, and I think all women have the right to have the conversation for breast reconstruction, and then we can go over the details and figure out who's good for immediate reconstruction or delayed reconstruction? To kind of put it simply, because this is an elective procedure, patients who are medically optimized, have their medical issues controlled, are good candidates, and very specifically typically patients who are non-smokers or don't use any nicotine products. BMI, ideally less than 40, and if they're diabetic, to have controlled sugars.

Host: Now, can you walk us through the different types of breast reconstruction that are available today?

David A. Sterling, M.D.: Yes, absolutely, and for this part I'll focus primarily on patients who have had a mastectomy because that's the most common reason a patient comes in for reconstruction. There are two primary types of breast reconstruction. One where we use implants or implant-based reconstruction, and then autologous where we use the patient's own tissues for the reconstruction. And it gets kind of complicated, and I always tell patients one of the nice things is that they all kind of have a common starting point, which is starting with implants. We typically, if we do immediate reconstruction, we start with tissue expanders the same day as the mastectomy. They're kind of like placeholders.

They're implants that we can inflate slowly over time to get to the desired volume. So they're temporary implants to start things off. Then later on down the road, we might switch out to, at least for my practice, which is primarily implant-based to more permanent silicone implants. At that point, if if a patient needed to proceed with their own tissue or if that was their desire, you can also switch out to using their own tissue for a reconstruction.

So, like I said earlier, to achieve the volume and shape, to get that from the own tissue on their body, which might be a deep flap is a common, autologous reconstruction that patients perform. So that's using abdominal tissue, or tissue perhaps on the back, like a latisimus flap. These are all a little bit technical, but these are all options.

But if you could boil it down just to reiterate, either implant-based reconstruction using implants to restore volume and shape, or using the patient's own tissue.

Host: And what have you seen in terms of success rates for these surgeries?

David A. Sterling, M.D.: Overall very high success rates. And I pointed this out earlier, but we do choose our patients pretty carefully, so we try to optimize and increase our likelihood of success by choosing patients who are the healthiest, at least for the immediate reconstruction. Because when you're combining two surgeries, like a mastectomy and a whole nother surgery with the reconstruction, it's just a longer surgery, you increase your odds that potentially something could happen. Upfront, you could have a higher rate of issues or risks. And largely I think that is because we're trying to start the reconstructive process on the same day as the mastectomy, in which case you can see upwards 10 to 30% issues or complication rate. Not life-threatening issues, but still they could impact what's going on in your life? For instance, you might have travel plans and then all of a sudden maybe you have an infection brewing, or there's some other issue that I say, you know, we gotta go to the hospital, get antibiotics, and take it from there. Again, not super common, but compared to my other surgeries, it's a little bit more common.

Host: You mentioned that there are some medical conditions that might get in the way of someone, or complicate being a good candidate for breast reconstruction, but we can do something about those. Can you discuss also then the potential risks and complications associated with the surgery?

David A. Sterling, M.D.: Sure, like all surgeries, there are just general surgical risks, bleeding, infection, wound healing issues, things like that. Some things that I worry about in particular for implant-based reconstruction, is if the implants get infected or if there is a wound healing issue and then an implant gets exposed, that's a much more significant issue because we most likely have to go back to the operating room to take care of it.

Those are more common if they happen at all, early after surgery within the first 30 days. But even infections, they could happen anytime even up to a year after surgery.

Host: Well, what does the recovery process look like for patients who undergo breast reconstruction? Either kind.

David A. Sterling, M.D.: Broadly speaking, it really depends. All my patients are a little bit different and their recovery process and time definitely varies from patient to patient, but I would say like a general trend that I've noticed is about two weeks of downtime, that first week, you're feeling probably the most level of discomfort.

By that second week, you're starting to regain your energy and feel a little bit more normal. Although that energy might not come back until maybe upwards of four weeks after surgery. I do like to hold my patients back and say, no strenuous activity for four weeks and no heavy lifting for four weeks. So broadly speaking, about four weeks. I feel like people are starting to feel a little bit more normal after two weeks.

Host: And how do you address cosmetic concerns that some patients may have either before the surgery or after?

David A. Sterling, M.D.: I try to, with all my patients, understand what their goals are, and then I really try to hone in on realistic expectations, like I've done enough reconstructions or cosmetic breast surgery where I have a pretty good idea of what I can realistically achieve and just having a, a pretty frank conversation with that with patients.

But I want to make patients happy, and my goal is to make, like I said earlier, is to make them feel whole and happy, and then to use the tools that I have to achieve that. So I think I listen to everything. It's not just reconstruction to have volume, it's to feel happy in and outside of clothes when they're looking in the mirror or if someone else is looking at them.

So it certainly, cosmetic concerns are at the top of my mind all the time.

Host: What resources or support systems are available for patients who might be considering breast reconstruction?

David A. Sterling, M.D.: We have in our office, a lot of literature to help give patients an idea of the different type of reconstructive options and what to expect. Also, part of their journey is with the breast surgery team, so they'll also get education through our oncologists and surgical oncologists.

It's great having such a large team of so many different people because they get to hear so much different information. So by the time they finish up with their providers, they often feel pretty well-educated. And then of course, there are a lot of support groups out there on social media, and I know for a fact many of my patients seek these out.

Host: Do you follow patients, long after the surgery or just until that initial healing process?

David A. Sterling, M.D.: Oh, no, I, I absolutely follow them, follow them for a long time. At least for a year, just to make sure that everything is settled out well, and that could oftentimes means upwards of four or five postoperative visits after that final surgery, just to get me to that point. Then at that point I have a conversation with the patient because they've just been seeing doctors, a lot of doctors for the last year, and sometimes they just want to close the door.

I don't want that door to ever necessarily be forced closed for them. So I always say that they're welcome to come back and I do like to see my patients for long-term surveillance with their implants, but I leave that one up to them. They can give us a call if they want to after that time.

Host: So I mentioned in the introduction that there have been great advancements in the last decade or two in breast reconstruction. How do you see the field evolving in the coming years?

David A. Sterling, M.D.: Breast reconstruction is a constantly evolving field. We have new and improved implants and medical devices that can help patients with improved outcomes or recover quicker or reduce risks. We're designing and are optimizing our surgical techniques all the time. Then of course the field of medical breast cancer treatments is always improving too, and this has an impact on breast reconstruction as well.

Host: Well, Dr. Sterling, thank you so much for sharing your insight and your expertise and explaining the journey of breast reconstruction.

David A. Sterling, M.D.: Absolutely. Thank you so much for having me.

Host: To make an appointment at the UAMS Plastic Surgery Clinic, call 501-686-8111. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. Thanks for listening. This is UAMS Health Talk.