Maggie McKay (Host): Nobody wants a diagnosis of breast cancer, but when you do hear that, it's scary. And you probably have a lot of questions about what happens before and after surgery. So today we have with us Dr. Laura Klein, Director of the Valley Breast Center, Valley Mount Sinai Comprehensive Cancer Care and Associate Professor of Surgery for the Mount Sinai Icahn School of Medicine, plus Breast Surgical Oncologist. She is going to tell us the answers to some of the questions she hears most often from her patients.

Welcome to Conversations Like No Other presented by Valley Health System in Ridgewood, New Jersey. Our podcast goes beyond broad everyday health topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. Thanks for listening. I'm Maggie McKay. So good to have you here today, Dr. Klein. Thank you so much for making the time.

Laura Klein, MD: Thank you, Maggie, for having me today.

Host: So no doubt you've heard the same questions from patients time and time again. So let's start with what if a plastic surgeon was not available at the time of a mastectomy, is it too late for reconstruction later?

Laura Klein, MD: So as you were alluding to, doing the reconstruction immediately in the same setting is the standard of care today. And I would say that in the area where we are and surrounding areas that it should be what is expected. However, it is possible to have a primary mastectomy and closure and come back another day.

Also, some people just aren't sure of the kind of reconstruction that they're interested in. They're not sure who their care team is, or will be in the future. And very rarely, they have a type of breast cancer that may not be conducive to having immediate reconstruction. But again, that is very rare.

Host: And how does a patient decide on breast size?

Laura Klein, MD: I kind of leave that up to the conversation with the patient and the plastic surgeon. And it depends a little bit on what they're coming to the table with. Some people want a reconstruction on the side of the mastectomy that helps them to be balanced with what they already have.

And some people want to perhaps go a little bit larger, or even a little bit smaller. So, it's a conversation that is one that is front and center with the plastic surgeon when the patient is meeting with them and that's decided then. There are limitations, however, that could be of issue with people who have a very high body mass index. They only make implant reconstruction to a certain size. I believe it's five or six hundred cc's of an implant. So there are limitations in that way. If they're using autologous tissue, tissue from their own body, they may be able to go beyond that type of limitation.

Host: Dr. Klein, if somebody decides not to have implants, can the chest be made to look like no breast cancer surgery was done?

Laura Klein, MD: So there are a few options in that setting. One of the options is kind of a very popular thing to do today, which is, quote, going flat, unquote. That is where we preserve as much of the skin, the nipple, and the areola as possible and removing the breast tissue underneath and making the chest wall look flat like it would be in, you know, in a male breast or a male chest.

So that's one way to do it, that would be accepting no reconstruction, but having a nice flat closure, a nice cosmetic result. Another trick or option that some people might have is what we call a Goldilocks mastectomy, where when we're doing the mastectomy, the subcutaneous tissue, which is not removed with the breast, is preserved and separated from the skin and kind of tucked and rolled under to give a little bit of a chest wall reconstruction or a little bit of a breast mound with a little bit of an inframammary fold.

It's a nice procedure in somebody who has more subcutaneous fat who needs mastectomy, who does not want an implant reconstruction and is also not a candidate for autologous tissue reconstruction for one reason or another. Those are a couple of the current approaches to making the chest wall look nice without having an implant reconstruction.

Host: Why would people not want implants? Because they don't think they're safe or all the news how they break. Why?

Laura Klein, MD: So a lot of that news about implants and not being safe and how they break comes from two main places. One is in the 1970s, there was an implant that the way it was manufactured, when the outer capsule broke down, there was leakage of the inner silicone material. Those were removed from the market. The structure of the implants were re-engineered and we just haven't seen that happen since the 1970s. So I don't worry about the safety as far as leakage from implants anymore. One of the more later concerns has been regarding textured implants, which we also don't use anymore. So I think that some of the reasons people would choose no implant reconstruction would be one of two things; either unfounded fears, which sometimes it's like ringing the bell you can't unring and the other is the idea of having a foreign body. They may not feel comfortable with having a foreign body, again, with whatever bias they come to the table with. And then one of the other reasons is after people have had a prior radiation treatment, their risk of having an infection with that foreign body placed, it becomes much greater.

So we talk to people about the loss of an implant, the loss of that foreign body with the past history of having radiation and that their risk is about 60 percent of having a loss of an implant due to infection. So they may just may choose not to want to assume that risk and go through the pain of, you know, the expectations of the reconstruction and then having a potential infection.

Host: What is a typical timeframe for someone having breast reconstruction surgery and what factors can affect the timing?

Laura Klein, MD: The time frame should be immediate. Standard of care should be immediate reconstruction. That means if we go to the operating room to perform a mastectomy, that at least the first stage of reconstruction with an implant or autologous tissue should be done in the same setting. So that means you have a team with the plastic surgeon and you go to the operating room together.

The patient has had the consultations with both the surgical oncologist and the plastic surgeon prior to that setting, made all of those choices of what they want, presented the options, risks, benefits, and alternatives. And it's done in that setting. And it can either be done either as a single stage which means you go to the operating room and you have what is expected to be the complete reconstruction performed in that setting.

However, what's the most common, is a two stage reconstruction, where you go to the operating room and you have a tissue expander placed after mastectomy. Today, with skin and nipple sparing procedures, it's more of a placeholder than an expander most of the time. But that device is placed, some time passes, whether the patient requires post mastectomy radiation or not, either two months or even up to a year passes, and then the second stage operation is performed by the plastic surgeon only, where the expander is removed, the final implant is placed, maybe some fat grafting at that same time, or if it's after radiation, the choice perhaps may be autologous tissue.

Again, the expander is removed, the autologous tissue reconstruction is performed, and the patient is on to having that final stage completed. So it can vary, and it can vary by region, it could vary by patient desire, and one thing I really like to stress is when we're putting together a team, and what I teach my fellows, and my residents is, you want people who are a part of the team that are well versed in all of the procedures.

So, when a patient comes to that consultation, they really get a very unbiased look at what their options are. Whether it's implant, whether it's autologous tissue with a DIEP flap reconstruction using the abdominal fat for placing in the breast position. That's a microvascular flap. Whether it's using a latissimus flap with implant, you just, you want a team that really can offer the full array of options to the patient, so the best choices can be made.

Host: And what is oncoplastic surgery?

Laura Klein, MD: Oncoplastic surgery is, in my opinion, two things. One is a philosophy. Combining oncologic practices with plastic surgical techniques. So the philosophy of that is looking at the patient's case and the patient's anatomy with the eyes of an oncologist. How do I get the tumor out? How do I give this patient the best cancer treatment possible.

And then, as soon as that is decided, the very next thought is, and how do I do that and make this person look as good as they possibly can? Because for women, whether you're 20 years old, 50 years old or 90 years old, I believe we're still very vain creatures at the heart. And we want to look as good as possible.

And it doesn't necessarily mean we want to look good for somebody else, but we want to look good for ourselves. And so being able to have that as a philosophy when you're approaching your patient's care, I think is really important and it's something that has really taken hold over the last 20 years.

For instance, when I trained, I trained with the great Mel Silverstein, who really coined the phrase Oncoplastics and brought that into mainstream breast surgery. He is one of our thought leaders, and now every national conference that we go to, there's a course on Oncoplastics. So, what that means on the second hand, is not only the philosophy of the approach to the patient, but this cadre of techniques where we are removing areas of the breast by lumpectomy and then reconstructing the breast locally with established plastic surgical techniques such as mastopexy or mammoplasty, which would be, you know, in layman's terms, a reduction or a lift, and by the way, that would also include balancing the other side.

So we don't want one perfect, beautiful breast and then the other side also perfect in its own way, but not balanced. So we want to balance the patient. And then all the way to that idea of can we do nipple sparing procedures and mastectomy with that viewpoint of letting the patient look and feel as much like themself or even better as possible.

Host: Dr. Klein, if someone has dense breasts, does that indicate the type of reconstruction they need?

Laura Klein, MD: It doesn't. Dense breasts are an issue when it comes to screening. So people with dense breasts may benefit from the addition of ultrasound. And if they are at a particularly higher risk, such as over 18 or 25%, they may also benefit from having yearly MRI. In the setting of high risk, a strong family history or mutation carriers. So, dense breasts are more of an issue in the screening, surveillance, and workup once a person has been diagnosed. But once it comes to the time for surgery, the dense breasts are not an issue in terms of mastectomy, because the tissue planes are what they are. However, if you're operating in a setting of lumpectomy, it may actually be of benefit because it gives you more tissue to work with, a better quality tissue to work with when doing the local reconstructions.

Host: It seems like there are a lot of options and a lot of decisions to be made for the patient. So what suggestions or considerations do you recommend women think about when they have to have surgery?

Laura Klein, MD: I think the best approach is identifying a program that has a comprehensive, multidisciplinary breast program where there are a team of doctors working together in a cohesive manner, such as the Valley Breast Center. There are many centers in Bergen County that function either similarly, or I call it virtually where you have the radiologists, you have the pathologists, the breast surgeons, the plastic surgeons, the medical oncologists, the radiation oncologists, all together working as a standard team, making sure that the people that you're working with are specialty trained. There are some of the more seasoned, older group of surgeons that in their day did not go for fellowship training, however, had the benefit of being able to narrow their practice to breast only, and those people kind of paved the way for creating a breast fellowship.

So today I would say a fellowship trained breast surgeon in a multidisciplinary breast program is what to look for.

Host: And I know you touched on this a little bit, but just in a nutshell, what is aesthetic optimal flat closure or chest wall reconstruction?

Laura Klein, MD: The difference between an aesthetic chest wall reconstruction is where you're taking into account how the skin is laid over the chest. If you're preserving the nipple and areolar complex, the positioning of that on the chest wall, it's not as obvious as it would seem to maybe a general surgeon. But when we're looking at the chest wall after reconstruction, there's a lot of extra skin that may need to be tailored and marking the patient standing up and really thinking about how the skin is going to be draped over the chest wall is important.

Also taking into account what the depth of subcutaneous fat a person has. And what's not immediately apparent is that most Americans have a degree of body fat. And so just removing the breasts would leave an indentation in that space of where the breast was. So taking that into consideration to mobilize some of that subcutaneous fat and laying the skin over it properly, it's really a very high level kind of chest wall closure.

Host: What are options for nipples after reconstructive surgery? Are tattoos an option?

Laura Klein, MD: There are a number of different options for nipple reconstruction. Tattooing and the 3D tattooing that has really come into fashion is fantastic. I mean, some of these artists create these nipple and areolar tattoos that you feel like you can reach out and touch and feel the contour of the Montgomery glands or the nipple.

They really fool the eye with the 3D texturing. It's a great option for people who were not able to preserve their own nipple areolar complex. There are also the more traditional reconstructions with small rotation flaps that create the nipple and tattooing around that or even bringing in skin from the inner part of the thigh and creating a full nipple areolar complex just by these standard plastic surgical techniques that have been around for a long time, it's a good way. And what's interesting to me is how probably about 40 percent of women who have non-nipple sparing mastectomies never go for nipple reconstruction. And I'm always surprised. So I think with the new 3D tattooing, that number may be decreasing because it's not like you need to go for another surgery per se. It's more going for a procedure that seems more superficial and they're really, really nice.

Host: That's helpful for someone going through it, you know, that they have choices. This has been so educational and hopefully has taken away some of the fear and the unknown for a person going through this journey. So thank you so much for making the time.

Laura Klein, MD: Absolutely. Thank you so much, Maggie, for having me today.

Host: Of course. Again, that's Dr. Laura Klein. For more information on today's topic, or to be connected with today's guest, please call 201-291-6090 or email Valley podcast@valleyhealth.com. And for more information about Valley's Breast Center, please visit valleyhealth.com/breastcenter or call 1-800-Valley, 1-800-825-5391 to schedule an appointment.

If you found this podcast helpful, please share it on your social channels and check out our entire library for topics of interest to you. I'm Maggie McKay. This is Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. Thank you for listening.