Oct 30, 2018
Surgery is the gold-standard breast cancer treatment, but some techniques leave women flat-chested or with lopsided breasts. Dr. Patricia Wehner discusses how many women can benefit from oncoplastic surgery, which offers a more natural breast shape so women can look and feel more confident after surgery.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: We’re speaking with Dr. Patricia Wehner, a surgeon with fellowship training in breast surgical oncology and MedStar Washington Hospital Center. Today we’re discussing breast oncoplasty. Welcome Dr. Wehner.
Dr. Wehner: Thanks for having me today.
Host: What is breast oncoplasty?
Dr. Wehner: Oncoplasty in and of itself, what that actually means is it just means removing the area of cancer with attention to cosmesis. So, it’s really removing the area of cancer by doing a partial mastectomy and figuring out a way to cosmetically and acceptably close the defect that you’ve created and making certain that you leave the patient with a very reasonable size and shape breast. So, the goal is always to make it so patients don’t necessarily need to ever remember that they’ve had surgery because you’re trying to make them look how they looked before or at least minimize the disruption that you’ve caused. So, , I trained at USC, so University of California, and it is a huge oncoplastic program there. So, there I learned a lot of various plastic surgery techniques to employ in my daily operative time. So, because of that, I don’t need to have a plastic surgeon come in for most cases. Unless, again, we’re doing sort of a larger reduction or larger reconstructive surgery. Every single patient who undergoes a partial mastectomy, really is a candidate for breast oncoplasty. And again, the point of breast oncoplasty really is to just pay attention to cosmetics. So, what I tell patients is cancer surgery first, because obviously we’re all here to get rid of their cancer and to treat their cancer, but cosmetics is still really important for women undergoing breast surgery because anybody who has to deal with the loss of breast tissue or even the loss of the breast, while they’re going through it they obviously feel it. If they’re undergoing chemo, if they’re undergoing radiation, then obviously it’s something that’s very much on their mind. But five years later, when they’ve completed all of their treatment, and they've completed the chemo and they’ve completed the immediate surgery and they’ve completed everything that needed to be completed right around the time of their diagnosis, I want them to not have to look at their body and also be forced to remember day in and day out. I want them to get back to where they were beforehand, meaning, I feel good, I look good and I don’t want to stare at something that’s going to remind me on a daily basis of what I went through. So, any type of breast surgery, breasts are not twins, they’re sisters, so no matter what they're going to look a little bit different and the goal is just to minimize that difference. So, you’re never gonna reconstruct or recreate what you had prior to surgery. There’s just no way around that. But we want to at least keep it as close to that as possible and to minimize those differences.
Host: If a woman has this procedure and then they have oncoplasty at a younger age, say in her 30s, so the breasts change as we age--how does that compare as their other breast that might be healthy?
Dr. Wehner: With oncoplasty, really you’re taking the patients natural tissue and just sort of rearranging it to fill in the defect. So, I’m not adding anything, meaning I’m not placing an implant in there or I’m not placing something foreign within the breast. So, it’s still the exact same tissue you had before, just maybe a little bit less of it. But, with that, the density of that tissue can change as you get older. You’re breast, as you get older, if you gain weight or lose weight, your breast can gain weight or lose weight and so the same thing with that area of reconstruction can gain weight or lose weight. So, it’s really still retaining everything that you had before it’s just kind of moving it around in a different location. Now, there’s a lot of discussion about skin and nipple sparing mastectomy. So, a mastectomy is different than a partial mastectomy because the goal of a mastectomy is to remove all of the breast tissue. Previously when we did a mastectomy, we would make an incision, we’d remove the nipple, we’d remove the areola complex, we’d remove a good majority of the skin and try to close it as flat as we could. Then we kinda sort of started saving some skin and placing an implant in there and so creating a decent or reasonable breast. And now for certain patients that are fairly well selected, we can actually preserve the entire breast envelope, meaning the nipple, the areola complex, and the skin and still remove all of the breast tissue that’s living underneath of that and then reconstruct it with an implant or even an autologous tissue, so tissue from someplace else. It’s a very technical surgery because it’s a large amount of real estate, I guess for lack of a better term, of what you need to get to in order to remove it.
So, we go through an inframammary fold incision, meaning the incision is at the very bottom of the breast. And through that incision we reach the very top of the breast and remove all of the breast tissue. So, anything that lives above the pectoralis muscle and underneath the skin gets removed. Overall outcomes, so what a patient look like afterwards then tends to be very favorable because you still retain the nipple and you still retain the areola complex. Now they don’t function like they did before surgery, but they still look good because they're there. So, I kind of liken it to the earrings that you would put in an ear. So, while it maybe loses its function, it still looks good, so we leave it there for cosmetics and we know that there’s no increased risk of cancer recurring at that location. This doesn’t hold true for each and every patient because some of this depends on size of the natural breast, shape of the natural breast before reconstruction and just overall body habitus. But for certain patients it really is a great option.
Host: Is there a general criteria that you have for women who would quality for nipple sparing surgery?
Dr. Wehner: So for skin and nipple sparing surgery, most of these women do tend to be a little bit thinner and that’s just because patients who do best with an implant reconstruction tend to be a little bit thinner so they don’t have a very wide chest and they’re beasts have to be a little bit smaller, so generally we say A through C cup. Now we have started doing a two-stage approach for patients who have a large breast, so those who have Ds, DDs, even maybe a little larger than that. Or we actually do a surgery where we reduce the size of the breast first, so we reduce it down to a B or a C cup, let that heal and then after that’s healed then we go back and then do the skin and nipple sparing mastectomy. So, we do have options, it’s just again not a one size fits all type of option and it really kind of depends on the patient and what the patient looks like and even the type of cancer the patient has.
Host: Why is it that how the woman feels afterwards and how she feels about her self-image has become so important?
Dr. Wehner: So, losing a breast is the same as losing an appendage. Even though it doesn’t function like an arm, it’s still an appendage, it’s still an organ and for most women it has a lot to do with who they are as a women, it has a lot to do with their sensually, it has a lot to do with their body image, it has a lot to do with just how they feel about themselves. So, when they put a shirt on, do they feel normal? Do they look normal to the outside world? And that is what the goal of some of this reconstruction is. Is when a patient gets dressed and they go out, how can they give and portray sort of their best self-confidence to the world and nobody’s gonna want to do that if they don’t feel self-confident. So if they feel very anxious about how they look, if they feel very worried or afraid or if they’ve lost a breast and now it’s flat and not reconstructed and so it’s really obvious because they’re other breast is very large and now the other side clearly have tissue loss--does that make them feel sort of uncomfortable and not want to go out in public. So there’s lot to do with just body image that goes along with this type of surgery and there’s a lot to do with sensuality that has to do with this surgery and that’s why it’s really important that when you have a breast cancer diagnosis that you find a provider that you trust and a provider that really can understand that. All cosmetic follow-up procedures are not cosmetic because they are done under the purview of reconstruction operations in the setting of a cancer diagnosis. So, they are considered oncoplastic. And that’s onco meaning oncologic or cancer and plastic meaning cosmesis. So, everything covered by insurance. This is a not a paid out of pocket. We’re not trying to augment you or place implants just because you want them. We’re doing it because this is a legitimate cancer diagnosis and so you should be able to undergo treatment and surgery and come out on the other side feeling good.
Host: What is the oncoplastic surgery recovery like compared to say if they hadn’t had a reconstruction?
Dr. Wehner: So oncoplastic surgery in a partial mastectomy is the same recovery time as a regular partial mastectomy. There's not really any difference. Now if we do oncoplasty in a setting of a reduction surgery, meaning a patient has really, really large breast and they’re heavy and they cause strap indentations on their surgery or they cause them back pain and we chose to reduce the size of their breast all while removing the cancer, that recovery is a little bit different because it’s a more extensive surgery. But even those patients go home the exact same day.
Host: Why is MedStar Washington Hospital Center the best place to seek oncoplastic surgery?
Dr. Wehner: Each and every breast cancer patient that is treated at MedSTar Washington Hospital Center will have oncoplasty employed in their surgery. And whether that’s done by the main surgeon, which I do most oncoplasty myself, or whether that’s done with the aid of a plastic surgery, which is done by my partner here always employs the help of a plastic surgeon. Every patient still will have oncoplasty and still will have the opportunity to have some of these types of procedures brought into their regular partial mastectomy procedure. Historically anybody who underwent a partial mastectomy came out looking essentially like a shark bit off part of their breast. I mean, part of their breast was removed, the skin was closed and that was just it. So, a lot of patients who were treated many years ago have a lot of indentation, a lot of asymmetry and they don’t feel good about it. They really don’t want anybody to see. Whereas now, there’s plenty of patients who come and again are just like oh right, I don’t remember where that scar is.
Host: Is there anything that can be done for those women now that had surgeries maybe ten, fifteen years ago when techniques weren’t so good?
Dr. Wehner: So, there is some plastic surgery options. Some involve reconstruction. Some involve something that’s called fat grafting which is done by our plastic surgeons where they can actually suck fat from one part of the body and inject it within the breast to fill in some of that area. So, there’s options, but it really just depends on what surgery they had, what treatments they had and kind of what they look like now.
Host: Thanks for joining us Dr. Wehner.
Dr. Wehner: Absolutely.
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