New Hope for Breast Reconstruction

More and more women are choosing to have a double mastectomy after a diagnosis with breast cancer and nearly half of those who do will need radiation, which can impact their ability to have breast reconstruction. Now a new option is giving women hope- where before, there was none.

It's been a long recovery for busy mom Megan Houk, after being diagnosed with breast cancer nine years ago.

"In that moment, it was sort of, a little blindsiding," Houk told Ivanhoe.

A week later she had a bilateral mastectomy, then reconstruction. The reconstruction failed and Megan struggled to feel like herself again.

Houk explained, "That is one of the major hurdles of being a cancer survivor."

It's something Michael Zenn, MD, MBA, Plastic Surgeon at Duke University Medical Center sees every day. Only about 40 percent of women are offered reconstruction after mastectomy.

Dr. Zenn told Ivanhoe, "There are only so many choices once someone has been radiated because tissues once radiated get very scarred and very firm and hard to deal with."

Now a new procedure using a patient's own fat is giving women like Megan hope.

"The good thing is that even women who were told they never could have reconstruction, and they might be five years, 10 years, 15 years out, are candidates for this and it's not big surgery," Dr. Zenn explained.

Once injected, the fat helps the irradiated tissue regain elasticity so that tissue expanders can be placed that allow implants later.

For Megan, the results have been life-changing. She said, "My journey has been amazing in emotionally being able to heal by these opportunities." Opportunities she hopes others will take advantage of.

Dr. Zenn says he's seeing women from all over the country who once thought they'd never be able to undergo a successful reconstruction. The procedure is done over the course of about a year, typically utilizing three fat grafting sessions separated by three months each to get the skin to stretch like normal. Then tissue expanders can be used and implants can be placed.

Contributors to this news report include: Cyndy McGrath, Supervising Producer; Jennifer Jefcoat, Field Producer; Cortni Spearman, Assistant Producer; Jamison Koczan, Editor/Videographer.

BACKGROUND: Cancer is caused by an overgrowth of cells. There are more than 100 different types of cancer, and every year another 1.5 million cases are diagnosed in America alone. The cell mass is called a tumor. If the tumor stays in one place and has limited growth, it is considered benign and is easier to treat. If it moves throughout the body or keeps growing, the tumor is considered malignant. Once the cancer spreads to other parts of the body, invading and destroying healthy tissue, it has metastasized. Breast cancer develops when cells have multiplied uncontrollably within the breasts. Breast cancer primarily develops in the breast tissue and milk ducts. It usually begins with the formation of a small, confined tumor and then begins to spread through the channels of the breast to the lymph nodes or through the blood stream to other organs. Different types of breast cancer grow and spread at different rates. While some grow and spread quickly, others may take years to spread beyond the breast. (Source: http://www.webmd.com/breast-cancer/guide/understanding-breast-cancer-basics)

TREATMENT: Typical treatment for breast cancer patients includes surgery and radiation therapy. Surgery, either a mastectomy or a lumpectomy, is used to get rid of the cancer. A mastectomy is surgery that removes the entire breast. After surgery, many women may also undergo radiation therapy, or radiotherapy. Radiation therapy uses targeted high energy X-rays to kill cancer cells. Radiation is used in order to kill any cancer that might be left in or around the breast after surgery.

(Source: http://www.webmd.com/breast-cancer/guide/breast-cancer-treatment)

NEW TECHNOLOGY: Many women who undergo a double mastectomy and radiation treatment may not be able to have their breasts reconstructed because the radiation makes the breast tissue very hard to work with. Now there are more options. Michael Zenn, MD, MBA, Plastic Surgeon at Duke University Medical Center said "A lot of times when patients have radiation, that skin is shiny and thick. It has little blood vessels and the fat cells take all of that away." Dr. Zenn has found that using a patient's own fat cells and placing them where the radiation treatment was done makes the skin, which is very firm and not very elastic, "hard to work with". This radiated tissue actually becomes and looks more normal and allows for a more traditional breast reconstruction.

(Source: Dr. Zenn)


Samiha Khanna

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Michael Zenn, M.D., MBA, Plastic Surgeon at Duke University Medical Center talks about a new way to help breast cancer survivors after radiation.

Interview conducted by Ivanhoe Broadcast News in February 2015

First, can you talk about what happens when a woman comes in and has to have a mastectomy?

Dr. Zenn: When women have a mastectomy nowadays, they have a choice: to go through their cancer therapy and think about doing a reconstruction later or no reconstruction, or having a reconstruction right at the time of the mastectomy. Often times, people can be overwhelmed with that decision-making process, there are a lot of choices, most people are concerned with the cancer itself. It gets a little trickier when patients are going to have radiation as part of their therapy because it actually affects what I would do as a plastic surgeon. There are only so many choices once someone has been radiated because tissues once radiated get very scarred and very firm and hard to deal with, so very simple reconstructions, like just putting a breast implant in, become very difficult, and often times we can't do that. Patients-- when they want a reconstruction, especially once they've had radiation therapy, need to have a whole other procedure. Generally, they have to have parts of their body moved, like the tissue from the back or tissue from the belly moved to that chest area, so that there's some tissue that's never been radiated. That's a lot of surgery for a lot of people.

In the past, there haven't been a whole lot of choices for a subset of the population?

Dr. Zenn: They have limited choices. In someone, especially if we know someone is going to have radiation, what we've learned over time is we don't want to do a reconstruction at the time of mastectomy. Anybody who's going to have radiation for the most part is not having an immediate reconstruction because we want that reconstruction to be durable and to last over time. Adding new tissue in helps us to do that. A woman who has had radiation will have to wait a minimum of six months before they can even think about any type of reconstruction. Generally, their chemotherapy might be done at that time, and at that time the tissues have settled enough that we can go and do a surgery. Again, that involves generally taking tissue from the back or taking tissue from the belly or thighs or somewhere that has never seen radiation. Those procedures can be pretty long. They can be anywhere from four to eight hours. They can be anywhere from three weeks to eight weeks of recovery. They're major surgeries for a lot of people.

How does this new technique work then?

Dr. Zenn: Somebody a lot smarter than me figured out that if you took fat cells, and this is fat removed literally with liposuction cannulas, and if you place those fat cells in the area where there's radiation, they do a couple of really interesting things for you. First, that skin, which is very firm and not very elastic and hard to work with, actually changes its character. This has been shown histologically under the microscope. It becomes more normal and looks more normal. A lot of times when patients have radiation, the skin is shiny, it's thick, it has little blood vessels we call telangiectasia and the fat cells can take all that away.  There's something that the fat cells are doing to the neighboring skin. The other thing that's very helpful is these thin, irradiated skin coverings are now getting thicker and thicker as we put more fat in there. It's surprising that the fat can survive in this area where there's been radiation; we've always felt it a hostile area. The fact that it changes skin to a point that we can almost treat it like normal skin. Women who have had, say a radiated chest after a mastectomy, don't necessarily need to have these big, extensive surgeries taking tissue from their back or belly or buttock. They can actually come for a series of just very simple liposuction procedures and fat grafting placements. We do it about three or four times, separated by about three or four months. Then, after a period of nine months or so, patients often times can then have a balloon or tissue expanded placed under the skin, and the skin stretches like normal. It has been very exciting.

That procedure you said takes six to nine months, so basically you're removing the fat each time, and you're able to place it in the chest, and then at that point, you're using the tissue expander?

Dr. Zenn: The procedure is as follows: If a woman has had a mastectomy and radiation, they need to wait six months. At six months, they have an outpatient surgery. Taking some fat with the liposuction cannula can be done even under sedation anesthesia. Place the fat into the chest area, and initially these areas are so firm and so tight that there's not a lot of fat you can place. You can put a little bit of fat there, and then we wait about four months, and the waiting period is to see how much of the fat cells survive because they all don't survive, but also so they can have their effects on the skin. We can see each time it gets a little softer. They'll come back in four months, and we'll do it again. This time, we can get more fat in because now there's more space and it's softer. After a while, you can almost start to pinch the skin, whereas before it was matted and sort of shiny and firm. You can reach a point where it feels like there's enough thickness and softness, and then you'll do a surgery. Now maybe after three fat graftings, maybe it's nine months to a year later at that point, you get an outpatient surgery to go and just put the balloon in, that tissue expander. The thing about liposuction is that it's not a big surgery. The patients generally the next day can even be back at work. They'll have some bruising where the surgery was performed, but they can hide that with their clothes.

It's an added benefit for the woman?

Dr. Zenn: It is an added benefit. We'll take that opportunity to say where the area is that you don't like or is there a little fullness in the hip area or the abdomen. Because this is so new, we're trying to figure out now which are the best parts of the body to take fat from, because not all fat cells are the same. Are the cells better in the belly and things like that. Generally, we can make it a cosmetic procedure, so to speak. Now we're going to be going back and taking more fat. In the first operation, we don't want to take all of it because then we would need some. It's interesting because even patients who are very, very thin can have this done. With the types of liposuction cannulas that we have now, we can get 30 to 40 cc's, which is not a lot. If you came for a cosmetic liposuction, you might have 300 to 1,200 cc's removed to make a difference. Often times, in these procedures, you don't see a big difference, but we certainly don't want to cause any problems. If there's an area that we can make look better, certainly there's no reason we can't do that as well.

That was my next question-- if weight made a difference or not.

Dr. Zenn: It's easier if they have fat tissue. The other question we often get: what if they gain weight or lose weight? What happens? I think there are not as many fat cells there that you'd see a difference, like you're not going to lose it if you lose a lot of weight. There is something about these fat cells once they've survived in this sort of environment that they tend to persist and they tend to stay. The changes to the skin seem to be more permanent. A lot of these patients haven't had their implants in for more than just a couple of years, so the curious thing is we'll see what happens over time. Women who can have this and don't have to go through the big surgery are ecstatic because otherwise their option is to wear prosthesis and a bra and really have no durable reconstruction, which makes it hard to wear bathing suits, to wear clothes, to be physically active without a prosthesis moving around.

Probably or just to feel normal I would think.

Dr. Zenn: I think people do get used to it, and it becomes part of them. Definitely some people will incorporate it better than others and feel like it's their breast as opposed to the implant that's under there. The good thing is that even women who were told they never could have reconstruction, and they might be five years, ten years, 15 years out, are candidates for this, and it's not big surgery. They may have been told surgery is too big or it's too dangerous. This is something that's not very invasive.

What's the recovery like?

Dr. Zenn: I think that most of the patients will tell me that the liposuction part of taking the fat out causes some discomfort for a day or two. Bruising can certainly last for a week or two. Placing that balloon and the tissue expander, I think can have a little bit more discomfort. We ask them to take a week off, but usually within a couple of days, people can be back at work. They come in at two weeks after that balloon is placed, and they can come in weekly or every other week at that point. We start putting fluid in a little at a time. Most patients will say they feel some discomfort that evening, maybe for the first day or two, but usually nothing that requires more than Advil. They can be back at work, and it really doesn't take a lot of time. There is a surgery to take that balloon out once the skin is stretched and put a final silicone implant in. We usually ask them to take a week off for that because generally there'll be a drain tube or something, and we want to make sure there's no bleeding or any problems with infection.

Do you feel silicone now is okay?

Dr. Zenn:  Yeah, we've sort of been through the whole silicone scare, and now we've come full circle. The Institute of Medicine has given the silicone implants really a good bill of health. Really the silicone implants and saline are the same. The reason why I think most plastic surgeons prefer the silicone is they feel just like normal tissue and feel soft. Sometimes saline implants in someone who is having a breast augmentation, which is covered by a natural breast, can't feel the implant that much. With a woman who's had a mastectomy, it's literally just skin covering it, so with a saline implant sometimes feels more like a bag of water. Whereas a silicone gel implant can actually feel like natural tissue.

Anything you think we missed?

Dr. Zenn: The question is how many people will get reconstruction? It's known nationally only about 40 percent of women are offered reconstruction after a mastectomy, which at a place like Dukes seems so impossible to believe because it's part of your consultation when you have a diagnosis of cancer. There's a whole population of people who don't know about anything, and it's amazing with the internet and with people being able to go and find things out themselves nowadays. We get a lot of calls, and we get a lot of people coming in really from all over the country who are interested in having reconstructions that they just didn't know where to help.


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