WEBVTT - Let’s Be Clear About Reconstruction...with Dr. Jay Orringer (Part1) 0:00:02.560 --> 0:00:08.400 This is Let's Be Clear with Shannon Doherty. Welcome to 0:00:09.119 --> 0:00:12.000 a new episode of Lesbie Clear with Shannon Doherty. And 0:00:13.039 --> 0:00:17.920 I have on one of the loveliest, loveliest doctors I 0:00:18.079 --> 0:00:22.799 have ever encountered, doctor j Oranger. He is a plastic surgeon. 0:00:23.560 --> 0:00:28.560 He is also a reconstructive plastic surgeon, which is how 0:00:28.600 --> 0:00:34.640 I know him because he reconstructed my breasts and then 0:00:34.680 --> 0:00:35.720 the other one to match it. 0:00:36.440 --> 0:00:40.120 Hi, Hello, Shannon, Hi doctor j. Great pleasure to be 0:00:40.159 --> 0:00:40.680 here with you. 0:00:40.920 --> 0:00:44.080 Good to see you. You really are one of those 0:00:44.120 --> 0:00:48.440 doctors who takes so much time with your patients. You 0:00:48.560 --> 0:00:52.680 don't overbook yourself. I just remember you drove to my 0:00:52.840 --> 0:00:56.240 house constantly to check on me when I had the 0:00:56.280 --> 0:00:59.640 expander in, and you know the drains all of that. 0:01:00.560 --> 0:01:03.840 I'll get into everything that you did for me and 0:01:03.920 --> 0:01:06.560 what you do for so many others, But can you 0:01:06.600 --> 0:01:10.320 tell us how you started down this path? 0:01:10.720 --> 0:01:15.200 Sure? So. Originally, Shannon, I was believing that I was 0:01:15.240 --> 0:01:19.800 heading down the path of chest surgery thoracic surgery. And 0:01:19.880 --> 0:01:22.280 I was in my general surgery training, which is one 0:01:22.319 --> 0:01:26.800 of the prerequisites for that, and very early in that training, 0:01:26.840 --> 0:01:30.800 I was on the oncology service, and we rounded on 0:01:30.880 --> 0:01:32.959 a lovely young woman who had just had a mess 0:01:32.959 --> 0:01:38.080 stect to me, and in those days, the reconstructions weren't 0:01:38.080 --> 0:01:41.200 done immediately, if done at all, they were often done 0:01:41.319 --> 0:01:45.560 as a subsequent stage following the mess stec to me, 0:01:46.080 --> 0:01:49.720 as opposed to today, when we do the vast majority 0:01:49.720 --> 0:01:52.800 of our reconstructions immediately, at least start them immediately so 0:01:52.880 --> 0:01:57.480 that the patient wakes up with some form of breast 0:01:59.160 --> 0:02:02.320 I felt so bad for this woman when I saw 0:02:02.520 --> 0:02:05.680 how this affected her and how it would affect her. 0:02:06.160 --> 0:02:09.359 It changed my life. That day changed my life when 0:02:09.400 --> 0:02:13.720 I rounded on that patient and I just saw what 0:02:13.960 --> 0:02:19.040 resulted from that life saving procedure, what she would face 0:02:20.840 --> 0:02:26.640 unless her wholeness were able to be restored through a 0:02:26.680 --> 0:02:31.040 good quality reconstruction. And I then said that day, that's 0:02:31.080 --> 0:02:32.480 what I want to do for the rest of my life. 0:02:32.520 --> 0:02:36.520 I want to help these people. And so I completed 0:02:36.520 --> 0:02:39.720 my general surgical training. I feel that as a surgeon 0:02:39.720 --> 0:02:43.799 who operates on the breast in any capacity, or any 0:02:43.840 --> 0:02:45.800 part of the body for that matter, it's helpful to 0:02:45.840 --> 0:02:49.520 be fully trained in general surgery. So I completed a 0:02:49.600 --> 0:02:54.960 wonderful training and then my boards in general surgery and 0:02:55.000 --> 0:03:00.359 then completed my plastic surgical residency in training, and then 0:03:00.400 --> 0:03:04.280 following that, as if that weren't enough, I decided that 0:03:04.400 --> 0:03:10.000 I wanted to do it super specialization in microsurgery. Microsurgery 0:03:10.160 --> 0:03:17.440 is a subspecialty of plastic surgery where it's used by 0:03:17.440 --> 0:03:20.200 others specialty as well, where we use the operating microscope 0:03:20.200 --> 0:03:25.239 to reattach blood vessels or nerves, and we can transplant tissue. 0:03:25.480 --> 0:03:30.120 And what's remarkable about it is we can take tissue, 0:03:30.200 --> 0:03:34.000 let's safe from the tummy. A woman says, I have 0:03:34.120 --> 0:03:37.560 excess tummy tissue. I don't like this extra skin in fat. 0:03:38.120 --> 0:03:40.760 I've thought about having a tummy tuck, but instead now 0:03:40.840 --> 0:03:44.680 I need a mast ectomy. We can take that tissue 0:03:45.360 --> 0:03:49.400 and using techniques of microsurgery, reattached blood vessels so that 0:03:49.400 --> 0:03:53.320 that tissue can be shaped to create a breast. It is, 0:03:53.360 --> 0:03:56.720 in many instance is almost indistinguishable from a real brust 0:03:58.760 --> 0:04:04.600 So said I wanted to acquire that expertise, and so 0:04:05.880 --> 0:04:11.240 the microsurgery has been a very nice adgent to sort 0:04:11.240 --> 0:04:14.520 of complete my armamentarium in terms of what we can 0:04:14.560 --> 0:04:21.159 offer patients. In general terms, there are two ways we 0:04:21.200 --> 0:04:25.240 can reconstruct the breast, one uses some form of implant, 0:04:26.080 --> 0:04:33.760 one uses one's own tissues, and each has advantages and disadvantages. 0:04:34.440 --> 0:04:38.480 The advantages of using an implant include the fact that 0:04:38.680 --> 0:04:45.040 it is typically a shorter and simpler procedure associated with 0:04:45.360 --> 0:04:50.840 a somewhat shorter recuperative period in most instances, and the 0:04:51.600 --> 0:04:56.760 site of the surgery is limited to the chest using 0:04:56.839 --> 0:05:02.440 one's own tissue. Where we transfer tissue, basically, we transfer 0:05:02.720 --> 0:05:05.560 an orgon of fat to make a new breast and 0:05:05.600 --> 0:05:09.680 it has its own blood supply, as opposed to situations 0:05:09.720 --> 0:05:13.680 where commonly today surgeons will liposuction fat and injected to 0:05:13.760 --> 0:05:16.880 the chestwell and hope that that fat will live. In 0:05:17.040 --> 0:05:20.800 reality being that much of that fat will resorb when 0:05:20.839 --> 0:05:25.280 we reattach blood vessels that are attached to this organ 0:05:25.320 --> 0:05:29.480 of fat. It lives just like a kidney transplant. 0:05:29.120 --> 0:05:31.320 Right because you're pumping blood. 0:05:31.160 --> 0:05:35.440 Too into it and out of it. And so it's 0:05:36.120 --> 0:05:39.680 quite a remarkable concept. And we can take tissue from 0:05:39.680 --> 0:05:41.600 the tummy that again the tissue that would be the 0:05:41.640 --> 0:05:45.640 scarter with a tummy tuck, we can revascularize, put it 0:05:45.760 --> 0:05:48.000 under the skin, under the nipple, under the skin of 0:05:48.040 --> 0:05:52.080 the breast, and when you feel it, it feels just 0:05:52.279 --> 0:05:56.480 like a breast, because the breast is an organ largely 0:05:56.480 --> 0:06:00.000 a fatty tissue, and there's fatty tissue now placed under 0:06:00.120 --> 0:06:03.320 the skin. So it feels very much and looks very 0:06:03.360 --> 0:06:07.839 much like a natural breast. Similarly, in a very thin woman. 0:06:07.960 --> 0:06:10.240 You know, there's some people who are quite thin, and 0:06:11.040 --> 0:06:13.440 you know, you're in you're in great shape. You didn't 0:06:13.440 --> 0:06:14.839 have a lot of tissue to work with, and we 0:06:14.880 --> 0:06:17.360 had to use, you know, everything we could from that 0:06:17.600 --> 0:06:21.440 from that small tummy. There's some women that are simply 0:06:21.440 --> 0:06:24.120 there isn't enough tissue on the tummy to even do 0:06:24.279 --> 0:06:29.279 a single breast, and so then those women generally will 0:06:29.320 --> 0:06:33.080 have enough tissue on the upper buttock or gluegal area 0:06:33.279 --> 0:06:38.880 where we can in essence to a buttock lift and 0:06:38.960 --> 0:06:43.320 take that tissue and transplant it to make the new breast. 0:06:44.640 --> 0:06:50.440 The scar that results from that simulates a butt lift 0:06:51.360 --> 0:06:53.480 on the upper buttocks. A bathing suit is sort of 0:06:53.560 --> 0:06:59.560 high cut will cover that. And so the advantage of 0:06:59.640 --> 0:07:04.480 using one's own tissue is that, unlike an implant, doesn't 0:07:04.520 --> 0:07:08.839 require maintenance. Implants can be a great option for a 0:07:08.839 --> 0:07:14.840 lot of women, especially if radiation hasn't taken place. Implants 0:07:14.840 --> 0:07:18.920 can be a good option, but it must be understood 0:07:19.000 --> 0:07:22.680 that they require maintenance. Implants are likely to need to 0:07:22.680 --> 0:07:26.040 be replaced multiple times in the course of a young 0:07:26.120 --> 0:07:29.559 patient's life. I don't really know exactly what the life 0:07:29.560 --> 0:07:34.120 expectancy of an implant is, and it will vary from 0:07:34.120 --> 0:07:38.960 the setting and from the individual, but it's commonly said 0:07:39.000 --> 0:07:42.680 that an implant may last ten or fifteen years if 0:07:42.680 --> 0:07:46.679 we're lucky. They then will often at to be replaced 0:07:46.760 --> 0:07:50.040 either because of where and tear. Where the implant cracks, 0:07:51.160 --> 0:07:54.000 in other words, it can leak. The newer implants are 0:07:54.040 --> 0:07:57.240 more cohesive. We can talk about that cohesivety or the 0:07:57.240 --> 0:08:02.800 gumming beer implants. If it cracks, you know, there's some 0:08:03.080 --> 0:08:06.120 element of leakage, although it tends to be more contained 0:08:06.160 --> 0:08:10.320 with the newer implants. So when they crack or leak, 0:08:10.400 --> 0:08:14.480 we tend to replace them if they encapsulate or form 0:08:14.600 --> 0:08:16.640 tight scar tissue around. 0:08:16.280 --> 0:08:19.760 Them, which is when they get very hard and uncomfortable. 0:08:19.840 --> 0:08:25.440 Often encapsulation is the formation of height or thick scar 0:08:25.600 --> 0:08:30.160 tissue around the implant. It's the body's response to the implant. 0:08:30.200 --> 0:08:33.040 It's tissue. It's not part of the implant, it's the 0:08:33.120 --> 0:08:38.400 patient's own tissues. When that gets hard, then that scar 0:08:38.559 --> 0:08:43.439 tissue will have to be released or removed in many instances, 0:08:45.000 --> 0:08:47.520 and so the implant has to be replaced another operation. 0:08:48.600 --> 0:08:53.439 The problem is that once encapsulation forms, an individuals prone 0:08:53.480 --> 0:08:55.960 to have it occur again. There's just no guarantee that 0:08:56.000 --> 0:09:01.480 it won't come back. As implants a oftentimes the tissues 0:09:01.520 --> 0:09:05.880 overlying them thin, and implant imperfection such as implant edge 0:09:05.920 --> 0:09:10.959 and implant rippling becomes more apparent. And so for cosmetic reasons, 0:09:11.400 --> 0:09:13.880 particularly if we have a better quality implant that's been 0:09:13.920 --> 0:09:18.960 developed since the implant was first placed, for cosmetic reasons, 0:09:19.000 --> 0:09:23.280 we may want to replace the implant. So rupture, encapsulation 0:09:23.400 --> 0:09:27.840 of scar tissue, and cosmetic modifications, those are all reasons 0:09:27.840 --> 0:09:31.800 that an implant might be maintained. Use of your own 0:09:31.880 --> 0:09:38.600 tissue is associated with a permanent reconstruction. It will droop 0:09:38.640 --> 0:09:42.880 a bit over time, just like a normal breast, but 0:09:42.960 --> 0:09:47.080 it's not going to encapsulate and it's not going to 0:09:47.840 --> 0:09:54.080 rupture because it's your own tissue. Now, if you have 0:09:54.200 --> 0:09:58.000 a young individual who's in wonderful shape and putting a 0:09:58.040 --> 0:10:00.760 scar on the tummy is not going to be an 0:10:00.800 --> 0:10:05.200 acceptable option. We have to really consider whether we should 0:10:05.200 --> 0:10:15.920 do that. 0:10:18.760 --> 0:10:22.600 Like you said, everybody's different. There are people that have 0:10:22.720 --> 0:10:27.760 had the same implants for twenty twenty five years and 0:10:27.840 --> 0:10:33.120 that when that scar tissue started forming, their doctor and yes, 0:10:33.480 --> 0:10:36.840 you know, it doesn't necessarily feel good, but pushes and 0:10:37.000 --> 0:10:39.640 breaks that scar tissue and go in over and over 0:10:39.679 --> 0:10:42.960 and over again until that scar tissue forms way outside 0:10:43.800 --> 0:10:47.320 of the implant. So it is possible. And I know 0:10:47.360 --> 0:10:51.280 that you've done implants where it's possible. And so there's 0:10:51.520 --> 0:10:54.520 the positive side of the implants and you get exactly 0:10:54.559 --> 0:10:58.160 the size that you want and everything else, and there's 0:10:58.280 --> 0:11:01.120 minimal scarring. Like you said, it's contained to like the 0:11:01.240 --> 0:11:07.360 chest area. And with flop surgery, the positives are everything 0:11:07.360 --> 0:11:10.120 that you mentioned, but there are some negatives. And those 0:11:10.160 --> 0:11:14.480 negatives are the scars, right, because you know, if you're 0:11:14.520 --> 0:11:17.160 taking from the belly, you have a scar from hipbone 0:11:17.240 --> 0:11:21.160 to hip bone. And sure, you know you can drop 0:11:21.200 --> 0:11:24.360 it a little bit lower. Hopefully you can, you know, 0:11:24.480 --> 0:11:26.800 keep stretching that skin and go back in and get 0:11:26.840 --> 0:11:30.679 that scar, you know, redone to drop even lower, but 0:11:30.720 --> 0:11:32.800 it's only going to go so so low. 0:11:33.320 --> 0:11:38.160 Yeah, there's there's no question Shannon that the heavier individual, 0:11:38.360 --> 0:11:41.240 or the more weight fluctuation she's had, or the more 0:11:41.240 --> 0:11:44.280 pregnancy she may have had, the lower you can place 0:11:44.360 --> 0:11:47.840 that scar. It is a scar of a tummy tuck. 0:11:48.360 --> 0:11:51.240 You have to decide, you know, if someone is thin, 0:11:52.559 --> 0:11:56.080 the scar is going to be higher by definition because 0:11:56.120 --> 0:11:58.480 you just can't get it quite as low if there 0:11:58.520 --> 0:12:01.360 isn't the laxia of the skin, and that trade off 0:12:01.400 --> 0:12:03.360 has to be weighed. You know, there are women who 0:12:04.360 --> 0:12:09.600 simply would benefit asthetically in some regards from getting rid 0:12:09.600 --> 0:12:11.720 of the excess skin and fat of the tummy, but 0:12:11.800 --> 0:12:14.240 the scar simply isn't worth it to them. So we 0:12:14.320 --> 0:12:19.000 always discuss that. You know, I spend typically an hour, 0:12:19.160 --> 0:12:21.640 sometimes an hour and a half with patients. As you know, 0:12:23.000 --> 0:12:25.600 there are a lot of options that are available, and 0:12:26.559 --> 0:12:28.560 you know, it's a great honor and privilege to work 0:12:28.600 --> 0:12:31.360 for the people that I take care of, and it's 0:12:31.400 --> 0:12:34.760 really important that they know the options that we discuss them, 0:12:34.800 --> 0:12:38.600 that they have an opportunity to ask questions and get 0:12:38.640 --> 0:12:44.800 their questions answered. So those are the things we talk about. 0:12:45.120 --> 0:12:48.480 You know, yes, you have this extra tissue on your tummy. 0:12:50.679 --> 0:12:55.520 Would you tolerate a scar? You know, and that really 0:12:55.600 --> 0:13:00.520 has to be an individual decision. A couple things that 0:13:00.679 --> 0:13:05.280 you mentioned that are relevant the concept of the close 0:13:05.400 --> 0:13:09.880 capsule otomy. I just want to mention we no longer 0:13:10.040 --> 0:13:15.160 accept the squeezing of an implant to treat a capsule 0:13:16.440 --> 0:13:18.680 as a generally well thought of technique. 0:13:20.120 --> 0:13:22.079 I'm talking about something that was done, you know, you 0:13:22.360 --> 0:13:24.120 literally I'm in the nineties. 0:13:24.640 --> 0:13:26.000 Sure is still being done. 0:13:27.000 --> 0:13:27.680 There are doctors. 0:13:28.400 --> 0:13:31.400 So I'm just telling the wonderful people that are that 0:13:31.880 --> 0:13:37.040 may be enjoying this benefiting if that suggested, avoid that option. 0:13:38.679 --> 0:13:40.000 Listen to the doctor, not s. 0:13:42.280 --> 0:13:44.400 You. I don't think you're advocating for You're saying that 0:13:44.480 --> 0:13:45.000 it's done. 0:13:45.160 --> 0:13:45.640 It is done. 0:13:45.720 --> 0:13:49.320 Yeah, that can rupture an implant, so yes, why you Well, 0:13:49.400 --> 0:13:55.840 you might might break the capsule, the scar tissue. You 0:13:55.920 --> 0:14:01.239 may also break plant the plants shell. Of course, sanon 0:14:01.360 --> 0:14:07.080 in terms of more specifically what technique is appropriate for 0:14:07.200 --> 0:14:12.840 what I think it's worthwhile mentioning the effects of radiation 0:14:14.440 --> 0:14:19.760 and reconstructions, I think that's a very important point. One 0:14:19.800 --> 0:14:26.160 must realize that while potentially life saving, life prolonging, radiation 0:14:26.560 --> 0:14:29.440 is a double edged sword. In that it permanently damages 0:14:29.480 --> 0:14:34.000 the tissue of the chest wall. That's permanent. Someone lives 0:14:34.000 --> 0:14:38.760 to be one hundred microscopically. You'll see the changes of 0:14:38.880 --> 0:14:44.080 radiation in the tissues as a result. When you place 0:14:44.120 --> 0:14:48.440 an implant beneath radiated tissues, or you radiate an implant 0:14:48.520 --> 0:14:54.920 after implant placement, the radiation incites a more vigorous cap 0:14:55.120 --> 0:14:59.520 or response, a thicker or tighter capsule formation the scar 0:14:59.600 --> 0:15:03.840 tissue around the implant. That's what radiation does. It incites 0:15:03.880 --> 0:15:08.720 a vigorous reaction. And so it's a very very common 0:15:09.840 --> 0:15:14.680 happening that if you radiate the chess wall that has 0:15:14.720 --> 0:15:18.440 an implant, the patient will within a fairly short period 0:15:18.480 --> 0:15:22.080 of time say, wow, this feels really tight. This feels 0:15:22.160 --> 0:15:28.560 tight and uncomfortable. That's not every patient, but it's very common, 0:15:29.920 --> 0:15:35.520 and it's common enough that I tell patients an implant 0:15:35.600 --> 0:15:42.480 beneath your radiated tissues may not be a comfortable long 0:15:42.560 --> 0:15:47.120 term option. I think in many instances it's not. It 0:15:47.240 --> 0:15:50.440 might be an acceptable option in the short term, but 0:15:50.560 --> 0:15:56.440 I think that over time the radiation induces increasing capsule formation, tightness, 0:15:56.600 --> 0:16:01.880 perhaps discomfort, and so it's particularly the radiated patient or 0:16:01.920 --> 0:16:05.120 the patient that has failed an implant, who just hasn't 0:16:05.120 --> 0:16:08.240 done well with implants, even in the absence of radiation. 0:16:09.720 --> 0:16:12.440 The use of your own tissue in that setting really 0:16:12.480 --> 0:16:16.720 is often a blessing because it brings blood supply to 0:16:16.760 --> 0:16:20.560 those radiated tissues. We hook up those blood vessels to 0:16:20.560 --> 0:16:25.080 transfer that tissue from that tissue that is under the skin. 0:16:25.160 --> 0:16:27.960 The tissue we transfer new blood vessels grow into the 0:16:28.000 --> 0:16:33.120 surrounding chess wall tissues. It grows from the flat the 0:16:33.200 --> 0:16:36.680 bony ay, into the muscle, into the overlying skin and fat. 0:16:37.480 --> 0:16:42.280 It brings new blood supply to the radiated chest wall 0:16:42.320 --> 0:16:46.280 and improves the quality of the radiated chess wall. So 0:16:47.400 --> 0:16:50.120 in the setting of someone who has had an unfortunate 0:16:50.240 --> 0:16:54.640 thinning of tissues from multiple implant operations, because each time 0:16:54.640 --> 0:16:59.120 you remove that capsule, the tissues overlying the implant become thinner. 0:17:00.040 --> 0:17:04.960 So someone who has had let's see, multiple AAP selectomies 0:17:05.080 --> 0:17:08.560 or removal of implants, they may be referred to me. 0:17:08.600 --> 0:17:11.200 They may come into my office and say, look, how 0:17:11.240 --> 0:17:16.120 you can almost see my implant through the skin. That's 0:17:16.160 --> 0:17:20.119 a very very difficult problem that I think is generally 0:17:21.240 --> 0:17:26.000 generally best treated with the addition of healthy tissue. 0:17:26.119 --> 0:17:27.960 Well, how often do you actually see that. 0:17:28.480 --> 0:17:34.440 It's pretty common, really, it's pretty common. Not everyone does 0:17:34.440 --> 0:17:38.520 well with implants, and you know, again it's hard to 0:17:38.680 --> 0:17:41.919 accept the concept that they have to be maintained. But 0:17:42.040 --> 0:17:46.920 I think in the last ten or fifteen years we've 0:17:46.960 --> 0:17:51.480 really come to accept that it's not often a one 0:17:51.520 --> 0:17:54.359 and done operation where you put an implant in. It's 0:17:54.400 --> 0:17:58.320 pretty common that they'll have to at some point be replaced. 0:17:59.520 --> 0:18:02.400 And there's some people who simply just don't do well 0:18:02.400 --> 0:18:05.200 with them. The body just doesn't seem to tolerate them. 0:18:05.119 --> 0:18:09.600 Right, rejects it and still identifies it as a foreign object, and. 0:18:09.560 --> 0:18:16.480 They get recurrent encapsulation. You get recurrent encapsulation over and 0:18:16.520 --> 0:18:19.359 over and over. There are certain things we can try 0:18:20.680 --> 0:18:27.359 and sometimes it's beneficial. There's a material what's called a 0:18:27.480 --> 0:18:32.040 cellular dermal matrix. It's a skin derived product and it's 0:18:32.080 --> 0:18:35.560 a hammock that you can put in under the skin 0:18:35.680 --> 0:18:39.879 to support the breast. Many surgeons use it as a 0:18:40.000 --> 0:18:45.760 means of potentially diminishing recurrent encapsulation. In addition to supporting 0:18:45.800 --> 0:18:53.440 the implant, it might decrease encapsulation either the first time 0:18:53.480 --> 0:18:59.520 implantation or may prevent recurrent encapsulation. Studies are ongoing, but 0:19:00.000 --> 0:19:02.960 there a number of studies that suggest that that might 0:19:03.000 --> 0:19:08.399 be a benefit. But despite trying everything, we know still 0:19:08.440 --> 0:19:12.200 there are patients who simply don't accept their implants well. 0:19:13.040 --> 0:19:17.159 And it's in that patient besides the radiated patient, or 0:19:17.280 --> 0:19:21.600 use of ones on tissues maybe especially beneficial. 0:19:23.119 --> 0:19:30.280 So so with my surgery, you know, I had the surgery, 0:19:30.640 --> 0:19:34.760 only one for us was removed, which is always so 0:19:34.920 --> 0:19:38.200 funny when when you make these decisions and you think 0:19:38.200 --> 0:19:42.160 you're making the right decision, and then later a couple 0:19:42.200 --> 0:19:45.040 of years later, you're like, oh, I should have you know, 0:19:45.200 --> 0:19:50.399 had both. And it's probably why this podcast is so 0:19:50.440 --> 0:19:53.880 important to me, so that I can share my experiences, 0:19:53.920 --> 0:19:58.720 the ones that I think were mistakes that still you know, 0:19:58.760 --> 0:20:01.639 the outcome was still good, just maybe I would have 0:20:01.680 --> 0:20:06.280 done things differently. So one of those was both breasts, goodbye, 0:20:06.359 --> 0:20:13.280 see you later. And because then for my particular reconstruction 0:20:14.400 --> 0:20:17.040 it I could have gone a lot smaller, I could 0:20:17.080 --> 0:20:20.439 have you know, there's those things. So let's tune the 0:20:20.440 --> 0:20:24.040 audience in for a second. And two, I had surgery, 0:20:24.720 --> 0:20:29.600 I only had one breast, removed. And then what you did, 0:20:29.600 --> 0:20:32.440 which was remarkable is you actually were in there with 0:20:33.160 --> 0:20:38.840 again one of the best surgeons, doctor g. I remember 0:20:38.880 --> 0:20:41.199 you did the final stitch. It was very important to 0:20:41.240 --> 0:20:43.440 you that you did the final stitch because you like 0:20:43.560 --> 0:20:47.680 the way that your stitches are. So you were literally 0:20:47.720 --> 0:20:50.520 there during that entire surgery. And there's not a lot 0:20:50.560 --> 0:20:55.359 of plastic surgeons for reconstruction that would actually be there 0:20:55.440 --> 0:20:58.199 for a surgery that they don't even get paid for. 0:20:58.440 --> 0:21:01.359 They don't have to be a part of You do that. 0:21:01.600 --> 0:21:09.439 You're remarkable. And then you you did expanders because we 0:21:09.480 --> 0:21:12.639 knew that I was getting chemo, and we knew that 0:21:12.720 --> 0:21:17.159 I was getting radiation, and we wanted all of that 0:21:17.280 --> 0:21:22.000 to happen right away. So you did expanders, which can 0:21:22.040 --> 0:21:25.359 you explain exactly what an expander does? And how many 0:21:25.400 --> 0:21:28.480 times I went back to see you and you sort of, 0:21:29.200 --> 0:21:32.760 you know, pared them up or deflated. It's like a 0:21:32.800 --> 0:21:36.679 balloon and where my breast was. 0:21:37.480 --> 0:21:42.280 I'm happy to discuss that an expander shan as you know, 0:21:42.320 --> 0:21:47.560 as a temporary adjustable volume implant. It has a port 0:21:47.640 --> 0:21:49.960 within it where with a mag that we can pass 0:21:50.000 --> 0:21:52.639 a magnet over the skin identify the center of that 0:21:52.800 --> 0:21:56.320 port where we can put a small needle in safely 0:21:56.800 --> 0:22:01.480 actually into the implant, into the expander, add salt water, 0:22:01.680 --> 0:22:05.879 sterile salt water, and adjust the size as the boss. 0:22:05.920 --> 0:22:07.880 You'll tell me, Jay, I want to be a little larger. 0:22:07.880 --> 0:22:09.199 I want to be a little smaller, but we have 0:22:09.240 --> 0:22:10.520 the capacity to do that. 0:22:10.680 --> 0:22:12.720 I kept just saying I want Kate Moss boots. 0:22:15.920 --> 0:22:19.959 By the way, Shannon, I don't disagree with anything that 0:22:20.040 --> 0:22:25.639 you did from from your reconstructive perspective. I think I 0:22:25.680 --> 0:22:31.920 think your thinking was was very reasonable. Each patient has 0:22:32.000 --> 0:22:35.960 to really do it with their with their oncologists, with 0:22:36.119 --> 0:22:42.480 their their metabal oncologists, their their oncologic surgeon, geneticist really 0:22:42.560 --> 0:22:46.200 has to do a risk assessment. It's very important as 0:22:46.200 --> 0:22:50.600 it pertains to the other breast. If they're gene negative 0:22:51.320 --> 0:22:55.160 and they have no family history and lack of variety 0:22:55.200 --> 0:23:01.840 of potential risk factors, leaving the other rest, it is 0:23:01.880 --> 0:23:06.480 not unreasonable. Bat breast has a nipple that has sensation 0:23:06.680 --> 0:23:12.080 and natural feel and natural shape, it's not unreasonable. I 0:23:12.119 --> 0:23:18.160 think that it is also reasonable sometimes to remove both breasts, 0:23:18.359 --> 0:23:22.040 especially if there's a very strong family history. If someone 0:23:22.080 --> 0:23:24.960 has a bracket gene or other genes. Their genes called 0:23:25.040 --> 0:23:29.359 check two PLB two, a variety of other genes that 0:23:29.560 --> 0:23:33.359 may place somewhat it significantly increased risks for cancer, and 0:23:33.520 --> 0:23:37.240 not just the involved breast, but the other breast. So 0:23:37.280 --> 0:23:40.880 it's not unreasonable times to do that. Do you really 0:23:40.920 --> 0:23:46.199 have to weigh that decision. I encourage patients not to 0:23:46.320 --> 0:23:49.800 act reactively where they say, we'll dog on and I 0:23:49.800 --> 0:23:52.040 got a cancer in this breast, I'm taking them both off. 0:23:53.760 --> 0:23:56.399 The issue at that time is the cancer in that 0:23:56.600 --> 0:24:01.240 breast that we have to deal with. It's very reasonable 0:24:01.240 --> 0:24:04.800 to think about the other breasts and future risk, but 0:24:04.960 --> 0:24:08.159 before you just reactively say let's take them both off, 0:24:08.880 --> 0:24:12.119 I really strongly encourage patients to do an analysis of 0:24:12.160 --> 0:24:21.080 their actual risk. It's important to understand that just because 0:24:21.160 --> 0:24:25.320 we elect to have a breast removed profilatically, the Good 0:24:25.320 --> 0:24:28.119 Lord doesn't necessarily smile upon us and say we're not 0:24:28.160 --> 0:24:30.399 going to have any issues with that breast. There won't 0:24:30.400 --> 0:24:32.879 be pain in that breast, there won't be healing issues, 0:24:32.880 --> 0:24:36.359 there won't be any situations that arise that we don't want. 0:24:37.440 --> 0:24:41.000 That press has the same risk of having pain issues 0:24:41.080 --> 0:24:45.239 or any other issues. There's the cancer breast, right, so 0:24:45.280 --> 0:24:47.600 you need to have a good reason for taking it off. 0:24:48.200 --> 0:24:51.520 That doesn't mean that there aren't good reasons. And for 0:24:51.600 --> 0:24:54.560 some people the reason to do it is peace of mind. 0:24:55.160 --> 0:24:58.679 And I understand that right, because for some people it 0:24:58.760 --> 0:25:05.760 becomes and even if in their heads or in reality, 0:25:05.880 --> 0:25:08.439 like like you said, there's a lot of people with 0:25:08.840 --> 0:25:16.120 different hereditary stuff, different genes that short, then you need 0:25:16.119 --> 0:25:22.199 a double both gone, but also mentally, if it makes 0:25:22.280 --> 0:25:27.920 you feel more secure in your future so that you're 0:25:27.960 --> 0:25:34.960 not walking around simply scared and worried and obsessing, then 0:25:35.000 --> 0:25:37.240 people do it for those reasons too, which is one 0:25:37.320 --> 0:25:39.520 hundred percent valid absolutely. 0:25:40.119 --> 0:25:42.919 I mean, there are certain findings on the pathology Shannon, 0:25:42.960 --> 0:25:49.000 in addition that aren't cancer, but they're finding something for example, 0:25:49.040 --> 0:25:55.760 called atypical lobular hyperplasia for example, which is a number 0:25:55.800 --> 0:26:02.560 of long words meaning not cancer, but it's a sign 0:26:02.600 --> 0:26:06.120 a marker that in the course of life that individual 0:26:06.840 --> 0:26:11.119 is it an increased risk for developing a cancer in 0:26:11.280 --> 0:26:14.960 that breast or the other breast, that breast or the 0:26:14.960 --> 0:26:18.880 other breast. So there's certain findings that can be found 0:26:18.920 --> 0:26:24.600 that aren't cancer. But besides a positive gene testing one 0:26:24.640 --> 0:26:28.520 can have findings in their breast pathology, it would suggest 0:26:29.000 --> 0:26:35.200 we might consider removing the other breast. So in your situation, 0:26:36.040 --> 0:26:41.639 you are going to have radiation. I think that with 0:26:41.760 --> 0:26:44.439 a desire to have a patient wake up with a breast, 0:26:44.440 --> 0:26:49.800 and I think that's really important in my way of thinking, 0:26:50.400 --> 0:26:53.400 having a patient wake up and look down and say 0:26:53.440 --> 0:26:57.520 to me, looks pretty good right away. I mean, that 0:26:57.800 --> 0:27:02.280 really makes me happy. That's my goal. And whether we 0:27:02.359 --> 0:27:03.960 do it by putting your tissue up there or a 0:27:03.960 --> 0:27:06.560 tissue expander, or go directly to an implant, that's my 0:27:06.720 --> 0:27:08.960 goal that someone wake up or leave the hostel at 0:27:09.000 --> 0:27:12.480 least saying okay, you know, I can't can see where 0:27:12.520 --> 0:27:13.600 this is going to look pretty good? 0:27:13.680 --> 0:27:18.280 Yeah, because having cancer is traumatizing enough. Absolutely, there are 0:27:18.320 --> 0:27:23.719 some of us, me specifically, that the idea of waking 0:27:23.800 --> 0:27:27.440 up with no breast at all and just this sort 0:27:27.440 --> 0:27:35.320 of horizontal scar that was really I thought for me 0:27:35.359 --> 0:27:39.520 it would mentally be even more damaging. Absolutely, and there's 0:27:39.840 --> 0:27:44.080 probably large percentage of women out there who who feel 0:27:44.160 --> 0:27:44.560 that way. 0:27:45.280 --> 0:27:51.200 So in your situation, we were able to preserve the tissues, 0:27:51.920 --> 0:27:57.399 nipple skin by using that expander and even though we 0:27:57.480 --> 0:28:00.000 knew that the radiation acts almost like a shrink wrap 0:28:00.040 --> 0:28:03.120 up on the tissues, it would tighten that the fact 0:28:03.160 --> 0:28:06.000 that the expander was in there to hold the mold, 0:28:06.080 --> 0:28:09.760 so to speak, to hold a position of the soft tissues. 0:28:10.840 --> 0:28:15.119 I then knew that after initial healing from the radiation, 0:28:15.640 --> 0:28:18.840 usually wait at least six months. You waited a little longer, 0:28:18.880 --> 0:28:23.920 which it was even better, but at least six months 0:28:24.000 --> 0:28:27.360 typically after the final radiation treatment, when the tissues are 0:28:27.600 --> 0:28:30.880 a bit more normalized. I knew then that we could 0:28:30.920 --> 0:28:34.439