Speaker 1: This is Let's Be Clear with Shannon Doherty. Welcome to
Speaker 1: a new episode of Lesbie Clear with Shannon Doherty. And
Speaker 1: I have on one of the loveliest, loveliest doctors I
Speaker 1: have ever encountered, doctor j Oranger. He is a plastic surgeon.
Speaker 1: He is also a reconstructive plastic surgeon, which is how
Speaker 1: I know him because he reconstructed my breasts and then
Speaker 1: the other one to match it.
Speaker 2: Hi, Hello, Shannon, Hi doctor j. Great pleasure to be
Speaker 2: here with you.
Speaker 1: Good to see you. You really are one of those
Speaker 1: doctors who takes so much time with your patients. You
Speaker 1: don't overbook yourself. I just remember you drove to my
Speaker 1: house constantly to check on me when I had the
Speaker 1: expander in, and you know the drains all of that.
Speaker 1: I'll get into everything that you did for me and
Speaker 1: what you do for so many others, But can you
Speaker 1: tell us how you started down this path?
Speaker 2: Sure? So. Originally, Shannon, I was believing that I was
Speaker 2: heading down the path of chest surgery thoracic surgery. And
Speaker 2: I was in my general surgery training, which is one
Speaker 2: of the prerequisites for that, and very early in that training,
Speaker 2: I was on the oncology service, and we rounded on
Speaker 2: a lovely young woman who had just had a mess
Speaker 2: stect to me, and in those days, the reconstructions weren't
Speaker 2: done immediately, if done at all, they were often done
Speaker 2: as a subsequent stage following the mess stec to me,
Speaker 2: as opposed to today, when we do the vast majority
Speaker 2: of our reconstructions immediately, at least start them immediately so
Speaker 2: that the patient wakes up with some form of breast
Speaker 2: I felt so bad for this woman when I saw
Speaker 2: how this affected her and how it would affect her.
Speaker 2: It changed my life. That day changed my life when
Speaker 2: I rounded on that patient and I just saw what
Speaker 2: resulted from that life saving procedure, what she would face
Speaker 2: unless her wholeness were able to be restored through a
Speaker 2: good quality reconstruction. And I then said that day, that's
Speaker 2: what I want to do for the rest of my life.
Speaker 2: I want to help these people. And so I completed
Speaker 2: my general surgical training. I feel that as a surgeon
Speaker 2: who operates on the breast in any capacity, or any
Speaker 2: part of the body for that matter, it's helpful to
Speaker 2: be fully trained in general surgery. So I completed a
Speaker 2: wonderful training and then my boards in general surgery and
Speaker 2: then completed my plastic surgical residency in training, and then
Speaker 2: following that, as if that weren't enough, I decided that
Speaker 2: I wanted to do it super specialization in microsurgery. Microsurgery
Speaker 2: is a subspecialty of plastic surgery where it's used by
Speaker 2: others specialty as well, where we use the operating microscope
Speaker 2: to reattach blood vessels or nerves, and we can transplant tissue.
Speaker 2: And what's remarkable about it is we can take tissue,
Speaker 2: let's safe from the tummy. A woman says, I have
Speaker 2: excess tummy tissue. I don't like this extra skin in fat.
Speaker 2: I've thought about having a tummy tuck, but instead now
Speaker 2: I need a mast ectomy. We can take that tissue
Speaker 2: and using techniques of microsurgery, reattached blood vessels so that
Speaker 2: that tissue can be shaped to create a breast. It is,
Speaker 2: in many instance is almost indistinguishable from a real brust
Speaker 2: So said I wanted to acquire that expertise, and so
Speaker 2: the microsurgery has been a very nice adgent to sort
Speaker 2: of complete my armamentarium in terms of what we can
Speaker 2: offer patients. In general terms, there are two ways we
Speaker 2: can reconstruct the breast, one uses some form of implant,
Speaker 2: one uses one's own tissues, and each has advantages and disadvantages.
Speaker 2: The advantages of using an implant include the fact that
Speaker 2: it is typically a shorter and simpler procedure associated with
Speaker 2: a somewhat shorter recuperative period in most instances, and the
Speaker 2: site of the surgery is limited to the chest using
Speaker 2: one's own tissue. Where we transfer tissue, basically, we transfer
Speaker 2: an orgon of fat to make a new breast and
Speaker 2: it has its own blood supply, as opposed to situations
Speaker 2: where commonly today surgeons will liposuction fat and injected to
Speaker 2: the chestwell and hope that that fat will live. In
Speaker 2: reality being that much of that fat will resorb when
Speaker 2: we reattach blood vessels that are attached to this organ
Speaker 2: of fat. It lives just like a kidney transplant.
Speaker 1: Right because you're pumping blood.
Speaker 2: Too into it and out of it. And so it's
Speaker 2: quite a remarkable concept. And we can take tissue from
Speaker 2: the tummy that again the tissue that would be the
Speaker 2: scarter with a tummy tuck, we can revascularize, put it
Speaker 2: under the skin, under the nipple, under the skin of
Speaker 2: the breast, and when you feel it, it feels just
Speaker 2: like a breast, because the breast is an organ largely
Speaker 2: a fatty tissue, and there's fatty tissue now placed under
Speaker 2: the skin. So it feels very much and looks very
Speaker 2: much like a natural breast. Similarly, in a very thin woman.
Speaker 2: You know, there's some people who are quite thin, and
Speaker 2: you know, you're in you're in great shape. You didn't
Speaker 2: have a lot of tissue to work with, and we
Speaker 2: had to use, you know, everything we could from that
Speaker 2: from that small tummy. There's some women that are simply
Speaker 2: there isn't enough tissue on the tummy to even do
Speaker 2: a single breast, and so then those women generally will
Speaker 2: have enough tissue on the upper buttock or gluegal area
Speaker 2: where we can in essence to a buttock lift and
Speaker 2: take that tissue and transplant it to make the new breast.
Speaker 2: The scar that results from that simulates a butt lift
Speaker 2: on the upper buttocks. A bathing suit is sort of
Speaker 2: high cut will cover that. And so the advantage of
Speaker 2: using one's own tissue is that, unlike an implant, doesn't
Speaker 2: require maintenance. Implants can be a great option for a
Speaker 2: lot of women, especially if radiation hasn't taken place. Implants
Speaker 2: can be a good option, but it must be understood
Speaker 2: that they require maintenance. Implants are likely to need to
Speaker 2: be replaced multiple times in the course of a young
Speaker 2: patient's life. I don't really know exactly what the life
Speaker 2: expectancy of an implant is, and it will vary from
Speaker 2: the setting and from the individual, but it's commonly said
Speaker 2: that an implant may last ten or fifteen years if
Speaker 2: we're lucky. They then will often at to be replaced
Speaker 2: either because of where and tear. Where the implant cracks,
Speaker 2: in other words, it can leak. The newer implants are
Speaker 2: more cohesive. We can talk about that cohesivety or the
Speaker 2: gumming beer implants. If it cracks, you know, there's some
Speaker 2: element of leakage, although it tends to be more contained
Speaker 2: with the newer implants. So when they crack or leak,
Speaker 2: we tend to replace them if they encapsulate or form
Speaker 2: tight scar tissue around.
Speaker 1: Them, which is when they get very hard and uncomfortable.
Speaker 2: Often encapsulation is the formation of height or thick scar
Speaker 2: tissue around the implant. It's the body's response to the implant.
Speaker 2: It's tissue. It's not part of the implant, it's the
Speaker 2: patient's own tissues. When that gets hard, then that scar
Speaker 2: tissue will have to be released or removed in many instances,
Speaker 2: and so the implant has to be replaced another operation.
Speaker 2: The problem is that once encapsulation forms, an individuals prone
Speaker 2: to have it occur again. There's just no guarantee that
Speaker 2: it won't come back. As implants a oftentimes the tissues
Speaker 2: overlying them thin, and implant imperfection such as implant edge
Speaker 2: and implant rippling becomes more apparent. And so for cosmetic reasons,
Speaker 2: particularly if we have a better quality implant that's been
Speaker 2: developed since the implant was first placed, for cosmetic reasons,
Speaker 2: we may want to replace the implant. So rupture, encapsulation
Speaker 2: of scar tissue, and cosmetic modifications, those are all reasons
Speaker 2: that an implant might be maintained. Use of your own
Speaker 2: tissue is associated with a permanent reconstruction. It will droop
Speaker 2: a bit over time, just like a normal breast, but
Speaker 2: it's not going to encapsulate and it's not going to
Speaker 2: rupture because it's your own tissue. Now, if you have
Speaker 2: a young individual who's in wonderful shape and putting a
Speaker 2: scar on the tummy is not going to be an
Speaker 2: acceptable option. We have to really consider whether we should
Speaker 2: do that.
Speaker 1: Like you said, everybody's different. There are people that have
Speaker 1: had the same implants for twenty twenty five years and
Speaker 1: that when that scar tissue started forming, their doctor and yes,
Speaker 1: you know, it doesn't necessarily feel good, but pushes and
Speaker 1: breaks that scar tissue and go in over and over
Speaker 1: and over again until that scar tissue forms way outside
Speaker 1: of the implant. So it is possible. And I know
Speaker 1: that you've done implants where it's possible. And so there's
Speaker 1: the positive side of the implants and you get exactly
Speaker 1: the size that you want and everything else, and there's
Speaker 1: minimal scarring. Like you said, it's contained to like the
Speaker 1: chest area. And with flop surgery, the positives are everything
Speaker 1: that you mentioned, but there are some negatives. And those
Speaker 1: negatives are the scars, right, because you know, if you're
Speaker 1: taking from the belly, you have a scar from hipbone
Speaker 1: to hip bone. And sure, you know you can drop
Speaker 1: it a little bit lower. Hopefully you can, you know,
Speaker 1: keep stretching that skin and go back in and get
Speaker 1: that scar, you know, redone to drop even lower, but
Speaker 1: it's only going to go so so low.
Speaker 2: Yeah, there's there's no question Shannon that the heavier individual,
Speaker 2: or the more weight fluctuation she's had, or the more
Speaker 2: pregnancy she may have had, the lower you can place
Speaker 2: that scar. It is a scar of a tummy tuck.
Speaker 2: You have to decide, you know, if someone is thin,
Speaker 2: the scar is going to be higher by definition because
Speaker 2: you just can't get it quite as low if there
Speaker 2: isn't the laxia of the skin, and that trade off
Speaker 2: has to be weighed. You know, there are women who
Speaker 2: simply would benefit asthetically in some regards from getting rid
Speaker 2: of the excess skin and fat of the tummy, but
Speaker 2: the scar simply isn't worth it to them. So we
Speaker 2: always discuss that. You know, I spend typically an hour,
Speaker 2: sometimes an hour and a half with patients. As you know,
Speaker 2: there are a lot of options that are available, and
Speaker 2: you know, it's a great honor and privilege to work
Speaker 2: for the people that I take care of, and it's
Speaker 2: really important that they know the options that we discuss them,
Speaker 2: that they have an opportunity to ask questions and get
Speaker 2: their questions answered. So those are the things we talk about.
Speaker 2: You know, yes, you have this extra tissue on your tummy.
Speaker 2: Would you tolerate a scar? You know, and that really
Speaker 2: has to be an individual decision. A couple things that
Speaker 2: you mentioned that are relevant the concept of the close
Speaker 2: capsule otomy. I just want to mention we no longer
Speaker 2: accept the squeezing of an implant to treat a capsule
Speaker 2: as a generally well thought of technique.
Speaker 1: I'm talking about something that was done, you know, you
Speaker 1: literally I'm in the nineties.
Speaker 2: Sure is still being done.
Speaker 1: There are doctors.
Speaker 2: So I'm just telling the wonderful people that are that
Speaker 2: may be enjoying this benefiting if that suggested, avoid that option.
Speaker 1: Listen to the doctor, not s.
Speaker 2: You. I don't think you're advocating for You're saying that
Speaker 2: it's done.
Speaker 1: It is done.
Speaker 2: Yeah, that can rupture an implant, so yes, why you Well,
Speaker 2: you might might break the capsule, the scar tissue. You
Speaker 2: may also break plant the plants shell. Of course, sanon
Speaker 2: in terms of more specifically what technique is appropriate for
Speaker 2: what I think it's worthwhile mentioning the effects of radiation
Speaker 2: and reconstructions, I think that's a very important point. One
Speaker 2: must realize that while potentially life saving, life prolonging, radiation
Speaker 2: is a double edged sword. In that it permanently damages
Speaker 2: the tissue of the chest wall. That's permanent. Someone lives
Speaker 2: to be one hundred microscopically. You'll see the changes of
Speaker 2: radiation in the tissues as a result. When you place
Speaker 2: an implant beneath radiated tissues, or you radiate an implant
Speaker 2: after implant placement, the radiation incites a more vigorous cap
Speaker 2: or response, a thicker or tighter capsule formation the scar
Speaker 2: tissue around the implant. That's what radiation does. It incites
Speaker 2: a vigorous reaction. And so it's a very very common
Speaker 2: happening that if you radiate the chess wall that has
Speaker 2: an implant, the patient will within a fairly short period
Speaker 2: of time say, wow, this feels really tight. This feels
Speaker 2: tight and uncomfortable. That's not every patient, but it's very common,
Speaker 2: and it's common enough that I tell patients an implant
Speaker 2: beneath your radiated tissues may not be a comfortable long
Speaker 2: term option. I think in many instances it's not. It
Speaker 2: might be an acceptable option in the short term, but
Speaker 2: I think that over time the radiation induces increasing capsule formation, tightness,
Speaker 2: perhaps discomfort, and so it's particularly the radiated patient or
Speaker 2: the patient that has failed an implant, who just hasn't
Speaker 2: done well with implants, even in the absence of radiation.
Speaker 2: The use of your own tissue in that setting really
Speaker 2: is often a blessing because it brings blood supply to
Speaker 2: those radiated tissues. We hook up those blood vessels to
Speaker 2: transfer that tissue from that tissue that is under the skin.
Speaker 2: The tissue we transfer new blood vessels grow into the
Speaker 2: surrounding chess wall tissues. It grows from the flat the
Speaker 2: bony ay, into the muscle, into the overlying skin and fat.
Speaker 2: It brings new blood supply to the radiated chest wall
Speaker 2: and improves the quality of the radiated chess wall. So
Speaker 2: in the setting of someone who has had an unfortunate
Speaker 2: thinning of tissues from multiple implant operations, because each time
Speaker 2: you remove that capsule, the tissues overlying the implant become thinner.
Speaker 2: So someone who has had let's see, multiple AAP selectomies
Speaker 2: or removal of implants, they may be referred to me.
Speaker 2: They may come into my office and say, look, how
Speaker 2: you can almost see my implant through the skin. That's
Speaker 2: a very very difficult problem that I think is generally
Speaker 2: generally best treated with the addition of healthy tissue.
Speaker 1: Well, how often do you actually see that.
Speaker 2: It's pretty common, really, it's pretty common. Not everyone does
Speaker 2: well with implants, and you know, again it's hard to
Speaker 2: accept the concept that they have to be maintained. But
Speaker 2: I think in the last ten or fifteen years we've
Speaker 2: really come to accept that it's not often a one
Speaker 2: and done operation where you put an implant in. It's
Speaker 2: pretty common that they'll have to at some point be replaced.
Speaker 2: And there's some people who simply just don't do well
Speaker 2: with them. The body just doesn't seem to tolerate them.
Speaker 1: Right, rejects it and still identifies it as a foreign object, and.
Speaker 2: They get recurrent encapsulation. You get recurrent encapsulation over and
Speaker 2: over and over. There are certain things we can try
Speaker 2: and sometimes it's beneficial. There's a material what's called a
Speaker 2: cellular dermal matrix. It's a skin derived product and it's
Speaker 2: a hammock that you can put in under the skin
Speaker 2: to support the breast. Many surgeons use it as a
Speaker 2: means of potentially diminishing recurrent encapsulation. In addition to supporting
Speaker 2: the implant, it might decrease encapsulation either the first time
Speaker 2: implantation or may prevent recurrent encapsulation. Studies are ongoing, but
Speaker 2: there a number of studies that suggest that that might
Speaker 2: be a benefit. But despite trying everything, we know still
Speaker 2: there are patients who simply don't accept their implants well.
Speaker 2: And it's in that patient besides the radiated patient, or
Speaker 2: use of ones on tissues maybe especially beneficial.
Speaker 1: So so with my surgery, you know, I had the surgery,
Speaker 1: only one for us was removed, which is always so
Speaker 1: funny when when you make these decisions and you think
Speaker 1: you're making the right decision, and then later a couple
Speaker 1: of years later, you're like, oh, I should have you know,
Speaker 1: had both. And it's probably why this podcast is so
Speaker 1: important to me, so that I can share my experiences,
Speaker 1: the ones that I think were mistakes that still you know,
Speaker 1: the outcome was still good, just maybe I would have
Speaker 1: done things differently. So one of those was both breasts, goodbye,
Speaker 1: see you later. And because then for my particular reconstruction
Speaker 1: it I could have gone a lot smaller, I could
Speaker 1: have you know, there's those things. So let's tune the
Speaker 1: audience in for a second. And two, I had surgery,
Speaker 1: I only had one breast, removed. And then what you did,
Speaker 1: which was remarkable is you actually were in there with
Speaker 1: again one of the best surgeons, doctor g. I remember
Speaker 1: you did the final stitch. It was very important to
Speaker 1: you that you did the final stitch because you like
Speaker 1: the way that your stitches are. So you were literally
Speaker 1: there during that entire surgery. And there's not a lot
Speaker 1: of plastic surgeons for reconstruction that would actually be there
Speaker 1: for a surgery that they don't even get paid for.
Speaker 1: They don't have to be a part of You do that.
Speaker 1: You're remarkable. And then you you did expanders because we
Speaker 1: knew that I was getting chemo, and we knew that
Speaker 1: I was getting radiation, and we wanted all of that
Speaker 1: to happen right away. So you did expanders, which can
Speaker 1: you explain exactly what an expander does? And how many
Speaker 1: times I went back to see you and you sort of,
Speaker 1: you know, pared them up or deflated. It's like a
Speaker 1: balloon and where my breast was.
Speaker 2: I'm happy to discuss that an expander shan as you know,
Speaker 2: as a temporary adjustable volume implant. It has a port
Speaker 2: within it where with a mag that we can pass
Speaker 2: a magnet over the skin identify the center of that
Speaker 2: port where we can put a small needle in safely
Speaker 2: actually into the implant, into the expander, add salt water,
Speaker 2: sterile salt water, and adjust the size as the boss.
Speaker 2: You'll tell me, Jay, I want to be a little larger.
Speaker 2: I want to be a little smaller, but we have
Speaker 2: the capacity to do that.
Speaker 1: I kept just saying I want Kate Moss boots.
Speaker 2: By the way, Shannon, I don't disagree with anything that
Speaker 2: you did from from your reconstructive perspective. I think I
Speaker 2: think your thinking was was very reasonable. Each patient has
Speaker 2: to really do it with their with their oncologists, with
Speaker 2: their their metabal oncologists, their their oncologic surgeon, geneticist really
Speaker 2: has to do a risk assessment. It's very important as
Speaker 2: it pertains to the other breast. If they're gene negative
Speaker 2: and they have no family history and lack of variety
Speaker 2: of potential risk factors, leaving the other rest, it is
Speaker 2: not unreasonable. Bat breast has a nipple that has sensation
Speaker 2: and natural feel and natural shape, it's not unreasonable. I
Speaker 2: think that it is also reasonable sometimes to remove both breasts,
Speaker 2: especially if there's a very strong family history. If someone
Speaker 2: has a bracket gene or other genes. Their genes called
Speaker 2: check two PLB two, a variety of other genes that
Speaker 2: may place somewhat it significantly increased risks for cancer, and
Speaker 2: not just the involved breast, but the other breast. So
Speaker 2: it's not unreasonable times to do that. Do you really
Speaker 2: have to weigh that decision. I encourage patients not to
Speaker 2: act reactively where they say, we'll dog on and I
Speaker 2: got a cancer in this breast, I'm taking them both off.
Speaker 2: The issue at that time is the cancer in that
Speaker 2: breast that we have to deal with. It's very reasonable
Speaker 2: to think about the other breasts and future risk, but
Speaker 2: before you just reactively say let's take them both off,
Speaker 2: I really strongly encourage patients to do an analysis of
Speaker 2: their actual risk. It's important to understand that just because
Speaker 2: we elect to have a breast removed profilatically, the Good
Speaker 2: Lord doesn't necessarily smile upon us and say we're not
Speaker 2: going to have any issues with that breast. There won't
Speaker 2: be pain in that breast, there won't be healing issues,
Speaker 2: there won't be any situations that arise that we don't want.
Speaker 2: That press has the same risk of having pain issues
Speaker 2: or any other issues. There's the cancer breast, right, so
Speaker 2: you need to have a good reason for taking it off.
Speaker 2: That doesn't mean that there aren't good reasons. And for
Speaker 2: some people the reason to do it is peace of mind.
Speaker 1: And I understand that right, because for some people it
Speaker 1: becomes and even if in their heads or in reality,
Speaker 1: like like you said, there's a lot of people with
Speaker 1: different hereditary stuff, different genes that short, then you need
Speaker 1: a double both gone, but also mentally, if it makes
Speaker 1: you feel more secure in your future so that you're
Speaker 1: not walking around simply scared and worried and obsessing, then
Speaker 1: people do it for those reasons too, which is one
Speaker 1: hundred percent valid absolutely.
Speaker 2: I mean, there are certain findings on the pathology Shannon,
Speaker 2: in addition that aren't cancer, but they're finding something for example,
Speaker 2: called atypical lobular hyperplasia for example, which is a number
Speaker 2: of long words meaning not cancer, but it's a sign
Speaker 2: a marker that in the course of life that individual
Speaker 2: is it an increased risk for developing a cancer in
Speaker 2: that breast or the other breast, that breast or the
Speaker 2: other breast. So there's certain findings that can be found
Speaker 2: that aren't cancer. But besides a positive gene testing one
Speaker 2: can have findings in their breast pathology, it would suggest
Speaker 2: we might consider removing the other breast. So in your situation,
Speaker 2: you are going to have radiation. I think that with
Speaker 2: a desire to have a patient wake up with a breast,
Speaker 2: and I think that's really important in my way of thinking,
Speaker 2: having a patient wake up and look down and say
Speaker 2: to me, looks pretty good right away. I mean, that
Speaker 2: really makes me happy. That's my goal. And whether we
Speaker 2: do it by putting your tissue up there or a
Speaker 2: tissue expander, or go directly to an implant, that's my
Speaker 2: goal that someone wake up or leave the hostel at
Speaker 2: least saying okay, you know, I can't can see where
Speaker 2: this is going to look pretty good?
Speaker 1: Yeah, because having cancer is traumatizing enough. Absolutely, there are
Speaker 1: some of us, me specifically, that the idea of waking
Speaker 1: up with no breast at all and just this sort
Speaker 1: of horizontal scar that was really I thought for me
Speaker 1: it would mentally be even more damaging. Absolutely, and there's
Speaker 1: probably large percentage of women out there who who feel
Speaker 1: that way.
Speaker 2: So in your situation, we were able to preserve the tissues,
Speaker 2: nipple skin by using that expander and even though we
Speaker 2: knew that the radiation acts almost like a shrink wrap
Speaker 2: up on the tissues, it would tighten that the fact
Speaker 2: that the expander was in there to hold the mold,
Speaker 2: so to speak, to hold a position of the soft tissues.
Speaker 2: I then knew that after initial healing from the radiation,
Speaker 2: usually wait at least six months. You waited a little longer,
Speaker 2: which it was even better, but at least six months
Speaker 2: typically after the final radiation treatment, when the tissues are
Speaker 2: a bit more normalized. I knew then that we could
Speaker 2: take out that expander, take out the capsule, put in
Speaker 2: your own tissue to bring new blood supply and a breast.
Speaker 2: It would much better match the opposite lifted breast than
Speaker 2: an implant. I will tell you that your own tissue
Speaker 2: will virtually always match an opposite breast of normal tissue
Speaker 2: than an implant. There is no implant that looks exactly
Speaker 2: or feels exactly like one zone tissues. So if someone
Speaker 2: makes the decision based upon analysis of their risk factors,
Speaker 2: their own worries, their concerns, that they're going to keep
Speaker 2: the opposite breast, and again, in many instances, it's entirely reasonable.
Speaker 2: I feel that your own tissue in that setting will
Speaker 2: typically match much better than an implant. Okay, let's talk
Speaker 2: a little bit about scarring. Let's talk let's talk about
Speaker 2: incisional approaches. And I think that's really important. You really
Speaker 2: touched upon something that was so important. I've spent many
Speaker 2: years of my practice analyzing incisional approaches. What is socially acceptable,
Speaker 2: what is most cosmetically pleasing, and how can we use
Speaker 2: the scars that are associated with cosmetic surgery. For example,
Speaker 2: a scar that's in the fold, which is commonly done
Speaker 2: for a breast augmentation, or the common breastlift incision. You know,
Speaker 2: there's a scar that may go around the nipple, or
Speaker 2: it may go under the nipple and down like an
Speaker 2: inverted t or an anchor that we think of as
Speaker 2: a lift scar. Lift scars are something that are somewhat
Speaker 2: socially known and socially accepted. If someone has a droopy breast,
Speaker 2: I'll often try to simulate the scar of a breast
Speaker 2: lift to do the mastectomy. And oftentimes we can lift
Speaker 2: the nipple that we keep by using certain nuanced techniques,
Speaker 2: I think we can we can get the nipple into
Speaker 2: a more youthful position save the nipple in many instances
Speaker 2: and do the whole procedure, the mestetomy and the reconstruction
Speaker 2: through incisions that in many ways mimic traditional known cosmetic approaches,
Speaker 2: and that's that's always my approach. In the now fairly
Speaker 2: rare situation where we have to remove the nipple, sometimes
Speaker 2: I will do that again using the breastlift incision and
Speaker 2: make the nipple on the top of that of that
Speaker 2: inverted T shaped scar. That breastlift scar will make the
Speaker 2: nipple on the top of that so that it looks
Speaker 2: like the patient had a lift or a reduction. If
Speaker 2: the nipple has to be removed in a transverse fashion
Speaker 2: because we can't use the breastlift scar because she doesn't
Speaker 2: have droopy skin of the breast, the scar can be
Speaker 2: limited in its inner extent, keeping the scar whenever possible,
Speaker 2: off the ascetically important duclette area, the center area that chose.
Speaker 2: So I think it's very important that we as surgeons,
Speaker 2: cosmetic surgeons, discuss with our patients a variety of incisional
Speaker 2: approaches and arrive at the one that, while being oncologically sound,
Speaker 2: is most cosmetically pleasing. I think that's very important.
Speaker 1: I mean it for sure. Is because again I don't
Speaker 1: I don't think women really want a lot of scars.
Speaker 1: And when we put on a bikini or when we
Speaker 1: find some one worthy of seeing as nude, we don't
Speaker 1: want them to focus on scars all over the body.
Speaker 1: And so it is important to think of those scars
Speaker 1: and where they are hidden. In my case, you did
Speaker 1: the expanders. I was able to heal from radiation, and
Speaker 1: then you did in the breast that was still left
Speaker 1: that didn't I just you know, didn't get chopped off
Speaker 1: by doctor g it. You know, we didn't you do
Speaker 1: a little bit of a reduction and a lift so
Speaker 1: that it would match. So, guys, I I obviously had
Speaker 1: the flap surgery. So he took fat and tissue from
Speaker 1: my stomach and created a breast out of that. He
Speaker 1: didn't you also take a blood vessel from there? Absolutely, yeah,
Speaker 1: in order to pump sure blood like we talked about.
Speaker 2: Right, So we use the techniques of microsurgery where we
Speaker 2: identified an artery in vein going to that and you
Speaker 2: didn't have a lot of fat. We had to really
Speaker 2: kind of work hard. That defined the sufficient volume fortunately,
Speaker 2: you know, yeah, just so that was helpful too. We
Speaker 2: identified an artery in vein that went to that fat.
Speaker 2: We took that up off the tummy. Normally that tissue
Speaker 2: and a tummy tuck would just be discarded. Because we
Speaker 2: had that artery in vein going to that tissue. We
Speaker 2: could plug that artery and vein into an artery and
Speaker 2: vein on the chest wall, and we would have, as
Speaker 2: you mentioned earlier, blow into that tissue and flow out
Speaker 2: of It's just like a normal organ that.
Speaker 1: So the tissue didn't die.
Speaker 2: Yeah, it's remarkable.
Speaker 1: The skin didn't die nothing.
Speaker 2: It's remarkable. You know. Having done this now for so
Speaker 2: many years, I still am excited by the amazing nature
Speaker 2: of that technology. It's really it's really something amazing. The thing,
Speaker 2: as we were talking about incisional approaches, one thing that
Speaker 2: I want people to be aware of about women to
Speaker 2: be aware of, I want colleagues to be aware of,
Speaker 2: is that if a woman has had previous surgery around
Speaker 2: her nipple or around her areola, that doesn't necessarily preclude
Speaker 2: the saving of a nipple at the time of the mastectomy.
Speaker 2: Unlike twenty years ago, the concept of preserving the nipple
Speaker 2: at the time of mastectomy is now quite quite often
Speaker 2: done you know, if the tumor is a prophylatic setting,
Speaker 2: or the tumor is remote sufficiently remote from the nipple,
Speaker 2: we often save the nipple, which is really really an
Speaker 2: aesthetic benefit.
Speaker 1: Can I interrupt you? I feel like this is going
Speaker 1: to become a drinking game with this, with this episode,
Speaker 1: where every single time you say nipple, somebody's going to
Speaker 1: take a drink.
Speaker 2: It's part of dress surgery. What can I tell you?
Speaker 1: I know, right, I'm like.
Speaker 2: That it's an integral and important part of the break.
Speaker 2: It is an important part of the brains and.
Speaker 1: So well, you saved mine.
Speaker 2: Yes, there there are times when if there's certain techniques,
Speaker 2: there's something called a nipple delay, the E l A
Speaker 2: Y E E l A Y procedure delay procedure, we
Speaker 2: are ten to fourteen days before the mass stectomy, we
Speaker 2: divide some of the underlying blood supply to the nipple
Speaker 2: so that that which remains gets heartier. Okay, that's just
Speaker 2: the concept. And so patients who have had radiation or
Speaker 2: prior surgery around the nipple and still often keep their nipple.
Speaker 2: It's really very valuable. So I just mentioned that, so
Speaker 2: that if people are told that their nipples have to
Speaker 2: come off because they've had a previous breast lift or
Speaker 2: a previous breast reduction, that may not necessarily be true.
Speaker 2: And so just just be aware of that.
Speaker 1: Right, maybe go see another doctor get a.
Speaker 2: Second opinion of their opinions in that regard.
Speaker 1: I mean, I think that that's what I sort of
Speaker 1: encourage on the podcast and on my Instagram is it's
Speaker 1: the white coat does not always know everything absolutely, and
Speaker 1: it's really important to go get a second opinion, even
Speaker 1: a third opinion. I mean, you weren't you weren't I
Speaker 1: met with I think four different plastic surgeons, just like
Speaker 1: I met with multiple oncologists. I don't think doctor G
Speaker 1: was my only meeting for you know. I just always
Speaker 1: thought I need to meet different people, see what different
Speaker 1: people say, and also find the person that I connect
Speaker 1: the most with.
Speaker 2: Absolutely, I couldn't agree more with that, And I think
Speaker 2: that unlike many areas of medicine, and medicine is an art,
Speaker 2: but sixth surgeon really is an art. And what you
Speaker 2: said about connecting, yeah, that's true. I mean the surgeon
Speaker 2: should be able to show you examples of his or
Speaker 2: her work, some examples, you know, I mean, just to
Speaker 2: get a sense of do you like they're aesthetic? Do
Speaker 2: you like what they see as beautiful? You know, there's
Speaker 2: some people, for example, who surgeons and find surgeons who
Speaker 2: like placing very large implants, so that.
Speaker 1: It's the same thing with you, like with people who
Speaker 1: do facelift. I mean, I know you do facelift. But
Speaker 1: there's this doctor that several women I personally know have
Speaker 1: gone to and they all look the same because that's
Speaker 1: his aesthetic. So you know, the mouth is always, you know,
Speaker 1: a little bit wider, it's a very specific eyebrows are
Speaker 1: and I see them and I'm like, uh huh, Okay,
Speaker 1: that's who your surgeon is.
Speaker 2: So you may not feel that that was that's how
Speaker 2: you're aesthetic, right, I mean that's important to they look beautiful,
Speaker 2: but but that beauty may not be optimal beauty for you, correct,
Speaker 2: And so that's what that's what I think has to
Speaker 2: be determined. And I think that if if the plastic surgery,
Speaker 2: I think that if someone can't show you their results,
Speaker 2: that's of concern. That's that to me. I think of
Speaker 2: as if you were to work with an artist and
Speaker 2: you said, I'm going to commission you to make a
Speaker 2: beautiful painting. You'd have to see their work to some.
Speaker 1: Extent for sure. Are they impressionists? Are they modern? Of
Speaker 1: course you want to know.
Speaker 2: Now, with that said surgeon may show you pictures and
Speaker 2: should show you pictures that get you some sense, give
Speaker 2: you some sense of what she he or she does.
Speaker 2: That obviously doesn't say that you're going to get that
Speaker 2: same result. Each patient is different, the body is different,
Speaker 2: the situation is different. At least she have the opportunity
Speaker 2: to get a sense of the artistry of that individual.
Speaker 2: I really think that's what you're doing. You're getting a
Speaker 2: sense of the artists the individual. Do you like the individuals?
Speaker 2: It's someone you can get along with.
Speaker 1: It's also somebody you want to find a surgeon who
Speaker 1: adjust to your desires, right because one of the plastic
Speaker 1: surgeons I met with for reconstruction was a big boop guy.
Speaker 1: He put big implants in and I'm five to four
Speaker 1: and one hundred and four pounds. I can't like big
Speaker 1: huge knockers. Is not my personal sthetic. Other people, it
Speaker 1: looks great on do whatever pleases you. I'm all for it.
Speaker 1: But for me, and it didn't really matter how much.
Speaker 1: I just kept on showing him a picture of Kate Moss, like,
Speaker 1: do you see how small her boobs are? Like? This
Speaker 1: is perfection to me.
Speaker 2: He it.
Speaker 1: Just wasn't resonating with him, and whereas with you. You know,
Speaker 1: maybe that's not even your personal style. Outher but you
Speaker 1: looked at me and you said, beautiful breast, let's try
Speaker 1: to get as close as possible. Just you know, because
Speaker 1: I opted to only have one removed, it was you know,
Speaker 1: you're still working with a real one. There's got to
Speaker 1: be symmetry, because that's what I would want. So ultimately,
Speaker 1: did I get tiny A's No? Am I happy or
Speaker 1: that I didn't? Yes, Like, I'm pretty happy with your work.
Speaker 2: It's important to determine if the surgeon hears you.
Speaker 1: Yeah.
Speaker 2: I mean, I'm sure that surgeon who made the large
Speaker 2: rest he or she might have been of find. But
Speaker 2: if he didn't hear what you were saying, you know
Speaker 2: that that's more of an issue. I think that the
Speaker 2: plastic surgeon, after a message a reconstruction, tends to follow
Speaker 2: you the most, you know, certainly among the surgeons. The
Speaker 2: general surgeon does his job or job, then the plastic
Speaker 2: surgeon really has to help you with the healing process
Speaker 2: and follow scars and uh, you know, make certain that
Speaker 2: you maintain a good path, you know. So I think
Speaker 2: it's important to like your doctor.
Speaker 1: I mean, well, you've visited me over the weekend at
Speaker 1: my house. You would drive all the way out to
Speaker 1: Malibu and you would check the drains see how much
Speaker 1: was draining before we could actually take the drains out.
Speaker 1: You you just you wanted to make sure the skin was,
Speaker 1: you know, staying alive, that there was no issues there.
Speaker 1: And you were really really very very very hands on.
Speaker 1: And I know that some people who have heard conversations
Speaker 1: between myself and my doctors have made a comment of well,
Speaker 1: you know, you're Shannon Doherty, so you're getting special treatment
Speaker 1: or maybe it's your insurance. And I'm just going to
Speaker 1: tell you guys that I know that doctor J does
Speaker 1: this for every single one of his patients. It doesn't
Speaker 1: matter if they're famous or not. You do this for
Speaker 1: every single one. And to just chalk off sort of
Speaker 1: my experience as well, you're famous, so you get extra
Speaker 1: it's incredibly unfair. It's not unfair to me because I
Speaker 1: don't really care what people say. It's unfair to my
Speaker 1: doctors because I know for a fact that you are
Speaker 1: this meticulous and hold your every single one of your patients.
Speaker 1: You literally hold our hands through all of this. And
Speaker 1: even after I was totally cleared by you, everything was fine.
Speaker 1: You know. We went to the Greek theater together with
Speaker 1: my mom and your wife jo Lynne, like you know,
Speaker 1: and then we went to the Italian place together. It's
Speaker 1: a relationship. You build relationships with your patients and you
Speaker 1: constantly check in with them, even years and years and
Speaker 1: years and years later, like when was when were we
Speaker 1: probably done with everything? Like twenty seventeen?
Speaker 2: I think I think that's I think it's about right.
Speaker 1: We still check in and there's a true you just
Speaker 1: you care. And it goes back to that story you
Speaker 1: told in the beginning. It does of seeing that young
Speaker 1: woman and wanting to help her and what that did
Speaker 1: to you mentally, that you want people to at least
Speaker 1: have as good of an experience through something like this
Speaker 1: that they possibly can.
Speaker 2: Thank you, Shan. I appreciate your kind words. Yeah, I think,
Speaker 2: you know. I often often tell my staff that we're
Speaker 2: we should be like like family for as long as
Speaker 2: we're needed, you know. And I had a young patient
Speaker 2: recently who I had wonderful young woman who I had
Speaker 2: reconstructed her breasts, who had a bad congenital problem which
Speaker 2: was born with very very asymmetric press and she she
Speaker 2: had she had her reconstruction completed, was thrilled, thankfully thrilled.
Speaker 2: And she said, so, so am I going to see
Speaker 2: you guys anymore? And I joked it, I said, no, no,
Speaker 2: we're done, and she started crying, you know, I mean,
Speaker 2: it was like and I said, of course you're going
Speaker 2: to see this. You'll see us for as long as
Speaker 2: you need us, and we're going to continue to make
Speaker 2: sure your scars you know well that everything is great,
Speaker 2: you know, in the coming months and years. I said,
Speaker 2: You're never done with us, you know, we're always here
Speaker 2: for you. But it made me feel great because you know,
Speaker 2: I tell my staff, look, as long as they need us,
Speaker 2: as long as they want us as both part of
Speaker 2: their extended family, as people who are really meaningful in
Speaker 2: their lives, that's a blessing. And when they're happy and
Speaker 2: we no longer hear from them, that also means we've
Speaker 2: done our good job because they no longer need us,
Speaker 2: you know, And so it's a very wonderful opportunity to
Speaker 2: help people. I every day in my life. I feel
Speaker 2: immensely grateful and honor to do what I do. It's
Speaker 2: really a privilege. And yes, Shannon, I mean, you're very important.
Speaker 2: You're a very wonderful person. I have so many patients
Speaker 2: who are also wonderful people who I deeply care about,
Speaker 2: and that's just the way it should be. You know,
Speaker 2: Medicine is it's very different, I think than anything else
Speaker 2: in society that near their job, so to speak. I
Speaker 2: think it's very different. And I grew up in a
Speaker 2: family of doctors, and you know, my dad instilled in
Speaker 2: me the concept that what we do really is a
Speaker 2: privilege and an honor, and I've never not felt that.
Speaker 2: That's always been my feeling from day one. And once
Speaker 2: I saw that patient and directed my life's professional path
Speaker 2: where I wanted it, it's really been just such a
Speaker 2: privilege and great honor to hear from people that I
Speaker 2: made a positive difference, you know, Shanneon we don't always succeed.
Speaker 2: We're not perfect, We certainly are not perfect, but by
Speaker 2: when we do succeed, it's the greatest feeling in horror.
Speaker 1: Right, Yeah, I know, I'm sure, I'm sure that feels
Speaker 1: amazing There's a lot more you guys with Doctor j Oranger,
Speaker 1: so stay tuned for part two.