Current Advances in Breast Reconstruction
Cleveland Clinic Akron General plastic surgeon, Sarah Bishop, MD, joins the Cancer Advances podcast to talk about some of the recent advances in breast cancer reconstruction. Listen as Dr. Bishop covers some of the different reconstructive techniques, which patients are the best candidates and when is the best timing for patients to undergo breast reconstruction.
Current Advances in Breast Reconstruction
Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase I and Sarcoma Programs. Today I'm happy to be joined by Dr. Sarah Bishop. Dr. Bishop is a plastic and reconstructive surgeon at Cleveland Clinic and at Cleveland Clinic Akron General. She is here today to talk to us about advances in breast reconstruction. So welcome, Sarah.
Sarah Bishop, MD: Well, thank you so much for having me. I'm really excited to be talking with all of you today.
Dale Shepard, MD, PhD: Absolutely. So maybe to start, tell us a little bit about your role here at Cleveland Clinic.
Sarah Bishop, MD: Yeah, so I do mostly breast reconstruction, and specialize in microsurgery. And so that means using one's own tissues to make breasts. And the microsurgery comes in where we are basically attaching the blood vessels from the tissue that we are moving distant on a patient's body, up to the breasts and hooking them up to nearby blood vessels there. And we use that with the aid of a microscope. So thus the microsurgery standpoint.
Dale Shepard, MD, PhD: Okay, well maybe to start, because we have a lot of diverse interests in terms of physicians listening in, let's start at the very basics. What are the techniques that are commonly used for breast reconstruction?
Sarah Bishop, MD: Breast reconstruction comes in many different forms. We can do breast reconstruction after partial mastectomy or after lumpectomies. And so those are patients that are good candidates when they have large breasts or they have a lot of ptosis, so their breasts kind of hanging really low, patients that have always kind of wanted a breast lift or a breast reduction at some point in their lives. They can be good candidates for oncoplastic techniques. And that's basically where we use the methods of doing breast reduction or mastopexies or breast lifts, and do that at the same time as removing the lumpectomy or the partial mastectomy. So that's more in the guise of breast conservation therapy.
And then we also have breast reconstruction more commonly associated after mastectomy. And those are either performed with implants or performed with autologous or using one's own tissues. And so the most common or what some people will consider the kind of gold standard for breast reconstruction after mastectomy is what's called a DIEP flap, and that's D-I-E-P, meaning deep inferior epigastric perforator flap. And that's where we're taking the lower belly tissue that women commonly have, especially after pregnancies or as we get older, and use that kind of excess tissue that gets thrown away from a tummy tuck, we use to make breasts.
Dale Shepard, MD, PhD: So that's the most common out in the community and at most centers?
Sarah Bishop, MD: Actually, across the country, it's about 75% of reconstructions are implant-based. And that's not entirely clear as to if that is really that number is 75% because patients may not have access to a microsurgeon. So to do the DIEP flaps where you're using that lower excess tissue, you have to have access to a microsurgeon. And so any of the larger facilities, like Cleveland Clinic, you're going to have access to microsurgeons, but if you're out in the middle of the community, you may not have that access. And so implant-based reconstruction may be all that you have available to you locally, unless you're willing to travel.
Dale Shepard, MD, PhD: So what were the sort of problems with the older techniques that have led to the development of newer techniques? What were the shortfalls and how have we overcome those with newer techniques?
Sarah Bishop, MD: Implant-based has gone through a significant journey from initially being underneath the muscle, and now we are kind of going back to where we're putting implants on top of the muscle, which had been tried in the 70s and 80s, but had not performed well. And now we are having better success with putting implants on top of the muscle. And this causes less pain, has a little bit more of a natural loop. So that's for implant based. As far as using your own tissue or autologous, they used to do TRAM flaps, which was using the entire rectus muscle. And then that went through a phase of using less and less muscle, like muscle sparing TRAMS. And now we do the DIEP flaps where we try to spare all the muscle.
And the most recent advances now are with trying to add sensation to the DIEP flaps, so we're neurotizing the flaps. So we take a sensory branch that goes into a perforator on the flap and then attaching this to intercostal nerves to try to get sensation. And these are kind of newer techniques that we are doing. We're also looking at neurotizing the mastectomy flaps. These are even newer techniques. And then the newest techniques, things that I'm going to be working on, is trying to do more minimally invasive DIEP flaps with the use of robotic surgery. So I think those are the kind of the newest things up and rising. We can also look at combining lymphedema treatments as well, because a lot of these patients have issues with lymphedema if they've had full axillary lymph node dissections. And so we will offer prophylactic lymphovenous bypass to help prevent lymphedema, or also prophylactic delayed as well.
Dale Shepard, MD, PhD: And so with these lymphedema procedures, are those usually at the same time as the reconstruction, or are those afterwards?
Sarah Bishop, MD: Yes. So we can do prophylactic lymphovenous bypasses immediately at the same time as axillary lymph node dissections. It's not always possible due to how the anatomy sets itself up, but I would frequently always like to take a look to see if we have the appropriate anatomy. You need to have the lymph vessels, and usually you can find those. But some of the issues are you need to find small veins that are nearby that will reach to your lymph vessels to appropriately bypass. If that's not possible, we're also looking into doing prophylactic lymphovenous bypasses more distally at the elbow region, also as a prophylactic and preventative measure. The only issues with some of these prophylactic treatments is that some insurance companies will consider them to be experimental. And so we are working on putting packages together that are reasonably priced for patients, especially when we're looking at doing this as a prophylactic but delayed, so not at the exact same time as the axillary lymph node dissection.
Dale Shepard, MD, PhD: What percentage, if you could remind me, of patients develop lymphedema? I guess the question being, can you sort of do a watch and wait and see who really needs that procedure?
Sarah Bishop, MD: Yeah, so the historical controls are anywhere from 20 to 50%. So it's a high risk. And the kind of trifecta, patients getting an axillary lymph node dissection, chemotherapy, and radiation, and especially the radiation and the axillary lymph node dissections are a big assault and trauma. And really, these patients really have a very high risk of lymphedema. We will like to perform prophylactic if we can. That's obviously the best is trying to prevent something from happening at all. And there have been some reports as low as 4% after doing some of these prophylactic procedures. So even though insurance companies consider it to be experimental, it is and shown so far to be a very helpful measure. You also can do the kind of watch and wait, and those patients would still be treated with lymphovenous bypass. So essentially the same surgery, but you're kind of waiting for them to develop symptoms. But we do like to very early get patients put into lymphedema physical therapy and to start doing preventative treatment lymphovenous bypass as soon as possible to improve their outcomes.
Dale Shepard, MD, PhD: All right. So we're going to double back over to the breast reconstruction, but I'll remind everyone listening that there is also a podcast episode available where we talk to Dr. Graham Schwartz about management of lymphedema. So if anyone's interested, they can get additional information. Tell me a little bit about the robotic aspect of this. Is this something that's... it has been around for a while, or is this brand new? I never really thought about robotic surgery for this.
Sarah Bishop, MD: Yeah, so I did my microsurgery fellowship at MD Anderson and I studied with Dr. Jesse Selber, and he's really popularizing and really helping develop the use of robotic surgery and plastic surgery. And we just finished a series on 20 patients that will be published here pretty soon in Plastic and Reconstructive Surgery on those outcomes. The robotic aspects really, just as they do in other kinds of surgery, they give us a lot of high dexterity and allow us to do kind of a much smaller approach. So when we do the traditional DIEP flaps, it can be a pretty significant dissection through the abdominal wall. So we do make large cuts on the anterior fascia, and then we're having to split the muscle to release the perforators, to connect to the deep inferior epigastric pedicle. And so all that is somewhat significant. Conversely, when you do the robotic approach, for patients that qualify, you're making very small, maybe two to three centimeter anterior fascial incisions, just enough to dissect out the perforator to the level of the pedicle.
And then you go in robotically and then you're dissecting out the deep inferior epigastric vessels robotically because they run underneath the rectus muscle. So you just have to cut through the transversalis fascia, and then release the pedicle that way. And so then you're only having a very small anterior fascial approach. So this is a relatively recent venue, but it really should significantly improve patients' pain and should improve any kind of long-term risks of hernia and certainly muscle bulging as well. Because when we do the traditional approach, we do have to cut some motor nerves to the rectus muscle that gets left behind. And this can lead to muscle bulging from loss of muscle tone, and that can be distressing to patients afterwards. So even though they don't have a hernia, they still have this abnormal abdominal contour that is distressing to them. So all of these things really should bear out in the future when we kind of get long-term data for improved outcomes.
Dale Shepard, MD, PhD: Are there any patient characteristics that would drive who would benefit from these newer techniques like robotic procedures? Either a patient characteristic from a health standpoint or lumpectomy versus mastectomy? Are there certain situations where this would be much preferred?
Sarah Bishop, MD: Yeah, I think for every procedure there are patients that benefit more from others. So specifically for the robotic DIEPs, obviously you don't want to have had a lot of abdominal surgeries or that's going to be a higher risk to going inside the abdomen. And then specifically for them to have more benefit from the robotic approach, you want to have one or two closely grouped perforators with short intermuscular courses. And we determine that based on CAT scan, and that's determined by the plastic surgeon. And so that makes those patients that are good candidates. As far as autologous tissue versus implant-based, you do want patients to be healthy for autologous if you're doing unilateral versus bilateral. It could be up to 12 hour, even more longer surgery. And so they need to be able to tolerate a lengthy surgery and be healthy enough for that. And you'd like their BMIs to ideally be below 32. But I would say for me, at least below 35.
And I will see patients and help them and work for them to get to that point, if they're not there right away. And the more excess tissue that they have in the lower abdomen, then the more likely they are candidates for DIEP flaps. I would say though, that patients that are really thin, still are candidates for multi-flap, or what we call stacked flap procedures. So if you have patients that really want to avoid implants, and there are a lot of women out there that are very kind of anti-implant and don't want to have any implants, but they are very thin. So a lot of times they've been turned away for using their own tissues. We can use multiple sites to be able to reconstruct a breast.
So you can use the lower abdominal tissue, and you can also use the back of the thighs, which we call a PAP flap for profunda artery perforator flap. And you can stack these, meaning that you do one flap and then another flap on the same breast. So you have two flaps on each breast for bilateral reconstruction. So these are, again, bigger surgeries. So they need to be healthy to be able to tolerate that. And the only patients that I would be doing four flaps on in that circumstances would be thinner women that are very much motivated to having a full autologous reconstruction. For implant-based, a lot of people are candidates, except for there are patients that have had very significant radiation injury. And for those patients, they may be best served with using their own tissue or autologous reconstruction.
Dale Shepard, MD, PhD: What's the primary concern among patients for use of implants? You mentioned that some women were sort of adverse to using an implant. What kind of drives that concern?
Sarah Bishop, MD: Well, there are certainly people that talk about something called BII or breast implant illness. And so far right now, we don't have any solid data to support this as a medical diagnosis. And so far it's not a diagnosis that is described in our literature. Breast implants have really been probably more studied to any other medical device in history. And so as now, we don't have anything that supports that. But you will go on Facebook and you will have hundreds of thousands of women on Facebook sites that support this as a diagnosis, and there's about 50 different symptoms that correspond to it. So it's challenging. And so you will sometimes have patients that are very afraid of this, or have implants in place and want to have them removed. And I'm always willing to remove implants for patients if they desire that. But as of right now, we're not able to really show that this is a real diagnosis. But at the same time, I think you had to be careful to not be dismissive over what patients are feeling.
Also out there as well is something that's called BIA-ALCL, that stands for breast implant-associated anaplastic large cell lymphoma. And so this is a new kind of cancer that is associated with textured implants. This is implants that have texturing on the surface. And initially these were found to hopefully be decreasing the risk of capsular contracture or the capsule that forms around the implant. And then they were used as a way to have shaped implants or more anatomic shape so that the implants didn't flip. The texturing helps kind of hold the implant in place. Unfortunately, they did find that this was associated with this rare type of lymphoma.
And so in July of 2019, the FDA banned the use of textured implants. They did not say however that we need to remove these implants in patients, but we are no longer allowed to further put these in place. Now worldwide, the use of textured implants is still going on. And also there was a timeframe where we were aware that there was this association and we're still putting these on patients with informed consent, mostly because when we started using these implants, we were placing them on top of the muscle to try to get away from placing implants underneath the muscle. And we didn't have implants that performed well on top of the muscle. Since then, we have come up with smooth implants that do perform better on top of the muscle. So we have other options. And so that we don't have to use these implants anymore, or nor are we allowed to.
So when patients start hearing some of these concerns with the BIA-ALCL, and then they also hear about breast implant illness, sometimes these things kind of merge together for patients and they just become too afraid of using implants or having anything that they consider to be foreign in their body, and want to do anything that they can not to have that.
Dale Shepard, MD, PhD: So you mentioned previously that women with breast cancer, it's a multi-modality treatment, oftentimes surgery and radiation and chemotherapy. And so where does reconstruction fit in, in terms of when patients can get procedures for reconstruction, and do the newer procedures change that? Do they shorten the time to completion, lengthen it? How does that look?
Sarah Bishop, MD: Well, ideally breast reconstruction should happen immediately. Now, there are factors that could lead to patients having delayed reconstruction, but the best outcomes and I would say the easiest, are to be there from the outset. So when you're doing oncoplastic, that by definition is going to happen at the same time as the lumpectomy or the partial mastectomy. If you're doing mastectomies, there are patients that you can do almost everything at the same time. So there are patients that are candidates for immediate DIEP flaps. So these are patients with DCIS or that are completely prophylactic, may have BRCA or other genetic factors. These patients, you can do DIEP flaps actually at the initial time of the surgery. You can do direct to implants. I tend to stage my implant-based reconstruction with tissue expanders, and then later exchanges for implants, but you are still putting in something to save that breast pocket and skin for optimal outcomes.
And then also once they wake up from their mastectomy, they have basically a breast construct or breast shapes in place. And so you're already kind of on your way. So there are some circumstances where you could literally do all the breast reconstruction in one surgery, but by far and large, there are revisions that are needed. And so I really kind of say that breast reconstruction is a journey, and I tell patients that in many ways, it kind of starts and stops when they tell me. But I would generally expect most patients to probably have two surgeries. And if they want more beyond that, then a lot of times they are kind of driving that and asking for some revisions to do some small improvements here and there.
Dale Shepard, MD, PhD: Do either of those procedures lead to a significant difference in when they could start their chemo and radiation? So does their overall journey change in length or is it all about the same?
Sarah Bishop, MD: I think all of our hopes as plastic surgeons as not to delay their adjuvant treatments in any way. That is my number one concern with all of the patients that I help with is that they get to their adjuvant treatments as soon as possible. So it's possible that what you do could delay their chemotherapy or radiation that they're getting post-operatively because there's complications. That's always possible so you have to be with upfront that. But you're also trying to make sure that there's no issue there. For patients that are really, really high risk and that you're concerned that you could delay, then you can delay these patients completely. And so if patients are significantly obese, if they have a lot of medical comorbidities, if they're smokers, and these are patients that are going to need chemotherapy and radiation, then they're at really high risk for problems. And so you may be better served by waiting until all of those things have happened, and then coming in and doing delayed reconstruction later.
Dale Shepard, MD, PhD: You mentioned before that some of the newer innovations looking to be minimally invasive, adding sensation. What are the gaps? What's the next step?
Sarah Bishop, MD: Well, I think a lot of it is with insurance approval. A lot of the things that we're doing with neurotizing, we are using grafts or cadaver nerve grafts, and those are expensive. But so far for neurotizing our DIEP flaps, we have pretty good success rates with most of the insurance companies for covering that. I'm not entirely sure how well neurotizing mastectomy flaps, that may be a little bit more challenging. Every time we come up with a new technique, insurance companies will consider it to be experimental. And so it takes some time. We run into some of those issues with doing the prophylactic lymphovenous bypass as well, that it's not always getting covered. So we have to continue to do them, unfortunately, and then finally come up with continued data to support what we're doing. And then eventually I think we can get those things covered.
Dale Shepard, MD, PhD: Very good. Well, thank you very much for all of your insight. I appreciate you being with us today.
Sarah Bishop, MD: Yeah. Thank you so much. I really appreciate it.
Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget you can access real-time updates from Cleveland Clinic's Cancer Center experts on our Consult QD website at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.