In this episode, Melissa talks to Dr. Michael Gimbel, her plastic surgeon in Pittsburgh, PA. Dr. Gimbel addresses the different options available for reconstruction for women diagnosed with breast cancer, as well as the possible advantages and disadvantages. He addresses the current concern related to breast implants. Dr. Gimbel shares his preferred sequence of treatment when other therapies are needed for a patient. He discusses the different options available for nipple reconstruction when a woman is not a candidate for a nipple-sparing mastectomy. He shares how he helps to support women how are struggling emotionally in the process of their cancer diagnosis and decisions to be made. Dr. Gimbel provides tips for seeking out a qualified plastic surgeon.
Dr. Gimbel is an Assistant Professor at the University of Pittsburgh, Department of Plastic Surgery. He currently works at Magee Women’s Hospital. He has a focus of general plastic surgery with a specific focus on breast surgery. Many of the women that show up at Dr. Gimbel’s office arrive by necessity. A majority of his patients are active patients or survivors. Many patients are coming to learn about reconstruction options that can be completed at the time of surgery or at a later date.
Dr. Gimbel shares the different options for reconstruction to include implants, autologous surgery, and a hybrid of the two. At the consultation appointment, Dr. Gimbel assesses what a patient is a candidate for and what the best option may be. Some patients are a candidate for all three options while others may not be. One of the most important things in determining if someone is a good candidate and the best option for treatment is what the woman wants. Some women have already done research and have an idea of what they want and some are learning about the different options for the first time. If a patient is a candidate for all three options, Dr. Gimbel relies on what the woman wants as each person has different views on what is important.
The method of implant placement has branched into many different methods. The standard approach is a staged approach where a tissue expander is placed under the pectoral muscle and inflated over the course of several months. Then the expander is removed and replaced with an implant. The other methods for implants is acellular dermal matrix, where material is used on the inside to lessen the tightness of skin and to improve the shape. The third method is pre-pectoral, where material is placed over top of the pectoral muscle to create space for an implant.
The advantage is that all implants come in different shapes and sizes, and the patient can select the option she would like. The surgery to place the implant and recovery time is fairly quick. The disadvantages is that implants are man-made material and will not last forever. There is a risk of developing a leak. There is a 5-10% chance of developing some kind of issue within 10 years. The infection rate is approximately 10-15%. Some patients do not like the idea of having a foreign body inside their body. Other patients are worried about the previous scare in the 1990’s with silicone-based implants.
The previous scare with implants in the 1990’s was focused on silicone implants. It was suspected that silicone implants were causing many health related issues such as lupus, autoimmune disease, or even cancer. Silicone implants were pulled from use for approximately 15 years and studied. There was no correlation found between the implants and health related concerns. The FDA approved them for use again. The current concern is related to textured silicone implants and the correlation to ALCL, a type of lymphoma that can develop around specific areas of textured implants. It is rare and evident in approximately 1 in 10,000 to 1 in 30,000. The FDA has not yet pulled this type of implant but Dr. Gimbel and many other plastic surgeons have discontinued the use of textured silicone implants.
Autologous is the use of one’s own tissue to recreate a breast or breasts. The most common place to obtained the donated tissue is the abdomen. The tissue has to be removed in a certain way with appropriate anatomy and with connect blood vessels. The tissue is taken as a block of tissue to recreate the breast and reconnect the blood vessels to bring the tissue back to life. The use of the abdominal tissue has been most successful with this method. Sometimes the tissue can be transferred from the abdomen without disconnecting the blood vessels. There can be signiificant trauma to the abdomen muscles during this surgery. A more typical method employs the use of microsurgery that causes little disturbance to the abdominal muscles. Sometimes people are not a good candidate to use their abdominal muscles for a number of reasons. In these cases, tissue can be borrowed from the inner thigh, outer thigh, and gluteal muscles; however, these are secondary options to the abdomen. With this type of surgery, the operation, hospital stay, and recovery time are longer. There is a scar on the abdomen and there is a 5% chance of developing a bulge in the abdomen. The advantage of this method is that it does not have the same disadvantages as implants. An infection can still occur but it typically does not harm the tissue. Your own tissue is more durable and seems to get better over time.
The hybrid option utilizes both an implant and the borrowing of tissue from another part of the body. For this option, the tissue typically comes from the latissimus muscle.
Many doctors have a different sequence of treatment. This requires tight communication with the breast oncology surgeon to find out what other treatments may be necessary. It is very common to have immediate reconstruction at the time of surgery; however, there are times when delayed reconstruction is more appropriate. For those who will require radiation as part of their treatment, delayed reconstruction may be a better option as radiation can impact the skin, displace the implant, and increases the rates of short- and long-term complications. Different surgeons do different things but Dr. Gimbel tries to avoid putting in implants for those that have already undergone radiation or when it is known that a patient will undergo radiation.
There are times when radiation is not expected at the time of surgery but after surgery, it is determined that radiation is needed. In this case, the expanders would be inflated as though an implant will be put it, the patient undergoes radiation, and then after several months post-radiation, the patient returns to discuss the next steps. Dr. Gimbel indicated that the appearance of the skin helps determine the appropriate method of reconstruction. If a patient’s skills seems to have tolerated the radiation, the patient can move forward with the implant reconstruction. However, there has to be a clear understanding that there are still long-term risk such as capsulary contracture that can cause asymmetry, tightness, and discomfort. There can also be short-term risks to include the incision line not healing well or even opening up, as well as the risk for infection. If a patient presents shiny skin, tightness, and the implant is pushed in an upward position, these are signs that implant based reconstruction should be reconsidered. The recommendation would be to use the abdomen muscles to recreate the breast or perform a hybrid procedure of using both implant and one’s own tissue.
Nipple reconstruction is another part of the reconstructive process. Some women are candidates for nipple-sparing mastectomy, where the nipple is maintained and intact. However, it is typically numb. Many women, on the other hand, are not candidates for nipple sparing mastectomy. There are several different options to recreate a nipple. One method is using one’s own tissue to create a button and then tattooing of the areola. Regular tattooing is a flat tattoo of a nipple and areola. Three-dimension tattooing is a more sophisticated method that looks like a picture of a nipple to make it appear more realistic. Over the last 10 years, the availability of 3-D tattooing has increased.
When a woman comes into the office out of necessity due to a recent diagnosis, there is a tendency for her to be more emotional. Trying to understand the diagnosis, treatment, options, and prognosis can be overwhelming. Typically women are less emotional when undergoing a delayed reconstruction method. Dr. Gimbel shares that it is important to speak to women as though she is a family member. It is important to remind the woman that the first thing is to take care of the cancer. Dr. Gimbel attempt to gain an understanding of the state the woman is in and tailor the approach based on that.
Due to the vagueness of the word plastic surgeon, Dr. Gimbel recommends that a patient look at the credentials of the surgeon. Sometimes patients think they are getting someone fully trained but that is not necessarily true. He suggests checking out the surgeon and being certain that the surgeon is a Board Certified Plastic Surgeon with the American Board of Plastic Surgeons, which is the official, validated training system for plastic surgeons. He recommends asking the surgeon what kind of practice he/she has, what kind of patients does he/she take care of in high quantity, does the surgeon perform a lot of breast reconstruction, and how often does the surgeon perform the different methods of reconstruction.