According to the American Society of Plastic Surgeons, the results shown in this study “alleviate concerns that immediate reconstruction leads to increased complications” and make a strong argument for immediate breast reconstruction,

Reduced psychological trauma is one of the commonly cited benefits of immediate breast reconstruction, as the patient can go in for mastectomy and come out of surgery with the breast intact. Other benefits include decreased cost and shorter recovery time.

The 10-year study was based on the results of 170 women who had undergone breast reconstruction immediately after mastectomy. 13 of the patients had even undergone bilateral reconstruction to reconstruct both breasts. Surgeons primarily used a TRAM flap technique to compelte the surgery.

To determine if immediate reconstruction was justified, researchers analyzed the following outcomes:

• complication rates
• timing of other cancer treatments
• aesthetic appearance

They found a complication rate of 8.8 percent, which led to delays in further cancer treatments (chemotherapy/radiation) in eight patients. While fifteen patients experienced recurrence of the breast cancer, immediate reconstruction did not delay recognition of these recurrences.

Authors of the study say they hope these results will reassure breast cancer patients and plastic surgeons of the safety and efficacy of immediate breast reconstruction. They argue that it offers a safe and beneficial alternative to delayed breast reconstruction, which can involve waiting weeks or months for surgery.

Read more on plasticsurgery.org

“Radiographic follow-up of breasts treated with fat grafting is not problematic and should not be a hindrance to the procedure,” concludes study author Dr. Michaël Veber, of University of Lyon-Léon Bérard Cancer Center in France

An article about this research was published in the March issue of Plastic and Reconstructive Surgery journal.

During fat grafting for breast surgery, a surgeon removes small amounts of fat from one part of the body (such as the hips or thighs via liposuction) and then transfers it to the breasts.

To determine if fat grafting for breast augmentation, what the authors call “lipomodeling,” caused any problems with mammogram screenings for breast cancer, the researchers reviewed mammograms performed 16 months (on average) after lipomodeling in 31 women.

In over half of the cases, the mammograms showed no abnormalities. Some women’s mammograms showed small calcifications or cysts that were thought to be caused by the fat transfer procedure, and a few women had other abnormalities related to scarring from their breast surgery. However, the authors concluded none of these changes were considered likely to raise suspicions of breast cancer on routine mammograms.

In 20 women, researchers evaluated mammograms performed before and after fat transfer. They found no significant differences in the mammographic results from before to after breast surgery. Overall, breast density remained stable over time and “radiographic follow-up was not more difficult after lipomodeling.”

The authors suggest that women undergoing lipomodeling have a complete evaluation — including mammograms — before and after the procedure.

Basically all cancers, whether breast, brain or blood, start when a single cell’s DNA gets a mutation or is damaged.  This means that a normal gene, that produces a protein that goes on to provide a certain function, becomes abnormal.  This abnormal gene produces an abnormal protein.  Now our cells are really smart and there are other proteins that detect abnormal genes and remove them or even signal for the entire cell to be destroyed.  However, it’s often these removing genes, known as tumor suppressor genes,  that are abnormal.  This prevents the cell from removing the other abnormal genes or proteins.  When the cell divides the abnormal gene is passed on to the next cell.  Both cells divide again passing along the abnormal gene and so on and so on.  This is very basic so all you molecular biologists just relax.

The problem is that it’s usually not the same abnormal gene in each patient.  So although the end result may be the same, e.g. invasive breast cancer, the starting point is different.  Some cancers have virtually the same starting point.  This is the premise behind “silver bullet” research.  These therapies aim to exactly target the cells with the abnormal protein while leaving all other cells alone.  This is the goal of all researchers for all diseases-find the “silver bullet.”

What Lance Liotta and Emanuel Petricoin are doing at George Mason University is unique.  They are determining what the initial abnormal protein is for each patient with metastatic breast cancer.  Then they will figure out which of the many drug therapies best attacks those specific cells.  It’s analogous to using a smart bomb vs carpet bombing.  Although, in theory, there will still be some collateral damage it will be significantly less if all works as suspected.

What really struck me with this research is that Liotta and Petricoin get “it.”  They understand that we need to continue the fight even when the cancer is metastatic.  In fact, we need to step up our attack on the disease.  So often metastatic cancer patients are written off for dead.  Why?  Just remember, Lance Armstrong was a metastatic cancer patient.  By all rights he shouldn’t even be alive.  And yet not only did he survive but went on to win the Tour de France 7 times!!  And why did he survive?  It was the research behind the treatment that made things possible.

We’ll continue to track the progress of Liotta and Petricoin and let you know how their study goes.  Let’s keep our fingers crossed.

In the mid-1960′s the modified radical mastectomy came into existence. This surgery involved removal of everything that the radial mastectomy did except the pectoralis major muscle.  As minimal as it may seem this was a huge surgical advance and allowed for much better reconstructive possibilities.  This surgery was the standard of care well into the 1990′s.  But in the late 70′s and 80′s innovative surgeons introduced the skin-sparing mastectomy that removed the nipple areola complex and used a much smaller incision.

Finally, in the mid-1980′s the nipple sparing mastectomy was introduced.  However, as with many procedures the indications for its use had to be determined and therefore it was not widely used.  Finally we have understanding and indications for its use.

The nipple sparing mastectomy is the greatest advance in breast cancer surgery.  We have gone from removing everything associated with the breast and chest wall to only the breast tissue.  This leaves the nipple areola complex, an excellent breast skin envelope and all of the muscles of the chest wall.   In addition it may or may not be combined with a sentinel lymph node dissection.   The incision for the nipple sparing mastectomy can be as short as 6cm, hidden in the inferolateral inframammary fold or breast crease (see the picture).  This incision is only one centimeter longer than an incision used for a primary silicone breast augmentation!  With this surgery an immediate breast reconstruction may be done with an acellular dermal matrix and tissue expander or permanent breast implant.  I do not use a permanent breast implant in this setting because the final result will never be as good as a two-stage procedure using an expander first followed several months later by exchange to the permanent implant.

So why don’t we always do this fantastic surgery?  The reason is tied to anatomy.  Invasive ductal breast cancer means that the cancer has started in the milk duct of the breast and has spread through the duct into the surrounding tissue.  All ducts are connected to the nipple so theoretically there could be cancer cells in the nipple.  Remember this is only theory.  Therefore current dictum (and lack of tort reform) states that all of the breast tissue and the nipple areolar complex should be removed to remove any possibility of recurrence.  Therefore the current indications for nipple sparing mastectomy are really limited to DCIS (ductal carcinoma in situ), prophylactic mastectomy or non-cancerous breast disease.  DCIS is cancer that has not mutated enough to become invasive through the milk duct wall.  Given time it will.

Ten years ago DCIS was not considered cancer, but since we now know that if given time it becomes invasive cancer, then by definition it must be cancer (just not invasive).  Other researchers and surgeons believe that the nipple sparing mastectomy should be considered even for patients with invasive cancers of less then 2cm in size, located at least 2.5cm from the areola (see indications).  While this remains to be determined what is important is that we have outstanding surgeons like Dr. Virginia Chiantella, of Reston VA that are on the forefront of breast cancer surgery.  Few surgeons can perform a thorough and complete mastectomy through such a small incision.  It is this level of understanding, skill and caring that allows plastic surgeons like me to give patients, like our 31 year old, breasts that are imperceptible from normal breasts.

Just to clarify, young women typically have very dense breast tissue.  This is why mammograms aren’t done in younger women; it’s very difficult to see any pathology or disease through the dense tissue.  If there are any concerns, an ultrasound is the first test performed.

The ultrasound was performed and read by a radiologist as normal.  Fortunately, this radiology group uses two radiologists as a sort of checks and balances system.  The second radiologist, either due to experience or intuition, suggested that the patient get a mammogram for clarification.  The mammogram confirmed the doctor’s suspicions, something irregular, was there. Our patient was then referred to a breast surgeon, Dr. Virginia Chiantella.  Dr. Chiantella (can-tell-a) is well-trained and performs outstanding breast surgery.

Now just take a minute.  Think about the whirl-wind that this woman was undergoing.  She was living a normal, happy, suburban life one day and in a very short period of time she’s going to see a surgeon for a potential cancer.

Just take a moment and put yourself in that position.

There aren’t enough adjectives to describe the feelings that would go through your mind and body.  But our patient is tough. Tough, like so many other women in this situation, because she has to be-children don’t understand when mom is sick.  And the thought of your own children having to grow up without you will drive any parent to do what is necessary.

Dr. Virginia Chiantella MD FACS, is incredibly talented, smart and caring.  She performed a needle biopsy on our patient.  This involves using a needle to take an actual piece of breast tissue.  The pathologist determined that the this tissue contained cancer, DCIS (Ductal Carcinoma In-Situ).  Now when I was a resident physician DCIS wasn’t considered “cancer” but over the course of time and multiple studies we know that this is the first stage of invasive breast cancer.  In addition, because of her young age and an extensive family history of breast cancer, gene testing was suggested.

Gene testing looks for damaged BRCA 1 and BRCA 2 genes.  These genes are in the class of tumor suppressor genes.  What they do is produce proteins that go out and repair DNA that has been damaged.  Like a power company fixing a power line-they either repair it or replace it. Damaged DNA, if not fixed or removed, will proliferate as the cell it is contained in multiplies.  There are lots of these gene in our DNA that protect us from cancer and other diseases.  The problem is that these genes, like any gene, can become damaged and not able to perform their duties.  When this happens cancer occurs.  When these damaged genes are present they can increase the possibility of breast cancer as well as other cancers AND be passed onto offspring in their damaged state.  Our patient got tested and her results indicated….