Dr. Randall Feingold talks about breast reconstruction on Medical Update, a show that explores various medical treatments. Dr. Feingold, of Aesthetic Plastic Surgery, PC, has a unique approach to breast reconstruction surgeries, with a focus on personalized treatment. He views each case in terms of the bigger picture, taking in all aspects of the patient's life to determine the most appropriate treatment.
Dr. Field: Today when a woman learns that she has breast cancer she has many lifesaving therapies and new tissue and muscle saving surgical options to choose from. Today on Medical Update we'll learn all about the state of the art breast reconstruction surgery. Stay with us.
Our subject today is breast reconstruction and joining us today is Dr. Randall Feingold. He's a plastic and reconstructive surgeon at North Shore University Hospital in Long Island Jewish Medical Center. Welcome to our program Dr. Feingold. Before we get into it, I would like to introduce a patient that I think she's your patient.
And before we get into to a discussion with her, I'd like to read this statement. On the screen we see, "My doctor," this is from a patient, a woman of 35, "My doctor told me that I could have a lumpectomy but I would rather have a double mastectomy and reconstruction." To me it's an astonishing statement. But this woman that we're introducing has done a similar thing. Let's listen to her.
Barbara Ludwig: The lump was first discovered in 1994. And so I did have I had a biopsy and the biopsy came back positive for abnormal cells. So I went to my gynecologist and he was a little concerned as well. There is breast cancer in my family. I have a history. My mom has breast cancer and my three aunts also had breast cancer. So that has always been on my mind. So I did have to go into a hospital and have surgery. And then you have to wait, you know, once they remove the mass, you have to wait a week and it came back benign but with atypical cells which is a pre-cancerous cell.
Over the next five years I had three more surgeries for three more masses that came back in the same spot and they call it a hot spot. It's a very stressful time. You never know, it's on your mind constantly. You're waiting for the next surgery, you're waiting for the next mass to show up and whether it's going to be cancerous, pre-cancerous. It's just a matter of waiting for the other shoe to drop.
It's enough I've had enough. It's been many years. I'm not going to wait until I have cancer. I'm going to take control now while I can. I want to be the one who chooses. My breast surgeon was wonderful. He said, "You know, you do not have cancer now. It's a personal choice. You have to be comfortable in your choice." And then and that is how I came to meet Dr. Feingold. And I told him my story and he couldn't have been more receptive to it and he again, put me at ease and I was amazed at... because again I didn't know about reconstructive surgery, because again, you find a lot of people when they think of mastectomy and reconstructive you think of, it's a frightening thought. It's a long journey to get to this decision. A very long and personal decision and it's a long journey coming.
My quality of life has improved tremendously. Tremendously. I feel I feel a rebirth. I feel I feel alive and not that my life, I don't want to say my whole life was terrible before. It wasn't. But mentally it's like I got to a recharge. I've been recharged. That's the perfect word, like my battery has been recharged.
Dr. Field: What strikes me here Doctor is that when I began reporting on breast cancer and breast surgery 50 years ago, what she said was she made the decision. Fifty years ago with this kind of a situation, the doctor would have said, "We'll have to wait until the cancer appears and then we'll just have to take your breast. Wherever it is." It's been a remarkable change in this kind of a history. What is happening here?
Dr. Feingold: Well that's right Frank. Even when I was a surgical resident in the 1980s, there was an attitude from the male doctor to the female patient that you have breast cancer. You must have a mastectomy. And you're just lucky to be alive. And reconstruction was rarely offered. And things have changed a lot over the last two decades. And to understand this is change the social phenomenon, there are several issues that we need to discuss together and I put them together on this slide.
First the history of surgery for breast cancer and then the tremendous psychological impact of mastectomy upon a woman and how that's led to the development of new techniques including the very latest techniques that we're going to show you today. And then most recently this big trend toward bilateral mastectomy in women, some of whom do not absolutely need it but prefer it.
Dr. Field: Well the history is such that, what was it, just within 25 years this change, this sudden change where the physician is not making the decision. It’s the patient and I find it hard to believe.
Dr. Feingold: Well this is rooted actually back into the late 1800s, when Dr. William Halsted, who was originally a New York surgeon and then moved to Baltimore to Johns Hopkins, devised an operation for breast cancer that he termed the radical mastectomy. And his concept was remove the whole breast, remove the muscles of the chest wall. Remove the lymph nodes or glands under the armpit and by doing a very big operation, albeit a disfiguring operation, we can save women's lives.
And in fact for about 80 years that concept stood unchallenged and plastic surgeons were reluctant to offer reconstructions because even he admonished that any attempt to perform a plastic surgical repair might hinder the success of the breast cancer therapy, which we know now of course is untrue.
Dr. Field: But it evolved it seems that it went from major surgery removal to total removal as you just mentioned, to saying, well, maybe the best way to do this if there's a sign of breast cancer, is remove just a little piece, just a lumpectomy.
Dr. Feingold: Well that's right. His hypotheses were challenged in the '50s and '60s and then in 1990, the National Institute of Health came up with the consensus statement that said that it is appropriate to perform a breast conservation therapy to just remove the lump, a lumpectomy, in many women that are just stage one or stage two. Although they must have radiation therapy afterward and watch their breasts for about 10 years because some percentage of those women will develop recurrence. But the demand for lumpectomy soared after that consensus statement came out.
Dr. Field: What is the psychology here?
Dr. Feingold: Well it's difficult to overstate the psychological impact of mastectomy upon a woman. First we have the anxiety of having cancer and the fear of death of course. But the prospect of having a mastectomy is really viewed as a disfiguring operation by a woman. To a woman, their breast is their symbol of femininity, motherliness, and sexuality. So to remove that breast is a degenderizing or dehumanizing operation and so that leads to significant psychological impact upon the patient.
For example, alterations in mood. Women who have mastectomy have a higher incidence of depression or suicidal ideation. Women who have mastectomy feel the change in their body image. They'll say that they're hollow or that they're imbalanced. And nevertheless they feel unattractive because of this. So this impacts their sexuality, their willingness to show themselves to their spouse. And then it impacts their social occupational functioning as well because they find it difficult to wear clothing. And so they're inhibited in many activities and every day social life or work life that we take for granted.
Dr. Field: When you say we take for granted, is it the men who cannot understand this?
Dr. Feingold: Well I think there was an attitude that if we're doing our best job to treat someone's cancer that they would somehow get by with these changes. But because of these powerful psychological impacts there was a stimulus for plastic surgeons to develop solutions to this problem. And so began the breast reconstruction subspecialty. And there are basically two major categories of breast reconstruction that we can talk about.
Dr. Field: Now when we talk about these, we're talking about what? Because the public or the media I would say, has fed the public all kinds of information about dealing with the breast and surgery. And what most people are aware of are either enhancement or reduction. Generally television and movie starlets and so on and so forth, it's been a cosmetic thing. We're not talking about that now are we.
Dr. Feingold: Now we're talking about a woman who's having a total mastectomy and having to rebuild a breast from scratch including nipple reconstruction. So this is not a cosmetic operation. This is a reconstruction. It's restoring a woman's body back to a normal balanced appealing shape so that she can feel good about yourself inside and out.
Dr. Field: But I think most people when we think about this, think of this and it is radical major surgery. It's not to be taken lightly. But they think in terms of, how do we get this procedure done without any danger to the woman without any impact on her. And shy away from it but that's not what is happening out there is it.
Dr. Feingold: Well there are two major categories of reconstruction that are time proven and fairly safe. And so they've been embraced by the public. The first category is reconstruction with a breast implant. And this is probably the most common method done in the country. It was first devised in the 1960s and then with the addition of a temporary device called the tissue expander in the 1980s, we were able to come up with a reasonably good re-constructive option for women.
You may have heard that silicone gel implants were taken away from use by the FDA in 1992, and that's because these early generation devices leaked and there were allegations that they caused cancer themselves or autoimmune disorders. And so from 1992 till about 2006 we used saline implants, which again yielded a reasonably good solution for most patients. But around the world the gel implant, the silicone gel implant still remained the implant of choice.
Dr. Field: And the new one has been approved by the FDA.
Dr. Feingold: That's right. In November 2006 a lot of research was done and the data showed that there was no link between silicone gel implants and autoimmune disorders or cancer. And so they are available again to use for women.
Dr. Field: Okay, let's go into the area now of breast reconstruction. But we're going to take a break and when we come back we're going to show this on camera, I want the audience to understand that they will see the breast and what you do and how you manage to reconstruct this kind of a physical change.
Okay, so let's stay with us and we'll be right back.
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Dr. Field: Our subject today is breast reconstruction and joining us is Dr Randall Feingold. He's a plastic and reconstructive surgeon at North Shore University Hospital on Long Island Jewish Medical Center. Much of the media has already told us about the kinds of surgery that are performed on the breast for enhancement and the changes. But this is strictly for total reconstruction and there's a history here. Take us through that.
Dr. Feingold: Well we had just touched upon the use of breast implants and breast reconstruction and originally silicone gel implants were popular and then the saline implant as we discussed. And now with the latest generation silicone gel implant, we're able to achieve the best results we've been able to obtain. And I have a slide that shows the most modern technique that we're using now.
Dr. Field: The early is using flaps, just using tissue from the body?
Dr. Feingold: Well no, this is the latest generation of implant reconstruction and then we can talk about using flaps from the abdomen.
Dr. Field: All right.
Dr. Feingold: But I have a diagram here that shows you in the first panel how at the time of mastectomy we place a temporary implant called a tissue expander under the muscle on the patient's chest wall and we support it with a sheet of collagen which is called Aloderm to allow us to properly shape the expanding pocket that we're going to create for the implant. And then at a second operation a few months later, we substitute a permanent implant. It could be saline, it could be the new silicone gel implant. And once that's completed, we make a nipple reconstruction.
Dr. Field: Is this the item that you brought?
Dr. Feingold: That's right. This is the latest version of silicone gel implants and as you can see they're very soft. And they get warm to the touch and they feel very natural, just like body fat and so in a woman's body this is a very comfortable implant. And in fact we've had women who had saline implants who've chosen to replace them with these new silicone gel implants. And uniformly they have said this is a far more comfortable experience for them to use these devices.
Dr. Field: All right and is this what you do in the reconstruction of the breast?
Dr. Feingold: For the patients who choose to use implants, this is the most modern approach. But we also have patients who choose to use tissue from their abdomen, skin and fat and we call that a flap of tissue. And this approach started about 25 years ago, when skin and fat was transported from the abdomen onto the chest using a technique called a TRAM flap and I have a diagram that shows that. Well actually we have a postoperative image of the implant patient that we had wanted to show our viewers. And this is a very natural realistic result. This is the diagram of the TRAM flap. This is the first operation that was devised.
Dr. Field: What is TRAM means? TRAM.
Dr. Feingold: Well that's an acronym for transverse rectus abdominis myocutaneous flap which is awfully complicated to say and it's based upon the fact that we use the rectus muscle to transport the skin and fat on to the chest. And this was really an ingenious operation when it was developed decades ago. And if you look in the diagram, you can see in this first panel, our normal anatomy where we have these two rectus muscles that we use for getting out of the bed and getting out of a chair and doing sit ups and it just retains your normal contour to your abdomen.
And some people are so thin that you can actually see the segments of that muscle and they call that a six pack. And if we sacrifice one of those muscles which we can afford to do, then that muscle can provide blood flow into the skin and fat to transport the skin and fat onto the chest to make a breast mound.
Dr. Field: Now the muscle itself has a circulation of blood?
Dr. Feingold: That's right. There's blood flow that's in that muscle and that's what allows us to transport that tissue. But there are some deficiencies of this operation because some women will develop some bulge or some hernia on their abdomen and because of that, a better technique was devised. And I can show you in our next slide. The operation that we call a TRAM free flap or a micro vascular free flap. And this is actually an operation where the skin and fat of the lower abdomen is completely detached from the body. The muscle is tunneled up on to the chest and there's a different circulation at the very bottom of the muscle that feeds that muscle and thus the skin. And we can sacrifice just a little piece of muscle in order to get that blood vessel out and transported up on to the chest.
So if you look at the woman who had the TRAM flap in the previous slide, she went from having a six pack to having a three pack. But if you look at the patients who have the TRAM free flap, she's only lost one segment of muscle. She has the equivalent of a five pack in terms of retaining her original muscle. And we can get actually a better shape on the new breast because it's no longer tethered to the abdomen and we can get a stronger abdominal wall.
There is some weakness here and some patients can get some bulge and so an even more sophisticated operation was devised in the last decade. And on this slide we see the DIEP flap and that stands for deep inferior epigastric perforators flap. And that's an acronym for the blood vessel at the bottom that sends little branches to the skin and fat. A lot of women are put off by the TRAM flap or the TRAM free flap because it sacrifices muscle.
But in this operation we take the skin and fat and we tease the blood vessel out of the muscle and leave all the muscle behind. So whether we're using the skin and fat to make one breast or two breasts, the breast is created taking no muscle whatsoever from the abdomen. And this is really the state of the art in reconstructive microsurgery. And as you can see in this post-operative image it helps create a very natural result that can match an existing breast. So I think this is the most elegant solution we have to offer women who want to use their own tissue and would otherwise be fearful of sacrificing muscle.
Dr. Field: Now how long has this procedure been in effect now. How long has it been used?
Dr. Feingold: I would say it was popularized about a dozen years ago. But it's only done by a handful of microsurgeons around the country.
Dr. Field: Why is that? Is it a difficult operation or do you need to time? Are you actually connecting blood vessels when you take some of the fat in this latest operation and the blood vessels? Are you actually putting blood vessels and connecting them?
Dr. Feingold: That's exactly right. In the conventional TRAM flap, the skin and fat is tunneled on to the chest and doesn't require any special micro-surgical skills to accomplish that. In the free flaps, one has to detach the tissue and then reattach it with a microscope. So I suppose there are hundreds of plastic surgeons that may do the TRAM free flap. But in order to tease the blood vessel out of the muscle and retain the muscle that does require extra effort and time on the part of the surgeon.
So its the hardest for the surgeon, but it's actually the best for the patient. And so there are a few dozen of us around the country that prefer that approach. And in fact the patients will actually have less pain after the operation and go home faster.
Dr. Field: Give me an idea of the time. When you do this surgery, is it a matter of weeks, days, months? What are we talking about here in a patient going through this procedure, for one breast let's say.
Dr. Feingold: Well I think patients who say, have chosen an implant they will stay overnight after the mastectomy with that temporary tissue expander under their skin and muscle. And then over several months we'll inflate that tissue expander and ultimately substitute the permanent implant several months later at a separate outpatient procedure.
If they choose a flap from the abdomen, there's going to be a longer recovery period initially. However when they go home from the hospital their breast reconstruction is complete with natural living tissue. It's warm, it'll gain weight if they gain weight, it'll lose weight if they lose weight and even they'll have some feeling back. The TRAM flaps are probably in the hospital from five to seven days because of the sacrifice of muscle. And the TRAM free flaps in the DIEP flaps are generally in the heart for only about three days.
Dr. Field: That's fascinating. But are you saying then that you restore the blood circulation to normal in the breast?
Dr. Feingold: Well this is not a breast. It's skin and fat from the abdomen.
Dr. Field: Well, but it's a breast when one looks at this reconstruction.
Dr. Feingold: That's right.
Dr. Field: Why would they feel that? Are the nerves too restored? Did they grow back?
Dr. Field: Well I would say the body is a lot smarter than the doctors are. We can reattach the skin and fat on to the chest and make a natural living breast out of it and while we're not hooking up nerves, the body seems to know what to do. Little nerves will grow into it and patients will report sensation in that breast that we can account for. But that's sort of the miracle of healing.
Dr. Field: The idea that this is available to women, give me a sense of how, I don't understand the feeling, but to go through this is not an easy thing, is it now.
Dr. Feingold: No it's not. But women feel that they're put in a very difficult position that they didn't want to be in and we do have a good solution for them. And that's why there's this trend now toward bilateral mastectomy that we hadn't experienced before. And there are several categories of women that now are very interested in the bilateral mastectomy.
Dr. Field: What are those categories? I know that we now have the gene approach where you were told there was a possibility or that you have a high probability of developing breast cancer and it can be a therapeutic approach or a preventative approach. Is there much of that going on?
Dr. Feingold: Well there is. There are certain high risk groups of women that should have that testing for the BRCA1 or BRCA2 gene and if their testing is...
Dr. Field: What does that testing mean? How do you get this? Is it a blood test? Is it a simple blood test?
Dr: Feingold: It is a simple test and when that result is tabulated, it's going to be a predictor of your risk. And some women may have a risk as high as 80% of having a breast cancer or an ovarian cancer in their lifetime. So these women are directed toward having double mastectomy. But we even have women that are tested and are found to be gene negative, but they have such a strong family history of breast cancer, their mother, a sister, some aunts, that they also feel very strongly that to protect themselves they should have a double mastectomy.
And there may be a third gene or a fourth gene that we just haven't discovered yet. We have women that have undergone a lumpectomy and radiation therapy and have developed a recurrence in that breast or cancer in the other breast. And from their perspective they gave breast conservation a try, it didn't work out and they don't want to take any risk anymore.
So the bottom line is, for a lot of women, there's a tremendous psychologic relief to removing all of the at risk breast tissue and that's why that young woman whose quote you read at the age of 35 with young children at home said , "I don't want to take any chances. I'm going to feel more comfortable removing this breast tissue."
So the take home message from this is that quality choices and breast reconstruction now have empowered women and they're making difficult decisions that they couldn't make before they had better options. And so we see a shift now, it's a paradigm shift from an era of doctor-driven care where the doctor told the patient, this is what you must have and that's it. To an era of patient-driven care where educated patients are making decisions by themselves.
Dr. Field: Are women aware of this option in general?
Dr. Feingold: Well increasingly so. I think breast cancer awareness has never been greater than it is now. October is a month where it's heavily advertised and there are many foundations that support fundraising and walks for breast cancer research. So I think it's really a very timely topic that people are increasingly aware of.
Dr. Field: Do you turn down women who come to you for this kind of surgery? Are there contraindications? I don't want to leave the impression that everyone can be suited to this.
Dr. Feingold: Well I think that if a woman is able to undergo a mastectomy, they're able to undergo a reconstruction. Some women will be better suited physically for an implant reconstruction, some women will be better suited physically for a flap reconstruction. But most patients are good candidates for either approach, in which case it's really the woman's choice how they choose to go with that. And we never turn women down on the basis of insurance because in New York State there are laws that protect women that insurance companies cannot declare this a cosmetic procedure. It is truly a reconstructive procedure.
Dr. Field: I thank you so much for coming here. You've educated me a great deal and I'm looking at the other side now too. So thank you.
Dr. Feingold: You're very welcome.
Dr. Field: Thank you for joining us and we'll see you again next week.