Dr. Potter was recently featured in the American Society of Plastic Surgeons Panel on Breast Reconstruction. Read on to see Dr. Potter and patient Deborah discuss DIEP Flap Breast Reconstruction.
Dana Donofree: [00:00:04] Hi and welcome to the American Society of Plastic Surgeons Panel on Breast Reconstruction. We’re excited to bring both physicians and patients together to have a really awesome conversation to both educate and empower those that are diagnosed with breast cancer. I’m Dana Donofree. I’m the founder of Anaono intimates designed differently for those that have undergone breast surgery. I’m also approaching my 12 years of breast cancer survivorship, and I’m excited to be here to moderate this panel. First, I’d like to introduce Dr. Elisabeth Potter, a board certified by the American Board of Plastic Surgery. Dr. Elisabeth Potter completed her undergraduate studies at Princeton University. She has a medical degree from the Emory University School of Medicine. She’s completed her residency at the University of Texas Southwestern Medical Center and had microsurgery fellowship with MD Anderson. Dr. Potter. specializes in natural breast reconstruction and has performed over a thousand DIEP flap surgeries using patient’s natural fat and tissue. She’s also a champion of animals, and Dr. Potter’s rescued numerous dogs over the past few years, and in her spare time, she can find her about with her six pack in Austin, Texas. Not to be confused with six pack, but I think it’s awesome. Dr. Potter, we’re so excited to have you here, and I would love for you to kick this off. I mean, after a thousand flap surgeries in your Rolodex, can you just explain to us what actually is a flap surgery?
Elisabeth Potter,MD: [00:01:41] Of course. Ok, so great to be here with you guys. So what is flap surgery? Flap surgery is a kind of plastic surgery where we utilize your own natural tissue to do something that you need. So in breast reconstruction, we use part of the body that isn’t the breast to reconstruct the breast with natural tissue. That’s sort of the nuts and bolts of it. The more specific details are that there are blood vessels that we can transfer and sew into place and a new area so that tissue say from your thigh or your belly is now living on your chest. And then we use our all of our artistic skills after we’ve done the difficult microsurgery stuff to shape a new breast.
Dana Donofree: [00:02:38] I mean, as as a patient myself for the last 12 years, I can personally say how far microsurgery has has really come. And I’m just wondering how long has microsurgery been an option for people with breast reconstruction?
Elisabeth Potter,MD: [00:02:54] Microsurgery has been an option in breast reconstruction for actually quite a long time. When I was initially training in plastic and reconstructive surgery, even DIEP flaps were an option, but we have come so far in the last ten years. I think even in the last five years, we’ve seen huge transformations in our ability to do more beautiful reconstructions with more benefits for the patient more efficiently. For me, the biggest changes I have seen have really been in those two areas and the cosmetic outcome of natural breast reconstruction and also in efficiency. I think that the benefits we’ve seen in the cosmetic outcome have largely been due in part to doctors and patients working together to achieve the most beautiful results that we can. I think that efficiency naturally develops over time as doctors like myself and Dr. Tanna and others perform, you know, thousands of these surgeries, we naturally get better and patients benefit from that. When I was training in residency, it was not uncommon to see or participate in a surgery for breast reconstruction that lasted 10 or 12 hours. And today you’ll hear about some of the efficiencies that we’ve achieved in surgery. Our patient today surgery took four and a half hours to do bilateral DIEP flaps. Patients do better when they’re under anesthesia, less time still with a safe and beautiful result. So, yeah.
Dana Donofree: [00:04:41] So amazing. So helpful. I know we’ve come so far. I’m super stoked to dove into all of these details and and Dr. Neil Tanna is our other physician here with us today to talk about flap surgeries and other options. But he’s a double board certified plastic and reconstructive surgeon with a practice focused, focused on surgery of the breast and face. Dr. Tanna is a leader in his field, a respected educator and a prolific author. He serves as Professor of Surgery at Zucker School of Medicine. He’s Associate Program Director of the Plastic Surgery of Northwell Health, the Medical Director of Northwell Health Ambulatory Surgery Center. Dr. Tanna’s attention to detail, appreciation of the individuality of every patient and the respect for form and function are reflected in all of Dr. Tanna’s work as a plastic surgeon. He’s committed to achieving safe, long lasting and natural looking results, and we’re going to just touch a little bit on some of his approach to flap surgeries here with his beautiful patient that’s joining us today as well. Dr. Tanna, thank you so much for joining us.
Neil Tanna, MD: [00:05:52] Yeah, no, thank you so much, Dana, thank you to the American Society of Plastic Surgery, thank you, Dr. Potter and our patients. This is this is an exciting panel. It’s it’s our patients that inspire us and it’s exciting to have patients and surgeons, you know, really pushing limits and driving breast reconstruction past the 21st century. So thank you for having me.
Dana Donofree: [00:06:16] One hundred percent, like, what a great way to kick this off. Like, I think again, going back to my experience being a patient for over a decade, there was really only conversation of one flap surgery when I was diagnosed in twenty ten and that was the DIEP flap. But there are so many more options. Can you break it down for us, all of the different donor sites and options for flap surgery?
Neil Tanna, MD: [00:06:38] Yeah, absolutely. I think, you know, when we meet with the patient, you know, we want them to understand that breast reconstruction is now very individualized. We will look at a patient’s preferences and their anatomy and try to come up with a plan that meets both of those. And in a flap surgery, you’re essentially taking tissue from one area of excess and transferring it. You’re transplanting it for lack of a better word. And it’s very much like the monitor you’re looking at right now or the television you unplug it, walk it across the room and plug it in somewhere else. So same concept. You’re taking tissue from an area of excess and transferring it, so you need to have the tissue and the blood vessel. So commonly, the abdomen is the source that we look at first, which is the DIEP flap. And in patients who’ve had previous abdominal surgery or who have had, you know, who lack the excess fat, we’ll look at alternative sites and sort of we can look at the thigh, the inner thigh. There’s a flap based on blood vessels. They’re called the TUG flap. We can look at the back of the thigh. The posterior thigh called the PAP flap. Historically, surgeons have looked at the buttock. There’s the GAP flap based on vessels there and and you know, there’s also the lumbar artery perforator flap, the LAP flap from the flanks. The reality is, is that we can, you know, we push limits and we consider even additional sites when when we have to, when these are not not an option. So essentially there has to be tissue with blood vessels.
Dana Donofree: [00:08:14] I’m excited to also bring forward to incredible patients, Deborah and Stacey, actually both patients of Dr. Tanna and Dr. Potter, where they’re going to share a little bit in their own patient perspective and experience. So I’ll kick it off with Deborah, who is diagnosed with breast cancer in December of 2020. She’s sixty five years old and she’s a proud grandmother of six. She received an invasive ductal carcinoma. Stage two hormonal positive breast cancer. After her diagnosis, she opted for a bilateral DIEP flap surgery with Dr. Potter, and she’s so happy to get the chance to cheer on both her grandson and his football practice and her granddaughter at cheerleading. So, Deborah, thank you so much for being here today and being so brave to share your story with all of us.
Deborah: [00:09:02] Well, thank you for having me. I would just first like to say that after receiving my diagnosis, I was referred to the surgeon, Dr. Sprunt, and she gave me a wealth of information, including the binder that you see over my shoulder there. It gave me the different options for reconstructive surgeries, and I was able to gain a lot of information using that binder. I also used Dr. Potter’s website. I was able to see the before and afters that was very helpful, and then I got the the opportunity to meet Dr. Potter. And she further explained, I was pretty much set on the DIEP flap and she pretty much, you know, gave me the examination and explained that yes, I would be a good candidate for that. So I’m very happy to have had that opportunity to meet her and confirm that what I was thinking was the more natural reconstruction for me would be workable for me. So I was very glad for that.
Dana Donofree: [00:10:01] Well, Deborah, you had such an incredibly positive experience after your diagnosis by receiving and getting information from the practitioners around you. Tell us a little bit when you saw your breast surgeon, how how did they address the option of breast reconstruction with you?
Deborah: [00:10:18] Basically, they she laid out multiple options for me, and we didn’t go into great detail on some of them, but I was drawn to the DIEP flap after reading that information, I was drawn to that because I felt that it was going to be a very natural option for me. I’m not one to want to introduce foreign objects into my body, so I just felt like that would be. I was hopeful it would be an option for me. And Dr. Potter confirmed that, yes, it was so.
Dana Donofree: [00:10:50] So, Dr Potter, when somebody like Deborah comes into your office, she’s received some powerful educational information from her surgeon. How do you start processing that with the patient now post diagnosis and kind of comes to you with the idea of flap? But are you talking about all of the reconstruction options or share with us a little bit about how you and Deborah first met and what your process was with the patient?
Elisabeth Potter,MD: [00:11:16] Absolutely. I remember meeting Deborah for the first time. You can’t help but be drawn to her very positive energy, and she exuded that even in the face of a diagnosis of cancer. And I felt like I wanted to meet all of her expectations and deliver a beautiful breast reconstruction for her that was first safe. And then second in line with her goals as a breast reconstruction surgeon, I offer all options for breast reconstruction. I perform implant reconstructions. I perform flap closures. I do on capacity. And I do different types of flap procedures like the DIEP flap. I think it’s important for me in my own practice to offer all of those options so that I’m not directing a patient towards the surgery that I like. I am directing a patient towards an empowered position where they are making the best choice for themselves. I think in Deborah’s case, she was very interested in a natural breast reconstruction and on examination had just the beautiful donor site that I knew we could work and achieve a beautiful reconstruction with from her belly. I think that my approach to breast reconstruction has evolved over time. Not every woman wants to have a flap reconstruction and not every patient who walks through my door as a candidate. But every woman deserves to hear about her options to discuss with her team what her own personal desires are, what her risk tolerance is. That’s as individual for a patient as their fingerprint. How much? How much surgery do they want to have? How much risk are they willing to to take? Right? And then there’s my personality, and my personality is that I love natural breast reconstruction. I am here to offer it to women who are good candidates and want to have that. But it’s a process safety, first empowered education for patients. And then, of course, you know, surgeons like Dr. Tanna and myself are proud of our skills and are happy to deliver beautiful reconstructions when the patient chooses that.
Dana Donofree: [00:13:51] I love how you mentioned that there’s a platter of opportunities here because you’re absolutely right, it’s not only just a medical decision, it’s also a personal choice. And I think that it’s so awesome that you empower your patients back with that information that there’s an option to do something and there’s an option to do other things as well. And I applaud you for that conversation with your patients. So thank you so much for that. Next, I’d like to introduce Stacey. And just to get this out of the way. Happy birthday, Stacey. Thank you for joining us on your birthday.
Stacey: [00:14:25] Thank you. Appreciate it.
Dana Donofree: [00:14:27] Of course, Stacey was diagnosed in 2019 after finding a mass in a routine mammogram. It led to a stage two diagnosis, and later she found out that she was indeed BRCA2 positive. She’s a fitness enthusiast and loves hot yoga and wanted to pursue a natural reconstruction, but did not have the tissue required for a DIEP. So her and Dr. Tanna, went on a search for the best site to use for the recreation of her breasts. Her story is quite unique, and I’m excited to share her path through reconstruction. Thank you, Stacey, for joining us and also being so brave to share in your story.
Stacey: [00:15:05] Thank you so much for having me as well. So it really was quite the story. I mean, it all started the timing of the series on NBC Nightly News and Today Show about the textured implants causing that rare lymphoma A.L.C.L., which I believe Dr. Potter might have been interviewed on as well. One of the women happened to have had breast cancer that had these textured implants, and it scared me to think that I could potentially get sick again. And that’s when I started doing research. I found social media as a platform and learned about breast implant illness and the flap reconstruction as a natural, safe alternative.
Dana Donofree: [00:15:50] One hundred percent, I think that you came into this so educated and so informed, and you were actually diagnosed in January of twenty nineteen, right before the pandemic had all hit down. And I know that the world was was stressful and things were changing. And you know, you share a lot about being a fitness guru, right, and enjoying your hot yoga. How was your decision to come to a flap surgery? What did you personally weigh as you were viewing those options, both from a medical perspective, but also from a personal perspective?
Stacey: [00:16:27] So it was important that, you know, Dr. Tanna and I, we spent hours reviewing my abdominal scans looking for the perfect way to make me whole again. And we came up with this love handle area, flank area. And once I went back to working out and doing hot yoga again, it worked out really well because it didn’t impact my core.
Dana Donofree: [00:16:58] I love for you to share a little bit about how you discovered that you had this flank meat, right that we described earlier, like can you share a little bit about that story, how you approach Dr. Tanna with with this idea?
Stacey: [00:17:16] Sure. So we spent about two hours reviewing my abdominal scans, using a Doppler, listening to my blood vessels. They put little X’s. I almost look like he was doing football plays on me, and we came to the point where we almost gave up and we thought maybe implants might just be the only option. And I kind of just from exhaustion, just put my hands on my hips and sighed and I said, Hey, I got some meat here. Why don’t we look at this and we turn back to the scans again, and it was the perfect fit. He said it was just enough tissue and the blood vessels would work well.
Dana Donofree: [00:18:02] We’re going to tap into a little bit of that later, but before we do Dr. Tanna, I think Stacey’s experience leveraging social media and the community is a very real one that we all face today. Are you finding more patients are coming into your office questioning the efficacy and safety of breast implants? And how are you addressing that with those patients?
Neil Tanna, MD: [00:18:24] So we’re seeing more and more patients who are questioning the safety of breast implants or at least expressing their desire against them. What’s really important is that we respect patient preference. I would say what’s changed the most in the last decade with breast reconstruction is that the incorporation of patient preference is very paramount here. Traditionally, it was sort of their diagnosis and their anatomy that was driving their reconstructive options. And and now we can place an emphasis on preference. And so just the same way we can acknowledge that I like chocolate ice cream and my wife likes vanilla ice cream, respect each other’s opinions. We could say the same that one patient wants to have an implant reconstruction because they had previous breast augmentation. But the next patient may say, I don’t want that. I want nothing foreign in my body. And and we have to respect that. So we are seeing more and more patients who are expressing their desire to use their own tissue or otherwise stated to avoid an implant. And what we do is we as clinicians, share the advantages and the disadvantages, the pros and the cons. And the reality is is there’s pros and cons to both implants as well as your own tissue. And so the key is to educate patients on both. And we do it evidence based. It’s not anecdotal, it’s the science, it’s the data. Let it speak for itself. But at the end of the day, after you present all of that, if the patient still says, I want X, we respect that and we’re going to do our best. And ultimately, it’s patients like Stacey who inspire us to want to give them what they desire.
Dana Donofree: [00:20:09] Yeah, that’s so great, and I couldn’t have teed this up better because I think to add to this right, Stacey’s path through reconstruction was a bit of a disappointment based upon what she wanted and looking for this donor site that was going to do the right job or give her, yield her the right results. So, Dr. Potter, why don’t we pull that back a little bit and say, like, who are the best candidates for microsurgery? And are there limitations to who can and who can’t receive microsurgery?
Elisabeth Potter,MD: [00:20:38] I think that in considering who is a candidate for microsurgery in the last five or ten years, we have found out that so many more people are candidates than we maybe initially thought ten or fifteen years ago. I think that a woman who is healthy and is safe to undergo general anesthesia and has the anatomy to allow for transferring part of the body to the breast. There’s a candidate that can be a young woman that can be a woman who is more mature, that can be someone who is very active, who, you know, uses their muscles a lot, that can be someone who has had surgery on their belly or another part of their body before. I actually think that these days. I rarely meet someone who I don’t think it’s reasonable to discuss and consider and investigate a flap surgery option that also goes back to that that key concept of empowerment. I don’t think that I know enough about every woman when she walks in my door in the first few minutes that I meet her to be able to make the decision. Yes or no. You’re a candidate or not. I think I have to approach that discussion with an open mind. As Dr. Tanna said, considering patient preference, right, I want to present options and then have a conversation. Consider the science, and I find that so many women are interested in flap reconstruction and our candidates. I’d also say that when you’re facing cancer and you’re facing a mastectomy or mastectomies, so much is being taken away and so much is being dictated to the patient, you know, your chemotherapy needs to happen in this order and radiation. I love that in breast reconstruction, we introduce a component of agency for the patient choice. So I’m not saying you have to have an implant or a flap or a flap closure, I’m saying, you know what? Let’s have a discussion about what the future is going to hold. Where are you going to be in ten years? And what’s your body going to be like? And let’s plan for that. I think that’s a really positive part of this work that we do, and it keeps us all, you know, doing it better and making advances.
Dana Donofree: [00:23:19] Yeah, I love that, and I think that leads us right into Stacey’s story here, so Stacey, you had a complicated flap surgery. You had to have back fat removed and moved to the front. So tell me a little bit about how you and Dr. Tanna had those conversations about your surgery time, your recovery and things like that and how that helped you make your decisions.
Stacey: [00:23:43] Sure, there was definitely a lot of challenges. It was a very long surgery for sure, and fortunately being fit, I was able to be able to since I’ve been having compromised arm movements. Having your back now and your chest, you know, it was difficult to sit down, lying down just even basic things like opening up the refrigerator. I think the most important thing for me was that I had the support system at home helping me during the recovery time.
Dana Donofree: [00:24:24] So it’s recovery time a lot in these these flap cases, right, that are really important to the patients and an operating time. So Dr. Tanna, when you realize that the host site was going to be from her back, how did you express that to the patient? Can you give us any insight on on what should be considered from a patient’s perspective, either from longer surgery times or and or recovery time as well?
Neil Tanna, MD: [00:24:48] The DIEP flap is probably the most common form of, you know, free tissue transfer, natural tissue breast reconstruction. And that’s because, you know, a lot of women carry fat in that distribution just from having children. And, you know, men also carry it. But the reality is is that it lends itself nicely because you can have a mastectomy and the reconstruction done at the same intervention with patient positioning. So while the breast surgeon is working up top on the chest, the plastic surgeon can be working on the abdomen. So you’re you’re not losing any time operative type when we start looking at alternative donor sites or alternative flaps. So these are women who are not candidates for abdominal based flap reconstruction. Things outside of the donor site have to be taken into consideration, like patient positioning or what’s where’s the scar going to be? In Stacey’s case, the donor site is on the exact opposite side of the breast. And so it becomes very hard to do a mastectomy. It becomes impossible to do a mastectomy in and the the tissue harvest from the back, removing the harvest. The other consideration in Stacey’s case, or in anyone considering tissue from the love handle is that, we describe a flap is taking tissue from one area and transferring it over just like you’re taking the TV with a plug, unplugging, walking across. The back, the flank, the love handles, that that blood vessel is actually quite short. So that cord like TV cord is short. So you need to get an extension cord. So you need to actually take an extension cord or a separate blood vessel to hook up to the other blood vessels.
Neil Tanna, MD: [00:26:33] So it becomes, you know, a little bit of complicated plumbing. And so in Stacey’s case, we took those blood vessels from the armpit and then hook those up. So it becomes a lot, a lot of micro surgery and and that’s okay. That’s what we love to do. So in Stacey’s case, quite simply, we took the tissue from the back. Flipped her back over onto her, you know, stomach side up and then and then took the extension grafts from the armpit and then hooked everything up into the chest. So it’s a lot of surgery and it’s done safely and and it gives her the outcome that she wants. And so we tell Stacey that like anything in life, right, if it’s if it’s hard, it’s worth it. And so in the long term, this is what she wants. And in the short term, you know, yes, you’ll have a surgical site in the back, you’ll have a surgical site, you know, in the armpit. For taking this connection, you’ll be in the operating room for eight to ten hours. And, you know, four week recovery because yes, this is this is, flap surgery is a long surgery, but it’s when done in the appropriate place by the appropriate team. It’s extremely safe. And Dr. Potter is a micro surgeon and I’m a micro surgeon and and any micro surgeon is going to tackle this in a safe and efficient manner. So yes, we educate all of our patients that there is a donor site scar. There is a recovery, but like anything, it’s well worth it.
Dana Donofree: [00:28:06] And it’s really incredible, I mean, I’m just like, I totally geek out on this, which is super cool and and Deborah, just to throw this over to you a little bit, you know, you didn’t have a family history, you were sixty five years old running around with all of these grandchildren. You get diagnosed with breast cancer and you find out these options and you decide the DIEP flap. But like, you know, hearing all of this like little technical jargon, like how did you really step into making that decision? And did you know this surgery was going to be that complex?
Deborah: [00:28:37] I did not initially know it was going to be that complex. However, I felt like I got enough information from both my surgeon and Dr. Potter explaining to me, You know her her place in the operating room when I had the removal that she would be there to put in the expanders and after the the healing process that, you know, she would then come back and do the reconstruction. So, you know, I just felt really comfortable with her help there.
Dana Donofree: [00:29:13] And you talked a little bit, too, about making the decision for the DIEP flap and having the breasts and the stomach worked on, can you? Can you share a little bit about how you decided that the DIEP was the right host site for you?
Deborah: [00:29:26] I felt that the DIEP is going to be the right choice for me because it was the most natural of the options that was presented to me and I felt like, wow, if I have to go through this, I’m going to get a tummy tuck out of this too. And by the way, the cutest belly button I’ve ever seen. So, I thank Dr. Potter for that.
Dana Donofree: [00:29:47] That’s what I wanted. I love that you love your cute belly button. So, Dr. Potter, you know, when these patients are coming in with some sense of an idea that it’s going to be a flap surgery, but not necessarily understanding how the flap might work or where the donor site is, how do you walk your patients through making these really complicated decisions?
Elisabeth Potter,MD: [00:30:10] It’s a great question. When patients come and don’t have the background information to understand all of the details regarding flap surgery, I think we just pause and try to fill in the gaps. We show photos. We have a lot of photos available on our website. We have an amazing photographer, Geysha Soltero, here. Who is willing to sit down with patients and go through photos. I think just that visual is so powerful for patients. Once they see photos, they can imagine themselves there, and then that leads to questions, right? Just that visual example. Oh, is that where the scar will be? I often take out a marker and draw on a patient and say, This is where your scar is going to be. And we talk about different, different ways of performing breast reconstruction and in Deborah’s specific case we did a special procedure where we saved her nipple and lifted it. And so she got a breast lift first when we had our mastectomies and then came back and did the DIEP flap a couple of months later. And so we talk about those details and show photos. I think that that’s probably the best way for me to describe it. We also spend a lot of time talking about expectations and what your life is going to look like right after surgery and the hospital, what your positioning will be like. As Stacey said, like what, what are your limitations in terms of your arm movements and how much weight can you lift? We try to get as specific as possible, but honestly, I think it boils down to a feeling of trust between the team, me and my team and the patient, and just knowing that we’ve got all of these amazing skills and tools at our disposal and the best of intentions. And when we combine those things together, I think we sort of jump together, right? I’m always so honored when a patient trusts me to perform a surgery like this, and I think Deborah understood as much as she could understand and then trusted.
Dana Donofree: [00:32:22] That’s actually that’s a really beautiful way to describe that patient and physician relationship that gets built over many, many, many visits. Stacey, I would just love for you to touch upon your own recovery and how and how that was for you knowing that you sort of you had incisions that you needed to care on care for on the back and on the front. Anything unique to your recovery that you feel like you could share with somebody who might be considering that same procedure.
Stacey: [00:32:51] So actually, I think my recovery might have been slightly easier than the DIEP flap, only because I was able to lie down flap as opposed to laying down an inclined position. Fortunately, strong enough, I was able to use my legs and my thighs to get up and down without worrying about utilizing your arms or your core in the middle of the healing process. So it really helped a lot substantially. And it was just it just takes time, and my advice is just to be patient and to let your body heal, and it will comes.
Dana Donofree: [00:33:36] That’s beautifully said. Dr. Tanna we talked a little bit earlier about the length of time that’s required for recovery of microsurgery. What tips and tricks do you provide to your patients so they can really ensure a smooth recovery in that longer extended process of four or five or six weeks?
Neil Tanna, MD: [00:33:55] Patients who are considering flap surgery have to understand Yes, it is a longer surgery than the more conventional options and breast reconstruction like implants, and the recovery is a little bit longer. But it’s all state of mind. And so what we do is that we spend a lot of time with patients before surgery because the reality is is that the anxiety comes from the unknown. So if you can teach a patient about every step that is going to happen from the minute they walk in the hospital through the surgery, their recovery during the hospital and then after care, they are prepared and that’s going to come in two forms. The first is the surgeon and their care team in the office, right, that we are going to spend a lot of time. So a typical breast reconstruction patient, I will spend, you know, we’ll have four or five conversations on different settings before their surgery and that could be in the office. That could be on a cell phone call that can be on a Zoom call. But the other aspect is we try to match patients with other patients. And you know, when we surgeons like Dr. Potter and myself, when you do a high volume of flap reconstruction, there is this volume outcome relationship that the more you do, the better you are and you just have access to those patients. So we can actually nail down another patient who’s similar age, who is having a similar surgery. One side, both side donor site nerve reconstruction. No nerve reconstruction and repair that patient up. So tomorrow I’m seeing a patient who’s being referred to me for, you know, removal of implants and potentially a lumbar artery perforater flap. So if that’s the avenue, she will get Stacey’s contact info. And Stacey has talked to other patients because I can give the medical facts. But have I walked the walk and talk the talk for that? No, absolutely not. So it comes in two forms. It’s it’s the surgeon patient relationship and then the patient to patient relationship. And that advocacy is a huge part of our practice. And I would tell patients, considering flap surgery, ask to speak to another patient because they’re the ones that are going to give you that unfiltered, genuine sort of answer as to what it is, and we don’t want to hold anything back. You really want to know what you’re getting yourself into, because once you know you’re going to have no anxiety, you’re going to expect everything along the course. So that’s that’s sort of how we counsel our flap patients.
Dana Donofree: [00:36:21] Yeah and Deborah shared with me that she had such a positive recovery process, and it was partially because she expected the worst. Deborah, can you just touch on that a little bit like what your expectations were and how Dr. Potter’s team took care of easing some of those concerns for you?
Deborah: [00:36:41] Sure. Now I spoken with other individuals who had been diagnosed with breast cancer and some of the stories that they gave for just horror stories. But in talking with Dr. Potter and her team, they were able to put me more at ease, helping me understand the position that I was in and the surgery that I was about to undergo. I just feel like they the information they gave me kind of pushed out some of the old ideas about what breast cancer surgery was about. It really helped to push that out of my mind and gave me a more positive outlook on what I was facing.
Dana Donofree: [00:37:24] So, Dr. Potter, how does your team do that? I know you’ve got a few things that you can say here as well because you also have an all star team on your side.
Elisabeth Potter,MD: [00:37:31] I, I love this team. I mean, I just think that they have their hearts in it and they want every patient to be educated. They want women to feel possibilities and not feel like they’re being told what they can’t have. I think that that just a sense of partnership and a desire to sit down and have really thoughtful discussions with patients is is probably key here in my office. We always talk about the sister test and I think that sort of sums up, in two words, how we treat patients. What would you tell your sister before this surgery, knowing all the things that you know? And that’s how we educate our patients. We often say, Hey, I’m not God, it’s not going to be perfect, but I’m going to do my best. And if you have any questions, I’m here for you. I think I was taught not to say things like that to patients when I was initially trained, but that just resonates with me, and it’s been a good guiding principle for me and my team. What would you do for your family? And that’s what we do.
Dana Donofree: [00:38:48] I love that because I am I’m the big sister to a little sister and I and I know exactly what I would say to her, so I love the sister test. That’s a that’s a really beautiful way to do it. Deborah, if you could give your advice to anybody who’s considering a flap surgery, what would that advice be?
Deborah: [00:39:04] My best advice to anyone considering flap surgery is to understand all of the options that are available to you and then consider what’s best for your lifestyle, as well as getting to know and trust your surgeon. And I felt like that is what I did. I, I trusted Dr. Potter and her team from from the beginning, and they treated me like the Queen Mother. I so appreciate that. I just love them for it.
Dana Donofree: [00:39:31] And Stacey, what about you?
Stacey: [00:39:34] I would say very similar to what Deborah is saying, do your research, speak up, find a surgeon that will listen and work with you.
Dana Donofree: [00:39:46] I think it’s both great advice, and this is a great way back to you, Dr Potter. From a physician standpoint, what what would you share with a patient if they’re on the edge of going for an implant reconstruction versus a flap reconstruction?
Elisabeth Potter,MD: [00:40:01] That’s a great question. Many patients find themselves considering both implants and flap reconstruction. And I think it’s always important to allow a patient some space. I think if someone is sitting in front of me saying, I just don’t know what to do, then what I say is you don’t need to know in this moment. Let’s talk a little bit and let’s have you sit with that information and see what resonates with you and what doesn’t. I think that having a good conversation about risks and benefits and what can be done and undone and what can’t be undone is always important in my practice. If someone is not sure and we have a timeline where we have a cancer we’re dealing with and we we need to move forward, we often offer placing a tissue expander and that can be the first stage to a flap reconstruction or an implant reconstruction. I found that to be really helpful in my practice and something that my breast surgeons and I agree on. It allows us to treat the cancer first to prioritize getting negative margins, making sure our pathology doesn’t require us to do chemotherapy or radiation really quickly. And then once we have that peace of mind, of having all the information, sometimes that allows a woman to be in a place where they can more, more thoughtfully or in a less stressed way, consider their options. So I try not to make the decision for anybody, but I think giving someone space and offering that staged reconstruction can can help.
Dana Donofree: [00:41:50] One hundred percent, I love that because I, you know, as a patient advocate, we try to say not every decision needs to be made today. Some can be made tomorrow, and I think that’s a beautiful way to get that moment to breathe, to really actually consider what’s right for you and your body. So to follow that up, is there any long term considerations compared to an implant and or flap surgery that should be accounted for when patients are making the decision?
Elisabeth Potter,MD: [00:42:18] I think that long term implications exist for any surgery that you have, as the FDA has engaged more in the discussion about implant safety. I feel like patients have been empowered with more information about what does it mean to have an implant over time. Implants are safe, but it’s very important for women to know how to be informed and understand what the risks and benefits of implants are. I think the most important points that the FDA pointed out within 2019, 2020, and again just a few weeks ago are that implants are not lifetime devices that they need to be maintained over time. Implants can have complications like rupture or capsular contracture or infection. Implants and radiation may not mix, and your surgeon can discuss the specifics about your case with you. But radiated implants have a higher complication rate than un-radiated implants. And then there’s those two entities that Stacey alluded to earlier breast implant illness and breast implant associated lymphoma. So I think those are two. Those are kind of a checklist, if you will, of items that the the really solid surgeons want to share with their patients. Patients want to hear about and the FDA has told us that we need to be talking about. I think that with lap surgeries, there are long term implications for your body. There’s no scare-less surgery, you’re going to have a scar. And if scars are the bane of your existence, then flap surgery may not be for you. There’s always numbness around an area of a scar. Flap surgeries are longer surgeries and longer anesthesia means that your, your heart and your lungs have to deal with that surgery. So I think, you know, there’s there’s pluses and minuses on either side. And I can imagine myself choosing either type of reconstruction in different situations. It’s just a matter of what fits my lifestyle best at the moment. And what does that woman need?
Dana Donofree: [00:44:27] Well, Dr. Potter, I couldn’t have asked you to tee this up better for Dr. Tanna, because what I’d love to dove in with you, Dr. Tanna, is what is your perspective and what are the options to either address maybe an explant surgery due to BII or ALCL or potential infection or another complication? And or somebody who might be looking at a revision surgery once it is time to remove an implant because they aren’t lifetime devices, and maybe they’re twelve or fifteen years out of their initial breast cancer diagnosis. What are the options for those patients that were previously implanted that may be considering a flap? Is is that possible?
Neil Tanna, MD: [00:45:08] We’re seeing larger and larger numbers of patients who are considering breast implantation or removal of their implant. And you know, that’s a large discussion in itself, and it starts by first asking a patient, What’s the reason you want the implant removed? Do you feel like the implant is hard? What we call capsular contracture? Is there a rupture? Is it just your preference over time? You don’t want it? Do you feel like you have breast implant illness where you’re having these autoimmune symptoms, where your implant is causing you illness? Do you have concerns for lymphoma with the textured device? When you sort of delve into that, you can start asking a patient. Well, once that implant comes out, how do you want to manage that? Pocket that footprint and start talking about flap reconstruction? And absolutely, that is a huge area. And I think in the next five to ten years, it’s going to be greater and greater numbers of patients who are seeking explanation or implant removal and using a flap. The reality is, is that, you know, micro surgeries are getting better and better and the innovation is incredible. What we were doing two years ago, we’re not doing today, ultimately in a patient who’s seeking a revisionary procedure and if I can go even more pervasive than that and say a patient who seeking any type of, you know, autologous or natural flap reconstruction. Micro surgeons like Dr. Potter and myself have probably spent twelve to forteen years becoming a micro surgeon because we are enamored with the concept of transplanting tissue. It is the reason why I became a plastic surgeon, so there is nothing more that irritates me than when a patient has been told by another provider that they’re too old, they’re too sick, they’re too thin. Their insurance won’t cover it. They’re not allowed whatever host of reasons. And that that is unacceptable because every patient who has an implant reconstruction or thereby even a flap reconstruction is eligible to a visionary procedure. And the reality is, is that we have the skill set now and certainly the technology and the drive and the innovation to provide a result that a patient will be happy with. And I think that every patient should be, you know, do the research. No, is not an answer. We’re not going to settle for no. So they have that option for revision procedures.
Dana Donofree: [00:47:39] I love that. And to just dove into a tiny little bit more detail in regards to that. I think oftentimes a lot of patients can come into that conversation because they they are required and or need radiation therapy as a part of their cancer treatment. Is that a different consideration from an implant to a flap as well?
Neil Tanna, MD: [00:48:01] You know, I think that there are, you know, subtleties to consider in a patient who is getting radiation treatment. You know, you have patients who are getting implants and then going on to get radiation. So you know, you counsel them that their risk of complications with an implant goes up. Some may choose to forego an implant reconstruction and go on to a flap reconstruction, or some may say, no, I want to consider a I want to continue on the path with an implant reconstruction. We as providers again respect that choice and will modify the treatment plants. We may choose to put an expander or temporary implant first and then go on to a final implant. Alternatively, we have patients who say, You know what, I’ll proceed with the flap reconstruction and then go on, you know, lastly, there are patients who want to flap reconstruction may be small volume of donor site, and let’s put a temporary expander in before you go on to radiation just because you don’t want to damage that tissue that you do put. So there’s there’s so many ways that you can, so many ways you can go with radiation. The reality is it’s not an answer to forego any pathway of reconstruction. Every pathway is at place just about tailoring the timing and the course of treatment to that individual patient.
Dana Donofree: [00:49:18] Well, I think what I’m taking away from this is that microsurgery is constantly evolving, and I really dare I say, cutting edge wink. But there is this reality like you guys are learning and you’re figuring it out in so many different minute details that are like just expanding the possibilities and the potential of what these patients can see in the future. And I, you know, as an advocate and activist myself and as a patient, thank you both for all of the hard work that you are putting in to improve and our lives after breast cancer and and or trying to prevent one from ever occurring. And I just, you know, on behalf of the entire community, your work has not gone unnoticed and I’m excited to see what comes in the years ahead. So as we wrap up here, I’d love to just do a quick little speed round on a few words of advice and Dr. Potter to you first. If there was one thing you could share that you wish you knew or that you wish that patients knew before they came in for surgery, what what would that be?
Elisabeth Potter,MD: [00:50:22] The one piece of advice that I would share with any patient who comes to see me or is facing breast cancer, considering considering breast reconstruction is that we don’t always control what happens to us, but we control how we respond. And that’s where we find our power. So, you know, here, here we are with cancer, how are we going to respond? And I love being kind of reframing the discussion into that position of power.
Dana Donofree: [00:50:58] Love that. Dr Tanna, what about yourself?
Neil Tanna, MD: [00:51:03] Yeah, I think you know what I would tell any prospective patient who’s considering breast reconstruction. You know, after mastectomy anywhere in the United States or for the world, I think just do your research. Do your homework. Educate yourself. Empower yourself. And when you meet that surgeon, you will know if they’re the one that’s going to take care of you. You’re going to know if they’re the one that’s going to answer the phone at two in the morning, or they’re the ones that are going to be passionate about finding you the solution that fits your needs. And if you do that, then you are well prepared and the outcome will be positive because it is it’s almost fifty percent surgery and fifty percent state of mind, and we got to treat both right. We’re not just treating breasts or breast cancer, we’re taking care of people here. So I think that’s the most important thing is is do your homework and empower yourself.
Dana Donofree: [00:51:59] Amazing. So Deborah, what about yourself? What was one thing that you found out after your surgery that you wish you knew before your surgery?
Deborah: [00:52:08] We just have to say that life can be better and healthier after receiving a breast cancer diagnosis.
Dana Donofree: [00:52:17] That’s beautiful. Stacey, what about yourself?
Stacey: [00:52:22] I would just say to be patient, give you a chance. Give yourself time for your body to heal and have a support system at home to be there with you mentally, physically and emotionally.
Dana Donofree: [00:52:38] Absolutely, absolutely. Well, on behalf of the ASPS, Dr. Tanna Dr. Potter, thank you so much for being here, supporting the patient population and clientele, and a special thank you to both Deborah and Stacey for both being brave and courageous and sharing their stories today, both with their recovery and their cancer diagnosis. So thank you all for being with us today. And I appreciate your time.
Neil Tanna, MD: [00:53:04] Thanks, everyone.
Stacey: [00:53:05] Thank you.
To learn more about DIEP flap surgery recovery time, what to expect after breast reconstruction and options for breast reconstruction, send us an email. We’re happy to answer any questions you might have. To connect with other women who have had, plan to have or are considering breast reconstruction surgery, Dr. Potter’s Breast Reconstruction And Virtual Empowerment (BRAVE) Facebook Group is available to join and we also have a list of resources that may be helpful.
