This Breastcancer.org podcast focuses on breast reconstruction and features Frank DellaCroce, M.D., F.A.C.S., cofounder of the Center for Restorative Breast Surgery and the St. Charles Surgical Hospital. Dr. DellaCroce is board certified in plastic and reconstructive surgery, and his pioneering work in microsurgery has made the Center for Restorative Breast Surgery an international leader in the art and science of breast reconstruction. He has performed thousands of breast reconstructions on women from around the world. Listen to the podcast to hear Dr. DellaCroce discuss:
- the advances in reconstruction that have happened in the past decade
- what microsurgery is and why it’s so specialized
- the most popular breast reconstruction options
- how he assesses a breast reconstruction that a woman is unhappy with
Running time: 34:52
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Show Full Transcript
Jamie DePolo: Hello, everybody. Welcome to the latest edition of the Breastcancer.org podcast. My name is Jamie DePolo. I’m the senior editor here at Breastcancer.org and we have a very special guest today for our podcast.
It’s Dr. Frank DellaCroce, who is cofounder of the Center for Restorative Breast Surgery and the St. Charles Surgical Hospital. He is board certified in plastic and reconstructive surgery, and his pioneering work in microsurgery has made the Center for Restorative Breast Surgery an international leader in the art and the science of breast reconstruction. He has performed thousands of breast reconstructions on women from around the world. Dr. DellaCroce, welcome to the Breastcancer.org podcast. It’s a pleasure to have you here today.
Dr. Frank DellaCroce: Thank you for having me. It’s a pleasure being with you.
Jamie DePolo: So, to start, obviously this podcast is going to be about breast reconstruction. And I know many, many things have changed, been learned. What would you say are some of the top things we’ve learned about breast reconstruction in the last decade?
Dr. Frank DellaCroce: Well, it’s all good news. That really is the takeaway in where we are in the world of breast reconstruction now in 2014. Our listeners can take great comfort in knowing that plastic surgeons and breast surgical oncologists and breast surgeons of all varieties have worked very hard over the last 10 to 20 years to improve outcomes, to make recovery shorter, to allow these types of operations to fit in our busy lifestyles. So, there have been many very important advances.
A few basic points in that regard are that we’ve learned that the best outcomes start with a cohesive team. And that team includes the oncologist, it includes the radiotherapist, it includes the mastectomy surgeon, and it has to include the plastic surgeons on the front end as well. We know that we need to begin our planning when we’re talking about a mastectomy from that first decision. And so the ultimate goal when we think like that is to move from a reconstruction where there is just a filler for clothing and to provide balance with the opposing breast to an outcome that is aesthetically and artistically beautiful.
So, that’s some of what we’ve learned about in the last decade, and those are some of the outcomes that have evolved from it. We additionally know now that we can take tissue from another part of the body and still preserve function in the donor site. We’ve learned that the donor site itself, when we’re talking about a flap-type operation, is as important as the breast reconstruction itself, if not sometimes even more important.
We’ve learned that we can preserve the nipple in a great number of instances when we’re performing a mastectomy. Nipple-sparing mastectomy is an evolving science. There’s been great progress in that, and some of the early studies shows that it can be safe in a great number of circumstances when we’re talking about an ordinary mastectomy.
We’ve learned that silicone implants aren’t dangerous. We’ve learned that the manufacturers are working very hard to provide products that are more durable, that last longer, that provide a better look and outcome. We know now that we can produce results with implants and with flaps that sometimes mimic Mother Nature so closely that in an unclothed state, no one would be the wiser.
But it has to start, as I mentioned, from the very first incision with a cohesive team that communicates with one another on a regular basis about each case to provide proper choice in terms of the modality, and to communicate and collaborate with respect to the anticipated course of therapy and the time for reconstruction. Often immediate reconstruction provides a better outcome. We’ve learned that that’s applicable in almost every situation. We’ve learned that immediate reconstruction with flaps in particular can help mitigate the risk for lymphedema. So, we have a lot of things that we work very hard to develop. And we just have to do a better job getting the information out to the women who need our services.
Jamie DePolo: Okay. You were talking about flap surgery, and I know a lot of that is done with microsurgery. Now, until a woman needs reconstruction, probably it’s unlikely that most people have heard of microsurgery. And can you explain to us a little bit what that is and why it’s so specialized? And I know on our site we sort of recommend to people that you talk to your potential surgeons and you make sure that he or she has a lot of experience with that technique, because it does require somebody who has quite a bit of experience.
Dr. Frank DellaCroce: True. Microsurgery, when boiled down to its simplest common denominator, is a way for plastic surgeons to move tissue from one part of your body to another. And it is, in its essence, a transplant operation. Only instead of borrowing tissue from a separate donor, we’re borrowing tissue from a different spot in your own body. And to facilitate that transplant, we have to collect that tissue whether it be fat, fat and skin, or any other kind of tissue, for that matter, in a way that it brings its own blood supply to the area that we’re moving it to.
And to do that, in the case of breast reconstruction, we collect the skin and fat, whether it be from the tummy or the hip area or sometimes the back. We collect that tissue by dissecting it away from its donor site and bringing with it the little blood vessels that enter its undersurface, and then we’re able to move that tissue, connect those blood vessels into the spot where we’re recreating the breast, and it has its own blood flow. It has its own life force. It has its own vitality.
To accomplish that, we have to use microsurgery. Microsurgery just means small surgery. And the reason it’s small and requires microscopes and special magnifying loupes and things of that sort is because the blood vessels that feed and nourish the tissue we’re moving are very tiny. And so to dissect them and to bring them out without harming them, we have to use special instruments. We have to use special lighting, special magnification, whether it be microscope or other, so that we can collect that tissue, its little tiny blood vessels, separate it away from the donor site, close the donor site incision, and bring that composite tissue into the area where we’re recreating the new breast, and then manually connect the blood vessels that are associated with the tissue to blood vessels in the donor site. It requires tiny sutures about the caliber of a spider web.
And so that’s where the word microsurgery comes in. It’s kind of a fancy word, and it’s just a tool at the end of the day. But the reason it’s so specialized is primarily because of that. Specialized instruments, specialized magnification, specialized training, and a very delicate, experienced hand that allows those blood vessels to be collected without damaging them, without breaking into them, without squeezing them and producing a tendency towards making a clot, without cutting branches that we need to facilitate the blood flow to the flap.
And as a general rule that requires hundreds if not thousands of operations to perfect. And so there are fewer doctors out there who have gone down that road in terms of training and experience level and basic technical skills than there are who have elected to perform operations that are not quite so technically complex and not quite so technically sophisticated.
It’s a little bit like the analogy of craniofacial surgery or cleft lip and palate surgery to any other kind of surgery. It requires a dedicated team that does that every day to carry it out well and to produce a nice-looking repair of an infant’s lip and things of that nature. So that’s why it’s specialized, a couple of different reasons that it is something that isn’t for the occasional operator. But, in a center where many of these operations are performed and an expert team is on hand, it’s a tremendously powerful technical procedure that can deliver outcomes that are otherwise sometimes unachievable. The ability to move fat and tissue around with complete freedom and liberty is a very significant accomplishment in terms of medical technology. And, again, we just haven’t done a very good job educating the public with respect to what that is about and what it can do and when it is most appropriate.
Jamie DePolo: From your viewpoint, given all the reconstructions you’ve done, what is the most popular type of breast reconstruction surgery right now, and why do you think that is?
Dr. Frank DellaCroce: It dovetails right from the question you just asked. The most popular reconstructive procedure is, by far, implant reconstruction. It doesn’t require a specialized team. It doesn’t require years of specialized training, years of — over and over, thousands of case experience levels. It’s an operation that any graduate plastic surgeon from a residency program should be well-tooled to do in any community setting, anywhere in the nation or the world, for that matter.
And so, that is part of the reason that implant reconstructions outweigh flap reconstructions by nearly 5 times. We know that there were 91,000 breast reconstructive operations in the last year. We know that 71,000 of those were implant operations. There were only 13,000 flap operations. We also know that there almost 17,000 implant removals. So simpler is not always better. Implants are devices, and implants are subject to wear and tear. Implants develop capsular contracture. Implants sometimes break through incisions, sometimes they get infected.
But as a general layperson’s concept, it’s easy to get your mind around the breast implants. It’s a simple concept, and so it has appeal on the consumer side as well, because there’s not an incision somewhere else in the body. They know someone who had implants for any one of a different set of reasons. So there’s a certain bit of appeal there. It’s often conceptualized as a shorter operation, a shorter recovery. Implant operations take a couple hours to do, and you’re in the hospital a night or so. Flap operations take 5 to 7 hours to do, and you may be in the hospital for 2 or 3 nights.
I tell women that those things won’t really help you decide. Those aren’t deal breakers or deal makers. What you need to think about is, is this the proper procedure for me. What you’ll find in the plastic surgery community, all surgical communities, all of medicine in fact, is that there always will be some biases within the provider. So if they are very good at any one of a different set of things, they often will encourage patients to consider that thing because in their hands that will often provide a reliable and predictable result. It doesn’t always mean it’s the best choice for the case at hand. And so the fact that implants outweigh flaps by that much tells me that we have a little work to do with respect to educating folks, surgeons and patients and anyone who would refer to a plastic surgeon, when one of the others is maybe a more proper choice. Don’t try to fit the patient to the operation, fit the operation to the patient.
Jamie DePolo: Okay. I know you talked about some of the things that can go wrong with implants. I know that you correct reconstructions that women may be unhappy with. I’m wondering, how do you assess that, or how should a woman assess that, and then how do you decide what to do?
Dr. Frank DellaCroce: Right. So, that’s a tremendously interesting question. We know that there are 300,000 breast cancers diagnosed every year. We know that there are some 2.5 million women living in the United States post cancer treatment. And we know, I know from experience, that a great number of those women have unsatisfactory outcomes with respect to their breast reconstructions.
How do we know that the reconstruction is unsatisfactory? Well, it comes from the person who is living with the reconstruction. Are they happy with it? Is it beautiful? Are they happy when they step out of the shower in the morning? Are they comfortable when they’re intimate with their partner? Are they in chronic pain? Do they have imbalance? Is one breast wildly different than the other? Symmetry is 90% of the game when we talk about reconstruction.
And so the crux of the question is, how do we assess when someone is not happy or their reconstruction is insufficient or inadequate? When the patient tells us they’re not happy with it. And then they define their reasons. And if their reasons meet the measure of the mark with respect to something that we can do something about, then we may have something we can offer to make it better. Oftentimes that’s the case.
But women often don’t have ready access to the information to know what could be done. And so there are thousands of women living in the United States with either overt disfigurement after reconstruction, chronic pain, imbalance, or a result that is far from what it could be. And so yes, probably half of what I do now are corrective operations for women who had a result from one variety of operation or another in the past that just hasn’t met the measure of the mark.
And so when we see someone like that, that’s a more complicated patient to take care of. It’s always best to get it right the first time when we have a blank palette and we can paint the painting out of what we chose. That’s a lot easier than erasing and trying to apply marks over what’s been created already. And so to offer a meaningful opportunity for improvement in women like this, it’s important that the surgeon who is taking care of them — and this is sort of the unique thing in our practice at least relative to our region — the surgeon taking care of them has to have every tool available in their toolbox when it comes to, “What can we do to make it better?” They have to be an expert at implant reconstruction. They have to be an expert in using acellular dermal matrix. They have to be an expert at every kind of flap, be it latissimus flap, gluteal flap, perforator flap, TRAM flap, minor skin flaps, you name it. If you have every tool, fat injection, and the whole gamut at your disposal, then you can look at this situation and you can begin to apply the individual tool that best gives an opportunity to improve it.
Jamie DePolo: I’m curious, too, I know you said that many more implant reconstructions are done than flap or autologous reconstructions. My guess would be that you’ve corrected all kinds of reconstructions? Do you also sometimes correct lumpectomy? Does that ever happen? Or is it pretty much just for mastectomy?
Dr. Frank DellaCroce: No. We correct lumpectomy, we correct women with Poland syndrome. [Editor’s Note: Poland syndrome is not related to breast cancer. It is a disorder in which affected individuals are born with missing or abnormal muscles on one side of the chest wall. Breast and nipple development may also be affected.] We correct bad implant outcomes, we correct failed flap outcomes. Lumpectomy in particular is an evolving specialty within a specialty. Sometimes that requires a simple flap turned on a small blood vessel to fill in a defect or a divot in the area where the lumpectomy and/or radiation was performed.
Very often after lumpectomy, radiation — it’s written about as a breast-conserving operation, but we know on the back end, being in the plastic surgery arena, that lumpectomy and radiation protocols often produce a breast with a divot in it, a breast with a retracted, distorted nipple, a breast that’s shrunken compared to the opposing side. So lumpectomy in and of itself is not always terrific in terms of the “conservative” idea, breast conservation, breast preservation. In some cases, removing the breast may be side-stepping the need for radiation by acquiring clear margins and negative node sampling and a straight, immediate implant — or even flap reconstruction can produce a better outcome than a lumpectomy and radiation. We don’t talk about that very much.
So, the correction of lumpectomy and things of that nature are on a case-by-case basis. Sometimes, as I mentioned, it requires a very simple little flap. Sometimes fat injection can be offered. We have to be careful with that when we’re fat-injecting an irradiated field. Fat injections require robust vascularity to work well, radiation tends to reduce that.
Jamie DePolo: I’m sorry, I don’t mean to interrupt, but when you say robust vascularity, I assume you mean it needs to have a good blood supply?
Dr. Frank DellaCroce: Yes, exactly. So when we apply fat injections we need to put it into an area that has strong blood supply. Because they’re just little drops of fat, and if you don’t have a ready blood supply in the area that you inject it, it will just die, melt away, and resorb or drain or get infected. So, radiated fields are more complicated in that regard, because radiation tends to reduce blood supply to the area that it’s been applied to.
Jamie DePolo: Okay. And kind of following along with that, you touched on this a little bit, but I’m wondering if you have more details. Are there long-term side effects from reconstruction that isn’t done well? And I know you mentioned a few of them, but how can those be addressed? How do you address those issues?
Dr. Frank DellaCroce: Okay, so long-term side effects, there are so many ways to talk about that question we could take up six of these podcasts…
Jamie DePolo: All right, then you have to promise that you’ll come back, and we’ll specifically focus on that.
Dr. Frank DellaCroce: Sure. So, long-term side effects from reconstruction that’s done poorly. More often than not it’s imbalance, it’s asymmetry, or chronic pain. Let’s talk about implant reconstruction for just a moment. We know that capsular contracture is a very common side effect or follow-up effect after implant reconstructions, upwards of 30% or so. If we apply radiation to the implant-reconstructed breast it’s nearly 100%.
So, capsular contracture is a tendency for your body to make scar tissue around a device. And in the context of implant reconstruction it’s the implant and the capsule is scar tissue, and it tends to tighten around the implant, produce a breast that is higher, rounder, sometimes overtly distorted, and often chronically painful.
Jamie DePolo: Because it’s so tight.
Dr. Frank DellaCroce: Right. So chronic pain can be a long term side effect from implant reconstruction with capsular contracture. Weakness. We try to get away from TRAM flap operations in as much as we’re able in a practical sense within the world of plastic surgery, because we know that when a TRAM is done and we take all of the muscle out of the abdominal wall that there is going to be a price to pay for that. That muscle is there for a reason. And so with operations that sacrifice muscle tissue, be it a TRAM flap, a latissimus flap, or any other operation that doesn’t just bring skin and fat but brings muscle along to the party, we have to think about the donor site. So long-term side effects from an operation — that was performed poorly or perfectly — that takes muscle tissue can be weakness, hernia formation in the abdomen, bulges and contour irregularities in the tummy donor site. There is a study that just came out last month finally giving a consensus statement about latissimus flap and that yes, low and behold, it does produce some weakness in the arm after you do it.
Jamie DePolo: That would make sense.
Dr. Frank DellaCroce: In our community we sort of talk like, “No, you’ll get along fine with it, you don’t need to necessarily worry about that.” But that is a huge muscle in your back. Again, it’s there for a reason, so we have to think about that. If we educate women on the front end, they can make informed choices that make sense for them. It may help them to avoid these complications.
You know that in the context of reconstruction, there is a very powerful thing called intellectual leverage. And so when you talk to me, or you talk to any other expert, and if I have a bias built in, I can lead you down a road that helps you, or encourages you, to choose what I want you to choose. You have to be careful of that. People need to know about intellectual leverage, need to recognize it when they see it, and need to do their own homework. And we need to know that not every surgeon is the same. And that experience breeds better outcomes.
There’s a recent article that came out, it was from CNN. Doctor out of Detroit. Looked at complication rates and things of that sort, bad outcomes, and what are they about? All doctors with degrees, things of that sort, should be, in terms of popular perception, equal. We all have credentials, we all have diplomas on the wall, so why are there differences in outcome? Bad outcomes, great outcomes, and everything in between? And they looked at hernia operations, and they found that doctors who perform 600 or more of those in a year had around a 1% recurrence rate compared to the 10-15% average. And that 15% of the total number of operations performed by a lesser experienced group produced 32% of the overall complications. What does that tell us? That tells us there’s a human element.
And so to give yourself the best, there’s no clearing house. There’s not completely objective information source. Breastcancer.org is doing a tremendous service to the community by hosting podcasts like this, by the voluminous information that is deep inside your website, but there is otherwise very few, in terms of resources, for women to go and say, “Okay, let me look at my doctor. Let me see, what is he about?” Ask to talk to patients who have had operations by the same provider. Do your homework. Get on the Internet, look around, Google things, realize that there are jacks of all trades and masters of none out there. And then there are overt masters.
There’s a terrific book, I can give you a reading list. If you ever want to read a great book about mastery, Robert Green has written a terrific book about that. Malcolm Gladwell has written a terrific book about that called Outliers. It’s the 10,000 hours thing. It’s the violinist who practices for 10,000 hours and then is suddenly regarded as a genius. It’s the time you don’t see Tiger Woods on the driving range that gets lost when you watch the wonderment of his golfing ability. And the same thing applies to surgery.
So, think about that when you’re choosing your doctor. Think about that when you’re taking in a set of recommendations. You have to be your own advocate today, you just do. And you have a great resource, the Internet is a terrific resource. And women who had treatment within the same center, under the same care provider, are an even better resource, so seek them out when you can.
Jamie DePolo: Along those lines, would you recommend that a woman talk to several different plastic surgeons and see what that person’s specialty, or sort of intellectual bias, might be before making a decision? Does that make sense?
Dr. Frank DellaCroce: Absolutely. Now here’s the qualifier. Very often in the hurricane that is a diagnosis of breast cancer, you can get lost. You get lost in the multitudes of opinions, family, professionals, TV, media, magazines, Internet. You get lost in the turmoil that is a life-threatening diagnosis. It all can become a whirlwind where you just say, “You know what, I just want to have the mastectomy done and the treatment done, and I’ll think about reconstruction later on.” Whenever I see that — and I’ll see that next week in the clinic. It’s an almost all-the-time thing. So you have to reel people back in and say, “Hold on, before we make a decision, let’s think about things. Let’s consider multiple opinions, let’s boil it down to its simplest common denominators.” I always encourage multiple opinions because, again, the human element almost mandates a consensus.
That’s why in the first question we talked about a team. We talked about a collaborative team that talks back and forth. Even within individual plastic surgeons there are going to be different opinions, and you have to ask, “Well, why do you recommend that for me?” And if the answer doesn’t make sense, that’s okay. It just means that you need to go and get another opinion. You’ll know, your little voice will always tell you when you’re getting information that makes sense and seems focused on your best interest as opposed to any other secondary things that might be out there. Multiple opinions, do your own homework, try not to get lost in the turmoil and the hurricane that is the diagnosis. Do yourself a service by taking a time out, no matter how long that takes, an hour, a day, a week or two, it’s not a 911 emergency. You’ve got time to think, you’ve got time to make decisions. Be sure you don’t do a disservice for yourself by making a decision that produces regret after the fact, because you’ll live with that for life. Whereas the recovery of an operation that requires borrowing of tissue from your tummy or whatever else to produce your reconstruction is just a short window of time relative to the big picture. And taking that into account on the front end can often produce a lifetime of satisfaction and happiness with the outcome and an overtly positive experience.
I have a unique place in the breast cancer treatment world. I get to live on the encouraging side. I get to live on the reassuring side. I get to live on the side that is rebuilding, that is producing beauty, that is pushing cancer and its devastating effects back into the box a little bit. Giving women opportunity to feel uninjured, to feel healed, to feel whole. I love being in that place, and I take it very seriously. And I think that we just have to do a better job communicating to make women aware of what can be done with modern surgery.
We are far more sophisticated than just about everybody realizes. The ability to transplant tissue, the ability to create a breast on the day of mastectomy. One of the greatest benefits of immediate reconstruction, and I hear this over and over and over again, “I woke up from surgery and I didn’t feel like I lost my breasts.”
Jamie DePolo: I do want to go back to where you were saying that women should take their time, gather the information, make a decision. Because one thing that occurs to me now with the option for immediate reconstruction and gathering this team, which now would include a plastic surgeon — in the past, it always seemed like reconstruction came later. And you could make that decision later, and so you had to make your decisions about treatment, about what kind of surgery, lumpectomy, mastectomy — and now it’s kind of pulling reconstruction in so you’re making yet another decision up front. But I really like what you said, that yes, there is time. So I just want to reiterate that, too, and have you say that again, that it’s nothing that needs to be rushed. There is time. Yes, cancer is a life-threatening disease and can very well be, but there is time to make the treatment decision that is going to be right for you and your individual situation.
Dr. Frank DellaCroce: Absolutely. If there is any big takeaway message from our time together today it’s that. You need to be your own advocate, you need to take a time-out. Don’t necessarily follow along with advice that doesn’t make sense to you. Seek multiple opinions. If it means you have to travel out of your hometown to get it, do it. Again, this will be a small window of time. Your treatment overall compared to the rest of your life, living with the decisions that you’ve made. And the truth is that with modern technology, almost every single time we can produce a lovely outcome, a beautiful result is a life-long thing. It’s important for women not to get swept into that mental and emotional turmoil, even though it’s almost unavoidable, just give yourself a moment.
Jamie DePolo: Take a breath.
Dr. Frank DellaCroce: Take a deep breath. Sit in a quiet space. Go out and take a walk in the park, whatever it takes to recollect yourself, and then come back to the table and analyze things and make sure that what you’re hearing makes sense. Also, remember that we have built into our own psychology — me, you, and everyone listening — something called confirmation bias. And confirmation bias is, we tend to seek out advice and opinions that agree with what we already think inside. So, when we hear someone say something that we kind of already agree with anyway, we tend to agree with them almost instantly. When we hear take the opposing opinion, that doesn’t necessarily agree with what would be termed our preconceived notions, it’s sometimes harder to take in and sometimes we don’t hear it, and sometimes we don’t listen carefully enough.
Jamie DePolo: Well, especially if you’re upset because you’ve just been diagnosed with cancer. So it’s hard to take in a lot of things.
Dr. Frank DellaCroce: Exactly. So give yourself the service of time. Give yourself the service of even calling different offices. You can often do a communication with a surgeon or a caretaker just by phone. There are many surgeons and caretakers who are very willing to do things like that. Sometimes face-to-face is better. Looking someone in the eye is the beginning of a relationship.
And so I value women who take the moment to come down, go to all the trouble to fly to New Orleans, to meet me, and it gives me the opportunity to sit with them and to kind of read where they are, and to break things down for them. And then to go into the exam room and let them help me show what we can do. Look in the mirror together, “Where do we want to go with this. Here are the six different things we can do. Here are the top three. I’ll rank them for you, now you tell me what you prefer, and let’s see if we can come up with a recipe that you and I work together to create.” I tend not to be… modern physicians, I hope, are moving towards a separation from that dogmatic god-like expert in the white coat, “It is how I say it is, here is your protocol, have a nice day.”
I hope that we are getting better in terms of the way we talk to people and realize that this is important, and it demands the same level of attention that any terrifically important decision in your life mandates. And we as surgeons and caretakers, we can help.
Jamie DePolo: Absolutely, absolutely. Dr. DellaCroce, thank you so much for joining us today. There are probably 500 more questions I would like to ask you, but we just don’t have the time right now. You do have to promise me that you will come back and be a guest again, and we can focus on some very specific topics, because I’m sure our listeners would love to hear more from you.
Dr. Frank DellaCroce: Absolutely, Jamie, thank you so much for having me.
Jamie DePolo: Thank you.
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