“I Wish I’d Known”
“Dr. D” speaks on what you need to know to make an empowered and informed decision for breast reconstruction with a comprehensive review of the pioneering work our Center is known for.
Dr. D’s Mastectomy Rule of 3’s and Why Details Matter
Dr. Dellacroce (00:19):
Basic truths that seem obvious, but it’s surprising how easy it is to get lost in the sea of information and conflicting opinions when it comes to making decisions about our health.
But some truths are constant. Details do matter, and the first steps in your care journey are often the most important and most impactful medical professionals know this, and our friends and families have the special advantage of direct access to this kind of insider information starting now. So do you. Hi, I’m Dr. D, and I wanna share with you the number one thing that I would change today about breast cancer treatment across the board and the things we’re doing to march towards better outcomes for you. So what is it? What is it that makes everything harder when it comes to post mastectomy breast reconstruction? Well, it goes all the way back to 1894 when Dr. Halstead revolutionized the treatment of breast cancer with the first mastectomy. His approach was called radical, but he did push for progress in the field. Since then, breast cancer treatment has evolved in nearly every way from genetic testing to dramatic leaps forward in plastic and reconstructive surgery. Nothing is the same as it was 100 years ago, except for one thing, The football shaped side to side transverse across the breast, parallel to the floor incision design that removes the breast in a wedge
Bad because it takes away the tip of the breast and flattens it into a permanent and irreversible dome. This leaves an empty space in your bra and complicates clothing options for all the obvious reasons. But the good news is it’s completely avoidable. I really don’t. Maybe folks just get used to doing things a certain way. Maybe it’s a lapse of logic or a failure to apply art to the science of the treatment plan. I don’t know. But what I do know is that you can’t afford to allow yourself to be overwhelmed in the moment that matters most, and you mustn’t let yourself get swept away by it all. If you feel that happening, stop, breathe, and take one step at a time because knowledge is power and it’s simpler than you might think. So listen closely and let’s break it down with my rule of threes.
First, we start with the three situations where the transverse ellipse parallel to the floor across the breast. Flattening incision design may be reasonable to consider, number one, when you have made a personal decision not to have breast reconstruction at all. Number two, if you have very advanced disease and reconstruction isn’t advised early on. And number three, if after doing all your homework, you’re still unsure about having reconstruction and wanna put that decision off till later, understanding that you will lose the advantages of look and touch sensation that are enhanced when we carefully preserve your outer breast skin.
The second part of my rule of threes is how the art of modern mastectomy incision planning overcomes the 100 year old problem. Here they are in no particular order. These designs can be used for all breast sizes, all breast shapes, and they can be applied to all situations. Whether we are treating active disease or performing preventive mastectomies for our high risk patients, they work for implant placement and when we’re rebuilding the breast with natural living tissue all on the same day of your mastectomy, otherwise known as immediate reconstruction, let’s look at them one by one. First is the side incision. It can be used for compact breasts. Breasts that aren’t saggy nice because it’s hidden away from the midline and can’t be seen in even the lowest cut garments. It can be used for nipple sparing as well as non nipple sparing procedures. Number two, the vertical or lift incision. I use this one for women with large breasts and those with a sag shape. It allows me to lift the nipple position and reshape the overall breast, and it also works for nipple sparring and non nipple sparing plans. Side note, this design can do some incredible things for women with even the largest breasts. I wrote a paper about it a while back, and you can check that out here later if you like.
Finally, the underneath or fold incision used for women with moderate size and is particularly appealing because we can hide the incision completely. It’s generally only for women who are having nipple preserving surgery, and it can leave the breast with an untouched look.
So that’s it. Our goals are to hide, incisions, reduce or eliminate scarring, preserve, and even enhance shape. Yes, you can usually keep your own nipple, and we don’t cut away skin unnecessarily to place islands, patches, or paddles as they’re called when doing natural tissue reconstruction. I see this all the time in women who come to see me from outside and it detracts from the result. The only exception to that is when tumors are close to the skin requiring substantial excisions to deliver safe margins, which fortunately isn’t too common anymore with early detection. Remember my rule of threes and that your final outcome begins at the beginning with the first brush stroke. I want you to be encouraged. You’re now armed with knowledge, so be your own advocate. Seek a second opinion if you need to. There’s no reason to live 100 years in the past and early decisions are important. When all things come together and the best of modern techniques are combined with an experienced team, your opportunity for a quality outcome increases greatly. The sun will come up. Don’t forget that. The goal ultimately is to choose best care first. I’ll say that again. Best care first, so that you enjoy a result that mirrors progress and you get back to being you.
My hope is that this gives you a strong foundation of understanding. Remember, not every situation is the same, and the skillset and experience of every team is different. Consult with your personal physician for individual advice and care planning. Until next time, I’m Dr. D. Take care.
Dr. D Introduces APEX Breast Reconstruction and Why the DIEP Flap Isn’t Enough
Dr. Dellacroce (00:15):
Breast cancer care and breast reconstruction is what we do. And today I’m very pleased to announce the publication of our latest advancement that helps it all work better for you. Hi, I’m Dr. D and I’m about to share something with you that we’ve been working on for a very long time, Perhaps more important than ever. With recent headlines about breast implant safety, we set out to do some serious myth busting and along the way reinvented a 25 year old operation called The DIEP Flap. Our purpose was to dive into the little known flaws of older procedures, raise the bar and establish a long overdue standard for work in this area. The result of all this produce a new innovation that helps us better deliver the quality patients expect when they choose breast reconstruction with natural living fat. Hot off the presses, we call it the APEX flap.
This advancement builds on a well known breast reconstruction operation called the DIEP Flap. It’s been around for a quarter century and was supposed to help us recreate new living breasts from extra belly fat without damaging stomach muscle Along the way. The premise was good that a new breast could be made out of soft living fat without hurting the six pack muscles. But in the real world, the DIEP flap often failed to live up to its promise. It’s flawed in its purest form. It can’t always give us enough blood flow to keep the new breast soft. And when surgeons try to add more blood flow power, they end up cutting up the muscle and nerves in the stomach defeating the whole purpose. And so over time, as we begin to see more and more women referred in from all over the place with problems, it became clear that something was wrong.
So we made it our mission to open up the dialogue and look for ways to fix the flaws. The issues start here. Sometimes the little blood vessels are lined up nicely. We can collect things by simply spreading the muscle fibers apart. No cutting. The operation is straightforward and pure. Other times things aren’t lined up so well and one of two things can happen. Either one of the extra blood vessels is cut and we risk having part of the fat wither and turn hard, or the surgeon cuts across the muscle patching between to join vessels together, creating a whole new set of problems, cut enough of the muscle and you’ll leave loose ends that can spasm and cause pain. Cut more and you’ll be weakened. Cut more still, and you may suffer a hernia. It’s a conundrum. Either way, your surgeon’s not really to blame. It’s just the way the good Lord made us, but the implications are significant nonetheless.
So those are the problems. The DIEP flap by itself fails to consistently deliver what patients may think they are getting when they sign up for it. And that is where our latest work comes in. The apex flap picks up where the DIEP flap falls short in our practice. We’ve been doing this for about 10 years, but didn’t write about it until now because we didn’t want to get ahead of our skis with what we thought we were seeing, and we wanted enough experience to say something meaningful. Now the paper goes into great detail on this, but the takeaways are that this decision tree governs the whole complex of operations and is anchored centrally by the apex conversion. This allows us to branch away from the flaws of the DIEP flat when the need arises, and by doing so, gives us a significant reduction in fat necrosis while at the same time consistently maintains the promise and premise of maximum structure protection.
It’s done with high level microsurgery, but the goals are simple, better blood flow to avoid hard spots and perfect attention to preservation of muscle nerves and strength. Now listen closely. One of the most important parts of all of this is our suggestion that work of this type be supported with documentation of the surgical field, both for your reassurance and for the sake of furthering study. In this case, that means an image of the muscle work is always taken and placed in the medical record, which of course a patient may request copy of if she’s so desires. This is nothing exotic or out of the ordinary is very routine in other specialties like orthopedics and laparoscopic work. It helps us audit our technique and monitor quality. Ultimately, the point is to exchange hard spots in the new breasts for healthy, soft, permanent results. Our dependence on high blood vessels around the belly button for freedom to lower incisions so that we avoid high unsightly scars and the tummy look is more in line with what she expects.
And we exchange damage, pain, and weakness left behind by dated procedures for precision, faster recoveries and lasting strength. Remember, the only way you can have assurance that your operation, whether a DIEP flap, an apex flap or other was done according to a standard of some sort, is to add a picture of the muscle work to your medical record. Ask your doc about it. Hey, doc, do you or will you put a pick of the work you did for me in my record? It’s your right to know how your work was done. If they can’t want or don’t, let’s rubbish find another doctor. Doesn’t have to be here. There are plenty of docs out there who are very interested in doing the best work possible and are very open to your questions about quality. Do yourself a favor and look for them. Insider tip. I can assure you, if it was my wife, I would accept nothing less. The photo would be in the chart, and that’s all I have to say about that.
So don’t settle. Ask hard questions. Take your team to task. We are here to serve you. It’s your right to know how your work will be done and how it was done. The point at the end of the day is to make breast reconstruction work better for you. None of this is rocket science. These concepts are all basic and are now out in the open for you so that you can be a better decision maker when it counts. Before I leave you, remember, no operation is perfect, No surgeon is perfect. All surgery carries risk as a trade off for benefits. So consult with your doctor before making any decision for surgical care. Our final exchange is this, As of today, rather than uncertainty, smoke mirrors our fancy doctor talk. You are given the benefit of clear information and a new advancement developed in the interest of your health and wellbeing. Until next time, I’m Dr. D, be well. Be empowered and be encouraged.