Morton Kahlenberg, MD, Medical Director, Baptist Network for Cancer Care and Baptist Health System in San Antonio, Texas talks about the hidden scar for breast cancer.
Interview conducted by Ivanhoe Broadcast News in August 2018.
The question is: why didn’t this happen years ago? I guess years from now we can look back and ask why they were cutting to begin with, but what’s the beautiful part of this for women?
Dr. Kahlenberg: The beautiful part of this for women is being able to still provide appropriate cancer surgery but with a cosmetic result that’s far more appealing to the patient. It’s far less anxiety provoking for the patient and really affects two very important points: one is ridding somebody of breast cancer and the other is minimizing emotional trauma that can sometimes come with surgery. Having less scar means patients are often happier at a time that can be really anxiety provoking.
For women, this is a part of them and if it just disappears, a part of them goes away. So talk a little bit more about the mental and physical interconnection and how this is critical for them.
Dr. Kahlenberg: Body self-image is incredibly important. While not every patient requires a mastectomy, there are certain medical instances where that is required. With the wonderful techniques that our plastic surgery colleagues provide, it really minimizes the difference in the before and after pictures. That can be huge when a woman has to deal with the issue of part of her body failing without the usual harsh reminders that a portion of one’s body has been changed or altered, so it really is easier. It’s never easy to go through cancer treatment or surgery, but if we can do so through a more cosmetically appealing approach, that’s incredibly meaningful for patients.
Technologically speaking, what is the cutting edge breakthrough of this procedure?
Dr. Kahlenberg: It really is the ability to hide a scar. While we cannot do surgery scarless, we can approach things in a way where the scar is hidden in one’s own anatomy. For example, the lowest aspect of the breast is called the inframammary fold. The ability to do a mastectomy through a very small incision at the very lowest aspect of the bra line that can be hidden when a woman is upright is phenomenal. Similarly, we have had and continue to practice the ability to save the entire skin envelop, including the nipple areola, through a small incision just to the side of the nipple areola. So you can imagine that the idea of performing a full mastectomy, which by definition is the removal of the entire breast through one of these incisions, is dramatically different. It’s the technology in the operating room that allows us to do that and minimize blood loss and have great outcomes. It’s also the skill sets of both the person doing the removal of the breast, the mastectomy, and even more so, the plastic surgeons who provide patients with phenomenal results.
Describe to me the difference in the operating room when one is performing a traditional mastectomy and this?
Dr. Kahlenberg: Sure. While the equipment may very well be the same, it’s the approach and the expertise of the surgeon that’s dramatically different. The traditional mastectomy has been a wide incision to include the removal of the nipple areola and removal of skin through a much longer incision. We can resect that skin, importantly the breast tissue and the breast tumor, and then either reconstruct or not reconstruct. That was the traditional approach. Now we can remove the breast tissue with tinier incisions, better lighting, and better retraction and perform the mastectomy through this much shorter, better positioned incision.
So this is a technique, but technology wise, is there different equipment that you’re using in the OR?
Dr. Kahlenberg: There are some lighted retractors that had not been available previously that really allow us to operate through small incisions. They’re narrow, they’re long, and they provide an ample amount of lighting right to the area where we are working. You can envision a tunnel of tissue as you get further and further away from the incision so that’s very important. The ability to confirm for a woman that her skin envelope is viable with healthy blood supply requires special OR equipment called the Spy. One injects a fluorescent dye into the blood stream and then through special lighting you can see that the dye is taken up in the skin. This confirms that we’ve got good blood flow all the way around that skin envelope which helps confirm for the plastic surgeon that the patient is going to have good wound healing.
When you’re actually performing the surgery, are you doing it with what I call the Nintendo? Do you have robotic sticks that you’re using?
Dr. Kahlenberg: There’s a lot that can be done with Nintendo, to use your terminology, but this is not one of them. There is very little, at least in 2018, that a robot would add to breast surgery. You have two surgeons at the table working through a very tiny incision. A robot for other procedures would be great because there are numerous tiny incisions to affect that change. Would I be shocked to read in the literature that somebody is trying robotic surgery for mastectomy? The answer is no. Do I think it would provide anything more than what we can provide today? Probably not. These are expertly performed procedures by skilled providers across the country and in our region and when performed by experts, patients recover very well from the surgery and have great cosmetic results. I don’t think a robot would add anything significant.
You have two surgeons in there, a surgical oncologist or breast surgeon and a plastic surgeon. Briefly walk us through what’s happening.
Dr. Kahlenberg: Sure. We have the anesthesiologist who, first and foremost, is in charge of making sure our patients are well positioned, comfortable, off to sleep, and provided with great anesthesia. The surgical planning is always performed by the surgical oncologist or a breast surgeon and the plastic surgeon. Not every general surgeon can do this hidden scar or scarless technique. We plan in the holding area with the patient so that the patient can see where the incision is going to be, and then we go ahead to the operating room. I go first, as I am the surgeon performing the mastectomy. If a patient chooses to have her own tissue utilized for reconstruction, the plastic surgeon starts at the very same time. They begin to create the abdominal flap that will come up for the reconstruction. If an expander is utilized, then the plastic surgeon comes in to do the reconstruction after I perform the mastectomy. Again, it’s always through the very same incision.
The incision, from what I’m hearing, is underneath the breast for the most part?
Dr. Kahlenberg: Correct.
You literally can’t see it when they get done?
Dr. Kahlenberg: Yes.
Going back to the technology, how is this radically different from the radical mastectomy?
Dr. Kahlenberg: It’s different in the minimalist approach to the incision. Technologically, it’s the use of those retractors as I was describing before. The technology that we use to move the breast tissue is very modern. Bovie cautery or other instruments that are probably a little bit less harmful and gentler to tissue than instruments we had yesteryear. The techniques are the same, but it’s done through very small incisions.
How exciting is something like this to you as a surgeon?
Dr. Kahlenberg: As a cancer surgeon, it’s very exciting. I take tremendous pleasure in treating patients by removing their cancers and seeing the relief that often comes from learning the cancer has been removed. To be able to do that with my partners in plastic surgery and afford somebody phenomenal cosmetic results, sometimes to the point of many patients declaring, “wow, you really have to look closely to see that I’ve had a mastectomy”, is just tremendously, personally, and professionally satisfying.
Now that you guys are certified to perform this particular method, how widespread is this across the country? How many physicians actually use this?
Dr. Kahlenberg: It’s not widespread, so you do have to show proficiency, both in number and expertise with results. Baptist Health System in San Antonio is the only system of certified excellence throughout South Texas. There are probably double digit numbers of surgeons throughout the United States who do this. It’s not as if it’s only available in South Texas, but it’s probably still the minority of skilled surgeons who do the hidden scar technique with the scarless surgery. We’ve got great plastic surgeons throughout the country that are skilled at reconstruction. It’s working with the person doing the mastectomy that really can afford the decreased incision length or size.
You must think to yourself that this is going to be widespread, because why would you do something major when you can do something minor.
Dr. Kahlenberg: I agree wholeheartedly, but it may not be widespread, I don’t think that it’s going to be a technique that everybody can technically offer. There already is a role today for specialty centers, not only for this type of surgery, but really for a lot of cancer care. What we’re trying to achieve here in the Baptist Health System is to really focus expertise in different tumor types and breast cancer obviously is one of those within our Baptist Network for Cancer Care.
So the focused expertise that the other systems would not be able to perform, is that what you’re getting at?
Dr. Kahlenberg: It really requires a system dedicated to cancer care. It’s something that can be achieved elsewhere but it requires significant resources. It’s the resource allocation from navigators who hand walk patients through the process, genetic counselors for patients who need it, and dedicated participating physicians who show a track record of expertise. Whether in surgical oncology, plastics, or medical oncology, it really is very much organizationally dependent. It’s not something that can’t be achieved elsewhere, it’s just very resource intensive to be able to offer patients this level of expertise and this degree of excellent outcome.
We are going to interview one of your patients, Amy Case. Can you address briefly how you helped her?
Dr. Kahlenberg: Sure. Amy is a wonderful example of how meaningful this type of surgery is. She came to me with a higher risk for the development of breast cancer. As a younger woman, she was understandably anxious about what that type of surgery would mean. Body self-image, married with children, what her friends as contemporaries might think, etc. It’s a priority for her, which I completely understood and understand to this day. You’ll see from her that she was able to alleviate her anxiety by having a bilateral mastectomy before cancer developed in her breasts, ending with a wonderful cosmetic result. Amy and others often say that it’s hard to see that they even had surgery, from a scar standpoint. She’s a perfect example of that.
What would you tell potential patients to ask their doctors to get this done?
Dr. Kahlenberg: Patients should make it known that they not only want to decrease their risk for development of cancer or if they are diagnosed with cancer, that they want to pursue care with surgeons who can provide them with the best absolute cosmetic result. A scarless or hidden scar technique is something that should be asked for. While not everybody is a candidate for it, those who are skilled at providing it will help educate patients on who can and who cannot benefit from it. Even if we cannot do a technique where it’s hidden, for example, in the lower fold of the breast, the end result from an incision around the nipple areola or to the side of the nipple areola is still phenomenal in comparison to a traditional mastectomy that removes nipple areola and a lot of skin. So the results are far better.
Summarize the procedure.
Dr. Kahlenberg: The procedure is one where we can remove the entirety of breast tissue, saving the entire skin envelope, saving the nipple areola through a small incision either in the lower breast fold called the inframammary fold, or sometimes with an incision around the nipple areola complex, which is around the nipple and the areola and often just off to one side through a very tiny incision compared to traditional approach.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please call:
833-345-4892
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here.
