Jaime Flores, MD, Plastic and Reconstructive Surgeon, Aesthetic & Reconstructive Surgeons LLC, talks about a new treatment option to help women preparing for breast reconstruction surgery.
Interview conducted by Ivanhoe Broadcast News in September 2017.
Tell us a little bit about women going through breast reconstruction surgery. Obviously they’ve been doing it for many, many years but is it still very popular for women after breast cancer surgery to go through reconstruction? Are they still opting for that and is it a difficult process?
Dr. Flores: It certainly has gotten better in the percentage of women getting reconstruction at the time of the mastectomy. We’re still not there completely, and it’s a regional difference. Women in more rural places are not getting reconstructions. One, they either don’t have access to a plastic surgeon, two, they don’t want to delay their care, so it’s a little bit regional. Bigger cities obviously the gold standard is to perform some reconstruction at the time of cancer treatment. That’s the gold standard because it affords them the ability to give them an esthetic optimal outcome at the end.
Do we have any numbers you can throw out?
Dr. Flores: Yes, but the numbers are all regional.
It is a difficult decision is it not for women to make that choice?
Dr. Flores: Yes, it’s challenging. Once they get the cancer diagnosis, they become overwhelmed with the amount of information that is given to them. The last thing they are thinking about is getting new breasts. Fortunately, we’ve had a lot of stars and actresses that have been very vocal about reconstruction, and that has led to more people coming forward. It’s all part of the journey of breast cancer. So more and more women are seeking it, more and more women are achieving those optimal results.
Exactly because as a woman esthetically and how you feel as a woman this is an important part of that journey is the breast reconstructions. So they can feel good.
Dr. Flores: Correct, they feel whole. They feel like themselves, they feel like a woman. The worst thing you want is someone to walk past a mirror, look and not see part of their humanity. That’s tough psychologically, and it makes a difference in restoring them when they completed their reconstruction from nipples to tattoos.
Part of this is the tissue expansion process which a lot of people don’t know can be a very painful, tedious process. Can you take us through that process and what it was like with the traditional saline expanders?
Dr. Flores: Traditionally, for decades, when the implants came out about forty years ago, they were the only choice. Now, they have come a long way from those initial implants to saline implants to expanders. The expanders have made a significant impact these last twenty years. In the past, they were saline, they had an internal port, and I always tell my patients that this is one of the most painful procedures we do to patients. That and maybe an abdominoplasty, it hurts. There is a long recovery initially after mastectomy and placing these temporary expanders. There’s a lot of diligence that you have to do. You have to come to the office, you would inject them with saline, once or twice a week and they would go home and be in pain for two or three days towards the end of their expansion; it’s painful. One of my best friends and patients was in tears towards the end part of her expanders. It was the only way to recreate a breast shape, so that was the initial traditional saline expanders. Now in the last couple years, we have a different expander.
Explain why the expanders are a critical part of it and this is obviously in between the mastectomy and the reconstruction.
Dr. Flores: The expanders allowed us to do many, many things. One, it maintains the breast shape. The expanders are shaped like a teardrop, so it gives them a breast shape, but even before that, it allows them to let the skin heal after a mastectomy without any undue tension and pressure. The worst thing that can happen from a mastectomy as a result of too much pressure is skin necrosis. This can lead to an infection, and then we have to take out the expander, and then the reconstruction gets reset. It’s tough to create a great looking breast after an infection and scar tissue. The expanders also allow us to give them radiation, if they need radiation. The expanders are very hardy so they can withstand the radiation damage as opposed to an implant that’s very soft and can be distorted easily. Furthermore, you can create the size that you want. It gives women the opportunity of re-introducing a new breast size whether it’s bigger or smaller than what they had before.
So not every woman who does opt for reconstruction needs an expander is what you’re saying because some women get the reconstruction right then and there after the mastectomy?
Dr. Flores: Correct.
But then there are others who have to wait and during that period use the expander?
Dr. Flores: Yes.
Tell us about this new type of expander AeroForm and how does it work, how is it comparing to the expander of the past?
Dr. Flores: AeroForm expander, for me, is groundbreaking. One thing that I’ve always talked to my patients about is safety. I’m on their side, anything that would decrease pain and anything that would reduce the risk of infection and allow them to participate in their care I’m all for it. Safety is first and foremost. The Aero expanders are relatively new; they no longer require saline to fill them. Mostly they go in the same position as any regular expander underneath the muscle. You let it heal; you let the tissues heal on top. The difference is they don’t need to get introduced with a needle and saline in the office that could potentially cause an infection. That’s big. For me, that’s my biggest fear when operating is the risk of running an infection. Secondly, they can expand slowly at home as opposed to coming in and experiencing that pain. The pain threshold lets you get back to work if you’re not having pain; it enables you to get back to your family, and your daily chores. Or it could completely cripple you. So now they’re in control, they can expand as much, or as little as they want, they can choose the size themselves. They can look in the mirror; they can go bra shopping, and pick a new bra size. It’s putting the control back into the patient’s hands.
And as you mentioned they could do this at home. And how is it working for them at home and it doesn’t use saline?
Dr. Flores: It doesn’t use saline, there’s a CO2 cartridge internally in the expander, and you have a Bluetooth device that you set it, you get certain bars. Once you have it past four bars, you know you have a good connection. You press the center button, and the Co2 releases ten CC’s of air into the expanders. We have a master control in the office, so we let the patients expand up to thirty CC’s a day at home. They can do as little as ten CC’s; they can come to our office once they are ready to override the limits and expand it further.
So they do this on their own and normally it takes a couple of weeks or months or how long would it normally take?
Dr. Flores: With the saline expanders, it could take up to two to three months to fully expand to where they want to be. AeroForm has cut that time in half. Right now, we’re obligated to operate on patient’s three months after their initial surgery, the ninety-day global period. But with more rapid expansions, they won’t need to wait that long. They’re full filled in five to six weeks.
And ready for surgery?
Dr. Flores: Correct.
What are you hearing from your patients who have used the air expander?
Dr. Flores: Well, all my patients love it. There hasn’t been a single woman that doesn’t love the fact that they can expand at home: the comfort, the decreased pain, and risk of getting an infection. I mean that’s all a big plus. The one downside is if they do need radiation, the radiation ports are different than the traditional expanders. The radiation oncologists are now working with the company to re-angle their ports and most people throughout the country. They are willing to do a little more work to give them the radiation with the expanders.
So they’re working on that, they’re getting closer, is this accessible to all patients? Is this something is it just getting out there or can they get it? Is it easily accessible?
Dr. Flores: Certainly, I’ve spoken to all my colleagues throughout the country. John Hopkins, Memorial Sloan Kettering are starting to use it and they are putting it in all of their patients. Unfortunately, the supply and demand are going to be a big problem. Only confident surgeons now have access to them and use it, but I foresee in the next couple of months, it’s going to replace all of the expanders even internationally. A lot of my international patients love it because they’re at home in Venezuela or the Dominican Republic and they’re expanding in their comfort as opposed to having to come to my office consistently and do it, so I foresee more plastic surgeons using it. It’s so much easier, the ease, the comfort, and the decreased risk of getting an infection. I mean there’s no risk to putting in the new expanders.
So there’s really no downside to it. Nothing that the patient can do at home that could essentially mess it up?
Dr. Flores: None, none at all.
Is it covered by insurance yet or are they still in that process?
Dr. Flores: No, yes. It’s one hundred covered by insurance. It’s the same as any other expander it’s just a different company. Of course, we have to get them to the hospital because there are guidelines that we have to follow, but once it’s approved at the hospitals, it’s covered by insurance.
Where is this going in the future?
Dr. Flores: That’s a good point. The expanders are changing the way we do breast reconstruction. One, we’re going to need more sizes, different sizes. I think just like with any new device, it’s a bit big and bulky, and in the future, it’s going to be smaller devices, more comfortable devices. I hope that one day; we won’t have to change the expander anymore, it kind of coverts into its soft implant.
Do you think this option will make it more appealing for women to go for the reconstruction?
Dr. Flores: Yes, I think so. What happens with breast cancer is they know that the reconstruction is fairly elective and they don’t want to add further risk to their surgery, pain, or recovery. I mean, for a lot of the women, they are the main person in the household. They have a job; they take care of the kids, downtime is a big, big decision. They can choose the expander, and two months later, they’re all recovered and done so more women are choosing it more. There’s no right or wrong way to do it.
END OF INTERVIEW
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