Aldona Spiegel, M.D., Plastic Reconstructive Surgeon at Houston Methodist Hospital, talks about breast reconstruction surgery and how her creation of the internal dermal brassiere gives it a more natural look.
Who knew, back when we all took home economics years ago, that this would come up. This is an exciting innovation for people. How did this come to pass?
Spiegel: Well, it’s very exciting for me to see something that you create in your mind, design it, and then implement it, and then really see the effect that it has. It’s probably the most amazing thing about plastic surgery, and that’s really why I fell in love with plastic surgery. When I was 13, I knew I wanted to be a doctor and I loved to do art and sew and design and draw. Never really having any medical people in my family, I thought, in my child’s mind, that being a plastic surgeon would be the best combination of the two. When I decided that was my trajectory, I fast-tracked through medical school. I did my medical school in Canada, where you’re able to really go a little bit faster. My path through my training took me to Johns Hopkins for general surgery, and then came down to Houston at Baylor College of Medicine for plastic surgery, and breast reconstruction, for me, was what I totally fell in love with because it’s really a marriage of art and technique and creativity.
Go back a little bit to when you were a little girl, because I think that’s such an interesting combination of creating art and working on the human body, which itself is a work of art, plus performing a medical procedure. I mean, it’s an unusual combination, but one that really does fit nicely.
Spiegel: When I was a little girl, I grew up in Poland, where we really didn’t have a lot of material things. Nowadays, in the United States, you have the American doll, where there are thousands of outfits. Back in Eastern Europe, when I grew up, you had one doll maybe with one outfit, and that was it. I loved fashion and design and I started making doll’s clothes for my doll. When I immigrated to Canada, we really didn’t have a lot of means to get any designer clothes, and I loved designer clothes. I actually made my own prom dress, which was where I really understood the three-dimensional shape of the torso and a corset and kind of how that worked together. It was fantastic, even back then, to see something that I saw in a magazine and to create it with my own hands and to wear it. I never really thought, at that time, that many years later, this would be something that I could do for my patients. So that was a very fulfilling part of my career.
That’s just almost an unbelievable tale from there to here. Then, you get someone like Blitz, who is young and about to be married. She has to have that conversation with her future husband about what’s going to happen. And you created, with her, a work of art on her body. Let’s tie those two together.
Spiegel: In order to really answer that, I want to give you a little background about how we got to where we are. I started practice 20 years ago, and my first love was very much about using your own tissue. I started a procedure which was something that was in its infancy, where you transplanted a patient’s own tissue from the tummy to the breast micro-surgically in a way that really spared the abdominal muscle. At that time, that was a novel procedure. I really worked hard at that for the first years in my practice, but I deal with a lot of breast cancer patients, and I felt that not all patients were candidates for using their own tissue. Implant-based reconstruction wasn’t as good as I thought it could be as far as the way that the breasts looked. At the time, the implant was placed under the muscle, which caused some difficulties aesthetically and functionally. We have these beautiful young women who now are diagnosed with BRCA and need to have a preventative mastectomy. It felt like we needed a new solution, and so, in plastic surgery, we always evolve. In fact, many of the things that I do now, I didn’t do when I first started practice, so we’re always evolving. I think this was a solution that came through the evolution of various things being available, such as nipple-sparing mastectomy, which is something that wasn’t really normal or traditional or standard when I first started practice. Now, especially for BRCA patients, it’s pretty much the standard. So that allows the breast to look very un-operated. Internally, we wanted to figure out how to make the breast appear very natural, almost like using your own tissue, but when you really couldn’t use your own tissue. Using this combination of collagen, which acts like an internal brassiere that holds the implant in a way that it isn’t deformed by the muscle allows a direct to implant reconstruction for women like Blitz who, you know, is young and beautiful and about to start her family and getting married. I really wanted it to be a decision that was made that wasn’t so scary and that the result was something that allowed women to feel normal. That’s probably the most beautiful thing I would say about my patients now is that I used to only get that “I feel normal” from my patients who I used their own tissue, but I feel, with this new technique, it allows the implant patients to feel the same way.
Can you walk us through the technique of how it actually works?
Spiegel: When the mastectomy is performed, we try to hide the scar under the breast so it’s not on the visual part of the breast. The mastectomy is performed through a scar under the breast where the general surgeon removes all of the breast tissue, which is what we’re trying to remove preventively or, in a cancer patient, remove for oncological reasons. Then, we have to reconstruct the breast, and that is involving what we call composite reconstruction. Nowadays, it involves three things: the collagen, which is the design that I have, which allows the surgeon to have really amazing control of the way that the breast looks as far as where it is, how it looks, holding the implant exactly where it needs to be. Then, occasionally, on a second procedure, we will go in and add some fat to improve the contour and some padding over the implant, and it’s a wonderful technique that allows women to have less pain because it is under the muscle, so there is less pain fibers in that type of procedure, and it’s been amazing so far. We are publishing a study that involves 70 patients that we did with this technique that we have followed for two years, and we do a very important test not only to see what the complications are but also to see what the patients feel about their reconstruction. That is done by a standardized test that’s now called the Breast Q, which is a survey that patients take to really explain how they feel because, ultimately, the result is dedicated or judged by the patient. In plastic surgery, that’s sometimes a very hard thing to really base your statistics on, but now, we have a way to measure that. What is really fulfilling is to see those surveys. Those women feel that they’re back to being whole and feminine, and that’s really wonderful.
You know, the human body – any time you touch it, alter it, do anything to it, it’s going to feel it. So that brings up an interesting point. After this surgery, is it easier on them in terms of movement, lessening of pain – anything that you might associate with post-op complications?
Spiegel: Yes. It’s an easier procedure to recover from, unlike procedures where we’re using your own tissue because we don’t have a donor site, so those are a little bit easier. The recovery takes about four weeks for patients to be able to go back to a desk job. We do recommend that women take it slow. One of the challenges I think I have with a lot of my patients is that they feel really good after the surgery and sometimes they don’t want to give themselves the time – you know, all women are busy, usually taking care of families. That’s usually my challenge. I’m sometimes strict with my patients – you’ve got to take it easy; you have to take time for yourself to recover. But the results are really great. Once everything’s healed, women can go back to being very active, doing whatever exercise they want to do – pretty much going back to their normal routine.
She mentioned to us, when she discovered that she had the gene, that there was no question in her mind she was going to have that surgery done. When you have this sort of outcome, how much easier is it for you, as a physician, to deal with that?
Spiegel: Yes. That’s a very important question. As I mentioned, in my career, this has evolved. So maybe 10 – 12 years ago, nipple-sparing mastectomy wasn’t routine. Back then, it was very difficult to have a conversation with a young woman who’s in the prime of her life who has to elective make this decision. It’s really wonderful to be here today in 2020 and have the ability to deliver this to my patients. It’s been a real blessing.
When you’re actually in surgery, describe to us what that is like. Are you using any kind of robotics? Are you always hands-on? What does it look or feel like?
Spiegel: The surgery is very specific. We do a lot of markings. The nice thing about this design is it’s a template that keeps improvement of symmetry because it allows a very specific kind of design of the breast. One of the important things that we try to do is to evaluate the blood flow to the skin, which is now something that we interoperability test by using a special kind of flow machine to take a picture of the breast to actually look at the blood flow that’s flowing into the nipple because that’s a very key component of the success of the surgery. It allows us the ability to really predict how things will heal. There’s a lot of combinations and evolutions of things that really culminated to allow us to do what we do now.
Describe to us the thought process. When you start thinking about something like this and then you sort of get a concept of it and then implementation happens – what is that like for you?
Spiegel: I think the key thing for me is really listening to my patients. When you think that you’ll have it perfect, and really, before we started this – which was about five years ago – we did what we thought was a great reconstruction on an implant-based reconstruction. We put the implant partially under the muscle and partially under collagen – that dermal kind of design, which was fantastic because that allowed a direct to implant reconstruction. However, when patients came back, they sometimes complained of muscle animation, which meant that you could sort of see the muscle moving, which meant some discomfort and some deformity of the implant. Thinking and listening to the patients and really using their evaluation of their reconstruction is key for surgeons to keep on evolving. At that time, I thought, well, if we’re using this collagen for the bottom part of the breast, can we avoid using the muscle and develop a way that we don’t have to put it under the muscle to minimize pain and improve aesthetics? That’s kind of how that evolved. In my mind, thinking back to my design days where I sort of built this corset for a dress, I am realizing what the breast needs to look like three-dimensionally to allow this collagen to make a form for the breast and improve the shape. Nowadays, we try to use smooth implants because of issues with textured implants, and those implants are traditionally round. But the beautiful thing about this design is it allows the implant to function like a normal-shaped breast because it changes shape dynamically. When a woman is laying down, it’s more circular or round or spherical. When a woman is sitting up, it’s more teardrop shaped because that pocket allows the implant to change shape. It made it much more natural for the patient. It’s really been fantastic both on an aesthetic level and I think a functional level.
On a chronological timeline, how far this breast reconstruction surgery has come, percentage-wise?
Spiegel: I think much better. In fact, there are some of my own patients that I’m actually converting to above-the-muscle because of the improvement of the result. That’s what I love about plastic surgery is I look back at my previous presentations over the years – and I love to lecture – and in fact, we have surgeons that are flying into Houston Methodist to observe this technique. We have a preceptorship where we have six to eight surgeons coming in every couple of months to observe this technique – because my hope is that we really have this available to patients around the country. I really feel that it’s really changed my own patients’ results, and I hope that it can help other surgeons do the same.
How far away is this technique from basic breast reconstruction surgery? Is it a radical difference? Because the basic mechanics are probably similar.
Spiegel: Yes. I think most surgeons are in an evolution of going to this type of reconstruction. You know, it takes a little bit of comfort level to make sure that you’re comfortable with it. I think many surgeons are looking at their results more critically and evolving and continuing to improve. That’s really one thing that I think all plastic surgeons do. That’s why they are doing what we’re doing, because unlike other specialties where the result is hidden, that’s the beautiful thing about plastic surgery – you can really see what you’ve done and what you’ve created readily. If you want to improve it, you can keep on using your experience to keep on evolving.
As brave as women try to be, particularly those with cancer, breasts are a big deal with them and with their significant others. How do you mentally prepare them to get past this and go on to live a normal life?
Spiegel: Being a breast reconstruction surgeon is a combination of all the things we talked about, but there’s a very personal component, and that’s another reason why I’m very passionate about what I do because it’s a privilege to be able to hold a patient’s hand through the breast reconstruction journey. Initially, when they come in, whether it’s a BRCA diagnosis or a cancer diagnosis, it’s a shock. It’s a lightning bolt in the middle of their busy lives. Every woman deals with it differently. Some women go through the grieving process where there is anger and denial until there’s acceptance where I’m in awe of how strong they are. You know, they’re warriors and they will deal with everything – their chemo, their radiation – in the midst of being young mothers, in the midst of being the sole providers. It’s really amazing. That’s why we love the butterfly as kind of an analogy to the metamorphosis that women go through in their reconstruction journey because, when they’re done – one of my patients told me she feels it’s cancer vive – that going through the cancer and the breast reconstruction journey had made her a stronger person, and the way she lives her life is much better than she did before cancer. I think, you know, if we can ease the burden in the way that we can improve our techniques but also be there for patients is a privilege.
I think the backstory on this is so interesting because it doesn’t really involve technology from its very origins – from when you were a little girl. Like you just said during the surgery, you’re thinking about making that corset and designing that gown – just something on that because that, to me, is the nugget here.
Spiegel: Yes. I think visualizing that in a three-dimensional way is probably why this works so well. It’s basically making a two-dimensional flat object into a three-dimensional beautiful spherical conical representation of a breast. I think that’s the wonderful thing – that it allows us to do that. I think, for me, one of the most fun things was when I was returning back from a symposium where I was teaching this technique to other surgeons and it just so happened that the flight attendant on the plane was my patient who I had done this procedure on a year prior. She was flying to a beach destination. One of her things was to take a picture of herself on the beach in a bikini, which she then texted to me. I mean, out of the thousands of flights that could have happened, the serendipity of that made me just be so grateful that we have this possibility.
You’ve got this neat story of being a little girl in Poland and coming to where you are. Now, you’re teaching other surgeons this technique. What kind of reaction are you getting from these other surgeons?
Spiegel: Anytime you develop something, especially in plastic surgery – plastic surgeons have a lot of creativity and everybody has their own ideas. When this first came out, I knew it worked for me, but I wasn’t sure about how others would perceive it. It’s been really amazing – in fact, it’s been adopted much quicker than I think a lot of the company that is producing it expected. We’ve had some back orders for it because it’s something that grew really quickly. We want to make sure that it’s used properly, and so that’s why we have a preceptorship for other surgeons, and a lot of them will use it in their own way. That’s the beautiful thing about plastic surgery is that everybody evolves their technique.
I’m guessing that you’re already thinking down the road a little bit, but how can you make this better and what do you see right around the corner?
Spiegel: Yes. It’s a great question because, as I mentioned, we’re always thinking, this is so great. Five years later, we’ll be talking about something new. There’s a lot going on in the field of composite breast reconstruction – 3-D printing, using new biomaterials, really fine-tuning what we can do. I really think there’s a lot of innovations on the horizon.
END OF INTERVIEW
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