David Lipps, PhD, Assistant Professor, Movement Science at the University of Michigan School of Kinesiology talks about the lat flap procedure.
Interview conducted by Ivanhoe Broadcast News in April 2019.
How did you get interested in this particular line of study? I know it was a couple of steps.
LIPPS: During my post-doctoral training at the Rehabilitation Institute of Chicago, I began a collaboration with a radiation oncologist at Northwestern Memorial Hospital. We discussed how my training biomechanics and ultrasound imaging could be beneficial to the rehabilitation needs of his patients. Around the same time, my mom received her own breast cancer diagnosis and was actually going through radiation therapy. This led me to develop more interest into understand how radiation therapy changes the quality of muscle tissue. During radiation therapy, the beam placements make it unavoidable to prevent incidental doses of radiation reaching muscles around the breast. I learned this was the effect of a variety of breast cancer treatments on shoulder health had not been explored in depth. This project evolved into me wanting to learn more about breast cancer surgeries and their effect on shoulder function and muscle function.
Can you tell me a little bit about what it is about the surgery that that impacts the shoulder and chest area?
LIPPS: There’s about 250000 new breast cancer diagnoses each year. About 40 percent of those women will undergo a mastectomy. The mastectomy is a surgery that removes all of the breast tissue. Typically, this is performed in women who have a more advanced breast cancer diagnosis or in women who decide they want to remove all the breast tissue rather than go through a lumpectomy, which would just remove the tumor but keep the breast tissue intact. After the mastectomy, ~50% of women will opt for a breast reconstructive surgery to restore the aesthetic appearance and feel of a natural breast mount. There are a couple different options for breast reconstruction that depends on the patient’s preference, the clinician’s training, the breast cancer diagnosis itself and the treatments patients are undergoing. The most common procedure is an implant procedure where they place an implant beneath the pec muscle. In order to place that implant, it involves cutting upwards of about a third of the attachment beneath the pec to place a tissue expander and eventually a permanent implant.
You said they have to cut about one third?
LIPPS: Yes, up to about a third of the muscle. The pec is a large muscle and approximately two-thirds of the muscle remains intact after these procedures. In women who require radiation therapy, the skin and soft tissue above the pec muscle becomes compromised, so alternative tissues are needed to perform a reconstruction. One common procedure a surgeon can do is called a lat flap where they basically detach this large muscle off the back, move it into the chest wall and then use that to house the permanent implant.
For women who have had that lat procedure, what’s the impact again on their mobility and their function?
LIPPS: In both procedures, both of those muscles are very important for bringing your arm down and the side and rotating at the shoulder. Our research shows a more severe impact on shoulder function in women who have the lat flap, where it becomes more difficult to bring your arm down, produce force as you move your arm down, as well as rotating at the shoulder. This could impact a variety of functional tasks like lifting a bag of groceries off the ground or reaching your arm behind your back to hook a bra.
So, you’re talking about quality of life.
LIPPS: Nowadays I think the stats are ninety five percent of women are surviving that breast cancer diagnosis five years after treatment. At the initial diagnosis of breast cancer, patients and providers are most concerned with the management that breast cancer diagnosis and ensuring that the disease is eradicated. However, you also seem to have these secondary outcomes pop up in these women. I think a lot of women feel that this is just a consequence of their breast cancer diagnosis and that they can’t do anything about it. But the reality is if we get better at optimizing the surgeries and the treatments as well as identifying patients earlier who would benefit rehabilitation, we could improve overall quality of life in breast cancer survivors.
Tell me what it is that you do in your lab along those lines.
LIPPS: In our lab, we’re interested in studying the mechanisms of why women are impacted by breast cancer surgeries. We have a variety of techniques for doing this. One technique we have is a robot assisted measure of shoulder stiffness so we can measure globally how all the muscles around the shoulder are impacted as patients are stabilizing their shoulder. We also have some novel ultrasound techniques in the lab – ultrasound elastography – where we can measure specifically how the stiffness of different individual muscles changes following different breast cancer managements.
I want to talk a little bit about the robot assisted measurement of stiffness. Talk me through how that works.
LIPPS: We use a robot to move the individual’s arm. As the individual arm is being moved we can measure the forces and torques that are produced at the shoulder. We then can directly measure shoulder stiffness by relating how much we move the arm and how much force gets produced as a result of that movement.
And what are you able to tell from those measurements that you get?
LIPPS: We can tell from those measurements is how stiff a patient’s shoulder is after these breast cancer treatments. If you went to clinician and you said my shoulder is stiff, they would move one arm to another arm and say, yeah, one arm feels a little more resistance than the other. We can actually quantify how much resistance you have to movement and explore how the shoulder adapts to different breast reconstruction options.
When you have that information, how are you able to apply that to help women?
LIPPS: Right now we’re trying to use this to detect which surgeries impact the shoulder the most. We are really at the forefront of this research right now and want to gain a better understanding of the mechanisms of why certain surgeries impact the shoulder more than others. A recent study from our laboratory shows that women who have a mastectomy followed by a lat flap reconstruction have significant reductions in shoulder stiffness when compared to healthy controls or standard implant patients.
How much more stiffness do they measure? How much more of an impact does it have?
LIPPS: Women who have a lat flap procedure have around a 30 percent reduction in shoulder stiffness when compared to women who had surgery where the implant was placed just beneath the pec.
I’m going to ask you only because you said a reduction, or is it an increase in stiffness?
LIPPS: It’s actually a reduction. So the reason why is because you’re removing muscles around the shoulder, making it harder to stiffen up that joint. We have seem the opposite with radiation therapy, where you get an increase in shoulder stiffness. But in this case because you’re actually cutting muscles around the shoulder, making it harder to stabilize your joint and that can also impact you functionally.
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 contact:
Emily Mathews, Marketing for Dept. of Kinesiology
734-647-3079
emathews@umich.edu
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