017: Holistic Breast Reconstruction - a Physician's Perspective

Updated: Jun 22, 2021

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Episode Summary:

What is a holistic approach to breast reconstruction? Tammey talks with Dr. Minas Chrysopoulo, a board-certified plastic surgeon, microsurgeon, President of PRMA Plastic Surgery, and founder of the Breast Advocate App. Together they cover a variety of topics, from the different types of breast reconstruction available to women, breast reconstruction options for men, nipple reconstruction, and the importance of shared decision making. They also discuss the loss of feeling that many women and men are left with post-mastectomy, options for retaining as much sensation as possible, and methods for restoring sensation. This is a powerful episode packed with information, resources, and tools, no matter where you are in your breast cancer journey.

Topics in this Episode:

  • Intro

  • Setting Expectations takes Communication from the Patient and the Surgeon

  • Reviewing Various Breast Reconstructive Options

  • Let’s Talk about Tissue Reconstruction

  • Loss of Sensation and Options

  • Choose Your Entire Team from the Beginning

  • Consider a Plastic Consult even for Lumpectomy or Aesthetic Flat Closure

  • Male Breast Reconstruction – Yes, it is an option

  • Men Need Mammograms. Men can be Gene Mutation Carriers. Men can be BRCA Carriers.

  • Nipple Reconstruction, Nipple Sparing, Nipple Tattoos

  • Self-Advocate for Greater Success

  • Sign off

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Tammey Grable-Woodford: Hello, and welcome back to Your Killer Life. I am so excited to have you joining us today. And I have an amazing guest, and we are going to be talking about some of the hot topics that we see oftentimes out in the Facebook group. And really, as we chat amongst ourselves, after our diagnosis. And I know that even though Dr. C just told me how to pronounce his name, the likelihood of me getting it correct is wrong. So he'll probably correct me, and that is perfectly okay. But we have with us today; a board certified plastic surgeon, breast reconstruction surgeon, and microsurgeon, all of those things very important.

I'm going to ask Dr. Chyrsopoulo to talk a little bit about that. His interests are state-of-the-art breast reconstruction techniques, short scar breast surgery, cosmetic surgery of the breast and body, and scar healing. Also, something that we all often are coaching each other through as we go through this.

And the thing I think I was most impressed with Dr. C is really your commitment to shared decision making between physician and patient and really your understanding of how crucial that is in achieving the best outcomes. And we talked a little bit in the green room about that accountability side of things, but you sold me with is holistic breast reconstruction.

And not that you were trying to sell me, I came across you doing my research, and I was like, I want to talk to that guy because that sounds right up... right up my alley. So, Dr. Chrysopoulo, would you please tell us a little bit more about you and your background and what the heck you mean by "holistic breast reconstruction?"

Dr. Minas Chrysopoulo: Yeah. So breast reconstruction is really the focus of my professional life, and it has been for a while. Now. I'm very lucky to be in a group that.... we're a big group. We've just hired our eighth physician. Who'll be starting with us in January, but we're seven surgeons all are very passionate about breast reconstruction, uh, all techniques.

Um, we have a phenomenal team. I'm really very, very lucky to be surrounded by people who share the same passions and goals. And you're only as good as your team. And I have a great one. So we're in San Antonio, Texas, because of what we do and the techniques we use, which aren't used or offered by every plastic surgeon because of our niche.

We do see a lot of people who travel specifically for breast reconstruction to our practice, PRMA, in San Antonio. In terms of things that people want to talk to me about, tap me on the shoulder about it's very much what you mentioned, actually. It's things like that holistic approach that includes shared decision making.

I also talk a lot about restoring sensation after mastectomies, because unfortunately, many women who have a mastectomy end up being numb, and to many, it's a surprise, which is difficult to believe that patients aren't told. But a lot of the time, unfortunately, they're not.

So holistic means complete. Right? So breast reconstruction isn't just about breast reconstruction options, right? There are a whole myriad of techniques. Some techniques are very complex. Others are very simple, and there is no best technique for everyone. So the holistic approach really needs to incorporate what the patient brings to the table because you can get a great breast reconstruction with any technique, but it's not up to the surgeon to define what great is. It's up to that collaboration between the patient and the surgeon. The patient needs to be happy, and the patient needs to feel that it's great. And for them to feel the result is what they wanted. It's got to jive with other things, other things in their lives, their situation, what they like to do, activities, all sorts of stuff.

So basically, holistic means considering whatever factors the patient brings that are important to the patient. So that's their decision making angle. And then obviously also, um, their medical status, uh, psychological status, emotional wellbeing, nutrition. All these things really play into a holistic approach.

So that's a long answer, but that's what holistic is in my eyes.

Tammey Grable-Woodford: I love that. And I really love what you said about the patient defining success. I know that with my plastic surgeon she was wonderful and how she phrased it. And what she said to me is that. She set an expectation, but gently in that I'm; I'm never going to look the way that I did that, that ship had sailed.

And for me, there's no way to get back to the same size and the whole bit, which actually was a bonus. That's not a bad thing. I was happy to have a little bit of a reduction as a side effect, but also just, she kind of set the tone of, of the goal being to get me to look as, as normal as possible, or as good as possible, with clothes on. Now, she met, she far, she met and beat that expectation, quite frankly, but could you talk with us a little bit, because that is a hard thing.

Every surgery is different; everybody is different. And so when it comes to kind of setting those expectations with your patients or giving patients tools for those conversations with providers, what tips would you have?

Setting Expectations takes Communication from the Patient and the Surgeon

Dr. Minas Chrysopoulo: Oh, you've gotta be blatantly honest. This isn't a vanity procedure; breast reconstruction for some women is important, very imp... it's crucial for some women because it defines them as a woman, as a woman, other women are defined at all by their breasts. It's a very personal thing, and there's no right or wrong. But what we need to do is learn, uh, where the patient stands and what her take is.

And then we need brutal honesty. Some women… they are at a point in their lives where looking good in clothes is very important to them. They want to look physically whole, but when they're naked, they don't care. Other women want to be able to wear a bikini and look phenomenal. You know, there are expectations that we all need to discuss, and sometimes they do need to be reigned in a little bit, depending on what the patient's expectations are.

But the time to do that is before surgery; there's a lot of emotion obviously, that comes with the breast cancer diagnosis. Um, a lot of the time, patients feel like they... that it's an emergency. They've got to take care of this today. Uh, sometimes they're made to feel that way by their healthcare teams, by their physicians, you know?

But the reality of the situation is that patients actually have more time than they think they do to make a decision. I'm not saying that you want to sit on, uh, a new invasive breast cancer diagnosis for six months while you look at all your options. That's not what I'm saying at all, but you don't need to rush into a mastectomy the day after tomorrow.

Okay? So you've got on a little bit of time. You've got, you've got a couple of weeks, a few weeks. It doesn't make a difference in terms of the longterm outcome, survival; the prognosis doesn't make a difference.

Some women, until they get the cancer taken care of, they can't even wrap their heads around breast reconstruction. They may know that they want it. But in terms of decision making, it's just way too much at that month. And, you know, reconstruction at the same time as the mastectomy gives you the best cosmetic results, but it can be performed at any time. So again, this is another conversation that patients need to have, and physicians need to have. Their plastic surgeons, we're all, you know, we want things to look great. We want the best cosmetic outcome; it's in our... it's ingrained in us obviously. And so if, if a patient's a really good surgical candidate for an immediate reconstruction, so that they go in for the mastectomy and they come out with breasts, their different breasts, but they go in whole, physically whole, they come out physically whole, and then they have less the scarring, and the cosmetic results are the best that you can get, you know, we tend to push for that.

But we, we, we need to remember that sometimes people just aren't ready. And that has to be respected too. As long as the patient understands that, you know what, no cosmetic result may not be as good. That's okay. They may not care. Right? So honesty is really important, really important to both sides. Both sides. And patients can't be fearful of you know; they can't waste time. Uh, these days, we don't get enough time with your physician, as it is. You can't waste time working out what's appropriate, what isn't appropriate. If it's on your mind, it's important to you. So speak up, mention it.

Tammey Grable-Woodford: I love what you said about time. And I was very fortunate that I was able to actually attend a cancer retreat prior to even my mastectomies. Like timing just could not have been better. And I'll never forget the doctor at the retreat saying that you, you can take a breath. You have time to take a breath.

Everything is coming at you so quickly. And I call it the cancer train you get on, and it just takes off. And it's a bullet train and unless you slow it down and pull the brake yourself. You do kind of get shuttled along through the process, and that's not a bad thing unless you need to go through some, some research and breathing, and figure out what is best for you.

I know for, for me, I asked my general surgeon for a referral to a plastic surgeon. So I could have that conversation prior to the mastectomies. And for me, part of it was wanting to make sure that even though I had decided on delayed because I had so many unknowns that I was leaving the best, I guess, the landscape for the plastic surgeon to be able to do their job after the fact.

And that also helped me because I was able to ask about the different types of reconstruction and, and there were so many things I didn't know. I think that so often. As you said earlier, this isn't a vanity procedure, but a lot of times, the only thing we know when we're first diagnosed is about implants, and there are so many other reconstruction options that I had no idea about until I had the chance to have a conversation with a plastic surgeon. And that really opened my eyes in helping me make that decision for myself. Could you talk with us a little bit about the different types of reconstruction options that are available?

Reviewing Various Breast Reconstructive Options

Dr. Minas Chrysopoulo: Absolutely. So women actually have many options. Uh, implants are the option obviously most women know about already, and you can get a very nice reconstruction with a breast implant, but women need to know that it's not a boob job. Okay. So it's fundamentally very, very different. Uh, we use the same manmade materials - implants, saline-filled, or silicone gel-filled.

They're the same implants that we use in both cosmetic patients and breast reconstruction patients. But the main difference is this, even if your smaller breasted and that's why you want a cosmetic enhancement, you still have breast tissue. You have skin, you have fat underneath that skin. And even if you're in A cup and you feel like your flat, or however you describe yourself, you still have more tissue than a mastectomy patient has after the mastectomy is done.

And so generally speaking, the more padding you have over an implant. The better the result, the more cosmetic the result, the more natural the result, the less padding you have, the higher the risk, being able to see the implant through the skin. We call that rippling. Something called breast animation, which is what women experience when implants are put under the muscle, the implants are put under the muscle so that there's more padding and more protection, but then when the patient uses their chest, and the pec muscles are engaged, then they squeeze down on the implant, and it can actually make the breast look a little weird until you stop doing what you're doing and relax and then everything goes back to looking normal again. So. That's a big issue. We we've moved away. Many of us have moved away from putting implants under the muscle in reconstruction. And now there's prepec reconstruction, which is basically putting the implant on top of the muscle. And there are pros and cons to that, but a lot of us are doing that to avoid breast animation, and there are some pretty good data now to support doing that, even in ladies who are going to get radiation.

One point I'd like to make before we move away from implants and talking about the other techniques is, is this - for ladies who may be listening, who have friends who have a breast cancer diagnosis, one of the worst things I think you can tell a patient if you've had it cosmetic breast augmentation, and then you have a friend who's been diagnosed who hasn't had a cosmetic breast augmentation before, but maybe she was considering it, or maybe you guys were talking about it. Don't tell them that at least now they can get the boob job they always wanted. It's completely different. And I know it's coming from a position of love and support, but I think, you know, when I, when I have really honest conversations with my patients, in terms of things, you know, what not to say to someone or what they hate hearing the most, that's got to be in the top five things, right?

Because you know, I have some nice results. Okay. People who do a lot of specific procedure tend to get really nice results, but I've got to tell you, you know, those, those lovely pictures that everyone shows at meetings and stuff, those are the best results. Okay. I have some phenomenal results after implant reconstruction, you look at the pictures, and it could be a cosmetic breast augmentation. I hate to break it to you, but that's less than 10%.

Tammey Grable-Woodford: I appreciate you saying that so much because I mean, face it, we all highlight our best work in general. Right?

Dr. Minas Chrysopoulo: Yeah, we do absolutely.

Tammey Grable-Woodford: And I joke all the time with my significant other, that for, you know, $250,000 four surgeries later, right? It's not the supermodel Victoria's secret stage boobs that you see that is not at all. And to find your way to reclamation after all of that and having so much removed, I just, I don't think, and I call it a breast amputation. I don't church it up. You literally are having everything removed except for the tissue that you work with your surgeons to leave behind, and to get to restoration is that... it's almost like being a teenager again in learning to love your body again because it is not, it doesn't feel... it doesn't look... it doesn't, it is different, and there's, uh, there's no getting back there and I I'm sure almost all of us have had that where I've had people say to me, well, at least you got the free boob job.

Well, it's not free, and I'm not even talking money.

Let’s Talk about Tissue Reconstruction

Dr. Minas Chrysopoulo: Yeah. That's exactly right. So in our practice, uh, we are known for our tissue reconstruction. So the other group of procedures that women are able to have and men, because men get breast cancer too, of course. The other group of procedures is the patient's own tissue. So usually that's in the form of what we call a flap.

A flap is a piece of tissue taken from another part of the body. Skin, fat, sometimes muscle. The newer techniques that we use focus on a PRMA are called perforator flaps. Perforator flaps are muscle-sparing procedures so that they just involve the skin and the underlying fat and we will go into the muscle sometimes get the blood vessels that we need. These blood vessels come from deeper tissues. They pierce the muscle; they perforate muscle. That's why they're called perforators. To supply the overlying fat and skin. So then we took this, the skin, the fat, and the little blood vessel, and we can disconnect it from any part of the body and transplant it to the chest and reconnect in the chest using microsurgery.

So the most advanced techniques we have now involve microsurgery. In our practice, we specialize in microsurgical breast reconstruction. So you can take tissue from the lower belly, the buttock upper buttock, lower buttock, back of the thigh, the upper thigh, underneath the buttock, that crease inside the thigh, the inner thigh, and the outer thigh. I mean basically, you've got to be able to tailor the techniques, what the patient brings to the table.

And, of all the tissue procedures, the one that probably is the most it's well known still to this day is the TRAM flap. We haven't done a TRAM flap in our practice, and I can't remember how long it's been. It's been forever. It's still a good procedure. But the problem with it is that it sacrifices the patient's muscle. And if you're having a one-sided reconstruction, you can live without one of your six-pack muscles. If you're having both breasts, reconstructed removing both six back muscles can be quite debilitating.

So we strongly prefer techniques that save the patient's muscle. Uh, the vast majority of our patients can get back to doing whatever they want to do once they're fully recovered in terms of activities.

You know, breast cancer doesn't, you know, differentiate really, you know, it's we have athletes, we have triathletes, we have working moms, we had farmers, we've got people from all, all demographics. Right. So saving the muscle is really central to the procedures that we prefer to do. And so the number one procedure that we do is the DIEP flap.

And really that uses the same skin and fat from the lower belly has a TRAM flap does, but it leaves all the muscle behind. So we saved the muscle. We saved the nerves that power, the muscle, and that's not talked about enough. And that, again, that's when being a microsurgeon helps because if you save all the muscle, but cut all the nerves, then the muscle basically is almost useless. You know, if you know anyone who is a paraplegic, for example, paraplegic patients have no muscle mass in their thighs. All the muscle they had before is there. It's still there. It's just all wasted away because there's no, there are no nerve impulses. The nerve supply to those muscles has basically been removed by their spinal cord injury.

And it's the same in the belly. If you save all the muscle, but you don't care about the nerves, or you don't go out of your way to preserve them, or if one needs to be cut to repair it. Then you can end up with belly complications, which a lot of TRAM flap patients, especially online, there are some pretty vocal patients about issues after TRAM flaps, hernias, bad bulging, all these issues that come from not saving the muscle. Especially on both sides, if you're having a bilateral reconstruction.

So muscle-sparing techniques, perforator flap techniques, that's the kind of the cutting edge now. And we can take it from any part of the body, pretty much depending on your body. And then the other thing that a lot of these procedures lend themselves to, especially the DIEP flap, the DIEP flap is the best procedure for this, and that is for transferring nerves that supply feeling.

So there are two nerves, two types of nerves, the motor nerves that power, the muscle, they need to be preserved, protected, repaired if one is cut. And then the other type of nerve is the nerves that supply feeling. And when you look at the distribution of nerve fibers in the belly to the belly skin, that nerve anatomy is actually very close to the nerve distribution in the breast skin. So we find a nerve with the lower belly tissue that typically that travels up through the muscle as well. And we take that with the flap, with the tissue, and then we find a nerve that has been cut by the mastectomy in the chest. And now we reconnect the two. So now, you not only replace the breast gland with the patient's own fat but now that can potentially have some feeling return.

It's not like mother nature, but our results show that it's, uh, certainly beats the alternative. Some women get close to what they had before. Women who don't get close at least have improved protective sensation because that's something else that isn't talked about enough. Women who don't have protective sensation, because then there's no feeling they're more prone to burn injuries, to thermal injuries.

I've seen several patients from other places that have come because of bad burn injuries from a hot compress. Or they've had implant reconstruction or whatever reconstruction, and then, you know, "I had some pain. I thought I'd put a warm compress on it. I guess it was too hot. I got a wet towel, hand towel. I put it in the microwave for a minute, and I put it on my breasts. And before I knew I burned my skin."

So please, anyone listening to this, don't do that. If you're thinking about putting anything on your breasts that isn't room temperature, test it on your on your inner forearm. This part of your forearm. Test it there. If that thin skin on the inside of your forearm, if it's too hot for that, it's too hot for your breasts. It needs to be very, very comfortable here, and then maybe put it on your breast, and you gotta be really careful.

So thermal injuries are also an issue because women don't have the protective sensation. So this is nerve reconstruction that we do in any and every patient I can, they may not have erogenous feeling like they had before, but even protective sensation is better than nothing.

Tammey Grable-Woodford: And that is so true. We were talking a little bit before we went live about how that is not discussed enough, and you can… hindsight, right. You can look back and say, well, of course, if I have trauma like that, I'm likely not going to have sensation. I had, you know, a neuroma surgery on my foot and where the scar is, is still a little tingly, but there's so much going on, and you're trying to learn so much. Waking up and, or I just, I remember being unwrapped and seeing the staples. The, you know, the surgical staples and looking at that thinking, Oh my gosh, this is going to hurt so bad when they take these out. And then to have him remove one and not know he was even there. And that was just shocking. So it's exciting that we are paying attention and looking to restore as much of really any sensation as possible. That, that is, that brings me hope. My surgeries were a little over five years ago now, and it's amazing the difference between even then and now. And so that's, that gives a lot of hope to a lot of us that.

And a lot of information for having conversations with our providers. As we go through this, especially someone newly diagnosed, who's going to be having these conversations.

Loss of Sensation and Options

Dr. Minas Chrysopoulo: Yeah, there was a, there was a New York Times article that I mean, maybe you saw it, it was to address, the numbness, you know. The angle, the message was that it was a surprise to many patients. I think this was in 2017, maybe, um, when it came out.

And what was interesting was, you know, we have a, a big, we are part of a big multi-disciplinary breast cancer center here in San Antonio.

And it's usually on a Wednesday, the Wednesday after that article came out. I remember this, like, it was yesterday. You know, some of our breast surgeons brought up the article, and it was, there was interesting because they kind of blamed it on us. And that was one of the messages in the article in this New York Times piece, it kind of implied that it was, you know, the failing of breast reconstruction, the failure of breast reconstruction.

So, you know, so you go through all this, you want to get your breasts back and then your numb, well, a really important part of the conversation, but my response to the breast cancer surgeon was, um, I'm telling them that I can restore their feeling. Are you telling them that your mastectomies making them numb?

And so really, this is something for all of us to be discussing with our patients. First and foremost, we need to be discussing techniques with the breast surgeons as to how sensation can be preserved because preservation is better than reconstruction, especially in terms of sensation.

If you can preserve those nerves, you're better off than you are reconstructing them. You're far better not needing to reconstruct the nerves. So I had a lady today. She didn't get nerve reconstructions because the breast surgeon that I work with is absolutely phenomenal. And he gave me an exceptionally high-quality mastectomy, and he set the stage for a phenomenal result.

And that's another big point that I would like people listening to this podcast to take away. I know we're talking about breast reconstruction, but. When you're doing your research, look at the team, don't just pick your breasts, you're your plastic surgeon because I'm very proud of my results. But again, newsflash, I wouldn't get the results I get if it weren't for the breast surgeons with whom I work. Because they are there, they do great work and, you know, they, they, they set the stage for a great breast reconstruction.

I wouldn't get the results I get if it weren't for the breast surgeons with whom I work.

So if you have a mastectomy by someone who maybe doesn't do it very often or, or isn't up to speed with the latest techniques or, you know, if they don't do a good job and you have wound healing issues, and some of the skin dies and all this kind of stuff, you know, your plastic surgeon is behind the eight ball before he, he, or she even touches you. Right?

So look at the team. Pick people who work together routinely a lot, find out who they like working with. Talk to previous patients, you know, find out which patients had what, which combination of surgeons, who are happy, who had issues. I mean, and all this takes time and effort. And I fully appreciate when you've got a breast cancer diagnosis like we've mentioned before, you know, there's only so much you can take on.

Right. But sometimes, and especially if your a, a gene mutation carrier, if you're carrying a high-risk gene, you've got time to do this level of research. Right. You really do.

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And I think that really it's just, if you can allow yourself to take that moment to really begin with the end in mind and, I will be honest. I, it was luck for me that my general surgeon was as good as he was because that was the one, one provider that after I went through the process, I got second and third opinions for just about everything else.

But the general surgeon. The breast surgeon, thankfully, the gynecologist made a great recommendation, and I did check along the way, but I didn't do the homework like I did with the plastic surgeon, with the medical oncologist, with the naturopathic oncologist, with radiation oncologist, I didn't go through that of second opinions, and thankfully he did leave an excellent foundation and did have conversations with a plastic surgeon as part of the decision making. So the three of us were having that conversation.

Choose Your Entire Team from the Beginning

Dr. Minas Chrysopoulo: Yeah. And that's a great point because you know, the reasons the team you pick work so well is because of communication. Right? And so, uh, our breast surgeons are very quick to send people to us for a consultation, even if their breast cancer treatment dictates that they're much better off holding off on, you know, waiting on the reconstruction until later, you know, if there are lots of questions about radiation. You know, radiation and breast, radiation impacts, potentially the timing, the optimal timing, and the best procedure.

Because really, implants and radiation don't go great together. I mentioned before about pre-pec implants, uh, doing okay with radiation, but, that's true, they do better than under the muscle, uh, implants do with radiation. But there's still no comparison to tissue. So tissue is by far what we consider the, you know, the way to go, the gold standard, the safest approach in someone who has received radiation.

And you can also do immediate reconstruction with tissue in people who are going to get radiation. But again, the team is crucial because the radiation oncologist needs to be on board. There are certain techniques that you can adjust with the radiation to protect the reconstruction, minimize the impact on the reconstruction.

Cause you know, radiation, we talked a little bit in the green room before, right. Radiation it's come a long way. It's come a very long way. Um, but everything has side effects. It impacts your tissues, the color, the quality, the texture. It can impact your organs, depending on how deep it goes. There are organ sparing techniques that have been used now for a few years.

The one thing that we can't control, which is a huge factor, is the patient's own biologic response. So you can have sisters, same diagnosis, same treatment, both getting radiation. One can do just fine, and one and can have bad, bad complications. Both the same radiation oncologist, the same protocols, but the, you know, the biologic response to it we can't control. And we can't predict.

So picking the team is crucial seeing a plastic surgeon, even if you're not sure if you want reconstruction. If I had my way, if the healthcare system allowed for it, the logistics allowed for it, if time allowed for it, I would want us to see patients who even want lumpectomies.

Okay, because there are plastic surgical techniques that can be used with lumpectomies to get the best cosmetic results there too, that a lot of women aren't being offered. They're called oncoplastic techniques. So for some reason, in this country, when you look at the adoption of oncoplastic techniques by breast surgeons, the way they've embraced that kind of subspecialty or those procedures.

There's only about a 10% take-up rate amongst breast surgeons here in this country. So they'll, they'll do a lumpectomy and a lot of women, the lumpectomy really doesn't alter the breast very much. But then you add the radiation, and then that kicks the scarring kind of into overdrive in a lot of women. And then that can cause a deformity.

So there are plenty of women where the lumpectomy is deforming because you know, if you're removing a third of a breast, well, if you're a double D that's different to you being a B, or even a small C, and certainly an A, if you remove that amount of tissue that is deforming.

So doing a lumpectomy, you're not really, if you don't have patient selection, even doing a lumpectomy to preserve the breasts, what are you preserving if you're leaving the lady with a very big deformity? So if I had my way, we would see all patients that were having a breast cancer procedure to really, really optimize the conversation.

I see there that a lot of women, having lumpectomies, would have been better served if they've had, if they'd had oncoplastic procedures, you know, to minimize the impact.

Tammey Grable-Woodford: I can definitely affirm at least, you know, in, in my observation from groups that I'm in and women I've spoken to that kind of like numbness thing. The deformity is often unexpected. And again, you can say hindsight 20/20, right? If I were to look and think about what's happening, then obviously I'm going to have a divot, and there's going to be changes, but you know, you don't think about this. This is not—part of your, your life until it is. And you're just really in so many ways, as a person diagnosed with cancer your every day, what decisions do I need to make within the next 24 hours to optimize my survival? What decisions do I need to make within the next seven days to optimize my survival?

And so a lot of those things kind of take a back seat because they don't feel, they just don't, they don't rise above the noise of everything else that you're really truly contending within the moment. And the after impact, it sort of leaves you like, well, is this what it's supposed to be like, should I have done something different?

Should I have communicated differently? And that actually kind of leads me to my next question for you, which is now the aesthetic flat closure, which has been such a challenge for so many.

Consider a Plastic Consult even for Lumpectomy or Aesthetic Flat Closure

Dr. Minas Chrysopoulo: That's another great example. Right? So that's in the same category as what I just said about the oncoplastic. Right? So do you need a plastic surgeon on your team to have a lumpectomy? No. Should you have a conversation with one beforehand? Yes. Do you need a plastic surgeon on your team if you've already decided your breast reconstruction isn't for you and you just want to you want to go flat?

Well, no, you don't need one, but you should have a conversation with one because aesthetic flat closure is a thing it's, it's, it's real, and it's important.

To that lady who wants to be truly flat being left with these extra folds of skin, these big contour issues. You know, one, one area, like on the side of the chest, they've got kind of extra skin they don't know what to do with. Then in the middle of the chest, there's hardly any tissue left covering the rib. You know, it's very uneven.

Well, that's not what that patient asks for when she wanted to go flat. And so there is work involved. And a lot depends on the breast, the size, the patient's habitus, the body.