Breast Reconstruction 2021 by PlasticSurgeryNews

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201

A Supplement to Plastic Surgery News

PLUS: Survivor has women Fighting Pretty after diagnosis Page 16

A patient’s guide to understanding treatment options

Traveling for reconstruction Page 24

Understanding your options Page 29

WHEN YOU SEE US

Amplifying the narratives for thrivers of color Page 6

TABLE OF CONTENTS 4

The PSF’s President’s message: ‘You inspire us’

SHARE program brings hope to patients in Africa

For the Breast of Us: Changing the game for breast cancer thrivers of color

11 California Breast Reconstruction Awareness fundraiser supports local communities 12 Breastoration: Removing barriers to reconstruction 16 Survivor reminds women of their strength and beauty after diagnosis 21 Survivor launches intimate apparel to help women reclaim femininity 22 Breast reconstruction after COVID-19 24 Traveling to a new city for reconstruction 26 Reshaping Lives America helps uninsured women close the loop 29 Knowing your options 30 Tips to create a functional and safe living space 31 Industry support vital to Breast Reconstruction Awareness efforts The views expressed in the articles in this supplement are those of the authors and do not necessarily reflect the opinions of ASPS. Acceptance of advertisements is at the sole discretion of ASPS. ASPS does not guarantee, warrant or endorse any product, program or service advertised. Cover Photo Ride the Wave Photography Designer Elena Bragg Illustrations iStock by Getty Images ASPS website plasticsurgery.org Breast Reconstruction Awareness website breastreconusa.org © 2021 The American Society of Plastic Surgeons

Download a free electronic copy of PSN: Breast Reconstruction at plasticsurgery.org/breastreconissue

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FALL2021

A note from the editor

hen I was a kid, I wanted to be an architect. By “kid,” I mean freshman year of college. The classes I attended were held on a Gothic-style campus with ornate masonry and vertical buildings accentuated by flying buttresses. I was fascinated by the idea that a residence hall – or any other building for that matter – could be both functional and beautiful. As I progressed through my studies and realized I wanted to be a physician, I struggled with the thought of having to give up the balance of form and function. Boy, was I wrong. I discovered reconstructive surgery, where structural principles are balanced by aesthetic goals. I am reminded of this every day as I cross my new Gothic-style campus at the University of Chicago. As a reconstructive microsurgeon and researcher, I love what I do. I have the opportunity to help rebuild more than just the breast and have seen firsthand the effect that cancer treatment, with or without reconstruction, can have on one’s quality of life and survivorship. In the face of the COVID-19 pandemic, many life-enhancing surgeries have been put on hold, and breast reconstruction is often completely delayed. Now, more than ever, public awareness of options for breast reconstruction – both techniques and timing – is paramount. There is no expiration on reconstruction or the impact it has on an individual who has faced breast cancer. Since 2012, The Plastic Surgery Foundation (PSF) and American Society of Plastic Surgeons have supported the Breast Reconstruction Awareness (BRA) campaign to promote education and awareness of options for breast reconstruction. This is the only public campaign that I am aware of that focuses the breast cancer discussion on reconstruction. Although the pandemic paused many aspects of life over the past year-anda-half, The PSF remains committed to our mission of continued dedication to innovation in plastic surgery. Building on our understanding of adipose (fat) tissue and stem cells, plastic surgeons are able to aid the body in regeneration with a goal of restoring sensation and repairing damaged tissue. Immediate lymphatic reconstruction at the time of oncologic surgery is a novel approach to preventing the development of lymphedema after cancer treatment. Techniques in nerve reconstruction are being explored as a way to preserve or restore sensation after mastectomy. As always, patient safety is paramount in any reconstruction, and The PSF has two international initiatives tracking outcomes of reconstruction by our board-certified plastic surgeon members: the National Breast Implant Registry (NBIR) and the General Reconstruction Autologous Fat Transfer (GRAFT) registry. In celebration of Breast Reconstruction Awareness Day USA (Oct. 20), Plastic Surgery News has again produced this special magazine dedicated to breast reconstruction education and advocacy. This year’s issue highlights support. Within these pages are stories to promote patient care, education, awareness and research. You will read personal narratives from breast cancer survivors and reconstructive surgeons. We highlight key information to know when considering breast reconstruction at any age or any time during recovery, particularly in the COVID era and beyond. Finally, we feature community and patient advocates for breast reconstruction, helping all patients to understand and access this critical component of comprehensive cancer care. We hope you enjoy this sixth special edition of PSN Breast Reconstruction and join our efforts in closing the loop on breast cancer. Please get vaccinated. Summer E. Hanson, MD, PhD PSN Associate Editor

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Consumers choose MENTOR® MemoryGel® Xtra Breast Implants as feeling more like a natural breast 14

1. 1.1 MemoryShape Post-Approval Cohort Study (formerly Contour Profile Gel Core Study) Final Clinical Study Report. Mentor Worldwide, LLC; 02 June 2015. 1.2 MemoryGel Core Gel Clinical Study Final Report. Mentor Worldwide, LLC; April 2013. 1.3 Mentor MemoryShape Post-Approval Continued Access Study (formerly Contour Profile Gel Continued Access Study), Final Report. October 2014. 1.4 Mentor MemoryGel Breast Implant Large Post Approval Study Re-Op Phase Annual Report. 17 June 2016. 1.5 Adjunct Study Final Report for Mentor’s MemoryGel Silicone Gel-filled Breast Implants. 02 November 2012. 1.6 Mentor MemoryShape CPG Styles Study: A Study of the Safety of the Contour Profile Gel Breast Implants in Subjects who are Undergoing Primary Breast Augmentation, Primary Breast Reconstruction or Revision, Final Clinical Study Report. 20 October 2015. 2. Mentor Worldwide LLC. Mentor Worldwide Sales Data 2019 – Data on File. 3. Based on patient survey at 10 years in the Mentor® MemoryGel® Breast Implant 10-Year Core Gel Clincial Study Final Report. Mentor Worldwide LLC. MemoryGel® Core Gel Clinical Study Final Report, April 2013. 4. Summary of the Safety and Effectiveness of Mentor’s MemoryGel® Silicone Gel-Filled Implants in Patients who are Undergoing Primary Breast Augmentation, Primary Breast Reconstruction, or Revision. 10-Year Core Gel Final Clinical Study Report. April 2013. 5. MemoryGel® Post Approval Study Seventh Annual Report, November 5, 2013. 6. Adjunct Study Final Report for Mentor’s MemoryGel® Silicone Gel-Filled Breast Implants, 02 November 2012. 7. Mentor Worldwide, LLC. MemoryShape™ Post-Approval Cohort Study (formerly Contour Profile Gel Core Study) Final Clinical Study Report. 02 June 2015. 8. Mentor Becker Expander/Breast Implant Clinical Trial 2013 Annual Report. 9. Adjunct Study Annual Report for Mentor’s Becker Adjustable Breast Implants: Year 18 (September 1992-November 2010) October 3, 2011. 10. CPG Styles Study: A Study of the Safety of the Contour Profile Gel Breast Implants in Subjects who are Undergoing Primary Breast Augmentation, Primary Breast Reconstruction, or Revision. 2015. 11. MemoryShape™ Post-Approval Continued Access Study (formerly Contour Profile Gel Continued Access Study). 2014. 12. Athena Study annual report (Sept 2018): A Study of the Safety and Effectiveness of the Mentor® Smooth and Textured Larger Size MemoryGel® Ultra High Profile (UHP-L) Breast Implants in Subjects who are Undergoing Primary Breast Reconstruction or Revision Reconstruction. 13. Glow Study annual report (Feb 2018): Memory Gel and Shape Combined Cohort Post Approval Study. 14. Head-tohead blinded in-person tabletop product comparison (MemoryGel Xtra vs. Inspira Responsive vs. Inspira Cohesive) with 452 respondents. Mentor Consumer Preference Market Research Report - July 2017. IMPORTANT SAFETY INFORMATION The MENTOR® Collection of Breast Implants are indicated for breast augmentation - in women who are at least 22 years old for MENTOR® MemoryGel® Breast Implants or MENTOR® MemoryShape® Breast Implants, and at least 18 years old for MENTOR® Saline Breast Implants.Breast implant surgery should not be performed in women: With active infection anywhere in their body; With existing cancer or pre-cancer of their breast who have not received adequate treatment for those conditions; Who are currently pregnant or nursing. Safety and effectiveness have not been established in patients with autoimmune diseases (for example lupus and scleroderma), a weakened immune system, conditions that interfere with wound healing and blood clotting, or reduced blood supply to breast tissue. Patients with a diagnosis of depression, or other mental health disorders, should wait until resolution or stabilization of these conditions prior to undergoing breast implantation surgery. There are risks associated with breast implant surgery. You should be aware that breast implants are not lifetime devices and breast implantation may not be a one-time surgery. You may need additional unplanned surgeries on your breasts because of complications or unacceptable cosmetic outcomes. Many of the changes to your breast following implantation are irreversible (cannot be undone) and breast implants may affect your ability to breastfeed, either by reducing or eliminating milk production. Breast implants are not lifetime devices and breast implantation may not be a one-time surgery. The most common complications for breast augmentation with MemoryGel® Implants include any reoperation, capsular contracture, nipple sensation changes, and implant removal with or without replacement. The most common complications with MemoryShape® Implants for breast augmentation include reoperation for any reason, implant removal with or without replacement, and ptosis. A lower risk of complication is rupture. The health consequences of a ruptured silicone gel breast implant have not been fully established. MRI screenings are recommended three years after initial implant surgery and then every two years after to detect silent rupture. Detailed information regarding the risks and benefits associated with MENTOR® Breast Implants is provided in several educational brochures. For MemoryGel® Implants: Important Information for Augmentation Patients about MENTOR® MemoryGel® Breast Implants. For MemoryShape® Implants: Patient Educational Brochure – Breast Augmentation with MENTOR® MemoryShape® Breast Implants and Quick Facts about Breast Augmentation & Reconstruction with MENTOR® MemoryShape® Breast Implants. For MENTOR® Saline-filled Implants: Saline-Filled Breast Implants: Making an Informed Decision. These brochures are available from your surgeon or visit www.mentorwwllc.com. It is important that you read and understand these brochures when considering MENTOR® Breast Implants. Mentor Worldwide, LLC | Irvine, CA 92618 USA © Mentor Worldwide, LLC 2020 136012-200401

You inspire us to innovate and educate By Gayle Gordillo, MD The PSF President Although The Plastic Surgery Foundation is known primarily as the “research wing” of ASPS, I’m often reminded of its philanthropic role, giving back to both communities and patients – and that is most often made clear through The PSF’s continued efforts supporting Breast Reconstruction Awareness events. From fundraising luncheons held in multiple cities throughout the United States to the money we provide to organizations doing their part to support breast reconstruction advocacy around the country, to our annual Close the Loop 5K and countless events held in celebration of Breast Reconstruction Awareness Day, we strive not only to educate patients about their options following a breast cancer diagnosis, but also to enable some of those patients to receive the reconstructive surgery they might not otherwise be able to access or afford. Since 2013, The PSF has awarded more than $780,000 in charitable care grants and more than $936,000 in public awareness grants – both of which are tied specifically to breast reconstruction awareness. Within our specialty, plastic surgeons often allude to their given mission of restoring form and function – or making people whole again. Over the course of my years in practice and organizational leadership, I’ve seen countless instances of the tight bond formed between a plastic surgeon and patient, but what strikes me time and again are the local events held in support of Breast Reconstruction Awareness – whether it’s fashion shows, cookouts, races, galas or any number of creative

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ideas our doctors and patients realize. It’s always rewarding to see the sisterhood forged through breast cancer journeys and the doctor-patient relationships fostered through these experiences that last years after the surgery is complete. Statistics show that about 13 percent of women will develop invasive breast cancer in their lifetime and in 2021, an estimated 281,550 new cases of invasive breast cancer are expected to be diagnosed in the United States alone (adding to a total of 3.8 million women in the country who have a history of breast cancer). Of course, the prevalence of breast cancer isn’t a domestic phenomenon – breast cancer became the most common cancer globally as of 2021, accounting of 12 percent of all new annual cancer cases worldwide, according to the World Health Organization. As such, our educational efforts stretch beyond U.S. borders and continue to grow each year. Last year, more than 311 affiliates participated in raising awareness around the globe. More information on our fundraising and educational efforts can be found online at breastreconusa.org. As we approach a decade of the work done through the Breast Reconstruction Awareness campaign, it’s humbling to see how much the effort has grown and hear the stories of the lives affected by this work. Every year, PSN’s Breast Reconstruction supplement shares stories of courage, hope and inspiration and this year’s edition adds to that lineage. The message to patients who have been stunned by a breast cancer diagnosis is simple: You are not alone. There are options and there are many who have been in your shoes as you take the first steps on a seismic personal journey. There are incredible plastic surgeons in every state ready and willing to help you. You are our inspiration – and our efforts will not stop.

GLOBAL AWARENESS

SHARE seeds hope for

breast cancer patients in Africa By Paul Snyder

It is by no means an easy task to change a culture of thought on breast cancer when that culture links it to mastectomy, loss of a sense of self and abandonment. Many patients in sub-Saharan Africa not only lack the education about reconstruction options after a mastectomy – they severely lack the medical professionals to perform such options. Now The Plastic Surgery Foundation (PSF) aims to change that culture.

Surgeons in Humanitarian Alliance for Reconstructive, Research and Education (SHARE) is a program from The PSF that seeks to enhance collaboration to improve care and surgical capacity in regions that have limited numbers of plastic surgeons and high incidences of conditions requiring plastic surgery treatment. The program is tailored to local learners and their environment through three core components: global learners, global educators and global researchers. In partnership with COSECSA (The College of Surgeons of East Central and Southern Africa) and the Surgical Society of Kenya, the program provides plastic surgery training and long-term sustainability to areas in sub-Saharan Africa such as Rwanda, where there are two plastic surgeons for a population of more than 12 million. “The whole idea is to increase plastic surgery capacity in areas that desperately need it – and where training simply doesn’t exist,” Andrea Pusic, MD, MHS says The PSF past

President Andrea Pusic, MD, MHS, who is also one of the founders of SHARE. “By leveraging ASPS resources, we’re able to start with this inaugural group of 17 African learners, who can then bring these skills to their local hospitals and help train others. The goal over the next few years is to expand the program to other regions around the world that have similarly limited resources.” Dr. Pusic, who has experience traveling to Africa, India and Bangladesh in the past to help perform breast reconstruction procedures, knows firsthand the impact of a lack of education and access to women diagnosed with breast cancer in low- and middle-income countries. That’s why it’s an immediate area of focus for the first class of the SHARE program. “Breast reconstruction is extremely limited in Africa – to the point of there being practically no hope of reconstruction,” she says. Women in Africa typically present with breast cancer at a later, more advanced stage, Dr. Pusic notes, adding that the reasons are varied. It could be related to financial means, poor physician access or, quite simply, fear. A breast cancer diagnosis means the patient’s breast will be amputated with no further recourse. “It’s the end of the story from a selfesteem and body-image perspective,” she says, adding that the social factor in terms of women feeling that their role in their marriage, family or society can easily become a little less secure as a result of

mastectomy. The procedure could mean the loss of a husband or other concerns about abandonment. “As a result, there tends to be a lot of thinking along the lines of ‘I’m going to be OK,’ and then not doing anything about it,” Dr. Pusic says. Although SHARE does not have the capacity or scope to bring breast reconstruction education and options to sub-Saharan Africa at the level available to patients in the United States, Dr. Pusic notes the young plastic surgeons taking part in the program are eager to learn reconstruction techniques and teach those to their colleagues and, by extension, future generations of plastic surgeons. One of the program’s learners, Irene Asaba Mugisha, MBChB, MMed, will help lead an educational portal for her peers on breast reconstruction with Dr. Pusic. It might seem like a small step for the Irene Asaba Mugisha, medical community MBChB, MMed in the area, but the ramifications for future generations of African women cannot be understated. “It improves the overall message to women in the area,” Dr. Pusic notes. “There’s a huge appetite to learn as much about breast reconstruction as possible among the plastic surgeons we’re training in Africa – not least of all because this is something that plastic surgeons do all over the world. More than that, though, we have the chance to change the way women think about breast cancer in Africa and provide a bit of hope for these patients’ futures.” PSN: BREAST RECONSTRUCTION 2021 l

COVER STORY

BREAST CANCER SURVIVORS

BUILD THEIR OWN TABLE TO EMPOWER WOMEN OF COLOR FACING THE DISEASE By Kendra Y. Mims-Applewhite Photos by Ride the Wave Photography 6

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Meet Marissa Thomas (left) and Jasmine Souers – two breast cancer survivors changing the game for women of color in the breast cancer community.

COVER STORY

“ Women of

Color Deserve to be Seen” Jasmine Souers and Marissa Thomas struggled to find breast cancer survivors who looked like them after their diagnosis. As young Black women with concerns about keloids and hypertrophic scars – a greater risk for ethnic patients with darker skin pigmentation – they turned to the Internet and social media platforms to find images of Black and Brown women with mastectomy and reconstruction scars, but their search yielded no results. The stories and faces of women of color in the breast cancer community seemed impossible to find. “When I first searched for Black women with mastectomies, I started getting blackand-white images of white women,” Jasmine recalls. “I was confused and initially thought my doctors were giving me an option that other Black women weren’t given. As a young Black woman, it didn’t seem like there was a place for me while trying to find photos of other Black survivors. I felt like an outlier.”

Jasmine, of Jacksonville, Fla., and Marissa, of Seattle, became friends online before they met in-person at the 2019 Young Survival Coalition Summit. The conference opened their eyes to racial disparities in breast cancer care, including the staggering mortality rates among Black women and the underrepresentation of women of color in clinical trials. As they watched and listened to the women of color in the room, they noticed a frustration that mirrored their own. The moment solidified their shared goal to change the narrative. “In communities of color, there’s a perception that we don’t want to talk about our weaknesses, struggles and health, but it’s those things that connect us to other people because we know we are not in it alone,” Jasmine says. Jasmine and Marissa joined forces after the conference to challenge health disparities and help women of color feel visible during their breast cancer journey. In 2019, they launched For the Breast of Us, the first inclusive online community for women of color affected by the disease, to empower all women of color through education, advocacy and community. “There are several spaces solely dedicated to Black women, so we decided to go against the grain and harness the Jasmine Souers and Marissa Thomas

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collective power of marginalized voices,” Jasmine says. “It’s one of the things that sets us apart from the work being done in these spaces. A lot of us took our search online because it’s so difficult to find women we connect with in our local communities. Giving women a space to support other women while they are going through the struggle is powerful.” “We knew there were disparities all around, so we wanted to make sure their voices were heard collectively and not siloed,” Marissa adds.

Rewriting the narrative

When a powerful photo series of breast cancer survivors baring their mastectomy tattoos went viral a few years ago, Jasmine concedes she was astonished – and disappointed – at the glaring absence of Black and Brown women. The mainstream narrative often overlooks women of color, she notes. To that end, Jasmine and Marissa have set out to amplify the experiences of marginalized voices through campaigns that let the women in their community define and share their stories. Their latest #WhenYouSeeUs photo series celebrates the visual diversity of their Breast Cancer Baddies community. The campaign features Jasmine and Marissa alongside Baddie ambassadors of different ethnicities, cancer stages, sizes, ages, socioeconomic backgrounds and surgery types, ranging from bilateral mastectomies and aesthetic flat closures to lumpectomies and implantbased reconstruction. What started off as a branding photoshoot for marketing materials evolved into a campaign that garnered international attention and sparked a conversation about representation in breast cancer care. “When the photos came out, we started to realize it was much bigger than a brochure or website photos,” Jasmine says. “We needed people to understand we weren’t just highlighting the experiences of Black women. We have women from

different cultures who feel as strongly as we do, and the campaign was a big moment for them. “The photos gave a face and body to breast cancer,” she continues. “We are becoming the women we looked for when we were diagnosed, and we are demanding the industry to add the ‘and’ – we are Black women, we are Latina women, we are Asian/Pacific Islander women, and this is how we feel. The campaign showed we are multidimensional. A one-size-fits-all approach will not work when it comes to treating us. We want to be treated like people and not like diseases and stereotypes. That means considering the ‘and.’ ” Marissa hopes their campaign will challenge other organizations to follow suit and include the experiences and faces of women of color in their breast cancer campaigns. You won’t be able to find similar photos of Black and Brown women diagnosed with breast cancer online, she points out. “We are pushing the envelope and it is opening other people’s eyes to ask, ‘Why aren’t we doing this?’ ” she says. “When they do similar shoots, they don’t include us. We are usually included in that space as an afterthought – or they are showing the same two faces in the breast cancer community instead of a full range of women of all shapes, sizes and surgeries. Hopefully, they are open to change and it’s not a moment in a movement. Jasmine and I are going to continue to push the envelope. We are not doing this for the moment.” Since launching the campaign, the duo has received an outpouring of support and appreciation from breast cancer patients and survivors nationwide. Women frequently reach out to express gratitude for helping them feel seen and heard, Marissa notes. “We deserve to see images of women who look like us and are going through the same thing,” Marissa says. “So many women have told us, ‘This is what it feels like to be seen’ or ‘I just had surgery and now I know it’s OK for me to show my scars.’ We’re

“#WhenYouSeeUs, do not censor our scars or dismiss us as ‘too young.’ Do not treat us as mere statistics. When you see us, include us.” also showing beautiful Black and Brown women from all different shapes and sizes. #WhenYouSeeUs gives them an idea of what they will look like. It may seem small to some people, but it is so powerful to us. Women of color deserve to be seen.”

Closing the gap

Research shows ethnic disparities exist in breast cancer care and prognosis. According to the American Cancer Society, Black women are more likely to develop triplenegative breast cancer than women of other races due to poorer short-term prognosis and represent only 6.2 percent of cancer clinical trials; Hispanic women are more likely to be diagnosed with tumors that are larger and hormone receptor-negative than non-Hispanic white women and comprise only 2.2 percent of cancer clinical trials; and Asian/Pacific Islander women represent only 3.3 percent of cancer clinical trials and have seen their incidence of breast cancer increase steadily. Women of color are also less likely aware of their breast reconstruction options after diagnosis. “I had to advocate for myself because doctors wouldn’t give me all the information, and I wasn’t given many options,” says Jasmine, who was initially

misdiagnosed at age 25 and accurately diagnosed with stage 1 breast cancer seven months later. She opted to undergo implant-based reconstruction following her bilateral mastectomy in 2017. “Almost all of my breast tissue was infected when they finally caught it, so I knew I was going to lose one breast. I decided to have both breasts removed for peace of mind.” Marissa, diagnosed with stage 2 breast cancer right before her 36th birthday, underwent a lumpectomy and two breast reconstruction surgeries in 2016. She says For the Breast of Us is shifting the narrative around breast reconstruction, so women of color know their options. “Women didn’t have many options outside of a mastectomy or radiation during our grandmothers’ era,” Marissa says. “Today, there are different types of breast reconstruction options available and more board-certified plastic surgeons. We are giving women their power back by letting them know they have many different options, and they can still live their best life in whatever way that looks to them. We want them to feel empowered to ask their surgeons certain questions or get a second opinion, which doesn’t always happen in our communities.” PSN: BREAST RECONSTRUCTION 2021 l

COVER STORY

Marissa and Jasmine are also providing webinars to give women an opportunity to engage with board-certified plastic surgeons and breast reconstruction patients. ASPS member Frederick Durden, MD, of Cancer Treatment Centers of America Atlanta, says participating in their webinar helped him understand better the hardships tied to misinformation and poor communication. “Listening to the attendees’ candid discussions about their experiences helped me improve how I interacted with my patients,” Dr. Durden says. “We understand women of color have disparities that put them at a disadvantage in terms of survival and recurrence rates. Improving the care we deliver to breast cancer patients starts with patient education. That’s where For the Breast of Us comes in. These women can speak freely about their issues and concerns and share knowledge with women who look like them in a safe space. The work they are doing is outstanding.” Dr. Durden commends Jasmine’s and Marissa’s efforts to equip women of color with information about reconstruction so that they can advocate for themselves throughout their treatment. It’s necessary work, he notes. “More women of color are aware of their options because of groups like For the Breast of Us, but we are still far behind and have a long way to go,” Dr. Durden says. “It’s 2021, and I still have women of color tell me they weren’t informed of breast reconstruction options at their diagnosis, or they were only informed of one procedure. They should have the option of knowing what’s possible and not be limited to the physicians taking care of them. “Breast reconstruction is not right for every woman, but it will definitely improve some patients’ quality of life,” he continues. “There shouldn’t be a patient going through this process who doesn’t know all of her options. We have not gotten to the point where everyone with this diagnosis has the information to make a decision. There’s still work to be done to close the gap.”

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“#WhenYouSeeUs, understand women of color face multiple barriers, such as gender, racial, ethnic and other disparities. Be an advocate for us as we navigate life with breast cancer.”

Beacon of hope

While searching for a plastic surgeon for her upcoming reconstruction procedure, Marissa says she was adamant about asking certain questions to ensure her concerns were addressed – a lesson she learned while navigating her own treatment. “I know that I develop keloids whenever my skin is cut, so I had to make sure I found a plastic surgeon who could treat keloids,” she explains. “I told the office the plastic surgeon’s gender didn’t matter, but I did ask if they had a surgeon who knows how to treat ethnic skin. Thankfully, my first plastic surgeon was a Black woman, and she knew what prescriptions I needed to help with my scars. Asking those types of questions throws people off, but it’s a real concern for us.” Jasmine and Marissa say they will continue placing a demand on the healthcare industry and the breast cancer community to be seen and acknowledged. “When you’re dealing with a community that has a long history of medical mistrust, it doesn’t help when you feel like medical providers aren’t used to treating people who look like you, or they aren’t familiar with your skin type or culture,” Jasmine says. “Little things like that can make a significant difference in the way we navigate treatment. Our experiences deserve to be considered. We want our concerns to be taken seriously.” Jasmine and Marissa hold down full-time jobs outside of their voluntary

positions as the Chief Visionary Officer and Chief Executive Office of their organization and they work tirelessly to pay it forward and help the women behind them overcome the barriers they faced during their breast cancer journey. They want their online platform to be a welcoming space for women of color at any stage of their journey who search for community, imagery and stories of women who look like themselves – a beacon of hope for the thriver of color, so she doesn’t feel alone or forgotten. “Everyone deserves to have hope,” Jasmine says, adding that her faith helped her through challenging times. “Imagine going through a life-altering situation that impacts your body, mental health, relationships and job and you’re trying to find people who can identify with your experience, but none of them look like you. That feels hopeless. When you come into a place and connect with women who look like you and can relate to your experiences, it gives you hope. “At the end of the day, we want to change the narrative and shift the paradigm,” she continues. “We want women to live longer lives and their best lives, and that starts with hope.” For more information about For the Breast of Us and to view photos and stories from the #WhenYouSeeUs campaign, visit breastofus.com/whenyouseeus/.

COMMUNITY AWARENESS

The inaugural San Francisco/California Breast Reconstruction Awareness Benefit By Karen M. Horton, MD, MSc

I am truly honored to chair the first-ever San Francisco/California Breast Reconstruction Awareness (BRA) Fundraiser, being held virtually this fall.

Inspired by past Chicago Breast Reconstruction Awareness fundraising events, The Plastic Surgery Foundation chose San Francisco as an additional host city for an exciting on-demand Breast Reconstruction Awareness benefit, where participants can participate at any time from Sept. 1 to Oct. 31. Once participants register, this event will feature exclusive access to heartwarming patient stories and the plastic surgeon’s perspective on why breast reconstruction is so important to women facing a breast cancer diagnosis. Breast reconstruction patients will share stories about their surgical experience and how their lives were improved through this important plastic surgery spectrum of procedures. The San Francisco/California Breast Reconstruction Awareness event will feature a virtual patient fashion show where breast reconstruction patients will model Everviolet, a beautiful collection of lingerie and loungewear designed to nurture changes in a woman’s body following treatment for breast cancer and other meaningful life events. Patients were guided by experts Keira Kotler, founder and CEO of Everviolet; and Charleston Pierce, a model, actor, fashion show producer/choreographer and author who has worked with Cindy Crawford, Tyra Banks, as well as Versace and Calvin Klein models, and many more. In addition to patient stories and entertainment, an exclusive grand prize drawing and a luxury shopping experience will be offered. Honorary chairs include San Francisco Mayor London Breed and San Francisco Fire Chief Jeanine

Nicholson, herself a breast cancer survivor. Although breast cancer in general receives considerable funding nationally, the reconstruction component is often overlooked; many patients are not even aware of all options when told they have breast cancer. However, breast reconstruction can help patients feel whole again, and it is a vital aspect of helping women facing cancer recover mentally and emotionally. Breast reconstruction can be important to help a woman regain or preserve her femininity and sense of feeling complete, in terms of symmetry and proportion to the rest of her body. There have been several advances in breast reconstruction techniques over the past 15 years, including preserving nipples whenever possible, avoiding the sacrifice of major muscles, completing the reconstruction in the least number of surgeries and emphasizing the importance of aesthetics in reconstruction in addition to the cancer treatment. As a plastic surgeon, I have always dedicated part of my practice to breast reconstruction, as I consider it vitally important to help women recover more completely after a cancer or BRCA-gene diagnosis. I strive to make the breast reconstruction experience as positive as possible for women. As chair of the San Francisco/ California Breast Reconstruction Awareness Event Committee, I aim to produce an event that can raise money to support these efforts nationwide. In contrast to other organizations that promote research for breast cancer treatment – but not for the subsequent reconstruction – The PSF’s effort is unique as it is one of the few national organizations to promote breast reconstruction following ablative procedures for breast cancer treatment. All proceeds from this

fundraiser will remain in California to support and fund research focusing on breast reconstruction and provide financial assistance to organizations supporting uninsured or underinsured women. With every donation of $350 or more, registrants will receive a Breast Reconstruction Awareness tote bag and a 100 percent silk twill scarf, hand rolled and stitched with the Breast Reconstruction Awareness logo made exclusively for The Plastic Surgery Foundation. Donations of $500 will support medication, supplies and clinic fees for breast reconstruction patients; contributions of $1,000 will support lost wages and childcare during reconstruction and recovery; and donations of $2,200 supports breast reconstruction for one woman! As a participant, you can directly help reach women below the poverty line. Please show your support and help raise awareness about breast reconstruction options. We encourage you to participate in the event by registering at brabenefit.com and sharing event details with your colleagues, patients, family and friends. ASPS member Karen Horton, MD, MSc, is internationally board certified in plastic surgery by both the American Board of Plastic Surgery and the Royal College of Surgeons of Canada, specializing in cosmetic and reconstructive surgery for women. Based in San Francisco, Dr. Horton’s private practice focuses on providing personalized care with meticulous attention to detail in a warm and welcoming environment. Her practice is centered on providing beautiful, natural and long-lasting results for breast cancer survivors using microsurgery or prepectoral implants in a single stage. PSN: BREAST RECONSTRUCTION 2021 l

FEATURE

Removing the barriers to reconstruction Breastoration is about more than providing educational and financial assistance to women facing a breast cancer diagnosis – it’s also working to change the way the state of Louisiana helps these patients By Paul Snyder

Maria Stambaugh is a single mother who was working as a hostess at The Chloe New Orleans, the boutique hotel and restaurant in the heart of the city. After being diagnosed

with breast cancer and going through the process of reconstruction, her financial situation became somewhat strained. One day a woman came in wearing a lymphedema sleeve. Maria walked up to the customer and asked if she was a breast cancer survivor.

The customer said she was. Excited to have someone to share her experience with, Stambaugh began to discuss her own journey with the customer, and how she had taken the parttime job at The Chloe to help cover the expenses incurred by the diagnosis and reconstruction. The customer began to tell her about Breastoration, a local nonprofit that not only raises awareness about

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breast reconstruction options, but also provides educational and financial resources to women diagnosed with breast cancer. Unbeknownst to Stambaugh, the customer with whom she was conversing was Amelia Leonardi, president of the Cancer Association of Louisiana (CALA), which distributes Breastoration funding. Suddenly, Maria burst into tears. Earlier that day, she had received a call informing her that she would be awarded Breastoration funds to help cover some of her necessary expenses. “I can’t describe the feeling of how much I needed to hear that help was on its way,” Maria recalls. “I’ve been angry, sad and felt that I had no support. Breastoration lifted me up when I needed it most. I felt like someone cared.” There are several women who share the sentiment.

Take Ashley Gautreau, who opted for bilateral mastectomy with reconstruction after being diagnosed with cancer at age 36. With two young children, the diagnosis and reconstruction forced her to miss an entire month of work without pay – and when she was able to begin working again, she was told she could only do so part-time. Despite the lost wages, Ashley’s family was able to help take care of her children, but the expenses incurred through continued medical treatment began to raise her debt load. She, too, ended up a beneficiary of Breastoration. She would go on to host a Jazzercise-themed fundraiser that raised $2,000 to help other women who faced financial hardship as a result of a breast cancer diagnosis. Susan Granger had a full-time job and good health insurance, but when she was diagnosed with stage 2 breast cancer in 2015, she noted that her out-of-pocket costs still ended up around $20,000. Falling back on her training as a journalist, Susan began researching the diagnosis, what to do and who could help. However, she says the answers she found at the time were lacking. “One doctor I went to literally handed me a pile of business cards and said, ‘Go call some plastic surgeons,’ ” Susan recalls. “I thought, ‘Are you kidding?’ Do I have time to go make multiple appointments and see if I like this doctor or do research about all these names and their patient outcomes? I mean, you’re already running this overwhelming gamut, and now there’s this whole new pile of research to do – and by the way, you better do it quickly because you might have a lifethreatening illness.” Fortunately, the answer was right down the street. Susan’s neighbor was Amelia, and like Maria, Susan had noticed Amelia’s lymphedema sleeve. One day as Susan was out for a walk, Amelia drove by and asked how she was doing. Susan shared the news of her diagnosis. “We ended up with the same oncological surgeon, and she steered me on how to figure out the reconstruction element of it,” Granger recalls. “Then she said, ‘By the way,’ and told me about Breastoration.” Still moved to this day by Breastoration’s generosity and support, Susan vowed to pay it forward and help other women facing the same uncertainty she did in the days after her diagnosis. Today she sits on the CALA board.

For Amelia, it’s not just a matter of happening to be in the right place at the right time – it’s a matter of paying it forward like others did for her and the community spirit fostered by women who have either benefitted or taken part in Breastoration. “I was very blessed with a lot of support when I had breast cancer and my reconstruction surgeries,” Amelia says. “It’s so rewarding to be part of an organization that helps women in the community.”

I can’t describe the feeling of how much I needed to hear that help was on its way. I’ve been angry, sad and felt that I had no support. Breastoration lifted me up when I needed it most. I felt like someone cared. —Maria Stambaugh

Multifaceted advocacy

Breastoration was founded in 2011 by a trio of breast cancer survivors, Kim Sport, Sandy Keller and Eve Wallinga. As it celebrates its 10-year anniversary, Breastoration has made its vitality clear not only by raising awareness about breast reconstruction options, but also providing educational and financial resources to women diagnosed with breast cancer. To date, the organization has provided more than $700,000 to more than 200 women throughout Louisiana (and beyond), covering 537 reconstructive procedures from 49 referring surgeons. Breastoration was initially administered by the Cancer Association of Greater New Orleans (CAGNO), which was formed in 1959, to reduce barriers to cancer patients undergoing treatment. Breastoration became a registered agent in 2017. CAGNO grew in recent years and partnered with local hospitals to become CALA and help more patients across the state. Although the Breastoration fund prioritizes local patients, the organization’s leaders note that out-ofstate patients can also receive help if funds are available and their reconstruction procedures are performed in Louisiana. Women can apply for funding as each reconstruction is scheduled, and based on their needs, PSN: BREAST RECONSTRUCTION 2021 l

FEATURE

receive up to $5,000 per year to help during their reconstruction journey. Breastoration is committed to ensuring all women are informed with any updated information available to make a collaborative decision concerning their reconstruction options. “No woman who has been diagnosed with breast cancer and has to have a mastectomy should ever have to live with a deformity because of a lack of knowledge or lack of money,” Kim says. For Kim, the time and effort put into Breastoration is personal. A three-time cancer survivor, first diagnosed with stage 2 breast cancer in June 2001, Kim opted for a lumpectomy and chemotherapy, only to be diagnosed with cancer for the second time in the same breast seven years later. As she had already had radiation to that breast, she knew this time she would have to undergo a mastectomy. “I had already been active in the not-for-profit world because of my first diagnosis, which put me in an entirely different position to decide to have a bilateral mastectomy and simultaneous implant reconstruction,” she notes. “Still, I was very surprised to learn after I had my bilateral mastectomy and reconstruction that seven out of 10 women did not know that reconstruction was an option for them – and an insured option, no less.” Encouraged by her plastic surgeons, Frank DellaCroce, MD, and Scott Sullivan, MD, who knew of her work in the

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community and offered vital seed funding, Kim set to work forming a group to help provide patient education on the Women’s Health and Cancer Right Act (WHCRA) of 1998, which was instrumental in expanding healthcare benefits to women diagnosed with breast cancer who sought immediate or delayed reconstructive surgery after mastectomy. The WHCRA specifically mandated that medical insurance providers include coverage for women who sought reconstruction after a unilateral or bilateral mastectomy, as well as balancing surgery (for symmetrical purposes) for the unaffected breast. “I am a lawyer and I started doing research,” Kim says. “I wanted to see if we had a state law that followed federal law and came to find out that we were probably one of the first states in the nation to adopt the federal laws regarding insurance for breast reconstruction. Louisiana went even further in that it required the state board of medical examiners to prepare an oral and written summary of breast cancer treatment options – including breast reconstruction – that had to be given to a patient. Unfortunately, the state did what it was supposed to do for one year, then it just sort of got put on the shelf.” She not only helped get enforcement of that law off the shelf – and updated the information to be given to every woman in the state diagnosed with breast cancer – but over the past decade, led multiple legislative efforts that separated Breastoration from

other breast reconstruction awareness groups. In addition to working for the Louisiana Supreme Court, Kim also was the public policy chair for the United Way of Southeast Louisiana and worked with the state Legislature on various issues. She used the lessons taken from those roles to help push Breastoration to the front line in the state capitol. “I just said, ‘Oh, we need legislation?,” she recalls. “ ‘OK, let’s sit down, let’s find some sponsors, and let’s move it.’ We were able to get a number of bills passed very quickly.” These efforts included removing outdated laws that required that a mastectomy and reconstruction be performed under the same insurance policy; the inclusion of tattooing and liposuction in the definition of breast reconstruction; insurance coverage for complications from surgical procedures; clarification that insurers could not penalize physician reimbursements or patient benefits for type of reconstructive surgery selected by a women in consultation with her physician; and insurance coverage for preventative imaging screens annually for women who had mastectomies. During the pandemic last year, Breastoration was informed by breast surgeon Amy Rivere, MD, that insurance companies were declining coverage for a prophylactic mastectomy on a noncancerous breast, but providing coverage for reconstruction of that same breast. Within weeks, Kim drafted the new legislation

When you’re already dealing with the fear and anxiety of a cancer diagnosis, it’s a big help to not have to compound that with being able to meet some basic expenses. —Jules Walters, MD to include prophylactic mastectomies in the definition of breast reconstruction, found a Senate sponsor and the practice was prohibited in a new law that passed unanimously. “We have legislators who quickly grasped the problems facing breast cancer patients, leading to the passage of the strongest breast reconstruction laws in the nation,” Kim says.

Support from the plastic surgery community

Breastoration hosts an annual fundraiser on or near Breast Reconstruction Awareness Day, the most prominent of which is Galatoire’s Goes Pink in New Orleans, which includes plastic surgeons, oncologists, hospitals, breast surgeons and local community leaders. Several Louisiana plastic surgeons also became supporters of

Breastoration, including ASPS member and Louisiana Society of Plastic Surgeons President Jules Walters, MD, who is a CALA board member and helped the organization on some of its legislative efforts. He says he’s continually inspired by the sense of community Breastoration fosters in his patients. “I remember one particular patient learning about the organization,” he recalls. “She went through the reconstruction journey and knew patients who were helped by Breastoration. Around Christmas one year, she called me out of the blue and said, ‘I want to do my part and help another breast cancer survivor. Is there anyone that you know that might need help buying Christmas presents?’ I mean, this is what life’s all about – bringing people together and finding that sense of community and wanting to make a difference in each other’s lives.” It’s also a big reason why in addition to educational and advocacy work, the philanthropic help for patients – even if it’s assigned a particular dollar value – is often invaluable. Patients must have a diagnosis of breast cancer or be in need of reconstruction due to a prophylactic mastectomy due to genetic findings. The second criteria is that the surgery be performed in the state of Louisiana by a state-certified plastic surgeon. To ensure that no preference is given to individual physicians or hospitals within the Cancer Association’s service area, once the agency staff have verified that the surgeon

and hospital are within the service area, the name of the treating physician and hospital will be redacted from the applications prior to distribution to committee members. Funds are to be used for ancillary needs such as rent, utilities, food, child care and lost wages. “As medical bills start to accumulate, patients are often left with the decision of, ‘Do I put gas in my car or do I pay my medical bill?’ ” Dr. Walters says. “When you’re already dealing with the fear and anxiety of a cancer diagnosis, it’s a big help to not have to compound that with being able to meet some basic expenses.” The continued growth of the community fostered through Breastoration is something that still amazes Tammy Swindle, the executive director of CALA, who has administered the Breastoration fund since its inception. “This fund has a direct effect on the lives of women undergoing reconstruction due to their cancer diagnosis,” she says. “I love that we get to be a part of women's lives and watch them grow, blossom and change throughout their reconstruction journey. My hope for Breastoration in the future is that we continue to do what we do best – and that is remove barriers to reconstruction, along with educating more women about their options.” For more information about Breastoration and to access an application or provide support to the non-profit, visit breastoration.org.

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COMMUNITY AWARENESS

Fighting Pretty PROVIDING STRENGTH BEAUTY TO WOMEN BATTLING BREAST CANCER By Kendra Y. Mims-Applewhite

“How do you look so good?” Kara Frazier was often asked about her radiant appearance during her chemotherapy sessions.

Determined not to let her stage 3 breast cancer diagnosis dampen her confidence and spirit at 26 years old, she rocked her bright head scarves after losing her hair and wore hot pink lipstick throughout treatment. She says a pair of mini pink boxing gloves from a family friend helped her tap into her inner strength.

“The pink lipstick was the one thing that brightened up my face with my scarf,” she says, noting she also showed up to treatment in stylish attire instead of loungewear to make herself feel better. “But even more than the lipstick and clothes, the boxing gloves inspired me to stay strong and made me want to try and feel beautiful.” Three years after her treatment ended, Kara felt a pull to do something based on her experience as a young breast cancer survivor. Her vision became clear when she sent a care package to another woman facing a breast cancer diagnosis. The box included pink lipstick and the boxing gloves she received as a gift. The impact of that message spurred Kara to create an organization that shipped care packages to remind women of their strength and beauty while fighting the disease.

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“I have a supportive family that instilled that confidence in me, but not everyone has that support system,” Kara says. “I thought maybe I could do that for people.” Kara launched her nonprofit organization, Fighting Pretty, in 2013. Within the first year, she shipped 500 “Pretty Packages” from her home in New York, and her reach doubled when she relocated to Portland, Ore., the following year. To date, Fighting Pretty has reached more than 15,000 women in all 50 states and 17 countries. “Our biggest achievement is that we continue to grow and help more women every year, even through COVID,” she says. “We are nimble enough to inspire and support women, regardless of their stage or whether they’ve just been diagnosed, still in active treatment, just got out of surgery or they’re 10 years out of cancer treatment. We are relevant to anyone who has ever experienced cancer and could use a reminder of their strength and beauty.” The inspiration behind the organization stemmed from a conversation Kara had with a woman in her support group who conceded she slept in her wig. After listening to her fears about taking off her wig in front of her husband, Kara reminded the woman she was still beautiful without hair and taught her how to wrap a head scarf. She says the encounter shed light on some of the challenges women battling breast cancer were facing. “Her husband never saw her without her wig, and she was terrified, but she felt like a million bucks after we wrapped her head scarf,” Kara says. “That woman made me think this was an opportunity to inspire and empower these women to own it. It made me realize women are losing a sense of themselves because

they don’t have the inner confidence. I want to help remind women they are not ‘cancer patients.’ They are still themselves and still beautiful, sexy, amazing women whether they have hair, eyelashes, breasts, ovaries or not.” Through Fighting Pretty, family members, friends and caregivers can support women battling breast cancer through several initiatives. The Pretty Package program lets supporters send customized packages with inspirational items (such as apparel, mini boxing gloves, a wine set, earrings and more), with the proceeds from all shop items going right back into the nonprofit to support the mission. “Everything in the shop is designed to empower women and remind them that they are fierce,” Kara says. “Once they get that Pretty Package, they can join our network and communicate with other women just like them.”

Strength and beauty

Kara and her team launched the Strength and Beauty program during COVID-19. When the pandemic halted volunteer events and prevented the organization from prepackaging orders with volunteers, they shifted gears and partnered with cancer centers, hospitals, support groups and plastic surgeons throughout the United States and Canada to provide Strength and Beauty kits – a miniature version of the Pretty Package – to women battling cancer in active treatment. “With COVID, these women were going through cancer alone, so it was even harder to feel supported, inspired and PSN: BREAST RECONSTRUCTION 2021 l

COMMUNITY AWARENESS

beautiful,” Kara notes. “But our focus is crystal clear now more than ever because of the Strength and Beauty program. We started reaching out to cancer clinics and plastic surgeons and offering to partner with them so that patients wouldn’t feel alone coming out of surgery and through their treatment. The program took off.” The Strength and Beauty kits come with a pair of Fighting Pretty mini boxing gloves, an inspirational card and lipstick donated through Thrive Causemetics, a clean beauty brand. Despite the pandemic’s unprecedented disruption, Fighting Pretty shipped more than 3,000 Strength and Beauty kits during COVID-19 and is on target to send 5,000 kits to hospitals and plastic surgeons this year. “We work directly with plastic surgeons, and we get amazing feedback that these kits really do help their breast reconstruction patients,” Kara says. “Your body changes after reconstructive surgery, whether it’s an implant or explant, and it’s such an emotional process. The surgeons say they are so thankful for having a kit they can provide to their patients because it makes their relationship closer and reminds patients that they are beautiful. We are helping so many women in active treatment now and getting the word out to providers that we have this resource.” ASPS member Juliana Hansen, MD, experienced the impact of Fighting Pretty firsthand during her battle with breast cancer when their paths crossed at OHSU Knight Cancer Institute five years ago.

The women in this photo are three of five recipients of the original pink boxing gloves.

Kara packs and ships Pretty Packages from her mother's home in 2013.

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“We met to discuss my role in breast reconstructive surgery and the overlap with hers as the marketing manager for OHSU, but she immediately recognized the head scarf I was wearing to cover my bald chemo head,” Dr. Hansen recalls. “Our meeting’s topic took a different turn as we traded cancer stories, and I learned of her own diagnosis at 26. While my response to breast cancer was to just keep on with daily life, Kara’s response was to start helping and inspiring others.” After their meeting Kara hand-delivered a Pretty Package to Dr. Hansen with her signature mini pink boxing gloves, lipstick and other comforting items, including a copy of her own story for inspiration and guidance. Dr. Hansen, who serves on Fighting Pretty’s board, says the organization helps women smile through their adversity and delivers hope to her reconstruction patients. “I have watched patient after patient of mine light up when receiving their own Fighting Pretty gift and the powerful knowledge that they are being provided a supportive network of strength and love,” Dr. Hansen says. “Kara is a force of exquisite beauty and profound strength.”

Making an impact

In 2018, Kara made an appearance on the “Today Show” to discuss her organization – a defining and proud moment for Fighting Pretty, she says. They received 2,000 Pretty Package orders on that day alone. “It wasn’t just about being on TV, but it was more about sharing our message with anyone watching and having 100 volunteers behind me,” Kara says. “My family, friends and supporters flew in from around the country to help us make 400 Pretty Packages on the show that morning, which we handed off to cancer patients in local hospitals. It was the perfect representation of what Fighting Pretty does. It brings together a community of people who care about helping women to feel strong and beautiful through cancer.” Kara says the moment was much bigger than her personal story. “It enabled us to have a megaphone to inspire women and help families and friends of cancer patients know they could do something,” she says. “It was such a proud moment because it wasn’t just about Kara who had cancer at 26. Now there are 15,000 women out there who consider themselves to be ‘Fighting Pretty.’ That’s a small number in comparison to the number of women battling cancer, so we have a lot of work to do. But inch by inch, mile by mile, we are making an impact.” In addition to running Fighting Pretty with volunteer staff, Kara is a full-time marketing manager at OHSU Knight Cancer Institute. She says following her passion to launch Fighting Pretty has changed her life and afforded her unique and exciting opportunities, such as ringing the New York Stock Exchange Closing Bell, appearing on the “Today Show,” walking in the AnaOno/Cancerland fashion show at New York Fashion Week

and participating in the Gap Body and Ulta Beauty breast cancer awareness campaigns. “I could have never imagined this in my life,” Kara says. “Professionally, I have never had a job that has taught me as much as Fighting Pretty. On a personal level, it has made me much more confident about the woman I am.”

Still Fighting Pretty

In 2020, Kara decided to have her breast implants removed for personal reasons following a device withdrawal a decade after her breast reconstruction procedure. Although she felt great physically as a 10-year cancer survivor, she says her explant surgery and new body reawakened her past trauma. The Fighting Pretty boxing gloves provided her strength as she planned her wedding. “The idea of Fighting Pretty was reinvigorated for me personally last year when all this PTSD from my cancer battle came flooding back because of the surgery,” says Kara, who recently tied the knot. “I was trying to ‘Fight Pretty’ while searching for a wedding dress and swimsuits for my honeymoon without any breasts, and I was doing it as a healthy woman who had beaten cancer. Healthy women 10 years out of treatment may be Fighting Pretty for as long as they live because they are still looking at their scars and going through emotional challenges that were brought on by the disease. These little gloves remind women to keep Fighting Pretty and stay strong even when they are cancer free.” Kara is moved to tears when she considers what Fighting Pretty means to her at this stage in her life. “I have a new flat chest that looks scary in comparison to when I had implants, and it’s extremely emotional,” she says through tears. “If you continue to remind yourself that you’re strong and beautiful, and you have a healthy body, even if it doesn’t look like everyone else, you’re Fighting Pretty, and that is something to be proud of.” ASPS member Alison Nauta, MD, of OHSU Knight Cancer Institute, worked with Kara on several projects at OHSU and attended her Fighting Pretty events before she performed her explant surgery last year. She says she admires Kara’s infectious positivity and drive to help women in their darkest hour. “Kara’s journey through cancer has not only given her a new lease on life but has enabled her to inspire others to do the same,” Dr. Nauta says. “She has taken an event that happened to her when she was young and turned it into a positive by giving women something that makes them feel confident and maintain a sense of self. Through her personal connections with patients and providers in Portland, she’s been able to help them as they go through their journey.” Dr. Nauta and Kara note their relationship has evolved from colleagues to physician-patient to friends. Kara credits both Dr. Nauta and ASPS member Peter Cordeiro, MD, who performed her

Fighting Pretty Story: Rowena Bergman, New Jersey

was diagnosed with DCIS (pre-invasive breast cancer) in 2016 after a routine mammogram. I decided to undergo a bilateral mastectomy and breast reconstruction. My friend sent me a Fighting Pretty package around surgery time. There were these cute, pink boxing gloves inside the box. I hung them up in the rearview mirror in my car. I occasionally joined group fitness classes and always liked boxing, but I never got into it. After healing from my reconstruction, I looked at those gloves and told myself I needed to get in tip-top shape. Coincidentally, I started boxing after my recovery and have been doing it for five years now. My first pair of boxing gloves were pink because of Fighting Pretty. Throughout the last five years, the road to recovery has had a lot of ups and downs but boxing was the one thing that kept me strong physically and mentally. Kara’s organization is so inspiring and empowering. Cancer is a scary thing. Her boxing gloves symbolize fighting through it. The peer-to-peer-inspiration is phenomenal and powerful for survivors and women going through it. My motto now is: I’m going to fight like a boxer. Breast reconstruction is an extremely personal choice, but for me, it was a no-brainer. My decision had a lot to do with my plastic surgeon. His bedside manner was amazing, and I loved him immediately. He was so comforting and explained everything to me so well. I knew I was in good hands. I didn’t think about breast reconstruction as a big piece of it at first, but the procedure was like a silver lining for me. The size of my chest hindered a lot of things. I’ve always been top heavy, so I avoided going to the gym. Breast reconstruction was necessary for me to carry on with life. Now I can work out, take up boxing and move around easier than I could before. I can enjoy the life I wanted, remain active and run around with my kids or go to the pool with them. Breast reconstruction has improved my quality of life. You have to count your blessings. PSN: BREAST RECONSTRUCTION 2021 l

Fighting Pretty Story: Paula Flory

breast reconstruction procedure, for helping her through her reconstruction journey. “Dr. Corderio did such an amazing job with my breast reconstruction, and I was happy with the outcome for many years,” Kara adds. “Dr. Nauta became a surgeon and a sister after my explant surgery. They are both caring, professional and amazing.”

New Jersey

n 2011, I was diagnosed with stage 3 breast cancer after finding a lump in my armpit. I was 45 and in the best shape of my life. I chose implant-based reconstruction following a mastectomy. I discovered Fighting Pretty long after my initial diagnosis while working as a director of a breast cancer organization in New Jersey. We received Fighting Pretty packages to distribute to breast cancer patients. I was on a quest to find the simplest way to feel whole and restore myself to feel good in my own skin. In the midst of my journey, I received this beautiful pink box. It was a little box of hope. Fighting Pretty validated that many of us on this journey are faced with the prospect of dying but also the reality of knowing our body will never be the same. There is this whole community and world of women facing breast cancer who feel like something is taken away from us that won’t come back. I’ve met many women who feel superficial about missing their breasts, but I tell them it is a big deal. It’s an amputation. For many of us, it’s part of who we are. It’s okay to mourn the loss of your breasts and the way they were before cancer. It’s OK to continue to fight to be pretty. I was not alone in my quest to feel beautiful again. What Fighting Pretty is doing with their boxes resonates so deeply with some of us. Receiving the box, opening the box, using the products and hanging on to those pink boxing gloves is an entire experience. It inspires hope in a big way. I was into boxing before cancer, and I continued boxing with pink gloves to remind myself to keep fighting. When I received the mini pink

What pretty means to you gloves in the box, I knew it was a sign to keep moving forward. I had a long and complicated reconstruction journey, including nine revisions. Six years after my initial procedure, my plastic surgeon recommended I undergo latissimus dorsi flap reconstruction surgery, and that improved my quality of life tremendously. I had a desire to remain athletic and exercise, and the recovery was a complete 180. I had challenges, but my life is so much richer because of all of it. I found a plastic surgeon who encouraged me through my journey. I appreciate plastic surgeons who combine their artistry and compassion and dedicate themselves to helping us feel whole again. My feminine form is so important to me. The reconstruction aspect is just as important as the oncology piece. Many of us would feel dead inside without having a compassionate plastic surgeon by our side to tell us, ‘We are going to help you feel like the woman you are.’ It’s really the most important piece for some of us. Yes, we survived, but now we don’t have to be ashamed when we take off our tops. Yes, we have these scars, but they have meaning. I fought for my life and these scars are a roadmap of that fight. But I have a plastic surgeon by my side who made me feel beautiful not in spite of, but because of what I went through.

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Although the idea started with hot pink lipstick, Kara wants people to know Fighting Pretty is more than a beauty product. The Fighting Pretty mentality empowers women to define beauty on their own terms. Fighting Pretty means different things to different people, Kara adds. “Whether you put henna all over your head and hands because that makes you feel powerful, or you lay around in your sweats to watch your favorite movie because you don’t want to think about cancer today, you’re Fighting Pretty,” she says. “Or you could be the woman who wears big earrings, hot pink lipstick and high heels. Fighting Pretty means something different to everybody because it’s a feeling that says, ‘I want to pick myself up and feel good today and face whatever is coming my way.’ That’s what our mission is all about.” Kara wants Fighting Pretty to become a household name in the future. Her goal is to continue expanding its reach and get Pretty Packages and Strength and Beauty kits into every woman’s hand who needs them. With more funding, she could make her dream a reality. “When a woman hears she has breast cancer, or any type of cancer, I hope she encounters us at some point in her journey and feels like, ‘I got this, and I can take on this challenge because I know I am strong enough and beautiful no matter what,’” Kara says. “I hope people can use the Fighting Pretty name to describe themselves and they can embrace whatever comes their way and ‘Fight Pretty’ through it all.”

SURVIVOR STORY

Breast Cancer Survivor Creates Intimates Brand to Help Women Reclaim Femininity By Keira Kotler

was only 40 years old when I was diagnosed with breast cancer following a routine mammogram. With no known risk

factors or family history, I underwent a bilateral mastectomy, followed by tissue expanders and silicone implant reconstruction. As a young woman in a new relationship, the decision to have reconstruction was not a simple one. I knew there might be complications or ongoing maintenance if I elected to do it. But I also wasn’t prepared to not have breasts at all. Thankfully, my breast reconstruction surgery went well, and while I have experienced some minor issues with scar tissue and nerve damage, I am happy with the choice I made. Following surgery, however, I was shocked to discover that getting dressed in the morning was one of my greatest challenges. My old lingerie and sports bras didn’t fit or caused pain, and the existing post-operative garments I found were synthetic and scratchy – not to mention incredibly unattractive. It honestly felt

Keira Kotler

like adding insult to injury. After trying on more than 200 bras in a six-month period, I finally started speaking with other women and quickly found the issue to be universal with both newly diagnosed women and decades-long thrivers alike. The more women I spoke with, the more I learned how this issue went far beyond clothing. The inability to start each day free of pain and discomfort represented a barrier to healing on emotional and psychological levels. With this realization, I

decided to pay my good prognosis forward and solve this problem for others with Everviolet, a collection of intimate apparel designed for the special needs of women following cancer surgery and treatment. My mission is to help women reclaim a sense of self and femininity following change, enabling them to feel like people first and patients last. The Everviolet collection is for women in all stages of healing and recovery, accommodating limited arm mobility, asymmetry, prosthetic breast forms or flat chests, skin sensitivities, swelling, incision and nerve damage sites and lymphedema. Having been through cancer surgery and treatment personally, I understand firsthand how incredibly sensitive skin can feel after these procedures – not to mention that when one’s body is altered or becomes limited for any reason, it’s common to experience feelings of loss, detachment and shame. I want to help women find acceptance and confidence in themselves and feel their most beautiful, regardless of how their physical shape may have changed. Women should not have to compromise elegance and beauty for comfort and functionality. I believe that we should love the lingerie we wear every day, and if we can do so with a renewed sense of confidence and comfort as well as feeling sexy, feminine and beautiful, we approach life differently and more positively. It is my honor as a founder and a designer to nurture these feelings in others. In addition to our intimate apparel collection, Everviolet also focuses a great deal on community. With a journal that shares individual woman’s stories and offers health and wellness resources, the people we serve are far more than customers. They’re family. We welcome all women to join our Facebook group, Beauty of Change, which is an inclusive, empowered and nurturing community dedicated to helping women support each other during any life changes or transitions they may be experiencing. PSN: BREAST RECONSTRUCTION 2021 l

PATIENT SAFETY

Breast reconstruction after COVID-19 By Daniel Liu, MD

The modern world has transformed since March 2020 when the COVID-19 pandemic took hold in the United States. COVID-19 affected all aspects of life, resulting in

drastic policy measures in an effort to “flatten the curve.” Early in the pandemic, non-urgent breast reconstruction procedures were restricted by healthcare facilities to protect vulnerable patients and preserve hospital resources. ASPS even recommended that microsurgical autologous breast reconstruction be delayed, due to the need for higher resources and prolonged hospitalization compared with implant-based reconstruction. At the time of this writing, the world has confirmed more than 200 million cases (36 million of those in the United States) of COVID-19, resulting in more than 4.3 million deaths (more than 600,000 in the United States). Multiple waves of infection caused by variants of COVID-19 continue to affect both the economy and healthcare system. However, the introduction of multiple, highly effective COVID-19 vaccines is nothing short of a medical miracle. In other words, COVID-19 has essentially become a preventable disease. Immunized individuals can enjoy a radical risk reduction in contracting the virus, spreading the virus, hospitalization, serious illness and death. This remains the best way that breast cancer patients can protect themselves while undergoing treatments including breast reconstruction surgery. So far in 2021, hospitals in developed countries have not been overwhelmed with COVID-19. Nevertheless, rising hospitalizations among unvaccinated individuals may threaten

hospital capacity and delay elective procedures again. COVID-19 accelerated the pace of innovation across all specialties treating breast cancer, ultimately improving care and reducing costs. Plastic surgeons embraced the rise of telemedicine to meet new patients and efficiently provide follow-up care without travel. There has been an emphasis on more short-recovery procedures, such as direct-to-implant breast reconstruction. Most surgeons have finally adopted Enhanced Recovery After Surgery (ERAS) protocols, liposomal bupivacaine for pain control and outpatient reconstructions to reduce hospital stay. Some questions remain about potential thrombotic complications after COVID-19 infection, which could affect the risk of undergoing microsurgery, and evidence will be forthcoming. Experts acknowledge that COVID-19 is here to stay. Preoperative screening has become commonplace before surgery and chemotherapy. Antibody-level checks could become part of risk assessment. Infection-control safety protocols remain in place across hospitals and clinics, which limit the number of caregivers to support patients in the hospital. Universal masking will be required in the foreseeable future in healthcare settings. Nevertheless, it is important that women do not put off getting treatment because of COVID-19 fear. Vaccinations are now widely available, and the healthcare system is better equipped to handle spikes in new COVID-19 variant cases. Experience over the past 18 months has shown that immediate breast reconstruction is safe with all of these precautions in place. There is no evidence that either COVID-19 or the vaccine interferes

Breast Implants: What Patients Need to Know with anesthesia. Still, undergoing surgery temporarily places extra strain on the immune system. For patients who have recovered from COVID-19, the American Society of Anesthesiologists (ASA) recommends waiting from four weeks (for those with no symptoms or mild symptoms) to 12 weeks (those admitted to the ICU) before having elective surgery. Because the COVID-19 vaccines available in the United States do not contain live viruses, they can be safely used in people with weakened immune systems – including cancer patients. The vast majority of people with breast cancer or a history of cancer should receive a COVID-19 vaccine. Minor side effects are to be expected and represent a sign that the vaccine is working by mounting an immune response. Women who have undergone axillary lymph node removal could theoretically experience transient lymphedema as a side effect and should ask to have the vaccine injection in their opposite arm or upper thigh. Some people have experienced enlarged axillary lymph nodes under one arm, which is harmless, but may lead to unnecessary stress and additional testing. The Society of Breast Imaging recommends that women try to schedule their routine screening mammogram at least one month after vaccination. Recently vaccinated patients undergoing scans to monitor cancer progression (such as PET/ CT) may lead to misinterpretation of enlarged lymph nodes, and coordination will be essential to reduce wasted scans. Regarding the timing of elective surgery, the vaccine should be administered at least one week before surgery so that symptoms, such as fever, can be correctly attributed to vaccine side effects rather than surgery. Vaccination can also occur once patients are recovered, one to two weeks after breast surgery, to be assessed on an individual basis. If the current COVID-19 vaccines continue to be effective, the pandemic should be nearly over in developed countries. For the short term, COVID-19 will likely become a seasonal illness, until global vaccination can be achieved. Challenges lie ahead including revaccinating against variants, treating long COVID and mental-health issues. Humans are remarkably adaptable, and your surgeons remain committed to helping you navigate through breast reconstruction in a safe environment. ASPS member Daniel Liu, MD, is a boardcertified plastic and reconstructive surgeon at Cancer Treatment Centers of America® in northern Illinois. He specializes in all forms of breast reconstruction and is passionate about promoting public education on breast reconstruction and plastic surgery.

reast implants are FDA-approved devices that offer many quality-of-life benefits for patients. Many women undergo these procedures successfully each year but, as with all devices, there are risks associated with breast implants that you should be aware of to make an informed decision.

Breast Implant Reconstruction Procedures

Breast implants remain an important option for breast reconstruction procedures. Patients considering breast implants should seek out a board-certified plastic surgeon to help weigh the benefits and potential risks to make the best possible decision. For more information on reconstructive breast implant procedures, please visit our Breast Reconstruction procedure page at plasticsurgery.org.

Breast Implant Safety

The American Society of Plastic Surgeons takes all patient safety concerns seriously and has developed several registries that work together to advance patient safety and research. In collaboration with the FDA and breast implant-device manufacturers, The Plastic Surgery Foundation has developed the National Breast Implant Registry (NBIR) to strengthen the national surveillance for breast implant devices in the United States. ASPS/PSF and the FDA also developed a Breast Implant-Associated ALCL Registry, the PROFILE Registry, to increase the scientific data on ALCL in women with breast implants. The primary goal of this collaboration is to better understand the role of breast implants in the etiology of BIA-ALCL. The research also will focus on identifying potential risk factors and criteria detection and management of this disease. FDA-approved breast implants undergo initial, mandated testing to demonstrate reasonable assurance of safety and effectiveness. The FDA continues to monitor patient experiences with breast implants, review emerging safety data on an ongoing basis and communicate with patients and physicians if any new risk emerges. The majority of women with breast implants experience no serious complications, but that's not to say a patient could not have a negative reaction to any medical device. If a patient desires to have her breast implants removed, she should consult with her plastic surgeon.

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PATIENT EDUCATION

Traveling to another city for breast reconstruction By Constance M. Chen, MD

Women undergoing mastectomy must make several decisions about breast reconstruction: whether, when

and how to have breast reconstruction, and, crucially, who should perform the surgery. Often, women are referred to a plastic surgeon by their breast surgeon and assume that all of their options will be presented. Both mastectomy and breast reconstruction have come a long way, and not all plastic surgeons are able to offer all reconstructive options. Cutting-edge innovations can be life-changing, but patients often have to conduct extra research 24

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to educate themselves to find the right solution for their problems.

There have been significant advances in breast reconstruction in recent years. When working with a mastectomy surgeon who can preserve the breast skin and nipples, a reconstructed breast can look and feel just like a normal breast, and sometimes other doctors don’t realize that it is not the woman’s original breast. Surgical options to create a soft, warm, natural breast from the woman’s own tissue have improved to the point that new microsurgical techniques allow plastic surgeons to reconnect nerves and restore feeling to the

breast. Sometimes, however, it takes some work to find highly specialized surgeons who have the skill set to achieve the best results. In some cases, women may need to travel away from home for a team who can provide them with adequate breast reconstruction options. Surgeons vary widely in their experience and in operations they feel comfortable undertaking. Patients should understand a surgeon’s certifications and ask how often they have performed various procedures. Importantly, each woman should make sure that the recommended surgery is the best one for her and not simply the one preferred by the plastic surgeon that she happens to meet. For example, newer procedures for autologous reconstruction (with the woman’s own tissue), such as the DIEP or PAP flap, require specialized microsurgical skills to reattach tiny blood vessels under an operating microscope. Plastic surgeons with advanced microsurgical training are not available everywhere. Furthermore, just because a surgeon can perform the technical operation does not mean that the final overall outcome is the same. Surgeons often have drastically different philosophies about the importance of the final medical and aesthetic outcome. Beyond professional qualifications, patients must find a surgical team with which they feel most comfortable. Are questions welcomed and answered fully? Do you feel you can speak freely and have open and honest communications about your concerns? What kind of support will you get on administrative and financial matters? If the best team for you is far from home, what kind of assistance and support can you count on for travel arrangements and for managing follow-up care? Open communication with the surgical team is the most important factor in arranging for surgery far from home. Here are several things to consider when traveling to another city:

• Whether your plan is to have the mastectomy and immediate reconstruction in a single surgery, or to have reconstruction after the mastectomy, many of the issues regarding travel are similar.

• You may need to coordinate local care in advance with a primary care physician or local surgeon for a presurgical exam and lab work as well as for post-operative follow-up care once you return home.

• You will need accommodations in a hotel or short-term apartment rental that caters to and has special rates for surgical patients. Your surgeon’s office or hospital should be able to provide recommendations and help you estimate how long you will need to stay for follow-up care after your discharge from the hospital.

For a woman recovering from breast surgery, breast reconstruction is often a crucial aspect of the healing process – both physically and psychologically. For some women, traveling to achieve the best breast-reconstruction option provides an enormous boost to her sense of self. Knowing that she has found the surgeon who is committed to her well-being puts her on the right road to recovery so that she can live a long and healthy life beyond cancer.

• Some cities have special facilities for patients, such as the American Cancer Society’s Hope Lodge, which offers guest suites for patients and caregivers as well as communal kitchens and activity rooms. Hope Lodge has 30 locations in the United States. • Several charitable organizations including Corporate Air Network and Angel Flight provide free air travel for cancer patients. More information on charitable medically-related travel is available at patienttravel.org, a national referral service.

ASPS member Constance M. Chen, MD, of New York, is a board-certified plastic surgeon with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. Dr. Chen is committed to aesthetic restoration of the breast and body and enjoys helping her patients achieve overall well-being.

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COMMUNITY OUTREACH

Mission Plasticos:

Reshaping Lives By Amy Carpenter-Aquino

ASPS member Karen Leong, MD, is so committed to helping breast cancer survivors in need of reconstructive surgery that she performed a volunteer surgery while 37 weeks pregnant. Dr. Leong is lead surgeon for Reshaping Lives California (soon to be Reshaping Lives America), which serves, among other patients, low-income and uninsured women who are postmastectomy and in need of reconstructive breast surgeries. “These women are able to have their disease treated, but once they have the cancer removed, it’s deemed a cosmetic concern for them to receive reconstruction,” Dr. Leong explains. “It’s pretty devastating for a woman to, first of all, receive a diagnosis of breast cancer; second, to go through all those treatments to be given the diagnosis of cancer-free; and then to be left with a daily constant reminder of what was taken away from them.”

The loss of one or both breasts leaves female patients feeling less feminine, less attractive to their partners and less than whole because part of themselves has been taken away, Dr. Leong notes. “Every time a breast cancer survivor takes off her clothing or is unable to wear a certain type of clothing because of the result of her cancer treatment surgery, I think it changes the way that they view themselves and how they think others view them. It’s like they have that scarlet letter on them: ‘Yes, I’m a survivor, but now I’m deformed.’ ” Reshaping Lives California is the domestic arm of Mission Plasticos, which since 1999 has provided more than 15,000 life-changing reconstructive surgeries to underserved populations through medical mission trips to Mexico, Guatemala, Bolivia and other countries. The shutdown of international travel due to COVID-19 halted trips to foreign countries and prompted Mission Plasticos to shift

There are so many people here with similar reconstruction needs but who were lacking the resources, connections and financial funding necessary. We can’t have a strong international component without an equally strong local component. —Karen Leong, MD

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its focus and resources to Reshaping Lives California. “I’ve always been interested in medical missions internationally, but I also thought that there was a domestic, local need that was not being met,” says Dr. Leong, whose practice is based in Newport Beach, Calif. “There are so many people here with similar reconstruction needs but who are lacking the resources, connections and financial funding necessary. We can’t have a strong international component without an equally strong local component.”

A national initiative

Mission Plasticos Executive Director Susan Williamson says they started the Reshaping Lives California program in 2016 after discovering that a primary need in the United States was breast reconstruction surgery for women who had undergone mastectomies. “Fifty-thousand U.S. women live below the poverty line and have breast cancer, and 30,000 of those women are uninsured and can’t afford reconstructive surgery,” Susan notes. Each year, Reshaping Lives California’s volunteer plastic surgeons screen patients and perform surgical procedures supporting breast reconstruction, including placement of tissue expanders and implants, nipple reconstruction and performing a lift on a patient’s original breast to match the reconstructed breast, if only one side was affected. About one-third of the patients who receive a consultation from

a Reshaping Lives California volunteer plastic surgeon are deemed eligible for a reconstructive procedure, Susan says. “The reasons they may not be eligible could be morbid obesity, being a heavy smoker or having had heavy radiation treatment during their care after their mastectomy,” she says. If a patient’s breast cancer was treated in a country that still uses cobalt radiation, for example, the tissue damage would make performing reconstruction too challenging and risky. “However, many of our patients have gone ahead and had several procedures with us to complete their recovery journey,” Susan adds. Beginning in October, Reshaping Lives California will support even more patients along their recovery journey with the launch of a national expansion and a new coalition dedicated to breast reconstruction called Reshaping Lives America, Susan says. The expansion is being funded in part by a fouryear partnership between Mission Plasticos (The PSF Charitable Care Grant recipient), and Sientra, which donated $1 million for hiring additional staff and will provide all the tissue expanders and implants needed for reconstructive surgeries. Sientra CEO Ronald Menezes will serve as the chairman and trustee of the Reshaping Lives America Corporate Council. “Women who are dealing with breast cancer are in one of the toughest fights of their lives,” Menezes says. “Sientra’s partnership with Mission Plasticos allows us to help women during this challenging time and highlights our mission of bringing transformative treatments and technologies to patients and surgeons.” Susan says she was inspired to approach the company about the expansion and partnership after attending the 2019 ASPS annual meeting. “We liked the fact that they only sell to board-certified plastic surgeons,” she says. “Many of Reshaping Lives California’s patients are prone to scar tissue because they are years out from their mastectomy, and their bodies are sensitive to rejecting the implant.”

(Above) Karen Leong, MD, (far right), and her team with patient Kareen Sandoval for the first stage of her breast reconstruction procedure. (Right) Dr. Leong poses with her team.

Moreover, as Dr. Leong points out, delayed reconstruction cases can take several procedures. “We have to put a balloon in there and stretch out the skin to try to recreate the semblance of a breast,” she says. “We have to add fat. We have to do symmetry procedures if it’s only on one side.” Susan emphasizes that because Reshaping Lives works with board-certified plastic surgeons, their patients receive the same treatment as any other patient. “The patients are not treated differently,” she says. “They’re not going to the giant low-income clinic where they’re made to feel marginalized. The plastic surgery office staff do not know that they’re Reshaping Lives patients. The only difference is the plastic surgeon interacts

with us when it comes to billing. And there is no bill.” With the national expansion, Susan says the goal is to connect thousands of women who cannot afford breast reconstruction with volunteer plastic surgeons. “We’re asking surgeons to commit to one surgery a year, and we’re hoping they’ll commit to more,” she says, adding that surgeons, anesthesiologists and nurses reach out regularly to Mission Plasticos looking for volunteer opportunities. “I think that is fantastic. And this is a way for them to give back in a very meaningful way with a structure around it.” Dr. Leong says that volunteering her time is the best part of her job as a plastic surgeon. PSN: BREAST RECONSTRUCTION 2021 l

COMMUNITY OUTREACH

“In Orange County, Calif., practitioners mostly serve cosmetic surgery patients, so this is a completely different population, where there’s nothing in it for us other than being able to give them back what they’ve lost,” Dr. Leong says. “I think it brings us back to our roots, back to the reasons why we went into medicine or why we were drawn into reconstruction – to just purely serve the need without any other driving forces for ourselves.”

'We don’t give up on them’

Dr. Leong shares the story of her “perfect patient,” Kareen Sandoval, and the impact that reconstruction surgery had on Kareen’s quality of life. “She was so excited by the time she received her implants that she says, ‘Look at my cleavage!’ ” Dr. Leong recalls. “She just has this amazingly positive attitude, and she’s been so grateful every step of the way. That’s the thing I find about all of these patients. Even before you touch them, they say, ‘Thank you, thank you, thank you,’ because you’re offering them an option that would be otherwise closed to them.” Kareen is the patient Dr. Leong operated on right before her due date. “She remembers feeling my baby kick against her side before she fell asleep,” Dr. Leong says. “And she held my 9-monthold baby before we took her back for her second and final stage of reconstruction. She says having a baby in her arms helped calm her nerves and take her mind off the upcoming surgery.” At a Mission Plasticos gala event where she was invited to share her journey, Kareen showed Dr. Leong a video she’d taken with a girlfriend who had supported her at every surgical visit. “They went into the pool, and she was twirling in her bathing suit with her cleavage, and she was just glowing,” Dr. Leong says. After Kareen’s heartfelt gala speech, which she delivered in English even

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Patient Kareen Sandoval holding baby Bristol, daughter of Karen Leong, MD, before her second and final stage of reconstruction.

though her comfort was in Spanish, Dr. Leong says there was not a dry eye in the place. Kareen only had good things to say about the process – even with the unavoidable delays and unexpected rescheduling of procedures. Dr. Leong notes she was grateful for the faith and patience that Kareen and all the Reshaping Lives patients place in their surgeons. “They don’t give up on us,” she says. “And we don’t give up on them.” Reshaping Lives California has a robust patient outreach system centered on local churches, clinics, and community centers, and advertisements in publications that serve low-income populations and on social media. Referrals come from Susan G. Komen and local healthcare agencies. However, the unmet need is still great, and Dr. Leong is passionate about spreading awareness to more low-income and uninsured women in need of postmastectomy breast reconstruction. “I know we’re only reaching a small percentage out there, and we want women to know that we are here, we will review every case personally, and we don’t turn people away. I don’t want them to say, ‘I wouldn’t be a good candidate.’ Just apply.”

Dr. Leong says she was “beyond thrilled” about the potential to reach more women in need through Reshaping Lives America. “I believe that giving back begins with serving within our communities, and a big part of our mission is to help complete the journey of care for women in poverty in the U.S. in need of post-mastectomy breast reconstruction,” Dr. Leong says. “Sixty percent of women living in poverty with breast cancer are not given the opportunity or option to receive the final step, a step I believe is critical for them to regain their sense of femininity and self. These women are breast cancer survivors, but they deserve to continue their lives without a daily reminder of all they lost to be called survivors. These numbers are significant, and this partnership with Sientra gives us the ability to make a difference. “I’m calling out to all my fellow breast reconstruction colleagues to please join us,” she continues. “If we each pledge to help one woman in need of breast reconstruction, we are taking a step towards eliminating this gap in our healthcare system and providing a much-needed service to our home communities.”

PATIENT EDUCATION

Surviving breast cancer

Knowing your options after diagnosis By Sybile Val, MD

Surviving breast cancer is often accompanied by a sense of loss if you have also suffered a mastectomy, double-mastectomy or lumpectomy. If you lose one or both

breasts because of cancer surgery, or because you elected to reduce your risk of breast cancer by having your breasts removed, breast reconstruction can help you can begin to look and feel like yourself again.

Know your options

Every woman’s anatomy is unique, which means the breast reconstruction technique that is right for you is based on a comprehensive evaluation of your situation and needs. As such, plastic surgeons take the time required to create a customized treatment plan specifically for our patients. However, the three most common types of breast reconstruction are breast implants, tissue expansion and flap techniques. • Breast Implants: Breast reconstruction can be accomplished using either silicone or saline breast implants to create the breast mound. Implants are often combined with tissue expansion or flap techniques. • Tissue Expansion: With this technique, a tissue expander is placed underneath the skin and is filled gradually, over time, to stretch the skin, making room for an implant. This is somewhat a lengthy process that involves several office visits, but the recovery period is easier and quicker compared to flap procedures.

• TRAM and Latissimus Dorsi Flap Techniques: These procedures recreate a breast mound by using muscle, fat and skin from other parts of your body – such as your buttocks, abdomen or back. The tissue is tunneled to the mastectomy site and remains attached to the original blood supply. In many cases, a flap technique may be combined with a breast implant. • DIEP, SGAP, PAP and ALT Flap Techniques: These free-tissue flaps require advanced microsurgical techniques in which blood vessel harvest and reconnection to chest vessels are required. The advantage of free-tissue flaps is that they use only skin and fatty tissue for reconstruction, thereby sparing the muscle.

Nipple Reconstruction

Breast reconstruction may also entail reconstruction of your nipple, if you choose, including tattooing to define the dark area of skin surrounding your nipple (areola).

What you can expect after surgery

You may be tired and sore for a few weeks after your surgery, and your plastic surgeon may prescribe medication to control your pain. In addition, you may have drainage tubes in place for a brief time after your surgery to remove excess fluids that collect in the surgical site. Wearing an elastic bandage or support bra can help keep swelling down and support your breast while it heals.

You will also have stitches after your surgery. They will probably be absorbable, though, so you won’t need to have them removed. Scarring is permanent, but the scars generally fade over time. Getting back to normal activities may take up to six weeks or more. Your plastic surgeon will let you know of any restrictions to your activities, such as avoiding overhead lifting or strenuous physical activities. Do not be surprised if it takes a long time to bounce back from surgery – some women report that it takes as long as a year or two before feeling completely healed and back to normal. Winning the battle against breast cancer shouldn’t mean losing your sense of femininity. Women who have lost one or both breasts to breast cancer can regain their figure and a sense of their old selves with breast reconstruction. Reconstructive breast surgery helps empower many breast cancer survivors looking to put cancer completely behind them. ASPS member Sybile Val, MD, has helped many Atlanta-area women improve their appearance with plastic surgery. She is a board-certified plastic and reconstructive surgeon and has extensive training in plastic and reconstructive surgery techniques and a strong interest in breast reconstruction. Dr. Val is dedicated to providing her patients with compassionate care in a private, warm and safe environment in her private practice is in Atlanta. PSN: BREAST RECONSTRUCTION 2021 l

WELLNESS

tips to create a functional and safe living space By Kendra Y. Mims-Applewhite Sanem Surel of San Francisco was diagnosed with infiltrating lobular carcinoma in her late 30s and elected to undergo breast reconstruction following a bilateral mastectomy. Her journey to recovery was not easy, as her treatment required multiple revision surgeries during an 18-month timespan. While navigating through her reconstruction journey, the interior and landscape designer renovated her home to create a safe, functional and comfortable environment during her treatment. Sanem is passionate about using her skills to help breast cancer survivors renovate their living spaces to better accommodate their needs after mastectomy and reconstruction. Sanem took time to share six designer tips:

Switch up your lighting You may be recovering in the same area for days. The space can get boring, so it’s helpful to switch things up and have a transitional space that gives you a different feeling during the day and in the evening. You can accomplish this by lighting. Your daytime and nighttime environment should be different. Use infloor lighting and floor lamps to change the ambience. I switch to dim lights in the evening, so I can calm down and play relaxing music before bedtime.

Declutter Your mind is already overloaded, so it’s important to eliminate clutter. You want to create a clean and open space. This also means getting rid of unnecessary furniture. You might have to run to the bathroom on the days you’re not feeling well, and you don’t want to run into a chair or trip over a pile of clothes. A minimalistdesigned space will provide comfort and enhance your safety.

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Power of pillows I had issues with my arms because of the drains in my arm pits, so a high-back sofa or platform bed wouldn’t work for me. You may have difficulty closing your arms, so stocking up on pillows and cushions will be beneficial. Your current furniture may not provide the comfort you need, so the inexpensive and easy solution is to invest in firm pillows and cushions in various sizes for optimal support and comfort, not only for your bedroom but also for other living spaces.

Create places without a roof I have been helping people create trendy and functional rooms for many years, which includes extending their interior space by designing outdoor living spaces. Transform your balcony or outdoor space into a living area to get fresh air and see the sky. Being in a room where you can’t see the sun or feel the wind can impact your mental health. Your circulation is important. You should still be connected to the real world. I was in the hospital often for surgeries, and the first thing I wanted to do when I returned home was to feel the wind on my face. Sitting outside on the balcony helped me a lot. I would read a book and drink sparkling water and hot tea. Enjoying a few moments outdoors can give you inspiration and hope that things will get better. Don’t limit yourself to your bed, as you will go through mood swings and challenges minute by minute. Spending some time in an outdoor area of your home will help. Even minor changes will uplift your spirit.

Keep living things around you As a landscape designer and outdoor lover, I like incorporating greenery around the house. Taking care of plants with an assortment of colors and textures changed my mindset. Even creating a small herb garden on my little balcony and using those herbs in my food for lunch or adding mint to a cup of tea in the afternoon gave me motivation. Having living things around you that you can taste, smell or see will connect you to the real world and foster positive energy around your home.

Sanem Surel enjoying her renovated outdoor living space.

R&R is key Rest and relaxation is essential during recovery. I created a calming atmosphere with scented oils instead of candles (the latter option had a stronger scent, and I preferred a lighter fragrance). If you have trouble sleeping, you can use pillow sprays to help fight insomnia. You need to rest while you’re healing – and everyone’s approach to the healing process is different. I engaged in mediation and spiritual practices to calm down after a difficult day. Find a ritual that works for you. Sanem's final tip: It’s difficult not knowing what is next for you while dealing with physical pain or mental exhaustion. The best tip is to be strong and remain positive. I respect and admire every woman dealing with a major health issue such as breast cancer, especially the warriors and survivors. The journey is rough and challenging, with lots of unknown variables and pain. Recreating your own environment during those rough days opens up your physical space and mind – and it shifts your energy. Living in a space with less clutter and adapting to new functional areas with increased circulation gives you more room for discovering freedom and joy. It’s time to make room and free up your mind for the new version of yourself that you will meet on the other side of your breast cancer journey. Sanem Surel holds a Master of Architecture degree from the Academy of Art University, San Francisco and a bachelor's degree in Urban Design and Landscape Architecture from Bilkent University in Turkey. For the past nine years, she has been involved in the design and construction of residential and commercial projects throughout the Bay Area, working as a designer for interior design, landscape architecture and urban design firms. You can learn more about her work at toolboxsf.co/ or follow her on Instagram @sanemsurel.

CORPORATE SPONSORS SUPPORT

Breast Reconstruction Awareness Day efforts

ven with increasing education about options after a breast cancer diagnosis, research shows that far too many women diagnosed with breast cancer still don’t know about their reconstruction options following a mastectomy. Launched by the American Society of Plastic Surgeons (ASPS) and The Plastic Surgery Foundation (PSF) in 2012, the Breast Reconstruction Awareness USA campaign is instrumental in providing these women with both education and information about their reconstructive options as they undergo breast cancer treatment. Breast reconstruction can help women rebuild their self-esteem and improve their quality of life following breast cancer surgery. Plastic surgeons play an important role in a breast cancer patient’s recovery process – and the annual Breast Reconstruction Awareness Day movement gives those surgeons an opportunity to empower cancer patients, celebrate survivors and help women make an informed decision at the time of diagnosis. The 10th annual Breast Reconstruction Awareness Day will take place on Oct. 20, 2021. The Breast Reconstruction Awareness Campaign would not be possible without the generous support of our dedicated corporate sponsors. Thanks to their commitment, the campaign continues to provide education and resources about reconstructive surgery and raise awareness to close the loop on breast cancer – both on Breast Reconstruction Awareness Day and throughout the year.

2021 SPONSORS Four companies have generously lent their support to the 2021 Breast Reconstruction Awareness Campaign. This year’s Diamond Sponsor is Allergan Aesthetics, an AbbVie company, one of the country’s leading suppliers of medical products for the global aesthetic medicine market. Sientra, a Silver Sponsor this year, has been a longtime supporter of the Breast Reconstruction Awareness Campaign. Both companies have launched multiple reconstruction solutions and are committed to continued innovation that will provide surgeons with the tools to improve patient outcomes in breast reconstruction. Integra Foundation and CareCredit are this year’s Breast Reconstruction Awareness Campaign Bronze Sponsors. Every corporate partner contributes annually to the campaign’s success and continues to make a difference in empowering women facing a breast cancer diagnosis, as well as providing them with reconstructive education. Donations from sponsors are applied directly to programs that support related research and awareness efforts, and provide charitable care. ASPS and The PSF sincerely thank the 2021 Breast Reconstruction Awareness campaign’s generous sponsors for their continued support and dedication to women’s health, patient education and innovation. For more information on the Breast Reconstruction Awareness Campaign corporate sponsors, visit breastreconUSA.org.

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SUNDAY | 10.31.21

Atlanta, Ga.

Join this year’s Close The Loop 5K campaign The Plastic Surgery Foundation and its Breast Reconstruction Awareness campaign have created a fun and easy way for you to help us raise awareness and reach new supporters. We’ve launched the 2021 Close The Loop 5K campaign and ask that you be one of the first to register and help spread the word! Participate in person Oct. 31 or virtually, anytime between now and Oct. 31.Register as an individual, as a team member or as a fundraiser only through the No Sweat Challenge. Here’s what you can do: • Join the 5K • Invite at least three others to join the campaign. • Raise at least $100 for the campaign. PARTICIPATE IN 5K ONSITE OR ONLINE! 7:30 a.m. CST | Oct. 31, 2021 Atlanta, Ga.

Breast Reconstruction 2021

Articles inside

Mission Plasticos: Reshaping Lives

Fighting Pretty: Providing strength & beauty to women battling breast cancer

SHARE seeds hope for breast cancer patients in Africa

Breastoration: Removing barriers to reconstruction

You inspire us to innovate and educate

Breast reconstruction after COVID-19

The inaugural San Francisco/California Breast Reconstruction Benefit