Breast Reconstruction 2022

2022

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PLUS: A LIFE OF SURVIVAL AND SERVICE Page 21

A Supplement to Plastic Surgery News

A patient’s guide to understanding her treatment options

Q&A:

Breast Reconstruction: Clearing up common misconceptions

Chicago doctor shares her journey and research efforts to reduce racial disparities in care

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Page 13

4 things to consider when finding the right plastic surgeon Page 16

Capturing a moment in time

LIFE CASTS HELP WOMEN RECLAIM THEIR LIVES AFTER MASTECTOMY Page 6

TABLE OF CONTENTS 4

Why the NBIR Matters

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Clearing up common misconceptions

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Life casts help women reclaim their lives after mastectomy

13 Chicago doctor shares research efforts to reduce racial disparities 15 New study sheds light on a fullrange of options after diagnosis 16 Finding the right plastic surgeon for your breast reconstruction procedure 18 Telemedicine: Improving access 20 A closer look at the lumbar flap in breast reconstruction 21 A life of survival and service 24 Hospitalist shares her reconstruction journey 26 Management of postoperative pain 28 SHARE looks to advance breast reconstruction in Rwanda 29 Exercise guidelines after breast reconstruction 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 Erez Sabag Designer Elena Bragg Illustrations Adobe Stock ASPS website plasticsurgery.org Breast Reconstruction Awareness website breastreconusa.org © 2022 The American Society of Plastic Surgeons

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

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2022 A NOTE FROM THE EDITOR

With progress made comes more work to do

A

s the medical editor of Plastic Surgery News and a breast reconstructive surgeon, I have the opportunity to work on important public education pieces such as this annual magazine focused entirely on breast reconstruction. Although I tend to keep up with what’s new in breast cancer treatment and breast reconstruction, I always take a few minutes to Google “breast reconstruction” to see what other information our readers may be faced with as they embark on their journey. Recently, I came across an editorial on “Breast Reconstruction After Mastectomy” published in 1976. The author cited that of the 90,000 new cases of breast cancer diagnosed each year, only about 5 percent of those patients will go on to have reconstruction. Closing in on a half-century later, that number is approaching 50 percent of more than 200,000 patients annually. Nevertheless, there is still work to be done.

As a plastic surgeon and scientist, 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. Since 2012, The Plastic Surgery Foundation (PSF) and American Society of Plastic Surgeons (ASPS) have supported the Breast Reconstruction Awareness USA 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. 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 that it can have on an individual who has faced breast cancer.

There is no “one size fits all” option for breast reconstruction. Although we’ve seen many aspects of life and business pause over the past couple of years, our dedication to innovation and awareness remains The PSF mission and has never waned. Our surgeon members, patient advocates and ASPS/PSF staff work tirelessly at the local and national level to fight for appropriate coverage of all options for breast reconstruction. Immediate lymphatic reconstruction at the time of oncologic surgery is a novel means to prevent the development of lymphedema after cancer treatment.

Building on our understanding of adipose tissue and stem cells, plastic surgeons can aid the body in regeneration with a goal of restoring sensation and repairing damaged tissue. We continue to study our use of breast implants – still the most common method of reconstruction worldwide – to achieve safe and reliable outcomes for our patients. Patient safety remains 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 (Oct. 19), this year’s edition of Breast Reconstruction is dedicated to breast reconstruction education and advocacy. This 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 points to know when considering breast reconstruction at any age or any time during recovery, drawing on extensive research and patient reported outcomes. 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 seventh special edition of Breast Reconstruction and join our efforts in closing the loop on breast cancer.

Summer E. Hanson, MD, PhD PSN Chief Medical Editor

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THE NBIR MATTERS

By Katie Sommers, MPH In October 2018, The Plastic Surgery Foundation (PSF) launched the National Breast Implant Registry (NBIR) in collaboration with the FDA, patients and breast implant manufacturers to help strengthen the collection of meaningful data on breast implants.

In the time since, the NBIR has collected clinical, procedural and outcomes data on more than 65,000 breast implant procedures.

Collecting this clinical data allows plastic surgeons and breast implant

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manufacturers to identify trends and other information that can be used to improve the safety of breast implants for current and future patients.

The next steps for the NBIR in the coming years will be to further refine the data collection form, ensuring that the most relevant information is collected; incorporating patient reported outcomes to allow for patients to provide input on the non-clinical endpoints and potentially to serve as the infrastructure for future studies.

Allergan Aesthetics, an AbbVie company, Mentor, and Sientra currently support the NBIR.

Katie Sommers is director of research and scientific affairs for the American Society of Plastic Surgeons.

PATIENT EDUCATION

Breast Reconstruction: Clearing Up Common Misconceptions

By Constance M. Chen, MD, MPH

The American Cancer Society estimates that more than 287,850 new cases of invasive breast cancer and about 51,400 new cases of ductal carcinoma in situ will be diagnosed in 2022. Less than half of

women who undergo mastectomy are offered breast reconstruction, however, and less than 20 percent of women who undergo mastectomy elect to undergo immediate reconstruction.

Although geographical and socioeconomic disparities prevent all women from having equal access to care, there is also a lack of information that enables outdated misconceptions to persist.

The Breast Cancer Patient Education Act (BCPEA) was implemented in December 2015 to inform breast cancer patients about the availability and coverage of breast reconstruction. Although breast reconstruction numbers have increased over time, there remains a wide variability associated with access to reconstructive surgery. Many women feel that breast reconstruction improves their quality of life. To deliver the best possible care, comprehensive and appropriate patient education can help each woman make the best individual decision for her.

Clearing up myths and misconceptions

Myth #1: Breast reconstruction increases the risk of the cancer recurring or makes a recurrence harder to detect.

The risk of breast cancer recurrence depends on many factors, including the stage of the disease and the biological characteristics of the cancer. Your doctor will take into account your level of risk in recommending the best option for

reconstruction, but numerous studies over the years showed no evidence that reconstruction increases the risk of recurrence or makes a recurrence more difficult to detect or treat.

Myth #2: I’ll have to wait months after the mastectomy and have another surgery for reconstruction.

Many women can have immediate reconstruction – that is, breast reconstruction that occurs in the same operation as the mastectomy. In fact, immediate reconstruction often yields the best aesthetic results since it enables the surgeon to preserve the skin – including the nipple and areola – and can minimize scarring. It can also reduce the need for additional surgical procedures.

Myth #3: Implants will be uncomfortable and look unnatural.

Breast implants have come a long way since silicone implants were developed in the 1960s. New materials and techniques made them more aesthetically pleasing and comfortable. Implants are not the only – or necessarily the best – option for breast reconstruction, however. Natural tissue or “autologous” reconstruction uses your own tissue – often taken from the abdomen – and produces a breast that is soft, warm and living. In combination with skin- and nipple-sparing mastectomy techniques, the best reconstructed breast can be difficult to distinguish from a woman’s original breast.

Myth #4: I can’t have reconstruction if I’ve had or will need radiation or chemotherapy.

determining the timing and type of reconstruction that will be safest, but it does not rule reconstruction out.

In fact, for women who will need radiation after mastectomy, natural tissue breast reconstruction is usually the preferred option.

Myth #5: Breast reconstruction is too expensive.

In 1998, Congress passed the Women’s Health and Cancer Rights Act (WHCRA), a federal law that requires group health plans and individual health policies that cover mastectomy to also cover breast reconstruction. Among the benefits are coverage for all stages of reconstruction of the breast on which the mastectomy was performed, as well as surgery and reconstruction of the other breast to achieve symmetry and balance.

The WHCRA provides a crucial baseline benefit in helping women recover from breast cancer and enables them to focus on getting well without undue anxiety about the costs of breast reconstruction.

In the midst of the emotional turmoil that follows a diagnosis of breast cancer, a woman faces crucial decisions about treatment and how to manage her life going forward. It’s important for her physical and emotional recovery to have comprehensive, accurate information about the options available to her. By dispelling myths and misconceptions about breast reconstruction, every breast cancer patient can make informed decisions about her future so that she can move on to live a long and healthy life.

Dr. Chen is a board-certified plastic surgeon in New York.

She is committed to aesthetic restoration of the breast and body and enjoys helping her patients achieve overall well-being.

Having had or needing radiation and/or chemotherapy are considerations in PSN: BREAST RECONSTRUCTION 2022 l

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COVER STORY

Capturing a moment in time:

Life casts help women reclaim their lives after mastectomy

By Kendra Y. Applewhite Photography courtesy of Erez Sabag

Jocelyn Schaltenbrand, 44, underwent a bilateral mastectomy and DIEP flap breast reconstruction after facing a ductal carcinoma in situ diagnosis in one of her breasts.

In New York last fall, she stood before life-cast sculptures of her torso that that showed her before and after nipple reconstruction. Tears welled up in her eyes as she processed the cast sculptures of her body alongside sculptures of 11 other breast cancer survivors.

“It was really touching to see all the people there looking at your torso, physique and photos as an art form,” Jocelyn says. “Seeing all the women together was breathtaking and powerful. It was done in such a tasteful, beautiful and celebratory way.”

The roots for the event were planted 10 years ago, when ASPS member Ron Israeli, MD, created his first series of life-cast sculptures depicting breast cancer patients to highlight breast reconstruction as an important aspect of their journey and healing process. Dr. Israeli, who studied European sculpture techniques under master

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sculptor Kiril Tzotchev, says an encounter during his residency sparked the idea.

“There was a particular surgeon I worked with who was doing life casts of his patients before and after breast surgery, and I kept that in the back of my mind,” he recalls. “I realized the impact that can have on the women undergoing the surgery – to see, touch and feel what they look like not in the mirror and not in a photograph but in a three-dimensional format.”

“Restored” debuted at the 2012 ASPS annual meeting in New Orleans, coinciding with the first Breast Reconstruction Awareness Day USA – an ASPS/PSF initiative to inform women of their reconstruction options following breast cancer treatment. Dr. Israeli’s exhibit featured six white life-cast sculptures of his mastectomy and breast reconstruction patients.

ASPS member Jonathan Bank, MD, recalls seeing the original exhibit in New Orleans and being drawn to the artistic approach.

“I was a resident at that time, and I was intrigued not only by the aesthetics of the

COVER STORY

The "Restored" multimedia exhibit and book launch in NYC unveiled each woman's life cast sculptures and photographs at the public event.

reconstruction but also the artistry involved and the ability to portray the impact of breast reconstruction awareness through art,” Dr. Bank says. He went on to launch his own art exhibition five years later and created “Project Reconstructed,” a series of photo essays capturing women’s personal victories over cancer through images that interlaced their scars with gold. “‘Reconstructed’ wasn’t driven by Ron’s original project, but it was in the similar realm by combining art and surgery specifically with breast reconstruction, which we are both passionate about,” Dr. Bank says.

Nearly a decade after their first encounter in New Orleans, Drs. Israeli and Bank, who now practice together at NYBRA Plastic Surgery, joined forces and set out to shift the narrative surrounding breast reconstruction by creating a new and reimagined “Restored.” The latest version merges artistic elements from their individual projects to include body-cast sculptures, multimedia and photography.

“The first exhibit in New Orleans was a limited display and an eight-minute

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“All surgery is a collaboration, and when you combine surgery with art and partner with experts in their respective fields, the impact can be powerful.” documentary with no other elements,” Dr. Israeli explains. “There was no real collaborative aspect. I worked with my patients and created those individual sculptures under the guidance of my sculpture teacher. This version of ‘Restored’ is very different. It was a collaborative project with Jonathan, a creative director, photographer and additional artists – much more involved and extremely exciting.”

Dr. Bank says the reimagined “Restored” is not only more visually interesting, but it adds new layers to the experience.

“All surgery is a collaboration, and when you combine surgery with art and partner

with experts in their respective fields, the impact can be powerful,” he says.

Creative director David Warren and acclaimed fashion and beauty photographer Erez Sabag came onboard to photodocument the artwork and process and develop an art book. The creative duo, who worked with Dr. Bank on his “Reconstructed” project in 2017, expressed their excitement to help women celebrate their victory with a new and expanded concept. To that end, Warren divided the book into three parts: the women’s stories, casting process and celebration of their victory.

‘HOPE IN THE AFTERMATH’

Name: Jocelyn Schaltenbrand Procedures: • Areola-sparing bilateral mastectomy • Immediate deep inferior epigastric perforator (DIEP) flap reconstruction • Nerve grafting • Staged nipple reconstruction

“Similar to ‘Reconstructed,’ helping women close the chapter – after undergoing reconstruction – and seeing their joy from being a part of the project is the best part,” Warren says. “We love the emotion and experience of holding the physical finished art book, but we are not just doing this project for us. We are trying to help other women, and the project might help someone facing a similar situation. She might feel like she can do it, too.”

Moment in time “Restored” tells the stories of breast cancer previvors and survivors and includes life casts of 12 women after mastectomy and breast reconstruction. Each sculpture captures one specific moment in time during their recovery and reconstruction journey, Dr. Israeli notes.

“The actual process of creating these sculptures requires multiple stages, which is very similar to the staged nature of breast reconstruction,” he says. “Creating a sculpture is a shared process between the sculptor, surgeon and patient. We created more than one sculpture for some women

to show the first stage of reconstruction and then the final stage. The women in this project are reclaiming their lives after mastectomy, and the project is meant to portray that.”

The project features women from all walks of life, from a fashion designer and boudoir photographer to the first model with a mastectomy to grace the pages of Sports Illustrated. Warren notes they approached the project with representation in mind to portray women of all shapes, sizes, socioeconomic and racial backgrounds.

“We wanted it to be a true melting pot in that it is a disease that can hit any woman, so we identified a dozen patients we thought might be interesting stories,” Warren says. “We then documented the casting process, sometimes pre-operatively and then subsequently post-operatively, so we could really show what it’s like to go through the reconstruction process. It’s one thing to tell the story, but it’s quite another to actually see visible forms of that story.

It was powerful to experience and witness that firsthand.”

Why did you participate in “Restored?”

I discovered Dr. Bank and his previous book, Reconstructed, after my diagnosis.

I work in the beauty industry – I love art and creativity – and I knew I wanted to work with him. I participated in the project a few weeks after my second surgery with Dr. Bank. I was fresh out of surgery when they did my body cast, but I wouldn’t have it any other way. I wanted to be a part of it to inspire someone else. There’s a lot of stigma and fear surrounding breast reconstruction. There are horror stories out there of women unhappy with their results. I participated in “Restored” without hesitation because it was important for me to let people know there are other options. Going through something scary and challenging doesn’t mean the outcome has to be horrible. I want women to know there is hope in the aftermath.

What do you want other women to take away from this project?

To always love yourself no matter what.

You never know the curveballs life may throw your way. But there’s hope, and you're so much stronger than what you thought was capable. There is always a rainbow at the end. It’s hard to see it when you’re going through something, and you’re just trying to go through the motions. It’s a scary process. You have to find a surgeon that is right for you, and you have to feel comfortable with your doctor and challenge the norm. It can be the most beautiful and hardest process of your life, but there are plastic surgeons out there who can help make you whole again.

What can’t cancer take away?

Your spirit and your love. Those things are innately deep down in your core.

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COVER STORY

Sabag photographed each woman’s reaction to the unveiling of their sculptures, giving them the freedom to interact with their cast in a way that felt true to them.

Some threw paint at their cast. Some hid behind their sculpture.

Some roared.

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The women underwent silicone molding of their bodies to generate casts that were used to create life-sized sculptures. The process, he explains, begins with painting the liquid silicone directly on the patient’s body to create a mold.

Once the silicone dries, plaster is applied to maintain the shape of the mold, and the materials chosen for the life casts are poured into the molds to create each final sculpture. Warren notes they used varied casting materials, textures and colors to reflect each woman’s personality or circumstance during their photo shoot.

“We did not repeat the same material, so all 12 women were photographed in a very different way,” he says, noting one previvor created two life casts well after her reconstruction process to capture her pregnancy journey at three months and seven months. “We thought it would be lovely to conceptually photograph her in a bath of milk and then create her cast using porcelain. We tried to make these connections between each woman’s cast and her photo shoot with us. It was about capturing the essence of the women through the material we ended up using.”

Sabag photographed each woman’s reaction to the unveiling of their sculptures, giving them the freedom to interact with their cast in a way that felt true to them.

Some threw paint at their cast. Some hid behind their sculpture. Some roared.

“We wanted emotional images that represented personal victory over their disease as they reclaimed their identity and femininity after undergoing treatment,” Sabag says. “We reminded them that they were beautiful no matter what and the cast was a second element for us to glorify their beauty and strength. We’re creating awareness to help other women around the world feel better about themselves. At the end of the day, this is about the powerful women who were willing to be a part of this project. We salute these brave women.

They are warriors.”

The “Restored” project took nearly two years to complete. The team faced a

series of challenges during the process, which included managing photography and surgical schedules, collaborating with artists, traveling and transporting the sculptures all while navigating through the COVID-19 pandemic.

“The entire project was a fairly large undertaking,” Dr. Bank says, explaining that creating each life cast required hours of time. “We had a lot of moving parts. It took weekends and evenings, and we sacrificed time with family and friends. But it was worth it.

“Dealing with the variables that you can’t control comes with the territory as a plastic surgeon,” he continues. “It’s similar to how these women end up in our lives and we end up in theirs. We are there to help pick up the pieces and try to make things beautiful – not just physically but emotionally as well. Art is just an extension of that.”

Dr. Israeli credits his partner’s persistence for helping them cross the finish line when they encountered delays and setbacks.

“Doing this project during the pandemic was extremely challenging,” he says. “We had late nights when we did not know if the patient was coming or where we were going to do it, but Jonathan would say, ‘We are going to do this, we are going to make it happen.’ And we did.”

The unveiling The 12 courageous women who bared their scars for the project joined Dr. Bank, Dr. Israeli and their creative team for the “Restored” exhibit last fall at a New York gallery. The event, sponsored by Allergan Aesthetics, an AbbVie Company, unveiled the patients’ casts and life-scale photographs to the public and celebrated the launch of the coffee table book, which represents the culmination of the process.

Survivor Dana Donofree describes the exhibit as a beautiful moment.

“The presentation of the body cast along with the multimedia and the video of all the patients being highlighted together was so beautiful and outrageously well

‘MORE THAN A DIAGNOSIS’

Ron Israeli, MD, (left) and Jonathan Bank, MD, begin the casting process for their first silicone mold, right after preparing the skin with a non-stick primer. A silicone mold is first made by painting the liquid silicone directly on the patient's body.

done,” says Dana, who was diagnosed with breast cancer at 27. Now 40, Dana underwent a bilateral mastectomy with implant reconstruction. Her life-cast sculpture paid homage to her cherry blossom mastectomy tattoo.

“It was incredible walking around the room with the women from the project and hearing how our photos impacted people who didn’t know a lot about breast cancer and reconstruction,” she says. “Someone could look at a photo and body cast of me on the wall and see me in real life and share how that photo impacted and informed them in different ways. I felt special.”

After working with each woman over an extended period, Warren and Sabag say witnessing the women’s reactions at the event was the highlight of the project.

“We can feel their joy and satisfaction of having gone through that process, but also going through the process with us to create this book,” Warren says. “To have each of them standing beside their cast and their images as well as linked together as a part of this tribe who have won the battle was pretty cool. They are fierce warriors, and it’s extraordinary to be a part of their stories.”

Light in the tunnel “Restored” exerted a far-reaching impact on patients facing a breast cancer diagnosis. Dr. Bank says they have received an outpouring of support from women from around

the country and volunteer requests for future projects.

“Most women who come to see us for surgery almost expect to be involved in a project at some point,” he laughs. “They tell us they want to be a part of the next thing. It touches people in ways we can’t even anticipate. Someone close to home said they had scars from an accident that happened to them years ago, and they see their scars differently thanks to the project.

It definitely adds a dimension to what we do, which is the beauty of art.”

The art projects allow the doctors to have a deeper connection with their patients.

“It wasn’t that hard for us to find patients who were interested because we get to know our patients extremely well and frequently create a special bond with them while helping them through their mastectomy and reconstruction, which takes time,” Dr. Israeli says. “That’s also a reflection on our practice as breast reconstruction surgeons. It’s one of the reasons why I enjoy what I do, and this project is an extension of that.”

Drs. Israeli and Bank debuted “Restored” at the ASPS annual meeting in Atlanta last year, nine years after they crossed paths at the initial exhibit in New Orleans. Looking ahead, they hope to take “Restored” on the road as a traveling exhibit to raise awareness and bring more visibility to breast reconstruction.

Name: Dana Donofree Procedures: • Skin-sparing bilateral mastectomy • Subpectoral immediate tissue expander reconstruction • Staged implant-based reconstruction • Decorative breast tattoo Why did you participate in “Restored?”

I loved the concept of highlighting breast reconstruction in a different light by casting the bodies in moments of surgeries during a specific moment in time. Our bodies are always changing and evolving, especially with breast cancer, so doing it in a way that’s permanent like a body cast felt interesting. It was special for me because I had reconstruction nearly 12 years ago at age 27. Breast reconstruction has come so far in the past decade. As a patient that gets an opportunity to live well beyond my initial diagnosis, it was really impactful to have the cast created with my original breast reconstruction before I underwent a revision surgery with Drs. Israeli and Bank.

We were able to reinterpret my cherry blossom mastectomy tattoo in multiple ways throughout the shoot, which was nice.

What do you want other women to take away from this project?

I hope people learn and understand that breast cancer is incredibly serious. As cancer patients, we have to go through multiple steps and phases in our lives to put some of the pieces back together. Breast reconstruction is one of those pieces. It’s different for everybody, and everyone has a different path to the right answer that’s right for their body.

“Restored” portrays something that feels so devastating and destructive in an incredibly beautiful and palatable way. It shows not only breast reconstruction but also those of us who have it and how we feel. Maybe our nipples are gone. Maybe our breasts are not perfect.

Maybe they’ve been restored. I just hope someone can say, “They are beautiful people who have been through a lot,” and understand breast cancer is more than just a diagnosis. It’s body altering and life altering.

What can’t cancer take away?

My joy. If something in my life isn’t going to bring me joy, I’m going to rip it away. That was one lesson that cancer taught me, and I won't let it take it away from me, either.

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‘YOU LEARN HOW TO CARRY ON’

COVER STORY

Name: Jen Rozenbaum Procedures: • Skin-sparing bilateral mastectomy • Subpectoral immediate tissue expander reconstruction • Staged implant-based reconstruction • Prepectoral implant conversion and revision reconstruction Why did you participate in “Restored?”

After two faulty reconstructions, I was unhappy with the outcome of my procedures, and I went to Dr. Israeli. He gave me a lot of hope. Sometimes we forget where we came from when things are good and the dust settles. For me, doing a before-andafter cast of my breast revision surgery was an opportunity to memorialize that part of my journey. It’s so vulnerable, but in that vulnerability, you are helping people understand the breast reconstruction journey.

I feel honored to have that opportunity.

“Restored” models Laura (top) and Liz (bottom) strike a pose with their life casts.

“As plastic surgeons, our work in breast reconstruction can provide light at the end of the tunnel,” Dr. Israeli says. “Breast reconstruction has a dimension of physical healing, but there is also the dimension of inner and emotional healing, which is similarly manifested through this project for each woman. The idea of reclaiming life after mastectomy is something that patients can experience through this journey of reconstruction, and we hope these beautiful three-dimensional life-cast sculptures show what reconstruction is all about and provide women facing mastectomy with hope.”

Jocelyn has no regrets about undergoing breast reconstruction. She hopes “Restored” reduces the stigma and fear surrounding breast reconstruction and informs women of their options.

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“There are horror stories out there of women who are unhappy with their reconstruction,” she says. “Going through something scary and challenging doesn’t mean the outcome has to be horrible.

Breast reconstruction can be the most beautiful and hardest process of your life, but there are plastic surgeons out there who can help make you whole again. I want women to know there is hope in the aftermath.”

To learn more about “Restored” and purchase the book, visit restoredexhibit.com.

What was your favorite part of the process?

Being photographed. As a photographer, I just wanted to let go and enjoy being present in the moment. Being on the other side of the lens was a little nerve-wracking – but also a lot of fun.

What do you want other women to take away from this project?

There is life after cancer and mastectomy.

You’ll never feel the same, but you can feel whole in a completely different way. Your femininity is not about your breasts. I always thought breast cancer was an attack on my femininity – removing my breasts and ovaries – but the truth is we can redefine where femininity comes from and feel whole again. I’m five years cancer free, and I’m finally starting to feel things are settling and my body and mind are in a good place. I want women to know that removing your breasts will change your life, but your life can be even better after.

What biggest lesson have you learned during this cancer journey?

Healing is not a linear process. It takes a lot of patience. You don’t get over this. You learn how to carry on with it.

What can’t cancer take away?

I refuse to let it take away my femininity.

FEATURE

Q&A:

Chicago doctor shares her journey and research efforts TO REDUCE RACIAL DISPARITIES

By Tonya Russell

Sometimes we set out on a path, and life forces us to alter our course. That

excited that I’m focusing on this patient population. I’m not only hoping to help those patients, but I’m also hoping to move my own career forward so that I can clinically apply the things that I see in terms of gaps in care for Black women.

was the case for ASPS member Tokoya Williams, MD, who faced a breast cancer diagnosis during her third year of medical school in Chicago.

Although she started medical school with the intention of pursuing a career as a cardiac surgeon, her breast cancer treatment that made her reconsider. Not only did she endure chemotherapy and a double mastectomy, but she required breast reconstruction and several subsequent revisions due to scar tissue buildup – a common outcome for Black women.

Driven to help other breast cancer patients, Dr. Williams teamed up with her plastic surgeon, ASPS member Robert Galiano, MD, to study racial disparities in breast reconstruction.

She took time to discuss her breast cancer and reconstruction journey as well as her dedicated research efforts to close the gap and reduce racial disparities among Black women.

PSN: What made you want to pursue reconstructive surgery?

Dr. Williams: I was at the end of my third

year of medical school in Chicago, and I felt a lump. I was actually on my surgery rotation as a medical student when I was diagnosed. Upon completing that rotation, I had a double mastectomy and tissue

PSN: What trends are you noticing in breast cancer and reconstruction?

Dr. Williams: The pathway is usually a

Dr. Williams (left) and Dr. Galiano

expanders placed. I later went back for my permanent breast implants. After my reconstruction, I decided that I wanted to do breast reconstruction surgery.

PSN: Can you tell us about your work?

Dr. Williams: I’m still on the surgery path.

I finished two years of general surgery and did a burn surgery fellowship. After that, I went on to complete a research fellowship in plastic surgery at Stanford University before coming to Northwestern University.

My research at Northwestern focuses on Black women and racial disparities in breast reconstruction. People are really

breast cancer diagnosis followed by breast surgery, which can be lumpectomy or a mastectomy. From there, you have the option of pursuing breast reconstruction. Some of the trends that we’ve seen are women of color not being reconstructed as often as their white counterparts. Now, that trend has improved significantly especially over the past five to 10 years, although the aesthetic outcomes of those breast reconstructions are significantly different. Studies have shown that, overall, Black women are less satisfied with their outcomes and have poorer aesthetic results than their non-black counterparts. They develop complications, such as scar tissue, from reconstruction surgeries far more than white women. That’s just our biology and our genetics.

Hypertrophic scars, keloid scars, scar revision procedures and capsular contracture are unfortunately common for Black women after breast reconstruction surgery. A large part of what I do and the studies that I design look at ways to PSN: BREAST RECONSTRUCTION 2022 l

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FEATURE

"We think that by giving them this computer program, and making sure that it works for Black, Latin and Asian women, that you’re really empowering the patient to be an active participant in their care and their decision." potentially improve aesthetic results and minimize those complications. What interventions can we make to improve information for Black women when they are preparing to undergo breast reconstruction? There's definitely a disparity still present in terms of Black women even receiving breast reconstruction and that’s the result of multiple factors, such as socioeconomic reasons and insurance coverage, for example.

The Women’s Health and Cancer Rights Act (WHCRA) of 1998 states that those with breast cancer are entitled to breast reconstruction if they so choose, which a critical step in ensuring that women have reconstruction as an option.

However, not all women are aware of this – especially women of color.

PSN: If all aspects of treatment are covered, where is the breakdown?

Dr. Williams: What we’re seeing is that

Black women just don’t know as much about that option. Depending on the healthcare facility, you might not really get the education or tools that you need.

“Hey, by the way, you can be reconstructed and your insurance has to cover it and if something goes wrong, your insurance still has to cover it!” A lot of women don’t know that, or they assume that surgery just means cosmetic surgery.

PSN: How did you team up with Dr. Galiano to study racial disparities?

Dr. Williams: I had my final surgery last

year, and the person who performed that procedure happened to be Dr. Galiano.

Part of Dr. Galiano’s research focus is on Black patients. I was already a patient, I’m already an MD and I already have surgical training. I’m interested in plastic surgery and he is interested in research on behalf of Black women. It was the perfect fit.

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PSN: How does the computer program fit into your research?

Dr. Williams: It is called BREASTChoice, and it was created at Washington University in St. Louis by a team of clinicians and patients under the lead of Mary Politi, PhD. BREASTChoice aids patients by going over their options, including the option of not being reconstructed. It also calculates risk based on the patient’s personal medical history of having a complication after reconstructive surgery. That’s really what makes the computer program novel and potentially useful.

However, the primary problem in the creation of that program, is that they studied it using about 86 percent highly educated white women. So we don’t really know how universally applicable that program is for women of color, or whether it appropriately takes into account the issues that are specific to women of color.

Dr. Politi graciously agreed to let us use her program to study it in a more ethnically and racially diverse patient population. This time, we’re selecting women of color and exposing them to the computer program and investigating how efficient it is for them – as well as gathering their feedback.

Why is this important? Well, the whole idea is to equip women with information before they even walk into their consultation with a plastic surgeon.

Something Dr. Galiano talks about a lot that is especially true in his Black female patients is that they’ll come in and say, “Just do whatever you think.” They don’t really realize – or even feel like – they have autonomy over their own bodies in terms of what happens and what their options are. In terms of breast reconstruction, patients should be educated about their options and have time to think about those

options, and that conversation should be tailored to each individual patient.

We think that by giving them this computer program, and making sure that it works for Black, Latin and Asian women, that you’re really empowering the patient to be an active participant in their care and their decision. Like I mentioned, breast reconstruction is all about restoring you back and providing that psychological relief of, “My cancer is over.”

PSN: What do you hope to uncover over the next few years?

Dr. Williams: In addition to the work

that we are doing with BREASTChoice, I have multiple projects that I'm building that are focused on scarring and overall aesthetic outcomes in Black women after breast reconstruction. We’re in the IRB-approval process for several of these projects. Many post-surgical interventions have been studied and proven effective in improving scar outcomes after breast reconstruction surgery – although they were never really tested and focused on this group. My goal is to get clear on how to optimize those interventions for darkerskinned individuals.

Those interventions involve superficial radiation therapy, steroid injections and a newer technology called a steroid plaster. My specific aim for that project is to study the efficacy of pursuing these interventions in Black women who have breast reconstruction surgery and seeing if it works. What can we tweak? When and how should we use these different interventions? My overall goal is to create a standard that is propagated as the national standard when you are operating on a woman of color who is at higher risk of developing these scars after her procedure.

This is actually a protocol you should consider following.

PATIENT EDUCATION

New study sheds light on the importance of a full-range of options after diagnosis

By Paul Snyder

New research suggests that women who are facing a breast-cancer diagnosis and opt for less-invasive treatment options could feel longer-term satisfaction in their choice. It’s a study that not only underscores

the importance of women knowing their options after a diagnosis, but also demonstrates why a plastic surgeon should be part of a patient’s care team as early as possible

In a study published earlier this year in JAMA Surgery, authors from the University of Texas MD Anderson Cancer Center surveyed and analyzed results from 647 patients who had early-stage breast cancer and surgical treatment between 2006 and 2008. Of those participants, about 356 people received breast-conserving surgery and 291 underwent a mastectomy with breast reconstruction. Nearly a decade later, the respondents filled out their surveys, sharing their feelings about both their treatment and body.

“I’ve been in practice for about 10 years, and a lot of what we do in breast reconstruction and how we counsel patients has evolved in that short time,” says ASPS member and Breast Reconstruction Chief Medical Editor Summer Hanson, MD, PhD, the study’s lead author. “Some of the concepts have been around forever and are still tried-and-true – and plastic surgeons are responsive to the wishes and goals of patients who want to undergo reconstruction. What this study really demonstrates is that, regarding overall satisfaction, there was no significant difference in the outcomes between breast conservation vs. mastectomy with reconstruction. When the respondents were asked if they had any regrets about their decision, they almost uniformly expressed comfort or happiness with their decision.”

Researchers used the BREAST-Q patient-reported outcome measure, co-developed by The PSF past President Andrea Pusic, MD, MHS, to quantify patient satisfaction, with secondary outcomes including BREAST-Q physical well-being, psychosocial well-being and sexual well-being.

The survey’s results show that women in both the breast conservation and mastectomy with reconstruction groups had equivalent scores on long-term quality of life and that satisfaction rates were about equal. Digging deeper, Dr. Hanson notes that the two groups did differ in some ways. For example, the women who had breast-conserving surgery had higher scores on measures of psychosocial well-being (how they felt about themselves and their bodies) and sexual wellness than those who underwent mastectomies.

Although a lumpectomy with radiation can change the texture and look of breast tissue, it does not usually have a major effect on the sensation of the breast tissue or nipples. As a mastectomy removes all the tissue and many nerves, sensation is often dulled – if not lost. That can have a psychological effect on a woman’s sense of herself.

The benefit of the study is that by providing further research in this area, doctors and surgeons can have more informed conversations with their patients who are choosing their treatment options – and Dr. Hanson says the results underscore the importance of involving a plastic surgeon in those consultations as early as possible.

“It’s crucial,” she says. “One of the biggest challenges we face as plastic surgeons is being brought in after the fact in some cases.

What we know in terms of techniques, candidacy for different options and just providing support and proper consultation is invaluable. There are plenty of patients who come to say that seeing a plastic surgeon was almost an afterthought. ‘Maybe you can see a plastic surgeon later,’ and that kind of thing. By the time they do involve us, the choices may be different and can be much more limited.

“The satisfaction that patients shared in this survey speaks to the importance of getting plastic surgery involved early and at least having the conversation,” Dr. Hanson continues. “Maybe you learn that what you thought might work isn’t a good option for you right now, but what could be done further down the road.

Any woman facing this kind of diagnosis deserves to know what options exist.”

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PATIENT EDUCATION

4 things to consider:

Finding the right plastic surgeon for your breast reconstruction procedure

By Aisha M. Baron, MD

You’ve had the misfortune of being diagnosed with breast cancer and must face the fact that you need to have a part of your breasts – or one or both of your breasts – removed or altered to save your life. Aside

from your breast surgeon, who you choose as your plastic surgeon plays a huge role in how your breast cancer journey plays out. You might find yourself asking, “Who do I choose? Do I have a choice? What should I look for? What should I know?”

I often tell patients that their relationship with their plastic surgeon, should they choose to perform breast reconstruction, is one of their most important decisions. After breast cancer is removed, patients often spend most of their recovery time with their plastic surgeon. My breast cancer patients often become like family to my practice. We get to know their families and friends, as well as their fears and concerns. It is an honor to care for these patients, and I often pause to consider exactly how their journey led them to me.

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Educate yourself.

Make sure your surgeon is board-certified in plastic surgery. This ensures your chosen doctor has adequate training in reconstructive techniques and can inform and ethically perform a range of procedures. Do your homework and look at your potential surgeon’s website and social media pages. Make sure that the procedures you are considering are performed by the surgeon you are seeking. Look at beforeand-after photos to get an idea of what to expect after a reconstructive procedure. Conduct a little research to familiarize yourself with oncoplastic (tissue-rearrangement breast lift or reduction after lumpectomy), implant-based or autologous (tissue flaps, fat grafting) breast reconstruction.

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Use this checklist as a guide during your breast reconstruction consultation: ☐ Are you certified by the American Board of Plastic Surgery? ☐ Were you trained specifically in the field of plastic surgery? ☐ How many years of plastic surgery training have you had? ☐ Do you have hospital privileges to perform this procedure? If so, at which hospitals? ☐ Is the office-based surgical facility accredited by a nationally- or state-recognized accrediting agency, or is it state-licensed or Medicare-certified? ☐ Am I a good candidate for this procedure? ☐ What will be expected of me to get the best results? ☐ Where and how will you perform my procedure? ☐ What surgical technique is recommended for me? ☐ How long of a recovery period can I expect, and what kind of help will I need during my recovery? ☐ What are the risks and complications associated with my procedure? ☐ How are complications handled? ☐ What are my options if I am dissatisfied with the outcome? ☐ Do you have before-and-after photos I can look at for this procedure, and what results are reasonable for me?

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Ask around.

Polling family, friends, co-workers and support groups can help lead you to a surgeon that’s right for you.

Word-of-mouth referrals are often the most reliable – and might result in personal testimonials that make the decision-making process easier. You can also check the American Board of Plastic Surgery and ASPS websites for potential surgeons. Your breast surgeon will often recommend a plastic surgeon, which can be convenient, but the ultimate decision of who becomes part of your care team belongs to you.

3

Connect.

If time permits, have more than one consultation. This will help you familiarize yourself with the options for which you might be the best candidate and allow you to make an informed decision on your reconstructive path with your surgeon. Consultations also provide the opportunity to see if you and the surgeon have compatible personalities. After all, it helps if you like the person operating on you.

Remember that you and your surgeon are interviewing each other to ensure the surgeon-patient relationship is positive and successful.

These four easy but important steps can empower you as a patient and lead you to the right plastic surgeon and a successful breast reconstruction process. I wish you all the luck on your journey.

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Communicate.

It’s important for you to feel good about the plan you and your plastic surgeon create.

You also should be comfortable expressing your concerns, fears, aspirations and expectations with them. If you are unable to do that, then you may need to keep looking.

Dr. Baron, best known as the breast and body doctor (@breastnbodydoc), is a board-certified plastic and reconstructive surgeon at Breast Body Beauty Plastic & Reconstructive Surgery in the metro Atlanta area – and a cancer survivor herself. In addition to cosmetic breast and body contouring, Dr. Baron has a love for breast reconstructive surgery and microsurgical (DIEP flap) breast reconstruction.

Ready for a consultation?

Here’s what you can expect: During your breast reconstruction consultation, be prepared to discuss: • Your surgical goals • Medical conditions, drug allergies and medical treatments • Current medications, vitamins, herbal supplements, alcohol, tobacco and drug use • Previous surgeries Your plastic surgeon will also: • Evaluate your general health status and any pre-existing health conditions or risk factors • Examine your breasts and take measurements of their size and shape, skin quality and placement of nipples and areolae • Take photographs • Discuss your options and recommend a course of treatment • Discuss likely outcomes of breast reconstruction and any risks or potential complications Be sure to ask your plastic surgeon questions. It’s very important to understand all aspects of your breast reconstruction.

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PATIENT EDUCATION

Telemedicine: Improving patient access to breast reconstruction specialists

By Minas Chrysopoulo, MD, and Lana Cobb

Although some women who are candidates for breast reconstruction may choose against having the surgery for a variety of reasons, many women who wish to explore the full spectrum of their reconstructive options unfortunately don’t get the chance. Common

obstacles that limit patient access to breast reconstruction can include a lack of access to specialists, not enough time for adequate research and financial burden. Telemedicine uses technology to deliver care at a distance – and it is a very effective tool in overcoming these barriers.

Easier access to specialists Patients living in or near larger urban areas usually have access to plastic surgeons who provide breast reconstruction services. However, for

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those living in less-populated areas, access to a plastic surgeon can often be extremely limited. Furthermore, regardless of where you live, not all plastic surgeons offer the full spectrum of breast reconstruction options. Meeting with the right specialist can therefore be problematic, especially if you are considering one of the more technically complex procedures, such as the DIEP flap.

Our practice, PRMA Plastic Surgery, in San Antonio, Texas specializes in breast reconstruction, and we routinely welcome patients from across the United States and other countries. Several years ago, we instituted online virtual consultations to provide patients access to our surgeons from the comfort of their own home, regardless of where they live.

Prior to the COVID-19 pandemic, our virtual consultations were almost exclusively used by patients who were

considering traveling from outside of Texas. During the pandemic, due to recommendations from the CDC and local health authorities, in-person consultations and visits to the office were restricted. Virtual consultations and telemedicine follow-up visits allow us to continue caring for our patients in the safest way possible.1

Better patient experience Convenience is an essential component of patient experience in modern healthcare delivery, and this is one of the many benefits of telemedicine. A telemedicine appointment is also much easier to schedule between other commitments a patient might have during the day. Many of our patients schedule their telemedicine visit during a break at work.

Video-conferencing platforms, such as Zoom and multiple others created specifically for healthcare, allow patients to experience personalized care without wasting time traveling to the clinic for an in-person appointment. These time savings can be significant depending on where you live or work.1,2

Cost savings Cancer care is costly even with excellent health insurance. Traveling for care that isn’t available locally quickly adds to the expenses. Telemedicine not only

eliminates the costs1,2 associated with traveling, but it also minimizes the time lost from work1,2 so patients can maintain their income.

Positive patient response Patients increasingly say they make decisions about which healthcare providers and/or practice to choose based on whether they provide telemedicine appointments. Patients report joining a video chat with their doctor is easy and saves them time and effort.

Most insurance companies also cover telemedicine visits now, usually with the same co-pay as an office visit.

By eliminating the expenses related to commuting (e.g., gas, parking, tolls, airfare and hotels), patients save money and avoid spending their limited paid time off for doctors’ visits.

Interestingly, our out-of-town patients also report feeling more connected to their healthcare team than ever before because video conferencing has made it so much easier to communicate “face-to-face” on a regular basis from home.

New normal?

will obviously be clinical situations that are best addressed with an in-person visit. In our practice for instance, if the patient needs a physical examination, or we are concerned the patient may have a post-operative complication, we will see them in the clinic for full evaluation and appropriate treatment. However, we found that most routine visits can be performed via telemedicine, and this is a standard option for our patients.

Telemedicine and video conferencing platforms offer the security required to ensure that full patient privacy is maintained and all HIPAA requirements are met. This must remain a prerequisite for their use. Now that telemedicine visits are covered by insurance, we are hopeful more plastic surgery practices will adopt the technology and expand access for patients.

Everyone has the right to know all their breast reconstruction options.

Telemedicine is the key to making this a reality.

Dr. Chrysopoulo is a board-certified plastic surgeon and the president of PRMA Plastic Surgery in San Antonio, which specializes in microsurgical breast reconstruction.

SOURCES: 1.

2.

Saad, N., et al. “Telemedicine and Plastic and Reconstructive Surgery: Lessons from the COVID-19 Pandemic and Directions for the Future.” Plastic and Reconstructive Surgery: November 2020, Volume 146, Issue 5, p680e-683e Yesantharao, P., et al. "Telemedicine for Breast Reconstruction: Exploring Patient Satisfaction Using the Breast-Q Tool.” Plastic and Reconstructive Surgery - Global Open: October 2021, Volume 9, Issue 10S, p118-119

Many medical practices began offering telemedicine during the COVID-19 pandemic out of necessity. For us, the benefits – even for a surgical practice – have been clear for many years. There PSN: BREAST RECONSTRUCTION 2022 l

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PATIENT EDUCATION

A closer look at the lumbar flap in breast reconstruction

By Filip Stillaert, MD

Breast reconstruction involves the use of implants or your own tissue – a choice made by the patient and driven by her expectations and the surgeon’s expertise. A breast

reconstructed with your own tissue (removed from elsewhere in the body) provides a natural look and a lifelong result that ages naturally with the rest of the body. The drawback is that an additional scar is made to “heal” the breast, as the gold standard in breast reconstruction is to remove skin and fat from the lower abdomen below the belly button, the DIEP flap, which leaves a scar across the lower part of the abdomen.

The DIEP flap, however, is not always an available option – particularly for slender patients or those who have undergone previous surgery in the abdominal region. Fortunately, there are alternatives and tissue can also be removed from other areas to rebuild the breast without the need for artificial breast implants. One such option is the lower back region (also referred to as “love handles”). The skin and fat removed from this area is called the lumbar flap (LAP flap) and is removed in the same

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way as the DIEP flap, sparing the lower back muscles.

What makes the lumbar flap attractive is the quality of fat tissue to make a natural looking (and normal feeling) breast. Even in thin patients, an abundance of fat can be removed from the “love handle” region – and the final scar is well-hidden along the lower back without creating a body contour deformity.

With a lumbar flap procedure, the surgeon can also restore sensation in the breast as nerves that are included in the flap are long, negating the need to use nerve grafts. Patients have expressed satisfaction with immediate postoperative results thanks to the conic shape of the lumbar flap and the fact that fewer revisions/corrections are required after such a procedure.

Patients should know, however, that there are also some downsides to the procedure. A higher degree of experience is required for the procedure, as the lumbar flap is more complicated than more standard approaches such as the DIEP flap. Lumbar flap vessels are smaller and the surgeon must harvest an additional blood vessel graft to lengthen the shorter, smaller vessels. The procedure

is also slightly longer because the patient needs to be turned over during surgery to remove the lumbar flap. The amount of skin that can be removed with the lumbar flap is also limited and depends on the skin laxity in the lower back region.

Patients sometimes experience some numbness and tightness in the lower back and buttock regions after removal of the lumbar flap – the result of removing the cutaneous nerves that run within the flap.

Postoperative care after a lumbar flap procedure typically consists of a fourto five-day hospital stay followed by a moratorium on performing heavy physical activity for six weeks. The tightness in the lower back will disappear during the months following surgery, with an improvement of the numbness in this area.

Wearing a pressure garment will help to provide comfort and support.

Dr. Stillaert is an international member of ASPS and works in the Department of Plastic and Reconstructive Surgery at University Hospital in Gent, Belgium.

SURVIVOR STORY

lifeofofsurvival survival AA life and service and service Four-time cancer survivor Cinde Dolphin on how to survive – and thrive

By Kaitlin Clark

A

cancer diagnosis is not often considered something to laugh about – and repeated diagnoses are a less humorous prospect. For four-time cancer survivor Cinde Dolphin, however, optimism – coupled with a persistent can-do attitude and a dash of humor – comes quite naturally.

“I threw a party before my mastectomy,” Cinde laughs. “I called it a ‘Bye Bye Boobie’ party. I got all of my friends together, and I asked all of them to bring a pint of ice cream so when I was recovering, I had something like 40 pints of ice cream in my freezers. I was really glad I thought of that.”

The party marked her third breast cancer journey, and her fourth bout with cancer. The first was a carcinoid tumor in her lung, which required an intensive lobectomy procedure that ultimately removed most of her left lung, followed by a regimen of chemotherapy.

“Frankly, I was shocked to hear the words ‘You have cancer,’ because the surgeon was 100 percent certain it wasn’t cancerous,” she recalls.

“So, when I was told that yes, in fact, it was cancer, it was pretty upsetting.”

Immediately, Cinde’s “village of support,” as she calls her friends and loved ones, rallied around her, coordinating an extensive schedule filled with alternating shifts to assign household chores, from walking her dog to making a meal or cleaning up around the house. Cinde credits their support as her bedrock of recovery.

Cinde Dolphin

“Not one of them ever had breast cancer, so I give them a ton of credit, because they didn’t know what I was going through, but it didn’t matter,” she says. “They jumped right in and had both hands open to give me help.”

Not one to stay down for too long – despite having to take an extended period of time off from work – Cinde eagerly resumed her busy social life and active lifestyle, climbing Half Dome in Northern California and running half marathons.

Seven years later, Cinde found a lump in her breast.

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SURVIVOR STORY

This microloan project means the world to me.

It helped me heal emotionally and physically, but really giving something back made all the difference in overcoming cancer. "

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“For my first breast cancer, I had a lumpectomy for the first surgery,” she says, adding that while her surgeon was great, a pre-op miscommunication led Cinde to awake from anesthesia to a few unwelcome surprises. “During the pre-op, I was never given a heads-up that when I came around after anesthesia, I would have medical drains attached to me.

That sent me into a little bit of anxiety, but then it was explained that they were temporary.”

Even with the promise of the drains being temporary, Cinde says she felt vulnerable and exposed. Drains dangled from her chest, fashioned to her hospital gown with safety pins. The discomfort wasn’t easy to shake.

After several years of remission along with an annual check-up, Cinde again noticed irregularities in the same breast as before. A needle biopsy confirmed a second round of breast cancer, which she says was a bitter pill to swallow.

“The second breast cancer was the most disheartening because I was certain after having breast cancer once, I was through with it and it was in the rearview mirror and I wouldn’t have to deal with it again,” Cinde recalls.

As with her first diagnosis, Cinde’s inner circle again sprang into action and enveloped her with love and care.

“My family were the ones responsible for keeping my head above water,” she says. “I had a few dark days, but they kept me going.”

When the breast cancer returned for the third time, Cinde was resolute.

“I thought, ‘I’ve got to get rid of that breast – there is nothing good with this breast,’” she says. “In a way, it was easier to deal with because I made that decision to get a mastectomy, and we’re going to get

rid of all of it and it won’t happen again.”

Her plastic surgeon, David Sahar, MD, at UC Davis Medical Center, suggested a DIEP procedure, and after doing her own research, Cinde agreed that it was the best path forward.

“It seemed like a reconstruction that would be the most natural looking and still safe from what could still be lurking in that breast area,” she says. “Dr. Sahar’s work was impeccable and now I think I have a beautiful breast. It’s not, of course, a complete matching set, but it’s far better than I could have ever imagined, and I feel very lucky.”

No longer a rookie to surgery – Cinde counts nine different procedures over her four rounds of cancer – she knew the procedure would also require the burdensome and clumsy drains, which she dreaded.

“Typically, they give you a safety pin for each drain and tell you to pin these drains on your clothing, which is embarrassing,” she says, adding that showering is especially challenging because there’s not a piece of clothing to pin it to, so the drains simply dangle.

This time, for her reconstructive surgery, she was determined to recover in her own way – with modesty and without safety pins, thanks to a comfortable, homemade mesh apron she constructed with her nephew out of materials they found at the Dollar Store. The result immeasurably improved her recovery.

The mesh apron stored her drains, rather than safety pins. Cinde also says that her invention helped nurses reach and empty the drains during her three-day post-op stint in the ICU after the eight-hour reconstructive surgery.

Dr. Sahar remains impressed by Cinde’s perspective and determination.

SURVIVOR STORY

“She had a great sense of humor and outlook,” he notes. “She wasn’t a person who complained or felt sorry for herself. She always maintained a positive attitude. She just wanted to move onto the next thing.”

It was exactly this “infectious and altruistic” energy, as Dr. Sahar describes it, that enabled Cinde to recover quickly.

“I decided since I was so blessed to have overcome cancer four times that I wanted to give something back to the world, so I signed up to live in Africa for three months and work with women in microloan groups near the base of Kilimanjaro,” she says.

Together, they formed small businesses.

Cinde provided the financial backing to purchase sewing machines and fabric for the group and taught them how to sew her aprons.

“They made beautiful, vivid aprons out of the local materials and sold them in hospital gift stores,” she says. “It was a win-win because I felt like I was giving back to the world, and they found a business that worked extremely well for them. They can teach their children how to do it and the money they’ve made has paid for school fees, medical care, farming supplies. It’s empowered them to feel really good about the fact that they can be entrepreneurs.”

Even so, Cinde believes she got the better end of the deal.

Cinde and members of the microloan group in Tanzania celebrate after securing funds to pay school fees for their children and other local youth.

“This microloan project means the world to me,” she says. “It helped me heal emotionally and physically, but really giving something back made all the difference in overcoming cancer. I felt I could do something, I could give something back, it wasn’t out of my control. It made all the difference.”

To learn more about Medical Drain Carrier and African aprons, visit medicaldraincarrier.com and kilimanjarocarrier.com.

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DUAL PERSPECTIVE

On the Other Side:

Hospitalist Shares Her Experience with DIEP Flap Reconstruction and Resensation

By Barbara Brody

For Catherine Seangio, MD, June 2, 2022, will always be a date worth celebrating. It’s not her birthday or wedding anniversary, but the day she had a bilateral mastectomy, followed by DIEP flap reconstruction and resensation.

“I call it my cure date,” she says. “It marks me not having to undergo any more mammograms or worry about breast cancer.”

A hospitalist for the U.S. Department of Defense in Northern Virginia, Dr. Seangio, now 50, learned she had cancer after a routine mammogram detected changes in a calcification her doctor had been tracking for a few years. A subsequent biopsy confirmed that she had ductal carcinoma in situ (DCIS), or stage 0 breast cancer, in her left breast.

“It was localized, so it hadn’t spread yet,” Dr. Seangio says.

She might have considered a unilateral mastectomy, but when an MRI detected a lesion in her right breast, she opted to go the bilateral route.

She says she would have done the same thing had her genetic tests come back positive, despite having an older sister who’s a breast cancer survivor.

“When I heard there was a lesion [in the right breast] and that I needed another biopsy, I told them not to bother – just take it all out,” she says.

Today she has no regrets, even though the pathology report that came back after surgery didn’t detect any cancer on the right side.

“I didn’t want my life and my happiness and my fear to be dictated by having mammograms every six months,” she notes. “I decided I’d rather do this when I’m young and pretty healthy than have to deal with breast cancer 10 years from now.”

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Catherine Seangio, MD, recovers after her procedure.

From doctor to patient Shortly after her diagnosis, a referral from a gynecologist friend led Dr. Seangio to David Weintritt, MD, a breast surgeon at the George Washington University School of Medicine & Health Sciences. When Dr. Seangio expressed interest in reconstruction, Dr. Weintritt pointed her to ASPS member Alex Mesbahi, MD, a breast reconstruction specialist with the National Center for Plastic Surgery in McLean, Va. Dr. Seangio initially assumed that reconstruction meant getting implants, so she was surprised when Dr. Mesbahi said she was a candidate DIEP flap reconstruction, which eschews implants in favor of transferring tissue from the stomach to the chest.

“I didn’t even know that you could use your own belly fat,” she recalls.

Although DIEP flap is a longer, more extensive procedure compared to getting implants, Dr. Seangio was intrigued by the possibility of combining a tummy tuck into her post-mastectomy reconstruction. The fact that she could use her own tissue, which seemed more natural and would eliminate any risk of having an immune reaction to foreign implants, was also appealing.

When Dr. Seangio then heard about ResensationTM, a nerve-grafting procedure, she was sold.

“I wanted to get rid of the cancer,” she notes. “To be able to have sensation afterward was a bonus.”

He adds that some patients can develop hypersensitivity, but that problem seems to be temporary and Dr. Seangio did not experience it.

Recovery and beyond

Novel technique Mastectomy patients are typically left with numbness in their chests, which can impact their intimate relationships as well as their everyday quality of life. Resensation is a relatively new procedure that aims to restore sensation by connecting nerves in the chest to nerves in the reconstructed breast tissue.

Dr. Mesbahi had performed other types of nerve grafts before, but he and Dr. Weintritt traveled to San Francisco to learn the Resensation technique from ASPS members Anne Peled, MD, and Ziv Peled, MD, prior to Dr. Seangio’s surgery. Dr. Mesbahi believes that Dr. Seangio is one of the first patients in the Washington, D.C., area to undergo Resensation.

“Resensation can be done with flap or implant procedures, though it’s more often done with tissue transfers,” Dr. Mesbahi says. “Generally, anyone can get it, though some patients with very large breasts aren’t candidates just because there’s some limitation to the length of the nerve graft that can be used.”

The procedure works best for women who have undergone a nipple-sparing mastectomy, but it may also be used in other patients to preserve sensation in the breast skin.

The technique makes use of an allograft nerve provided by Axogen.

Surgeons connect the nerves that were cut

(Top) Dr. Seangio and her surgeon, Alex Mesbahi, MD; (Bottom) Dr. Seangio enjoying time with her family.

during the mastectomy to nerves in the reconstructed breast, and the processed allograft nerve tissue serves as a bridge between the two. Over time, the graft regenerates and becomes part of the body. The goal is to restore feeling and prevent the numbness, so mastectomy patients can feel more like themselves.

Because Resensation is still in its infancy, long-term success rates are unknown. Dr. Mesbahi is among the surgeons collecting patient data at baseline as well as three, six and 12 months after the procedure.

“Looking at the data so far, the procedure has a lot of promise,” Dr. Mesbahi says. “It’s not a particularly difficult technique to do, and it doesn’t add a lot of risk. It brings a lot of hope to patients to be able to get more normalcy after a mastectomy. That’s really critical to the evolution of breast reconstruction.”

“As a physician, it’s definitely very strange being on the other side, anticipating surgery and possible complications,” Dr. Seangio says, adding that she was most concerned about the risks of going under anesthesia for six hours. Fortunately, everything went as planned.

Pain medication kept her relatively comfortable after the procedure, though her belly felt tight which made it difficult to sit up. Nurses monitored her closely to ensure that the nerve graft was taking. At first, Dr. Seangio was just thrilled to have made it through the procedure. Then she realized she could still feel her breasts.

“I’m not going to say it feels the same, but I definitely have sensation,” she says, adding that she expects continued improvement as the nerve regenerates.

Since her surgery, Dr. Seangio has been steadily improving and working on increasing the range of motion in her arms. She also enjoys having a trimmer midsection.

“They chopped off my mommy belly,” she laughs, adding that her son is now 12. “Aesthetically, it’s beautiful. I’m very happy.”

This summer, Dr. Seangio, her husband and her son traveled to Greece to celebrate her progress. Finding out that she had a trip on the horizon – her husband surprised her with the idea, pending her doctor’s greenlight to travel – gave her extra motivation to keep moving and getting stronger.

“It’s hard to be a patient, but I’m so grateful for the whole medical team that took care of me, as well as the support of my family during my recovery,” she says.

“You have to wake up every day and do well because you have people in your life who believe that you will succeed.”

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PATIENT SAFETY

Management of postoperative pain: A closer look at ERAS protocols

By Raman Mahabir, MD, and Silvia Kurtovic, MD

After learning about your options following a breast cancer diagnosis and choosing mastectomy and reconstruction, it’s understandable to still have questions – not just about the procedure itself, but also what to expect afterward. One of the

most common questions we’re asked is: “How much will it hurt?”

A mastectomy removes all of the breast tissue from one or both breasts. It is an effective weapon against breast cancer – although in the process of removing breast

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tissue, nerves and other tissues are also necessarily removed. In years past, it was not uncommon to experience significant postsurgical discomfort during recovery.

A recent survey showed that patients’ No. 1 concern leading up to surgery was pain. Uncontrolled, acute postoperative pain can lead to an increased surgical stress response, which also affects various organ systems. In addition, uncontrolled acute postoperative pain is associated with longer stays in the recovery room and hospital.

Up to 30 percent of patients suffer chronic

pain after mastectomy, and as such, effective acute pain control remains vital to patient recovery following breast cancer surgery.

Fortunately, recent developments have markedly improved the experience for patients. We now understand there is a role for treatment before, during and after surgery to ensure a fast, comfortable and smooth recovery. The “before” focuses on “enhanced recovery after surgery” (ERAS) protocols. During surgery, nerve blocks can be used to significantly reduce discomfort after surgery. By understanding and implementing these novel strategies before and during surgery, the postoperative treatment almost takes care of itself. The vast majority of patients then can use nothing more than Tylenol or anti-inflammatory medications to manage discomfort after surgery. Here is how we accomplish that.

Although the classic post-surgical pain management protocol consists of narcotics (also known as opioids or prescription painkillers) – which are potent pain relievers – they can cause unwanted side effects such as drowsiness, itching, nausea, vomiting, constipation and even difficulty breathing. Additionally, the opioid crisis that has become increasingly prominent in recent years has illustrated the risk of addiction these treatments pose. The good news is that narcotic use can be minimized – and even avoided entirely – with ERAS and nerve blocks.

Sensation in the breast comes mostly from the intercostal nerves located under each rib. With the patient asleep in surgery, a needle is used to inject local anesthetic just below the lower edge of the rib. This is then repeated at multiple levels. Next, a local anesthetic is injected as a “field” block around the breast to numb the other minor nerves supplying the breast. This makes it possible to essentially numb the entire area.

Most local anesthetics last 4-6 hours at most, although some new pain medications can provide pain relief that last multiple days. It is possible that very little narcotics are necessary when using ERAS protocol,

allowing patients to be home one or two days after surgery and then taking only over-the-counter medications.

By using a combination of non-narcotic analgesics (pain medications) and the long-acting local anesthetic, patients can withstand the most difficult portion of their recovery without putting them at risk for narcotic-related side effects.

Starting a dialogue with your surgeon can be as simple as asking, “How will my pain be managed after surgery?” Don’t be afraid to ask. Many patients either take safe and adequate pain management for granted or are too overwhelmed with information and never broach the issue with their doctor. By not initiating a discussion, you’re missing an opportunity to have a voice in choosing the types of pain treatments or medications you’ll be given.

Don’t wait until the day of your surgery to talk to your doctor about pain

management – and don’t be afraid to express your preference to minimize the use of narcotics after surgery. You are your best advocate.

Drs. Mahabir (right) and Kurtovic are passionate about helping breast cancer patients regain a sense of wholeness following mastectomy.

They have advanced training and experience in restorative surgery for patients who are recovering from breast cancer or have genetic abnormalities, and are excited to share their expertise in reconstructive and cosmetic breast surgery with the Tucson community.

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GLOBAL AWARENESS

SHARE looks to increase capacity for breast reconstruction in Rwanda

By Paul Snyder

With an increased government focus on improving cancer treatment in Rwanda, plastic surgeons are taking important steps to increase the availability of breast reconstruction to women in the country.

Surgeons in Humanitarian Alliance for Reconstruction Research and Education (SHARE) is a program from The Plastic Surgery Foundation (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 fellows, global educators and global researchers.

In partnership with COSECSA (The College of Surgeons of East Central and Southern Africa), the program provides plastic surgery training and long-term sustainability to areas in sub-Saharan Africa. Areas such as Rwanda not so long ago counted only two plastic surgeons for a population of more than 12 million.

The SHARE program recently performed a needs assessment based on the training program in Rwanda, which has quickly established itself as one of the larger training programs in sub-Saharan Africa. One of the main areas of expansion has been in the field of microsurgery, and SHARE educators have recently been involved in virtual courses, teaching the program’s Fellows various techniques through synthetic and chicken-thigh models. The PSF past President Andrea Pusic, MD, MHS, and Amanda Gosman, MD – both of whom serve as directors for the SHARE

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During their recent trip to Rwanda, The PSF past President Andrea Pusic, MD, MHS, and Amanda Gosman, MD, advanced SHARE’s support of the plastic surgery residency program in Kigali, the nation's capital.

program – recently traveled to Rwanda to learn more about what training programs can help specific areas of clinical interest.

Breast surgery is a priority.

“I think it’s really critical,” Dr. Gosman says. “Rwanda has a very advanced approach to addressing healthcare needs in the country, and plastic surgery is a top priority. Their ministry of health is incredibly invested in cancer care, and in order to keep pace with advances in cancer treatment, reconstruction is certainly an essential component of that.”

Noting that most sub-Saharan African countries have limited access to implants,

Dr. Gosman notes that the most viable option for breast reconstruction is through using a patient’s own tissue, but the training programs have shown an interest in learning more autologous techniques.

“Over the next two years, we plan to send a series of SHARE visiting professors to Rwanda in collaboration with the ACS to participate in two-week teaching trips,” she says. “If we’re looking at a sustainable model of increasing plastic surgery capacity in the country, oftentimes these areas have large needs for burns and trauma treatment. In order to create a sustainable business model for plastic surgeons in the country, however, it’s important they have the skillset for a diverse practice and breast reconstruction becomes a key component of that. We have a unique opportunity to harness the talent of ASPS membership to do that.”

The domino effect of training these surgeons is a profound – and prolonged – message of hope to patients in the country.

“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.”

WELLNESS

Exercise guidelines

after breast reconstruction

By Ravi Tandon, MD

Exercise is a crucial part of a successful recovery after breast reconstruction surgery. Light

physical activity can promote healing and reduce the risk of post-operative complications. Exercise allows you to gradually return to normal activities and restore the full range of motion of the chest, shoulders and arms. It also provides incredible benefits for mood, energy and sleep.

With that in mind, it’s important to take things slowly. Listen to your body and give it the time it needs to recover. Healing is a process. Gradually increasing physical activity over the course of six weeks is ideal.

After your breast reconstruction surgery, you’ll want to avoid the following physical activities for the first two weeks: • Raising your arms above your shoulders • Placing your arms behind your back to stretch the chest • Lifting objects heavier than a few pounds • Pushing your body weight up from a prone position (such as a push up) • Pushing and pulling heavy objects

Immediately after surgery It is normal to experience some discomfort, pain and fatigue following surgery. Stretches, deep breathing and relaxation techniques can help manage pain and will aid in a gradual return to your prior activity level.

• Walking, even a little bit each day, is recommended as early as the first day after surgery. Walking promotes circulation, boosts energy and prevents muscle atrophy. In addition, walking for a few minutes at least two to three times per day helps to prevent the formation of blood clots, which is especially important in the first week after surgery.

• Deep breathing exercises are helpful for pain control, relaxation and to relieve tightness in the chest wall and back.

Sit in a comfortable chair or lie down on your back. Take a deep, slow breath through your nose to expand your chest and abdomen. Exhale slowly. Repeat this pattern four to five times, multiple times per day.

•

Light hand and arm exercises will help to maintain the mobility of your arms and shoulders. Lying flat on your back, prop your hands and arms up on pillows so they are higher than the level of your heart. Open and close the hand on the side of your body operated on 15 to 25 times. Next, with your hand relaxed, bend and straighten your elbow.

One to two weeks after surgery During the first two weeks after surgery, patients can perform low-impact exercises as instructed by their surgeon. Here are a few things to keep in mind after breast surgery: • Tightness in the chest, armpit and abdomen is normal and should decrease as you do your exercises.

• It may be helpful to exercise after a warm shower, when muscles are more relaxed.

• Perform each exercise slowly until you feel a gentle stretch. Hold the stretch and count to five. Repeat each exercise five to seven times, twice daily.

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WELLNESS

Some recommendations for low-impact stretching exercises include: • Shoulder shrugs: Inhale and slowly raise your shoulders toward your ears, then exhale and slowly relax your shoulders down.

• Shoulder rolls: With your shoulders relaxed, roll your shoulders forward slowly and then roll them back slowly. Squeeze the shoulder blades together when rolling your shoulders back.

• Shoulder raises: Touch your fingertips to your shoulders so that your elbows extend out to the sides.

Raise the elbows to where they are comfortable.

Slowly rotate your elbows clockwise and then counter clockwise.

Three to four weeks after surgery Patients will start increasing their shoulder and arm mobility three to four weeks after surgery. Exercises during this time will typically involve raising the hands above the shoulders and the head. This will help stretch the chest and shoulder area, building back strength and mobility.

• Side arm crawls: Stand and reach your arm out to touch the wall with your elbow slightly bent. Slowly walk your arm up toward the ceiling. Repeat on the opposite side.

• Side bends: Clasp your hands together in front of you, then slowly lift and straighten your arms above your head. Slowly bend your trunk to the right side, keeping your arms overhead. Return to the center, and then bend to the left side.

Six weeks after surgery After about six weeks, most breast reconstruction patients can return to their normal exercise routines. Light cardio and stretching are best, while patients may want to be more conservative with a return to strenuous cardio, weight training and strength training. High-impact workouts and heavy lifting should be avoided for at least six to eight weeks or until cleared by your surgeon.

Dr. Tandon is a board-certified plastic and reconstructive surgeon. He specializes in reconstructive microsurgery, having completed a microsurgery fellowship at New York University Medical Center.

Tandon Plastic Surgery serves patients throughout southeastern Louisiana. Dr. Tandon is dedicated to providing his patients with results that help minimize the impact cancer has had on their lives.

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Breast Implants: What Patients Need to Know

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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 of which you should be aware. The decision to have plastic surgery is extremely personal, and you'll have to decide if the benefits will achieve your goals and if the risks and potential complications are acceptable. Your plastic surgeon and/or staff will explain in detail the risks associated with surgery 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.

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 manufacturers, The Plastic Surgery Foundation has developed the National Breast Implant Registry (NBIR) to strengthen the national surveillance for breast implants 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.

CORPORATE SUPPORT

Thanks to corporate sponsors who support Breast Reconstruction Awareness Day efforts

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espite ever-increasing education about options after a breast cancer diagnosis, research maintains that far too many women diagnosed with breast cancer still don’t know about their reconstruction options following a mastectomy.

In 2011, Canada launched the first Breast Reconstruction Awareness Day. The following year, the American Society of Plastic Surgeons (ASPS) and The Plastic Surgery Foundation (PSF) launched the Breast Reconstruction Awareness USA campaign to provide women 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 11th annual Breast Reconstruction Awareness Day will take place on Oct. 19, 2022. 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.

2022 SPONSORS Four companies have generously lent their support to the 2022 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 and a longtime supporter of Breast Reconstruction Awareness Day efforts and events. Motiva, a Gold Sponsor, is another strong 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 2022 Breast Reconstruction Awareness Campaign’s generous sponsors for their continued support and dedication to women’s health, patient education and innovation.

For information on the Breast Reconstruction Awareness Campaign corporate sponsors, visit breastreconUSA.org.

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Join Close The Loop 5K 2022!

SATURDAY | 7 a.m.

Oct. 29, 2022

Castle Island in Boston, MA.

Join the Breast Reconstruction Awareness Close The Loop 5K and support empowering women to make the decision that is best for them following a breast cancer diagnosis.

Funds generated from the Close The Loop 5K will be awarded to organizations through the Breast Reconstruction Awareness Campaign of The Plastic Surgery Foundation (PSF), the philanthropic arm of the American Society of Plastic Surgeons. Raise your voice and help us make a difference!

CLOSE THE LOOP 5K BOSTON FEATURES: • A flat, fast, and a super fun course • Spectacular views of Boston Harbor and Fort Independence • Finisher’s medal and race t-shirt

GET INVOLVED – RUN IN PERSON OR VIRTUALLY! REGISTER NOW at p2p.onecause.com/bra5k Register before Oct. 10 and receive your Race Swag Bag before Oct. 29.