Breast Reconstruction 2023

2023 ● A Supplement to Plastic Surgery News

A patient’s guide to understanding her treatment options

Also in this issue: Page 14

Getting the word out Australian breast cancer survivor brings education to global audience Page 16

Helping your child understand

Doctor draws on family experience for new kids book

‘Fearless, yet fragile’ Page 6 Breast reconstruction patients show another side of themselves in Reblossom

Contents

2023

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Celebrate BRA Day

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Fighting for patient access

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Reblossom showcases survivors’ new form

A note from the editor

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Podcast provides global forum for breast reconstruction education

The work for patient education and awareness continues

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Family experience with breast reconstruction inspires kids novel

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Closing the gap on breast reconstruction discrepancies

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Evolving techniques to deal with post-surgical numbness

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Diet and exercise as reconstruction “prehab”

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What you should know about breast implants

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Industry support fuels Breast Reconstruction Awareness effort

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The NBIR matters

Our yearly supplement, Breast Reconstruction, put forth by the Plastic Surgery News team, is one of my favorite issues to work on. As the medical editor, I work with an amazing team focused on highlighting the concerns of patients, family and caregivers facing a breast cancer diagnosis. Nearly 300,000 women will be diagnosed with in situ or invasive breast cancer in the United States this year, joining the nearly 4 million survivors affected Summer E. Hanson, MD, PhD by this disease. Roughly 50 percent of those diagnosed will undergo breast reconstruction.

PSN Chief Medical Editor That’s why efforts to publicize and promote reconstruction are so important. Although that number continues to improve, there’s 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 see, 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’m aware of that focuses the breast cancer discussion on reconstruction.

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.

Now, more than ever, public awareness of the options for breast reconstruction – both in techniques and timing – is paramount. There’s no expiration and no “one-size-fits-all” mode of reconstruction. Rather, there’s a carefully crafted plan for each individual who faces breast cancer. There has been a considerable amount of discussion on insurance coverage for specific forms of reconstruction, in which microsurgeons use your own tissue from your abdomen or lower body – known as autologous reconstruction. Many of our patients have become concerned over the past year about these options being taken away based on a proposed change in the “coding” of these complex procedures. The decision to use your own tissue should be made between you, the patient, and your boardcertified plastic surgeon. It’s your tissue, your choice – you own it.

Cover photo Erez Sabag Designer Greer Mosher ASPS website plasticsurgery.org

Our surgeon members, patient advocates and ASPS/PSF staff work tirelessly at both the local and national levels to fight for appropriate coverage of all options for breast reconstruction. Autologous tissue reconstruction, such as the deep inferior epigastric perforator (DIEP) flap, are the gold standard of reconstruction. These procedures are not going away, although access to these more technically challenging options has been challenged lately. Thanks in part to advocacy efforts by ASPS, a federal agency in August withdrew a proposed change to DIEP flap coding. Nevertheless, ask questions. If you have concerns, start the conversation now with your insurance carrier and your plastic surgeon.

Breast Reconstruction Awareness website breastreconusa.org © 2023 The American Society of Plastic Surgeons

In celebration of BRA Day USA (Oct. 18), this special edition of Breast Reconstruction is dedicated to education and advocacy. Within these pages are stories to promote patient care, education, awareness, research and inspiration. You will read personal narratives from breast cancer survivors and reconstructive surgeons. We highlight key things 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.

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

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WA R N I N G : • Breast implants are not considered lifetime devices. The longer people have them, the greater the chances are that they will develop complications, some of which will require more surgery.

• Breast implants have been associated with the development of a cancer of the immune system called breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). This cancer occurs more commonly in patients with textured breast implants than smooth implants, although rates are not well defined. Some patients have died from BIA-ALCL. • Patients receiving breast implants have reported a variety of systemic symptoms such as joint pain, muscle aches, confusion, chronic fatigue, autoimmune diseases and others. Individual patient risk for developing these symptoms has not been well established. Some patients report complete resolution of symptoms when the implants are removed without replacement.

The sale and distribution of Mentor Breast Implant Devices are restricted to users and/or user facilities that provide information to patients about the risks and benefits of the device prior to its use in the form and manner specified in approved labeling to be provided by Mentor Worldwide LLC.

IMPORTANT SAFETY INFORMATION MENTOR® MemoryGel® Breast Implants are indicated for breast augmentation in women at least 22 years old or for breast reconstruction.

Breast implant surgery should not be performed in women with active infection anywhere in their body, with existing cancer or pre-cancer of their breast who have not received adequate treatment for those conditions or are pregnant or nursing.

Breast implants are not lifetime devices and breast implantation is not necessarily a one-time surgery. The chance of developing complications increases over time. The most common complications with the MemoryGel® Breast Implants include reoperation, capsular contracture, asymmetry, and breast pain. A lower risk of complication is rupture. The health consequences of a ruptured silicone gel-filled breast implant have not been fully established. MRI screenings are recommended three years after initial implant surgery and then every two years after to detect silent rupture.

Breast implants are also associated with the risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), an uncommon type of lymphoma. An individual’s risk of developing BIA-ALCL with MENTOR® Breast Implants is low based on the incidence of worldwide cases.

Patients should receive a copy of Important Information for Augmentation Patients about MENTOR® MemoryGel® Silicone Gel-Filled Breast Implants or Important Information for Reconstruction Patients about MENTOR® MemoryGel® Silicone Gel-Filled Breast Implants. Your patient needs to read and understand the information regarding the risks and benefits of breast implants, with an opportunity to consult with you prior to deciding on surgery.

For detailed indications, contraindications, warnings, and precautions associated with the use of MemoryGel® Breast Implants please refer to the Instructions for Use (IFU) provided with each product, or online at www.mentorwwllc.com.

Important information: Prior to use, refer to the instructions for use supplied with this device for indications, contraindications, side effects, warnings and precautions.

Caution: US law restricts this device to sale by or on the order of a physician. *Head-to-head, in-person tabletop product comparison (MENTOR® MemoryGel BOOST™ vs Allergan Inspira Cohesive) with 297 respondents; in-person consumer survey with 452 respondents; head-to-head form stability benchtop testing vs MemoryGel® Xtra and MemoryGel® Breast Implants.

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Patient Education

Celebrate Breast Reconstruction Awareness Day on Oct. 18 Breast Reconstruction Awareness Day is an awareness campaign designed to promote public education, patient care and research. It was first launched in 2011 in Canada and now occurs annually in October. This important initiative is a collaborative effort between the American Society of Plastic Surgeons, The Plastic Surgery Foundation, plastic surgeons specializing in breast surgery, nurse navigators, corporate partners and breast cancer support groups. These organizations and breast cancer patients – along with their families and friends – raise their voices on Breast Reconstruction Awareness Day by coordinating media events, question-and-answer sessions, lectures, flash mobs, fundraising parties, advertising campaigns and community events. Learn more about local events in your area at thepsf.org/braday and get involved with spreading awareness and education!

Caption goes here

Please share photos from your BRA Day 2023 events with giving@plasticsurgery.org.

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Patient Education

Working to maximize patient access to breast reconstruction

UnitedHealthcare (UHC), which announced in April 2022 that effective the following July, it would no longer reimburse practitioners for specific types of microsurgical breast reconstruction. The changes were rolled out in anticipation of the CMS-planned sunsetting of these codes, which was initially scheduled for Dec. 31, 2024.

The American Society of Plastic Surgeons (ASPS) has long been a strong proponent for ensuring access to the full gamut of breast reconstruction techniques for all patients, as no woman should be limited in her post-mastectomy options.

Without adequate reimbursement for these complex procedures, many private practices currently dedicated to providing post-cancer breast reconstruction could be forced to transition to other practice models. The shift in how payers treat private-practice breast reconstruction could portend a more concerted and expansive effort across the private health insurance industry to limit access to an essential form of breast reconstruction.

Advocating access

Women seeking microsurgical breast reconstruction have been steadily losing access to the procedure since November 2021, when some private health-insurance companies began to make categorical coverage-policy changes that drastically reduced the ability of private practices to perform this type of reconstruction. In February 2022, the Centers for Medicare and Medicaid Services (CMS) exacerbated the situation when it announced that it would be eliminating codes that doctors use to report the procedure.

The confluence of these issues threatened to result in many women losing covered access to microsurgical breast reconstruction outside of major hospital systems. Some patients are only medical candidates for microsurgical breast reconstruction due to the course of their cancer treatment.

For many women, major hospital systems can be difficult to access – even if the system is within their insurance network. Furthermore, although care provided within major these systems is often of high quality and well-coordinated, it’s not often available.

Academic medical centers are already providing tissue-based reconstruction to patients who travel great distances. The few community breast microsurgeons who have been successful in reaching agreements with health insurers that make a breast reconstruction-focused practice feasible also treat patients from outside of their geographic area.

The first major insurer to attempt to limit access to microsurgical breast reconstruction was

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In response to the moves made by the healthinsurance companies, ASPS launched the Initiative to Support Microsurgical Breast Reconstruction, which seeks corporate and public-policy changes that increase patient access to the procedure across all practice models. The objective is to improve payers’ understanding of the importance and broad patient and health-system benefits of microsurgical breast reconstruction – as well as the incredible expertise breast microsurgeons provide to make this type of reconstruction possible. As part of this initiative, ASPS pushed CMS to reconsider its decision to sunset the microsurgical breast reconstruction codes, arguing that private insurers were capitalizing on that CMS decision in order to reduce what they pay for the procedure. On Aug. 21, CMS reversed its decision and announced that it will continue to list the codes – a victory for women that helps maintain accessibilty to as many post-mastectomy options as possible.

ASPS has also developed proposed legislation to modernize the Women’s Health and Cancer Rights Act of 1998 (WHCRA) to clarify that more than implant-based breast reconstruction is covered and available within the insurance network. In conjunction with that, the Society also launched a nationwide effort to enact comprehensive breast reconstruction coverage laws across all 50 states.

In addition to local, state and regional medical organizations, ASPS is also collaborating with state legislators on developing new legislation.

The Society believes that commercial healthinsurance companies have the financial capability to reimburse any procedure at a level sufficient to allow for a sustainable practice to be built around it – and it remains committed to exhausting every avenue to make them more willing to do that.

Patient access to all types of breast reconstruction procedures – in as many locations as possible – remains of paramount importance to ASPS.

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Feature: Reblossom

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Feature: Reblossom

‘Each scar reminds me of a journey’ By Paul Snyder

Photos Erez Sabag

The plastic surgeon and patients behind Reblossom share their stories and demonstrate how breast reconstruction can be a point of rebirth and revitalization.

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Feature: Reblossom

Lisa Csentsis sees herself in the pages of Reblossom – albeit a transformed version of herself. It's a transformation that’s both unique and shared with the other breast reconstruction patients that grace the pages of the book.

“You see women of different ages, different races, different reconstruction procedures – all unique and individual stories,” she says. “When you think about a flower and how it comes back to life in the spring, it’s not reborn like its old self, right? It’s reborn with a resilience, determination, strength and beauty that might not have been there in the past.”

In fact, that’s the very theme of Reblossom, a new photography book published with support from Allergan Aesthetics, an Abbvie Company. Lisa is one of 12 patients featured in the book who underwent breast reconstruction, share a bit of insight into their own journeys and display their new bodies for all to see.

The book is the product of ASPS member Jonathan Bank, MD, Great Neck, N.Y., and photographer Erez Sabag (who planned the visual journey of the book, photographing, planning and designing it) to document those patients who wanted to share their stories, embrace their beauty and serve as an inspiration to other breast cancer survivors and reconstruction patients.

Dr. Bank has worked on numerous art projects with breast reconstruction patients over the years – some of them highlighted in previous editions of Breast Reconstruction – but the seed of inspiration for Reblossom actually came from orchids in his office. Every year, he says he receives a white orchid for his birthday, and he typically maintains the routine of watering them and

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watching them shed and blossom over several months. Nevertheless, doctors get busy and sometimes maintenance of office plants falls by the wayside.

“I had these dying orchids in my office – just some stalks and petals along the windowsill – and it got me thinking about the phases that we all go through in life,” Dr. Bank says. “I thought it was encouraging – enjoy the phases, see the beauty that’s there in everything. Then if you nurture the buds, they will rebloom. It might not be exactly the same as it was before – like with breast reconstruction – but it will still be beautiful in its own way.”

Lisa was 34 when she went for her first mammogram. She was told she had a lump and had to go for an MRI-guided biopsy. However, she says that’s not where her story begins.

“When my mom was 12, her mother passed away from breast cancer,” Lisa says. “I grew up knowing that, and when I was around that age, I became very fearful that I was going to lose my mother. Her older sister was diagnosed in her late 30s and passed away a few years later. My sister had a double mastectomy. There’s a very strong history of breast cancer in my family. When they found my first lump, I began a monitoring plan. In the summer of 2020, my sister called to tell me my mother had been diagnosed with breast cancer.

The very next morning, I called my breast surgeon. I had an MRI done within a week, and three weeks later, I had my double mastectomy scheduled.”

Although Lisa moved forward with her breast surgeon’s recommendation for reconstructive surgery, she concedes that she wishes she had done a little more research ahead of the procedure.

Feature: Reblossom

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Feature: Reblossom

“I received a couple options about what kind of reconstruction might be best for me,” she says. “I had to do expanders first, because my skin is very thin – but I’m also an athlete. I knew I wanted my reconstruction to be done above my pectoral muscles, because I didn’t want any limitations in movement. I also have two young boys and I want to be able to play with them. So my only request to the surgeon at that time was ‘I want to feel like a woman and play like a mom.’ ” Unfortunately, Lisa says her first reconstruction procedure did not achieve that goal. After a few months of pain and discomfort, she met Dr. Bank, who revised her first reconstruction procedure.

“This reconstruction gave to me a whole new perspective on life and more strength than I ever had – even before my double mastectomy,” she says.

The floral theme that runs throughout Reblossom doesn’t stop with the metaphor of returning stronger after a harsh winter or other tough phases of a life cycle.

“We wanted to demonstrate how women and flowers are similar in terms of their underlying anatomy,” Dr. Bank notes. “So we got X-rays of flowers, because we wanted to show the internal veins and composition that exist in plants. It turns out that, because flowers are so soft and delicate, the best way to image them is with a low-voltage machine – which happens to be a mammogram. So we weave that imagery into the book.”

When Erika Allen looks through Reblossom, she sees a woman she didn’t know was inside of her.

“It feels like breaking out of a box,” Erika says about her pictures. “Maybe now no one would believe it – because I’m such a people person – but growing up, I was shy. In the locker room, I was never unclothed. I hid my body. I didn’t wear clothes that revealed anything. I was always kind of self-conscious, but I’m really proud of this. This has opened me up. It’s a new chapter.”

Diagnosed with multiple sclerosis in 1997, Erika says she has always tried to stay on top of her health. However, when the COVID-19 pandemic arrived in 2020, she was in the process of trying to find a new primary-care physician. When the restrictions on seeing doctors lifted, she found a new doctor and went through a battery of tests, including a mammogram that showed calcification and required a biopsy. Scared of needles, Erika called the process terrifying – and adds she also had a sinking feeling about what news might follow. She found out she had ductal hyperplasia on the right breast. Taking time to assess her options, she connected with Dr. Bank, who did an MRI and found cancer in her left breast.

After removing the cancer, Erika opted for a DIEP flap reconstruction. She says Dr. Bank remained a trusted source throughout her journey, continually making her feel comfortable in the midst of a battery of tests and subsequent examinations that required needles and extra bouts of recovery time. She notes that some reconstruction patients will tell their stories as before-and-after anecdotes that gloss over some of the less-pleasant post-surgery details. But those are important parts of the process that need to be conveyed.

“When I came out of surgery, and I had eight tubes all over me, I joked that I felt like a cyborg,” Erika says. “Yes, you can absolutely come out of these situations with a new sense of confidence and strength in yourself, but it’s OK to have fears when you’re going in for follow-up exams the first week after, or the second week or a month later. There is a story to be told – but that story does not end right after your reconstruction procedure is done. That story is still being written.”

Both Erika and Lisa highlight the patient empowerment program in Dr. Bank’s practice that connects past patients to new reconstruction patients to gain additional perspective and reassurance. Both also said they want to pay that service forward.

Dr. Bank says that community has become self-sustaining with the more patients that he sees.

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Feature: Reblossom

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Feature: Reblossom

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Feature: Reblossom

Lisa attests to that line of thinking as well. Even as an athlete and mother, she remembers the fear that consumed her before her first reconstructive surgery, which ultimately prevented her from asking the questions she now believes she should have.

“I allowed that fear to prevent me from gaining the information and knowledge I needed in order to make that fear go away,” she says. “Fear is driven by unasked questions. You have to ask as many questions as possible, I think, while also limiting how much you Google as well. The internet is wonderful, but it can also feed the fear.”

As all the women in Reblossom note, reconstruction is another chapter in a rich tome, and a renewed sense of self and courage can lead to new achievement. Lisa, for example, won a USA Cyling Masters Road National Championship in 2022.

The results also put the work that surgeons do into sharp relief, as Dr. Bank says Reblossom provided him with a different perspective on the work that he does in the O.R. “As a plastic surgeon, I can get very hung up on small details – such as nipple placement being a millimeter off or something really miniscule like that,” he says. “With the pictures we do in our office for reference, they are very static poses against a wall, and it’s easy to overanalyze small things. I think the pictures in Reblossom reinforce the idea that we are dynamic creatures. We are not static. We are alive. We move. And to see these pictures is to truly see these patients as the incredible women they are.”

Getting to be part of the process of making the book also gave him behindthe-scenes experiences that he might never have enjoyed in his office.

“Going through the process is therapeutic in ways that go far beyond getting cancer out, doing a preventative mastectomy or facing the physical ramifications of those choices,” Dr. Bank says. “A lot of these women have told me this process and this project helped them look beyond themselves – and really made them want to help others and encourage other women to be proactive about their health for the sake of themselves, their families and their children.”

Erika says a dichotomy exists for every woman who undergoes a cancer diagnosis and breast reconstruction journey.

“Fearless, yet fragile,” she says. “Some people might think that you can’t be both – but that’s exactly what I see in Reblossom. Look, trivial things get to me – they can frazzle and upset me. Big things? I tend to respond more in terms of, ‘OK, what do I need to do to move forward?’ Maybe having M.S. made me process breast cancer more in a methodical way. But it’s OK to be both – and I hope the women that see this book understand that.”

“During one of the photoshoots for Reblossom, I was in the back corner of the studio, doing some other work,” Dr. Bank recalls. “One of the women had brought along her daughter, who must have been 14 or 15, to the shoot. We’re taking pictures of her mother basically naked, wearing this little floral crown.

So while the photographer is capturing these shots, the woman’s daughter is taking pictures of all this on her phone. At one point, she runs across the studio and startles me from whatever I was doing. She shows me her phone and says, ‘This is my mom! Look at my mom!’ She was so proud – and the mother had no idea this was happening. She’d invited her daughter along to show her strength and beauty survives despite breast cancer, reconstruction, second-stage surgery and recovery.”

With breast cancer playing a significant role in her family history, Lisa says she knows that all breast cancer patients are linked by some common threads.

However, the takeaway from Reblossom is that each woman’s journey is her own important story to tell.

“I’m stronger today than I was prior to my reconstruction,” she continues.

“Not just on the bicycle, but as a mother and a person. It’s important for me to see my scars and every imperfection on display, because it helps me demonstrate why I love each and every scar and imperfection. It is a part of me.

Each scar reminds me of a journey that, while scary and painful at times, led me to be the woman I am today. That is forever evolving, and it will continue to evolve with every other scar and wrinkle that comes about.”

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Patient Story

By Luan Lawrenson-Woods

From Unwritten to Rewritten Me —

In 2017, I was diagnosed with invasive pleomorphic lobular breast cancer in my right breast.

I was 46. Although I initially kept my diagnosis private and only told a few people, I now talk – and write – about it every day to raise awareness of breast reconstruction and support women in our community.

In 2018, I had neo-adjuvant chemotherapy, a skin-sparing mastectomy and radiotherapy. I was absolutely devastated when I was told I needed a mastectomy. I didn't know anyone who’d undergone breast reconstruction, and I had no idea about the different types of reconstruction.

When I heard about my breast reconstruction options, however, it gave me hope that I could be “me” again. I found reconstruction an empowering part of my treatment – but in Australia, as in other parts of the world, it was difficult to find information about it. I was told by my Australian reconstructive plastic surgeon to look to the United States for up-to-date information, and while I found some amazing evidence-based resources that were a huge help, I still had lots of questions – lots!

In 2019, I underwent a unilateral DIEP flap reconstruction, with tissue taken from my tummy to reconstruct my breast. I micro-blogged about my recovery on Instagram for 100 days (#100DaysDIEP) under my then Instagram name of @unwrittenme.

Unwritten me I was stunned when I was first called back for a biopsy after my mammogram.

I’d been generally unwell, but I didn’t have any noticeable lumps or bumps. I adopted a glass-half-empty logic and, despite not knowing the results of the biopsy, assumed that I had breast cancer. I was right.

I was mentally unwritten by my diagnosis. However, as I started to understand all the unknowns that came with it (scan results, pathology, surgery margins, side effects), I realized that I couldn’t catastrophise and assume the worst.

Inspired by Natasha Bedingfield’s song “Unwritten,” I flipped the word to mean something that served me better: Nothing was “written” until it happened. It wasn’t yet part of my story.

Today is where your book begins The rest is still unwritten I met a wonderfully supportive community on Instagram through sharing my #100DaysDIEP as @unwrittenme. Then, in 2020, I had my secondphase surgery, when I had a nipple reconstructed and my abdominal “dog ears” removed. This was combined with an abdominal hysterectomy and oophorectomy. Again, I shared my story daily on Instagram, this time under #100DaysDIEP2.

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Patient Story

Putting Breast Reconstruction Awareness Day on the map

Breast Recon 101 Live Q&A Treatment for breast cancer in Australia is among the best in the world. When it comes to reconstruction, however, many women in this country say they don’t feel they were given a choice in what reconstruction they had. Some aren’t offered reconstruction at all – even though it’s funded by Medicare, our public healthcare system.

I started to hear from women through Instagram – countless stories from women who’d undergone reconstruction and told me how they felt they weren’t offered all possible options, or they weren’t prepared for the reality of surgery – mentally, emotionally or physically. I also heard from women who were considering reconstruction and wanted more information, from surgical details to the reality of what life is like after reconstruction.

By Luan Lawrenson-Woods I launched BRA-va art to promote Breast Reconstruction Awareness Day – or BRA Day, as it’s known. BRA-va art is a social media campaign that asks people to create GPS “art” when they exercise using the free exercise app Strava and tag @bravaartoffical on Instagram.

In 2021, I devised the Breast Recon 101 Live Q&A series. I hosted the first with Australian plastic surgeon Joe Dusseldorp, MD. We fielded so many questions that the session went on for over an hour. It was clear there was an information gap, so I hosted more Live Q&As through 2022, with an expanding audience that included women who were planning a reconstruction and women who wanted to know more in case they needed to support a loved one in the future.

It’s a fun way to raise awareness about breast reconstruction options after mastectomy. Last year, participants from America, Europe, Asia and Australia took part. They ran, walked, kayaked, cycled and skied to “draw” BRA-va art such as hearts, flowers and faces, as well as reconstruction references, including “DIEP” and “TUG.” Of course, breasts were popular!

Rewritten me Deciding what reconstruction option is right for you can be an overwhelming process, and the medical terminology is confusing. Anyone who is having a mastectomy should know all their options to understand what’s involved in their procedure and to feel confident about advocating for themselves.

We want even more people to design BRA-va art on Breast Reconstruction Awareness Day (Oct. 18). I’d love it if you, your friends, family and colleagues would join us to help put BRA Day on the map – literally!

I launched Rewritten Me [luanlawriewoods.com.au/breast-reconstruction-podcast], a podcast about reconstruction after a mastectomy. I talk to leading surgeons and medical professionals from around the world (including ASPS member surgeons), as well as women who’ve lived and felt the experience of reconstruction.

Design an exercise route in any shape you want and share it on Instagram with a @bravaartofficial tag. It’s as simple as that.

I’m passionate about open access to evidence-based health information so that we can make decisions about our health that are right for us. I also want to raise awareness of reconstruction with people who don’t have a diagnosis.

• • • •

As more of us are fortunate to live life after a cancer diagnosis and seek a good quality of life (not just “surviving”), it’s increasingly important that our experiences are discussed within the cancer community and outside it.

Do it Map it Share it Tag it

Check out the BRA-va art Instagram account @bravaartofficial for inspiration and “how-to” guides.

There's no fundraising – just fun raising.

I would never have wished for it, but some good things have happened because of my breast cancer diagnosis. I have connected to an amazing community of women online who have helped me get through one of the hardest times of my life; I can never thank them enough. Now it’s time to pay it forward to support those who will, sadly, come after us. And I need your help! #LetsDoThis

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Patient Education

By Rebecca Zeidman, DO

Sharing your breast cancer and reconstruction journey with your kids

My computer screen was filled with pictures of naked women with deformed boobs. I didn’t get a chance to see the pictures clearly because I started crying again, but what I saw was horrifying.

There were at least 20 women who weren’t wearing anything over the top part of their bodies. The pictures showed the area between the waist and the neck, giving me a perfect view of their chest. Well, I guess that was the point. But their boobs looked terrible. Each had large, pink scars running from one side to the other. It looked like it was right out of a horror movie. It looked like the work of The Evil Breast Cancer Disease.

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The excerpt on the left comes from my recently published middle-school novel, Secrets Are No Fun. I wrote the story as a way to share my own experience with my mother’s breast cancer diagnosis. As a 10-year-old, I was frightened and overwhelmed watching my mother undergo surgery, chemotherapy and radiation.

Secrets Are No Fun explains everything from the diagnosis to treatment in a way that a child can understand – but it also provides insight for adults as to what a child might be thinking and feeling during such a difficult time.

Since the book was published, friends and family have reached out to me to apologize. They couldn’t fathom that I had all these emotions and thoughts as a mere 5th grader. During my mother’s diagnosis, everyone’s focus was on my mom – as it should have been – but after realizing the gravity of that diagnosis I, too, struggled.

I didn’t know what cancer even meant at the time.

After my mom was diagnosed, the doors in my house were always closed. All I could hear were hushed voices as I stood outside. I was afraid my mother wouldn’t make it. Although my mom freely shared her cancer diagnosis with me and my siblings, I know that not every family is as open. I’m thankful that my mother told me the truth about her situation while always choosing to remain positive.

Her attitude couldn’t change the situation, of course – but she hoped our family could rally around her.

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Patient Education

Discussing breast cancer and reconstruction with your children

When making decisions about her course of treatment and what type of surgery she would undergo, my mom opened the discussion to our family. She told us that she had the option of a lumpectomy or a mastectomy with reconstruction. I didn’t fully understand what a double mastectomy meant, but I came to understand that she had opted for a mastectomy because she never again wanted to experience the fear and anxiety of a mammogram. After going for my own mammogram recently, I now understand the weight of my mother’s decision.

My father was the one who left the photos of women postmastectomy and pre-reconstruction on our family’s computer.

As a doctor, he understood the medical implications of my mother’s decision better than the rest of us. He simply wanted to see for himself the reality of the procedures. When I discovered those pictures, fear overwhelmed me. What would my mom’s hugs feel like? Would she ever let me rest my head on her chest again? Would she be able to feel me lying on her?

What would it be like seeing her for the first time after surgery?

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Advice about how and when to speak with your children will come from every corner, but remember that you know your children best.

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Take your children’s lead and share information with them as they’re ready to accept it.

Recognize that as time passes, they might become ready to hear more. If they ask a question or want to see your incisions, be honest with them about what you think is best to share.

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Be there for your children. Give them support in whatever way you can manage at the moment. Post-surgery, it’s understandable to keep your distance physically – but reassure your children that you love them and are there for them.

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It’s OK to make mistakes. You are figuring out how to process everything that’s happened while also caring for – and even catering to – your kids. Cut yourself some slack if you say too much (or too little) at first, or if you’re unable to answer a question.

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If your child is up for it, explain the new medical vocabulary you’re using (e.g., mastectomy, reconstruction, implants, etc.). These are new words for your kids, and they might feel better knowing what these words mean.

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Make some “alone time” with your kids and focus on them. Between all the appointments and procedures you might have, try to set aside some time to speak with your child about what’s happening in their life.

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Know that you’re not alone – whether you’re struggling with your new body image or considering showing your scars to your children. Everyone’s story is different, but we can all draw from each other’s shared experiences to provide support.

Crucial support Thanks to my own medical training, I now understand that women have many options for breast surgery and reconstruction – and not all women look the same after surgery. As a child, all I wanted was for my mom to look like every other mom. When it came time for the reconstruction surgery, my mom had already undergone surgery and chemotherapy. A second surgery on her breasts meant another couple of weeks of recovery with friends and family sitting in my parents’ room around the clock.

I hated seeing my mom in pain again, unable to sit with us at dinner every night and wrap her arms around us in bed.

It’s crucial to provide support to children during their mother’s diagnosis, treatment and reconstruction – but every child will likely need something slightly different and unique to their own experience. Support can come from books, speaking with a professional, connecting with children who are going through something similar or practicing the language that your child may feel comfortable using to describe the situation to friends. Spending time discussing decisions you make with your child might seem unnecessary, but it’s reasonable to believe that your child might need to better understand what’s going on and what to expect.

Looking back on my own fears as a 5th grader, I realize that no matter how sad I felt by the change in my mother’s body, she experienced these emotions on a different level entirely.

During the time between my mother’s first surgery and her breast reconstruction, I witnessed my mother remove her bandages and see her new body for the first time. It wasn’t as scary as I had initially expected, just different. After her reconstruction surgery, she was hesitant to give us hugs and let us rest our heads on her chest as we had done before. That was the worst part for me – having my mother feel pain in response to my desire to be close to her.

Over time, however, she grew to love her body, and we have spent time together in the years since, marveling at her scars. I was afraid of the pink, angry incisions as a child, but we both became accustomed to her new normal. I learned to love those scars and know that she has, too.

Regardless of what fills my mother’s chest – silicone, normal saline or tissue – my mom is the same, strong woman she was before surgery and her hugs contain the same warmth they always have.

Dr. Zeidman’s book, Secrets Are No Fun, is published by AuthorHouse and available through most book retailers.

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PSN: BREAST RECONSTRUCTION 2023

Patient Education

By Ryan Gobble, MD

Working to reduce discrepancies in breast reconstruction

Although there are multiple efforts at local, state and federal levels to raise patient awareness of postmastectomy breast reconstruction options, the rate of patients who undergo breast reconstruction continues to be lower than expected. According to research, only about 40 percent of breast cancer patients actually undergo reconstruction. The reasons why patients may choose to defer might be personal, medical, financial and/or the lack of access to care.

Multiple studies have demonstrated that rates for reconstruction of patients in minority and lowerincome socioeconomic groups are significantly lower than rates for white patients and higherincome demographics. The American Society of Plastic Surgeons (ASPS) and The Plastic Surgery Foundation (PSF) have long been aware of this discrepancy and strongly advocate for policies and interventions (in addition to providing patient outreach and grants for hospitals, patients and plastic surgeons) that can lead to increased access to breast reconstruction for all patients and narrow the gap.

My own team at the University of Cincinnati was fortunate to be a previous recipient of these grants.

On Oct. 18, we will host our seventh consecutive Breast Reconstruction Awareness Day event at the University of Cincinnati – and although we’ve been able to increase our reconstruction rates to more than 50 percent of our patients, we recognize there’s still work to do in improving overall reconstruction rates and the rates of patients in minority and lower socioeconomic groups.

PSN: BREAST RECONSTRUCTION 2023

risk for hernias – and it’s referred to as the deep inferior epigastric artery flap (DIEP flap).

Performance of the DIEP flap requires special expertise in performing microsurgery, which not all plastic surgeons have. This introduces a further limitation for patients who want to pursue this type of reconstruction. Unfortunately, in addition to more-limited surgeon availability, women have seen access to this procedure restricted as a result of policy changes from some private health insurance companies that have neither accurately accounted for the level of technical training needed to perform the operation nor the complexity and the length of surgery itself.

The work of ASPS in improving patient outreach also added a new component in the past year to help maintain patient access to autologous reconstruction. Autologous reconstruction typically involves moving tissue from one part of the body to reconstruct the breast mound, with abdominal tissue being the most commonly used. An older version of this reconstruction would involve removing the abdominus rectus muscle (the six-pack muscle) along with skin and subcutaneous fat from the abdomen, which was known as the transverse abdominus myocutaneous flap (TRAM flap). Newer techniques allow for preservation of the abdominus rectus muscle, which allows greater core strength and reduces the 18

ASPS members who perform breast microsurgery are working to ensure our patients can continue to receive this vital service. A multipronged approach to educate patients, health insurers and policymakers about the importance of preserving breast microsurgery for all patients paid off in August, when we learned that the Centers for Medicare and Medicaid Services reversed course on a decision to sunset insurance codes related to DIEP flap coverage. It’s our hope and goal that this advocacy will not only continue to provide our patients with as many options as possible, but that our members will be able to provide breast microsurgical reconstruction for years to come.

ASPS member Ryan Gobble, MD, is an associate professor of plastic surgery in the Division of Plastic, Reconstructive and Hand/Burn Surgery and the Department of Surgery at University of Cincinnati College of Medicine.

Patient Education

By Andrea Moreira, MD

Your guide to mitigating post-mastectomy chest numbness

A common (though not often discussed) side effect of mastectomy is total or partial chest numbness, which results from nerves being cut when breast tissue is removed. Chest numbness is a potentially permanent side effect that can have devasting impacts on safety, intimacy, body image and quality of life.

Imagine not being able to feel your child’s head resting against your chest.

Not being able to feel the full embrace of a hug.

Not being able to feel if a curling iron or the sun is burning your chest.

Not being able to notice a wardrobe malfunction.

Imagine feeling like a part of your body isn’t yours – or that a part of you has been “deleted.”

These are the kinds of safety concerns and qualityof-life effects my breast surgeon counterparts and I discuss with patients before breast surgery. We also illuminate how we (breast surgeons and plastic surgeons with expertise in breast neurotization) can work together to mitigate sensation loss.

What to know about breast neurotization When a mastectomy and a breast reconstruction with neurotization happen on the same day, the breast surgeon and plastic surgeon can work together to care for the nerves. Breast neurotization (also known as breast-nerve repair surgery) is possible with implant reconstruction and free flap

Whether you’re planning to undergo immediate or delayed breast reconstruction after having a mastectomy, you may be a candidate for breast neurotization.

Ask your surgeon if they provide this option or if they can refer you to someone who does.

To help you explore your options and decide what’s best for you, consider asking your surgical team the following questions: Can you share more detail about what numbness may be like day to day?

Advancements in breast reconstruction over the past 20 years have been nothing short of amazing. Surgeons can now provide nipple-sparing mastectomies, multiple autologous reconstruction options, pre-pectoral and direct-toimplant reconstruction – all of which can create wonderful results from a cosmetic perspective.

Thanks to more recent advancements in nerve repair surgery, breast reconstruction can not only help women achieve their desired aesthetic results – but feel them, too.

Questions to ask surgical teams

It can be hard to imagine what living with chest numbness is like. Surgeons with experience in breast neurotization surgery can illuminate for you what this reality has been like for other patients.

reconstruction, such as a DIEP flap; it’s also an option during some revision procedures.

Nerves are like the body’s wiring system. They send signals between the body and brain that allow us to feel and move. During a mastectomy, nerves that provide feeling to the breast and nipple area must be cut to remove breast tissue. If the nerves are not reconnected, they can’t send signals to the brain, which results in permanent numbness or sensation loss. During the breast reconstruction procedure, allograft nerve tissue can be used to reconnect cut nerves in the chest. Over time, the nerve fibers regenerate, the allograft becomes part of the patient’s body and sensation can gradually return. The nerve-grafting portion of the procedure (performed by the plastic-reconstructive surgeon) adds only minutes to the surgery.

It’s important for patients and surgeons alike to have realistic expectations for regaining sensation because everyone is different. Sensation won’t be the same as it was before surgery, and it will take time for the grafted nerves to regenerate – typically several months, but in some cases, up to two years.

On average, nerves regenerate at a rate of one millimeter per day.

For many women, chest numbness serves as a constant reminder of the trauma of breast cancer. I want to help as many patients as possible avoid this unfair reality – and to feel whole and at peace again.

This what all survivors and previvors deserve.

They also may be willing to connect you with a patient who’s already had breast neurotization surgery. Talking with someone who’s experienced chest numbness and who has undergone this procedure can provide a level of real-life perspective that others can’t bring. If possible, consider asking them about any hesitancies they had, how they prepared and what their life is like now.

What should I expect after breast neurotization surgery?

Each patient’s experience is unique, but many describe feelings of “zaps,” “zings” and “tingles” as sensation gradually returns. It’s best not to have specific expectations, because breast sensation is different for everyone and return of sensation will vary.

Can my nerves regenerate on their own?

Studies have shown that only 30-60 percent of women spontaneously recover some sensation post-mastectomy. This happens randomly – many do not recover sensation at all. That said, when breast and plastic surgeons work together to actively repair nerves, sensation recovery may be improved.

ASPS member Andrea Moreira, MD, specializes in the use of advanced techniques in breast reconstruction.

She’s co-director of the Microsurgery and Breast Reconstruction Program in the Allegheny Health Network Division of Plastic Surgery in Pittsburgh.

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PSN: BREAST RECONSTRUCTION 2023

Patient Education

By Gordon Lee, MD

‘Prehab’ for breast reconstruction —

Breast reconstruction is a common plastic surgery procedure that’s performed every day by surgeons around the world.

There have been several studies and research pieces focused on surgical techniques, postoperative care and outcomes for breast reconstruction.

However, one of the most common questions that I get from patients is: “What can I do preoperatively to prepare before surgery?”

Over the past several years, increasing attention has been given to preoperative preparation for patients who are about to undergo surgery on other parts of the body. The activities that patients are encouraged to do to get healthy before having surgery have been coined as “prehabilitation.”

In the United States, doctors see many patients who are overweight or even morbidly obese. We know from previous studies that morbidly obese patients have a generally higher complication rate than patients who have a normal body-mass index. Having a healthy weight is, of course, important prior to surgery – but the long-term effects of obesity on the body’s general health (e.g., risk of diabetes, heart disease, ill effects on muscles and joints) have long been established.

Traditionally, doctors would tell their patients to eat healthily and engage in regular exercise to prepare for surgery. However, this is a rather vague set of directions for any patient – it’s also nearly PSN: BREAST RECONSTRUCTION 2023

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impossible to know whether a patient follows through on these recommendations.

With that in mind, doctors have begun formalizing a “prehab” program that’s not only easy for patients to follow, but that doctors can also track. These prehab programs should be tailored to an individual patient’s needs and body type, as not every patient would be expected to engage in the same types or levels of activities.

In the digital era we find ourselves, “prehab” programs utilize various technologies, specifically smartphone apps and wearable options such as the Fitbit. These programs work by reminding the patients to engage in various activities (cardio, strength and flexibility exercises), typically on a daily basis. They can also involve activities such as yoga, Pilates and other efforts that go beyond simply counting the number of steps one takes in a day. With these activities tracked by the technology, the doctor can check the patient’s compliance with the program.

Research has demonstrated that patients who engage in active “prehab” programs have improved their outcomes after surgery. Obviously, it follows that if a patient were to lose weight, the risks of developing postoperative complications (woundhealing problems, infections, etc.) would also be reduced. As plastic surgeons, we believe that

Patient Education

maintaining a healthy weight is important to maintaining long-term results after any procedure.

If you perform a breast reduction, breast lift or abdominoplasty in an obese patient, the likelihood for sagging or loose skin increases if the patient were to lose weight postoperatively, which could mean additional revisional procedures. The goal, therefore, is to have the patient lose weight ahead of surgery.

There is no standardized, formalized or agreedupon “prehab” program that has been universally accepted by plastic surgeons for patients. Every surgeon and every patient must decide the appropriate exercise program to prepare for surgery. With that in mind, I think it’s important for all patients to engage in regular exercise and a healthy diet prior to any surgical procedure.

Check with your primary care physician to ensure that the “prehab” program selected is appropriate for you and will not put you at increased risk for cardiovascular complications.

When I see patients, it’s often ahead of a procedure that will take place over the next few months, or even weeks. I recognize that doesn’t provide a lot of time to make dramatic lifestyle changes.

My general strategy is to assess what activities the patient currently engages in and to explore their diet. It’s usually more feasible to achieve

goals when they aren’t so far-reaching. I often tell overweight patients they can start by cutting back portions of what they are eating. Dramatic dietary changes, fasting or crash diets often don’t work and do not deliver lasting results. Some physicians would recommend reducing portions by 25 percent. Generally speaking, if one can control the amount of calories that they take, weight loss will follow – almost regardless of whether there’s any change in exercise activity. Weight loss is very much tied to reducing caloric intake. I also recommend cutting back on fatty foods, as well as foods that are high in carbohydrates or sugars.

Again, focus should be on incremental dietary changes rather than drastic ones.

For exercise, I tell patients to engage in regular exercise at least four to five times per week. Many patients lead a sedentary lifestyle, so this can simply be taking walks around your neighborhood or walking on a treadmill for 45 minutes at a time.

I tell patients that they should work up a sweat, as that’s an indication of burning calories.

The importance of having a healthy weight prior to surgery and the general benefits to overall health by engaging in regular exercise and a healthy diet cannot be understated. Ultimately, it’s up to the patient to comply with these recommendations – and it’s not uncommon that patients return ahead of surgery with the same weight or, in some 21

cases, heavier. That’s one reason a more formalized “prehab” program would behoove both doctors and patients. More work needs to be done in this area.

There are basically four elements that can affect one’s weight: diet, exercise, stress and sleep.

Caloric intake can be reduced through portion control and dietary changes. Regular exercise does not necessarily mean going to the gym for hours at a day, but engaging in regular activities that improve muscle strength and cardiovascular health. Stress can be difficult to control – particularly for those who have demanding jobs or are trying to balance professional careers with the demands of family. Meditation and other techniques to relieve stress can be very helpful.

Getting regular sleep is also important to allow the body to rest – and having a regular, consistent time to sleep at night is important. If a patient is smoking, they should quit ASAP. The negative effects of smoking on surgical outcomes, wound healing, infections and risk of necrosis (dead tissue) are well-established. Again, patients should consult their primary care physician if there are any concerns in the above.

ASPS member Gordon Lee, MD, is a professor of plastic surgery at Stanford University in Palo Alto, Calif.

PSN: BREAST RECONSTRUCTION 2023

Patient Education

Breast implants: What you need to know

Breast Implant Reconstruction Breast implants remain an important option for breast reconstruction procedures. Patients considering breast implants should seek 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 the American Society of Plastic Surgeons (ASPS) Breast Reconstruction procedure page at plasticsurgery.org/breast-reconstruction

Breast 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, in order to help you make an informed decision.

Breast Implant Safety ASPS 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 (PSF) 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.

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Corporate Support

Thank you to the corporate sponsors that support Breast Reconstruction Awareness Day efforts Despite 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 12th annual Breast Reconstruction Awareness Day will take place on Oct. 18, 2023. 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.

The NBIR matters 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.

2023 sponsors Three companies have generously lent their support to the 2023 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. The company has launched multiple reconstruction solutions and is 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 reconstruction 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 2023 Breast Reconstruction Awareness Campaign’s generous sponsors for their continued support and dedication to women’s health, patient education and innovation.

In the time since, the NBIR has collected clinical, procedural and outcomes data on more than 90,000 breast implant procedures. Collecting this clinical data allows plastic surgeons and breast implant 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 will 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.

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

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PSN: BREAST RECONSTRUCTION 2023

Race to Raise Awareness!

SATURDAY | 7:00 AM | Oct. 28, 2023 Brush Square Park, Austin, TX Close The Loop 5K Registration is Open!

Profits generated by the Close The Loop 5K will be awarded to organizations pursuing breast reconstruction surgery.

We believe every woman should have access to her choice of breast reconstruction options.

Register Early To Receive Discounted Rates!

Every participant will receive a race packet that will include a t-shirt and a participation medal.

The top fundraising teams will be recognized at PSTM’s Closing Ceremonies.

REGISTER NOW: RunSignUp.com/BRA5K

Help us raise $100,000 this year to support women and breast reconstruction awareness.