When it comes to breast reconstruction, David H. Song, MD, MBA, FACS, is focused on getting that reconstruction done in the best way possible. There is an internal conflict when the surgeon doing the oncological section and the reconstruction is one in the same, he says.

Song, an associate professor of surgery, chief of plastic surgery and director of the residency training program at the University of Chicago, believes there are many ways to ensure a patient is satisfied with her breast cancer reconstruction result.

First and foremost is the importance of a multidisciplinary approach, he says. Second, lumpectomy might not be the best choice for every patient.

PSP: What is the difference between performing reconstructive breast surgery following mastectomy and following lumpectomy?

Song: The thought processes are different. First and foremost, in lumpectomy reconstruction the best results are when lumpectomy reconstruction is performed immediate or early—immediate meaning at the same sitting as the cancer resection, early meaning that it is performed before radiation starts. This is typically a week or two after the lumpectomy, once the margins are clear.

When lumpectomy reconstructions are done in these time settings, the results can be quite dramatic and aesthetically appropriate. When they are done after radiation, it’s an uphill battle and oftentimes it’s a losing battle.

In lumpectomy reconstruction, because you are leaving a majority of the breast tissue intact and the patient has to get radiation for completion of oncologic treatment, you are radiating the majority of the breast tissue with the concept of having rearranged the breast tissue. In essence, you are radiating the entire breast that has been rearranged after lumpectomy. So, the entire breast is radiated together and not differentially.

We feel that somehow breast tissue may resist radiation a bit more than just transferred fat and skin, which is typically what we use when a reconstruction with abdominal tissue or gluteal tissue is performed. Because it is breast tissue that you are leaving behind, which needs to be radiated and the entire breast is radiated—even after rearrangement—the results, while not perfect, are much better than trying to attempt a lumpectomy reconstruction after radiation.

As plastic surgeons and, hopefully, breast surgeons, [we] have to be aware who the appropriate candidate is for the specific designated reconstruction. For instance, implant reconstruction—the most common reconstruction performed in the United States—is not for everybody, and vice versa. A DIEP flap or a GAP flap is not for everybody. When it comes down to reconstructive breast surgery, whether lumpectomy reconstruction or mastectomy reconstruction, the bottom line is that you have to fit the patient and the operation together in order to achieve the best result, both aesthetically, psychologically, and, most importantly, oncologically. It’s hard to say whether one is better than the other. Clearly, one is better than the other for each individual patient. Most of the tumors that occur occur in the lower half of the breast and outer portions of the breast. These quadrants are going to be affected more than the middle and upper, inner portions of the breast. With these facts coupled with patient desires, breast conservation is very desirable.

Figure 1. An example of a poorly done lumpectomy: a 37-year-old female after left breast conservation therapy and 6 months post radiation.

There are a lot of psychological benefits to a lumpectomy. Let’s put aesthetics aside for a minute. When a breast surgeon tells a woman that she can conserve her breast, save the breast, and that she doesn’t have to lose her breast in the face of cancer, that’s very attractive. What needs to be thought of is, what are you saving?

I often give a lecture when I travel. It’s called “Breast Conservation: Is It an Oxymoron?” When you are conserving a breast, especially when you are doing an aggressive lumpectomy or when the breast surgeon is doing a re-excision lumpectomy for positive margins, what a patient is often left with doesn’t even resemble a breast. Yet, it is called breast-conservation therapy, and that’s really the 25% to 30% of the population of patients who are unhappy with their lumpectomy outcome. That’s the target population that we really need to better educate—not just the patient but the breast surgeon; and about who can tolerate and have an acceptable aesthetic outcome, versus who mastectomy should be recommended to.

Though not common, there have been times when the breast surgeon has had to close a patient after lumpectomy surgery, anticipating an immediate lumpectomy reconstruction, and tell her afterward that she didn’t have enough breast tissue remaining to do an aesthetic reconstruction of the lumpectomy defect. The patient then becomes a better candidate for a completion mastectomy and a full reconstruction. That conversation takes place, rarely, but it does take place after the lumpectomy. It’s hard to switch gears all of a sudden when a patient is expecting a lumpectomy and then comes out with a mastectomy and a reconstruction.

Figure 2. A 48-year-old female with central pole defect, showing removal of right nipple and areola with immediate reconstruction. Far right: postop is 3 months after surgery, when she is undergoing radiation therapy.

PSP: Please describe the thought process that you go through when reconstructing the breast after lumpectomy.

Song: The concepts are in many ways best described by creative plastic surgery of the breast. The breast surgeon removes the tumor, and we, as plastic surgeons, have to figure out how to fill the defect, move the nipple, and close the skin in an aesthetically acceptable fashion.

These are concepts that are taught throughout one’s residency and fellowship, understanding all the different pedicles of breast reduction and mastopexy that are utilized in every case. Proper plastic surgery training allows you to analyze the defect in order to fill the defect, with intrinsic breast tissue and flaps, and also move the nipple and finally close the skin to achieve the mastopexy of the reduction-type of result or scar pattern.

That’s really the goal for immediate or early lumpectomy reconstruction.

Here’s an example of a more straight-forward case. A patient presents with an inferior pole tumor in the six o’clock position in the right breast. Mammography and MR has shown distinct margins. The breast surgeon and I feel it appropriate to remove the tumor and do an immediate lumpectomy reconstruction. In this situation where a patient is a C or a D cup, it really is akin to thinking about the resection and reconstructing the defect as if one is thinking about a vertical reduction mammoplasty using a superior medial pedicle.

The removal is where you would remove tissue in a breast reduction, so what one is left with is fixing that defect—much akin to a reduction mammoplasty type of operation. The results can be quite nice and, clearly, the patient will need a contralateral mastopexy or reduction to give her symmetry. Then the patient wakes up and has an aesthetic reconstruction and gets radiated. The breast, in general, does shrink, but it shrinks symmetrically, not in an adverse way so that there’s a contour deformity. After the radiation is done, the patient comes back for an outpatient procedure to complete the symmetry procedure on the other breast.

Preoperatively, we have a lengthy discussion with the patient. We can do an immediate reconstruction of your lumpectomy defect, but after your breast has been reconstructed, if the margins are positive, you are no longer a candidate for re-excision lumpectomy for several reasons. Number one, the architecture has been changed. Number two, removing additional breast tissue will leave you with much less breast tissue to rearrange and, thus, would preclude an aesthetic lumpectomy reconstruction. Because of those reasons, you are better off, if the margins come back positive, to then go on to have a completion mastectomy and full reconstruction. The patients are aware of that possibility going into surgery and are accepting of it.

Having said that, this situation happens probably less than 2% of the time because we work so well as a team here at the University of Chicago. We have some of the best mammographers and breast MR radiologists, we know exactly what we are getting into, and virtually know exactly how much tissue needs to be removed.

PSP: What about the woman who, when told she has cancer, is only concerned about removal and doesn’t want to think about or consider any type of reconstruction procedure?

Song: This is why the multidisciplinary approach is so important. My partner, a breast surgeon, understands the ramifications of that thought process. Many women, when diagnosed with breast cancer, want to cut out everything, not thinking about quality of life and returning back to normal after cancer. That’s why it’s so important for a breast surgeon who is dealing with the cancer, who is the first surgeon of contact, to say, “Wait a minute. I understand that, but you can have both. You can have an excellent oncologic operation and also an excellent reconstruction with very minimal additional surgery. Let me introduce you to my plastic surgeon colleague.”

That is where the discussion is so important in many ways, and that it comes from the cancer surgeon. If I just remove this, you will be cured of your cancer, hopefully; but you will not be happy with the outcome. When that message comes from the breast surgeon, that’s very powerful. We have worked very closely together for the last 10 years to get to a point where we are both thinking that way.

When a patient comes just for reconstruction, a distinct portion of my practice is people who find me on the Internet [who] come in for reconstruction. Mastectomy or not, they have been diagnosed with cancer and all they care about is the reconstruction. I’m the one who says to them, ‘Slow down. Have you received an MRI? Have you been properly worked up? Have you thought about being gene tested?’

This is where a multidisciplinary approach really translates into the best possible outcome for the patient. Often, there have been cases where I have delayed reconstruction in order to properly work up the patient from a cancer point of view. This is what the standard of care should be.

PSP: What other factors make the lumpectomy reconstruction process either easier or more challenging?

Song: The University of Chicago is a big referral center after patients have had a lumpectomy, so they’ll come in from an outside hospital having had their lumpectomy performed showing a positive margin. It’s 10 or 12 days before she’s even been seen by a breast surgeon here at the University of Chicago. Ideally, you want to do the early reconstruction prior to radiation so that you don’t delay the cancer treatment, but you want to do it before contraction starts to occur in the incision and the lumpectomy site. So, you really want to intervene within 2 weeks.

The challenge becomes when a patient presents 10 days after a lumpectomy from an outside hospital with positive margins. The breast surgeon feels she can shave a little bit more and get a negative margin. Now we need to do an immediate lumpectomy reconstruction.

The challenges are the time frame and, secondly, the coordination of schedules and operating time to get that patient taken care of.

Figure 3. A 56-year-old female with a tumor in the lower pole, after reconstruction and (far right) 2 years postop.

PSP: Let’s talk about asymmetry procedures.

Song: I bring up asymmetry with every patient to let them know that if they want as perfect symmetry as possible they have to consider something to the other side, whether it’s a lift or a reduction or an augmentation or an augmentation mastopexy.

First and foremost, perfect symmetry is not possible. No one has perfectly symmetrical breasts. Those are the things that are discussed before the first stage. We introduce it preoperatively, but it becomes a little overwhelming for the patient, so I like to go over it several times. Initially, to introduce the concept before we do any surgery, then really go into it after the first stage of the reconstruction.

PSP: As a plastic surgeon, do you prefer working together with a breast surgeon to perform the breast reconstruction at the same time as the lumpectomy as a single operation, or would you rather do a separate surgical procedure after the patient recovers and heals from the initial operation?

Song: When we work as a team in medicine, in a multidisciplinary approach, the outcomes are that much better.

There have been articles in The New York Times and The Wall Street Journal saying that oncoplastic surgeons should be doing the resection and the reconstruction. They cite that the reason why this is happening is because there is a lack of plastic surgeons willing and available for the breast surgeons.

My challenge—and hopefully the challenge to my colleagues—would be to create that team, to create that collegiality, to build those bridges for the patient’s benefit in mind. Oftentimes, that means being flexible. Once we show flexibility and a willingness to work together, breast surgeons will capitulate and say, “Yes, here are the results. They are amazing, and the patients are happier. We need to do this together.” The common theme is shared success.

When we get an excellent result at the University of Chicago, and the onco-reconstruction is done by me and the breast surgeon, the credit is given to the breast surgeon and the team—not just me. That’s an important concept to share with the multidisciplinary team: the success is a shared success. The patient ultimately benefits because she’s gotten the best oncological treatment and the best imaging and the best chemotherapy, if necessary, and the best radiation, if necessary, and the best surgical resection and reconstruction. And we are all a part of that. We are part of that greater team.

This is an important yet simple concept that others will hopefully practice, and once we start doing that and are more engaged in the hospital or medical center for these types of issues, the team mentality will be fostered and, ultimately, the patient will benefit.

PSP: According to the ASPS, women with breast cancer often undergo a lumpectomy and radiation to save their breasts and avoid the need for additional reconstructive surgery. However, approximately one-third of all patients are unhappy with how their breasts look after undergoing breast-conservation therapy. What is the likely approach to these patients and possible outcomes?

Song: There are a large number of women out there and, unfortunately, after lumpectomy and radiation (breast-conservation therapy) to reconstruct the lumpectomy defect after radiation is very difficult. And the outcomes are not as superior as at the time of the resection or prior to radiation therapy. The best approach is educating the public and educating breast surgeons about creating the multidisciplinary teams to deal with these issues for the benefit of the patients.

PSP: What new techniques are available for the lumpectomy reconstruction procedure?

Song: The whole concept of oncoplastic surgery being done as a multidisciplinary team is a newer concept in general. We are going to hear a lot about it. The technique of using all [of our training] for the benefit of the patient is not a new concept, but it is clearly a new way of organizing medicine.

In development: technologies to fill the lumpectomy defects that are not necessarily one’s own breast tissue is something new. This could mean potential matrices that are being looked at right now, because one of the biggest concerns about lumpectomy reconstruction is that the skin contracts. That is why it makes it so difficult to get a really nice result after the radiation has hit and after the skin has contracted. There is a concept of creating spacers for the lumpectomy—put them in and then come back at a later date, after radiation or before but clearly at a later date, to do reconstruction by whatever means necessary. Those are the new things on the horizon.

There are clinical trials being done that involve the injection of stem cells into lumpectomy defects. Harvesting stem cells through liposuction that are isolated and injected into lumpectomy defects. These are not necessarily stem cells but are preadipocytes. That is promising.

PSP: What is one of your most difficult or challenging cases, and how did you handle it?

Song: In this case, the tumor was centrally located just under the nipple-areolar complex. The patient’s right breast had a central tumor that required the removal of the nipple and the areolar complex, and she was a C-cup breast. She really wanted to conserve that breast.

If the breast surgeon just closed her up, she’d be missing the nipple and the areolar complex, but she would have a very boxy-shaped breast because you are decreasing the height of the breast and the result is somewhat flattened and boxy.

See also “Reconstructing the Radiated Breast” by Jane Petro, MD, in the February 2009 issue of PSP.

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In that situation, we know that the central portion of the breast is missing, and we would need to reconstruct that central portion using a medial pedicle of skin and breast tissue executed in a vertical reduction fashion (so pretending as if the nipple and the areolar complex were located in the six o’clock position and then moving that breast tissue with the skin into the central defect and closing that donor site, as if you’re closing the reduction mammoplasty).

At the end of the case, the patient’s own skin and breast tissue fill the defect that’s left behind after the resection of nipple and the areola, and the closure is much akin to a vertical reduction mammoplasty. Then the reconstructive surgeon has a platform to then create an areola with whatever means she or he deems fit, whether it’s tattoo or skin graft. Then build a nipple on top of that. And the results can be quite acceptable and aesthetically pleasing.

Implants don’t work well with lumpectomy defects. They actually can exaggerate the defects. What we have done in certain cases—and the indications are very narrow for this—if a patient really wants to preserve whatever breast tissue she has and does not want to have a mastectomy for whatever reason, and if the defect is too large for intrinsic breast flap reconstruction, then we will add tissue from the back in what is called a thoraco-dorsal artery perforator flap, sparing the latissimus muscle, taking the skin and fat and interpolating that tunneling into defect, and closing the donor site.

Amy Di Leo is a contributing writer for PSP. She can be reached at [email protected].