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Reconstruction Options After Lumpectomy
Monique Gary, DO, FACS
July 16, 2021

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Dr. Monique Gary is a board-certified, fellowship-trained breast surgical oncologist and medical director of the Grand View Health-Penn Cancer Network Cancer Program in Sellersville, Penn., where she also serves as director of the Breast Program. As a physician, advocate, and expert on health and healthcare disparities, she is passionate about developing integrative, holistic, and innovative approaches to cancer treatment, prevention, and general wellness.

Dr. Gary joined us to talk about oncoplastic lumpectomy surgery, which is lumpectomy to remove the breast cancer followed by immediate breast reconstruction. In many cases, lumpectomy and reconstruction are done during the same surgery. The goal is to have the best possible cosmetic outcomes, without the need for any additional surgery to correct any dents or asymmetry.

Listen to the episode to hear Dr. Gary explain:

  • how and why oncoplastic lumpectomy was developed
  • who is and isn’t a good candidate for oncoplastic lumpectomy
  • the benefits and drawbacks of oncoplastic lumpectomy
  • things to consider when deciding between lumpectomy and mastectomy

Running time: 25:05

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Show Full Transcript

Jamie DePolo: Hello. As always, thanks for listening.

Our guest is Dr. Monique Gary, a board-certified, fellowship-trained breast surgical oncologist and medical director of the Grand View Health/Penn Cancer Network cancer program in Sellersville, Pennsylvania, where she also serves as director of the Breast Program. As a physician, advocate, and expert on health and healthcare disparities, she’s passionate about developing integrative, holistic, and innovative approaches to cancer treatment, prevention, and general wellness.

Dr. Gary joins us today to talk about oncoplastic lumpectomy surgery, which is lumpectomy to remove the breast cancer followed by immediate breast reconstruction. In many cases, lumpectomy and reconstruction are done during the same surgery. The goal is to have the best possible cosmetic outcomes without the need for any additional surgery to correct any dents or asymmetry.

Dr. Gary, welcome to the podcast.

Dr. Monique Gary: Thank you so much for having me, it’s wonderful to be here.

Jamie DePolo: So, I gave a rather short description of oncoplastic lumpectomy surgery in the introduction, but it is relatively new. So, if you could, could you explain it in a little bit more detail, and maybe tell us how it came about, why was it created?

Dr. Monique Gary: Absolutely. So, oncoplastic surgery merges the principles of oncology surgery — which is removing the tumor entirely and getting adequate margins around it — and it merges that with plastic surgery to help reshape the breast. This is a way of helping to take larger tumor volume, it’s a way to help patients feel more confident and more empowered after their surgery, it can help reduce side effects and facilitate better healing, and overall, we just notice that by utilizing this technique more and more we find better patient outcomes.

And so, it’s an emerging field that really began… I think if we look at the history of oncoplastic breast surgery, there is a surgeon by the name of Krishna Clough, who — he is in France — he is considered the inventor of oncoplastic surgery. He was a plastic surgeon who began to do cancer surgery for patients because they really wanted to have more superior cosmetic outcomes. And prior to this, surgeons would place their incisions directly over tumors. They would take out large volumes and not replace that volume, which would result in things like dents and divots in the breast, or large fluid collections after surgery that then would require significant wound healing or drain.

And he said, “Well, why can’t we have the best of both worlds?” And he began this field. And from there, it really took off like wildfire with new fellowships developing in oncoplastic techniques. The Society of Surgical Oncology and Society of Breast Surgeons, and even the Plastic Surgery Society, all began to teach this, because it really is the next frontier in what we do as cancer surgeons — it’s not just about how the patient looks, but it’s about using these techniques to really accomplish all the things we want to do in cancer and do so in a way that is just cosmetically as appealing as possible to patients.

Jamie DePolo: Thank you. So, if a woman’s interested in this, does she need to go to a specially trained breast surgeon? How do you go about making sure that you are talking to the right people?

Dr. Monique Gary: I think starting with surgeons who are either fellowship-trained in breast surgery, because doctors who finish the fellowship will have training in both breast surgery as well as plastic surgery techniques, and they’ll be taught specific oncoplastic techniques. So, seeking out a surgeon who has that fellowship training, or finding a general surgeon who is knowledgeable in these techniques, are really great places to start.

And so, you can go to websites — for example, like the Society of Surgical Oncology, the American Society of Breast Surgeons — and you can find directories of surgeons in that state where you can see who’s got the technique. You can go to their website, you can look at their social media, you could look at their pictures and see, and really have a consult with those doctors. And it’s a scary thing to do when you’re facing cancer. And many patients come to us, and they say, “Well, I don’t really care how it looks, just get rid of the cancer.”

But when you realize that if you’ve got early-stage breast cancer, and you’re not likely to die from your disease, and you’re going to be around, you begin to think about [how] you’re going to look and where your scars will be, and how that will impact you. And from the medical perspective, it’s our job as doctors to think about how it impacts the patient. So, where their scar is can affect how much pain they have, how much scar tissue they have, where their radiation might be directed.

And so, there’s all sorts of considerations on the other side of fear that we should be helping guide a patient towards, so that they can make the best decision for them.

Jamie DePolo: Okay. That’s really good information to have.

Now, I know we talked about this — it is relatively new, how common is it? And are there a good number of surgeons trained in oncoplastic techniques, say, in each state, or are there still some areas where there might be a void?

Dr. Monique Gary: I think there are still areas where there’s a void. And when you look at who’s doing the majority of breast cancer surgery in this country, it’s still general surgeons who finished their training. And yes, they’re trained to do breast surgery and breast cancer surgery, but not really trained to do the plastic surgery technique, or the volume replacement, or all of the considerations — things like elevating and moving nipples, matching symmetry, and doing some of the other more advanced techniques.

And so, I think patients really do have to seek out those doctors. And it’s great to start with a first opinion and to see the surgeon in your area — or in your institution, or where you got your biopsy — but as you move forward in your process, you want to ask really specific questions to help understand if that surgeon has the skill that you need. And if they don’t, if they partner with a plastic surgeon who does. Because many plastic surgeons are trained in these techniques, as well, and while they don’t remove the cancer, they can then perform the cosmetic reconstruction that helps to marry the onco- with the plastic.

Jamie DePolo: Okay. Now, in your experience, how common is it for women who’ve had lumpectomy with no reconstruction afterward to have an additional surgery, or even more than one additional surgery, to improve the aesthetics of the breast?

Dr. Monique Gary: I think for a long time women didn’t know that they could have additional surgery to improve the aesthetic of their breast, and that’s really sad and disheartening. I see a number of patients who’ve come from other doctors and they’ve had their surgery many years ago, and they were never offered any surgery to help either replace volume, to remove scar tissue, to create symmetry or balance in their breasts, bilaterally. And it's really sad, because they are putting things in their bra, prostheses and things. They are just dealing and living with chronic pain from scar tissue, and they don’t realize that there are techniques that can help to improve those things.

And so, I think it’s more common than we believe. And as it becomes more widespread that patients realize that one: they have autonomy, and they have a choice, and they can decide what doctor they want to see, and who they want to do their surgery. But also that even if they weren’t offered those things at the time, they can now still be a candidate for oncoplastic symmetry procedures and for volume replacement through things like lipofilling, or liposuction and fat grafting into areas of scar tissue that can help improve pain, decrease scars, and improve cosmetic outcomes.

Jamie DePolo: Oh, that’s great! So, that was actually going to be my next question. So, there’s really no time limit on this — say, if somebody had lumpectomy surgery 15 or 20 years ago and does have a dent, she can still seek out an oncoplastic surgeon today and talk about some options to perhaps correct a dent or some asymmetry?

Dr. Monique Gary: Sure. She absolutely could. Even if she doesn't, I think it’s important for us as doctors to ask her about it — how much it matters to her — because she may not bring it up. She’s coming for her annual checkup, she’s 10 years out, or she’s got this area of scar tissue or this dent or this divot in the breast. And I want to be sensitive to patients because our scars for different people represent different things. And I know this because I‘ve got a scar on the back of my hand — I was in an automobile accident when I was in college, and I lost all of the skin on the back surface of my left hand, and there’s a very large area where there’s a skin graft there. And that scar to me means different things at different times.

And so I want to be sensitive to patients and say, “How comfortable are you in your bra? How comfortable are you with your scar? Do you have any symptoms? Are you having pain here? Does this cause you any discomfort, either physically or psychologically?” And if they say, “Yes,” it opens the door to having a greater discussion about what their options might be. And some patients really wear their scars as a badge of honor, and they don’t want to be offended by the suggestion that their scar is anything but theirs and completely appropriate.

But I find, by and large, it’s a great way to build trust and rapport with patients — to bring up the obvious thing, which is: “You’ve got quite the scar there, how does it make you feel?” And let them speak about their experience.

Jamie DePolo: That’s very good. Now, are all women good candidates for oncoplastic lumpectomy? Might there be some that it’s not appropriate for?

Dr. Monique Gary: Absolutely. That’s a great question. All women are not candidates, but, by and large, the majority of women are candidates for oncoplastic surgery. So, people who are not candidates for oncoplastic surgery would be individuals who might have had a prior breast cancer — prior radiation — because many times we are not able to re-radiate the breast. And those are patients who would be candidates for mastectomy, and there are certainly reconstructive options there.

People who have connective tissue disorders and their skin won’t do well with things like radiation might not consider a breast-conserving surgery at all, and they might be more likely to ask for things like a mastectomy. So, these would be people who have scleroderma, people who have lupus, connective tissue disorders, because we know that radiation can really affect the integrity of their skin.

Individuals who have inflammatory breast cancer, where cancer has entered the cells just underneath the skin that drain into the lymph nodes in the armpits. Those people who have that sort of angry-looking skin and inflammatory changes are not candidates for breast conservation or lumpectomies, either, and so, they’re not candidates for oncoplastic breast surgery or oncoplastic reconstruction via lumpectomy.

Jamie DePolo: Okay. Okay. Thank you.

Now, you did talk a bit about some of the benefits of oncoplastic lumpectomy. Are there any others that we didn’t talk about yet, and are there any risks? I’m wondering — what does a woman need to weigh when she’s thinking about this?

Dr. Monique Gary: Well, I think there’s a couple considerations. So, the first consideration is: “Where’s my tumor, and what’s my tumor biology?” Because when a patient understands what their tumor biology is, they know if they’re going to need something like chemotherapy. Even if the tumor is a small or a larger tumor — you know, the things that determine whether or not a patient needs chemotherapy — we can find out some of that information early, and some patients would benefit from it sooner. So, chemotherapy.

The type of tumor, the location of the tumor — so that if the tumor is very close to the nipple, “Is breast conservation an option, or am I going to lose the nipple and need to do some reconstruction thereafter?” I find that patients who have tumors that are involving the nipple, many times they’ll have a mastectomy — because if you do a lumpectomy, you take the nipple. Well, many patients would say, “Well, just take the rest of the breast tissue and reduce my risk thereafter by doing a mastectomy, and reconstruct the whole breast and not just reconstruct the nipple,” and that’s a matter of preference.

I think other considerations: where your tumor is located and the size and the symmetry of your breast. So, I always look at the patient with their hands on their hips, and I look at the symmetry. If one breast is larger than the other, if one nipple is higher or lower, or more lateral, or sideways, or more medial — how well are the breasts matched? And how much volume would I need to take for the surgery on one side? And then, do we need to do anything on the other side to make that other breast match? Because that can happen at the same time.

I also talk to patients about considerations like neck pain and back pain, and so they might be candidates for things like reduction.

And so, the things that a patient will want to consider are all of those things. And it’s up to the doctor, really, to ask and to educate the patient, because this patient’s facing a diagnosis of cancer and so there’s a lot of other thoughts besides how my breasts are going to look. And so it’s up to us to help to guide the patient from fear into feeling empowered enough to make decisions that they may not appreciate until 6 months or a year later.

I can’t tell you the number of patients I’ve had who’ve come back and said, “You know what? I’m really glad that we did this this way because back then I just wanted to live. And now I see some of my friends —” or, “Now I look at my breasts — and I feel really good about…,” or, “Now I can exercise, and I don’t have as much neck pain or back pain.”

Other considerations would be the amount of glandular density of the breast — or fatty tissue within the breast — because women who have more fat, meaning a bit less density, can get more scar tissue within the breast, called fat necrosis. And that’s when the fat cells get kind of hard and calcified.

And so, taking into account the breast density, the shape, the size, whether or not a patient is a smoker or not, those are all things that impact surgery as well.

Jamie DePolo: Okay. Okay. All very good things to know.

Now, for my friends who’ve been diagnosed with breast cancer, making the choice between lumpectomy and mastectomy was very personal. And I’ve talked to other women who were really, really concerned about the risk of recurrence or developing a new breast cancer in the other breast, especially if they have somebody else in their family who had been diagnosed with breast cancer. And so they opted for mastectomy, even if it was DCIS or a very small, early-stage breast cancer.

And I know, too, that some plastic surgeons have said, “Well, if you have a mastectomy, you’re giving me a better canvas to work on. I can give you a better result that way.”

So, how does oncoplastic lumpectomy kind of fit in all those scenarios?

Dr. Monique Gary: Well, that’s a great question! And for the patient, you’ve got a smorgasbord now, where 10, 15 years ago a surgeon would say, “Okay, we’re going to cut out your tumor.” And they wouldn’t tell you where the scar was going to be. And 20 years ago, a woman could wake up without a breast, even, and she’d go in for one surgery and come out and have something different that happened based on what that surgeon thought intraoperatively. And now there’s so much forethought that goes into this process.

And so, I say to patients, “You’ve got to take into consideration your tumor type — how aggressive it is, and what treatments you’ll need afterwards.” So, if you know that radiation’s not going to be a good fit for you — for whatever reason — then you’re already thinking, “I’m probably not going to do a lumpectomy.” There are indications for radiation after a mastectomy, and so you should talk about that, but you’re already thinking, “Okay, I really am vehemently opposed to — I’m not a candidate for — radiation.”

You think about your family history… And like you said, if you have a strong family history, there are calculators that we can do that can help a patient to know their risk of recurrence after a breast cancer. And we can help a patient to make informed decisions based upon knowing what the risk of recurrence would be.

In general, we recommend, and we suggest to patients — and the data suggests that — the risk of recurrence is fairly low after lumpectomy, as long as a patient does the radiation and/or complies with the anti-estrogen therapy — or the estrogen-blocking pill — that we recommend for certain patients who have estrogen-receptor-positive cancer. But when you look at the overall lifetime risks based upon the tumor type, the family history, aggressive features, et cetera, mastectomy is a good option for some people.

To the subject of plastic surgeons who say they have a better canvas, I think that that is…

Jamie DePolo: Is that too old school? I mean, this was a few years ago that somebody said that to me, so maybe that’s outdated by now.

Dr. Monique Gary: Yeah, it is. My plastic surgeons — I love the surgeons I work with because they don’t like to overpromise the patients. Let me say it this way: They want to help patients have a realistic expectation. And for patients who have droopy or tubular breasts or other things, sure, doing a unilateral mastectomy on one side is not going to get you the symmetry that you would desire, because an implant-based reconstruction is going to sit a lot higher. Or, doing a lumpectomy and taking out a large volume of tissue in one breast is going to significantly reduce the size of that breast, even after radiation.

And so helping patients to understand how they’re going to realistically look and how important symmetry is is the role of the plastic surgeon. But to just say, “I have a better canvas”? I think that that’s sort of an old-school way of thinking, and there are really great ways that we can help a patient to have better symmetry. And we should be discussing that more, rather than what would allow us to do our job easier. Our job is to do what the patient wants and to do so in a way that makes them feel whole and makes them feel empowered. And we’ve got all the tools and all the training to do just that.

Jamie DePolo: Okay. Thank you. And finally, to wrap up, you gave a very good overview of things that a woman should consider when she’s making her decisions for lumpectomy versus mastectomy. But you did mention something and — I wonder how you help patients get through this — when somebody is told, “You have breast cancer — you’ve been diagnosed with breast cancer, we found it.” I’ve talked to so many women who say, “I heard that, and then all I heard was, like, ‘wahwahwahwahwahwah.’ I heard nothing else.”

And it takes a long time for things to sink in and to be able to kind of make some decisions. And, especially with lumpectomy, it seems to me like the surgery is going to be first in most cases. I guess I realize there would be some times where you might have chemotherapy first, and then surgery, so you’d have a little bit more time to think about it. But it seems like in most cases, it would be surgery first, and then radiation, and potentially chemotherapy, if needed.

So, that decision on surgery is going to be the first big decision to be made. So how do you help women kind of get past the “wahwahwah” phase and start to really think about their options?

Dr. Monique Gary: Wow. That’s a great question. I think that when a woman is diagnosed — you’re absolutely right, all she hears is, “You have cancer.” And then everything else is — you’re lucky if they hear every third word. So, making sure that you’ve got a team of support advocates, family members, loved ones — whomever you choose — who can ask good questions, who can write down things, who can help you sort through some of the fear and some of the noise — is a huge and important thing to do. And I always ask patients, one, when I’m seeing them even before their biopsy, “Who is your support?” Because I want them to start thinking, “Who am I bringing back with me?” So, “When you come back to see me to discuss these results, who are you going to bring with you?” And they’re already thinking, “Okay, I’m going to bring my sister, I’m going to bring my husband, I’m going to bring my friend who already had cancer who’s been through this before.” So, having great advocates and a good team is super, super important to be able to even hear the conversation.

Helping patients to know that they have some time to make decisions. You know, the doubling time for a single cancer cell can be anywhere from upwards of 90 to 120 days even for a single cell, and so we like to do surgery — or to do a first line of therapy — within the first 30 days. But within that timeframe, you’ve got a team of people who are going to make sure that you’ve got phone calls, you get a second appointment, you get to see your plastic surgeon, you get to get a second opinion if you would like to do that. And so, the ball starts moving pretty quickly. So, the sooner a patient can wrap their mind around their diagnosis, understand what their stage means and implications of their stage on their survival and on their type of surgery — because if you’ve got locally advanced cancer, if it’s in your lymph nodes, well, then we might be talking about chemotherapy and other things, and you might opt for reconstructive options or symmetry procedures later on.

And, the last thing is, I always tell patients that if all else fails, we can always plan to do the cancer surgery first and then do additional things later. And what that means is, as the surgeon, it means that I’m being very selective and very thoughtful about where I’ll place the incision, about where volume could be missing, about what to do in the other breast. So that when that patient is ready to have that conversation and to think about those things, they’re able to do so in a way that hasn’t compromised the breast — so they can have the best cosmetic outcome, so I can hide that scar around the nipple and we could go back later and lift that nipple, or lift the nipple on the other side, for example.

And so, there aren’t a lot of wrong answers, and oncoplastic surgery has really given us the freedom to do just that. We know that insurance now can cover cosmetic and symmetry procedures in the opposite breast, as well. So now we can get that lift or that reduction that you’ve always been wanting, so that you can have a better quality of life. Now we can make those nipples match. Now we can do more things.

So, taking the patient through the journey of, “You’ve got cancer,” to, “Let’s talk about what your wishes are, are there things that maybe you haven’t been as thrilled with with your breasts,” right? Because everybody kind of — you know, we don’t always love our bodies before cancer. And so, it’s hard for us to really put on our pink tutu and love our bodies and live our best lives after cancer sometimes. But if there are some things that you’ve been thinking and maybe some ways that you haven’t been pleased, how can we make you a little bit happier as a result of this?

And so, I try to take that approach with patients, and I find that they’re able to ease their way into thoughts about one: surgery on the opposite breast that doesn’t have cancer, and two: feeling like they’ve got some measure of control again in a situation where they really didn’t have a lot of control.

Jamie DePolo: Oh, that’s so important. Dr. Gary, thank you so much. This has been so informative. I think this is going to help quite a few people. I really appreciate your insights.

Dr. Monique Gary: Oh, thank you so much for having me! This has been a great conversation, and I hope it helps some folks and that we can help people to make these decisions. And one of the great things about your organization is that you’ve got all these wonderful resources online, so that as soon as somebody gets diagnosed — or if they have family or friends and they are the advocate and they are the support — they can go to websites like yours and podcasts like yours and listen to great information. So, thanks for letting me be a part of it.

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