Early detection and improved treatments have dramatically increased survival rates for breast cancer patients in recent decades. In another advance, one-step breast reconstruction has greatly improved breast cancer surgery, allowing doctors to restore a patient’s breast immediately following a mastectomy, so they can leave the hospital feeling more whole with fewer body image concerns.
“The history of breast reconstruction is really interesting because back in the 1970s and ’80s when we first started doing breast reconstruction after mastectomies, women didn’t have the option of immediate reconstruction,” said Dr. Andrew Salzberg, Plastic Surgeon at Cleveland Clinic Indian River Hospital’s Scully Welsh Cancer Center. “Instead, we had to put in spacers or tissue expanders in order to stretch the skin. In those days, surgeons used to take out a fair amount of skin and nipple with the cancerous tumor. It was almost impossibly rare that they were able to save the nipple.
“Now breast surgeons have techniques that allow them to leave the nipple and not remove a lot of skin. Instead, they just remove the breast tissue, leaving us with enough skin to insert an implant immediately.”
Dr. Salzberg is a pioneer of direct-to-implant or “one step” breast reconstruction, which has largely replaced the traditional tissue expander method. His first direct-to-implant procedure was done in 2001 and since then he has reconstructed more than 1,500 breasts on more than 950 patients as part of breast cancer treatment or prevention for women at high risk of breast cancer due to a BRCA mutation or family history.
“Nipple-sparing mastectomies have been the norm since the early 1990s, but I was still putting in tissue expanders for these women and it always went under the muscle. It proved to be torture for women with a lot of discomfort and a lot of inconvenience because they’d have to come to my office on a regular basis to have the expander filled over time. They had to wait three to six months before we could fill it up enough to get a good shape. I was frustrated – so I came up with an idea to … put an implant in directly after the mastectomy.”
Dr. Salzberg developed this surgical technique while he was the Chief of Division of Plastic and Reconstructive Surgery at the Mount Sinai Hospital System in New York. He came to Florida two years ago at the request of his good friend Dr. Eleni Anastasia Tousimis, director of the Scully-Welsh Cancer Center, where the technique is now used for reconstruction after a mastectomy much of the time.
“Everyone was using expanders until I came up with this idea and tried it,” he continued. “I started doing this slowly over a couple of years and wrote many papers, and the procedure has evolved over time. The patient comes in to have a mastectomy and we immediately put in an implant during the same procedure. She leaves the hospital the same day with a full breast and a sense of being whole.
“It’s very different from the old days when a woman had to look deformed and maimed for months while recovering. The key is to have a skilled breast surgeon who can do a very good mastectomy and remove all the breast tissue, yet still leave enough skin to cover the implant.
The skin must also be viable so when we put the implant in it doesn’t compromise the skin blood flow. During the procedure we inject dye into the patient’s bloodstream and take images of the breast to make sure the blood flow is adequate.”
The implant is positioned above the muscle allowing the patient to have less discomfort. The scar is very well-hidden underneath the fold of the breast. Immediate reconstruction can have a profound positive impact on the patient’s psychological well-being as it helps them maintain a positive self-image and self-esteem, reducing the emotional burden associated with breast cancer surgery.
Some patients opt to come back for a secondary procedure where fat from the belly is suctioned out, cleaned and injected into the breast to enhance the overall contour.
“The two generalized methods for breast reconstruction today are one-step implants and injecting the patient’s own body tissue into the chest,” Dr. Salzberg explained. “Using the patient’s own fat, mostly from the belly, is a much longer procedure taking as long as six to eight hours. But the woman wakes up with a full breast and a tummy tuck simultaneously.
“If a patient wants a reconstruction after a mastectomy, there is no reason not to do it at the same time. It’s suitable for nearly everyone. We have extensive consultations with the patient to discuss the possibilities and a 3-D imaging device that images the body and show what that patient would look like afterwards.”
Dr. Salzberg said recovery time is minimal, with patients able to resume normal activities within a week post-surgery. Patients are fitted with a special bra while still on the table in the operating room, to support the bandages and keep them comfortable during that first week. After that they transition to a sports bra.
Nearly half of Dr. Salzberg’s patients undergoing the procedure are having it because they have the BRCA gene that gives them an 86 percent lifetime risk of getting cancer.
“Getting a prophylactic mastectomy decreases the risk of ever developing breast cancer from 86 percent to below 1 percent,” he explained. “It’s about the best preventative measure there is. In my opinion anyone with a family history of breast cancer should be tested for the BRCA gene. The simplest and probably the least expensive way to be tested for the BRCA gene is to do a swab test with 23&Me. Knowledge is power and once you know if you have it or not you can decide where to go from there.”
Dr. Andrew Salzberg graduated from the University of Florida Medical School and completed a residency in general surgery at Mount Sinai Beth Israel and a Plastic Surgery residency at Mount Sinai Hospital. His office is located in the Scully-Welsh Cancer Center at Cleveland Clinic Indian River Hospital, 3555 10th Court in Vero Beach: 772-770-6856.
