The Truth About Fat Transfer, Breast Cancer Reconstruction and more. Drive to Explant Episode 4

All right, back for another episode. So today I thought I would just go over breast cancer reconstruction with or without implants, with or without your own tissue? Fat transfers, flat closures. There is a variety of ways to do breast reconstruction. And yesterday I was actually joking about. I'm old enough to have done all the surgeries before we had some of the. More from. From a tech standpoint, before we had some of the very cool things that we do now routinely. So when I started general surgery training, we did all gallbladder surgery open, which means we made an incision underneath the rib cage on the right to go down and get the gallbladder. And by the time I ended our training, I trained in general surgery from 1996 to 2:2. It was completely taboo basically to do an open gallbladder. And all that transpired while I was in training. So. Other things that happened while I was in training certainly were the coming to fruition of doing instead of modified radical mastectomy for breast cancer with axillary lymph node dissection, which was the standard of care when I started training, to a lumpectomy and a sentinel lymph node biopsy, followed by radiation therapy. And so all of those things happened while I was in training. So I was trained by a group of surgeons who transitioned from all open surgery like I just described, to doing more minimally invasive surgery and trying to teach, you know, the students, the residents and the fellows, all those techniques all kind of on the fly because they were all happening. So many of us who were being trained, it was definitely an interesting time. So as it pertains to, like, open surgery, I remember I had a mentor. He really did not like doing laparoscopic surgery. So he would almost. And out of respect for him, he was just not comfortable doing it. So in that transition time, we did a lot more open cases for him, which means we made the bigger incision and did it in the traditional way. That's what he was most comfortable doing. So as it pertains to breast surgery, when I started, we offered, like I said, modified radical mastectomies and axillary sections to transition to lumpectomies and lymph node biopsy. And certainly we still did mastectomies. And then the plastic surgery team would do reconstruction. So I would see what the plastic surgeons would do. And I hadn't decided I wanted to go into plastic surgery. I initially wanted to do a pediatric heart surgery, but two and a half, three years into it, I adjusted that I really got interested it in microsurgery so microsurgery is taking basically suture finer than your hair and sewing together blood vessels that are about 2 millimeters in diameter. So think of like putting together coffee stirrers to re establish blood flow. And so you can take what's called a composite of tissue or a flap could be skin and fat connected to the blood vessels. It could be skin, fat, fascia, which is a thin layer of connective tissue. It can include muscle, it can include bone, it can just be skin and fashion bone. There's all sorts of ways to do it based on what you're trying to reconstruct. And so I became extremely interested in that in my laboratory year doing vascular research. And so I transitioned to my interest and focus being on going into plastic surgery and doing microvascular surgery. So I completed six years of surgery training and started plastic surgery training and did. We were the center for burn care in the state of Indiana. So we took care of all the burn patients, but pediatric and adults. We did oncology reconstruction for breast cancer and had neck cancer predominantly and then certainly all sorts of other infections and trauma and things of that nature. And then when I transitioned into my first teaching job, I was very focused on microvascular breast reconstruction. And there had been a traditional technique called a TRAM flap. And that was where you left the lower tissue of the tummy. Like if somebody has a little belly, the tissue below the level of the belly button that would be used but left in continuity with one of the six pack muscles and it would be rotated either to the same side or to the opposite side to help reconstruct the breast after mastectomy. The other technique that was common was called the latissimus dorsiflap. And I did both of those in training. And those were your tissue reconstruction options really in training. And then everybody was taught in training how to do an expander and implant based reconstruction because those are just basic techniques. And then when I went into my first teaching job, I really expanded that by taking trips to Europe and Africa to learn how to do Asia to learn how to do more complex microsurgery called perforator flap surgery, which was being done in the United States by Bob Allen predominantly and then in Europe by Dr. Philip Blondil and others, Fu Chinwei in Taiwan. So anyway, I wanted to learn those advanced perforator flap techniques and I started a fellowship where I taught at to just do those techniques for both breast reconstruction and head neck reconstruction predominantly. And then I did a lot of lower extremity reconstruction for sarcomas but the going forward for breast. So we did a lot of the newer technique for breast reconstruction which in 2005, basically when I started teaching was called a DIEP free flap. So that's just one type of reconstruction. The types of reconstructions are, you know, first and foremost an aesthetic flat closure, which is a form of reconstruction. It's just that person has chosen not to have any other tissue placed or any other materials placed. And you perform an aesthetic flacposure if you want to then add after discussion. A patient wants to do an expanded implant based reconstruction. You start with the tissue expander at the time of mastectomy and that's placed normally in the United States behind the muscle. And then when I was Starting out in 05 06, biomaterials or acellular dermal matrix, something called aloderm was kind of coming into the fold and that became a substance that we used a lot to help reinforce the lower third of the reconstruction. So that was incorporated acellular dermal matrix is cadaverodermis. That's had all the cells removed in a proprietary process. And so that was a very common technique that two stage. And then I even back in I think it was 0607 was doing stage technique to help in more patients who couldn't tolerate longer operations or needed a single operation. People who in particular one had diabetes and was on dialysis. I remember taking care of where we just wrapped the whole permanent implant in aloderm and placed it. And that became a more common technique that's practiced now. And I was doing that in 06 07. And then all the different forms of autologous reconstruction that were what I described, perforate or flat bass we practiced and those became higher on the list to perform rather than those traditional techniques that I was taught. So I would rarely do latissimus flap or I would rarely do a tram flap or I would rarely do any kind of rotational flap surgery. So it was really the DIEP free flap was the predominant thing. And then I would do gap flaps. And then we would do. Flaps either from the tug flag, tug flaps from the inner thigh. Those were the predominant ones that we would do. And so I think, you know, what everybody should understand is when someone gets a mastectomy, especially bilateral mastectomies, those are different operations per side. Usually cancer is not on both sides. And one side will have a more aggressive or intense surgery taking more tissue on the cancer side. That's pretty normal. They'll always be sampling lymph nodes. And that Helps, you know, set forth how they're going to therapeutically take care of the patient afterwards. Is the patient going to need chemotherapy? Is the patient going to get radiation therapy? And it used to be that when people had mastectomies, they didn't get any radiation therapy. And then that change followed training. They started adding plasmastectomy radiation therapy, which really complicated reconstructive cases at times because you didn't know who was gonna get that therapy. So you had to have a plan of action to take care of that. And so we'll say in the best case scenario, we did reconstruction and I did a free flap based reconstruction, dip free flap, which is my normal. I tried to do bilaterals to help the patient because that technique can only be done one time. Using the tummy tissue can only be done once. So if that patient was going to have a bilateral or they had decided to have a bilateral mastectomy, we would perform that technique. After explaining the risk benefits of that procedure, we had a 95% success rate connecting those blood vessels and getting all the tissues to perfuse and heal. Because it's your own material that will never be rejected. It just has to heal and have good blood flow. We used to use CT scans with contrast to help us identify which were the best blood vessels to help help perfuse those flaps. So we would do those predominantly get those done. We started using Exparel, which was a long acting local anesthetic back in 05 to help those patients have less pain. And you know, now it's very commonplace in 2024 to use exparel in a combination with other blocks to really help reduce patients most operative discomfort to get them up earlier, really avoid all the kind of complications come with sitting around with blood clots and just lack of expansion of the lungs and all the things that from sitting or being not moving really. So we would do those cases and patients stay three, four days in the hospital, go home, see them out a week and a month, three months, that was my protocol. And then, you know, that three month window, get a set sense of how things are settling out and then may not see them for quite a while after that because many of them have to start chemotherapy or they'd start radiation therapy and then those appointments would supersede our appointments. And then I would have to check on them if there was an issue with healing. And then they would circle back sometimes nine months later, sometimes a year later. And at that point we could see what other effects either treatment had had or if there had Been no treatment, how the flaps had settled. And typically the upper pole is the problem. So whether it's a breast reconstruction, whether it's an explant procedure, many of these will have different areas that affect portions of the breast that then we have to use strategies and techniques to help offset the changes. So in a breast reconstruction, it's typically always going to be the upper pole because the tissue reconstructions don't reconstruct the upper pole well. They just don't have enough volume. And then with the implants, when I started, all we had was round and rounds. Really, it didn't reconstruct the upper pole that well either. And then later we got shaped implants back. But going back to the tissue reconstructions, when we have those upper pole hollows or deficits, we would use fat transfer. So fat transfers have been around 100 years. Over 100 years. And so the joke was back then at our place, we needed to do a lot of fat harvest and we didn't have all the sophisticated equipment I have now. So we'd sterilize a Williams Sonoma colander to strain the fat and then help get different particulate matter out of the fat. And then we transfer it back in a syringe based way using what's called a Coleman cannula. As plastic surgeon, he came up with fat transfers for facial surgery using a small set of cannulas. And that's how everybody started because that's what everybody had available. That's what you could use from a technical standpoint to execute those steps in the operation. Then later on you could have different types of liposuction. I would never advocate using laser anything that overheats the fat. That was not something I would do. Certainly you could use ultrasound assisted. You could use anything, you know, that would not harm the fat. Power assisted manual, adding more water with hydro placements. So the fat would get harvested, get processed and put back. So fat transfers were done routinely for those patients. You can imagine if I was doing those every week, multiple times a week, patients would need fat transfers, transfers all the time to help offset those changes, especially like I said, in the upper pole. So that was a really common thing. So I would do fat transfers, you know, 100, 150 times a year. So as we fast forward to doing, you know, say an explant here, an explant can be the upper pole and the lower pole. Typically the lower pole is a problem because the implants are placed behind the muscle. So we're doing fat transfer in those areas to help fill both upper pole leavage area and then the lower pole. That helps offset many of the changes in the chest wall. All right.