Dr Joe & Luan

Luan:

Hi, my name's Luan, and I have a history of breast cancer and breast reconstruction. Today, I'm going to be talking to reconstructive plastic surgeon Dr. Joe Dusseldorp about breast reconstruction options for women in Australia who have had a mastectomy. Today, we're going to be talking in general about breast reconstruction options. If you want personalized advice about what options are available to you, you should seek a consult with a FRACS-qualified surgeon. Hi, Joe.

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Dr. Joe:

Hi, Luan. How are you?

 

Luan:

I'm good, thanks. Yeah, how are you going?

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Dr. Joe:

Great, thank you.

 

Luan:

Great. Thank you so much for joining us today to talk about the different breast reconstruction options that are available.

 

Dr. Joe:

Pleasure.

 

Luan:

You are a FRACS-qualified reconstructive plastic surgeon, aren't you?

 

Dr. Joe:

That's correct, yeah.

 

Luan:

I wonder if you could explain a little bit about that as you introduce yourself and tell us what it is that a reconstructive plastic surgeon does?

 

Dr. Joe:

Sure. So yeah, I'm Dr. Joe Dusseldorp. I'm a reconstructive plastic surgeon based in Sydney, Australia. I do have FRACS qualification, which is the Fellowship of the Royal Australasian College of Surgeons, and that's a qualification that really is, the peak body of surgery bestows upon people who've done enough training to be qualified to be a specialist in our country. And my focus is on breast reconstruction. That's the predominant work that I do, and I think that really it's only FRACS-qualified surgeons that should be doing this work, because it's quite complicated, as you are aware.

 

Luan:

Yeah, okay. Thank you. Thanks. And we sometimes hear that term breast surgeon as well, don't we? So what's the slight differentiation between the work that you do and the work that breast surgeons do?

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Dr. Joe:

Yeah, so breast surgeons are really responsible for managing a breast cancer patient from their cancer diagnosis through the MDT process and getting opinions from other specialists all the way through to their reconstructive options as well. And a lot of breast surgeons do reconstructive surgery as well, but we work with breast surgeons as plastic surgeons when the reconstruction is perhaps more complicated or requires microsurgery in terms of reconstruction. So really, it becomes a team type of reconstruction at that point. But breast surgeons are critical to breast cancer care.

 

Luan:

So when we're talking about the term reconstruction there, what do we mean by that term?

 

Dr. Joe:

Yeah, so breast reconstruction really is about helping women to regain the form and the aesthetics of their breasts after they've had a mastectomy. It can also be used with regards to when you haven't had to have a mastectomy. So for example, a wide local excision or a lumpectomy can still require some reconstruction at different times, depending on the size and shape of the breasts. But really, it's about trying to restore the form and function of the breast in some way, and that may include sensation as well.

 

Luan:

Thank you. And you mentioned the term mastectomy there as well, and as well as having different types of reconstruction, which we're going to talk about in a second, there are different forms of mastectomies as well, aren't there?

 

Dr. Joe:

Yeah, I think it's critical to understand that, actually, because the words get used sometimes without reference to what they exactly mean. And so really, there are three main types of mastectomy. There is what's known as a simple mastectomy, which really implies removing the whole breast and having a flat chest at that point. There is a skin-sparing mastectomy, which keeps the skin of the outside of the breast, so that you can fill that pocket with an implant or your own tissue, and we'll talk about that. And then there is a nipple-sparing mastectomy, which keeps really all of the skin and nipple of the front of the breast, and all you're filling then is what's inside the breast. So these lead to very different scars, very different sort of overall aesthetics of the breast, and I think it is important to understand what the difference is, particularly between a simple mastectomy and a flat closure and a reconstructed breast.

 

Luan:

Okay, thank you. So that term there, flat closure, we sometimes hear that term when people are talking about reconstruction, a chest reconstruction after a mastectomy, don't they?

 

Dr. Joe:

Yes. Yeah, okay. I do hear this word thrown around, an aesthetic flat closure is another term that's used in literature, and really, it's not a breast reconstruction. It is a chest wall reconstruction. It's really making the chest look quite smooth, not having bumps or lumps and things like that. But there really is no breast mound or breast shape there after that procedure.

 

Luan:

And that is a valid choice for someone.

 

Dr. Joe:

Absolutely. And in certain circumstances, that will be recommended to women if they have a particular type of breast cancer, for example. However, with the vast majority of breast cancers, a breast reconstruction is available and is something that women should know before undertaking a mastectomy.

 

Luan:

Thank you. So thinking now about breast reconstruction, we often hear about implant-based reconstruction. So what's involved with that type of reconstruction?

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Dr. Joe:

So yeah, that would be the most common type of breast reconstruction used in Australia. Essentially, what that implies is that the mound of the breast, that shape is being taken up by an implant, usually a silicon implant. It can also be using a tissue expander, and sometimes the two, so a combination of having the expander first and the implant later. And really, it's an option that is relatively quick to recover from, but also can achieve quite a fulsome shape quite quickly, and that's really the main advantage.

 

Luan:

Okay. And would that, an implant-based reconstruction, would that reconstruction be undertaken by a reconstructive plastic surgeon or a breast surgeon, or both?

 

Dr. Joe:

Both. Yeah, it could be either. So different breast surgeons have different practices. Many do quite a lot of implant-based reconstruction very well, and certainly the breast surgeons I work with are very, very capable and do beautiful implant-based reconstructions. So yeah, just a matter of talking to your specialists and finding out what their level of experience and interest is in doing the reconstruction themselves.

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Luan:

And you talked there as well about how quick that particular procedure can be, and that might be a preference for women who are making their decisions about reconstruction. What are some of the other reasons why someone might choose an implant-based reconstruction, from your experience in talking to your patients?

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Dr. Joe:

Yeah, I think it comes down to certainly if people are needing radiation therapy after their mastectomy, we do go down the path of using some kind of expander, usually, or potentially an implant while the radiation is going on. That just really means that if we then want to do an own-tissue reconstruction, which we'll probably talk about, then you can remove that expander implant and put in tissue after radiation, and then that tissue's not affected by radiation. So that's a very common pathway for women when they need radiation therapy. But also, it could be just the time of their life. They have young children, perhaps they're just trying to get back to work as quickly as possible. There's a number of different factors that this reconstructive option should try and fit in with someone's life, as opposed to define what their life is about for that period of time. And so that's where these options, it's good to have options, essentially.

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Luan:

Yeah. And good to take into consideration what your life is like, and how you live your life with regards to your reconstruction options.

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Dr. Joe:

Yeah.

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Luan:

Thank you. So you mentioned there own-tissue reconstruction, so that's sometimes called autologous reconstruction as well.

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Dr. Joe:

Exactly.

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Luan:

So you do want to explain a bit about that, because there are different types of own-tissue or autologous reconstruction as well, isn't there?

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Dr. Joe:

Yeah, it can be really confusing. The simple principle is that it's possible to reconstruct the mound of the breast using your own tissue. So it means we don't need an implant, and we can use the fat and the connective tissue, usually of the tummy where there's a bit of excess in a lot of people, myself included, and other parts of the body like inside of the thigh or the buttock region, even on the upper back. There are pieces of tissue on the body that reconstructive surgeons can use and transfer into the breast region to create a mound, and then that is more soft, more warm, but has the downside of needing to be taken from somewhere else where there will be some scarring.

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And that's really, I think, an important factor to go through and for people to understand, that you can't take from one area of the body and move to another area without some downsides. But a lot of the times, if we're taking from an area where there's a relative excess, that can be actually a good thing. People actually can feel quite good about those parts of their bodies as well.

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So overall, the most common operation I do is called a DIEP flap, and that's taking the tissue from between the belly button and the pubic hair. There's usually some tissue there that we can use to make one or two breasts, and that then leads to a relatively aesthetic closure of the tummy, which is known as a tummy tuck in the cosmetic surgery world. But we use those cosmetic principles to enable a breast reconstruction for one or both breasts.

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Luan:

Okay, thank you. And who would perform an own-tissue, DIEP-type reconstruction?

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Dr. Joe:

So really, only reconstructive micro surgeons would do that operation, and that tends to be plastic surgeons, I think that's fair to say, and generally only people who really specialize in breast as well. I think there are very relatively few of those around, which is one of the issues that we have with regards to access to this operation. Certainly, there aren't really reconstructive micro surgeons outside of capital cities, but that is not to say that women can't access those surgeons from outside, and we have many patients that come from regional areas to have this procedure done in capital city areas. But there's definitely, there are issues to access, and I'm sure we've talked about that before and will again, but it's something we're trying to improve.

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Luan:

Yeah, yeah. And that's all part of the discussions that we're having around Breast Reconstruction Awareness Day as well, isn't it? It's why we're making a video today.

 

Dr. Joe:

Exactly, yeah. And as soon as women understand, look, there are three main options, essentially, you can have implant-based reconstruction, you could have your own-tissue reconstruction, you don't have to have a reconstruction at all, which is a flat closure. And I think if people just, even women who didn't have breast cancer yet knew those three options before they were confronted with this very difficult decision of having to have a mastectomy, I think it would help in the process of normalizing some of this discussion and not making it so confronting at the time of a diagnosis.

 

Luan:

Yeah. Thank you for talking to us about the different reconstruction options, because having a dialogue is really important, as you said, to raise awareness of what options are available to women who have a mastectomy. But also, having a dialogue with your specialist, with your surgeon is really important to understand those options, isn't it?

 

Dr. Joe:

Yeah, I think it's really something which there is no right answer for breast reconstruction. It's a very personal decision, and I think that's where this concept of shared decision-making is key, because really, I can't make the right decision with you without knowing more about you, without you really engaging with what it is that are your options. And I think that's where understanding where someone's at in their life, what their goals are for the future, that's critical to getting the right outcome.

 

And the outcome might change later in their life. So for example, someone's finished having their family, and potentially they've already had implants, but they're not happy with how the implants are sitting, or the implants have changed or moved or developed a capsular contracture. That's something where it's still always on the table to have a discussion about new types of reconstruction, or whether we can potentially, maybe if they weren't a candidate for a DIEP flap earlier on, they might be later in their life. So there's definitely, it doesn't need to be a one and done type of situation. The conversation can evolve throughout the course of someone's life.

 

Luan:

Great.

 

Dr. Joe:

And the other group of people I think we don't talk about enough is the people making the decision about whether to have a prophylactic mastectomy, and what reconstruction might mean for them. And I think that's a really important conversation to start early, because options do change, and I think even younger women who maybe are thinking about this in their thirties because they know they have a BRCA gene or something like that should really have all the options well explained and should know all the downsides, and really make an informed decision that's not made out of fear, because that's very clouding type of emotion, but really from a position of power and information.

 

Luan:

Yeah, yeah. An informed and shared decision made with your specialist team, and I love that term, it's not one and done. It's about having continuous dialogue afterwards so that you can make the right decision for you at different points in your life.

 

Dr. Joe:

Absolutely.

 

Luan:

Great. Thanks so much, Joe. Thanks for helping-

 

Dr. Joe:

No worries, Luan.

 

Luan:

... raise awareness of all the different reconstruction options.

 

Dr. Joe:

It's a pleasure, and congratulations on everything you're doing to raise awareness as well.

 

Luan:

Oh, thank you. Thanks so much.

 

Dr. Joe:

Looking forward to BRA-va Day.

 

Luan:

Yeah, BRA-va Day. Thank you.

 

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