Angelina Jolie's surgery: What you need to know about breast reconstruction

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  Brad Pitt and Angelina Jolie

As more women are learning about the heroic steps that Angelina Jolie took when she decided to undergo a prophylactic mastectomy, I’ve received many questions regarding the surgical techniques used in these reconstructions and how they have improved. We spoke to leading reconstructive surgeon Dr. Richard Winters, vice chairman of plastic and reconstructive surgery at Hackensack University Medical Center in New Jersey, about the latest techniques.

Once a woman decides to have this surgery, what are her options?
“When a woman decides she is having a prophylactic mastectomy, the first consideration is whether she will keep her own nipple or not. Will it be ‘nipple sparing’ or ‘skin sparing’ surgery? Angelina Jolie had ‘nipple sparing’ surgery. Nipple sparing is simply that – you leave the nipple.  If a woman comes in who has breast cancer, it is not conventional to ever leave the nipple behind. In a prophylactic surgery, if a woman is going to keep the nipple, depending on the size or shape of breast, you have to decide where the incision will be made – the underside of the nipple or under the breast.”

Angelina Jolie said she had a ‘nipple delay.’ What is that?
“If the incision is around the nipple, you can do a preliminary procedure called a ‘nipple delay,’ where you make the incision, lift the nipple, and divide the blood vessels that supply it from within the breast. This allows you to redirect blood supply from surrounding skin to the nipple tissues so the nipple is more robust.  You also take a biopsy to make sure there aren’t any surprises – any breast tissue that has the potential to form breast cancer. You get a little black and blue, and it can also take away some sensitivity. It doesn’t mean it will be without sensation, but it might feel different.”

What’s the next decision women need to consider?
“With prophylactic surgery, you virtually always do an immediate reconstruction. Then, you have to decide on a technique. The first is the reconstruction, which involves an implant. The other type involves only autologous tissue – your own tissue. Then, there’s a type that I use very commonly, which bridges the two; it involves both the implant and your own tissue.”

What’s involved in an implant surgery?
“There are two different reconstructions that involve implants – one is done right away in one stage, and the other is several stages. It’s unusual to be able to do a one-stage implant. Unless the woman wants (a small breast), you need to stage it and expand underlying tissue to accept a larger implant.

“Angelina Jolie had a staged reconstruction with a tissue expander, which is a temporary device that goes in under the chest wall muscles and gets partially expanded at the time of mastectomy. Then over a period of time in the office as an outpatient, you can access a port and slowly expand the overlying skin. Then, she goes back for the second stage, (doctors) re-open the same incision, take out the expander and put in a permanent breast implant. This can take anywhere from six to 12 weeks.

“The advantages are: This is straightforward and simple. It doesn’t involve making separate incisions or taking tissue from anywhere else in the body. For women who like the fullness they get from an implant – which is not what a natural breast looks like – and want a straightforward operation, it’s a great choice. Some disadvantages are that the implant will need to be changed over time, and it has a very small chance of getting infected or could form scar tissue.”

What about the other options?
“On the other end, (there) are autologous tissue reconstructions. This requires bigger surgeries, but gives you a more natural looking breast if that’s what you want. We remove the tissue from where it lies, like in the abdomen, hip or thigh. We take it with its own blood supply, an artery and a vein. Then we transplant it to a chest so it can live as a breast, connected to a new artery and vein in the chest. It’s complicated but has achieved widespread use, and lots of places are doing them well. But it is a bigger operation with potential for bigger complications.

“There are also autologous surgeries where you take the tummy tissue and bring it up to the chest, but leave it attached to blood supply. So the blood supply comes from a vein from within the abdominal muscle. That is an easier procedure but has some disadvantages, because it results in abdominal wall weakness.

“Another type is to take a muscle from the back – the latissimius dorsi. You can take back fat with muscle, so sometimes that’s enough to make a breast without an implant.”

Is there a procedure that involves both options?
“The most common operation that I offer women is to take the latissimus muscle and put an implant in immediately. The reason I like that is although it involves an additional donor site, it’s in the same quadrant (of the body) as the mastectomy. Complication rates are extraordinarily low, and it gives you a breast right away; (there’s) no tissue expansion, and they come out beautifully. This requires one to two days most in the hospital and a relatively quick recovery with low chance of complications.”

What questions should women ask their doctors before having a prophylactic mastectomy?
“It’s important to know the surgeons’ experience with all types of breast reconstruction. Also, get a sense of what their individual complication rates are. Overall for prophylactic, I think it should be that the complication rates of any elective operation should be similar – less than a 1 to 2 percent chance of having serious complication, less than a 5 to 10 percent chance of having minor complications.”

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New approaches give women more options for breast cancer surgery

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  Shown here is the start of a race to benefit Susan G. Komen for the Cure and another cancer-fighting group in Lyndhurst, Ohio, on May 8.AP

CHICAGO –  Treating breast cancer almost always involves surgery, and for years the choice was just having the lump or the whole breast removed. Now, new approaches are dramatically changing the way these operations are done, giving women more options, faster treatment, smaller scars, fewer long-term side effects and better cosmetic results.

It has led to a new specialty -- "oncoplastic" surgery -- combining oncology, which focuses on cancer treatment, and plastic surgery to restore appearance.

"Cosmetics is very important" and can help a woman recover psychologically as well as physically, said Dr. Deanna Attai, a Burbank, Calif., surgeon who is on the board of directors of the American Society of Breast Surgeons. Its annual meeting in Chicago earlier this month featured many of these new approaches.

More women are getting chemotherapy or hormone therapy before surgery to shrink large tumors enough to let them have a breast-conserving operation instead of a mastectomy. Fewer lymph nodes are being removed to check for cancer's spread, sparing women painful arm swelling for years afterward.

Newer ways to rebuild breasts have made mastectomy a more appealing option for some women. More of them are getting immediate reconstruction with an implant at the same time the cancer is removed rather than several operations that have been standard for many years. Skin and nipples increasingly are being preserved for more natural results.

Some doctors are experimenting with operating on breast tumors through incisions in the armpit to avoid breast scars. There's even a "Goldilocks" mastectomy for large-breasted women -- not too much or too little removed, and using excess skin to create a "just right" natural implant.

Finally, doctors are testing a way to avoid surgery altogether, destroying small tumors by freezing them with a probe through the skin.

"Breast surgery has become more minimalistic," said Dr. Shawna Willey of Georgetown's Lombardi Comprehensive Cancer Center.

"Women have more options. It's much more complex decision-making."

Breast cancer is the most common cancer in women around the world. In the U.S. alone, about 230,000 new cases are diagnosed each year.

Most can be treated by just having the lump removed, but that requires radiation for weeks afterward to kill any stray cancer cells in the breast, plus frequent mammograms to watch for a recurrence.

Many women don't want the worry or the radiation, and choose mastectomy even though they could have less drastic surgery. Mastectomy rates have been rising. Federal law requires insurers to cover reconstruction for mastectomy patients, and many of the improvements in surgery are aimed at making it less disfiguring.

Here are some of the major trends:

IMMEDIATE RECONSTRUCTION

Doctors used to think it wasn't good to start reconstruction until cancer treatment had ended -- surgery, chemotherapy, radiation. Women would have a mastectomy, which usually involves taking the skin and the nipple along with all the breast tissue, followed by operations months later to rebuild the breast.

Reconstruction can use tissue from the back or belly, or an implant. The first operation often is to place a tissue expander, a balloon-like device that's gradually inflated to stretch the remaining skin and make room for the implant. A few months later, a second surgery is done to remove the expander and place the implant. Once that heals, a third operation is done to make a new nipple, followed by tattooing to make an areola, the darkened ring around it.

The new trend is immediate reconstruction, with the first steps started at the time of the mastectomy, either to place a tissue expander or an implant. In some cases, the whole thing can be done in one operation.

Nationally, about 25 to 30 percent of women get immediate reconstruction. At the Mayo Clinic, about half do, and at Georgetown, it's about 80 percent.

SPARING SKIN, NIPPLES

Doctors usually take the skin when they do a mastectomy to make sure they leave no cancer behind. But in the last decade they increasingly have left the skin in certain women with favorable tumor characteristics. Attai compares it to removing the inside of an orange while leaving the peel intact.

"We have learned over time that you can save skin" in many patients, Willey said. "Every single study has shown that it's safe."

Now they're going the next step: preserving the nipple, which is even more at risk of being involved in cancer than the skin is. Only about 5 percent of women get this now, but eligibility could be expanded if it proves safe. The breast surgery society has a registry on nipple-sparing mastectomies that will track such women for 10 years.

"You really have to pick patients carefully," because no one wants to compromise cancer control for cosmetic reasons, Attai said.

"The preliminary data are that nipple-sparing is quite good," but studies haven't been long enough to know for sure, Willey said. "It makes a huge difference in the cosmetic outcome. That makes the woman's breast recognizable to her."

Dr. Judy Boughey, a breast surgeon at the Mayo Clinic, said the new approach even has swayed patients' treatment choices.

"We're seeing women choosing the more invasive surgery, choosing the mastectomy," because of doctors' willingness to spare skin and nipples, she said.

It helped persuade Rose Ragona, a 51-year-old operations supervisor at O'Hare Airport in Chicago. She had both breasts removed on April 19 with the most modern approach: Immediate reconstruction, with preservation of her skin and nipples.

"To wake up and just see your breasts there helped me immensely," she said.

She chose to have both breasts removed to avoid radiation and future worry.

"I felt it was a safer road to go," she said. "I can't live the rest of my life in fear. Every time there's a lump I'm going to worry."

FREEZING TUMORS

Attai, the California breast surgeon, is one of the researchers in a national study testing cryoablation. The technique uses a probe cooled with liquid nitrogen that turns tumors into ice balls of dead tissue that's gradually absorbed by the body. This has been done since 2004 for benign breast tumors and the clinical trial is aimed at seeing if it's safe for cancer treatment.

"The technology is amazing. This is done in the office under local anesthesia, a little skin puncture," Attai said.

In the study, women still have surgery at some point after the freezing treatment to make sure all the cancer is destroyed. If it proves safe and effective, it could eliminate surgery for certain cancer patients.

"I'd love to see the day when we can offer women with small breast tumors a completely non-operative approach, and I do think that's coming soon," Attai said.

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Dr. Manny: Governor Christie is adding years to his life by having lap-band surgery

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  New Jersey Gov. Chris Christie answers a question in this April 30, 2013 photo taken in Long Beach Township, N.J., during a town hall meeting.AP

I am very pleased that Gov. Chris Christie came out publicly to talk about his weight-reduction surgery. I know that for years he has struggled with his weight, but one thing is for sure now: He will add years to his life.

By doing this at the age of 50, he could potentially reverse all the negative side effects of obesity, such as type 2 diabetes, hypertension, early joint-degeneration and cardiovascular disease.

I am also very happy that he is the governor of the state of New Jersey, because he continues to show us that pragmatism and common sense always works.

I spoke with Dr. Hans Schmidt, the director of the bariatric surgery center at Hackensack Medical Center in Hackensack, New Jersey, to find out more about the lap-band procedure.

What is lap band surgery?
“It’s a laparoscopic procedure, meaning it is done through small incisions. The gist of it is that you’re putting an adjustable band – a circular ring – around the upper stomach. It is then connected through tubing that goes to a port under the skin, which doctors can use to adjust the band.”

Who qualifies for this surgery?
“There is pretty defined criteria. You have to have a BMI (body mass index) of over 40, which is about 100 pounds over your ideal weight.  Or, you could (qualify with a) BMI of over 35 if you have weight-related medical conditions like diabetes, high blood pressure, sleep apnea or severe arthritis.”

How do you prepare for the surgery?
“Once you meet the medical criteria for surgery, each program has their own procedure. Most of the time, you have to be evaluated by a nutritionist beforehand and undergo medical clearance with your doctor to make sure you’re safe for surgery. Sometimes, you even go through a psychiatric evaluation to make sure you don’t have depression, an eating disorder or any other underlying reasons for overeating. Once the surgery is approved, some places encourage a modified diet a week or two before surgery – a liquid diet or a lighter diet to lose a few pounds beforehand.”

What is the recovery process like?
“The recovery process for the band is very quick. Many go home the same day, (but) some stay in the hospital overnight. Most people can go back to their normal activity within one to three days after surgery. That includes most normal activities – not going to the gym or doing heavy exercise –  but most day-to-day activities.”

What are the risks associated with lap-band surgery?
“There are risks associated with any surgery, of course.  It is under general anesthesia, so you have to be asleep, and there are always cardiopulmonary risks with that. But of the bariatric surgeries, it is probably the safest in the short-term. There are few immediate risks, other than injury to surrounding organs – but that’s very rare.”

How much can patients expect to slim down?
“We shoot for a loss of between a half and two-thirds of their excess body weight. With the band, the weight loss is typically pretty slow and steady. There’s a rapid weight loss after the first few months – maybe 10 pounds a month. And then with the band, it’s usually 1 to 2 pound per week, so 4 to 8 pounds per month over many months. Some other operations have really rapid weight loss, whereas weight loss with the band is slow and steady over time. If you lose weight slowly enough, the (excess) skin may be less of an issue.”

How do your lifestyle and eating habits change afterwards?
“That’s where the challenges come. You have to get the band adjusted every four to six weeks for the first year, (and) less as time goes on. The point of the band is to eat less food. It may take away your hunger to a degree, but the bottom line is you will get full faster and eat much less food throughout the day. If you’re a good patient, you should incorporate exercise too.”

What are the repercussions if you don’t follow a new diet?
“If you eat too much, or too fast, food tends to get stuck. It is trying to go down the esophagus into the stomach, which has the band around it. The food can get stuck in your throat and some people end up regurgitating or throwing up.  But the bottom line is if you don’t follow the rules, you won’t lose weight. It does require effort on behalf of the patient to lose the weight. If you do, the results are pretty good.”

Is this for everyone?
“You have to meet the BMI criteria; it’s not just overweight people but those who are morbidly obese. There are several different types of weight loss operations available.  The band is good for people who are compliant, able to follow up and come every four to six weeks, and are devoted to losing the weight and doing the follow-up. People who aren’t may be better served with other procedures.”

Dr. Manny Alvarez

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What to eat after lap-band surgery

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I know everybody is very excited about Gov. Chris Christie’s new effort to lose weight. Christie has reportedly lost 40 pounds so far, but it is important to remember that maintaining that weight loss will have a lot to do with adopting the proper diet and lifestyle. We talked to Rebecca Soloman, clinical nutrition coordinator at Mount Sinai Hospital in New York City, for the best diet tips to follow after lap-band surgery.

Eat small portions
In the weeks and months after surgery, it is essential for patients to focus on limiting their portion sizes. Lap-band surgery decreases the size of the stomach, making it very difficult, and even painful, to ingest large quantities of food.

“Most patients are full after a quarter to a maximum of half a cup of food at one sitting,” Soloman said.

Consuming more than that will cause discomfort and could lead to vomiting, Soloman noted. She recommends that patients eat slowly and chew food thoroughly to avoid discomfort.

Focus on high protein foods
“We found, especially in bariatric weight-loss patients, that protein is the food group from which they derive their greatest sense of fullness or satiety,” Soloman said. In the first three to four weeks after surgery, Soloman recommends focusing on soft proteins like Greek yogurt, pureed chicken, soups or cottage cheese. This will also help patients avoid becoming protein deficient.

After the first month, patients can begin experimenting with non-pureed foods, focusing on softer flaky fishes, the dark meat of chicken or lean ground beef. “We increase the texture but not necessarily the quantity,” Soloman noted. “We like to focus on the term ‘gentle satiety,’ you want to be mindful of not overeating.”

Avoid drinking and eating at the same time
One of the most important rules to follow after lap-band surgery: Avoid eating and drinking simultaneously. While staying hydrated is important, Soloman advises patients to stop drinking 10 minutes prior to eating, and then avoid drinking until 45 minutes after they’ve finished their meal.

In the first few weeks after surgery, the stomach is so tiny that consuming a liquid and solid at the same time could cause vomiting. Furthermore,  “just a few swigs of water could push food out of the stomach, causing a premature sense of emptiness,”  Soloman said.

Limit pasta, rice, bread
While eating a little bit of fiber is fine, most patients do not tolerate rice, pasta or bread very well.

“They all expand when they absorb more fluids, like gastric juices,” Solman said. This can cause discomfort in patients, and they typically learn to avoid these types of foods, or eat them only in very limited qualities.

Consume soft fruits and vegetables
In the first weeks after surgery,  all fruits and vegetables need to be pureed.

“You could do a natural applesauce or make your own, pureed carrots, broccoli. You can use seasonings, herbs, spices to the extent that you tolerate them. Make it flavorable, so that it is enjoyable,” Soloman said.

Later, patients can introduce whole fruits and vegetables, avoiding fruit skins (like apple skins) or stringier vegetables.

Overall, it is important to remember that while lap-band surgery will help you lose weight, it will only work if you monitor your diet, too.

“It’s a tool, not a solution in and of itself,” Soloman said. “It’s effectiveness is related to what you put in your mouth.”

Dr. Manny Alvarez

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Gerrard may need shoulder surgery

Shoulder surgery ... Steven Gerrard has been playing with a shoulder complaint all season. Source: Andrew Yates / AFP

Liverpool say captain Steven Gerrard may need surgery on his injured left shoulder after the season.

The 32-year-old Gerrard has played every minute of every match in the English Premier League this season. The team has four matches remaining.

Liverpool assistant coach Mike Marsh says Gerrard ``has been playing with a shoulder injury for quite a while now. We'll try to find the right time for him to get it fixed properly.''

If Gerrard has surgery right after the season ends on May 19, he would likely miss two matches for England, including a friendly against Brazil on June 2 at Maracana Stadium.

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