October 2023
- thestitchprs
- Oct 23, 2023
- 7 min read
Breast Cancer Awareness Month
Our October edition is all about breast cancer. Read our pieces below from our writers!
If you are interested in submitting a guest contribution or wish to share announcements or opportunities, please complete the form at the link at the bottom of the newsletter.
Best, The Stitch Editorial Board
The History of Breast Reconstruction
Timeline by Sarah Moffitt, USF Morsani College of Medicine
The American Cancer Society reports that a woman has a 1 in 8 chance of developing breast cancer during her lifetime. Although breast cancer is the second leading cause of cancer deaths in women, the death rate has fortunately been declining in recent years. This is thought to be attributed to screening practices, surveillance, and genetic testing of the BRCA gene, as well as better treatments. These better treatments include chemotherapy, radiation, and surgical interventions.
Today, if a patient diagnosed with breast cancer chooses to undergo reconstruction, there is a plethora of options from which to choose. But it wasn’t always this way, with techniques to spare the nipple, 3D tattooing the nipple if it can’t be salvaged, tissue expanders to prepare for a delayed reconstruction, and flaps from all over the body, to name a few. So, let’s dive into the history of breast reconstruction.
The radical mastectomy, which removes the skin, nipple, mammary gland, pectoralis major and minor, and axillary lymph nodes, was introduced by William Stewart Halsted in 1882. This technique left no room for reconstruction, as Halsted let the wound heal by secondary intention, forming scar tissue that he believed would prevent the spread of cancer. The influence of Halsted’s strong opposition to attempt reconstruction of the breast lasted well into the 20th century.
In the 1960s, Watson, a physician who treated breast cancer, represented the sexism in the medical world at the time, expressing that breasts were a “superficial easily disposable utilitarian appendage”. Reconstruction of the breasts was evidently not a concern, nor was it respected. Women who sought out reconstruction were thought of as “narcissistic” or “immature”.
Luckily, other surgeons were at work on breast reconstruction during the early 1900s, despite the sentiments expressed by physicians like Watson. Attempting reconstruction with autologous fat grafting was noted in 1895. The early 1900s also saw techniques such as shifting the other breast into the middle of the chest to try to restore volume, and the use of muscle flaps, such as the latissimus dorsi, to recreate a breast. These ideas, although important to the development of breast reconstruction, were largely unsuccessful.
The notion of a modified radical mastectomy, which preserves the pectoralis minor, gained popularity in Europe when it was introduced in the 1950s. The USA was slower to accept this idea, and it was not until 1965 that an American physician began preserving the pectoralis minor.
Silicone breast implants, created in 1963 for the practice of breast augmentation, were introduced to breast reconstruction in 1971. The use of implants in breast reconstruction encouraged the creation of tissue expanders as well. Implant-based reconstruction, although less invasive and faster, still presented complications such as surgical site infection, capsular contracture, and a high risk of re-operation.
The latissimus dorsi flap was reintroduced in 1976, a decade that was filled with the experimentation of muscle flaps in breast reconstruction. Abdominal and gluteal thigh flaps notably were initiated in the second half of the 1970s.
What do we have to thank for the rapid development of breast reconstruction in the 1970s? Radiology! The development of the mammogram and the introduction of a chemotherapy regimen revolutionized the treatment of breast cancer. Earlier detection of cancer, along with adjuvant chemotherapy, meant that less drastic surgical approaches could still result in patient survival and remission, without complete loss of the breasts.
Today, women with breast cancer have many providers and many options for their care. Surgeons, oncologists, and gynecologists all contribute to a woman’s ability to survive a cancer diagnosis and maintain a womanly appearance with breast reconstruction, if she so chooses.
References
Homsy, A., Rüegg, E., Montandon, D., Vlastos, G., Modarressi, A., & Pittet, B. (2018). Breast Reconstruction: A Century of Controversies and Progress. Annals of Plastic Surgery, 80(4), 457–463. https://doi.org/10.1097/SAP.0000000000001312
Empowering Survivors: Breast Reconstruction Awareness Day
Highlight by Parul Rai, University of Texas Medical Branch
Breast Reconstruction Awareness Day (BRA Day) is a special, yet often overlooked, component of Breast Cancer Awareness Month. Breast cancer, beyond its toll on a woman’s physical health, can deeply affect her self-esteem, body image, and overall well-being.
BRA Day aims to raise awareness about the breast reconstruction options available to women post-mastectomy and the importance of these choices for their self-confidence and quality of life.
Breast reconstruction is not merely a cosmetic procedure; it promotes psychological healing. It empowers women to regain a sense of normalcy, helping them move beyond the physical scars and emotional traumas of cancer and reclaim their femininity. Awareness about this option provides encouragement and hope, reminding survivors that life can indeed go on, beautifully.
Observed on the third Wednesday in October, BRA Day is a crucial piece of Breast Cancer Awareness Month, emphasizing the importance of emotional recovery alongside physical recuperation. It encourages open dialogues about breast reconstruction, dispels myths, and reduces stigma, fostering an environment of support and understanding. As we rally behind the pink ribbon, let's ensure that BRA Day continues becoming an increasingly prominent fixture, helping survivors navigate the challenging journey toward complete recovery.
References
Events, Fundraisers and Heightened Awareness Mark the 11th Annual Breast Reconstruction Awareness Day on Oct. 19, 2022. American Society of Plastic Surgeons. Accessed October 17, 2023. https://www.plasticsurgery.org/news/press-releases/events-
fundraisers-and-heightened-awareness-mark-the-11th-annual-breast-reconstruction-
awareness-day-on-oct-19-2022#:~:text=ARLINGTON HEIGHTS%2C IL
Chen W, Lv X, Xu X, Gao X, Wang B. Meta-analysis for psychological impact of breast reconstruction in patients with breast cancer. Breast Cancer. 2018;25(4):464-469. doi:https://doi.org/10.1007/s12282-018-0846-8
How Did The Recon Go? Let’s Ask AI
Article Review by Youssef Aref, California Univerity of Science and Medicine
Artificial intelligence (AI) has been shown to be effective in detecting key features of the breast. This team wanted to utilize AI to fill the gap from a lack of a gold standard in evaluating breast symmetry after reconstruction.
The team created an AI that could utilize a symmetry calculating tool, BAS-Calc, and underwent training with 622 manually annotated images. The AI was then asked to evaluate the symmetry of 81 breast reconstructions and compared against the evaluations of two plastic surgeons using the same BAS-Calc tool.
Eighty-one patients had a total of 405 landmarks for detection, of which AI was able to detect 399 (98.51%) as verified by human observers. The AI correctly identified landmarks for seventy-five patients with no penalization when missing only a single landmark. The AI results were consistently reproducible and found to show substantial or perfect agreement with the plastic surgeons (Cohen’s Kappas: 0.788, 0.832) and significantly correlated by Spearman and Pearson correlation coefficients (p<0.01).
The authors believe this model’s ability to accurately and efficiently function provides a useful tool for reconstructive surgery. They also believe these results could lay the foundation for future AI to build on as effective tools for plastic surgeons.
This article shows the growing importance of AI in plastic surgery. As a medical student, AI is a new field that should be understood and taught within plastic surgery as a tool that can revolutionize the field. Research focusing on AI has led to many being cautious about its use. However, more models such as that in this study show AI can be an effective device to improve a patient’s well-being through objective measures.
Reference
Kenig N, Monton Echeverria J, Chang Azancot L, De la Ossa L. A Novel Artificial Intelligence Model for Symmetry Evaluation in Breast Cancer Patients. Aesthetic Plast Surg. 2023 Aug 17. Epub ahead of print. PMID: 37592148.
Q&A with Thomas Steele, MD
Interview by Lauren Kim, UT Southwestern
Thomas Steele, MD is the current microsurgery fellow at UT Southwestern. We were fortunate to have a conversation about what drew him to the field.
Why are you interested in microsurgery and breast reconstruction?
A mentor once told me, “No matter how old you get, or how many times you do it, as soon as you take the clamps off the vessel and see the blood flow across the anastomosis, there's no feeling in the world quite like it.” One of the greatest aspects and biggest challenges about breast reconstruction is that it brings together the two major parts of plastic surgery – reconstruction and cosmetics.
While we are rebuilding a breast from nothing to help a patient who has been affected by cancer get back to their normal self, we are also meeting the expectations of a patient who wants their breasts to look as good, if not better, than how their breast looked before they had cancer. It’s an art to balance reconstruction with cosmetic expectations, and something that you don’t often see in other fields.
What is something people should know about breast reconstruction?
One of the reasons I want to do a microsurgery fellowship is because I see a big shift in reconstruction, away from implants and towards autologous tissue involving free flaps. While implants have been trending in and out for some time now, I think the development of complications like BIA-ALCL and breast implant illness in recent years are pushing reconstruction towards autologous tissue.
On a more technical level - microsurgical skills don’t come naturally for everyone and can be mastered with practice. It’s amazing that even though the skills of microsurgery now surpass the ability of the human eye, the human hand can still function at a microscopic level. While some people may already have excellent fine motor control, operating on this level is still something that can be learned. I’ve seen a remarkable improvement in my own skills from the repetition and practice of microsurgeries in the past three months of my fellowship.
What do you find most fulfilling about breast reconstruction?
Even though we may not be adding “quantity” to life by removing cancer, we are adding “quality” to life in the reconstruction. When someone goes through a breast cancer diagnosis and has had both of their breasts removed - they don’t feel like their normal self anymore. The ability to restore a sense of self, pride, and self-confidence in patients is the most rewarding part of breast reconstruction. We get to work with breast cancer patients and do everything we can in rebuilding their breasts to get them to a point where their cancer is just a memory.
If you are interested in submitting a guest contribution or wish to share announcements or opportunities, please complete the form at the link below.
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