You've heard of breast RECONSTRUCTION, but do you know about PRE-CONSTRUCTION?

Today I truly realized that my approach to breast surgery is quite different than the average surgeon in the Seattle & Bellevue metro areas. I have been told by numerous plastic surgeons, that my approach is unique and that my outcomes from a cosmetic standpoint are excellent. I had always assumed that these comments were a bit “inflated” and were the standard collegial niceties volleyed amongst surgeons. However, after being asked to explain my surgical approach numerous times, by physicians, surgeons, nurses, and operating room staff - I have finally come to the realization that I am truly offering women a unique approach to their breast cancer surgery. Whether my surgery is intended to cure a patient with breast cancer or to prevent breast cancer by risk reduction surgery (e.g. BRCA1 gene mutation carriers), I find that my approach and techniques often provide women with more choices and better outcomes.

One such example is PRE-CONSTRUCTION.

PRE-CONSTRUCTION is not a defined or standard breast surgery term, but it seems like the best word to describe the following scenario(s)…

Women who want to have a mastectomy (to treat breast cancer OR for risk reduction surgery) understandably hope that their cosmetic outcome will be good. For women with small to medium breast volume with little to no ptosis (medical jargon for what gravity + time does to our breasts!) nipple sparing mastectomy with reconstruction is a relatively simple solution. Most often these women wish to retain the same size and shape of their current breast(s). Because there are highly cohesive silicone breast implants (e.g. Gummy Bear Implants) available in their “size” these women are considered “excellent" candidates for this surgery.

Unfortunately, breast implants are NOT designed for reconstruction…they are designed for cosmetic breast augmentation. Therefore the size, volume, and shape of available breasts implants cannot address the needs of every mastectomy patient. This is when PRE-CONSTRUCTION is needed.

Some women have large to very large breasts and would like to be a smaller size. Some women with ptosis would like a breast form that places their nipple at a more desirable level. Some women need the volume and weight of their breast tissue lifted so that is correctly “sits” on their chest muscles; which will alleviate chronic neck/back/shoulder pain and posture strain.

What these women need is a breast lift or breast reduction (mastopexy and mammoplasty respectively). However performing a mastopexy/mammoplasty at the same time as the total nipple skin sparing mastectomy is NOT recommended. Once the underlying breast tissue is removed (i.e. mastectomy) the blood supply to the skin and nipple areolar complex of the breast is severely compromised. To then proceed with additional full thickness surgical incisions that divide and then suture back together the skin of the breast, to achieve the breast “reduction” or “lift” would result in eventual wound breakdown, wound infection, skin necrosis/skin loss, necrosis of the nipple/loss of the nipple, removal of the implant due to infection, and delayed reconstruction, interference with potential adjuvant breast cancer treatments…the list goes on and on. Most surgeons simply tell these women that nipple sparing mastectomy with reconstruction is NOT an option for them.

I do not agree with that. These women can become excellent candidates for nipple sparing mastectomy and reconstruction by first doing PRE-CONSTRUCTION.

For women who have a current diagnosis of breast cancer, I will perform a partial mastectomy (i.e. lumpectomy) and lymph node biopsy if indicated AND at the same time, perform a breast reduction or breast lift. The contralateral breast (i.e. other side) will also be lifted or reduced in size to achieve symmetry and balance. Once the wounds are sufficiently healed (~3 months later), we then go back to the OR and perform the total nipple skin sparing mastectomy with immediate reconstruction on the affected breast with or without a contralateral prophylactic mastectomy.

For women who need risk reduction surgery (i.e. prophylactic mastectomy) the lumpectomy and lymph node surgery is omitted but we still do the multi-step procedural approach; pre-construction, then mastectomy and reconstruction.

My approach is absolutely safe from a cancer treatment standpoint and is great for any women who needs/wants prophylactic mastectomy and reconstruction AND wants to have a smaller breast size.

Silicone breast implants are heavy, much heavier than natural breast tissue and therefore many women would like to be a “smaller” size to minimize the implant size/weight. Saline implants are not as heavy as silicone implants but saline implants are NOT a good option for reconstruction. This is because saline cannot hold its form and the implant will be very noticeable when used for reconstruction. Saline implants are great for cosmetic breast augmentation when women have a healthy layer of breast tissue and skin that will “drape over” the implant and thus make the implant undetectable.

Remember: Its Your Body, Its Your Choice

For more information about PRE-CONSTRUCTION or if you would like a consultation with Dr. Mikki Seagren, please click here.

FDA and Allergan issue recall of BIOCELL® textured breasts implants: What every woman needs to know.
 
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This week, emerging data prompted the FDA to notify Allergan, a global pharmaceutical company, about the link between their BIOCELL® textured breast implants and a rare type of lymphoma. France, Australia, and Canada previously made similar announcements. Although Allergan is NOT the only implant manufacturer offering textured breast implants, the incidence of Breast Implant Associated - Anaplastic Large Cell Lymphoma (BIA-ALCL) was more frequently associated with Allergan’s BIOCELL® textured breast implants. This has led Allergan to voluntarily issue a world-wide recall of their BIOCELL® textured breast implants and BIOCELL® textured tissue expanders. 


If you have an Allergan implant, it is important to know that the recall only affects certain styles. Here is a link to the specific styles that have been recalled. *Source: FDA 7/2019


THE FACTS

  1. Breast Implant Associated - Anaplastic Large Cell Lymphoma (BIA-ALCL) is NOT breast cancer. ALCL is a type of non-Hodgkin’s Lymphoma, which is a cancer of the immune system. The risk of BIA-ALCL is very low. Surgical removal of the implant and the capsule (scar tissue that naturally forms around the implant) is often curative. However, some patients may required chemotherapy and/or radiation therapy for treatment.

  2. There are no reported cases of ALCL associated with tissue expanders (temporary breast implants used for breast reconstruction). This is likely due to the fact that tissue expanders are removed within 3-6 months after placement.

  3. There are no confirmed cases of ALCL due to smooth implants (the surface of these implants are NOT textured). Reported cases had incomplete data, unknown implant type, or a history of textured implants.

  4. BIOCELL® is a proprietary implant shell surface created by Allergan. This shell surface is textured as opposed to smooth. Textured implants were designed to prevent future rotation and displacement of the implant, both of which can require re-operation to correct. Textured implants also facilitated the creation of “anatomic” breast implants. These implants are tear-dropped shaped as opposed to round and are intended to mimic the natural shape of the breast. Anatomic breast implants are more commonly used for breast reconstruction following mastectomy.

  5. Both saline and silicone breast implants were offered with the BIOCELL® textured shell. It’s important to know that Allergan manufactures numerous breast implants that are smooth and are therefore NOT included with this recall.

  6. Allergan is NOT the only manufacturer with a line of textured implants. Mentor and Sientra also offer textured implants, although the FDA has not issued a recall of these brands at this time.


WHAT NOW?

If you are considering implant based breast augmentation or breast reconstruction following mastectomy:

  • Allergan smooth implants and smooth tissue expanders are considered to be safe.

  • You might want to consider avoiding textured implants manufactured by other brands.

  • Make sure your surgeon talks with you about the implant type you will receive. You should be confident with your decision and well-informed throughout your surgical process.

If you currently have a tissue expander in place:

  • Try not to worry. Regardless of the type of expander (smooth vs textured) that was placed by your surgeon, all tissues expanders should be removed 3-6 months after placement. Because the expander is temporary, you can assume that your risk is pretty much ZERO. Also, remember that there are NO reports of ALCL associated with tissue expanders.

If you currently have a breast implant:

  • Take a look at the implant information card given to you by your surgeon. This will tell you the implant manufacturer, brand, and style.

  • If you don’t have this card or you’re unsure about the information, contact your surgeon.

 
Here is an example of an implant info card. The style here is SRF: Smooth Inspira Full projection. This implant was NOT recalled.

Here is an example of an implant info card. The style here is SRF: Smooth Inspira Full projection. This implant was NOT recalled.

 

If you currently have a BIOCELL® textured breast implant:

  • Contact your surgeon to discuss your options.

  • Mandatory removal has NOT been recommended because the risk of ALCL is very low.

  • If you have ANY concerns with your implant or breast tissue, you should immediately contact your physician and surgeon.

Possible signs and symptoms associated with BIA-ALCL:

  • Any sudden change in the implant or breast, especially late onset (years after surgery).

  • A new collection of fluid around the implant (i.e. Seroma).

  • Hardening adjacent to the implant.

  • Any mass associated with the implant or breast.

  • Skin changes, such as redness, irritation, thickening.

  • Capsular contraction (a change in the contour, shape, or placement of the implant).

  • A size increase of the breast/implant.

  • Persistent pain associated with the implant.

  • A lump in your armpit area.


To learn more please go the the FDA’s website and read the full press release. If you have any questions or concerns, please obtain a proper medical consultation with your physician and/or surgeon. The information provided here is not a substitute for medial treatment or consultation with a physician. This is intended to help educate the public and structure the conversations your should be having with your healthcare team.

NEW STUDY identifies women who do NOT need Tamoxifen
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A new study published in JAMA Oncology* by Dr. Laura Esserman (she is the Director of the Breast Cancer Program at UCSF; which just happens to be where I did my fellowship training in breast surgical oncology) identifies women who do NOT need Tamoxifen (or other similar medications referred to as Endocrine Therapy) after surgery for breast cancer. This study is a breakthrough as it now allows doctors to identify which patients may only need surgical treatment for their breast cancer. These women are referred to as UltraLow Risk and were identified by genomic profiling of their tumor. This test is called MammaPrint and I utilize it for all of my patients with hormone positive (ie. ER+) breast cancer. For women with ER+ breast cancer who are ALSO post-menopausal, lymph node negative and have tumors that are 3 cm or smaller; endocrine therapy may not provide a significant benefit, as their Breast Cancer Specific Survival after 20 years was 94% with surgery alone. For women in this group that DID take Tamoxifen, their BCSS at 20 years was 97% (not much better). This is great news for women who may be struggling with the side effects of Tamoxifen. Women who fall into this UltraLow Risk category, who are finding Tamoxifen difficult to tolerate, may safely discontinue treatment, while having the peace of mind that science “supports” their decision to forego endocrine therapy. For surgeons and oncologists, this study demonstrates how the 70-gene MammaPrint assay can identify UltraLow Risk patients who may only require surgery for breast cancer treatment.

Breast cancer treatment continues to evolve and improve. This is one of the reasons why I chose to become a breast cancer specialist. I believe each woman is unique, as is her circumstances, as well as the breast cancer itself. Doctors should continue to look for ways to personalize breast cancer treatment for their patients. Genomic profiling of the tumor itself- is the most technologically advanced and scientifically driven approach to breast cancer care and I am thankful that I get to practice medicine and surgery in a time where doctors and patients can benefit from these breakthroughs.

If you would like to review the study in more detail, I have provided a full text link to the publication below.

*Use of Molecular Tools to Identify Patients with Indolent Breast Cancers with UltraLow Risk over 2 Decades

Hereditary Breast Cancer Risk

Today, one of my dearest friends, Dr. Meghan Nadeau, was honored by the Puget Sound Business Journal as a 40 under 40 award recipient. She was selected for her dedication to caring for women with hereditary breast cancer. Exemplified by her contribution, as one of the co-founders, to Jane.

What is Jane?

Well as the other co-founder, I can fill you in on some of the details…After I completed my fellowship at UCSF, I began practicing in Seattle, WA as a breast surgical oncologist. I quickly noticed a very concerning pattern. I was caring for numerous young woman with breast cancer. Some in their early 20s. Often with advanced and aggressive forms of breast cancer. Sadly, this is not that uncommon. I cared for many young breast cancer patients in San Francisco. Although breast cancer is truly a disease that most commonly occurs in older women, it CAN affect women in their 20s and 30s, well before the typical age when women begin annual screening mammograms. So what was so concerning? Well…nearly EVERY young women I cared for had multiple “red flags” that should have been identified prior to her breast cancer diagnosis. I was counseling these young women about genetic risk, submitting a sample for genetic testing, and identifying a genetic mutation (such as BRCA1) after they had already been diagnosed with breast cancer. The healthcare system had failed these young women. If these “red flags” had been identified prior to their breast cancer diagnosis, perhaps these women could have made an informed choice about their healthcare. Specifically, about their breast health. I could not continue caring for these young breast cancer patients without doing something about this blindspot in the healthcare system.

Breast cancer remains the most common cancer diagnosed in women and as I have already mentioned, it is most commonly diagnosed in older women. That is why for years and years the recommendation for breast cancer screening was to begin annual screening mammograms at age 40. But what about the uncommon diagnosis of breast cancer in young women? Well, we (the collective medical community) are supposed to notice the occasional “red flag” in a young woman’s family history and then appropriately refer her for genetic testing. Seems reasonable.

I assumed (as I’m sure most of you do too) that young women with an increased risk of breast cancer are being appropriately screened and offered genetic testing when indicated. I trusted the “system” just like all of my young patients had.

The system is broken.

I could go on and on about all the various reasons the system isn’t working, suffice to say, trust me, it is broken. I have tried to fix it, but I assure you, it doesn’t want to be fixed. At least not anytime soon.

Jane is our solution to this problem.

Rather than fix a broken system we are abandoning the system. We are on a mission to put the knowledge and tools in the hands of those who stand to benefit the most, you! We want to empower every women to take control of her breast health. We want every woman to have access to understanding her own unique, personalized breast cancer risk. Every women should have the option to be tested for genetic risk.

This is just the beginning but our little start-up, Jane, has BIG plans!

To learn more, please check out our website. www.pastpreventfuture.org

Find out when YOU should start screening mammograms

Ladies...are you confused about breast cancer screening? Well, you are not alone. Many of your doctors are also confused.  This is due to the "disagreement" in screening recommendations amongst various organizations. Historically, women had yearly mammograms, starting at age 40. This was reasonable based on the knowledge we had at that time. We now know that a one-size-fits-all approach does not work. Wow, mind-blown, women are individual and unique [insert sarcasm]. Trouble is, the United States Preventative Services Task Force created a report that misled physicians to advise against annual mammograms for women in their forties. These recommendations have been rejected by the National Comprehensive Cancer Network, the American College of Radiology, and the American Congress of Obstetricians and Gynecologists, to name a few. The take home message is that screening recommendations should be personalized for each woman based on her risk. Physicians should utilize available risk assessment tools to discuss your risk of breast cancer and your options for screening. To learn more about your risk and to receive your personalized recommendation, you can schedule an appointment (in person or via telemedicine) with Dr. Seagren.