BREAST RECONSTRUCTION By DR. ERIC ARCILLA PLASTIC & RECONSTRUCTIVE SURGEON

MERYL GRAHAM-SCHLACHTERMAN (MGS):  This event hopes to empower everyone with significant information and experiences that deal with breast diseases. Today’s series of lectures will serve as an eye opener in fighting the long battle against breast cancer. I’m Meryl Graham, your moderator for this session. To share with us the great topic on breast reconstruction and other related matters including chemotherapy, radiotherapy and tumor recurrence is a well-known figure in the field of plastic and reconstructive surgery. He is a Medical Practitioner at the Asian Hospital and Medical Center, a diplomate of the Phil. Board of Plastic Surgery and a fellow of Philippines Association of Plastic Reconstructive and Aesthetic Surgeons. Ladies and Gentlemen… let’s give a round of applause to Dr. Eric E. Arcilla. 

DR. ERIC ARCILLA:  I would like to thank the organizers for invited me to speak this afternoon and actually even if they did not invite me I would have probably forced them to invite me for reasons you will find apparent sooner than later.

“I want to be whole again, a complete person”… “I want closure; to feel healthy again so I could move on.” “I feel like I’ve lost a friend, a very good friend.” What are these? Statements, phrases, words, but they mean a lot specially if you realized that they come from actual patients, who have undergone mastectomy. “My partner doesn’t understand; nobody understands.” And that’s the reason why I give this lecture as often as I can to as many people as I can… in my clinic, during my round with the residents, fellow-doctors, lay people like you. That’s why I give this lecture so that people or patients don’t have to say that nobody understands. I believed that we should all be able to understand a woman who has undergone a mastectomy and has lost one or maybe even two breasts and that is my personal crusade actually, that is why I have to have my self invited in as many of these occasions as I can in order for me to disseminate this information about breast reconstruction. 

To begin with what is Breast Reconstruction? In simple lay man term this is the simplest way I can put it: creation of a new breast mount that is aesthetically appealing and is, of course, as much as possible symmetrical to the opposite breast.  A very short statement but very loaded with information. 

First of all, aesthetically appealing. Of course it should look nice because you’ll see it everyday. The new breast, I mean. You’ll be seeing it everyday so it should look nice, it shouldn’t be ugly, you know… It should be something you would like to see every morning when you take a bath or look at yourself in the mirror. And symmetrical to the opposite breast of course, that’s also quite simple to understand but I think the most important phrase here is new breast mound. A new breast, a mound is not a real breast… it’s just a breast mound. This has a certain implications. 

Ok, first of all it’s just a breast mount it would not have the same sensation as a normal breast. You know what I’m talking about, that usual sensual feeling, touching, type of sensation that comes from the real breast that is not there & because it’s just a breast mound it will not be able to produce milk, of course. Most importantly because it’s just a breast mount and not a real breast, It will not produce new breast cancer, that is a myth. If will reconstruct your breast with this breast mount it will not grown your breast cancer, because it is not breast tissue, it is either an implant or tissue from somewhere else that comes somewhere else of  your body which I will elaborate more on later. 

Why do we do Breast Reconstruction? If you will notice this presentation is like an invitation. What, Why, Who, When, Where… I think I want to present it as an invitation, an invitation for everybody to understand breast reconstruction; an invitation for everybody to try find out what it is and to accept it for what it is. So, why do we do breast reconstruction, these are the usual reasons we will get when you do general articles, books, etc… etc… scientific stuff. It is the part of the holistic approach to breast cancer management, meaning right now it is an accepted fact that breast cancer management is not complete unless you do or at least you offer breast reconstruction. The patient is able maintain a positive body image, I’m saying that you don’t have a new breast you will not maintain a positive body image but this will help for you to maintain a positive body image. In a certain number of patients, it will help regain your self confidence or self worth much faster. Again, I’m not saying you will not regained yourself confidence or self worth without a new breast but most patients regained it faster and of course the will to survived and interact is enhanced. But this is the scientific reasons. Now these are the usual reasons I get in my clinic: “I want to wear a sando again (laughs).” “I want to go ballroom dancing.” My patient said “can you imagine twirling around with just weight in one breast and not on the other?” Socks, shoulder pads, scarf, moves. What are the socks and shoulder pads for? Well, some women stuff them in their bra. 

The prosthesis is too hot and itchy when you got during the summer day you want to enjoy yourself the maybe in the beach or wherever then you were a prosthesis, my patient tells me “It’s too hot, it’s too itchy, my bras don’t fit well anymore.” They tell me if you wear a bra and the other side, just you know… puffs around or moves, elevates or whatever and “I want to speak before an audience without worrying about my breast being out of position” (everybody laughs).This came from a bank executive. She had a mastectomy. She was speaking before large audience and after she spoke her friend approached her and said    “Did you know that your right breast was higher than the other breast?” (everybody laughs) Because she didn’t tell them that she had a mastectomy. (pointing to the visual presentation) I purposely left 2 blanks because I’m sure I’ll be hearing more reasons later on and probably even more. So these are the usual reasons why we do breast reconstruction. Who can undergo breast reconstruction? All patients. Of course all patients who have had a mastectomy regardless of the stage and age. The youngest done is 18 years old, so congenitally missing breast and the oldest is 78. As long as the patient is able and willing and that is important, able, meaning the patient is healthy enough to undergo the procedure and willing, meaning the patient really wants to have that breast reconstruction, she’s not being forced. You know, nobody’s pushing her to have it. But this ultimately of course will rely on the patient. What I want everybody to understand is, breast reconstruction is not for the husband ok…. Not for the husband or the spouse for the partner who says “but I still love you.. even if you have just one breast.” That’s not for the relative who says “hmmm…. Di mo na kailangan yan, pampaganda lang yun,” it’s not… it’s for the patient ok? And that is why ultimately the decision lies on the patient, even if the pressure is so great, which is usually the case in the Philippines, that’s why breast reconstruction is not yet well accepted. The pressure is so great for the patient not to undergo it, the patient suppresses her desire to have a breast reconstruction and that is I think is very unfortunate. 

Ok, when… ok so that’s what, why, who, when. When is breast reconstruction done? It can be done anytime. It can be done right after the mastectomy, during the same operation; it can be done 3 months later, 6 months, 1 year, 10 years later. It can still be done. But study that shows and from personal experience also, the best results can be achieved if it should be done immediately. 

Ok, now is the How, this is usually the technical stuff. When I present this to the MDs of course I have to be more elaborate. But for lay people, I’ll just go to the general techniques or options that we have when we do breast reconstruction. The first option we have is of course is with the use of breast implants, the same implants we use when we do breast augmentation. We can use breast reconstruction but for a certain number, a certain population of patients. We can use breast implants alone in expander or permanent. I will explain this later. Or we can use autogenous tissue, meaning your own tissue coming from your own body. Anywhere you go in the world, this is exactly the gold standard right now for breast reconstruction, using your own tissue to make the new breast mound. Ok, the Tram Flap, these are just the various options of tissues you can get from your own body. The Tram flap is the one you get from your belly, Lat Dorsi comes from your back, the TFL comes from your thighs, the Gluteal comes from your buttocks, etc… or we can even combine the 2 procedures, combining a Lat Dorsi with an implant etc… etc… So, I’ll just briefly go through each, so we’ll have an idea. 

Breast Implants first. The usual indication for expander reconstruction, expander implant, is when there’s a lack of skin when the patient is too thin, that she does not have enough tissue anywhere else in the body. When this happens, when the patient has mastectomy and she decides to wait for maybe 2, 3, 10 years, then her chest is already flat, her skin is tight so you can immediately put in normal breast implant. It just won’t fit, you have to expand the skin first, that’s why you use first an expander implant ok… So, this is how it’s done. I make incision in the skin put the expander implant under the skin and in the muscle and the patient goes back to me everywhere in my clinic and I’ll inject salt water in the implant and as the implant grows or expands it also expands the skin on the chest until we achieve the size that we want and then we take off the expander which is only temporary and put in a permanent breast implant.  

(Points to presentation) This is an example of a patient one that had a bilateral mastectomy, one for cancer and one for prophylaxis, meaning she just didn’t want to think about it anymore, so she’ll have her other breast removed also and then after 2 years she regretted it and wanted a reconstruction. This is her after the expansion. It’s very easy to obtain symmetry here because you do it at the same time. So I expanded the skin, first with the implant, expand the implant and after 6 months replace it with permanent breast implant or in some cases we can go ahead and do a permanent breast implant reconstruction right away. In this way the patient probably has DCIS or Stage I. The surgeon is able to save a lot of skin, so there’s still enough space to put in an implant immediately. Or some women, I’m sure you’ve heard, who’ve had silicon injections and develop problems later on. So the surgeon takes out just the breast, leaving the skin and the nipple so I can put a permanent breast implant right away. So again, indications for immediate breast implant, permanent breast implant, reconstruction, there’s adequate chest skin left and of course it is lack of tissue for flaps. So this is how it’s done. After the patient has undergone mastectomy and there’s enough skin and muscle left, I can immediately put the breast implant in and that would be the reconstruction.  

(Points to presentation)This is an example of a patient who had actually DCIS one side and silicon gel injection on the other actually, silicon gel injection on both. And then the surgeon took out the breast but left the nipple and the skin so I was able to put in immediate breast implant. The patient is happier because her breast looks better now. That’s the finish product on the left. Another patient same thing…this one she had silicon injection, which is very bad… so the surgeon took out breast tissue and left the breast skin and nipples. I was able to put in breast implants. But this is not usually the viable option for most breast cancer patients because most of the time the nipple has to go also. 

Autogenous flaps, meaning using tissue from your from your own body. The advantages: you don’t have to think about the breast implant. Of course that’s the first. It’s a more permanent reconstruction because it’s your own tissue; It grows with you, unlike the breast implant which, of course, because its man made; it has finite lifespan. By experience also, we gain better symmetry and better expected results when we use your own tissue. The disadvantages: it’s a longer procedure compared to one using just the breast implant; I heard cost, I think somebody said cost. Well, actually in the long run it may come out cheaper, actually, and of course, and the biggest disadvantage is, it has a steep learning curve. It’s not easy to teach this, somebody has to go to an extensive fellowship training program to learn it.

So the first one is the TRAM FLAP. This is actually the gold standard anywhere you go in the world. This is the preferred choice for breast reconstruction. The Tram Flap, as I said is the one that comes from the tummy. How was it started? How did somebody think of this very bright procedure? You’ve heard of tummy tuck, diba? Abdominoplasty so… some bright plastic surgeon, after doing a tummy tuck, he looked at the skin at the fat that he took out and said… “It’s such a waste, what can I do with this?” “Maybe in the future you can use it for breast reconstruction.” So that’s how he figured it out, so this is like a tummy tuck. You get a bonus tummy tuck, but instead of throwing away the skin and the fat that you take out, you use it to create a new breast mound. That’s the other reason why this is actually the most preferred technique because the scar you produce after doing this is the very same scar you get after the tummy tuck. So if a person was who is perfectly normal, who just wants a flat tummy, is willing to have this scar across her belly to beautify herself, why not for breast reconstruction? Why can’t you accept the same scar for breast reconstruction? 

(Points to presentation) So this is an example of a patient, a Filipino patient who underwent mastectomy after one year she’s not happy with her scar. If you can imagine, she can see also, she had enough tissue in her belly, from her belly that we can use to breast mound. This is her side view. This is the drawing of the thing that I’m going to take from her tummy and that I am going to transfer to her chest and this is her after. I said ang haba ng scar (laughs). Like I said, if she wanted the tummy tuck that’s the very same scar that she would have gotten.  A little longer than the (inaudible) CS scar, but that’s exactly the same scar that you get from a tummy tuck. Look, this is the final result. So, now she wants the breast implant on the other breast to make it look like the one that was newly created. 

Ok, just some more examples. (Points to presentation) This is a very young patient. 23 years old. I think 23 years old nurse. It would have been impossible to reconstruct her breast with an implant because it’s too big. There’s no implant that big, so we got from her tummy and she has become flat also and created a new breast on the right. You may be wondering, what’s that patch of skin there? That’s from the belly. That’s where we’ll make the nipple from later on. That’s why we always leave a piece of skin. 

(Points to presentation) Another patient, Filipina patient. Same thing, some more examples. As you can see, you have a very nice shape, very nice size. We intentionally make it bigger than the other side so when we do our revisions later, it’s easier to trim it down then if you make it small to begin with then you have to add something later on to match the other side. It’s better to have more now than less later, ok. Some more examples… Ok, now it can also, like I said, it can be done by patients who have had a mastectomy already. (Points to presentation) In this one, she had radiation already, and so it’s impossible to put breast implant on her and you can see the skin is burnt already, and this is her after the reconstruction. 

(Points to presentation) Same thing, patient already had radiotherapy and decided to have reconstruction later on. This patient decided that she wanted a breast implant because she doesn’t look nice. As I’ve said, symmetry is very hard to achieve if you use a breast implant because you can’t shape a breast implant, it has its inert shape. So finally she said she’s not happy, she wants a new breast using her own tissue. Again, you get it from the tummy. (Points to presentation) This is the breast implant after removal and this is her new breast. So, I just show this to show you that autogenous flaps are easier to manage and easier to shape.  

For bilateral cases: we just did two in PGH recently so we can even make two breasts by splitting the tummy in the middle. So, this is very important for women who decide to undergo prophylactic mastectomy. By Prophylactic mastectomy I mean, you know, that actually after you get breast cancer one side, the risk you get on the other side is a little bit higher than the ordinary normal population. So some women, after mastectomy on one side they decide to just take out the other breast also. That’s what we call prophylactic mastectomy. So you can make 2 breasts coming from the tummy. 

The LAT DORSY. This is another option in which the patient doesn’t have enough tissue from the tummy so we have to look somewhere else. The lat dorsy is the next choice, it comes from the back. (Points to presentation)This is just a diagram showing how it’s done. You take the skin and fat from the back and swing it in front. This is a patient who had breast conservation surgery. I’m sure you’ve all heard of that also. You just do a lumpectomy, so you preserve the breast, but in her case, look what happened, after a year her breast looks even uglier so of course she’s not happy. So, she decided to have a breast reconstruction. In her case because I didn’t need that much tissue, I just got it from the back and made a new breast, which is at the left. So before is on your left and the after is on the right. 

TFL, like I said, is the one that comes from the thigh. Usually it is used when again we don’t have enough tissue form the tummy and also from the back, we can use the one from the thigh or what women called the saddle bags, but the problem with this is the scar is not very nice and the fat from the thighs is very firm. So, it’s not easy to shape it. So the usual results are not that good as compared to the one that comes from the belly. So, this is the drawing (pointing to the visual presentation)… this is the patients thigh and that is the drawing of the skin and the fat that I will be taking and that’s the shape. See, the shape is not so good. Again I said the fat from the thing is not that soft so it’s not easy to work with.  

The Gluteal: you can get from your butt if you don’t have enough in your thigh or your tummy. (Points to visual presentation) This is again the drawing. This is a drawing of the patients’ buttocks where I’ll be getting the skin and fat from, and this is the breast. In some cases we have no choice but to get from the back, and then if the breast is too large and it’s hard to achieve symmetry with just fat from the back we might have to combine an implant with a flap from the back or with the tissue from the back, which is what I did in this case. This patient didn’t want her tummy touched. She said she still wanted to get pregnant, so she decided to get tissue from the back, but it wasn’t big enough, so I had add and implant. This is her after reconstruction. You will see from side view it’s not so bad, this is her real breast and that is her reconstructed breast. The shape and the size are more or less the same but you can see the scar at the back is not very nice. That’s why this is not a first option. Usually the patient will not be able to wear a backless dress or a sando after this. I’m just showing here how many we have done in PGH over the past 2 years since I came back. There have been complications, of course, but very minimal and more or less the patients have all been happy. 

Of course, after we do the first stage procedure, that’s not it we have to do minor revisions, like a tailor - he does the first cut then you fit it and then you say it’s too long or it’s too short or whatever, it’s too loose of course you have to do revisions. Also, and the most common one, is doing a nipple and areola. Of course, after the breast mound, you’ll do areola also… or do you? I would say not because 95% of my patients, they don’t have their nipples done anymore. They’re happy enough just to have that mound. So again, they can go ballroom dancing, they can wear a sando, they can wear a bra after that wala na… naglaho na parang bula. I’m happy na! I don’t like that nipple But 5% kahit 10% do come back and they said I want a nipple, so this is what I do. (Points to presentation)From the excess skin I got from wherever and I left it on the breast and I can shape a nipple out of it. So this is how it’s done and then the areola, ok, the dark circle around the nipple, you can either tattoo it or do what we call the skin graft. You get darker skin from the armpit or from the groin, so it’s darker or if the areola normal side is big enough we can also get from there, so this is showing me doing the tattooing. Ok...this is the final product. This one is bilateral and I show bilateral most of the time because they show better symmetry of course. If they do breast reconstruction at the same time then you’ll get better symmetry. So the areola here was skin grafted. I got the skin from the groin. This one was tattooed. This is probably the best I’ve ever done but again I say it’s easier to achieve symmetry when it’s done bilateral because you can shape the breast at the same time. Ok, this one the areola was tattooed on ok. 

I give this lecture to lay people patients and even doctors and this are the questions that I usually get from fellow doctors. This is what usually keeps them from offering the procedures to their patients and maybe this is also one of the reasons why patients tend to shy away from breast reconstruction, tthese two very controversial questions that I’ll be answering ok. The first: Does reconstruction delay chemo or radiotherapy? Suppose you need chemotherapy or radiotherapy then you decide na I’ll have a breast reconstruction, but wait baka ma-delayed yung chemotherapy ko and I will be endangering my life diba? So what do you think the answer to this is? 

AUDIENCE : No….

. 

(EA): No, of course not or else we wouldn’t be doing it. First and foremost, in medicine, our dictum is first, do no harm. If you think you will be doing harm, don’t do it, so of course, if I do the breast reconstruction and delayed the chemotherapy or radiotherapy, I won’t do it, but the fact is, it won’t delay chemo or radiotherapy.  Why? Doctors know for a fact that when you give chemotherapy, you will also delay the patients wound healing, so what they do is, after the mastectomy, wait usually 3 to 6 weeks before you start chemotherapy This is the same thing, the same wound that you would have after a mastectomy and the surgeon closes, it is the very same wound you would have if you undergo breast reconstruction. A wound is a wound, from one person to the other. The average time for a wound healing is 3 to 6 weeks, so whether you undergo breast reconstruction or not your wound should heal 6 weeks. If you’re normal, it should heal in 6 weeks, weather you just have mastectomy or mastectomy with breast reconstruction. The simple answer for me is no… it will not delay your chemotherapy or radiotherapy.  

Questions that everybody wants to ask but dare not ask… The big R… Recurrence. Will it prevent detection of local recurrence? First of all, as I’ve said at the start of the lecture, this is just the first mound so it will not produce its own breast cancer. So the danger now is, will it prevent detection of a recurrence, God forbid a recurrence does occur, will it? 

AUDIENCE : No….. 

DR. ARCCILLA: No… Of course not, or else, again, I would not be doing it if it will prevent detection of local recurrence. So I got this study from M.D. Anderson. They published this in 2003 and actually we’re now calling it a Landmark Study because all along we have been saying “No, it will not prevent detection, no it will not…” But when you ask us do you have  studies to prove it we’re ahhh  ehhh ganon.…  But then the finally came out with this, M.D. Anderson, probably the biggest center in the States with the most number of breast reconstruction every year ok... And so, they did this study.. they compared women who had breast reconstruction and those who did not. They followed them up. They tried to see who of this women developed recurrence, then they just figured, ok, how long did it take before we detected recurrence in women with breast reconstruction and how long did it take before we detected the recurrence of patients who had breast reconstruction? The difference in time was 1 to 2 months, so whether you have breast reconstruction or not the time difference between detection of the recurrent was between 1 and 2 months which is not significant in terms of progression of the disease. So, of course the conclusion was it will not prevent detection of local recurrence or it will not delay detection of local recurrent and I’m sure your surgeon will also tell you, if you ask your surgeon after mastectomy where will it usually recur? God forbid, it will recur the most common recurrence site is the mastectomy skin, the skin that was left behind, the breast skin that, of course, the surgeon has to leave behind or else he won’t be able to close the wound. He or she won’t be able to close the wound. That is the most usual site of recurrence. So if that’s the case and you will notice after you do reconstruction, all the reconstruction you do is under the breast skin. So, God forbid, a recurrence will occur under the breast skin, it will be on top of breast mound so it’s not hard to detect a recurrence, if it will occur. So again immediate breast reconstruction will not conceal recurrence, nor not influence the oncologic outcome. 

You are familiar, I hope, with St. Agatha, Patron Saint of Nurses, breast diseases, breast cancer patients. Legend has it that both her breast were cut off when she did not give in to the advances of a local lord, I think in England, or was it France? So the lord had her breasts cut off and she died because of her wounds. Had she survived, she would have had no breasts for the rest of her life; she would have been condemned to a life with no breast diba? Fortunately, for women nowadays, that should not be the case because breast reconstruction is available, so we shouldn’t have to suffer the same fate that St. Agatha would have faced if she had survived.  

Thank you…. 

MODERATOR: Personally, my mother’s sister is a 40 year cancer survivor and a year after she had her mastectomy 1962, she had breast reconstruction and she’s 82 years old and still dancing and still swimming. So that a personal thing.  

DR. ARCCILLA: Let me add to that, that was 1962, it is now 2005… that was 40 years ago, that how long it’s been around and unfortunately in the Philippines, when did we start hearing about this? 

MODERATOR: What is amazing is that her body looked like map of the world She got cut here, she got cut here, and then she had a gall bladder operation, but she was great in clothes. Still does.  Any other question?  

(QUESTION 1): You know, I’m sure everybody would want to know a little bit more about the cost? They’re just jahe to ask. Much as we like to have what I had, you have to talk about costs. 

DR. ARCILLA:  The first time I gave this lecture, somebody asked that question. I answered it, I regretted it. This is my dictum I don’t know if this is good for business or not but I said I’m on my personal crusade. My first rule, first of all is the breast reconstruction procedure will not be denied to a woman because of financial constraints. That’s my rule… financial concerns will not be a reason that I will deny a woman a breast reconstruction. I’m saying this now, maybe ten years from now, di na? (laughs) medyo mas kilala na. That’s why to rule right now and to prove the fact, I’ve done more charity in PGH and I’ve done in my private practices over the past 2 years, since I came back. PGH is an experience…around 50 plus peopleand they were all charity… No Charge! I do it in Makati, Manila Doctors, cheaper! I do it in Makati Med or Asian of course it’s a little bit more expensive but I know for free if you want it then you can stand the wards of PGH, I’ll do it for free! (all laughs) Honestly, I’m sure there are more Class C… Class D patients with breast reconstruction walking around now in Manila than there are Class A and Class B because this 51, those are just mine. I’ve already taught my residents how to do it and they have done a number also. They do it for charity. And so my dictum, as I said, financial concerns will not be the reason that I will deny a woman a breast reconstruction and corollary to that if I do it for free I’d do it for P1.00  (all laughs) Honestly, wag mo nang… don’t spread it around for… ah he’ll do it for P1.00 (all laugh and claps) noh… No but see, I get nga tindera, employees from SM, they come to me… they tell me in my private clinic. They tell me… Doc, ito lang yung kaya ko! Sabi ko… gawin na lang Charity kung kaya nyo na lang tiisin and ward sa PGH, gawin na lang natin dun libre or sa Manila Doctor’s is a little bit more expensive. We offer PGH if they really want private rooms, we do it in PGH for a cheaper price… may private din naman dyan. I don’t want to give cost because you know… it’s not that I don’t feel comfortable na something that should be packaged. 

QUESTION 2: I have a question? 

DR. ARCILLA:  Yes 

QUESTION 3: When you do a reconstruction with the implant, let’s say you do it to a forty year old and her remaining breast is still firm as she goes through her menopause and everything, her natural breasts starts to loose its skin tone and everything. So, what happens? You have an imbalance there. Will the same thing happen? 

DR. ARCILLA:  Well… let us put it this way. Whether with an implant or, you know, with an autogenous tissue, that new breast will be like a 1 year old or 1 day old. The other one, the other one has had like 30 years to 40 years to age eventually it will probably needs a Mastopexy, a breast lift. When that happens we can do a breast lift on one side but usually if the patient has the cancer today and of course you have to monitor the other breast, I usually suggest that we do not touch that breast for 5 years before we decide to our aesthetic procedure on that normal breast, just so it’s easier for the general surgeon and the patient to follow up her breast, make sure it doesn’t develop anything that has to be taken out. But definitely we could do a procedure on the other breast also.  

QUESTION 4:  Can we do a Tram Flap twice or just once? 

DR. ARCILLA:  No, unfortunately we can only do it once. 

QUESTION 4:  Because I was thinking if you have first one breast with the cancer … then you can used it only for the one breast? 

DR. ARCILLA: Yes, and then you will have to look to the other options later on if, God forbid, you developed another breast cancer. That’s why some patients especially when I was still in the states when we offer this we actually tell them that we can only use this once. There is such a thing as a prophylactic mastectomy. If you want just take both out. Its still controversial but some centers from the states actually doing it routinely already, prophylactic mastectomies, and that’s one of the reasons why because you can only use that tummy once.  

So, since your doing that already anyway, why not do it at the same time especially the patient already in menopause, she doesn’t really need to produce milk anymore, etc… etc… 

QUESTION 5:  Regarding the recurrence, you mentioned that usually the recurrence will only happens in the skin that’s left after the surgery. The recurrence does not happen on the tissue on anything that’s left. 

DR. ARCILLA: That’s good question. Actually, that study was more elaborate ok… I just didn’t delve into it. Of course, it can recur in the muscle on the chest skin underneath, ok… and yes it can happen. How often is this happen, like 5% of the time. And as that study says, I just did not go into it, once you get recurrence on the chest wall and it becomes apparent externally, by that time 95% of a time you already have metastasis to the bone, to the liver, elsewhere. So, it wouldn’t make a difference anyway. 

Actually, that was the one to two month’ difference from time of recurrence. They looked at the time of recurrence in patients who had no breast reconstruction and had chest wall recurrence underneath and those with breast reconstruction and had chest wall recurrence, and the time difference was just one to two months, and so whether you had that breast reconstruction or not, if it recurred on chest wall it would not have a difference anyway. The time delay would have been one month and by that time you would have had metastasis already, 95% of the time. Of course, you will say, what about the 5%? Well, see, medicine is not the exact science… you will have these one or two cases that unfortunate that you cannot avoid. 

QUESTION 6:  With a recurrence, the patient cannot be tested anymore using a mammogram, especially if the implant is made of silicon. How do you…. 

DR. ARCILLA: Ok, after you do a mastectomy there is nothing to do mammogram on anymore. If the surgeon did his job there will be no breast tissue left. You don’t do mammogram of the remaining chest wall muscle; you don’t do mammogram on that. All you have to do is monitor the skin. That’s why I said, most recurrences occur on the skin because that is the only thing that is left after a mastectomy. That is part of the breast, the skin. And of course, like I said, the surgeon couldn’t take off the entire breast skin or else he might be able to close the wound. Whether you have the reconstruction or not, he has to leave the breast skin and that’s why the monitoring you have after the mastectomy, you just look at the skin and the scar. You do mammogram on the other breast that is part of the breast, the skin. And of course, like I said, the surgeon cannot take out the entire breast skin or else he might be able to close the wound. Whether you have the reconstruction or not, so he has to leave the breast skin and that’s why the monitoring you have after the mastectomy, you just look at the skin and the scar. You do mammogram on the other breast but not on this breast. So, whether you have a new mound there for breast implant or autogenous tissue, you don’t have to do mammogram on those. 

QUESTION 6: One last question, if you get the reconstruction right after the surgery, that means that surgeon will have to leave more skin, to accommodate the reconstruction, is that right? 

DR. ARCILLA: On the contrary, because the surgeon has the luxury of taking out more skin than he had to in the first place, because he doesn’t have to worry about closing it anymore. I will close it for him using the skin from the belly. Of course, you’ll have a bigger patch of skin from the belly here, but now he has the luxury of taking out more. iIt’s a balance… 

QUESTION 6:  It happens after immediately, reconstruction? 

DR. ARCILLA: Yes, same operation… 

QUESTION 6:  Simultaneously after mastectomy….you can reconstruction immediately? 

DR. ARCILLA: Yes… Yes… one after the other… yes… so actually, on the contrary the surgeon has the luxury of taking out more skin if he wanted to, okay. As I was saying, actually it’s s balance between reconstruction and aesthetics, if the surgeon feels that he can comfortably take out all the tumor and leave as much skin as he can, that’s better for aesthetics. You get the better result with the aesthetics actually. 

QUESTION 7:  Once you decided to have the operation weather you have it simultaneously or not… let’s talk about after… how long it takes to heal and everything they have to go through after that. 

DR. ARCILLA: The main advantage of breast implant reconstruction of course is the recovery period. The recovery period is faster. Like I said the wound should heal in 6 weeks, but the recovery is faster because you don’t have any additional scars. You don’t have any additional wounds that you have to worry about. So, usually the patient is up and about in one week or even less and then back to normal activity in 3 or 4 weeks, with lifting etc… etc… because it just a breast implant.  

Now, if you get tissue from the belly is going to be like a Caesarean. It’s a major surgery. The patient usually goes for 4 to 5 days. And that’s the average 4 to 5 days, but the level of activity is decreased for like 3 or 4 weeks and then you don’t go back to really normal exercising until the 6th week. But definitely, if you’re a working woman it can go back to work in like 2 weeks, it depends also in your tolerance for pain. Usually by the 6th week you’re back to normal activity, exercising, dancing, etc… etc… But before that you decrease your level of activity. Like I said, you can’t actually go back to work as early as 3 weeks. 

QUESTION 8:  You are saying something about the expander… 

DR. ARCILLA: Yes… 

(QUESTION 8:  Like for me I’m already 3 years… do I need already the expander? 

DR. ARCILLA: Most likely… if you don’t’ want from your body, most likely you need an expander. 
 

QUESTION 8:  But there will be tubes sticking out? 

DR. ARCILLA: No… No… there’s no tube sticking out. There’s like an implant. There’s a very small tube that is also buried under the skin and then there’s a port where I can inject every week, but that also under the skin. I just feel for it and inject it every week. 

QUESTION 8:  So in the love making, it will never be a hamper?  

DR. ARCILLA: No it will not 

QUESTION 8: You will not feel the tube? 

DR. ARCILLA: No… no… actually I have a hard time feeling around for that port actually, even if I know where it is and I mark it… it’s still to difficult to feel. Well it depends also how good your husband is with his hands. (audience laughs) Even I cant, I have a hard time feeling for it. 

(QUESTION 9:  When I was operated 16 years ago in the hospital, I inquired about breast reconstruction, and the doctor discouraged me from going through it. So today while looking at the slides you presented I had goose pimples so that means I’m not a good candidate for that anymore. 

DR. ARCILLA: Why not? 

QUESTION 9:  Takot ako. Pag nakita ko yung mga stitches. 

SURVIVOR FROM AUDIENCE:   But you don’t feel that. Tulog ka. 

QUESTION 9:  My husband has been telling me it’s just not needed, but it’s for my own…. 

DR. ARCILLA: Yes of course. That’s the main point. That’s why it’s been around for 30 years and it’s not known yet here, because of this social, this cultural way of thinking… 

QUESTION 10:  I was thinking of an alternative for that. For us who are afraid to go through the breast reconstruction, can people like you, who have so many patients with no breast, can you probably suggest to manufacturers of bras to produce special bra for people like us here. 

DR. ARCILLA: Actually that’s bad for business (laughs). You would have to ask somebody else regarding that. Maybe it’s possible. I’m just kidding about that business thing. Well if you can get away without an operation, why not. Like I said, this is not for everybody naman. It’s not for everybody. You just have to weigh your needs and your lifestyle, how much you really need it or want it.  

MODERATOR: I thought I might mention also that those pictures look kind of gruesome because they were fresh, they were new operations also. Look at the scar of your mastectomy… it’s probably gone by now… in a couple years, unless you are very keloid, it won’t look that awful. Anybody else? 

SURVIVOR FROM AUDIENCE: Actually this is not a question. I just wanted to address all of them. I am a patient of Eric Arcilla and whatever you saw there, I went through. The whole nine yards. The mastectomy, the reconstruction, the chemotherapy, the radiation, and the Tamoxifen now. So, on his behalf, I have to say that if you have any questions ask it now because that’s what I did in the end. Ultimately, my husband matters a lot to me but in the end he looked at me and he said, it’s what you want. I don’t matter at this point, it’s what you want. Then at the same time Doctora Cua, who was my surgeon, told me you ask yourself years from now after you have taken out your breast, when all the dust settles, will you be happy with just one breast? So these were all the questions and when I spoke with Eric he really made me see that it was important to have another one. For me personally. This I did for me. And to this day I will never regret what I did. My only fear was the operation was 8 ½ hours from the time they took out the breast to the reconstruction. And whatever you see there, it looks much better than that. Trust me. He does a good job and if you, questions ask it now. Don’t be embarrassed; ask it now whatever questions you have. He has all the time in the world to answer your questions.  

DR. ARCILLA:   I could have shown them your pictures kaya lang… 

SURVIVOR FROM AUDIENCE: No I didn’t allow it. He asks you, you know, but I didn’t allow. I am not any of those there. (laughing) So it wasn’t a question, it was more an encouragement to let you know it works. It does work. It’s too sad that the procedure is only recent here. How long have you been doing this procedure in the states? 

DR. ARCILLA: Since 1998. No I mean it’s been there since 1960, 1970.  

QUESTION 11: This has nothing to do with breast cancer patients. But being a plastic surgeon, if someone has a lumpectomy done, would you advice that the fat and muscle taken out of there be used to sort of enhance the breast? 

DR. ARCILLA: No, this is, I feel and I think, the plastic surgeon community would also say that this procedure, the one from the belly, is reserved for breast reconstruction. You wouldn’t want a patient to undergo this extensive procedure just to beautify their breast. That why there are breast implants. That’s a totally different story but I assure you breast implants are safe. Just one more point about breast implant, I assure you you’ve all heard breast implants can cause breast cancer. I’m sure, you hear that practically everyday. And that’s it’s banned in the states. This is the final statement on that. How crazy is this… You can use breast implants in the states. And one of those is for breast reconstruction after mastectomy.  How crazy is that. If it causes breast cancer, why would they allow it to be used for breast reconstruction?  

MODERATOR: I have a question about that though. I think many of the cases were not necessarily breast cancer. But what about leaks in the silicone and then you have a case of your body getting toxic. 

DR. ARCILLA: Like I said, its man made, so it has a finite lifetime. Manufacturers would say 15 to 17 years before you have to change it. I’ve had patients who have had theirs for 30 years and no problem.  

MODERATOR: I think were out of time for the questions but I guess that as survivors were all quite happy that now we have options available to us, to make choices for us to move forward to weather or not to go through with reconstruction . Thank you very much, Doctor Arcilla.  

DR. ARCILLA: Thank you for inviting me.