breast reconstruction and surgical …breast reconstruction and surgical advocacy mitchell brown md...
TRANSCRIPT
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BREAST
RECONSTRUCTION AND
SURGICAL ADVOCACYMitchell Brown MD MEd FRCSC
Plastic and Reconstructive Surgeon
Associate Professor, Department of Surgery
University of Toronto
Toronto, Canada
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Thank you
to ASPSN
No Disclosures
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Advocacy is a political
process by an individual
or group which aims to
influence decisions
within political,
economic, and social
systems and institutions.
Health advocacy supports and
promotes patient's health care rights
as well as enhance community health
and policy initiatives that focus on the
availability, safety and quality of care.
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Based on the seven roles that
all physicians need to have, to
be better doctors: Medical
Expert, Communicator,
Collaborator, Manager, Health
Advocate, Scholar, and
Professional.
The CanMEDS Framework 2011
Describe knowledge, skills
and abilities that specialist
physicians need for better
patient outcomes
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As Health Advocates, physicians
responsibly use their expertise and
influence to advance the health
and well-being of individual
patients, communities, and
populations.
Respond to individual patient
health needs
Respond to health needs of the
community
Identify population based
determinants of health
Promote health of individuals and
communities
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Dr James Namnoum
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Pink Ribbon Story Foundation
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1 in 9 women will be diagnosed with breast cancer
Over 20,000 mastectomies were performed in
Canada annually
Post mastectomy breast reconstruction can improve
quality of life, assist in the recovery from breast
cancer, improve self confidence, help women restore
their body image and self esteem
Breast reconstruction is an OPTION and is not for
everyone
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Evolution of Reconstructionvolume
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Delayed Unilateral SP TRAM
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Free TRAM Flap
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Lat Dorsi with Round Gel Implant
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Two Stage Implant Reconstruction
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Shaped Implant and Nipple
Reconstruction
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Unilateral SSM, Single Stage
• 45 yo
• L Invasive CA
• Breast asymmetry with L
breast lower than R
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Surgical Plan
• Limited ellipse incision
• Oblique lift
• 115-401
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Bilateral NSM, Single Stage
• 34 yo
• BRCA1
• Bilat NSM
• PA and Lateral incision
• MF420
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BREAST
RECONSTRUCTION 101A crash course on Post Mastectomy Breast
Reconstruction
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GOALS
• Restore symmetry
• Ease of daily life
• Clothing styles
• No prosthesis
• Restore confidence
• Self image
• Sexuality
• Improve QOL
Rosalind Maingot 1935
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Timing of Reconstruction
• Immediate
• At same time as
mastectomy
• Ready to make a
decision
• Early stage or
prophylactic
• Unlikely to need
adjuvant therapy
• Delayed
• Any time after
mastectomy
• All options available
• Can obtain excellent
results
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Reconstruction Options
• Autologous
• Using your own tissue
• Abdomen
• TRAM flap
• DIEP flap
• Back
• Latissimus flap
• Buttock
• SGAP flap
• Alloplastic
• Using implants
• Two stage with use of a
tissue expander
• Single stage direct to
implant
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Why an Increase in Implant
Reconstruction?
Better devices
Internal support matrices
Morbidity of autologous
reconstruction
Changing demographics
younger patients
earlier diagnosis
more prophylactic
more bilateral
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TRAM and DIEP
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1995
• TRAM Patient
• ICU 24 hrs
• Epidural
• Foley
• 3-5 day admission
• PCA pump
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PROCESSES OF CARE IN
AUTOGENOUS BREAST
RECONSTRUCTION WITH PEDICLED
TRAM FLAPS:EXPEDITING POSTOPERATIVE DISCHARGE IN AN
AMBULATORY SETTING
Kristen Davidge, MD MSc
Mitchell Brown, MD MEd FRCSC
John Semple, MD MSc FRCSC
Pam Morgan, MD FRCPC
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Background
• Womens College
Hospital
• Transition from in
patient to ambulatory
facility
• Requirement to refine
the care of the TRAM
flap patient
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Develop a protocol towards less than 24 hour stay
following autogenous breast reconstruction
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Protocol
• Preadmission patient education
• Standardized peri operative protocol
• Multimodal analgesia
• Anti emetics
• Thromboprophylaxis
• Antibiotics
• Defined surgical protocol
• Post discharge phone follow up and information access
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Mean discharge time = 38.7 ± 27.6 hours (range
18-189)
Discharge <24h = 36
(40%)
5/35
(14%)
7/19
(37%)
24/29 (83%)
*Polychoric corr =
0.76
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Latissimus Flap
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Lat Dorsi with Textured Round Gel
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Implant Reconstruction
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Options
Traditional Two Stage Direct to Implant
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Patients and surgeons would
clearly prefer a single stage
approach to breast
reconstruction
BUT NOT
at the expense of inferior
outcomes or unnecessary
risks
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Creates a Balance
Direct to
Implant
Planned Two
Stage
More difficult
Less predictable
Limited indications
One shot only
Size limitations
Fewer procedures
Fewer recoveries
More rapid return to
“life”
Get two chances
Less risk of skin or nipple
compromise
Broader indications
Delays final outcome
Expansion period
More surgery
More recovery
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SSM, Direct to Implant
• 37 yo, L Breast CA,
BRCA1
• B Cup, no ptosis
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Surgical Plan
• SSM
• Direct to Implant
• MF295
• Alloderm
• 6x16
• thick
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Alloderm
• Acellular Dermal
Matrix
• Skin substitute
• Human cadaver
• Porcine
• SSM
• NSM
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Nipple Areola Reconstruction
• At final stage
• Variety of options
• Areola
• Tattoo
• Skin graft
• Nipple
• Local flap
• Graft
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Nipple Share and Tattoo
feet head
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Nipple Reconstruction – Areola Tattoo and
Nipple Graft
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Labial Graft and Tattoo
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C-V Flap and Tattoo
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In terms of artistry, beauty is in the eye of the
beholder and there are many artists to choose from.
Artist’s work can be printed from the internet and
held up against the breast for comparison.
Copyright - Cosmetic
Transformations
3 Dimensional Tattoo
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Nipple Sparing Mastectomy
• BRCA1
• SN-N 21R, 22L
• N-IMF 6.0 R, 7.0 L
• Bilat NSM
• IMF approach
• ADM
• Shaped gel implant
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Bilat NSM, DTI, MF335, 3 Month
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In Canada, less than 15% of
women who undergo
mastectomy receive
reconstructive breast surgery
Barriers to Access
Lack of Awareness
Failure to Adequately Educate
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Breast Reconstruction Awareness Day
BRA Day
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Breast Reconstruction Awareness Day
• Began in Canada 2011
• International launch
2012
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Breast Reconstruction Awareness Day
Third Wednesday of October – Wed Oct 21, 2015
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MISSION
Develop and advance an
internationally
recognized annual day
that promotes
awareness and access
to reconstructive breast
surgery
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VISION
Prior to undergoing breast
cancer therapy, all women
will be offered information
about the options for
reconstructive breast surgery
and be provided access to
breast reconstruction in a
safe and timely manner
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Values
Reconstructive breast surgery has a positive effect
on quality of life for women requiring breast
reconstruction
All women who are candidates for breast
reconstruction should be made aware of the
options available to them
All women who are candidates for breast
reconstruction should be offered treatment in a
safe and timely manner
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EDUCATION
ACCESS
AWARENESS
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Education and Awareness
• Patients and their families
• Plastic Surgeons
• Surgeons, Oncologists, Primary Care Physicians
• Allied Health Personnel
• Support Groups and Organizations
• Media
• Government and Health Policy
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Within the past two years, the states of New
York and Ohio have made it law that ALL
WOMEN who are diagnosed with breast
cancer or undergo a mastectomy MUST be
offered information about their options for
breast reconstruction
More states to follow
Breast Cancer Patient Education Act
Federal Law 2013
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Access
• Skilled reconstructive surgeons in all communities across
Canada
• Multidisciplinary teams to support the reconstructive
process
• Insure continued medical coverage for breast
reconstruction
• Resources to support the reconstructive need
• Operating facilities, flexibility for coordinated surgical care, budgets
for devices
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Utilize BRA Day to
deliver
KEY MESSAGES
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Key Messages
• Statistics• Incidence of breast cancer
• Incidence of mastectomy
• Incidence of breast reconstruction• Geographical differences
• Rural vs Urban
• Academic vs Community
• Changing demographics dictate greater need and understanding of reconstruction options• Younger, BRCA, Prophylactic
• Bilateral
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Utilization
• Published rates of population based post mastectomy
breast reconstruction
• US - 12.5-16%
• Ontario - 7.9%
• Nova Scotia - 3.8%
• Recent trends show steady increase
• Shift from Delayed BR to Immediate BR
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Barriers to Breast Reconstruction
• Patient awareness
• “Referral” awareness• Oncologists, surgeons, primary care physicians
• Reconstruction resources• Plastic surgeons (number and training)
• OR facilities
• Budgets for devices, ADM
• Ability to collaborate in complex health environment• Coordination of immediate BR
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Key Messages
• Breast Reconstruction is Evolving
• Changing technology• Microsurgery
• ADM
• Perioperative management resulting in shorter stays and rapid recovery
• Implants and expanders
• Fat grafting, stem cells, tissue engineering
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Bring LIFE through
BRANDING AND MARKETING
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BRA Day Logo
Utilizes concept of pink ribbon. Double meaning of inner
loop: 1. Infinity sign 2. Closing the loop on breast cancer
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BRA Day Poster
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BRA DAY
CANADA
PAGE
BRA Day Canada
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BRA DAY
CANADA
PAGE
16.5K Reached
with Twitter
@BRAwareness
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BRA DAY
CANADA
WEBSITE
1,568 online registrants
13,712 visits to website
1,785 Unique Views
on OCT 15, 2014
4,261 Page Views
on OCT 15, 2014
www.bra-day.com
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I attend
BRA Day
because…
“I was recently diagnosed
with the BRCA2 gene
mutation and am hoping
to increase my
knowledge of breast
reconstruction options
and to connect with
women who have been
through it and can show
me their results and
share their experiences.”
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Willow’s Show and Tell Lounge
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I Volunteer
because…
It is my great pleasure to
be on this side of the
breast cancer chapter and
to reach back and help
other women who are at
the early stages of the
journey. My hope for
every woman there last
night is that they all find
themselves in a position,
one day, to reach back
and help another woman
find courage and
acceptance and
wholeness.
Shelley
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BRA Day
helped me
because…Tonight offered me
information in a concrete
way that helped me
understand the
reconstruction process from
beginning to end.
I found the most powerful
and inspirational part of the
night to be the lounge at the
end. To meet and see
people who have been in my
place and stand on the other
side to talk about their
stories. To know that I will
one day be in their shoes.
Tracy
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Exhibitors, Friends and Supporters
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Bus Banner – Okanaga, BC
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Flash Mob – Kelowna, BC
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Partnership with Willow
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BRA Day Brochure
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International Launch 2012
United States
• Extensive PR campaign
• Over 175 events
• Jewel
• Charity concert
• Song release “Flower”
Jewel
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ASPS
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Over 30 Countries
• Australia
• New Zealand
• Taiwan
• Finland
• Spain
• Belgium
• Ireland
• Italy
• England
• Israel
Brazil Argentina New Zealand
Mexico Sweden Cayman Islands BVI
England South Korea Germany
Poland Switzerland Bulgaria Greece
Turkey Kuwait
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Ireland Belgium
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BRA Day Italy
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Bari Bologna Cagliari Catania Foggia Genova
Imola La Spezia Milano Modena Napoli Padova
Palermo Pavia Piacenza Potenza Roma Sondrio
Udine Varese
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“BRAVE” Bracelet
Braccialetto Cruciani
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Greece
Ατζέντα
Ηµέρα Ενηµέρωσης για την Αποκατάσταση Μαστού (Breast
Reconstruction Awareness Day- BRA Day)Τετάρτη, 22 Οκτώβριος 2014, 19:00 Εµφανίσεις : 131
Ο καρκίνος του µαστού είναι πρώτος σε
συχνότητα τύπος καρκίνου στις γυναίκες και η
δεύτερη συχνότερη αιτία θανάτου γυναικών µε
καρκίνο. Μία στις εννέα γυναίκες κινδυνεύει να
νοσήσει στη διάρκεια της ζωής της. Οι διάφορες
χειρουργικές θεραπείες του καρκίνου του µαστού
όπως ογκεκτοµή, τεταρτεκτοµή και µαστεκτοµή,
ενδέχεται να επηρεάσουν αρνητικά την
αυτοεικόνα και την ποιότητα ζωής της ασθενούς. Αναφορικά µε την αποκατάσταση µαστού, λιγότερο από το 20%
των γυναικών που κάνουν µαστεκτοµή υποβάλλεται σε αποκατάσταση κι ακόµη µικρότερο ποσοστό υποβάλλεται
σε άµεση αποκατάσταση. Μία βασική αιτία αυτών των χαµηλών ποσοστών είναι η έλλειψη σωστής και έγκαιρης
ενηµέρωσης. Η αποκατάσταση είναι εφικτή µέσα από διάφορες χειρουργικές επεµβάσεις πλαστικής χειρουργικής,
οι οποίες µπορούν να βελτιώσουν την ποιότητα ζωής της ασθενούς και να την βοηθήσουν τόσο στην ανάκτηση της
αυτοπεποίθησής της όσο και στη βελτίωση της ψυχολογίας της µετά από το ογκολογικό χειρουργείο.
Η αστική, µη κερδοσκοπική οργάνωση «Λωτός» έχει ως βασικό στόχο την ανάπτυξη και προώθηση ενηµέρωσης
και πρόσβασης στην αποκατάσταση µαστού. Αποτελείται από επιστηµόνες που δραστηριοποιούνται σε όλο το
φάσµα της θεραπείας του καρκίνου του µαστού.
Η οµάδα του «Λωτού» οργανώνει για πρώτη φορά στην Ελλάδα µια εκδήλωση στα πλαίσια του εορτασµού της
Ηµέρας Ενηµέρωσης για την Αποκατάσταση Μαστού (Breast Reconstruction Awareness Day- BRA Day). To BRA Day
θεσµοθετήθηκε στον Καναδά το 2011, και από τότε γιορτάζεται σε 30 χώρες σε όλο τον κόσµο.
Η εκδήλωση θα πραγµατοποιηθεί την Τετάρτη 22 Οκτωβρίου 2014 & ώρα 19.00 στην Αίγλη Ζαππείου και
είναι ανοιχτή στο κοινό. Στόχο έχει να ευαισθητοποιήσει και να ενηµερώσει για την αποκατάσταση ως µέρος της
συνολικής θεραπείας του καρκίνου του µαστού. Οι επεµβάσεις αποκατάστασης έχουν επανορθωτικό χαρακτήρα,
στοχεύουν στο καλύτερο δυνατό αισθητικό αποτέλεσµα και µπορούν να βελτιώσουν σηµαντικά την ποιότητα ζωής
των γυναικών που χρειάζονται αποκατάσταση και το επιθυµούν.
Γλυκερία Μάρτου MD, MSc, FRCS Πλαστική Χειρουργός, Fellow of EBOPRAS
Πρόεδρος της αστικής, µη κερδοσκοπικής οργάνωσης ΛΩΤΟΣ
Πρόσκληση στην ηµερίδα
Συνέδρια κ.λπ.
Εκδηλώσεις ανά Κατηγορία
Ηµερολόγιο Ατζέντας
Προβολή Ηµερολογίου
Τετ Οκτ 22, 2014 @19:00 -
Ηµέρα Ενηµέρωσης για την Αποκατάσταση
Μαστού (Breast Reconstruction Awareness Day-
BRA Day)
Σαβ Οκτ 25, 2014 @00:00 - 11:59µµ
1st Cyprus Breast Reconstruction Meeting
Τετ Νοε 12, 2014 @00:00 - 11:59µµ
29ο Πανελληνιο Συνέδριο Χειρουργικής και
Διεθνές Χειρουργικό Forum 2014
Παρ Νοε 21, 2014 @00:00 - 11:59µµ
1st Hellenic – Turkish Congress on Senology
Τρι Μαρ 17, 2015 @00:00 - 11:59µµ
23rd Stuttgart rhinoplasty course, 1st Stuttgart
nose reconstruction symposium and
Rhinoplasty Society Europe meeting
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Ελληνική ΕταιρίαΠλαστικής Επανορθωτικής &Αισθητικής Χειρουργικής
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Αρχική Η Εταιρεία Μέλη Πλαστική Χειρουργική Νοσοκοµεία Ατζέντα Επικοινωνία Σύνδεση
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Israel
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BRA Day October 21, 2015