Episode 42: Breast Sensation Restoration with Dr. Chrysopoulo

Could regaining the sensation in your breasts after a mastectomy transform your recovery journey? Join me, Jamie Vaughn, and the esteemed Dr. Minas Chrysopoulo to explore how innovative surgical methods are offering hope to breast cancer survivors. In an engaging conversation, Dr. C, a pioneer in plastic and microsurgery, shares his insights on the emerging possibilities in sensory restoration. We tackle the nuances of the process, discussing both the life-changing potential and the inherent limitations, and why even a partial return of sensation is a significant victory for patients. Dr. C's expertise from PRMA Plastic Surgery shines a light on the DIEP Flap method and the role of patient empowerment in navigating the complexities of reconstructive choices and insurance coverage.

In our in-depth discussion, we underscore the value of nerve-sparing mastectomies and the critical selection of a proficient surgical team. Discover how the techniques of both breast and plastic surgeons during tissue removal can have a profound effect on the outcome. Dr. C emphasizes the collaborative approach required to maximize sensory preservation and how real-world factors, such as patient anatomy, can influence results. We provide a candid perspective on the challenges faced following a mastectomy, including the possible patchwork of numbness, and stress the importance of managing expectations with your healthcare providers.

dr.chrysopoulo@prmaplasticsurgery.com

Dr. C on Instagram
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Breast Advocate® LinkTree 

Breast Advocate® website 

Breast Advocate® on Instagram 

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I am not a doctor and not all information in this podcast comes from qualified healthcare providers, therefore may not constitute medical advice. For personalized medical advice, you should reach out to one of the qualified healthcare providers interviewed on this podcast and/or seek medical advice from your own providers .

Transcript

Speaker 1: 0:01

Welcome to season two of Test those Breasts podcast. I am your host, jamie Vaughan. I am really excited to continue this journey and mission into 2024 to help shorten the overwhelming learning curve for those who are newly diagnosed, or yet to be diagnosed, with breast cancer. It has been such an honor and a privilege to be able to connect and interview many survivors, caregivers, oncologists, surgeons, nurses, therapists, advocates and more, in order to provide much needed holistic guidance for our breast cancer community. Breast cancer has become such an epidemic, so the more empowered we are, the better. By listening, rating, reviewing and sharing this podcast, it truly does help bring in more listeners from all over the world. I appreciate your help in spreading this knowledge. My episodes are released weekly on Apple, spotify and other platforms. Now let's listen to this next episode of Test those Breasts.

Speaker 1: 1:07

I am super thrilled that we get to have Dr Minos Crisopolo back on my show. He was on a previous episode where he spoke about his expertise in plastic and microsurgery, and we also brought in the concept of shared decision-making. He is also the founder of the Breast Advocate app that I have in my show notes. I am so excited about the Breast Advocate app because now I know, but I didn't know before that I could actually do some research on what kind of surgery I could have, but I just didn't really know enough. Once again, that's one of the reasons I started this podcast is because I want to make sure that people who have never even had breast cancer, or those who have just been diagnosed, have all the information that they need to be able to move forward with knowledge, because we know that knowledge is power. But Dr Crisopolo he likes to go by Dr C he is, just as a reminder, a board-certified plastic surgeon and microsurgeon and the president of PRMA Plastic Surgery in San Antonio, texas. He specializes in state-of-the-art breast reconstruction, with a particular focus on perforator flap breast reconstruction techniques to maximize aesthetic outcomes after breast cancer surgery and restoring sensation after mastectomy.

Speaker 1: 2:31

This is what we're going to be talking about. Today is about the idea of can we get our sensation back in our breasts, either at the time of reconstruction after mastectomy or even delayed reconstruction after mastectomy? Well, welcome, dr C. I am so happy to have you on my show again. I just love following all of your stuff on Instagram. You are out there and advocating and educating and all the things, and we just had this conversation about coming back on the show to talk about something really super important and that is the restoration of sensation with our breasts. So welcome. How are you doing?

Speaker 2: 3:15

Yeah, I'm doing very well. Thanks, jamie, great to be back. Good to see you again, good to see you too. You're doing amazing things, Well thank you Podcast is growing at a rate of knots. That's phenomenal work, congratulations.

Speaker 1: 3:26

Yeah, thank you, I just have this fire in my belly, as I told you before, to really help shorten that learning curve for people and as we talked about last time, we talked about shared decision-making and the importance of shared decision-making. We're going to talk a little bit about that at the end, where we talk about the importance of choosing your team and who you're comfortable with working with, but also that breast advocate app, which I'm going to definitely bring up again, because I do have them always in my show notes now.

Speaker 1: 3:59

And so I love showing that off because it is so brilliant. But today we are going to be really talking, getting into this really important topic. You know, at the beginning, when I found out that I had to have a mastectomy and I didn't even know what kind of surgery I was going to do, I thought that it was all there was was implants. That was before I even knew anything else about what kind of other options I had. But one of my biggest fears was losing that sensation in my breasts. You know, we women love our breasts. I mean, I know that that's not all of what makes us female, but that sensation is very important, you know, for intimacy and things like that. And so I want to ask you is there any way to bring that sensation back to the breast? And we'll talk about when that is possible, when it might not be possible, so let's talk.

Speaker 2: 4:49

Yeah, yeah. So short answer is yes, it is possible to preserve and or regain some feeling. I was careful which words I use there, because it's important for women to know that we're not talking about, you know, 100% preservation being guaranteed and we're not talking about 100% restoration of sensation being guaranteed. So there are definitely some very, very important nuances, but at the end of the day, the message is this many women, and maybe even most women I think it's most women in my experience when they have a mastectomy, they lose feeling. So it's exceedingly rare to have normal breast sensation after a mastectomy. The main point here is that there's a conversation to be had and that there are options for women to end up with a result that is absolutely better than being completely numb. You mentioned intimacy. We're also not talking about maintaining 100% erogenous sensation. Some women have some erogenous sensation, but most women do not. I'm painting a dark picture here telling you of all the things that isn't, but at the end of the day, I have yet to meet a woman who would turn down this option because she's not going to have 100% what Mother Nature gave her, so the ability to feel a touch, the ability to feel a hug, the ability to know that you're being touched during intimacy, even though it's not necessarily erogenous or it usually isn't. Those are all very important things. The knowledge that you won't unknowingly burn yourself because the skin of your breast now has protective sensation that's a big deal in and of itself. Thankfully it's becoming less frequent, but we still see it.

Speaker 2: 7:03

We see women come from other practices with full thickness Skin loss, with full thickness burn injuries to their breasts after they've had mastectomies and reconstruction, because they may have some achiness or they'll have some sort of pain or discomfort. Someone will tell them oh you know, why don't you put a hot compress on your breast? That really helps. And so they'll do something like you know this happens a lot. But they'll get maybe a face washcloth or something and they'll put in some water and then they'll pop it in the microwave so that it's nice and hot and then they'll put it straight on their breast without testing how hot it really is and then, because they don't have any feeling after the mastectomy, the skin basically gets burned. You know, we've had women come to our practice with their implants basically exposed because of this full thickness Skin loss from the burn, injury from putting something hot on the breast and the patient not realizing how hot it was.

Speaker 2: 8:11

So first point is for any woman who's had breast reconstruction or mastectomy without breast reconstruction for that matter, because it's not the breast reconstruction that makes you numb, right, it's the mastectomy that cuts the nerves. So even if you've chosen to go flat or have a static, flat closure, you still experience the same numbness. Right, it's not just for reconstructed ladies. But if you're ever going to put anything warm on your chest, for heaven's sake, please test it out on a normal part of your body first. So the forearm, the skin over the inner part of your forearm, just beneath the elbow area. That skin is pretty sensitive and pretty thin. So if you can tolerate that, if you can tolerate heat on that part of your body, then it's probably safe to put it on your breast.

Speaker 1: 8:58

I've never even thought about that.

Speaker 2: 9:00

Yeah, I mean it happens. It happens all the time. It's really unfortunate. So there's another opportunity there to educate. Yes, whether you've had breast reconstruction or not, it's another important point. It's the mastectomy that leads to numbness, it's not the breast reconstruction.

Speaker 2: 9:16

There was an article in the New York Times I think back here I think it was January of 2017, if I'm not mistaken and it was about Numbness. But the tone of the article I Took issue with it was great because it got people talking. But the tone of the article was a little bit unfortunate because it kind of blamed the breast reconstruction for the numbness, which is just factually wrong. It was fair enough to highlight that back then. Most breast reconstructions didn't Reconstruct nerves that provide feeling. That's a fair point, because that was the reality for most practices anyway.

Speaker 2: 10:01

But I remember going to breast cancer conference the following Tuesday morning. I received a Barrage of really kind of very Quite, aggressive questioning from our breast surgeons. So did you see this article in the New York Times? What are you telling your patients about them being numb? So what am I telling my patients? What are you guys telling your patients? Because it's the same patient, it's your operation that's causing the numbness. Oh, it's my challenge to restore the sensation, but the fact that they're numb. The initial shortcoming is not ours, it's the mastectomy.

Speaker 2: 10:40

It makes sense to me it's like that's why, even if you go flat without breast reconstruction, that's why you have the same resulting numbness it's the mastectomy that cuts nerves right Now. It was a very good article because it got the conversation going and just the reaction from our breast surgeons highlights the lack of understanding of what the true issue is. So fast forward to today, and we have two approaches. The first approach is to preserve as much feeling as you can, because preservation is always better than reconstruction. Our breast surgeons now many of them are way more cognizant of Breast nerves that provide the feeling.

Speaker 2: 11:23

There are several nerves in the breast and they try to look out for them when they're doing the mastectomy to try and preserve the nerves if possible. There are a couple that are super important for the nipple and the areal, especially for women who are having nipples sparing mastectomies. But there are some main nerves that supply the bulk of the breast Feeling and there is a lot of overlap between the nerves too. But if you're cognizant of the nerves and you're trying to look out for them Especially the main ones that tend to be larger caliber then you have a much higher chance of being able to save them if possible. There are surgeons now who are really trying to get the message out in terms of the breast surgery field and in terms of nerve sparing mastectomies. And and Zeve Pellet it's a husband and wife team in San Francisco. She's a plastic surgeon and a breast surgeon, zeve is a nerve surgeon and they've done a phenomenal job advocating for patients and for getting the word out about nerve sparing mastectomies.

Speaker 1: 12:26

So if you haven't interviewed yeah, I was gonna say and Pellet.

Speaker 2: 12:29

Yet I strongly recommend you give her a buzz. They're both lovely. They're phenomenal people as well as wonderful surgeons. So massive plug for their work and what they've been doing sure and is wonderful. So hit her up and she's very much been pushing not just nerve sparing mastectomies within her breast surgery niche and Within the societies for breast surgery. Throw it out there. But she and her husband are also getting the word out about nerve reconstruction.

Speaker 1: 13:01

So is her husband, the reconstructive surgeon.

Speaker 2: 13:03

Well, they both do it.

Speaker 1: 13:04

They both do yeah, they both do it, but are they both? Micro surgeons, the big buzzword like we need to know micro surgeons and that they've done tons of these. I know you've taught me a lot about that.

Speaker 2: 13:18

The other surgeons that I have Interviewed Dr Potter and Dr Cabling it's like it's so important to know what their experience they have for sure, for sure, absolutely irrespective of the procedure, you definitely want to research and find someone who does a lot of whatever is that you're seeking or whatever is that you need, irrespective of surgical specialty or any medical specialty for that matter. Right? But anyway, nerve sparing, mastectomies are a thing that's something to discuss with the breast surgeon. Okay, because, again, having sensation off the breast reconstruction, the plastic surgeon is only half the team. The breast surgeon determines how much feeling you could preserve by preserving those nerves. If your breast surgeon doesn't offer nerve sparing, you should ask why. We'll go into the reasons why people don't do things later on. But listen, sensation is super important and Any feeling beats being completely numb. You've got to have the right conversation and you've got to be willing to have the right conversation With your health care team, and there are some reasons why you can't preserve the nerve sometimes. Sometimes you don't have the right anatomy. The nerves come out of the chest wall and they travel in the breast tissue and a lot of them travel in the subcutaneous fatty tissue Just beneath the breast gland. It is possible to preserve some of the nerves. Now a lot of the nerves dive into the breast tissue and so, as you're removing the breast tissue, you end up cutting the nerves. Even if you're trying to preserve them, even if your breast surgeon is trying their hardest, it's not always possible. You also don't want your breast surgeon to leave a bunch of breast tissue behind just because they're prioritizing your feeling. You got to get the right Operation and with the mastectomy you've got to remove Anything that looks and feels like breast tissue should come out. Now, no mastectomy is a hundred percent Complete. So what does that mean? It means that there's always some breast tissue left behind, which is why women who have Mastectomies and then go on to have MRIs, often you'll see some breast tissue on the MRI and then women will freak out and say, oh my god, my surgeon didn't remove all my breast Issue. Well, they removed everything that looked and felt like breast tissue and sometimes there's some Breast tissue.

Speaker 2: 15:35

For most women it's not like a hard-boiled egg where you've got the egg yolk In the middle and there's obviously Markation between the egg yolk and the egg white. You know hard boiled egg. The vast majority of women are not like that. I mean most women. The breast tissue kind of spiders out as like it's got tentacles and kind of Spiders out and extends out between the fat and it's impossible to get every single breast cell.

Speaker 2: 16:02

Anyway, even if you're trying to preserve all these nerves, a lot of the time you can't because of the patient's anatomy. Then there's also, in a patient who's got cancer, the tumor Can sometimes be in a location where you can't preserve the main nerves right. So you got to get the cancer out. There are a bunch of reasons why. There are a bunch of reasons why, even if you find a breast surgeon who knows about nerve sparing mastectomies and is willing to do it, there are several reasons why you are still likely going to experience patchy numbness, even if you have some feeling. It's very common in women who have nerve sparing mastectomies where they have areas of fairly good sensation. Then they've got areas of a little bit of sensation, then they've still got a numb spot and then it's patchy. It's not uniform.

Speaker 1: 16:53

That's me Right.

Speaker 2: 16:55

Yeah, but again, that's better than a completely numb breast. Those are the reasons why, even with a nerve sparing approach, you can't be guaranteed to wake up and have full feeling, so you've got to have appropriate expectations. Then, as far as what we do as reconstructive surgeons, once our breast surgeons are done with the mastectomy, we'll take a look, we'll see if we feel the nerves are intact or if they're not, if we see a nerve has been cut and if it's a main nerve to the nipple and the areola or a main nerve to the rest of the breast. There's some very specific ones that we look for on the inner part of the breast, near the breast bone, the sternum, and then some nerves on the outer lower part and over the side of the breast too. We look for those nerves, and our breast surgeons a couple of them have taken the whole nerve sparing thing to a whole new level. They have this immense sense of pride and they're like, hey, look at this, how'd you like this? You like this nerve, you like this nerve. A lot of the time you can't see the actual nerves, but you can see the tissue that's been left behind and you know where the nerves come out of the chest and you know that it's highly likely that the nerve has been preserved. Other times you see a nerve that's been cut and it's very obvious it's been cut. So now you have a target to reconstruct. So what we do at PRMA is, whenever we don't feel a nerve sparing technique has been done and we see that there's a nerve that's been cut, we'll go ahead and reconstruct it, and this isn't quite as good as preserving, but again it beats a numb breast. So what we'll do then is with the techniques that we do mostly at PRMA, which is tissue reconstruction.

Speaker 2: 18:41

As you know, the deep flap is the main procedure the tissue reconstruction practices perform. So the deep flap is what we call the workhorse, it's kind of the Cadillac tissue reconstruction using the lower abdomen. So what we do routinely is when we take that tissue and transplant it to the chest, we also take a nerve with that tissue. That was basically providing feeling to that tissue on the belly, and we take the nerve with the skin, with the fat, and we take a nice length of it and then we can connect that directly to the cut nerve in the chest. And there are different ways to transfer the tissue. There are different ways to position it so that the nerve endings reach. Sometimes, if the nerve endings don't reach, you can use a bridging nerve graft, which is a cadaver product. It's a human product from cadavers and it comes in various lengths. If you've got a nerve with the flap that doesn't quite reach the cut nerve in the chest, then you can bridge the gap with this cadaveric nerve graft.

Speaker 2: 19:48

In our practice, we don't use nerve grafts very often. We like the product very much. When we do use the nerve graft, we use a product called Axogen, which we think is a great product. It's just the only reason we don't use it on every case is because we don't need to, because we do things in a way where we can connect the nerve endings directly, and we just don't need to use that.

Speaker 2: 20:12

The reconstruction technique, though, needs to be different when you're doing implants, because when you're doing an implant reconstruction, implants come out of a box. Whether it's a direct to implant, you're putting in the permanent implant. If you're doing a tissue expander reconstruction, it's a staged approach, but obviously neither one of those man-made devices have a nerve. So what do you connect? That's where the nerve graft is super helpful, because then you can use the nerve graft. If you see a cut nerve, you use the nerve graft and connect one end of the nerve graft to the cut nerve in the chest and then the other end of the nerve graft you can connect to a stump of the nerve under the nipolariola complex and that's actually the technique that is popularizing and has popularized. Even if you have an implant-based reconstruction and you don't use your own tissue, you can still get a nerve reconstruction if your surgeon offers it.

Speaker 2: 21:16

We have people that traveled to PRMA from all over. 10, 15 years ago they were traveling for the deep flap because there weren't so many people doing deep flaps as there are now across the country. Now patient access while it's still a problem and we're not there yet it's a lot better than it was 10, 15 years ago. But now a lot of people are traveling for the nerve reconstruction because the local folks don't offer that and they kind of put it down. You know, whether it's nerve-sparing mastectomy, they can't find a surgeon that will do that and then they can't find a plastic surgeon that works with a breast surgeon that will offer reconstruction.

Speaker 2: 21:52

So sensation is really the next kind of frontier that we have to cross in breast reconstruction. I mean breast reconstruction may not cause the breast numbness, but we have the opportunity to fix it at that. And really it's very obvious and it's well overdue. Especially if you have a holistic approach to breast reconstruction, which we should all have. It does really address the remaining aspect of restoring function. We haven't been doing a good job of addressing, you know we've been. I used to say I mean I remember earlier in practice when I was talking about tissue reconstruction versus implants and the pros and cons of each. One of the pros of tissue is its consistency, but I wasn't thinking in how I would phrase things, so I would say things like you know, an implant can provide a nice, very cosmetic augmented result if that's the look you want, and a tissue reconstruction provides a more natural feeling result. And then I never realized way back then. You know I've been in practice for almost well I don't want to say it's been so long, but anyway.

Speaker 1: 23:03

Actually, yeah, you do, because that gives you a lot of credibility.

Speaker 2: 23:09

OK. But back then you know when I would say if you use your own tissue, it feels more natural. I didn't think of the implications that the patient was hearing. And so because, ultimately, who did feel more natural to? It feels more natural to me. When I examine you as your physician, you know it feels more natural to your partner, but you don't many times don't feel anything. So what I meant was the consistency of the breast is more natural. But when you use the word feels, that means different things to different people. So you have to be very careful.

Speaker 2: 23:44

But now fast forward. Actually we've been doing nerve reconstruction. We started doing nerve reconstruction early 2000s, I think. In practice that's been many, many, many years. We've been part of a multi center trial. One of the reasons why some surgeons, or many surgeons still to this day, refuse to even buy into the concept is because they say, well, it just doesn't work, which isn't true. It does work. If you choose to not offer something because we can't guarantee 100% preservation and 100% restoration compared to Mother Nature, then I can't help you. Right, if that's what you need. But there are no. What we call the morbidity, in other words the risk of complications, is so low. There really are no risks associated with the procedure. It adds a little bit of time, especially once you're over the learning curve. It's negligible in terms of our time. So it's not like oh my God, you're under on the seizure now for so much longer because of this nerve reconstruction. That's false.

Speaker 1: 24:49

So it's worth a shot. I mean, it's at least. Well, why wouldn't you?

Speaker 2: 24:53

I mean for me it's like okay, it's not 100%. Okay, it's not 100%, so what? It's better than nothing. And actually it's a whole lot better than nothing. It's a whole lot better than the alternative. It's not even just a little bit, because, as I said, I haven't met a single woman yet who we've done a nerve reconstruction on or nerve sparing and who has feeling that regrets having feeling. Have you, have you met anyone who regrets having feeling after breast reconstruction?

Speaker 1: 25:21

I have not.

Speaker 2: 25:22

Okay.

Speaker 1: 25:23

And there's been a lot of conversation out there about sensation, and so I mean most of the conversations that I have, people don't know necessarily about that option.

Speaker 2: 25:34

Yeah, I think the only regret I've come across is women wishing their surgeons would have mentioned it or offered it. Yeah, there's still a lot of unanswered stuff, a lot of unanswered questions, a lot of things we don't know. Is using a nerve graft better than not using a nerve graft? Should we be using a nerve graft in everyone? The data doesn't suggest that, but we don't know for sure. What we know is that, whether you use a nerve graft or not, reconstructing the nerves leads to better feeling compared to not reconstructing the nerves, and it also provides faster return of feeling compared to not reconstructing the nerves.

Speaker 2: 26:14

We also know that if you don't do a nerve reconstruction, some women will regain some feeling on their own, regardless. That's another reason why some surgeons say, oh, you know, refuse to do it or refuse to consider it or explore it, because they say, oh well, I, you know, I've had women that have feeling, that have some feeling anyway, it comes back. Well, now, that's true. Some women do regain some feeling, even without a formal nerve reconstruction, because if you're doing a tissue reconstruction cut, nerves continue to grow back into the tissue that you've transferred and at some point you may get some feeling back. It's absolutely correct. So there's also a hope that even if you haven't had formal nerve reconstruction, and especially if you've had a tissue reconstruction, you may still get some feeling back, especially if it's been less than two years right by two years most people. It is what it is. So if you had reconstruction 10 years ago, you're probably not going to experience more over time at this point in terms of return of feeling.

Speaker 1: 27:23

What about, well, somebody who has a mastectomy and they have, I guess, delayed reconstruction? And also, how does radiation play a role in that?

Speaker 2: 27:34

Great question. So delayed reconstruction we look for a nerve that's been cut and we usually find one. So the delayed reconstruction actually is probably has. Of all the patient demographics, the patient groups, probably the delayed reconstruction folks, I think, experience the greatest change because typically they have a much larger area of skin that has to be added as part of the flap you know they have. The most people have a big skin paddle. That's a big area that you can potentially restore some feeling to, and so the delayed folks really appreciate it.

Speaker 2: 28:06

And in terms of radiation, that's another great question. I used to not do it or not stress about it in women who had had radiation, because radiation kind of sterilizes tissues and it prevents we thought it would prevent nerve regrowth and so there wasn't any point in doing a nerve reconstruction. But then I think, well, now we have studies that show that it helps with radiated patients as well. So the studies that we have now and there have been several papers, especially out of Holland, there's a group that's published a lot out of the University of Maastricht, we know now. So number one reconstructing nerves restores feeling, restores more feeling and quicker than not reconstructing nerves. And we know that that also applies to women who have had radiation. Now the radiated flaps don't do as well, so women who have had radiation, the degree and the quality of feeling that they get back isn't the same degree as women who have not had radiation.

Speaker 1: 29:15

Does it make a difference? And I don't know whether, prma, you all do this over there, but I know that there are some surgeons who will do mastectomy and will delay the reconstruction because of radiation. Does that make a difference, like if you were to do immediate reconstruction is it possible versus waiting?

Speaker 2: 29:37

Yes, you can do nerve reconstruction in any of those situations. Okay, yeah.

Speaker 1: 29:41

Okay. I know there's so much question around that, revolving around this radiation. I never had radiation and I didn't know that I wasn't going to have to have radiation until after my deep flap, until they pulled the lymph nodes and knew that they were not in my lymph nodes and I ended up not having to do it. But there's so many women who've had to do radiation.

Speaker 2: 30:05

It's still worthwhile having an nerve reconstruction, even if you've had radiation.

Speaker 1: 30:09

Okay.

Speaker 2: 30:09

If you had a mastectomy and then you had post mastectomy radiation and then you go and you have your deep flap. You should absolutely consider it Okay.

Speaker 1: 30:21

So questions we need to add to our list of questions that we ask these team. Right, we want to include do you do sensation restoration and what does that look like? Yeah, these are questions that we need to add to the list, for sure.

Speaker 2: 30:37

Yeah. So both for your breast surgeon if you're having an immediate, I mean if you haven't had the mastectomy the breast surgeon because you want to do a nerve, preserving if possible, yeah From the plastic surgery team. Whether they do it, yeah for sure.

Speaker 1: 30:52

Now that we know that really the nerves go away because of the mastectomy and they, if the surgeon, does perform that preservation after mastectomy, what if they do that and then the reconstruction person comes in? Can it sort of be a doubled up opportunity there?

Speaker 2: 31:10

Yeah, that's what I'm saying. Yeah, that's exactly right. Okay, so if the surgeon does a nerve sparing and then the plastic surgeon looks at the nerves and they look intact, then there's nothing to reconstruct. You're not going to want to cut a nerve, just to say you've reconstructed it.

Speaker 1: 31:23

Gotcha Okay.

Speaker 2: 31:25

So we have patients traveling to us now for this Actually, not just now, it's been many, many years and there are women that travel to us for nerve reconstruction and they don't even get a nerve reconstruction because they get nerve sparing. But you can't guarantee that they're even going to get the nerve sparing technique until the mastectomy has been done and you can see, see what their anatomy is like, see how the surgery went, see what your breast surgeon has done and there's communication during the surgery. The other issue is that even if you see the nerves and they look like they're intact as they travel into the mastectomy skin, you don't know what happens to that nerve as it branches and as it travels Throughout the skin. So it may have still been cut somewhere else, but that doesn't really matter, because if your breast surgeon has tried to spare the nerves, you're going to end up with way more feeling than someone who prioritizes how much tissue they leave behind. You know there are some surgeons that say, oh good, mastectomy, you should have eight millimeters of tissue.

Speaker 2: 32:31

Well, that depends on the patient's anatomy, depends on the patient's BMI, how much fatty tissue they have under the skin. It depends on so many things and there are layers of quality mastectomy and someone who's got a super low BMI, that tissue is going to be very thin. That's left behind because that lady doesn't have much fat. In a lady who's got a much higher BMI, she should have much thicker mastectomy flaps left behind mastectomy skin left behind because she's a bigger lady. And for a BMI of 35 versus a BMI of 18, you have a different thickness of adipose tissue, a fatty tissue. The fatty tissue layer underneath the skin is different in those two individuals. If a high quality mastectomy focuses on removing the breast tissue, then you should absolutely not have the same mastectomy skin thickness left after the mastectomy in both those people. Okay, makes sense. Good breast surgeons know that Not everyone has the same approach.

Speaker 1: 33:38

Okay, In your breast advocate app. I was just looking up on their nerve sparing when you go through the wizard right, that's what you call it on there. Are there options on there, because I didn't see that. Are there options on there that you can answer, to educate, make people aware of what to ask and to even know? That's even possible. Yeah, I mean in the wizard.

Speaker 2: 34:05

The wizard's just a question, right? It's like you know how important is breastfeeding to you. I can't remember the question we asked, but it's just a question. So the education is in the knowledge center and then actually the articles that we have in there, I think and Anne actually wrote one of the articles on the sensation.

Speaker 1: 34:21

There is free inferior. There's a flap harvest with sparing. Yeah, I'm just looking at some of the resources in here. I'll have to look for that because that's not something I was even looking for at the time. I do remember asking something about nerve sparing and one of the breast surgeons said that's not even possible, Like they said.

Speaker 2: 34:47

I respectfully beg to differ.

Speaker 1: 34:49

Okay, well, that's good. Yeah, good to know, because they said that, despite what people say, that really isn't something that can happen. And now we really do know that it can happen. I'm curious do you have?

Speaker 2: 35:02

And there's plenty of published data on this. So for ladies who like researching articles and stuff, and if you've got a PubMed, the articles are in breast advocates, so it's even easier to kind of.

Speaker 1: 35:14

I love that. Yeah love the breast advocate app. So nice to be able to have that all housed in that area. You probably have patients that have told their story about that.

Speaker 2: 35:29

yes, which bit about feeling yeah.

Speaker 1: 35:32

Oh, yeah, about, maybe. Yeah, like someone who might want to come on here and talk about it.

Speaker 2: 35:38

I'm sure yeah, yeah Because people want to know.

Speaker 1: 35:42

I mean, I know ladies out there want to know.

Speaker 2: 35:45

That shouldn't be an issue.

Speaker 1: 35:47

Okay, okay. Well, I'm really glad that you reached out and wanted to talk about this, and that does add another layer of how we pick our team, how the surgeons work together.

Speaker 2: 36:01

Yeah, it's procedure dependent when you're picking your team.

Speaker 2: 36:05

If you want implant reconstruction, if you decide that's what you want, then really you should focus on the pairing the breast surgeon plastic surgeon pairing.

Speaker 2: 36:17

Don't pick a breast surgeon and then go off and pick a plastic surgeon that never works with that breast surgeon. You should always pick a pairing because you should pick a plastic surgeon that works with a specific breast surgeon more often than not and vice versa, because you have an understanding between those two individuals. That's very important in terms of your outcome the level of trust that needs to happen between the cancer surgeon and the reconstructive surgeon. It's got to be a known relationship and it's got to be the flow to the procedure and the decision-making process and the respect to each party's importance in the decision-making. Where to put the incision, the nerves, what's the follow-up reconstructive surgery going to look like if it's going to be more than one stage, all these things? The model that exists in some places, where the breast surgeon does their thing and then the plastic surgeon just comes in and there's been no input and the plastic surgeon is just left to just make the best of it that's not what you want.

Speaker 1: 37:25

Yeah, the communication is key.

Speaker 2: 37:26

It's massive.

Speaker 1: 37:28

Yeah, it's like being a team teacher in a classroom.

Speaker 2: 37:34

And then if you're doing microsurgery, then the whole team thing. That's a whole new level, whole other level. Because microsurgical procedures are complex. A good surgeon can do those with a PA and get away with it most of the time. I know several across the country good surgeons that do these surgeries with a PA.

Speaker 2: 37:54

But we don't do that at PRMA. We have two surgeons on each microsurgery case because those cases when they go well, they go well and you know what. It can be straightforward and things go well and things go smoothly and things are slick and you get done at a decent hour and everyone's happy. It's when things don't go according to plan when you really want that second person there and microsurgery is very complex. And one thing we're seeing now with insurance and I bring this up too because you and I have spoken about the insurance issues before and the whole ESCO debacle for deep flap surgery and perforated flap surgery and what's interesting now is that insurance companies are actually turning down the co-surgeon, the second surgeon. So now there's this push for surgeons to do more and more on their own, which is the next battle we're going to be facing, because that's not pro-patient, that's not patient first, that's not advocating for the patient, that is-.

Speaker 1: 38:59

Cutting corners yes.

Speaker 2: 39:01

I mean we feel it is Now again. There are surgeons that can pull this off. But just because you can pull something off doesn't mean it's a smart approach, and if I'm the patient, I don't want to hear that you can pull it off. I want to hear that you have two microsurgeons on my case.

Speaker 1: 39:19

Yeah, and that you're very confident it's going to work out. Well, and it's going to work out. No, I agree Right.

Speaker 2: 39:25

And so that's another battle. Now that's kind of starting the heat up. We're seeing Okay, I'm seeing lots of colleagues around the country, the conversations we're having, lots of colleagues that used to work with another surgeon and now not able to as much or at all because of insurance contracting.

Speaker 1: 39:44

So this is one of the reasons. Like you know, we have a lot of conversations in our support groups about insurance and, yeah, I really wanted to go to PRMA but I couldn't because my insurance wouldn't approve it or wherever you're deciding to go. So it's really frustrating because, you know, I feel like people should be able to go wherever they want to go to get their surgery according to the surgeons that they've gotten, maybe talked to, and so it's very frustrating. So my question is is how do we help? How can we leave something maybe in the show notes that we can get out to patients and patient advocates? What can we do from our angle? Yeah, great question.

Speaker 2: 40:23

I think it's important to discuss the patient safety aspect of it. Two microsurgeons are always going to be better than one, and so advocate for yourself. If you have a choice, just take that into account and then you know. If your insurance is giving you a hard time, then it's funny. I think insurance plans, insurance companies, they do not like getting complaints from patients. They get complaints from surgeons all the time, right, so everything's negotiable.

Speaker 2: 40:51

Everything you know. You're the customer right. Ultimately, the patient is the customer. You have a stronger voice as patients, I think, than surgeons. I think than surgeons do.

Speaker 1: 41:01

Okay.

Speaker 2: 41:01

I would say talk about it. I would say, bring it up. I would say if your insurance company denies it and you want to go to a place that is using two surgeons, make a stink. It's not like the. It's interesting. If you guys were privy to the finances on the back end you would see that it's not even a financial, the financial decision. That's not really the conversation, because the X that they pay more for two surgeons is so negligible. That's not even the point. So it's just using things to say no, right.

Speaker 2: 41:37

So it's the latest thing after the CMS hearing and after the S code issue was remedied and the sunsetting of the code wasn't happening anymore, and I think you and I discussed about winning the battle and losing the war. The next part of the war is the co-surgeon is the second surgeon, because that's where insurance companies are focusing now and they're squeezing surgeons. So now more and more surgeons, if they want to do the surgery, they have to do it on their own with a PA. So how is that putting patients first? Yeah, we can dress it up all we like, but ultimately, how can one surgeon ever, one micro surgeon ever, be better for the patient than two micro surgeons for such a complex procedure Makes no sense.

Speaker 1: 42:27

Well, and I think that insurance companies don't even quite get you know, they don't see that side of it, they just see the bottom line, right.

Speaker 2: 42:35

Yeah, they do and they don't. You know, the data's out there, it's published. You know, two surgeon model is the gold standard. In that way, that's not a new revelation, right? That's standard of care. So I think, get the word out and patients should use their voices, because it's very powerful.

Speaker 1: 42:57

Well, I'll be keeping my eyes open on that and just keeping a close eye on what's going on and listening to what's going on and continuing to follow you. I really like that. You are a very reflective surgeon. You look back and you think about things that you've said to patients and you're clearly an empathetic surgeon, and that's why I really like you and I've learned a lot from you, and I'm glad to know that you actually can restore sensation not necessarily 100%, but it's worth a shot.

Speaker 1: 43:30

And if that's really important to people, which it is to a lot of us then we know the right questions to ask. We also know the right way to advocate for ourselves with insurance companies using our voice and making a stink and talking about things that aren't PC to. I was like that's, it's important, I think, and so with that, I really appreciate your being here and talking to us about that. Today I will be in San Antonio. I think I sent you a message. It just so happens that I will be there in March because I'm a public board member for social workers here in Reno and in Nevada and my new board member training is there in San Antonio and I've never been there, so I'm going to be coming into town. I don't know if you're going to be there, but I'd love to be able to stop by and see PRMA and meet you in person, if it works out.

Speaker 2: 44:21

Yeah, let's do that, and you can tour the facilities and take a look at our new place, landmark Hospital. I would love that. Yeah, yeah, that would be great to show you around.

Speaker 1: 44:31

We are having a girls trip, some girls that I've never even met before. I've known them for a long time because of the breast cancer, but I've never met them in person. I've met one of them in person when I had my last surgery, and we're making a girls trip to Perky Girls to get our nipple tattoos next July. I thought, you know, why not just make a girls trip out of it? So we're all going to be coming to San Antonio in July to get that done. So you know why not have the silver linings out there, right?

Speaker 2: 45:00

Oh yeah, plenty of worst places to visit. San Antonio is lovely July is pretty hot.

Speaker 1: 45:04

Okay, well, that's what I heard.

Speaker 2: 45:05

It's pretty hot July will be pretty hot, but that's okay.

Speaker 1: 45:09

Yeah, well, a bunch of us hot girls will be there, so, anyway, so okay, well, I'm going to go. I appreciate your time and your energy that you put into patient advocacy and you know I'll see you on Instagram and to my audience. I have all of Dr Crisopoulos Instagram and I think I have your LinkedIn in there and your website and the breast advocate app, of course, and your link tree and all the things.

Speaker 1: 45:36

So I hope you have an amazing rest of your day and week and thank you. Do you have anything else to say before we leave?

Speaker 2: 45:45

I just appreciate just you creating this platform. I appreciate you keeping it real. That's super important. Anyone can look up stuff online about procedures and stuff, but I appreciate how what you're doing allows people to learn about topics that relate to them. So congratulations and thank you. That's all I have to say.

Speaker 1: 46:08

Yeah, thank you for saying so. I'm I really appreciate you're saying that and that you see that I do like to keep it real and because that's really truly the only way to be so well. Thank you very much and, to my audience, I will see you next time, on the next episode of Test those Breasts. Bye for now, friends. Thank you so much for listening to this episode of Test those Breasts. I hope you got some great much needed information that will help you with your journey. As always, I am open to guests to add value to my show, and I'm also open to being a guest on other podcasts where I can add value, so please reach out if you'd like to collaborate. My contact information is in the show notes and, as a reminder, rating, reviewing and sharing this podcast will truly help build a bigger audience all over the world. I thank you for your efforts. I look forward to sharing my next episode of Test those Breasts.