Episode 44: Dr. Dhivya Srinivasa on the Art of Breast Reconstruction: Blending Aesthetics and Healing, Navigating Choices & Insurance

Embarking on a transformative journey alongside Dr. Dhivya Srinivasa, this episode of "Test those Breasts" transcends the typical medical dialogue, bringing to light the harmonious blend of form and function in breast cancer reconstruction. Dr. Srinivasa, with her microsurgical expertise, reveals how aesthetics play a pivotal role in healing—not just physically, but emotionally too. We uncover the empowering process of informed decision-making, discussing the significance of asking the right questions and understanding the diverse reconstructive paths that lie ahead.

Step into the consultation room with us as we dissect the essence of patient-centered care. Together, we navigate the nuances of each surgical option, stressing the importance of a personal support network and the necessity of expertise-driven advice.

Rounding out this heartfelt episode, we delve into the often daunting world of insurance navigation, arming you with strategies to overcome these hurdles and the importance of trusting your instincts.

Contact Dr. Srinivasa:
Dr. Srinivasa on Instagram 

Dr. Srinivasa on Facebook 

The Institute for Advanced Breast Reconstruction 

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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

Today I am honored to have Dr Divya Sharinovasa, who is a double board certified plastic surgeon and the founder of the Institute for Advanced Breast Reconstruction. In addition to being board certified in both general surgery and plastic surgery, she has completed a fellowship in microsurgery, enabling her to specialize in breast reconstruction, following breast cancer fully and offering the most advanced approaches to implant and microsurgical procedures. Dr Sharinovasa believes that to be the best breast reconstructive surgeon, one must possess the training and skill necessary to provide every patient with all possible options For breast cancer reconstruction. This means offering both implant-based procedures as well as autologous options that utilize the patient's own tissues. Dr Sharinovasa is highly inept at procedures that remove extra fat and skin from the belly, thighs and other areas, which can then be used safely and naturally to recreate breasts. The added silver lining you'll receive both contouring and breast reconstruction at the very same time. All autologous reconstruction procedures come with this two-for-one benefit, enabling our patients to enjoy consistently high rates of satisfaction after their breast reconstructions.

Speaker 1: 2:24

Well welcome, dr Sharinovasa. I really appreciate your being here today. I know we've had to postpone this once, and today it really worked out. I'm just very pleased that you took the time out of your schedule to join us on Test those Breasts. How are you doing today?

Speaker 2: 2:40

I'm so excited to be able to talk about something that I'm infinitely passionate about, which is breast cancer and breast cancer reconstruction. I'm great. Actually, it's a rainy day in LA, which almost never happens. The kids are off from school. It's been this—let me put it this way I'm really excited that I get to step away and do this awesome podcast.

Speaker 1: 2:59

Well, good, because, yeah, nobody has school here. I'm a former schoolteacher and for me, every day is no school. But it's President's Day. Yeah, I forgot about that. I almost forgot about that until our granddaughter came over today.

Speaker 1: 3:12

Well, as you know I've let you know before and as my audience knows I ended up having the deep flap surgery in New Orleans, and mainly, I only found out about it because of I call it Kismet. I had three different friends of mine actually reach out to me during the time that I—one before I started treatment for breast cancer, and then two more at the time that I found out that I had to have a mastectomy. They told me about the deep flap surgery and I had never even heard of such a thing. I only thought that there was implants, which is something that—this is the only thing that we do in our area, and so I ended up going to New Orleans because of those three people who reached out to me.

Speaker 1: 3:55

Along the way, I have been more educated about questions to ask surgeons Are they a plastic and are they a micro surgeon? How many surgeries have they done of that nature? And so I'm on a mission, doctor, to find the really good ones, and I fell upon you because I heard about you through a couple of other breast cancer sisters of mine, and I also have been on your website. I've watched your videos. You're in LA and so you're the first person that I know that is in LA. That comes highly recommended, so I'm just so happy you're here and I just wanted to ask you some questions for our audience.

Speaker 2: 4:37

Absolutely, absolutely. I'm flattered, thank you.

Speaker 1: 4:40

I want to kind of start out with, if you can sort of walk our audience through how you became interested in becoming a plastic surgeon and micro surgeon and in particular, dealing with breast cancer patients.

Speaker 2: 4:53

Sure, it wasn't automatic. It was sort of the right things kept happening to me to lead me to where I am today. So when I was in medical school and you wanted to be a plastic surgeon, I did general surgery. First I did general surgery. I found vascular surgery interesting, which now makes sense because I'm a microvascular surgeon. And I found transplant surgery interesting, which also makes sense because microvascular plastic surgery is a form of transplant surgery.

Speaker 2: 5:18

But really, the creativity within plastic surgery, I was immediately drawn to it and it never got old, I never got bored of it. So then I did plastic surgery training and in plastics I loved aesthetic cosmetic surgery and I was good at it. People would say like, oh, dr Srinivas, so you just make sense as a cosmetic surgeon. You should go to LA and be a cosmetic surgeon. But I loved micro surgery that much more. Those were the cases where I would get lost. In them. I didn't watch the clock, I was spellbound.

Speaker 2: 5:46

I think what really got me to where I am today is the love of both of those things, because I think that microvascular surgery is amazing and cool and I'm so glad I did the training for it. But I think what's equally important is the aesthetic part of it. It's not just about moving tissue from point A to point B, it's about making it look beautiful and transformative. You can't make the abdomen look bad when you make the breast. Everything has to be in balance and perfect and aesthetic.

Speaker 2: 6:13

And so I think I took the parts of what I really loved about plastic surgery, did the training that I needed to to be a microvascular surgeon, and then I went to work for a big hospital system, as most of us do when we graduate. And I think, being in that hospital system, I saw the holes. I saw the parts of it that I didn't love, and that's why I went private was because I wanted to be able to create an experience that I felt was exactly what the woman with the breast cancer diagnosis needed, and that's what I do in my practice today. So I really like to thank myself as an aesthetic micro surgeon. Yes, I'm going to do impeccable microvascular surgery and all the flaps you can dream of, but also that's not enough. You can't just check that box, you have to be able to make it look beautiful.

Speaker 1: 6:56

Yeah, and I figure you know you, being a woman, you know what makes us feel beautiful. So having that understanding from the get go that was my biggest concern was how mutilated I was going to look or what that was going to do to my femininity. And in the end, because I chose a really good surgeon and surgeons, I literally feel so different than I thought I was going to feel. So I think that's really important, and part of that has to do too with my abdomen area. That actually wasn't even a thought in my mind until I found out more about what good surgeons do when it comes to mastectomy and reconstruction. So that's really cool. I know that when you go to a surgeon, sometimes they will be making decisions for you, like the patient may not necessarily think to themselves. Well, that's not really what I want or what I had envisioned. What is your philosophy on shared decision making? You know working with the patient in decision making.

Speaker 2: 8:03

So I think that you should never, ever, ever, feel like someone is making a decision for you. If you have that gut reaction, find a new doctor. It may be that there is a one best option for you in your situation. That may be it, but you should never feel in a doctor's office that someone is telling you that that's what you have to do. So that's number one. I think shared decision making is it, it is the moment, it is it, it is what it needs to be, always and forever. I'm glad that it's getting sort of the tagline and the attention that it deserves, because it should have always been that way.

Speaker 2: 8:37

And I think in breast reconstruction especially, there's so many different ways you can approach reconstructing a breast and you have to be able to marry the patient's goals and expectations with what you can offer. And I think that's where the bridge kind of breaks down a little bit, because if you don't give the patient an opportunity to tell them, tell you what their goals are, then you can't possibly know as a physician. You're assuming. Then You're assuming they don't want an aesthetic flat closure, you're assuming that they want implants. You can assume a lot.

Speaker 2: 9:06

So that's number one. You got to give them the opportunity to tell you you got to lead with that Number two. You have to then have the skill set to provide them all the options, and if you don't, you then have to be able to check your ego at the door and say, hey, even though I can't give you what you're looking for, it exists, and I'm going to give you the names of either people or procedures that you can then look into, and I think all of that has to happen at the initial consultation for the magic to happen. It's really, really disappointing how often it doesn't happen that way.

Speaker 1: 9:38

Yeah, I like the fact that you mentioned that's really cool, that you mentioned checking your ego at the door and recognizing that you might not be able to follow through with what that person wants. So when somebody comes to you to ask you questions, what kind of questions do you kind of expect them to be asking you? Or what should they be asking other surgeons when they are getting a consultation?

Speaker 2: 10:01

I honestly think that for a patient it's an avalanche of information, it's a million doctor's appointments. It's like a blitz. You're doing it all quickly, you're checking the boxes because you want the cancer out. So I actually think the burden is on the surgeon to prompt the questions that they need to be asking. I always like to start with the general talk me through what brought you into the office today, and they'll give me whether it was cancer a long time ago or recently or whatnot. And then I always go through the same questions what size are you now? If in your dream world you could be anything you want to be, do you want to be bigger, smaller? The same. And then I always think do you want to be lifted? Do you want this? Do you want that Kind of get an idea and I go.

Speaker 2: 10:36

What have the other doctors told you? Are your options? Are you going to need radiation? Yes, no, maybe Are you going to need chemo Now, later, maybe Are you going to save your nipples?

Speaker 2: 10:45

I want to know everything that they've been told. And then, after I kind of give them a chance to get comfortable, get all that information out, I look at them and I go. So what do you want from all of this, like where can you and I be six months, in a year from now, that you're happy? And then they get to tell me and that's when I go, ok. Well, what do I think for you? Are options one, two, three, four, five in what I think is my opinion, the best to worst option. And sometimes we don't agree, and that's OK. That's actually where you find your sweet spot.

Speaker 2: 11:14

The patient says I want implant reconstruction and I say well, you're going to get radiated and your tumor is invading the skin and I'm not sure it's going to look so great.

Speaker 2: 11:22

And they go that's OK, I don't want the deep flap scar, I want to start with an implant. Then I go OK, I've heard you and you've been able to express to me what you want and why you want it, and I've explained to you the risks and benefits. And this is why it's informed and shared decision making, because we're going to be in the middle. I'll do it as long as it's not dangerous. I'll do it Because you've understood your risks and benefits and I get what you want and I'm going to try my best to get you there. And if I can't guess what, we have a backup plan and I can do the backup plan too. I have a hard time answering this question because I feel like the burden shouldn't be on the patient to have to come with this perfectly research list of things when they're also juggling 900 other appointments. The burden should be on the surgeon to lead them down a very meaningful conversation.

Speaker 1: 12:03

Absolutely. I mean, not all surgeons will actually do that. So we have to be able to get the patient to be able to advocate for themselves and go in armed with those questions in case a surgeon is not like you, which is unfortunately more often than not is that you may not get that experience.

Speaker 2: 12:24

This is why podcastic years are so helpful, right? Sometimes you don't know what you don't know, and most women who don't have a best cancer diagnosis are not doing the deep dive into information until they have to, and then all of a sudden it's on a time crunch. That was me I always say. I know everything seems like it's going a mile a minute, but actually slow down. I always recommend having a person whether it's a spouse or a significant other, a sibling, a parent, a best friend, a patient advocate have somebody with you that's hearing the same things that you're hearing, because you may not remember it the right way. You might be getting confused between what other doctors said. You might have your own sort of disclosures and biases in your own mind that are filtering what you're listening to and what you're hearing. So having another person there who's consistently there through your visits, I think is really important. I always say get that notes up on your phone and just write down ideas as you think of them, and that will help tell a story, too, of what you're most worried about and what's preoccupying you, I think, in general, understanding your options. So that's two parts. One you got to know what treatments you're getting. So what kind of mastectomy are we saving skin? Are we saving the nipple? Are you going to need radiation and chemo? If, when and why? And if you can answer those general questions for yourself, then you can present to the plastic surgeon the data that he or she needs to then give you options. Those options are going to fall into one of three categories Implant based, autologous. Auto meaning your own locus, meaning tissues, so using your own tissue, and what we refer to as a hybrid reconstruction. And then, if you can do your research on each of those topics, then you can kind of figure out what you think you want. And then you ask that surgeon in your hands what do you recommend for my case? And they're going to tell you what they recommend. And then you're going to say are there any other options? And they're going to tell you the other options and you're going to say what are the risks and benefits of each? And they're going to give you that and I have a whole bunch of information to chew and munch on and figure out what you want to do and where you want to go and who you want to do it.

Speaker 2: 14:10

And then it begs the question is the person who's giving you the information the best person to be giving you that information? And I think that's where it gets sticky. I have a lot of patients who come to me and say the reason I didn't choose a deep flap is because they made it seem barbaric. They made it seem crazy 16 hours and in the ICU for a week and a scar up here. And I go oh my God, who told you that?

Speaker 2: 14:32

And it was a surgeon who hasn't done the operation in 20 years, has only seen bad outcomes by one other surgeon in town. A million reasons why they may. I don't think anyone purposefully tries to mislead someone, but everyone is a victim to their own biases and disclosures. So if you really want a flat, go see someone who's an expert in that. If you really want a direct implant, don't go see the person who's been putting in tissue expanders under the muscle for 20 years. Go see the DTI expert, because that's likely the person who's going to give you the most information. And again, that person's bias or disclosure may be in the direction of what they do, but then at least you have balanced information.

Speaker 1: 15:07

Right and I like how you just brought up that. I don't think it's well. It could be ego based sometimes, but I don't think it's necessarily purposeful to mislead anyone. This sort of happened to me in my own town where I went to my surgeon. She told me I had to have a mastectomy.

Speaker 1: 15:27

I questioned her about this type of surgery and I didn't even know what it was called yet. I just knew that they take the tissue and she said she didn't know much about it. But her biggest concern was that there was no local care. So I would have to travel. And then there was no local care and at first I was like, ok, well, that makes sense. You know you want to make sure that you have good local care when you come back. And later on I learned that the place that I went to is a world renowned hospital and I've heard wonderful things about every surgeon there and that they in fact do have connection with local care in case something happens and they can make sure they get you taken care of. So it is a matter of who you're talking to and if they've ever done that kind of surgery and if they have, how many. So one of the questions I always now tell people is like when you go to talk to a micro surgeon, how many of these atologous surgeries have they done, and things like that.

Speaker 2: 16:24

And I almost want to add to that point I'm sorry, I don't mean to, that's OK.

Speaker 2: 16:28

You're making such an important point here. You know because I have worked in other systems and there were people who did my grocery fellowships but they maybe do 10 deeps a year. I do that in two to three weeks, right, and then not just me, there's others like me who do you know 10, if bilateral is two, they're doing five deeps in a week or in two weeks. So it's almost the more dangerous person as a person, you think does a lot of micro-surgery and they maybe only do deep flaps and they've been doing it the same way for 20 years and they do one a month and they're giving you advice Because I run across colleagues like that who will do that.

Speaker 2: 17:01

But they take so long they don't ever want to do immediate deep flaps. They'll always put the tissue expander in first. Because they take so long they don't want to do it in the same day. They themselves will make the operation seem impossible and difficult because they don't do it that often, and the patient will then come to me and say but I thought I did meet with the micro surgeon. It's annoying that it has to be this nuanced. I almost say not just how many have you done? How many do you do a week, okay, and if they respond with how many they do a month or how many they do a year, not enough. Okay. That's how many flaps do you do a week? Do you do any flaps other than deep flaps? How often are you doing those?

Speaker 1: 17:36

Somebody was asking about a stack flap. Is that what?

Speaker 2: 17:39

is that. Yeah, a flap is our generic term for the piece of tissue that we're moving from point A to point B. So if you need to use more than one or stack them on top of each other to get the result that you want, you would call that a stacked flap. There's a slight variation of that, called a bipedical flap. It just means that instead of physically cutting the flap in two and stacking them on top of each other, that you're folding it. So I always say think of layers of a hamburger versus a calzone. The bipedical flap is the calzone, the hamburger buns on top of each other are the stacked flap. But either way, it's the use of multiple flaps with multiple sets of blood vessels.

Speaker 2: 18:13

And I know a lot of microsurgents who are fellowship trained microsurgents, who do microsurgery, that have never done a stacked or bipedical flap and they don't want to start today. They'll just say you're not a candidate, but you could go see somebody else and you come to my office and I'll go, you're a great candidate, I'll just stack the flaps. So it's unfortunate that it's this nuance, because how could someone who is just diagnosed with breast cancer possibly wade through and navigate all of this nuance? It's unfortunate that it's this way, but I think the number one thing is what you're doing, which is just educating people so that they go in knowing what to ask for, so they don't get tricked or convinced to do something that maybe isn't best for them, right?

Speaker 1: 18:48

So this gets me to my next question about second opinions, because I cannot tell you how many people on the private Facebook groups that they come on. They're like I'm just so upset. You know, I just finished talking to my surgeon and he said that I was not a candidate for deep flap surgery, and then a bunch of other people will jump on there and say stop breathe, you need to go talk to someone else, like getting a second and maybe even a third opinion, because it's a matter of why did that person say that? Is that actually the truth? And can you talk to other surgeons who can maybe actually be able to do that for you, because they've done so many or have more knowledge or whatever? It is right, yeah, absolutely yeah. The second opinion thing so clearly you are an advocate for people to get a second opinion if they feel a thing.

Speaker 2: 19:40

I mean, it is a slippery slope. I've had patients on their seventh, eighth, ninth opinions and then I'm like well, but you want to just make sure that your second opinion is a worthwhile opinion. So if you see one person in a group and a small group and you don't like them, so you go to the other person in the group. I don't know that that's a worthwhile second opinion. I would say, take what you didn't like about the first person. Was it that they told you you were not a candidate but you really want flaps? Well then, go see a flap expert. Go find the person who is an expert in that. Was it just that you loved the plan? Maybe you want the drug to implant, but you just didn't like their bedside manner. Well then, maybe somebody else would be different. So if that person is I don't know an old male, maybe go see a young female. Or if they were a young female, maybe go see someone who's more seasoned.

Speaker 2: 20:24

Try and figure out what you didn't like about your first opinion before you just go hopping from plastic surgeon to plastic surgeon, because that will create a mess in your mind. And try to figure out what you want to do. So, yeah, absolutely. Second opinion, third opinion, if you need it and I don't know many surgeons who are good at what they do that are offended by that. In fact, I will tell patients to go get a second opinion. You seem uncomfortable with what I've told you. Why don't you go see somebody else and maybe you'll like them better, or maybe they'll say the same thing that I did. But whatever it is, help contextualize the information I'm giving you by talking to somebody else about it.

Speaker 1: 20:57

Yeah, see, this is why I wanted to interview you, because I felt, just based on what I saw on your website, in your videos you seem like a very genuine surgeon who actually cares about her patients and I really appreciate that. And I know from the cancer community we do appreciate that it's kind of like you know, it's this beginning of this holistic care as well, because we know that breast cancer is very traumatic and you know we go through all of these treatments. It is just a barrage of information that's so confusing and really can throw us into a really deep dark hole, which it really did for me on a couple of different occasions. So when you run across somebody that like you, who is willing to sit down and talk real and really begin that holistic care from the very beginning, I cannot tell you how much we appreciate that. So it's my pleasure.

Speaker 1: 21:49

Can we talk insurance for a second? Yeah, so one of the biggest pieces of difficulties for people is insurance. You know we'll have people come on the Facebook pages and say, oh my gosh, I had Anthem Blue Cross and I was told that this place takes Anthem and now I'm being denied. It is such a complex and very emotional issue and I'm actually in the process of putting together as much information as I can, using other people as well, because I grab knowledge from wherever I can to put together a document to help people understand the basics of insurance and things like that. So I know that you were involved with the CMS the coding crisis and we were able to get CMS to kind of walk back that sunsetting of the code that provided access for the deep flap surgery. But how do you help people with insurance conflicts issues?

Speaker 2: 22:45

It's a great question. It's a very complex one. I could probably give a two hour seminar on this topic alone. I think you have to understand where the problem is coming from to then know how you best should attack it as a patient. So I am out of network with all insurances. I don't accept the in network rates that insurances provide because they are insultingly low for the complexity of work that I'm doing and what I'm offering a patient and I'm very forthcoming with patients about that because I don't ever want anyone to be surprised by a bill. I want to be very transparent about what it is.

Speaker 2: 23:14

But as an out of network surgeon, one of the provisions that I take advantage of for almost every case is something called a gap exception or an LOA. Loa stands for letter of agreement or SCA, single case agreement, and the gap is essentially a gap in care. So if you live in an area where there isn't a good micro surgeon or isn't a micro surgeon at all and you need flaps and you go see someone out of state who's at a network, or maybe in another town who's at a network, or maybe even your same town and they're at a network you can then appeal to your insurance and say, hey, I've had radiation, the juries has decided what happens to radiated implants. I'm not signing up for that. I want a deep flap. And I found this person and guess what? They do this many hundred flaps a year and they're the best and I want to see them. And I'm going to apply for a gap exception and you have to see whether the insurance will agree to it. If they do, the insurance company will then reach out to the surgeon and then the negotiation that happens in price between me and the insurance company and not the patient.

Speaker 2: 24:08

If I accept their offer, then I am treated as an in-network doctor for the purpose of that surgery. I use that 90% of the time for my cases, which then allows me to provide surgery at no cost to the patient beyond whatever their normal deductible is. Most women have already met their deductible for medical reasons by the time that they're getting reconstructive surgery. That's number one. Number two the facility that I use is a network. I never go to an out-of-network facility because actually the cost of health care is a burden because of facility fees and big pharma. What those bills are for the chemotherapy if you've ever looked at your EOB, it's wild. It's crazy. Nothing compared to an IV bag that's hanging and going in, compared to hours of complex microvascular surgery. Every single time you have the infusion that's being built up. That's determined by big pharma.

Speaker 2: 25:03

Then you have hospitals that will say well, we hired all these doctors, we own these doctors. It's okay, if you don't pay the doctors, we already have them salaried, whatever to their fees. But you better pay the facility fee. The facility fee is $8,000, $150,000, whatever these crazy numbers. The insurance companies will cut deals to maintain a high facility fee while cutting physician fee. Those who are salaried. Well, they're required to do a certain X amount of work. They're going to do X amount of work. Every once in a while there's a jewel who's willing to go above and beyond. In general, I always tell patients think about your job. If you didn't get paid to work overtime, are you going to work overtime Right?

Speaker 1: 25:40

No, you're not. Well, actually I was a teacher.

Speaker 2: 25:45

I just did an Instagram story two days ago and I said you know the other people that feel my plate, the education system Everyone who's a teacher in the United States, because I said, you know what the problem is.

Speaker 2: 25:56

Teachers in America are asked to do the same thing as doctors in America work more and have less resources and take care of more complex problems More students in each classroom, students of all different, varying abilities and less funding. That's what they do. The education system in the United States that's what healthcare is. You have to know what system you're in. If you're seeing a private practice doctor who's at a network, that's going to be a different battle. Then seeing someone who works for a hospital system they work for a hospital system. I can promise you they probably don't care what your insurance is. They're just salary, they're paid work. So they leave all the billing and collections and insurance stuff to some person who works in an administrative position. So if that's the case, your best bet is to go. You got to just deal with your insurance directly and make sure that they understand what's going on. I think if you are seeing someone in private practice, generally those offices are probably well versed in handling insurances and they can be an ally for you in that situation. I know my patients feel a lot of frustration when they did go to a big academic center and they felt like just another number. And it's because, unfortunately, the doctor who's in that system, their salary, isn't affected by your insurance, most likely and so they just treat the patient that comes in the door. They offer what they offer book the case, not book the case. Move on Private practice different. Our whole practice is based on every patient who trusts us with their care and so we tend to have a lot more experience. I'm generalizing, but I think again, generally speaking, if you are at a big center and you're having insurance problems, I would deal with the insurance directly. Generally, you're probably not going to find the doctor's office that helpful. If you're seeing a private practice doctor, they probably will be a lot more helpful because they probably already had to do a lot of the insurance stuff. Drop the Women's Health Act. Okay, it is federal requirement to cover mastectomy reconstruction if you cover the mastectomy. So there is zero reason that any private insurance company in 2024 should be denying breast reconstruction.

Speaker 2: 27:37

Number two gather the doctors that you've seen and what they've said. So one of the best advice I can give you is if you saw a doctor and they told you you're not a flop candidate, get it in writing. You want to copy that note that they told you that they can't do it, because you know what you're going to do. You're going to submit that note to the insurance and say, hey, I went to somebody and network, look what happened. So now I'm going to go see so-and-so and you're going to pay for it, because that's why I pay my insurance premium. So get your opinions documented, get them in your hand, because that's going to really help. So that's number two.

Speaker 2: 28:07

Number three, I would say I hate that I have to say this, but they will just exhaust you, like their whole goal, insurance companies is to make it so hard for the patient that you give up because you're just exhausted. So you just have to have the stamina to appeal after appeal after appeal and I find that if you stick with it that it eventually comes out in your favor. It may have sucked years of your life and emails and hours and what not that helps. Last piece of advice I'll give you is if your insurance is through your employer.

Speaker 2: 28:38

A lot of times these big companies have contracts with Anthem or Atna or whatnot and they want to maintain that contract. So go to your HR person and say, hey, I want to see this doctor. I need the surgery. I have, or had, breast cancer. I've met with a lot of people. This is what I want and ask that HR person to help you, because, again, the company is incentivized to keep their employees happy and then the insurance company is incentivized to maintain their contract with the company that's using them to provide insurance to their employees.

Speaker 1: 29:07

Just excellent, excellent advice. I watched a documentary quite a while ago and I remember a couple of the employees of the insurance companies literally saying they are trained to deny first, always, and so just the stamina part of it. And I have seen people in those private Facebook groups that we are in say I finally got my insurance company to cover what I wanted because they stuck with it. These are things that we want to let people know because it's negotiable and we know it's not a provider that you choose.

Speaker 2: 29:41

You know I had a patient company, somebody who said Already had surgery with somebody else and then wanted needs another flat for another reason, came and I said, oh, you already saw so and so actually they did a beautiful job. Why are you switching providers? And her response was well, I just heard your office always gets figured out with insurance. Again, adding back to the list of questions you should ask if you think insurance is going to be a problem, ask the doctor's office about it right off the bat. Ask your surgeon about it and the very like open commando policy. You know I like to talk about the finances of things at the first visit because there's enough stress in all of this. I don't want to add the financial stress on top of it. Should be very clear how things work. So what vibe you get from your surgeon and from their office? Are they clear cut about it? Do they understand how it works? Do you feel like they're advocating for you and certain offices may do a better job of that than others?

Speaker 1: 30:26

okay, yeah, good to know, very good to know. You know we already talked about holistic care a little bit. When people come in to see you, clearly you know you're, they're getting good care right there. What does a typical deep flap look like? Are they in the hospital for a couple of nights? Are there anything? I know that, having a private practice, you have the autonomy to make your facility really nice.

Speaker 2: 30:49

Yeah, so I actually utilize hospitals for my deep labs and I do that for a couple of reasons. At the end of the day and some people disagree with me, this is controversial there are plastic surgeons that do deep flaps outpatients also in the patient home the same day. I just think it's a lot. Most of these patients have either had chemo, need to go into it, they may need radiation, they've been through a lot. This is a big surgery for them. They may not have the support at home. So I always go, like you know, a couple of days with a well trained nurse and a good physical therapist hurt. Nobody hang out in the hospital. Let me monitor your flaps. I like to keep them anywhere from two to four days, more if needed, although usually day three is a sweet spot for discharge and I'm really picky about having the right garments, understanding if you need home health and setting that up.

Speaker 2: 31:32

Physical therapy and lymphatic therapy I think all of those things are as important as my hands. I can do a perfect job, but if I haven't set the patient up to heal well, I haven't done as good of a job as I can. So I think all of those things are important. We're very aggressive about physical therapy and early range of motion with my patients. I'm very picky about garments and what I want them to use to get the best donor site is always crazy to me because patients will say well, my friends doctor didn't even have her wear a binder or told her not to wear compression. And I'm Shocked when I hear that because it's like how do you get that spells waistline and hip and all the benefits of the tummy tuck, and the reality is that certain probably didn't do a true tummy tuck, otherwise they would have their patients and all those garments. So I think all of those things are equally important.

Speaker 2: 32:13

But one of the hard things I have is I'll have patients reach out on Instagram and say, oh, I had surgery when so and so what do you recommend? I can't recommend things to you. If I wasn't your surgeon, I don't know how they do it. Every surgeon is going to know their patient population best. They're going to know how they do the surgery best. They're going to know how best to manage any complications that may arise. So you got to find the surgeon that's the whole package and then stick with that person, because going to one person for the surgery and then asking somebody else for help. Wires are going to get crossed, so ask your surgeon those questions ahead of time. Prepare for it, make sure you feel good about the answers.

Speaker 1: 32:43

That's fair enough, totally fair enough. I really like that. You also let you know you have the patient stay in the hospital for a few nights. It really astounds me what patients they will let go just that same day. I'm just like I know deep flap surgery and any of those flap surgeries it's no joke. I mean, having a mastectomy and implants is no joke, and so I can't have her to be honest, I know people do it and they'll say, oh, I use these blocks.

Speaker 2: 33:14

I'm like homie, I use those blocks too, but I don't know. You may be doing it, but I, if I called all those people up and asked them what their experience was like, I think they would have enjoyed being in the hospital for a night or two.

Speaker 1: 33:24

Oh yeah, I mean, and just the care itself and the monitoring of the pain and all that stuff is very, very helpful. Thank you so much for that information on the insurance. I'm telling you that is one of the biggest pieces that we talk about out there and we really want to help people understand so much more. So what I was saying is I was putting together this document with some friends of mine so that people can have it at their fingertips with good advice on questions to ask and what verbiage to use. Take the denial letter and use that denial letter verbiage when you are appealing and things like that. And also I like that you talked about keeping the documentation of. I went to this doctor. They said they couldn't do this or whatever. And I like the fact that you're in LA, because all of the other people that I have interviewed there I have interviewed people in Texas and Louisiana. It's nice to have someone over on the West Coast too, because we have so many women saying, yeah, but I'm in Oregon or I'm in Nevada or, and so it'd be nice to be able to have someone in your area to be able to talk to. Okay, well, so let's wrap up a little bit here.

Speaker 1: 34:29

You've given so much advice, so this is kind of like I don't even know how you can even answer this because you've given so much. But one in eight women get breast cancer. There's so many women and not all of them have genetics involved or anything like that. There are things that I wish I would have known before I was even diagnosed, and I know that when I was diagnosed there would have been a way for me to be able to research surgery. But we don't think about those things at the very beginning. So that's why I always go back to those women out there who are sitting on the sidelines listening to this podcast and they've never even had breast cancer. Is there any piece of advice that you might give to them to help arm them with knowledge before they even get hit with the? You have cancer.

Speaker 2: 35:18

Yeah, I'm going to make it twofold. I think one you have to learn to prioritize yourself. We all have busy lives and it's so easy to postpone that mammogram, not do the follow-up ultrasound, forget about your pap smear, all of those things. So I would say, prioritize yourself. In prioritizing yourself, what you will realize is that you will ignite a very intense curiosity in your own health and longevity. You just will. The minute you start thinking about what do I need to be healthy and happy on planet Earth, you will naturally go down a very important rabbit hole of how do I take care of myself? That's going to include all of these things for health maintenance and disease prevention. As you equip yourself with these things and how to stay healthy whether it's the food that you eat, whether you exercise, your habits, the doctor's appointments that you need to keep things like that in that process part two of my advice is you will find your gut feeling.

Speaker 2: 36:16

I think that every woman's gut feeling is intrinsically correct. One of the things that I hear most common from women is I just knew so-and-so wasn't the right surgeon for me. I just had this feeling that something wasn't right, or I just had to start listening to and into that voice, whether it's that voice telling you that you don't feel okay and you do need to go see a doctor, or that maybe you've lost too much weight recently, you're gained too much weight recently, your appetite has changed, or maybe something is off about whatever it is that's been bugging you and you keep shushing it in the back of your head that might lead you to a doctor's office. When it leads you to a doctor's office, you might have a gut feeling that says not the right doctor for me. They're ignoring my concerns. Listen to that gut feeling. Or you might get a gut feeling of why do I feel so connected to this person? And they're just such a great doctor. This feels great, great. Lead with that gut feeling. Listen to what that doctor says, because I think women are very intuitive creatures. We are born to multitask and we're also born to prioritize everybody else First.

Speaker 2: 37:16

Whether it's societal or intrinsic is a conversation for another day, but I find all of the women that I am honored to treat share that that it was really a journey of self-discovery and learning to prioritize themselves. It was unfortunately born out of necessity because they got a diagnosis and they never expected. But I think, if you're lucky enough that you haven't gotten that diagnosis yet. Learn their lesson now. Yeah, learn their lesson now. Any woman that you've talked to with breast cancer they'll tell you the same thing. They will tell you in the most heartfelt, tear-jerking fashion possible. Like I should have just taken care of myself. But I should have listened to those cues. I probably wouldn't have prevented anything, but it just makes your relationship with your own health and wellness so much more grounded so that when something does challenge that, you have few pillars of strength to fall back on. So prioritize yourself, tune into that feeling, tune into that intrinsic voice and go with your gut, and I think you will be as well equipped as possible to deal with whatever health problem may come your way.

Speaker 1: 38:12

Yeah, fantastic advice, and that is something I tell people all the time. It's like that's why I have this podcast is I want people to prioritize their health. I have always prioritized my health in a lot of ways. I've always been good with gynecological appointments and things like that.

Speaker 1: 38:29

And I remember leading up to my diagnosis, I did feel a lump, I did feel burning sensations and I was so excited to interview. I'd be driving along to my job and interview. I was so excited to retire that I had all these things going on. So when I would feel those things in my breast I would be like, huh, what was that? And then I'd go about my day. So I remember getting that phone call when I called to make my appointment for my mammogram that year. They asked me do you feel any different? Do you feel any lumps or any sensations? And I literally said no, because I knew that I was going in in three weeks to get my mammogram and I hung up the phone and my husband said that's not true. So he was listening to me. You do what.

Speaker 2: 39:13

It's a thing that we all do, whether we're sisters or mothers or daughters. Are you feeling? Ok? Yeah, I'm fine, I'm just going to go in my chair. Are you exhausted? No, no, no, I can take care of it, no problem. All day long we do this, but like, actually, we're all exhausted, we're all tired.

Speaker 2: 39:28

We're all doing every single thing that society demands of us and we're doing it while not taking care of ourselves.

Speaker 2: 39:35

And I think when that data came out, with the precipitous rise in breast cancer and cancer in general and women getting diagnosed at younger ages again, not only breast cancer but cancer in general is on the rise you got to ask yourself why.

Speaker 2: 39:48

And there are environmental factors, and we can talk about plastic and microwaves and cell phones and dairy and meat. We can talk about all of that, but I think one of the things that has really changed over time is sort of the multi-dimensional aspects of a woman in 2024 and what is required of us is so different than what has been required of us in the past. And so it's fine, we can do all the things, we're all doing all the things, but we have to be able to slow down and stop and say am I OK today? What did I feel? Is this normal? Has this changed? Do I need to go see a doctor? Do I need to eat better? Do I need to sleep? Do I need more water? Do I need all of the above? And I think, instead of shushing our little inner voice and our gut reaction, we should actually amplify it.

Speaker 1: 40:29

Yeah, I love that. Ok, Well, I really again appreciate your being with me and just talking about really important topics. They're hot topics and people want to know what opinions are out there. Professional opinions are out there, they want to know where the good surgeons are, and clearly I'm just so glad that you are on here with me today. Is there anything you'd like to leave us with before we wrap it up?

Speaker 2: 40:55

Trust your gut. I want to say the same thing again Trust your gut and ask questions. There's nothing wrong with asking questions. If you feel shamed for asking questions, there's something wrong about that situation. So, trust your gut, ask questions.

Speaker 1: 41:08

Awesome, I have found that I ask questions and I don't care what other people think.

Speaker 2: 41:11

So that's the way to do it.

Speaker 1: 41:14

Well, thank you very much, Dr Sharina Vasa. I really appreciate it, and to my audience, thank you again for joining us on this episode of Test those Breasts and we will see you on the next episode. 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.