Team-Based Approach to Breast Reconstruction

The team-based approach to breast reconstruction, who is involved in your care, and what each team member does is an important part of the process if you decide to have reconstruction after a breast cancer diagnosis. Patients can be overwhelmed so it stands to reason the healthcare team must have practice protocol in place for this to happen. There are many team players but I firmly believe that a plastic surgeon should on the healthcare team for those facing mastectomy. The options, risks involved in surgery, expected outcomes and aesthetic results can only be best imparted to the patient by one who will reconstruct the breasts, should a patient chose to do so.

The patient must be their own best advocate; keep track of who they have spoken to, how one physician will communicate with another, keep track of the plethora of information, and manage and organize it so that it makes sense. Often it takes hours of reading and re-reading reports trying to understand the information the healthcare team is giving them.

The healthcare team must enter in to a patient's care plan with a spirit of cooperation and listening to each other as trained professionals. They must have a staff on board that will relay urgent needs and have a system in place that makes it easy for the patient to FAX, email, or phone in information in a timely manner. What might be urgent information for the patient to know will not be urgent for the physician to get back to their patient on. It is a balancing act that requires work for both the patient and healthcare team.

Who will be on your healthcare team after your cancer diagnosis and how do you successfully utilize and maximize the benefits of the team approach to breast reconstruction? I will give the perspective from my experience and those I talk to daily who are currently going through the process. It is not an easy task to accomplish but with planning and communication you can use the team approach to breast reconstruction for a successful outcome.

The Team

My breast reconstruction team began with my primary care physician. She is the one who ordered the yearly mammogram that detected the second occurrence of breast cancer. She also was involved in completing necessary exams and ordering pretests necessary for my reconstructive surgery which included blood work and an EKG. I had to have all the FAX numbers available and ready for her to forward them to the plastic surgeon who performed my DIEP flap breast reconstruction. This involves communication with your primary care physician or the facility that will be performing these tests. You cannot expect to call them at the last minute to set up an appointment to do this. The plastic surgeon's office I went to had a protocol in place to have pre-op appointments at least two weeks prior to any phase of reconstructive surgery I had. This allowed flexibility in my schedule and the ability to get reports back to my plastic surgeon in a timely manner. It can cause patients undo panic if they get to the hospital for a scheduled procedure and are missing test results and procedures are potentially delayed because of poor coordination between healthcare teams.

My radiologist played a crucial role in my healthcare team as well. She was the first team member who told me about my second breast cancer. My radiologist performed the necessary biopsies and ultrasounds needed to confirm the diagnosis. She was certain what she was looking at on the mammogram was likely cancer. She took me back to the film room to show me what she was looking at but more importantly told me my next steps should be setting up an appointment with a breast surgeon. This would be my next team member. The breast surgeon would look at the report from the radiologist then come up with a plan to remove the cancer.

My breast surgeon discussed the test she needed to order to make sure that a mastectomy would be the best surgical option to remove the cancer that was now in both of my breasts. She also discussed the possibility of a nipple sparring mastectomy. This was all new information to me since the first time I had breast cancer I only had a lumpectomy. More importantly, and what truly became life-altering information to me, was the discussion and options she gave me about breast reconstruction.

My breast surgeon gave me information on breast implants and the methods and types of implants she would use should I choose that type of reconstruction. The most eye-opening information she gave me at that initial appointment was an option to reconstruct that she referred to as "the gold standard" in breast reconstruction, DIEP flap. She explained to me that this method used the patient's own tissue from the tummy area along with underlying blood vessels to create a new breast that was warm and soft. She was very clear that the surgery was long and involved, took more than one phase, and could be done immediately with her and a plastic surgeon involved or it could be delayed after all test results came back from the mastectomy. I was on board from the very beginning to use DIEP flap for the simple reason that I did not want anything foreign in my body but also knew I had the time and resources needed for the longer recovery period.

I chose to wait and have delayed DIEP flap breast reconstruction for two reasons. I wanted to know what the outcome of the mastectomy was, if there was lymph node involvement, and if I would need adjunctive therapy; chemo or radiation. This is important to note for this reason. Radiation can be very debilitating to the skin or cause healing problems. I had radiation to my left breast when I had my first breast cancer diagnosis. It had long term affects and changed the mobility of my left arm. I mention this for those who will have radiation after a mastectomy. It turned out that I did not need radiation but a radiation oncologist could then become another very integral part of the healthcare team for a patient's breast reconstruction. It will be imperative that they communicate with the plastic surgeon so that optimal aesthetic outcomes can be achieved for the patient during breast reconstruction.

The second reason I chose to have delayed DIEP flap reconstruction was to take the time I needed to choose a board-certified plastic surgeon who specialized in microsurgery to perform this type of breast reconstruction. There are many plastic surgeons who perform implant-based reconstruction but few who successfully perform autologous (using the patient's own tissue) breast reconstruction. I knew if I was going to commit to this intricate, involved, surgery I wanted the best. I researched a plastic surgeon with a high success rate, in my case 99% success rate, did a burn fellowship, and worked with a team during surgery.

Phase one of breast reconstruction gave me plenty of long scars, transferred tissue, and good reason to see the next healthcare team player, my physical therapist. My plastic surgeon prescribed ultrasound guided physical therapy just two weeks after my DIEP flap. The physical therapist I chose was also a specialist in lymphedema therapy. She also worked with me weeks after my mastectomy to improve my range of motion. She knew I was planning on DIEP flap reconstruction so she showed me methods of keeping my skin loosened so it would not adhere to the chest wall in preparation for my delayed DIEP flap.

The key take away listing the various team members I had in my breast reconstruction and the part each one played is the communication they had with each other. I had my radiology appointments, mastectomy, pre-surgical tests, and physical therapy done in one state and my breast reconstruction done in another state. Even though I traveled for breast reconstruction, my healthcare team was well-versed in communicating with each other as needed. They not only worked as a team to decide the best course of treatment for my breast reconstruction, they each made me an integral part of the shared decision making process. No one person's decision was more important than the other, including my own. It was a team effort from the beginning and resulted in me having an extremely positive breast reconstruction experience and zero regrets about making the decision to reconstruct my breasts after mastectomy. Being your own advocate, using your own voice is not always an easy task when you are faced with the shock and confusion that comes with a breast cancer diagnosis. It is OK to you use these words when talking to your healthcare team, "How will you use the team-based approach for my breast cancer and breast reconstruction care?" It may just make all the difference in your outcomes. It certainly did for me.

By: Terri Coutee

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