Paraphrased from Plastic and Reconstructive Surgery Journal. June 2017.

Postmastectomy Irradiation and the case for immediate or delayed Autogenous Tissue Breast Reconstruction

Colwell, Amy S. M.D.
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1289–1290

The evolution of mastectomy has advanced from radical to modified radical and now skin- and nipple-preserving mastectomy procedures without oncologic detriment to the patients.

In a similar way, radiotherapy has undergone significant changes from rudimentary two-dimensional planning with cobalt to more targeted three-dimensional planning with intensity-modulated radiation therapy, volumetric-modulated arc therapy, and proton therapy with pencil beam scanning.

This specificity has allowed improved targeted therapy and reduced the bystander effect on surrounding normal tissue, and this has been essential to the paradigm shift of radiation therapy as a salvage modality to radiation therapy as an integral part of modern breast cancer treatment.

Autologous reconstruction is an ideal option for many patients following mastectomy, particularly in the setting of radiotherapy.

Immediate autologous reconstruction has several advantages, including the psychological benefit of awakening from mastectomy surgery with a breast mound, and the practical benefits of fewer operations and decreased operative time if the reconstruction is begun simultaneously with the mastectomy.

However, experience gained from large series in the past showed high incidences of fat and flap necrosis, volume loss, and complications when immediate autologous reconstruction was performed before radiation therapy.

Therefore, delayed autologous reconstruction has been the most common choice in patients destined to undergo postmastectomy radiotherapy.

However, with improvements in surgery and radiation techniques combined, several authors have begun to reexplore immediate autologous reconstruction in this setting.

The Mastectomy Reconstruction Outcomes Consortium Study offered a potential way to answer the question of whether immediate autologous reconstruction should be performed in women who require postmastectomy radiation therapy.

In this article, immediate reconstruction was performed in 108 patients. This cohort was unique in having no total or partial flap losses and a very low (3.7 percent) rate of fat necrosis, which is a testament to the technical skills of the surgeons involved.

Information regarding the delivery of radiotherapy specifics was not collected at all sites, but the regimen at this center used slightly smaller fractions of radiation for delivery compared to other sites where doses were known, there were no radiation boosts, and selected nodal treatment was performed.

In comparison, the delayed cohort (67 patients) offered a true multicenter experience and reported rates of partial flap necrosis (7.5 percent) and fat necrosis (10.5 percent) comparable to those in the literature.

Overall, there was no difference in total breast complications between immediate and delayed reconstruction.

Furthermore, patient-reported satisfaction scores between immediate and delayed cohorts were similar at 1 and 2 years.

The results from this study show that as surgery and radiation therapy continue to evolve, immediate breast reconstruction should definitely be considered.

However, the question of whether immediate breast reconstruction should be performed can only be answered at each institute based on surgical expertise and radiotherapy delivery unique to each health care system.

REFERENCES

1. Clarke M, Collins R, Darby S, et al. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of
radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year
survival: An overview of the randomised trials. Lancet 2005;366:2087–2106.
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PubMed | CrossRef

2. Katz A, Strom EA, Buchholz TA, et al. Locoregional recurrence patterns after mastectomy and doxorubicin-based
chemotherapy: Implications for postoperative irradiation. J Clin Oncol. 2000;18:2817–2827.
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3. Kronowitz SJ, Robb GL. Radiation therapy and breast reconstruction: A critical review of the literature. Plast
Reconstr Surg. 2009;124:395–408.

Paraphrased from Plastic and Reconstructive Surgery, Jun 2017:

The case for Autologous Breast Reconstruction rather than Implant Reconstruction in Irradiated Patients.

Methods: From the 2009 to 20130, irradiated breast cancer patients who underwent implant or autologous reconstruction were selected.

Results: There were 2964 study patients. Most (78 percent) underwent implant reconstruction. The unadjusted mean costs for implant and autologous reconstructions were $22,868 and $30,527, respectively.

Thirty-two percent of implant reconstructions failed, compared with 5 percent of autologous cases.

Twelve percent of the implant reconstructions had two or more failures and required subsequent autologous reconstruction.

The cost of implant reconstruction failure requiring a flap was $47,214, and the cost for autologous failures was $48,344.

In aggregate, failures constituted more than 20 percent of the cumulative costs of implant reconstruction compared with less than 5 percent for
autologous reconstruction.

Conclusions: More than one in 10 patients who had implant reconstruction in the setting of radiation therapy to the breast eventually required a flap for failure.

These findings make a case for autologous reconstruction being primarily considered in irradiated patients who have this option available.

Reference:
Comparing Health Care Resource Use between Implant and Autologous Reconstruction of the Irradiated Breast: A National Claims-Based Assessment

Aliu, Oluseyi M.D., M.S.; Zhong, Lin M.D., M.P.H.; Chetta, Matthew D. M.D.; Sears, Erika D. M.D., M.S.; Ballard, Tiffany M.D.; Waljee, Jennifer
F. M.D., M.S.; Chung, Kevin C. M.D., M.S.; Momoh, Adeyiza O. M.D.

Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1224e–1231e

My experience with Dr. Michelow as a 4th year Medical Student

The following story occurred during my third year of medical school.

The man we were called to consult was 43 years old.  He was homeless, and due to prolonged lack of medical care a wound on his foot had developed into necrotizing fasciitis.  This occurs when an opening in the skin becomes infected with a destructive bacteria that subsequently ‘eats’ down to the fascia and muscle, and if left untreated can be deadly.  The surgeon I was following quickly evaluated the man and, with little explanation, told him that his leg would need to be amputated.  The man refused, and after we removed as much infected tissue as we could, was sent to the hospital’s inpatient ward with strong antibiotics.  The following day, we again consulted the man, and the surgeon again told him that the only option was amputation, with the only explanation being impending death.  The man again refused surgical removal of his leg.  I spent the next few weeks of my general surgery rotation checking in on him.  Four weeks later, the man left the hospital.  With his leg.

This is exactly the opposite type of care I have witnessed Dr. Michelow provide his patients.   I am now in my fourth year of medical school, and I have witnessed hundreds of interactions between doctors and patients.  I know a great doctor when I see one, and I believe Dr. Michelow is a great doctor, but allow me to explain what I mean by greatness.

Greatness can be achieved in any aspect of life, but I believe that greatness in the realm of medicine has two aspects; skill and humanity.  Skill is acquired through practice and training, which I will not delve into here as Dr. Michelow’s experience and training speak for themselves and can be found on his website.  Humanity, on the other hand, is something that I believe most physicians start their training with, but not all succeed in holding onto it.  I believe the surgeon’s pitfall in the above story, failure to recognize the patient as a fellow human being, was a loss of humanity.  However, Dr. Michelow has indeed held on to his, and will be a model for which I can refer to throughout my training.  Let me provide you an example.

A woman in her late 50’s came into the office requesting botox and fillers for fine lines and other imperfections she thought she saw in herself.  After a thorough discussion, Dr. Michelow softly recommended something I never expected to hear from a cosmetic surgeon; do nothing.  The patient I could tell was thrown off guard, and echoed my own thoughts by saying “I’ve never had a cosmetic surgeon tell me I didn’t a treatment.”  It was shining moment for medicine in my opinion, as the patient left seemingly happy and more confident in herself, and did so without any cosmetic treatment.

I will not be pursuing a career as a cosmetic surgeon, as my calling has been for pediatrics.  But what I’ve learned is that compassion and humanity can be found in all corners of medicine, not the least of which include Dr. Michelow’s office at Contemporary Cosmetic Surgery.

Nathan McGraw OMS-IV
2LT, US Army

Scar Care 101

Understanding Scars
When a person sustains a minor injury, such as a scrape after a fall, a scab typically forms.  When the scab falls off, the skin may be pink or reddish in color, but over time this will fade and the skin will return to normal.  Wounds such as these only cause a partial thickness skin injury and are likely to heal without significant scarring because there is sufficient remaining skin to regenerate the surface layers.

Conversely, when a full thickness injury through the skin occurs from an accident or following surgery, the skin does not regenerate, but rather it heals with scar tissue.  Scar tissue consists of collagen, whereas skin consists of the dermis and epidermal cells.  Although scar tissue is similar to skin, it is not identical and that is why a scar can always be differentiated from regular skin.

Scars are permanent!

Skin is elastic. When lacerated, the edges of the wound pull apart. When an open wound is closed with stitches, the skin along each side of the wound is pulled together with stitches.  The skin, being elastic, tries to return to its original position. Because the healing scar tissue is only 80% as strong as natural skin, the scar will stretch and may result in a wide scar.  

In an attempt to prevent the scar pulling apart, the healing scar may thicken and bulge above the level of the surrounding skin.

Scars typically thicken for the first few months after injury occurs and then will soften and flatten over a period of a year or two.  The red color of the scar will also fade over a period of a year or two. A mature scar will usually be lighter than the surrounding skin.

The surgeon has a partial role to play in the healing of the scar. The surgeon is able to control the neatness of his or her stitching of the scar and the tension in the closure of the wound. After the wound has been stitched, the healing that occurs thereafter depends on many factors.   Some of these factors include the following:

 Patient Factors
o The patient’s genetic makeup
o Overall health
o Diet
o Smoking
o Diabetes
o Tension of the scar
o Stretching/pulling of the wound (may contribute to a wide or thick scar)

 Complications
o Separation of the wound edges
o Development of wound infection

Scar Treatments
In general, there numerous options to improve the appearance of scars:

1) Over-the-counter or prescription creams, gels, oils, ointments, and tapes
2) Dermatological interventions such as chemical peels, microdermabrasion, dermaplaning,
        lasers, fat grafting.
3) Surgical revision.
4) Steroid or collagen injections – These injections help soften scars and may shrink them.
5) Indented scars may respond to dermal filler injections.
 

Scar Care Products 

While the wound is open, follow the treatment recommendation of your health care provider.

There are many products available on the market to improve the appearance of scars.  Wait until the wound is completely closed before beginning scar treatments.

Silicone-Based Products:
Silicone based products have been shown to improve the appearance of scars.  A study by Puri and Talwar (2009) found

that silicone produces an 86% reduction in scar texture, 84% in color improvement, and 68% reduction in scar height.  These products are available as gels and tapes.

Some advantages of using a silicone based product are the following:

      Increased skin hydration thereby facilitating the regulation of fibroblast production
         rather than collagen production. This results in a softer, flatter scar.
      Reduces itching and discomfort associated with scars.

Silicone Gels – A thin layer of a silicone based gel will dry within 4-5 minutes of application and work for 24 hours.

Silicone Based Tapes - These products come packaged as squares that can be cut into appropriate sizes to cover the scar.

Generally, patients should wear the scar strips over the scars for a number of weeks for optimal results.

Mederma:
Mederma products claim to improve the overall appearance, color, and texture of scars.  The active ingredient in this products is the common onion, or allium cepa.

Onion extract apparently reduces inflammation, inhibits bacterial growth, and regulates excessive collagen growth.  While these properties seem as though they would be effective, clinical research shows mixed results on scar products using the onion as the active ingredient.  

Bio Oil:
Bio Oil is a moisturizing oil that claims to improve the appearance of scars, stretch marks, uneven skin tones, aging, and dehydrated skin.  Bio Oil contains plant extracts and vitamins which are mixed into an oil base.  It contains both Vitamin A and E, but the breakthrough ingredient, PurCellin Oil, is what Bio Oil claims makes the formula light and non-greasy, allowing for better absorption of the vitamins and plant extracts.

Vitamin E:
Many believe that putting vitamin E on scars will improve their appearance; however, there is a paucity of scientific evidence that supports this notion.  Vitamin E does influence the formation and arrangement of collagen fibers.

Dos and Don’ts of Scar Care
To lower the chances of developing a more noticeable scar, we recommend the following scar tips:

• Protect the scar from the sun for several months to avoid permanent darkening of the scar.
• Do not apply any scar care products until the wound is completely closed. 
• Gently massage the scar twice daily to assist your body in the remodeling process.

Vanessa Lelli, CNP
Bryan J Michelow, MD

Tanning: How to Avoid the Dangers of Skin Cancer

While a bronzed glow is desired by many, the process to achieve this look can be deadly!

Whether you are catching rays outdoors or in a tanning booth, the ultraviolet (UV) rays are hard at work causing irreversible skin damage and premature aging.

Many believe that if they tan indoors for a shorter amount of time, they are limiting their risk; however, this is not the case.  People who regularly tan indoors are actually 74% more likely to develop melanoma, the deadliest of skin cancers, when compared to those that tan outdoors only (Skin Cancer Foundation, 2015).

Tanning and Skin Cancer
Did you know that in today’s world, the risk of developing skin cancer from tanning is higher than a person developing lung cancer from smoking?

The three most common types of skin cancer are Basal Cell Carcinoma, Squamous Cell Carcinoma, and Melanoma.

The risk for developing skin cancer increases significantly with UV exposure (Skin Cancer Foundation, 2015).

Melanoma, the deadliest of skin cancers, is on the rise in young adults and has become the most common form of cancer for those 25-29 years old. In addition, it is the second most common cancer for young people 15-29 years old.  On average, a person’s risk of developing a melanoma doubles if he or she has had more than five blistering sunburns (Skin Cancer Foundation, 2015).

How Do Sunless Tanners Work?
The safest way to achieve a tanned look is to use sunless tanning products.  

Sunless tanning products contain an ingredient called dihydroxyacetone (DHA) which is also known as glycerone.  Glycerone is a simple sugar, a triose, with the formula: C3H6O3. When the sugar interacts with the proteins (amino acids) that are naturally located in the outermost layer of your skin, the epidermis, it causes a chemical reaction that produces a tanned color ranging from yellow to brown.

Sunless tanning products contain DHA in concentrations ranging from 1% to 15%. Most products found in your local pharmacy range from 3% to 5%, with professional products ranging from 5% to 15%. The higher the concentration of DHA, the darker the skin color.

Lighter products are easier to obtain a more even tan but may require multiple coats to reach the desired depth of color.

Darker products produce a dark tan in a single application, but streaking may be a consequence.
The artificial tan takes 2 to 4 hours to begin appearing on the skin surface and will continue to darken for 24 to 72 hours, depending on formulation type.

Once the darkening effect has occurred, the tan will not sweat off or wash away with soap or water.

Since skin cells undergo rapid turnover and naturally slough off every 3-7 days, thus the tan will fade and will need to be repeated.  Exfoliation, prolonged water submersion, or heavy sweating can lighten the tan, as these all contribute to exfoliation of the surface skin cells that have been tinted by the sunless tanner.

Research has demonstrated that for 24 hours after sunless tanner application, the skin is especially susceptible to free-radical damage from sunlight. Therefore, it is recommended that for a day after self-tanner application, excessive sun exposure should be avoided and a sunscreen should be worn when outdoors.

An antioxidant cream may also minimize free radical production. Although some self-tanners contain sunscreen, the effect does not last long. Despite darkening of the skin, an individual is just as susceptible to harmful UV rays. A sunless tan, therefore, will not protect the skin from UV exposure.

A word of caution from a toxicologist and lung specialist at the University of Pennsylvania's Perelman School of Medicine: Inhalation of the fumes of the sunless tanners may enter the lungs and be absorbed into the body. The compounds may promote the development of cancers.

When used topically, sunless tanners have been approved by the FDA as safe.

Types of Sunless Tanners
There are many different types of sunless tanning products on the market. These products range from sprays, mousses, gels, lotions, creams, and cosmetic wipes that are available at your local drug store.

Professionally applied products include spray tanning booths and airbrush tan applications.

Common Tanning Myths 

• Tanning indoors before you go on a big vacation is good so you can get a base tan.  MYTH!

The body’s response to UV injury is a tan.  Regardless of whether you tan before or on your vacation, you are injuring your skin!  You are still at high risk of burning regardless of how tanned you are prior to your vacation.

• Tanning in a tanning bed is safer than tanning outdoors. MYTH!

Tanning beds are designed to give you significant levels of UV radiation in a much shorter time.  Tanning for 20 minutes in an indoor tanning bed is equivalent to tanning outdoors for several hours.  One indoor tanning session increases one’s risk for developing skin cancer by 20% and each additional indoor tanning session within the same year will increase your chance by an additional 2% each time (Skin Cancer Foundation, 2015).

• Tanning is a great way to get your Vitamin D. MYTH!

While getting an adequate amount of Vitamin D is important to our overall general health, there are better ways to get it than tanning! The risks of tanning, to boost vitamin D, certainly do not outweigh the benefits.

Fortunately, we don’t live in Iceland and so we usually get adequate amounts of sunshine and Vitamin D from being outdoors. The safest way to ensure adequate levels of Vitamin D is through our diet.  Foods high in vitamin D are mushrooms, mackerel, sockeye salmon, herring, sardines, catfish, tuna, cod liver oil and eggs.

A daily multivitamin with vitamin D is also recommended.    

• Can I still have a tanned torso?

The take home message is sun tanning is very dangerous.  The short term benefits of tanned skin are not worth the serious health risks that could result.  So, yes, you can be tan today, if you change your way.  Don’t delay, just change to a spray!


Vanessa Lelli, DNP, FNP-C
Bryan Michelow, MD

Kybella® - New option to eliminate a double chin without surgery

Prior to the recent approval of Kybella® by the FDA, eliminating a double chin meant liposuction and invasive surgery.  Not any more!

Kythera Biopharmaceuticals received FDA approval in April 2015, for its new product, Kybella®. This is a deoxycholic acid which is a “bile acid”. When injected into the fat below the chin, it helps destroy fat cells.

When the manufacturer was contacted so that an order could be placed for this new product, the representative stated that the “super quick” approval of Kybella® by the FDA was unexpected and injector training prior to distribution is currently in progress.

Kybella® is a bit more complex than neurotoxins or dermal fillers.  It requires a series of injections, for optimal results.

Kybella® will address the double chin fat but not skin or muscle laxity. It is not FDA approved for use elsewhere on the face or body.

How does Kybella® compare to liposuction or surgery?

Kybella® can be injected into the fat under the chin in the doctor’s office. There is unlikely to be any “down time”.  Its effect may last for a few years.

Liposuction offers a more customized treatment and is more predictable in contouring the fat. It also offers gratifying results when swelling from surgery subsides.

Surgical procedures have the advantage of removing the fat of the double chin, tightening the neck muscles and tightening any loose neck skin. The trade off of surgery is the need for an anesthetic and a few weeks for recovery.

Kybella® may “do” for double chins, what Botox® did for facial lines.

This is an exciting option for those patients who are concerned about having surgery and for surgeons who are excited to offer an additional less invasive procedure for unwanted fat under the chin.

Bryan J. Michelow, MD
Office: 216-595-6800

SPF Sunscreen: Is Higher Better?

SPF, or Sun Protection Factor, is a numeric value displayed on sunscreen labels to indicate their ability to block out harmful sun rays.

A common misconception about SPFs is that the higher the SPF, the better the protection.
While there is some truth to this, it is not quite as simple.

As the SPF increases, so does the protection from harmful sun rays, however, once you reach SPF 50 or higher there is only a slight increase in protection.

For example, an SPF of 15 will block approximately 94% of sun rays.  An SPF of 30 will offer you additional protection of about 97%.  Once you reach SPF 50, you will get about a 98% blockage from harmful sun rays, which is only a minimal increase from SPF 30 with 97%.

Thus, increases in SPF are not directly proportional and will only result in a minimal amount of additional protection as the number increases.

Excessive sun exposure increases one’s risk of premature skin aging as well as skin cancer.

We recommend the following to decrease the above mentioned risks:
• Daily use of a broad spectrum sunscreen with an SPF of at least 30.
• If you are spending more than 2 hours outside, be sure to reapply your sunscreen.
        Repeat every 2 hours at least.
• Avoid spending too much time in the sun during the peak hours of sun intensity (10am-2pm).
• When outdoors, protect exposed skin with clothing and a hat

When choosing a sun protection product, there are many options such as sprays, lotions, gels, sunblock, sunscreen, and more!

While the majority of products will work well, consider the following when making your selection:
1) Sunblock versus Sunscreen: 
                  Both will protect you from the sun, but their mechanisms of action differ.
                  Sunscreens contain chemicals such as Oxybenzone and Avobenzone that filter some of the sun’s UV rays to protect your skin.
                 These chemicals breakdown when exposed to UV light and need to be reapplied every 2 hours at a minimum.

                  Sunblock, on the other hand, acts as a physical barrier by reflecting the sun’s rays, thus, blocking harmful sun rays.
                  Most sunblocks will contain either zinc oxide or titanium dioxide.
                  Sunblocks are not broken down by UV light and will last longer provided they are still covering the skin.

2) Sensitive Skin: If you have sensitive skin, we advise you to select a sunscreen that is fragrance free, oil free, and hypoallergenic.

3) Acne: If you have acne prone skin, we recommend selecting a non-comedogenic (won’t clog pores), fragrance free, and oil free sunscreen.

4) Asthmatic:  If you or your child has a history of asthma, we advise caution if using a spray as these could provoke an asthma attack!

Desperately desire a tanned look?  See our next blog on sunless tanners!

Vanessa Lelli DNP, FNP-C 
Bryan J. Michelow, MD, FACS