I want to welcome members of the American Society of Plastic Surgeons and all non-member participants to this year's Plastic Surgery of the Meeting in San Diego, California. We are truly grateful for your participation in our on-demand session. Your time and effort are greatly appreciated. My name is Patrick Garvey. I'm a professor of plastic surgery at MD Anderson Cancer Center in Houston, Texas. I'll be the moderator for this session titled Better Together, Interdisciplinary Alliances Collaborating for Comprehensive Care in Plastic Surgery. Today we'll be hearing from some fantastic panelists who I want to introduce to you. Terri Coote is the founder and director of the Deep C Foundation. She's been a fantastic patient advocate for breast reconstruction patients for over two decades. She'll be talking about integrating patient advocacy into your breast reconstruction practice. Dr. Denise DeGiolo is a professor of plastic surgery at the University of South Florida in Tampa. Dr. DeGiolo will discuss how interdisciplinary connections can improve aesthetics and shorten timelines for breast reconstruction. Dr. Carolyn De La Cruz is a professor of plastic surgery at the University of Pittsburgh Medical Center. And Dr. De La Cruz will teach us the importance of a multidisciplinary approach to treating lymphedema. And Dr. Aparna Vijayazakaran is an instructor of plastic surgery at the Mayo Clinic in Rochester, Minnesota. Dr. Vijayazakaran will discuss working with your surgical oncologist to incorporate sensory innervation into your breast reconstruction practice. Hello, everyone. My name is Denise DeGiolo. I'm a professor at the University of South Florida Department of Plastic Surgery. I also work full time at Moffitt Cancer Center for the last 14 years. I'm honored to be invited to this panel for Interdisciplinary Alliances. I'd like to say hello to our moderator, Dr. Patrick Garvey, our fellow panelists, Dr. Carolyn De La Cruz and Aparna Vijayazakaran and Dr. Terry Coote. I'd like to talk about improving aesthetics with interdisciplinary connections and shortening timelines. I'd like to go over the communications between the breast oncologist and the plastic surgeon in the preoperative period, intraoperative and postoperative period and different types of settings and recent improvements in aesthetics and how we could shorten timelines with the recent advancements in the last couple of years. Again saying hello to our fellow panelists. I have no disclosures. I'd like to start with the goals of breast reconstruction, which is mainly aesthetics and symmetry, lifted look and augmented fuller look usually or a reduced look per the patient's desire. If you look at 2023 ASPS statistics, 157,000 women went through breast reconstruction and we can see most of them are immediate reconstruction, which is so important for the communication with mainly the breast oncologist. The other tendency that we're seeing in the recent years is the fact that they're pre-pectoral, so the importance of communication is even more important. For the patient's experience, if you look at the pre-op, the communication with the breast surgery, how long does it really take to see the plastic surgeon? It depends on the institution, on the times of the year or the schedules, but ideally it should be less than two weeks. How was the initial encounter on the reconstruction and how far out is the combined surgery scheduled? Due to block times or different various reasons, this could be an issue. In our institutions, sometimes to facilitate this, the breast surgeon would book the procedure and to hold some space in the operating room even prior to seeing the plastic surgeons at some point. In the end, does the patient feel good about all the decisions? The timely surgical scheduling and a patient that has active breast cancer that is a candidate for breast reconstruction is very important. Pre-op chemotherapy can be planned ahead of time, and then again, post-op radiation plans can always change our reconstruction plans, so we also communicate with the breast oncologist and the radiation oncologist as well. For the scheduling and to get to these patients early in a timely fashion, recently we found that the virtual visits have been tremendously helpful to get them in the system to screen them prior to seeing them actually in the clinic. We could potentially give them a surgical date that can reduce the wait times. So that's important for the alliances. It saves time for the patients and gets the surgical interaction quicker. So then once the clinic visits are done, then we are finally in the operating room. Pre-op communications with the breast surgeons are the part that I'd like to talk about. Mainly the markings and how we can do the markings with the help of the breast oncologist. For the patient's experience, they can palpate a tumor and they can notify us where they can feel the tumor, the lump. We always check the location of the tumor with the breast oncologist and to make sure if it's too close to the skin to incorporate it in our mastectomy skin markings, even if it's a skin-sparing mastectomy. We can offer different types of mastectomy scars, for example, nipple sparing or Weiss pattern at times. The Weiss pattern we rarely use, but the nipple sparing in surgical candidates gives us the ultimate best result if the patient is a candidate. Again, all these discussions are made with the breast oncologist the day or sometimes the day prior when the patient is able to come for certain markings. And whether to incorporate prior lumpectomy scars or some additional scarring, keloids, the location of the palpable tumor or DCIS or the marker have to be completely agreed on with the breast surgeon prior to them making the mastectomy incision. Basically the vertical mastectomy in our study many years ago found that it actually is a good adjunct and could be utilized and it actually takes away the stigma of the mastectomy scar and doesn't increase the complications. For the direct-to-implant patients, especially the pre-pectoral breast reconstruction being much more common in the recent years, certainly we have to make sure that the mastectomy flaps are healthy. If you look at the ASPS statistics, interestingly, 10% increase in pre-pectoral over the last year. Basically, 106,000 patients had pre-pectoral reconstruction, which is 68% of all the reconstructions in 2023, where it was 58% in 2022 and much less in the recent years prior to that. So we have a young, healthy patient going through a skin-sparing prophylactic mastectomy. The markings are done in the sitting position, I'm sorry, standing position and the markings are discussed with the patient and the breast surgeon. We take minimal skin and patient's expectations are to be slightly fuller, not necessarily bigger and we can proceed with this. So after we leave the patient to the breast oncologist and they start the procedure, then we come in, once they're ready for us, and then we communicate again about margins, if there was a need for additional skin excision due to positive margins, nipple excision, sentinel lymph node status, again, intraoperative communications, need for lymph node dissections, obviously, and if they had additional bleeding concerns, if they had skin thickness concerns that they would like to point out to us, to warn us, and basically to make the decision whether this is a direct implant versus a tissue expander versus sometimes even aborting some of these procedures. After the mastectomy is done, we want to make sure that we prep and drape again, at least prep again, and then basically do a lab count and start our part of the procedure. The SPI skin assessment has become increasingly important over the years due to the increase in pre-pectoral reconstruction. The intraoperative angiography has been a significant adjunct to our communication with the breast oncology. It helps us assess the mastectomy skin flaps nicely during the operation, gives us much less problems when we can use the SPI, especially when it's a direct implant reconstruction without the expander. So these are some studies that found the importance of SPI. Ideally, if we could do an immediate skin-sparing mastectomy with direct implant, that would save time for the patient. And if they can get away without any infections, which are surgical infection rates, with take-back rates in 30 days is about 7%, then that's a good thing for the patient, and less hospital visits, obviously no need for tissue expansions, and they can proceed with their normal lifestyle much easier, much earlier with this direct implant method, which mandates a healthy mastectomy flap. So once this is established, then they can move on to the next stages of their reconstruction. The SPI angiography is even more important in nipple-sparing mastectomies. We found that one of our studies and frequently used product, No Conflict of Interest, this was able to elevate and hold the tension of the flaps after mastectomy to support and improve the adherence of the acyloid dermal matrix to the skin by acting like a soft tissue splint without increasing the cost. We used this material, and the other ideal condition or situation is immediate nipple-sparing mastectomy with the DTI. This patient was a prophylactic BRCA patient that was able to do the direct implant with nipple-sparing mastectomy, and you could see some of the asymmetries could even be improved as a part of improvement of aesthetics as a part of the mastectomy. So this would not be possible without the alliance or coordination with the breast surgeon and the patient expectations of improvement of aesthetics. We can also improve some of the ptosis with this technique, and even when we have to use submuscular implants or expanders, which were much more frequently used maybe five years ago. Basically, the mastectomy, when we're doing a more complex procedure such as a mastectomy and immediate deep flaps, markings of the breasts should improve the breast aesthetics, and that also increases the communication with the breast oncology. We can work at the same time to decrease the operative time, which also requires coordination of care, and mastectomy skin thickness is even more important in deciding how much to de-up of our deep flaps and whether to include mastectomy flaps. Another aspect of interdisciplinary alliance is the nutritionist, because abdominal refinements is a part of aesthetics, and also to have a successful deep or abdominal-based free flap or pedicle flap, a successful result, we need a certain BMI, usually cut of 35 and below, and we can have some of those patients for weight loss, and instead of saying, please go ahead and lose some weight, we have a nutritionist under the same umbrella who can help with weight loss, and we had so many patients that I was able to lose some weight in preparation for their surgery and have their surgery safely, and that's another form of interdisciplinary alliance. With this in mind, also I would like to underline the LIPSTROM program, the YMCA potential where these patients can be referred to for sometimes free for personal training to help with their goals. Again, for goals of breast reconstruction, the same, but especially for the deeps and muscle-sparing pre-tramps, a flatter abdomen is the key. The deep flaps are still 8% of the reconstruction, 20,000-plus were done in the U.S. just last year. Again, the markings and mastectomy skin flap thickness, coordination, timing of these procedures, especially if there's an active cancer is very important. We do not want our flaps to be radiated. We prefer to do the radiation before, and then again, supporting those thin mastectomy flaps so they don't get compressed against the weight of the deep flap. Again, mastectomy incision planning requires the nipple to be elevated to improve the aesthetics at the planning stage, so this could be incorporated in our toolbox, and it should be considered while we're marking the patient in addition to everything else. This way, the nipple elevation with mastectomy incision improves the patient's aesthetics without increasing the complications. In our series, we were able to identify that, and also the abdominal flication was a part of it. The abdominal flication did not increase the complication rates in our studies. This is just an example of a patient that was able to lose weight prior to her prophylactic double mastectomy with deep flap reconstruction. With this motivation, she had a successful result for flaps, and then ultimately had 3D nipple tattooing. Mastectomy design should take into consideration the nipple elevation. So for postoperative considerations, the alliances continue with direct communication when to start chemo if needed, or you don't want to start immunotherapy too early before the healing takes place. So timing of these treatments are important, usually post-abradiation if it has to start, if everything is healed by one month. Latest three months are cut off, but mainly these require communication with those attendings. For regular direct implant reconstruction, one to two weeks follow-up, removal of our drains, followed by the breast surgeon following them in three weeks for their pathology. After the initial reconstruction is completed, hopefully with direct implant without the need for expansions, then another tool to decrease the timeline is 3D nipple tattooing, where they could tattoo the nipples in a 3D fashion. And there's another collaboration effort in terms of alliance with many of these 3D tattoo artists around our community that are successfully performing these procedures and improving patients' quality of life. Again, I'd like to thank everyone for listening. Hello, I'm Carolyn Delacruz, and it's my pleasure to be a part of this Better Together panel. I'd like to thank the ASPS for the opportunity to present, for Dr. Garvey for moderating. So let's get started. I'd like to speak today about the multidisciplinary approach to lymphedema care and how building an interdisciplinary alliance can lead to more comprehensive care in plastic surgery. I really do believe that teamwork makes the dream work. And it's important as plastic surgeons, particularly in lymphedema care, to set up a full team with complementary skills. The rationale for changes such as this is that multidisciplinary teams do better. There's documentation to provide and evidence that it leads to increased survival, improved outcomes, and really positive changes. On every level of input, including personnel skills, team skills, the environment, and the patients, multidisciplinary groups can provide improved outputs, including better patient experience, personnel well-being, better clinical outcomes, and more organizational outcomes. The three most important team competencies include maximizing collective intelligence, inclusive collaboration, and open communication. And I would like to take the next couple of minutes to try to convince you why. There's ample evidence in lymphedema care that a multidisciplinary approach is the best. And this has come out of a wide variety of institutions. At my institution, we have a whole team of experts now in my region. And for my patients, we include oncologists, radiologists, nutritionists, and lymphologists. But this can include a wide variety of people and experts that are tailored to your needs. This is an example of my team, including my research team, therapist, clinical providers as well. So why is LymphedemaCare need to be more comprehensive? Well, it touches on every aspect of patients' bodies. And there's such a wide variety of medical reasons for patients to suffer from lymphedema. They span from congenital, acquired, post-phlebitic syndromes, and can result from a wide variety of chronic medical conditions. As well, as many of you know, there's a wide variety of cancer-related lymphedema causes, including breast cancer, ovarian cancer, melanoma, head and neck, anytime essentially where lymph nodes or lymphatic systems are disrupted, as well as in post-surgical lymphedema, in orthopedic cases, and just in general plastic surgery reconstructive cases. As well, it can be multimodal in cause. Patients can have genetic predispositions and undergo surgery. They can additionally suffer from chronic venous insufficiency. And then there's obesity-related lymphedema. And of course, surgery plus infection can propagate the disease itself, rendering people with complicated medical courses. It as well is complicated for providers to understand lymphedema, because as many of you know, there's not a lot that we know about it. And in addition, the surgery and the specialty itself is evolving. It's not what it used to be. For that reason, it's important to master lymphatic care in conjunction with our multidisciplinary teams. Here's a group of surgeons at the NLN last year discussing surgical care. And here's a group of lymphatic therapists discussing care. I was curious about lymphedema therapy so much so that I actually obtained a lymphedema certification to understand more the components of it and what it can do. And the reason is because despite improved outcomes in the safety and efficacy of lymphatic surgery, we know that there's a significant portion of patients who will still require post-op adjuvant care. And so it's important to understand this, that surgery alone may not be the answer. Now I will bring this up because for a long time, patients thought that it was medical versus surgical care. But I believe in both medical and surgical care. There was a time in the late 80s where both surgeons and medical providers were pitted against each other. But now I think we're all committed to working together. So finding the end is really important. Also understanding the expert results that can be obtained by proper complete decongestant therapy is important. Nonetheless, we are often the leaders of these groups. The five key elements, I believe, to improve interdisciplinary care are listed on the slide. The first is understanding the hierarchy. Surgeons can be a bit much and can be difficult to deal with. As you can imagine, we can be a little bit demanding. But I think that in working with our team, it's important to get to know each other on a number of different levels. In my institution, we hold a number of different social events, retreats, and parties so that we can understand each of our perspectives and really get to know each other as well. I believe in respecting everyone's expert skills. As such, I believe that in a roundtable discussion, everyone deserves equal participation. We meet monthly together and discuss the patients, and everyone is part of the discussion. As well, we establish protocols together for protocols that will work for everyone. In addition, I believe that improved communication is also one of the keys. And it's important to set common goals together. These are some common goals for lymphedema care, which as you can see, do not include cure because to date, we do not believe that any of these modalities will lead to cure but improved quality of life. Now this is a care plan from a certified lymphedema therapist, where as you can see, sometimes it's difficult to discern that from the hieroglyphics. And I'm kidding, but just to highlight that sometimes the goals can be different. So shared decision making, shared goals can help. And also, there's a large benefit to feedback. I think that having meetings with key players, particularly those that are in the front line can be helpful. Measuring quality of life scores and using patient satisfaction reports can be extremely helpful when working with a mixed group. Here we are at a recent lymphedema conference, therapists, providers, surgeons, all like with collaboration at our core, really working better together. I'd like to close with a study that we performed at my institution to see if multidisciplinary approach is better. And we compared care that patient had received from single providers as opposed to our multidisciplinary approach. And this is an example of the survey that we conducted, asking them about their prior care as opposed to our multidisciplinary care. And the questions were grouped into specialized care level, patient education, and their satisfaction with their care. And as you can see, on all the responses, there was significantly improved care from a patient perspective, thus proving that multidisciplinary care is better. And as well, we believe that having all the multidisciplinary providers in one spot can improve efficiency as well. So thank you very much for joining in, and I hope that this convinces you that we are better together, especially when it comes to the complex care of lymphedema patients. Thank you very much. My name is Terry Kuti, and I want to thank ASPS for the invitation to speak along with your esteemed members and surgeons. I am the founder and director of Deep Sea Foundation. I will be speaking today on integrating patient advocacy in interdisciplinary care to improve your practice. I have no disclosures. How did I get here? How did I come to be recognized as a patient advocate? I will briefly share my story. What I came to realize over the past few years is that my story is but one of thousands of stories, voices of patient advocates. I will discuss what a patient advocate might look like, how you can engage with them in your practice, and finding the right advocates, investing time in nurturing relationships with them to improve your practice and assist with coordination of care. Before having breast cancer twice, I was a trained ESL teacher. In my work, I was placed squarely between parents, administrators, and specialists to best serve students and their needs. Most of the time was spent in the classroom teaching, diagnosing learning difficulties and creating lessons, adhering to district guidelines, addressing the individual needs of students. In addition to classroom hours, I attended early morning or late afternoon meetings with several individuals in the educational system. Support from administrators, parents, and specialists was the backbone and recipe of what I consider to be a successful teaching career, but it didn't always work out to the student's advantage all the time. To be expected in any profession, and similarly, these are the challenges we meet in the healthcare system and what each of you must deal with daily as surgeons and physicians. My life changed in 2002 when I was first diagnosed with breast cancer. My first appointment was with an oncologist, but in the months to follow, I would see a breast surgeon, radiologist, pharmacist, and several other specialists who would instruct my husband and me on infusion therapy, or what we would often refer to as confusion therapy, to manage the chemotherapy treatment I was given. There was the internet. It's what I used to research, but I was also handed a lot of hard copies of information from MD Anderson in the Houston Medical District where I was treated for my first breast cancer diagnosis. I was pleased with my care there, but I was fully engaged with my team, as was my caregiver husband. I was fortunate to have his support, support from our two sons and our extended family and friends, but not everyone is that fortunate. During both my breast cancer diagnosis, I met challenges in coordinated care and finding a team to work with. I changed oncologist once because of something that was said to me, and another time because a misdiagnosis happened due to lack of coordination of medical imaging records from one facility to another. An oncologist said to me, I'm going to make you very sick. I was a healthy 47-year-old woman at the time. These words did not feel like coordinated care to me. Another time, because of lack of coordination of medical imaging records, I was told I was stage four metastatic. Those words later had to be retracted when further scans were ordered. These can be dark days for patients, and when this happens and why this requires patients from the medical team and the patient emphasizing how important coordination of care is, even when it means coordinating care across state lines. After successfully completing two lumpectomies, 18 weeks of chemotherapy, six weeks of daily radiation, and five years of tamoxifen, I worked diligently to regain back my strength and return to teaching. We had moved to Arizona, and as planned, I was back in the classroom. In April of 2014, I had an annual mammogram revealing my breast cancer had returned, and now I had a new primary in my right breast. I was facing a double mastectomy. I had an amazing breast surgeon who introduced me to a term she didn't formally use, but diligently practiced, shared decision-making. What did that look like for me? She gave me all my options for breast reconstruction, knowing I was facing a double mastectomy. She honored my choice of using my own tissue and choosing DeepFlap. She listened, was compassionate, but realistic in what she could do for me and what expected outcomes would look like. She helped me look for a highly qualified microsurgeon to perform my delayed DeepFlap and respected and endorsed my choice to travel to have it done. She did everything she could to coordinate my care, even by prescribing lymphedema therapists to prepare the skin envelope she left after she successfully performed a skin-sparing, nipple-sparing mastectomy in May of 2014. In October of 2014, I met with the microvascular surgeon I chose to perform my DeepFlap. I chose one of your esteemed ASPS colleagues, Dr. Minas Crisopolo of PRMA in San Antonio, Texas. Once again, I needed coordinated care. His office worked with my primary care to get the proper lab work before surgery and my oncologist when key pre-surgical communication was needed. I was introduced to shared decision-making by my breast surgeon, but I began to understand the value of this form of communication even greater with Dr. Crisopolo. Within minutes of walking into his office for my first consult, he pulled up a chair right in front of me and said, you've been through a lot, haven't you? His focus and eye contact never strayed from me, his patient. This began our trusted relationship, and I knew I could ask for coordinated care needs during the entire reconstruction process. Meanwhile, his nurse was taking notes on the computer. I felt like I was part of this decision and a team member in my coordinated care. Remember this when you walk in your own consulting room with patients. If he had been facing away from me, occupied with other tasks, appeared hurried, it would have set up a different relationship. I would not have felt as comfortable asking their office to coordinate care with other specialists had this type of communication not taken place. On December 1st of 2014, he successfully and masterfully restored my breasts that were taken by breast cancer. Now I want to fast forward to what a patient advocate looks like, how you can engage with them in your practice, and how to find the right advocates investing time in nurturing relationships with them to improve your practice and assist with coordination of care. Some of you may or may not remember or know that in September of 2018, your organization chose me as their patient of courage. I admittedly may have been born with inherent traits that result in my being generally courageous, but courage grows and develops by being nurtured. Dr. Crisopolo saw something in me after he performed my surgery that led him to nurture the patient advocate relationship and utilize what he saw in me to benefit his practice, but more importantly, other patients. I honor him today, and if there are lessons to be learned in fostering relationships with your patients, look to the work we have done together since the day he called me on his way home from work and asked me to open what is and has been Deep Sea Foundation since 2016. But do all patient advocates look like mine did? Absolutely not. A patient advocate can be one patient. It can be a group of patients or a large, established, organized group. One patient can have a positive effect on your practice, or an organization of advocates can too. I encourage you to connect and recognize these patient advocates and nurture those relationships. This is just a small sample of national patient advocacy groups. They're making a much-needed and positive impact on patient education, support, changing policy, and providing resources and answers. Here's a term I've heard, and it's referred to as an e-patient. It means equipped, engaged, empowered, enabled. When your patients have experienced a diagnosis, surgery, treatment, and recovery from services you provide, identify those e-patients, collaborate with these patient advocates to provide emotional support and guidance to other patients, prepare them for their consultation with you, improve health disparities by connecting with marginalized patients, and streamline the health care system by providing education and support from lived experiences. Social media engagement can feel a bit like the Wild West at times, with unrestricted information and misinformation that can spread like wildfire. There are a variety of OHCs, or sometimes referred to as online health communities. In one study, they looked at the behaviors of breast cancer patients before and after a diagnosis. Patients were seeking information regarding symptoms. They wanted accurate, up-to-date information. And with so many sites available, patients expressed a desire to have them organized by type, so like government sites, support groups, etc. Online support groups are available 24-7, unlike their physicians. So think of sitting in a cozy coffee shop with friends versus waiting to be called back for an appointment in a physician's office. OHCs share real patient stories, tips on recovery, how to find help, how to find physicians. What are others doing to deal with side effects? I'd like to offer some of my own tips if you're thinking about engaging with any of these groups on social media. Providing evidence-based information is paramount. Online support communities are valuable for emotional support, but my experience tells me at the end of the day, evidence-based information gives patients a sense of control over the situation. They're at the beginning stages of coordinating care with their team. Patients are vetted by admins to eliminate the bots and folks who really have no interest in breast reconstruction surgery on the site that I admin in a private group on Facebook. So I have set tight parameters. Each new patient is welcomed by the rules of the group and the strict guidelines set forth to maintain respect among members. It is clearly stated that evidence-based information and interviews with healthcare professionals will be shared as part of the resources. It's very important to have a medical disclaimer on a site to indicate information should not be construed as medical information and to seek counsel by licensed physicians for medical advice. Here's the word on the street, and these are real questions and comments from this private group that I started in 2016. Hello, wonderful group. I have a question about hugs and sensation. I understand that loss of sensation in the breast will come along with this. I'm realizing that the sensation of feeling a solid hug on my chest, especially for my kids, is really magical, and I'm trying to emotionally prepare myself for how much of this sensation I will lose. I'm seeking advice from those that have been through this, and I think it will help prepare me for the procedures. Another one said, my plastic surgeon referred me to a deep flap doctor. I'm trying to gain insight from others, information regarding post-surgery pain, comfort, and emotional support for my decision to have deep flap reconstruction. And another one, I'm planning my double mastectomy and reconstruction for BRCA, and I'm hoping to find others in my region that can recommend a surgeon. Another one says, I was so lucky that my breast surgeon got me hooked up with a hospital occupational therapist with lymphedema credentials. On the day of my surgery, where she had removed nine lymph nodes, I then went in once a week in the beginning, and now I am on chemo. I go every other week. I was fitted for and wear a compression sleeve every day, and my occupational therapist has made all the difference in helping stretch and massage under my arm and single mastectomy area with the cording. I highly recommend it. Another person says, how long after completing radiation did you get your deep flap scheduled? Now, it's not medical advice, and many of these women know this, but what these groups do is give them a mental idea to prepare for what others have gone through. In as much as you can, communicate with other physicians to coordinate patient care. I can imagine this has to be challenging when you're working with patients already in a vulnerable and confusing place due to a diagnosis. Some patients are in a system of coordinated care, but we all know sometimes things fall through the cracks with the system. Sometimes things fall through the cracks with the system. We must remain nimble and open to collaborating with patient advocates to help us improve the patient experience. We are an underutilized resource. I invite you to let us help you find those potential advocates, and let's work together integrating patient advocacy in interdisciplinary care to improve your practice because I believe we are better together. Thank you. Hello, everyone. My name is Aparna. I practice at the Mayo Clinic, and I'm very excited to be part of this panel talking about interdisciplinary alliances, collaborating for comprehensive care and the care as a breast cancer patient. I have no disclosures, so I'm going to start my talk with this slide that I actually borrowed from one of my senior consultants, and he actually puts it as a talking point as a starting slide in a lot of his educational conferences for the residents just to go over the basic goals of breast reconstruction. He talks about permanent breast contour, the goals to make the breast look balanced, avoid the need for an external prosthesis, and to re-establish normalcy and confidence. Now, I would say that the wish list of a contemporary breast patient has evolved beyond that. I see breast patients, and we practice 100% breast, and we see patients with different things that are important to them. We have patients coming in while requesting a breast reconstruction with no implants, no foreign body. They want something that feels like their own tissue. They would like a nipple sphering, if possible, even though they have large, tautic breasts. We see patients who would like to pursue sensory breast reconstruction if at all possible. They want a down size, but they don't want scars. We see patients who want up size but would like to avoid a tissue expander. We see patients who, you know, want a more prioritized and aesthetic donor site. We see patients who would like to use their own tissue, but they don't really want a free flap. So, you know, while all of these, I joke, you know, add a lot of challenges to our breast reconstruction practice, I feel like truly patient needs are what drives and makes you think outside the box, at least in my practice. I feel anytime I've learned that, you know, if someone comes in and they kind of like ask about something that you don't routinely do, I always think twice about, can we do this safely, and is there a way to do it? So, I would say in the last 10 years, a lot has changed in breast reconstruction. I would say I can talk about 10 years because I've been in practice or in the field of plastic surgery, I would say for 10 years and in practice for seven years now, you know, a lot has changed. Prefectural reconstruction has now become the norm rather than the exception. You know, we have a wide variety of meshes, you know, including newer observable meshes. We have newer technology like hyperbaric oxygen therapy. It's fine. We have newer flaps. Sensory breast reconstruction has become possible. We have robotic surgery that's been possible, and we've also seen newer technical advances in lymphedema surgery. We have lymph, we have both prophylactic as well as therapeutic procedures for treating and preventive surgery for lymphedema as well. So, I wanted to just start the talk with a couple of things, you know, for the purpose of this talk, I was going to keep it broad and talk about all the things that we do together with our breast surgeons and the decisions that we make together that really helps optimize aesthetic and overall patient outcomes. So, this is a patient of mine. She, as you can see, has pretty large, tidy breast with a higher BMI, and I think she was someone that I did early in practice. She's more than five years out, and she came in at the time wanting a nipple spraying mastectomy, but again, she was a type one diabetic. She really didn't want to have implants. She had a lot of intravenous obesity, and she also didn't want to put herself through a free flap necessarily, but she still wanted some possibility of keeping a breast. She wanted to keep a nipple. So, this patient actually underwent a nipple spraying Goldilocks, and I can say, like, you know, me and my breast surgeon talked quite a bit before offering this to her because we know that this comes with increased complications, possible nipple necrosis. You know, we planned for three days of hypervioic in this setting, which is what she got. I did put an expander, and I, in retrospect, I probably could have got away without a tissue expander in this setting. She ended up getting two rounds of backrafting, and as you can see, this is her a few years apart with a relatively good outcome. She's happy. She never had to undergo a big flap, which I think was really good for her because if I remember correctly, this was someone who had borderline elevated creatinine. Her sugars were not the best, so I think she ended up with a relatively good outcome, which kind of lined up with her wishes and desires, and while I would say this is a surgical result, I would say this would not have been possible without, you know, working together with the breast surgeons, you know, involving our hypervioic colleagues to get her through the initial phase when she had a little bit of a complication, you know, and then we also have new advances in technology, which helped achieve this result. I want to touch upon lympha, which is another area where we collaborate with our breast surgeons almost routinely in all these cases. At our institution, we almost often offer lympha in any patient who undergoes axillary lymph node dissection, and early results have been promising. There's been more and more literature out from multiple institutions supporting good outcomes with this procedure for our patients. You know, again, I can say over the last five years, we've seen a lot of technical advances in this field, and I feel our surgeons have really gotten more efficient with reverse mapping and identifying and tagging lymphatics, all of which are invaluable to how it simplifies this procedure for us in the operating room. I wanted to also briefly touch upon robotic mastectomies. So, we did our first robotic mastectomy in our institution three years ago as part of the ongoing FDA trial. We've done more than 40 patients right now, and this is one of our earlier patients. As you can see, when they initially wanted to do it and our breast surgeon approached me to be the plastic surgeon on the trial, I was skeptical because I was like, you know, are we really going to add aesthetic benefit to the patient by doing this? I truly feel like we shouldn't do things just for the sake of doing it. I mean, we truly believe it's going to make it better, but you know, once that I've seen like a lot of our patients come through, I truly think there's an aesthetic benefit not having a huge incision on the fold. I think the patient's bruised less. We've had no complications with nipple or skin necrosis because the field is so pristinely clear on the screen. This is her results. This is a patient, one of my earlier patients. She's probably a year and a half to two out from her implant exchange, and you can see she has a very well-healed three and a half centimeter scar. I'm sorry, I didn't forget to put the lateral views in there, but it's a pretty small scar, and I think she had a good outcome, and she's overall happy with the results, and I can say while it was a challenge initially, like figuring out how to put the mesh in, how to do the same things through a small incision, I feel now it's become standard, and I see more and more patients having great outcomes with this. So going back to, you know, what I thought I would keep as a focus of my talk would be to talk about sensation. You know, we now have patients coming into a clinic requesting a sensory renovation or talk about, they want to talk about potentially sensory breast reconstruction. You know, we've been offering it for deeps for a while now, and then as you can see, it's been a long-standing problem. This is a paper that came out of Scottsdale a few years ago, and they really talked about patient-reported outcomes, and as you can see, it's pretty evident, you know, if there was one thing that really bothered the patients, it was sensation and arousal, and also they, it was pretty evident that if there was one thing that could change about the outcome, especially in regards to the nipple-areola complex, it was going to be sensation. So it's long been a problem, and again, solutions have been tried, but it's not relatively new. This, a little bit of background, so this is a paper that I was actually, I really think has a very catchy title, and I always go back to it, and it was a paper that was described by Dr. Blondell in 1999, and they talk about sensory breast reconstruction, and you know, he puts sensational as senseless because, you know, there was a lot to be known. Now, we can revisit this slide at the end of my talk, and you know, I truly still think that we don't have all the answers, but I think early results have been promising. While I wouldn't say universally we haven't seen great outcomes, we do have a lot of patients with a good early recovery and better sensory outcomes, and I just go over it. Now, for the purpose of this talk, I really just want to talk about working towards re-sensation with our breast surgeons in the operating room. I want to touch upon breast patient selection, as well as our techniques. I think both are equally critical in translating to a good outcome. Starting off with patient outcomes are basically indications. I think this is of utmost importance. You know, initially, when we started doing it, you know, we would offer it to any patient that we thought that we could technically do it, but I think the more we do, the more we feel that we need to be more selective so we can optimize our outcomes and truly identify patients who would benefit from this. The indications that I mentioned here, again, by no means have a lot of shades of gray in them. Even within our group of five or six plastic surgeons, each of those has some strong feelings about which patients would benefit the most from this technique. Ideally, we started off offering to patients with smaller breasts, anyone with an A to C cup. We have initially started off offering it for the prophylactic high-risk patients. We now offer it for the breast cancer patients. Again, I would highlight this because I truly feel like this has to be a really clean discussion with our breast surgeon. We now directly communicate. I think tumor location and oncological safety take precedence over any sensory reconstruction, and truly I defer to them to make the first call as to whether we really should be offering this to the patient. Other factors to consider are pre-op chemotherapy, whether the patient's at prior radiation, you know, and age, should we have an age cut-off. These are all things that we are kind of trying to figure out where and when we should put the calls and whether or not we should offer sensory breast reconstruction. According to just touching upon anatomy, as you can see, the key for this procedure, at least in the immediate setting, is to identify the lateral branches of the thoracic intercostal nerves. I would say we've been doing this for almost four, five years now. I remember our first case vividly. So our breast surgeons actually started off, you know, lifting the breast from posteriorly, and they really, we spent a lot of time trying to identify the nerves. We were in a small hole working through an IMF incision, lifting the breast off, and we did not have good visualization. And when we started off routinely, they would page plastic surgeons, and we would have to go in, and we would take like some time trying to figure it out. So, you know, it took a little bit of trial and error, and as you can see, the critical part of the case involves identifying and preserving the lateral thoracic intercostal nerves. So we have now come up with this sequence of events in the OR, which I think really works well for us. So our breast surgeons always start off with the anterior dissection first. Then they come around the breast medially. Then they do the posterior dissection, and they go medial to lateral, and they slow down when they reach the lateral border of the pec. And, you know, in talking to the breast surgeons, that's when, you know, they usually use the Bowie electrocardiogram. So things that they do differently now is they usually switch to a blunt dissection in the setting, and they start spreading around the lateral border of the pec to identify the nerves. So the other part that's been critical for us to make this actually part of our daily practice is that both of us are comfortable doing this. Say if they're, you know, running to a room, so they have to run the path for anything, like usually I just go in if I'm free, and I'm comfortable doing this, and so is the breast surgeon. And I think having this flexibility really I think makes it just a flow easier. So I'm just going to hopefully play this video a little bit. As you can see, it's taking a minute to load. This is our breast surgeon. This is one of her earlier videos when she started sewing, and as you can see, they're getting to the lateral border of the pec. She's using Bowie electrocardiogram and switching out to blunt dissection. I would add we had to actually redo our surgical trays. They did not have a lot of the dissectors. Like when I asked for tenonomies, they don't routinely have it, so we had to add some extra instruments on your tray. This is just for using something else in. We did go through a process of trial and errors because even when they identified nerves, initially we did not have initial length. Sometimes the edges were charred. So I think making these little changes and working together to find a good workflow has really helped translate this to daily clinical practice, and now it's just routine, and they actually get us long nerves. And as you can see, here our breast surgeon is dissecting a little bit into the breastbone, come out and get some length. Now I usually defer to them when it comes to this as to how much length they can give us. They always say the longer you can give to me the better, but I don't push them if they think it's oncologically not a good idea or if it's something that is close to tumor. You know, some things depend on patient anatomy and some things depend on oncological safety, so I usually defer to them totally as to what I'll take, whatever they can give me at this point. So this is just a picture showing a nerve graftation using a cadaveric allograft here. This is a picture showing that, you know, they started handing us longer and longer nerves. You know, with time, both of us got comfortable seeing things and making longer nerves a feasibility. And as you can see, this is a really long nerve. I mean, I think this is really long, but as you know, it's in a bad location. You know, this is not the traditional third, fourth, like the fourth intercostal nerve laterally that we would like. This is actually coming through the pack. It was going right through the breast tissue, so it was sensory nerve. So I do currently encourage them to preserve any nerve that they come across that they think they can technically and oncologically preserve. And what I do is I've been using them as autografts and all of us in our practice do it. We're still in the, I mean, currently, like I said, we don't have long-term follow-up, like of several years yet, but hopefully we hope that using allografts would translate to better outcomes. This is, again, another patient. Now this is purely dependent on patient anatomy, but again, you can see that it was a huge nerve, almost eight, nine centimeters in a small breast. And I think we were able to directly neurotize to the nipple. She wanted to be smaller. We actually did not even need an allograft in this situation. This, I think, is one of the most interesting slides is now that our breast surgeons are comfortable, like finding nerves, you know, they see nerves a little bit better and they, you know, we just becomes routine in our practice to really try to identify and preserve them. And this is just something that shows that they have preserved some nerves going into the skin really laterally. This is well beyond the lateral border of the pack and kind of at the lateral border. And I think trying to preserve these things make a huge difference in how much they have sensory outcomes. Again, we have early data that looks good, but again, this is also something that I think that adds a lot to their sensory recovery. So now that we have kind of, kind of fine-tuned the process of finding nerves and making this happen in the OR, you know, we're trying to expand our applications. You know, obviously the delayed setting is really up to us to offer. This is in the setting of robotic mastectomies. And you can see that we just started looking for them in our robotic mastectomies. And you can see, we started identifying them. We still haven't translated to figuring out how we can correct a nerve in this setting. But, you know, a couple of things, they do try to identify any nerves around the lateral border and see if they can leave it, see if they can preserve sensation a little bit better. And if this is something that we hope will translate to potentially be able to neurotize by the robot. So I'm going to end by just playing this little video clip about one of our patients. I think that, you know, I'm not sure if you can hear me. So these are just some early viewpoints from some of our patients. I would like to thank my partner, Dr. Harless, who was the one who shared this video with me of some of our patient outcomes. And as you can see, I would like to just end thanking everyone within the division of my partners. You know, I'm lucky enough to work with like a very cohesive group of all of our plastic surgeons who kind of have really worked well together to kind of improve our patient outcomes. And also give a shout out to all of our surgeons who, again, I love working with. And as you can see, this is just one of my kiddos hanging in one of my breast surgeon's kiddos. And we, and I would like to just highlight that a lot of this really depends on open communication. And I think that's been the key. You know, whether it be like our physical therapist, you know, talking about like breast edema or if they have post mastectomy pain or whether it's a breast surgeon to talk about incision planning or trying to figure out what would be the best procedure that we can offer the patient. I just think picking up the phone call, like picking up the phone and making a direct phone call or just clear communication, I think has been the key. Thank you, panelists, for those awe-inspiring presentations. We'll now begin the question and answer part of our panel. My first question is for Terry Coote. How do patients now navigate the decision-making process of choosing their care team? What are the biggest changes that you've seen and challenges that you've seen that patients face these days? You know, patients are spending a great deal of time, a high percentage of time, Dr. Garvey, on social media and in groups. And I do believe that's where they're making a lot of their decisions in finding information. I firmly believe, as you saw in my presentation, that we have to provide the utmost of information, evidence-based information, and positive support for these patients because that's where many of them are going these days to make their decisions because they want to share their experience with other patients, but they also want to ask other patients what they've been through. We are the customers, and so they know where to find those answers. That's what I'm seeing today. Great, thank you for that. Dr. Gigillo, since the pandemic, telemedicine and virtual visits have become a more common practice in contemporary healthcare. What is your advice to plastic surgeons about when to use telemedicine to most improve the flow of the planning process for breast cancer care? I think it's about the wait times to see the plastic surgeon. Our patients are going through so much that we don't want to burden them with having to wait for a plastic surgery visit for the surgeon of their choice. The other thing is to be able to, you know, be able to give them an opportunity to see us if they're living far away, sometimes out of state or far away in the state. That gives them an opportunity to see us prior to planning for their surgery. And sometimes the breast surgeons would want us to see them earlier than later, and that gives us a great opportunity to see them, screen them, prior to seeing them in the actual clinic and kind of get the ball rolling for their surgical planning. Time is of essence, so I think it's a great way to improve the flow and improve the patient satisfaction ultimately. So I think it's been very good for us to navigate through this planning phase for them. Yeah. Is anybody else using telemedicine in their practice as part of the improving just the throughput or flow of the breast reconstruction process? We did at Mayo during COVID, and then right now we have some regulations. We can't see new patients via telemedicine due to licensing issues, but we do do a lot of follow-ups. That being said, we have developed, especially for outpatient mastectomies, an app-based remote integrated care pathway, which enables them to get access to us much easily. It's integrated with Epic. We just tried it out, and I think it's been a really nice jump for our patients. But again, it's relatively new, but it is a much more secure way of patients having constant access to us. Great. I'd like to say also, like seeing the new patients versus established. In the beginning, we were seeing new patients. Now we can still see the new patients, but we prefer to see them in clinic as well. So there's like a secondary visit to follow prior to the surgery. But again, even for established patients or even some remote post-op visits for patients that are living far away, it's been a very useful tool, at least in our hands. Yeah. I mean, I agree. I love it for a secondary consult. You've already examined them. You've already put your hands on them, see what kind of tissue you're dealing with. You have the pictures often to refer to. And I do feel bad when patients do travel two or three hours to come to me for a 10-minute visit just for scheduling. So I love it to use it as a tool for that, especially when you've done all the hands-on work. And then it's just questions, answers, and scheduling. So I agree with that. Great. Dr. De La Cruz, you cited studies that have shown the benefits of multidisciplinary care and lymphedema care. Based on these studies and your own experience, what are the two or three most impactful practices that a plastic surgeon could employ to start an effective lymphedema center? Great. So thank you for the question and thank you for the opportunity to participate in this esteemed panel. And I think I really, you know, I love the title. I really do think we are better together. And I think in terms of lymphedema care, the recent studies that I included in my talk prove that, but a history actually proves that. Because in the late 80s and early 90s, when the idea of lymphatic surgery first emerged, you know, people didn't have the idea that it would be multidisciplinary. And it was a question of surgery or therapy. And so now to me, and I think largely most people would agree, it's a question not of surgery or therapy, but it's surgery and therapy. And so I think that not only the recent evidence proves it's better. So if I were to select for people who are out there trying to put together different groups, I think certified lymphedema therapy is critical. They are the ones that are familiar with how patients are gonna respond to those conservative treatments. They're the ones that are able to provide not only, you know, hands-on treatments in terms of CDT, but also patient education, which is critical, especially for people who may be at high risk. And that, so they bridge the gap. So certified lymphedema therapy is certainly number one. The number two person can, is a little bit of a harder question. In my practice, I brought in a nutritionist as a number two person, because a lot of these patients, so the two things we know that helps lymphedema the most is compression, CDT therapy, and then also like weight management. And I just find that some of my patients need that from a provider. So a number two person, maybe not a popular choice with other groups, but I like to think about bringing a nutritionist because those are the two things that we know are most effective in the literature. Other close ties for number two, maybe a radiologist. A lot of the nuclear medicine imaging, MRI, specialized reading of determined fluid versus fat can be done in partnership with radiologists. So other groups have leaned into that. I just don't have access to that in my personal practice. And then also like a medical medicine, we can't forget our medical support, medical internal medicine doctors. Vascular surgeons are also really key because they really understand that a lot of these patients may be medical. And so not everyone may be a surgical candidate. So also close tie vascular surgeons. I don't know. It can be really, the pieces of the puzzle can fit together depending upon what your demographics are or the patients that you see. So, but no matter what, everyone has an equal seat at the table. So Dr. Garvey, I do have a question for Dr. de la Cruz. More, I don't know if it's a question or a comment based on your presentation. I wanna tell you all that I gleaned so much information from each of you, you know, about sensory nerve preservation in breast reconstruction and also at, you know, just what you're doing with patients in terms of coordinating their care and integrating their care. My question is this. I know Dr. de la Cruz, that you mentioned that you had some monthly meetings or that you met at conferences networking to better improve patient outcomes and not to overuse a term, but seat at the table. Is, do any of you or Dr. de la Cruz in your meetings, do you see a place for patient advocates as a seat at the table to give feedback and to discuss their patient outcomes to improve any of the topics that any of you talked about today? I mean, I can just respond that we literally, literally all meet together, you know, in terms of the whole team when we have these monthly lymphedema multidisciplinary meetings. That's how we see all the new patients. Literally we go around the table and everyone, you know, throws their two cents in, in terms of patient compliance, candidacy for different operations. And then, I mean, there's literally an empty seat at the table that is in terms of insurance, right? Because a lot of these patients are not, may have trouble and need help with paperwork and getting them approved. And they're often denied. And that, the role for patient advocacy would be, we literally have an empty seat at the table in terms of patient advocacy. So if, which I would readily welcome because anyone that does lymphatic surgery, it may be different for breast reconstruction, I don't know, but anyone that does lymphatic surgery knows it's an uphill battle. And a lot of it really requires somebody to help from a patient perspective. So you're, we have an empty, empty chair at our table and happy to fill that with somebody that's willing to fight for patients because that's what we do all the time. So you'd be helping us. Love that question. Thank you. Thank you. Terri. Dr. Delacruz, quick question regarding CMC brought up insurance. You know, how much of a resistance or problems are you guys having with getting the prophylactic lymphoprocedures approved or is it something that is not an issue at all for you guys? Yeah. So thank you for the question. We, I think that that is a major question that a lot of centers ask, you know, and what, and so getting it approved, what are the codes and also what is the reimbursement on that? A lot of these are being done as part of prospective clinical trials, you know, which may fall into different categories for approval. Here at, in Pittsburgh, we're fortunate. We have worked with our health plan, which we have also a UPMC health plan, and we've been able to work closely with them to set up, you know, certain agreements. But what that means at the back end, how much we're getting for it, you know, are different problems. But, you know, we get that a lot, but that's, you know, maybe there was years ago where breast reconstruction wasn't covered and then we had to fight for that too. And now, so we're hoping for a day where, you know, these barriers have been eliminated. Dr. Vijayazakaran, I have a question for you. So you speak about working with your breast surgeon to preserve the lateral nerves when you do a mastectomy. And how did you get the breast surgeons to buy into this change in their practice? Just at the beginning, like, can you walk us through your pitch to the breast surgeons? You know, what was effective and your, you know, getting there to buy into this, what didn't work, just kind of a, give us some insight into your, you know, your change process for making what is a pretty fundamental change in surgical oncology at Mayo Clinic. Thank you for the question and thank you for having me. You know, yes, it's been a process. I mean, I think we have made, even just in the last three years, I would say, it's been, it's just become more routine now. So it started off, one, I think it was a lot of patient-driven requests that kind of led them to consider it. So patients come in now, they are on the recensation website. They are not of advocacy groups like Terry mentioned, and so it's important to them, so they bring it up. So when we initially mentioned, obviously our breast group here is very data-driven. So they were like, what is the data? Why do you guys want to do it? Why do you guys want to add to the procedure? And as you know, I mean, I think we have even less data than the lymphatic, but we do have early promising data from larger groups. Obviously lack of long-term data is still a limiting factor. So when they brought it up, we had an open discussion about what's out there and whether we should even think about offering this. So then we decided that, okay, if you're going to do this, we talk about pros, cons, and we realized there's not much downside other than we are actually increasing the operative time and to this possibly the expense of using a nerve graft sometimes. So then we decided, okay, let's just implement it as a practice change. And honestly, this came from them. And we have, I would say there was some reluctance from some of our senior breast oncologists compared to someone who was just coming out, but they were all willing to try. We started off, obviously some of the surgeons were bringing it up more often than others. I personally let them do the offering first, especially in the cancer patients, because sometimes it may not be oncologically, they may not be comfortable digging out nerves if the tumor's close to the chest wall, if it's close to the nipple. So cancer patients that I really don't overstep, I just let them bring it up. And then personally, I just add. So it kind of became like a routine dialogue with, you know, hey, what do you think? And they were open to it. In translating this to the OR, I think that was a little bit more, where initially when they started, they literally wanted us to go and dissect out the nerves. So, which, because they were just not used to it. So, but then, and I was open to it. Some of us, like, you know, depending, it's just harder because we have to leave our primary room, because a lot of times we have other cases going on and then go in and spend time in the mastectomy room. But we started doing it. And first couple of times, like there were, we went through the process, you know, they were doing things routinely. Like they were lifting the breast off the chest wall first and working in a tinier hole. So then we kind of tweaked it around and now we go up and over and dissect the breast off posteriorly, medial to lateral. So then we added a couple of things, you know, they didn't have actually tenotomy. They didn't have some instruments. We added the revamp their breast tray and they were open to using blunt dissections rather than Bowie electrocardiogram. Little changes, but you know, we scrubbed like two or three cases together and then they just started seeing things that they normally wouldn't. Like, you know, like I just say, hey, there's a nerve. And then it just translated. And interestingly, they're very interested in finding out the nerves for us themselves. So nowadays I would say 95% of the time they find the nerves. And I actually have a slide, like I think, where you can see they give us longer and longer lengths if they're more comfortable, if it's between a prophy patient. I mean, obviously they're all about oncological safety, but if they can get us some nerves. In fact, we have now progressed. I told them, find me any nerve on the field. Like if I can autograft it, I would like to do that. Then using it and kind of write graphs. So they've been able to even find me like 10 centimeter graphs, like, you know, say in the fifth, like the intercostal space, which anatomically is not a good place for nerve grafting, but I could use it as an autograft. So I think we have really seen an evolution of how they have adapted their techniques. And it was actually a pretty swift learning curve for them once they just thought what they were looking for. Yeah. And occasionally they do call us if they can. You know, they always call us at the lateral border of the pack. Like sometimes if they can't. If they can, they don't usually call us, but then I just go in and say, I just spent some time looking in. So I never get annoyed when they call me. I would rather they just call me so we can both make a conscious effort to find the nerves. So. Yeah. That's great that you're able to get them to buy into this change of practice. I know that's a lot of, a common question we hear from surgeons is, how do I get my surgical oncologist to change their practice, to kind of optimize outcomes in a breast cancer patient? Which kind of leads me into my next question for Dr. DiGiolo. In your talk, you described your handoff discussion with your breast oncologist after the mastectomies, before you proceed with reconstruction. What's your advice to the audience about how do you communicate with a surgeon when the skin flaps are injured, that you've done spy, you deem that the flaps are unsuitable for immediate reconstruction, there seems to be devascularized flaps. And how do you communicate that? And then how do you deal with, follow up question to that is like, how do you deal with a surgeon who that is a pattern? Like it's maybe they're an outlier and this is happening more than just every now and then. Thank you for this question. I think that's where our heart lies and it's important to communicate. I think that's the most important part of our practice. Basically like some, as we entered the room, we asked them, margins clear, they were invited to the room, to the operating room to do the reconstruction. And we enter, we just asked them about the lab counts, and rate accounts, EBL and margins, and the central nodes, so all clear. And then we start our part of the procedure, we scrub in with the hands on, we assess the flaps ourselves. And we asked them if there was additional extra bleeding that they recognized, if the bleeding was normal, or if they had some injuries or too close to the dermis or areas that they were particularly concerned about, if they had some sometimes even like coterie burns from inside, if they were concerned about any of that. And then we do the spy, which has been the most important practice recently. And then through the spy, we would ask them if possible to be in the room to see their flap circulation. I think that's a tremendous help for them to be able to be there, to see them by, some of them are very like interested and would like to see how it goes. And then some of them, they have another room they have to jump on to, but we can still like record it and discuss with them later. So we just, after that, we basically excise the edges that are not lighting up, but sometimes in that very bad scenario where we end up with, the skin is radiated prior, or you're doing a deep, and then all of a sudden the mastectomy skin flaps are not looking that great. So then we wanna excise those, we wanna make it symmetric as much as possible, aesthetically pleasing. At the end, it's not gonna do well if the spy isn't looking that great. We have to use our judgment of both spy and clinical analysis, of course, still together. And then as a second part of your question, if that happens, of course it's upsetting, but then we just communicate openly with the breast surgeon. Some of the things that can affect spy circulation, actually, or evaluation is some surgeons like to inject a lidocaine with epi that has been a little bit problematic. They might look a little bad in the beginning, but then they may actually be okay. Or sometimes some of the dyes that have magnetic, like some dyes that have iron in them can affect some of the spy. But apart from that, if this is a pattern, we just basically openly talk to them and they're very normal and okay with it. Like, I think we just have to communicate at the end of the day. And we're there for our patients and I feel very strongly about it. And so they do, I mean, so today, so then basically it's all about open communication and being on the same page. That's why working in the same place for many years, it's actually helpful. And you kind of have to understand the channel with every person, every different surgeon. And ultimately it's the patient's outcome. But the other physicians on the panel, thoughts about how to communicate with your breast surgeon about the mastectomy skin flaps? I mean, I love this question because, and I love that your idea, I love your handoff because usually, you know, they duck out and then they can just duck out of the room. And then they're like, oh, we buttonholed it. You know, could someone, you know, but I mean, that would be not ideal. But you reminded me of something, also a critical member of the lymphedema team, which is the surgical oncologist. And it reminded me of when, for lymphedema, when now we inject ICG in front of them and they can, like what Parna mentioned, the lymph. And so now they wait. Our handoff involves doing the ICG before I do lymph. And then they look and they can see where the ICG is pouring out at all the channels that they've divided. And then they're like, oh no, because they can literally see that, what we're going to reconnect immediately. And that's been just pictures worth a thousand words. And now I feel bad for them actually, because they stand there and then they just look and see all the damage that they created, you know, as a part of the axillary section. And so that just reminded me of your story. So I love that as a good handoff, just for the lymph. Those are my comments. You know, that's an interesting topic because it's very surgeon dependent, you know, and I must say I'm kind of spoiled. Like I may be, I don't want to say anything. I feel like I'm going to drink to myself. I maybe had like two actual skin necrosis that were unexpected, like in like seven years of practice almost. So it's, so most of the time, you know, it's, we get off pretty reliable flaps, but if we know, like we are going to be, they're going to have to really thin out the skin. Sometimes they'll be like, hey, I'm very nervous. You know, I'm going to be chasing margins not because of anything I do. I'm going to be having to shave into her skin laterally. Even if you do a Ys, it's going to be in a bad area. You know? So I think usually we talk in pre-op when we site market, like, you know, if there's any concern, we always recoup because there are certain things that they really can't avoid. And also then there's also, I call them the extreme nipple sparing mastectomies that we do right now. Like we've been doing like, there's no brush that they think is too large for a nipple sparing. I love that they're willing to play, but there are sometimes, you know, we've been doing Goldilocks, say nipple sparing, you know, with a nipple on it. So there are some high risk patients that we are someone would like prior radiation. I mean, now it used to be relative contraindication, but I feel like now almost they offer nipple sparing to those who have a prior lump radiation almost routinely. So if we see someone high risk like this, if both of us or either of us have any concerns, usually we try to do them earlier in the week, Monday, Tuesday. If we anticipate we're going to need hyperbaric, which I do think it helps in this situation. So this is something that we just added last year. And I think it has taken a lot of headache, like, you know, scheduling like problems off. Like say it's like really hard, especially for us, at least in our institution, to get hyperbaric. Like say we do a case on Friday and we are calling for help. Like they have to open the chamber in the weekend and get someone to dive someone once or twice. So we try to front load the week with the more complex cases. I don't know. I think it's been really helpful for our practice, just talking about it if we flag someone as high risk. Yeah. Great. My next question is for Terry. So you can hear that as plastic surgeons, we're downstream providers and we have to be diplomatic with multiple parties. Our referring surgeons, we have to be diplomatic with them. But then you spoke in your talk about the way in which the plastic surgeons communicate with the patients. So you spoke of your own journey as a breast cancer survivor. What are the two or three most important practices that plastic surgeons could employ to optimize their relationships with their patients? Well, as a trained educator, I think you have to provide education in all forms or any forms. That is key. At the end of the day, even through social media, where we find a lot of, I call it drama, I think we have to focus in on providing patients education. Because at the end of the day, that empowers them. If they're getting information from you guys, whether it's in the form of digital health, you know, handouts, groups that you provide at your cancer centers, all of this information is important for patients because it empowers them. They want this information to help them make decisions. I do believe when you're in consult, it is absolutely imperative for you to focus on the patient. I gave you an example of my own surgeon who, honestly, I felt like there wasn't anybody in the room except the two of us. He pulled up a chair right in front of me and he was laser focused on me. And I think that that has to be an extremely challenging thing for all of you these days because you have to, you know, document everything that's going on in that room. As a former teacher, I know documentation was so important in my practice, but work it out in your practice that you've got somebody to do that for you, have that other person in the room and really stay laser focused on your patient because the most important thing is for you to build trust from the very beginning. And those interactions, those human interactions, eye contact, acting fully interested, giving them information prior to the consult, if you can, to help them to come in an informed patient. I think all of these things are extremely important. And I think the third thing I would weave into this, Dr. Garvey, and by the way, thanks for asking this question because I think it's so valuable and important. The third thing is let them know how they can follow up because, you know, as breast cancer patients or BRCA patients, genetic mutation patients, our minds are full and we become unintended students or patients of all of these terms that we had no clue about before. We want to know about them, but we're not trained to know them. You guys are. So we're counting on all of you to get this right for us. So bring us into the conversation by establishing that trust from the very beginning and have them understand and know how they can follow up if they have questions afterwards. Great, thank you. Do any other panelists have any follow-up questions before we finish out this panel? Well, I think that's all the time we have for questions. And again, I want to thank our panelists for their efforts today and for devoting their time to making this panel happen. I also want to thank the audience for watching today. I hope you found the panel informative and learned something that you can apply to your own practices. And so lastly, I want to say goodbye to all of you and I hope you have an enjoyable rest of your meeting. Thank you.

Plastic Surgery of the Meeting

San Diego

American Society of Plastic Surgeons

interdisciplinary alliances

Dr. Patrick Garvey

patient outcomes

Terri Coote

breast reconstruction

telemedicine

sensory innervation

patient education

multidisciplinary approach

patient-centered care