1. IMMEDIATE BREAST RECONSTRUCTION FOLLOWING MASTECTOMY WOMEN’S HEALTHCARE SYMPOSIUM SEPTEMBER 10, 2010 Kiya Movassaghi, MD, DMD Assistant Clinical Professor, Plastic Surgery OHSU

2. DISCLOSURE STATEMENT Kiya Movassaghi, MD, DMD has disclosed that he has financial interest or other relationship with the manufacturers of medical commercial products: Angiotech Medicis Kiya Movassaghi, MD, DMD declares that discussion of any medical commercial product known to her as unlabeled, or outside of FDA approved indications will be clearly revealed by her to the audience as such. Kiya Movassaghi, MD, DMD, declares that discussion of any investigational medical commercial product outside of FDA approved indications will be clearly revealed by her to the audience as such.

3. BREAST CANCER ~500-600 new cases per year- In Lane county Nationally- ~70% breast conservation vs. 30% mastectomy Nationally-~20-30% will undergo reconstruction-

4. BREAST RECONSTRUCTION AND WOMEN’S HEALTH Congress guaranteed universal coverage for breast reconstruction after cancer surgery in 1998.

5. … So, why such a low rate of breast Reconstruction?

6. NATIONAL UTILIZATION OF IMMEDIATE AND EARLY DELAYED BREAST RECONSTRUCTION, (ALDERMAN PRS 2003) 10,404 mastectomy treatments for breast cancer On average, 15.4% breast reconstruction within 1 st 4 months  Atlanta- highest rate @ 33.6%  Hawaii- Lowest rate @ 7.6%

7. NATIONAL UTILIZATION OF IMMEDIATE AND EARLY DELAYED BREAST RECONSTRUCTION, (ALDERMAN PRS 2003) Race- W> H> A> B Socioeconomic status Geographic location Age- less than 45> 45-55> 55 Clinical factors- stage of disease, XRT, surgical oncologist, plastic surgeon

8. DARTMOUTH HITCHCOCK MEDICAL CENTER STUDY, (COLLINS, E; PRS 2003) Well integrated breast care program Average rate of immediate reconstruction 49% All females considering mastectomy offered consult with a plastic surgeon Is ~50% the “ideal” rate of breast reconstruction since all women are offered the option?

9. BREAST RECONSTRUCTION AND WOMEN’S HEALTH Concerns about masking recurrence overrated. Br Ca is mostly a systemic disease; local recurrence mostly superficial and not hidden by reconstruction.  Delaying reconstruction is not supported

10. BREAST RECONSTRUCTION AND WOMEN’S HEALTH Well proven psychological benefits of breast reconstruction for recovering mastectomy patients -Defining the “right” rate of breast reconstruction has clear policy implications for women’s health

11. (AUGUST 18,2010) “Before Breast Is Removed, a Discussion on Options” “ Now a state law,… will require New York hospitals and doctors to discuss the options for breast reconstruction with their patients before performing cancer surgery, to give them information about insurance coverage and to refer them to another hospital, if necessary, for the reconstructive surgery”.

12. ADVANTAGES OF PREMASTECTOMY CONSULT WITH PLASTIC SURGEON Allows the surgeon to assess patient’s baseline anatomy Allows the patient to learn all her reconstructive options Allows the plastic surgeon to take part in the oncological surgery planning and hence help produce the best possible cosmetic outcome It makes immediate reconstruction with all its psychological and cosmetic benefits to become a reality

13. Options for Mastectomy Modified Radical Mastectomy Skin Sparing Mastectomy Nipple Sparing Mastectomy

14. Options for Breast Reconstruction ImmediateDelay

15. ADVANTAGES OF IMMEDIATE RECONSTRUCTION Psychological Economical / Efficient Preservation of native breast skin envelope  Superior cosmetic outcome with less morbidity

16. Options for Breast Reconstruction Implant (Alloplastic) Patient’s Own Tissue (Autogenous) Combination

17. Breast Implants

18. TRAM flapLatissimus flap AUTOGENOUS RECONSTRUCTION Pedicled TRAM flap Free TRAM flap DIEP Flap Latissimus flap Latissimus sparing flap SGAP flap IGAP flap

19. George Town Protocol for Nipple-Sparing Mastectomy

20. IN SUMMARY All women should be offered a consult with a plastic surgeon prior to breast cancer surgery Nipple / Skin sparing mastectomy is the ideal mastectomy technique Immediate reconstruction is the ideal reconstruction for most patients