May 13, 2024 • 48 mins
Shannen decided to undergo breast reconstruction, and thanks to world-renowned plastic surgeon Dr. Jay Orringer, it ended up being a life-changing decision.
In part 1 of her conversation with Dr. Jay, they cover everything from the lifespan of an implant to how radiation can affect them.
Also, find out what may indicate the likelihood of getting breast cancer, and whether you should consider a mastectomy before being diagnosed.
See omnystudio.com/listener for privacy information.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:02):
This is Let's Be Clear with Shannon Doherty. Welcome to
a new episode of Lesbie Clear with Shannon Doherty. And
I have on one of the loveliest, loveliest doctors I
have ever encountered, doctor j Oranger. He is a plastic surgeon.
(00:23):
He is also a reconstructive plastic surgeon, which is how
I know him because he reconstructed my breasts and then
the other one to match it.
Speaker 2 (00:36):
Hi, Hello, Shannon, Hi doctor j. Great pleasure to be
here with you.
Speaker 1 (00:40):
Good to see you. You really are one of those
doctors who takes so much time with your patients. You
don't overbook yourself. I just remember you drove to my
house constantly to check on me when I had the
expander in, and you know the drains all of that.
I'll get into everything that you did for me and
(01:03):
what you do for so many others, But can you
tell us how you started down this path?
Speaker 2 (01:10):
Sure? So. Originally, Shannon, I was believing that I was
heading down the path of chest surgery thoracic surgery. And
I was in my general surgery training, which is one
of the prerequisites for that, and very early in that training,
I was on the oncology service, and we rounded on
(01:30):
a lovely young woman who had just had a mess
stect to me, and in those days, the reconstructions weren't
done immediately, if done at all, they were often done
as a subsequent stage following the mess stec to me,
as opposed to today, when we do the vast majority
of our reconstructions immediately, at least start them immediately so
(01:52):
that the patient wakes up with some form of breast
I felt so bad for this woman when I saw
how this affected her and how it would affect her.
It changed my life. That day changed my life when
I rounded on that patient and I just saw what
(02:13):
resulted from that life saving procedure, what she would face
unless her wholeness were able to be restored through a
good quality reconstruction. And I then said that day, that's
what I want to do for the rest of my life.
I want to help these people. And so I completed
(02:36):
my general surgical training. I feel that as a surgeon
who operates on the breast in any capacity, or any
part of the body for that matter, it's helpful to
be fully trained in general surgery. So I completed a
wonderful training and then my boards in general surgery and
then completed my plastic surgical residency in training, and then
(03:00):
following that, as if that weren't enough, I decided that
I wanted to do it super specialization in microsurgery. Microsurgery
is a subspecialty of plastic surgery where it's used by
others specialty as well, where we use the operating microscope
to reattach blood vessels or nerves, and we can transplant tissue.
(03:25):
And what's remarkable about it is we can take tissue,
let's safe from the tummy. A woman says, I have
excess tummy tissue. I don't like this extra skin in fat.
I've thought about having a tummy tuck, but instead now
I need a mast ectomy. We can take that tissue
and using techniques of microsurgery, reattached blood vessels so that
(03:49):
that tissue can be shaped to create a breast. It is,
in many instance is almost indistinguishable from a real brust
So said I wanted to acquire that expertise, and so
the microsurgery has been a very nice adgent to sort
(04:11):
of complete my armamentarium in terms of what we can
offer patients. In general terms, there are two ways we
can reconstruct the breast, one uses some form of implant,
one uses one's own tissues, and each has advantages and disadvantages.
(04:34):
The advantages of using an implant include the fact that
it is typically a shorter and simpler procedure associated with
a somewhat shorter recuperative period in most instances, and the
site of the surgery is limited to the chest using
(04:56):
one's own tissue. Where we transfer tissue, basically, we transfer
an orgon of fat to make a new breast and
it has its own blood supply, as opposed to situations
where commonly today surgeons will liposuction fat and injected to
the chestwell and hope that that fat will live. In
(05:17):
reality being that much of that fat will resorb when
we reattach blood vessels that are attached to this organ
of fat. It lives just like a kidney transplant.
Speaker 1 (05:29):
Right because you're pumping blood.
Speaker 2 (05:31):
Too into it and out of it. And so it's
quite a remarkable concept. And we can take tissue from
the tummy that again the tissue that would be the
scarter with a tummy tuck, we can revascularize, put it
under the skin, under the nipple, under the skin of
the breast, and when you feel it, it feels just
(05:52):
like a breast, because the breast is an organ largely
a fatty tissue, and there's fatty tissue now placed under
the skin. So it feels very much and looks very
much like a natural breast. Similarly, in a very thin woman.
You know, there's some people who are quite thin, and
you know, you're in you're in great shape. You didn't
(06:13):
have a lot of tissue to work with, and we
had to use, you know, everything we could from that
from that small tummy. There's some women that are simply
there isn't enough tissue on the tummy to even do
a single breast, and so then those women generally will
have enough tissue on the upper buttock or gluegal area
where we can in essence to a buttock lift and
(06:38):
take that tissue and transplant it to make the new breast.
The scar that results from that simulates a butt lift
on the upper buttocks. A bathing suit is sort of
high cut will cover that. And so the advantage of
(06:59):
using one's own tissue is that, unlike an implant, doesn't
require maintenance. Implants can be a great option for a
lot of women, especially if radiation hasn't taken place. Implants
can be a good option, but it must be understood
that they require maintenance. Implants are likely to need to
(07:22):
be replaced multiple times in the course of a young
patient's life. I don't really know exactly what the life
expectancy of an implant is, and it will vary from
the setting and from the individual, but it's commonly said
that an implant may last ten or fifteen years if
we're lucky. They then will often at to be replaced
(07:46):
either because of where and tear. Where the implant cracks,
in other words, it can leak. The newer implants are
more cohesive. We can talk about that cohesivety or the
gumming beer implants. If it cracks, you know, there's some
element of leakage, although it tends to be more contained
with the newer implants. So when they crack or leak,
(08:10):
we tend to replace them if they encapsulate or form
tight scar tissue around.
Speaker 1 (08:16):
Them, which is when they get very hard and uncomfortable.
Speaker 2 (08:19):
Often encapsulation is the formation of height or thick scar
tissue around the implant. It's the body's response to the implant.
It's tissue. It's not part of the implant, it's the
patient's own tissues. When that gets hard, then that scar
tissue will have to be released or removed in many instances,
(08:45):
and so the implant has to be replaced another operation.
The problem is that once encapsulation forms, an individuals prone
to have it occur again. There's just no guarantee that
it won't come back. As implants a oftentimes the tissues
overlying them thin, and implant imperfection such as implant edge
(09:05):
and implant rippling becomes more apparent. And so for cosmetic reasons,
particularly if we have a better quality implant that's been
developed since the implant was first placed, for cosmetic reasons,
we may want to replace the implant. So rupture, encapsulation
of scar tissue, and cosmetic modifications, those are all reasons
(09:27):
that an implant might be maintained. Use of your own
tissue is associated with a permanent reconstruction. It will droop
a bit over time, just like a normal breast, but
it's not going to encapsulate and it's not going to
rupture because it's your own tissue. Now, if you have
(09:54):
a young individual who's in wonderful shape and putting a
scar on the tummy is not going to be an
acceptable option. We have to really consider whether we should
do that.
Speaker 1 (10:18):
Like you said, everybody's different. There are people that have
had the same implants for twenty twenty five years and
that when that scar tissue started forming, their doctor and yes,
you know, it doesn't necessarily feel good, but pushes and
breaks that scar tissue and go in over and over
(10:39):
and over again until that scar tissue forms way outside
of the implant. So it is possible. And I know
that you've done implants where it's possible. And so there's
the positive side of the implants and you get exactly
the size that you want and everything else, and there's
minimal scarring. Like you said, it's contained to like the
(11:01):
chest area. And with flop surgery, the positives are everything
that you mentioned, but there are some negatives. And those
negatives are the scars, right, because you know, if you're
taking from the belly, you have a scar from hipbone
to hip bone. And sure, you know you can drop
it a little bit lower. Hopefully you can, you know,
(11:24):
keep stretching that skin and go back in and get
that scar, you know, redone to drop even lower, but
it's only going to go so so low.
Speaker 2 (11:33):
Yeah, there's there's no question Shannon that the heavier individual,
or the more weight fluctuation she's had, or the more
pregnancy she may have had, the lower you can place
that scar. It is a scar of a tummy tuck.
You have to decide, you know, if someone is thin,
the scar is going to be higher by definition because
(11:56):
you just can't get it quite as low if there
isn't the laxia of the skin, and that trade off
has to be weighed. You know, there are women who
simply would benefit asthetically in some regards from getting rid
of the excess skin and fat of the tummy, but
the scar simply isn't worth it to them. So we
always discuss that. You know, I spend typically an hour,
(12:19):
sometimes an hour and a half with patients. As you know,
there are a lot of options that are available, and
you know, it's a great honor and privilege to work
for the people that I take care of, and it's
really important that they know the options that we discuss them,
that they have an opportunity to ask questions and get
their questions answered. So those are the things we talk about.
(12:45):
You know, yes, you have this extra tissue on your tummy.
Would you tolerate a scar? You know, and that really
has to be an individual decision. A couple things that
you mentioned that are relevant the concept of the close
(13:05):
capsule otomy. I just want to mention we no longer
accept the squeezing of an implant to treat a capsule
as a generally well thought of technique.
Speaker 1 (13:20):
I'm talking about something that was done, you know, you
literally I'm in the nineties.
Speaker 2 (13:24):
Sure is still being done.
Speaker 1 (13:27):
There are doctors.
Speaker 2 (13:28):
So I'm just telling the wonderful people that are that
may be enjoying this benefiting if that suggested, avoid that option.
Speaker 1 (13:38):
Listen to the doctor, not s.
Speaker 2 (13:42):
You. I don't think you're advocating for You're saying that
it's done.
Speaker 1 (13:45):
It is done.
Speaker 2 (13:45):
Yeah, that can rupture an implant, so yes, why you Well,
you might might break the capsule, the scar tissue. You
may also break plant the plants shell. Of course, sanon
in terms of more specifically what technique is appropriate for
(14:07):
what I think it's worthwhile mentioning the effects of radiation
and reconstructions, I think that's a very important point. One
must realize that while potentially life saving, life prolonging, radiation
is a double edged sword. In that it permanently damages
(14:29):
the tissue of the chest wall. That's permanent. Someone lives
to be one hundred microscopically. You'll see the changes of
radiation in the tissues as a result. When you place
an implant beneath radiated tissues, or you radiate an implant
after implant placement, the radiation incites a more vigorous cap
(14:55):
or response, a thicker or tighter capsule formation the scar
tissue around the implant. That's what radiation does. It incites
a vigorous reaction. And so it's a very very common
happening that if you radiate the chess wall that has
an implant, the patient will within a fairly short period
(15:18):
of time say, wow, this feels really tight. This feels
tight and uncomfortable. That's not every patient, but it's very common,
and it's common enough that I tell patients an implant
beneath your radiated tissues may not be a comfortable long
(15:42):
term option. I think in many instances it's not. It
might be an acceptable option in the short term, but
I think that over time the radiation induces increasing capsule formation, tightness,
perhaps discomfort, and so it's particularly the radiated patient or
the patient that has failed an implant, who just hasn't
(16:05):
done well with implants, even in the absence of radiation.
The use of your own tissue in that setting really
is often a blessing because it brings blood supply to
those radiated tissues. We hook up those blood vessels to
transfer that tissue from that tissue that is under the skin.
(16:25):
The tissue we transfer new blood vessels grow into the
surrounding chess wall tissues. It grows from the flat the
bony ay, into the muscle, into the overlying skin and fat.
It brings new blood supply to the radiated chest wall
and improves the quality of the radiated chess wall. So
(16:47):
in the setting of someone who has had an unfortunate
thinning of tissues from multiple implant operations, because each time
you remove that capsule, the tissues overlying the implant become thinner.
So someone who has had let's see, multiple AAP selectomies
or removal of implants, they may be referred to me.
(17:08):
They may come into my office and say, look, how
you can almost see my implant through the skin. That's
a very very difficult problem that I think is generally
generally best treated with the addition of healthy tissue.
Speaker 1 (17:26):
Well, how often do you actually see that.
Speaker 2 (17:28):
It's pretty common, really, it's pretty common. Not everyone does
well with implants, and you know, again it's hard to
accept the concept that they have to be maintained. But
I think in the last ten or fifteen years we've
really come to accept that it's not often a one
(17:51):
and done operation where you put an implant in. It's
pretty common that they'll have to at some point be replaced.
And there's some people who simply just don't do well
with them. The body just doesn't seem to tolerate them.
Speaker 1 (18:05):
Right, rejects it and still identifies it as a foreign object, and.
Speaker 2 (18:09):
They get recurrent encapsulation. You get recurrent encapsulation over and
over and over. There are certain things we can try
and sometimes it's beneficial. There's a material what's called a
cellular dermal matrix. It's a skin derived product and it's
(18:32):
a hammock that you can put in under the skin
to support the breast. Many surgeons use it as a
means of potentially diminishing recurrent encapsulation. In addition to supporting
the implant, it might decrease encapsulation either the first time
(18:53):
implantation or may prevent recurrent encapsulation. Studies are ongoing, but
there a number of studies that suggest that that might
be a benefit. But despite trying everything, we know still
there are patients who simply don't accept their implants well.
And it's in that patient besides the radiated patient, or
(19:17):
use of ones on tissues maybe especially beneficial.
Speaker 1 (19:23):
So so with my surgery, you know, I had the surgery,
only one for us was removed, which is always so
funny when when you make these decisions and you think
you're making the right decision, and then later a couple
of years later, you're like, oh, I should have you know,
(19:45):
had both. And it's probably why this podcast is so
important to me, so that I can share my experiences,
the ones that I think were mistakes that still you know,
the outcome was still good, just maybe I would have
done things differently. So one of those was both breasts, goodbye,
(20:06):
see you later. And because then for my particular reconstruction
it I could have gone a lot smaller, I could
have you know, there's those things. So let's tune the
audience in for a second. And two, I had surgery,
I only had one breast, removed. And then what you did,
(20:29):
which was remarkable is you actually were in there with
again one of the best surgeons, doctor g. I remember
you did the final stitch. It was very important to
you that you did the final stitch because you like
the way that your stitches are. So you were literally
there during that entire surgery. And there's not a lot
(20:50):
of plastic surgeons for reconstruction that would actually be there
for a surgery that they don't even get paid for.
They don't have to be a part of You do that.
You're remarkable. And then you you did expanders because we
knew that I was getting chemo, and we knew that
(21:12):
I was getting radiation, and we wanted all of that
to happen right away. So you did expanders, which can
you explain exactly what an expander does? And how many
times I went back to see you and you sort of,
you know, pared them up or deflated. It's like a
(21:32):
balloon and where my breast was.
Speaker 2 (21:37):
I'm happy to discuss that an expander shan as you know,
as a temporary adjustable volume implant. It has a port
within it where with a mag that we can pass
a magnet over the skin identify the center of that
port where we can put a small needle in safely
actually into the implant, into the expander, add salt water,
(22:01):
sterile salt water, and adjust the size as the boss.
You'll tell me, Jay, I want to be a little larger.
I want to be a little smaller, but we have
the capacity to do that.
Speaker 1 (22:10):
I kept just saying I want Kate Moss boots.
Speaker 2 (22:15):
By the way, Shannon, I don't disagree with anything that
you did from from your reconstructive perspective. I think I
think your thinking was was very reasonable. Each patient has
to really do it with their with their oncologists, with
(22:36):
their their metabal oncologists, their their oncologic surgeon, geneticist really
has to do a risk assessment. It's very important as
it pertains to the other breast. If they're gene negative
and they have no family history and lack of variety
of potential risk factors, leaving the other rest, it is
(23:01):
not unreasonable. Bat breast has a nipple that has sensation
and natural feel and natural shape, it's not unreasonable. I
think that it is also reasonable sometimes to remove both breasts,
especially if there's a very strong family history. If someone
(23:22):
has a bracket gene or other genes. Their genes called
check two PLB two, a variety of other genes that
may place somewhat it significantly increased risks for cancer, and
not just the involved breast, but the other breast. So
it's not unreasonable times to do that. Do you really
have to weigh that decision. I encourage patients not to
(23:46):
act reactively where they say, we'll dog on and I
got a cancer in this breast, I'm taking them both off.
The issue at that time is the cancer in that
breast that we have to deal with. It's very reasonable
to think about the other breasts and future risk, but
before you just reactively say let's take them both off,
(24:08):
I really strongly encourage patients to do an analysis of
their actual risk. It's important to understand that just because
we elect to have a breast removed profilatically, the Good
Lord doesn't necessarily smile upon us and say we're not
going to have any issues with that breast. There won't
(24:30):
be pain in that breast, there won't be healing issues,
there won't be any situations that arise that we don't want.
That press has the same risk of having pain issues
or any other issues. There's the cancer breast, right, so
you need to have a good reason for taking it off.
That doesn't mean that there aren't good reasons. And for
(24:51):
some people the reason to do it is peace of mind.
Speaker 1 (24:55):
And I understand that right, because for some people it
becomes and even if in their heads or in reality,
like like you said, there's a lot of people with
different hereditary stuff, different genes that short, then you need
(25:16):
a double both gone, but also mentally, if it makes
you feel more secure in your future so that you're
not walking around simply scared and worried and obsessing, then
people do it for those reasons too, which is one
(25:37):
hundred percent valid absolutely.
Speaker 2 (25:40):
I mean, there are certain findings on the pathology Shannon,
in addition that aren't cancer, but they're finding something for example,
called atypical lobular hyperplasia for example, which is a number
of long words meaning not cancer, but it's a sign
(26:02):
a marker that in the course of life that individual
is it an increased risk for developing a cancer in
that breast or the other breast, that breast or the
other breast. So there's certain findings that can be found
that aren't cancer. But besides a positive gene testing one
(26:24):
can have findings in their breast pathology, it would suggest
we might consider removing the other breast. So in your situation,
you are going to have radiation. I think that with
a desire to have a patient wake up with a breast,
and I think that's really important in my way of thinking,
(26:50):
having a patient wake up and look down and say
to me, looks pretty good right away. I mean, that
really makes me happy. That's my goal. And whether we
do it by putting your tissue up there or a
tissue expander, or go directly to an implant, that's my
goal that someone wake up or leave the hostel at
least saying okay, you know, I can't can see where
(27:12):
this is going to look pretty good?
Speaker 1 (27:13):
Yeah, because having cancer is traumatizing enough. Absolutely, there are
some of us, me specifically, that the idea of waking
up with no breast at all and just this sort
of horizontal scar that was really I thought for me
(27:35):
it would mentally be even more damaging. Absolutely, and there's
probably large percentage of women out there who who feel
that way.
Speaker 2 (27:45):
So in your situation, we were able to preserve the tissues,
nipple skin by using that expander and even though we
knew that the radiation acts almost like a shrink wrap
up on the tissues, it would tighten that the fact
that the expander was in there to hold the mold,
(28:06):
so to speak, to hold a position of the soft tissues.
I then knew that after initial healing from the radiation,
usually wait at least six months. You waited a little longer,
which it was even better, but at least six months
typically after the final radiation treatment, when the tissues are
(28:27):
a bit more normalized. I knew then that we could
take out that expander, take out the capsule, put in
your own tissue to bring new blood supply and a breast.
It would much better match the opposite lifted breast than
an implant. I will tell you that your own tissue
(28:49):
will virtually always match an opposite breast of normal tissue
than an implant. There is no implant that looks exactly
or feels exactly like one zone tissues. So if someone
makes the decision based upon analysis of their risk factors,
their own worries, their concerns, that they're going to keep
(29:11):
the opposite breast, and again, in many instances, it's entirely reasonable.
I feel that your own tissue in that setting will
typically match much better than an implant. Okay, let's talk
a little bit about scarring. Let's talk let's talk about
incisional approaches. And I think that's really important. You really
(29:32):
touched upon something that was so important. I've spent many
years of my practice analyzing incisional approaches. What is socially acceptable,
what is most cosmetically pleasing, and how can we use
the scars that are associated with cosmetic surgery. For example,
(29:56):
a scar that's in the fold, which is commonly done
for a breast augmentation, or the common breastlift incision. You know,
there's a scar that may go around the nipple, or
it may go under the nipple and down like an
inverted t or an anchor that we think of as
a lift scar. Lift scars are something that are somewhat
(30:17):
socially known and socially accepted. If someone has a droopy breast,
I'll often try to simulate the scar of a breast
lift to do the mastectomy. And oftentimes we can lift
the nipple that we keep by using certain nuanced techniques,
I think we can we can get the nipple into
(30:38):
a more youthful position save the nipple in many instances
and do the whole procedure, the mestetomy and the reconstruction
through incisions that in many ways mimic traditional known cosmetic approaches,
and that's that's always my approach. In the now fairly
(31:02):
rare situation where we have to remove the nipple, sometimes
I will do that again using the breastlift incision and
make the nipple on the top of that of that
inverted T shaped scar. That breastlift scar will make the
nipple on the top of that so that it looks
like the patient had a lift or a reduction. If
(31:24):
the nipple has to be removed in a transverse fashion
because we can't use the breastlift scar because she doesn't
have droopy skin of the breast, the scar can be
limited in its inner extent, keeping the scar whenever possible,
off the ascetically important duclette area, the center area that chose.
So I think it's very important that we as surgeons,
(31:48):
cosmetic surgeons, discuss with our patients a variety of incisional
approaches and arrive at the one that, while being oncologically sound,
is most cosmetically pleasing. I think that's very important.
Speaker 1 (32:03):
I mean it for sure. Is because again I don't
I don't think women really want a lot of scars.
And when we put on a bikini or when we
find some one worthy of seeing as nude, we don't
want them to focus on scars all over the body.
And so it is important to think of those scars
(32:24):
and where they are hidden. In my case, you did
the expanders. I was able to heal from radiation, and
then you did in the breast that was still left
that didn't I just you know, didn't get chopped off
by doctor g it. You know, we didn't you do
(32:46):
a little bit of a reduction and a lift so
that it would match. So, guys, I I obviously had
the flap surgery. So he took fat and tissue from
my stomach and created a breast out of that. He
didn't you also take a blood vessel from there? Absolutely, yeah,
(33:10):
in order to pump sure blood like we talked about.
Speaker 2 (33:13):
Right, So we use the techniques of microsurgery where we
identified an artery in vein going to that and you
didn't have a lot of fat. We had to really
kind of work hard. That defined the sufficient volume fortunately,
you know, yeah, just so that was helpful too. We
identified an artery in vein that went to that fat.
(33:37):
We took that up off the tummy. Normally that tissue
and a tummy tuck would just be discarded. Because we
had that artery in vein going to that tissue. We
could plug that artery and vein into an artery and
vein on the chest wall, and we would have, as
you mentioned earlier, blow into that tissue and flow out
(33:58):
of It's just like a normal organ that.
Speaker 1 (34:02):
So the tissue didn't die.
Speaker 2 (34:04):
Yeah, it's remarkable.
Speaker 1 (34:05):
The skin didn't die nothing.
Speaker 2 (34:07):
It's remarkable. You know. Having done this now for so
many years, I still am excited by the amazing nature
of that technology. It's really it's really something amazing. The thing,
as we were talking about incisional approaches, one thing that
(34:27):
I want people to be aware of about women to
be aware of, I want colleagues to be aware of,
is that if a woman has had previous surgery around
her nipple or around her areola, that doesn't necessarily preclude
the saving of a nipple at the time of the mastectomy.
(34:49):
Unlike twenty years ago, the concept of preserving the nipple
at the time of mastectomy is now quite quite often
done you know, if the tumor is a prophylatic setting,
or the tumor is remote sufficiently remote from the nipple,
(35:11):
we often save the nipple, which is really really an
aesthetic benefit.
Speaker 1 (35:17):
Can I interrupt you? I feel like this is going
to become a drinking game with this, with this episode,
where every single time you say nipple, somebody's going to
take a drink.
Speaker 2 (35:27):
It's part of dress surgery. What can I tell you?
Speaker 1 (35:29):
I know, right, I'm like.
Speaker 2 (35:30):
That it's an integral and important part of the break.
It is an important part of the brains and.
Speaker 1 (35:37):
So well, you saved mine.
Speaker 2 (35:39):
Yes, there there are times when if there's certain techniques,
there's something called a nipple delay, the E l A
Y E E l A Y procedure delay procedure, we
are ten to fourteen days before the mass stectomy, we
divide some of the underlying blood supply to the nipple
(36:00):
so that that which remains gets heartier. Okay, that's just
the concept. And so patients who have had radiation or
prior surgery around the nipple and still often keep their nipple.
It's really very valuable. So I just mentioned that, so
(36:22):
that if people are told that their nipples have to
come off because they've had a previous breast lift or
a previous breast reduction, that may not necessarily be true.
And so just just be aware of that.
Speaker 1 (36:35):
Right, maybe go see another doctor get a.
Speaker 2 (36:38):
Second opinion of their opinions in that regard.
Speaker 1 (36:54):
I mean, I think that that's what I sort of
encourage on the podcast and on my Instagram is it's
the white coat does not always know everything absolutely, and
it's really important to go get a second opinion, even
a third opinion. I mean, you weren't you weren't I
met with I think four different plastic surgeons, just like
(37:15):
I met with multiple oncologists. I don't think doctor G
was my only meeting for you know. I just always
thought I need to meet different people, see what different
people say, and also find the person that I connect
the most with.
Speaker 2 (37:31):
Absolutely, I couldn't agree more with that, And I think
that unlike many areas of medicine, and medicine is an art,
but sixth surgeon really is an art. And what you
said about connecting, yeah, that's true. I mean the surgeon
should be able to show you examples of his or
(37:52):
her work, some examples, you know, I mean, just to
get a sense of do you like they're aesthetic? Do
you like what they see as beautiful? You know, there's
some people, for example, who surgeons and find surgeons who
(38:14):
like placing very large implants, so that.
Speaker 1 (38:19):
It's the same thing with you, like with people who
do facelift. I mean, I know you do facelift. But
there's this doctor that several women I personally know have
gone to and they all look the same because that's
his aesthetic. So you know, the mouth is always, you know,
a little bit wider, it's a very specific eyebrows are
(38:45):
and I see them and I'm like, uh huh, Okay,
that's who your surgeon is.
Speaker 2 (38:49):
So you may not feel that that was that's how
you're aesthetic, right, I mean that's important to they look beautiful,
but but that beauty may not be optimal beauty for you, correct,
And so that's what that's what I think has to
be determined. And I think that if if the plastic surgery,
I think that if someone can't show you their results,
(39:10):
that's of concern. That's that to me. I think of
as if you were to work with an artist and
you said, I'm going to commission you to make a
beautiful painting. You'd have to see their work to some.
Speaker 1 (39:29):
Extent for sure. Are they impressionists? Are they modern? Of
course you want to know.
Speaker 2 (39:35):
Now, with that said surgeon may show you pictures and
should show you pictures that get you some sense, give
you some sense of what she he or she does.
That obviously doesn't say that you're going to get that
same result. Each patient is different, the body is different,
(39:57):
the situation is different. At least she have the opportunity
to get a sense of the artistry of that individual.
I really think that's what you're doing. You're getting a
sense of the artists the individual. Do you like the individuals?
It's someone you can get along with.
Speaker 1 (40:15):
It's also somebody you want to find a surgeon who
adjust to your desires, right because one of the plastic
surgeons I met with for reconstruction was a big boop guy.
He put big implants in and I'm five to four
(40:39):
and one hundred and four pounds. I can't like big
huge knockers. Is not my personal sthetic. Other people, it
looks great on do whatever pleases you. I'm all for it.
But for me, and it didn't really matter how much.
I just kept on showing him a picture of Kate Moss, like,
(41:00):
do you see how small her boobs are? Like? This
is perfection to me.
Speaker 2 (41:04):
He it.
Speaker 1 (41:07):
Just wasn't resonating with him, and whereas with you. You know,
maybe that's not even your personal style. Outher but you
looked at me and you said, beautiful breast, let's try
to get as close as possible. Just you know, because
I opted to only have one removed, it was you know,
(41:32):
you're still working with a real one. There's got to
be symmetry, because that's what I would want. So ultimately,
did I get tiny A's No? Am I happy or
that I didn't? Yes, Like, I'm pretty happy with your work.
Speaker 2 (41:50):
It's important to determine if the surgeon hears you.
Speaker 1 (41:55):
Yeah.
Speaker 2 (41:55):
I mean, I'm sure that surgeon who made the large
rest he or she might have been of find. But
if he didn't hear what you were saying, you know
that that's more of an issue. I think that the
plastic surgeon, after a message a reconstruction, tends to follow
you the most, you know, certainly among the surgeons. The
(42:17):
general surgeon does his job or job, then the plastic
surgeon really has to help you with the healing process
and follow scars and uh, you know, make certain that
you maintain a good path, you know. So I think
it's important to like your doctor.
Speaker 1 (42:37):
I mean, well, you've visited me over the weekend at
my house. You would drive all the way out to
Malibu and you would check the drains see how much
was draining before we could actually take the drains out.
You you just you wanted to make sure the skin was,
you know, staying alive, that there was no issues there.
(43:01):
And you were really really very very very hands on.
And I know that some people who have heard conversations
between myself and my doctors have made a comment of well,
you know, you're Shannon Doherty, so you're getting special treatment
(43:22):
or maybe it's your insurance. And I'm just going to
tell you guys that I know that doctor J does
this for every single one of his patients. It doesn't
matter if they're famous or not. You do this for
every single one. And to just chalk off sort of
my experience as well, you're famous, so you get extra
(43:44):
it's incredibly unfair. It's not unfair to me because I
don't really care what people say. It's unfair to my
doctors because I know for a fact that you are
this meticulous and hold your every single one of your patients.
You literally hold our hands through all of this. And
(44:08):
even after I was totally cleared by you, everything was fine.
You know. We went to the Greek theater together with
my mom and your wife jo Lynne, like you know,
and then we went to the Italian place together. It's
a relationship. You build relationships with your patients and you
(44:30):
constantly check in with them, even years and years and
years and years later, like when was when were we
probably done with everything? Like twenty seventeen?
Speaker 2 (44:40):
I think I think that's I think it's about right.
Speaker 1 (44:44):
We still check in and there's a true you just
you care. And it goes back to that story you
told in the beginning. It does of seeing that young
woman and wanting to help her and what that did
to you mentally, that you want people to at least
(45:05):
have as good of an experience through something like this
that they possibly can.
Speaker 2 (45:12):
Thank you, Shan. I appreciate your kind words. Yeah, I think,
you know. I often often tell my staff that we're
we should be like like family for as long as
we're needed, you know. And I had a young patient
recently who I had wonderful young woman who I had
(45:38):
reconstructed her breasts, who had a bad congenital problem which
was born with very very asymmetric press and she she
had she had her reconstruction completed, was thrilled, thankfully thrilled.
And she said, so, so am I going to see
(45:59):
you guys anymore? And I joked it, I said, no, no,
we're done, and she started crying, you know, I mean,
it was like and I said, of course you're going
to see this. You'll see us for as long as
you need us, and we're going to continue to make
sure your scars you know well that everything is great,
you know, in the coming months and years. I said,
You're never done with us, you know, we're always here
(46:21):
for you. But it made me feel great because you know,
I tell my staff, look, as long as they need us,
as long as they want us as both part of
their extended family, as people who are really meaningful in
their lives, that's a blessing. And when they're happy and
we no longer hear from them, that also means we've
(46:44):
done our good job because they no longer need us,
you know, And so it's a very wonderful opportunity to
help people. I every day in my life. I feel
immensely grateful and honor to do what I do. It's
really a privilege. And yes, Shannon, I mean, you're very important.
(47:06):
You're a very wonderful person. I have so many patients
who are also wonderful people who I deeply care about,
and that's just the way it should be. You know,
Medicine is it's very different, I think than anything else
in society that near their job, so to speak. I
(47:26):
think it's very different. And I grew up in a
family of doctors, and you know, my dad instilled in
me the concept that what we do really is a
privilege and an honor, and I've never not felt that.
That's always been my feeling from day one. And once
(47:48):
I saw that patient and directed my life's professional path
where I wanted it, it's really been just such a
privilege and great honor to hear from people that I
made a positive difference, you know, Shanneon we don't always succeed.
We're not perfect, We certainly are not perfect, but by
(48:13):
when we do succeed, it's the greatest feeling in horror.
Speaker 1 (48:17):
Right, Yeah, I know, I'm sure, I'm sure that feels
amazing There's a lot more you guys with Doctor j Oranger,
so stay tuned for part two.
This is Let's Be Clear with Shannon Doherty. Welcome to
a new episode of Lesbie Clear with Shannon Doherty. And
I have on one of the loveliest, loveliest doctors I
have ever encountered, doctor j Oranger. He is a plastic surgeon.
(00:23):
He is also a reconstructive plastic surgeon, which is how
I know him because he reconstructed my breasts and then
the other one to match it.
Speaker 2 (00:36):
Hi, Hello, Shannon, Hi doctor j. Great pleasure to be
here with you.
Speaker 1 (00:40):
Good to see you. You really are one of those
doctors who takes so much time with your patients. You
don't overbook yourself. I just remember you drove to my
house constantly to check on me when I had the
expander in, and you know the drains all of that.
I'll get into everything that you did for me and
(01:03):
what you do for so many others, But can you
tell us how you started down this path?
Speaker 2 (01:10):
Sure? So. Originally, Shannon, I was believing that I was
heading down the path of chest surgery thoracic surgery. And
I was in my general surgery training, which is one
of the prerequisites for that, and very early in that training,
I was on the oncology service, and we rounded on
(01:30):
a lovely young woman who had just had a mess
stect to me, and in those days, the reconstructions weren't
done immediately, if done at all, they were often done
as a subsequent stage following the mess stec to me,
as opposed to today, when we do the vast majority
of our reconstructions immediately, at least start them immediately so
(01:52):
that the patient wakes up with some form of breast
I felt so bad for this woman when I saw
how this affected her and how it would affect her.
It changed my life. That day changed my life when
I rounded on that patient and I just saw what
(02:13):
resulted from that life saving procedure, what she would face
unless her wholeness were able to be restored through a
good quality reconstruction. And I then said that day, that's
what I want to do for the rest of my life.
I want to help these people. And so I completed
(02:36):
my general surgical training. I feel that as a surgeon
who operates on the breast in any capacity, or any
part of the body for that matter, it's helpful to
be fully trained in general surgery. So I completed a
wonderful training and then my boards in general surgery and
then completed my plastic surgical residency in training, and then
(03:00):
following that, as if that weren't enough, I decided that
I wanted to do it super specialization in microsurgery. Microsurgery
is a subspecialty of plastic surgery where it's used by
others specialty as well, where we use the operating microscope
to reattach blood vessels or nerves, and we can transplant tissue.
(03:25):
And what's remarkable about it is we can take tissue,
let's safe from the tummy. A woman says, I have
excess tummy tissue. I don't like this extra skin in fat.
I've thought about having a tummy tuck, but instead now
I need a mast ectomy. We can take that tissue
and using techniques of microsurgery, reattached blood vessels so that
(03:49):
that tissue can be shaped to create a breast. It is,
in many instance is almost indistinguishable from a real brust
So said I wanted to acquire that expertise, and so
the microsurgery has been a very nice adgent to sort
(04:11):
of complete my armamentarium in terms of what we can
offer patients. In general terms, there are two ways we
can reconstruct the breast, one uses some form of implant,
one uses one's own tissues, and each has advantages and disadvantages.
(04:34):
The advantages of using an implant include the fact that
it is typically a shorter and simpler procedure associated with
a somewhat shorter recuperative period in most instances, and the
site of the surgery is limited to the chest using
(04:56):
one's own tissue. Where we transfer tissue, basically, we transfer
an orgon of fat to make a new breast and
it has its own blood supply, as opposed to situations
where commonly today surgeons will liposuction fat and injected to
the chestwell and hope that that fat will live. In
(05:17):
reality being that much of that fat will resorb when
we reattach blood vessels that are attached to this organ
of fat. It lives just like a kidney transplant.
Speaker 1 (05:29):
Right because you're pumping blood.
Speaker 2 (05:31):
Too into it and out of it. And so it's
quite a remarkable concept. And we can take tissue from
the tummy that again the tissue that would be the
scarter with a tummy tuck, we can revascularize, put it
under the skin, under the nipple, under the skin of
the breast, and when you feel it, it feels just
(05:52):
like a breast, because the breast is an organ largely
a fatty tissue, and there's fatty tissue now placed under
the skin. So it feels very much and looks very
much like a natural breast. Similarly, in a very thin woman.
You know, there's some people who are quite thin, and
you know, you're in you're in great shape. You didn't
(06:13):
have a lot of tissue to work with, and we
had to use, you know, everything we could from that
from that small tummy. There's some women that are simply
there isn't enough tissue on the tummy to even do
a single breast, and so then those women generally will
have enough tissue on the upper buttock or gluegal area
where we can in essence to a buttock lift and
(06:38):
take that tissue and transplant it to make the new breast.
The scar that results from that simulates a butt lift
on the upper buttocks. A bathing suit is sort of
high cut will cover that. And so the advantage of
(06:59):
using one's own tissue is that, unlike an implant, doesn't
require maintenance. Implants can be a great option for a
lot of women, especially if radiation hasn't taken place. Implants
can be a good option, but it must be understood
that they require maintenance. Implants are likely to need to
(07:22):
be replaced multiple times in the course of a young
patient's life. I don't really know exactly what the life
expectancy of an implant is, and it will vary from
the setting and from the individual, but it's commonly said
that an implant may last ten or fifteen years if
we're lucky. They then will often at to be replaced
(07:46):
either because of where and tear. Where the implant cracks,
in other words, it can leak. The newer implants are
more cohesive. We can talk about that cohesivety or the
gumming beer implants. If it cracks, you know, there's some
element of leakage, although it tends to be more contained
with the newer implants. So when they crack or leak,
(08:10):
we tend to replace them if they encapsulate or form
tight scar tissue around.
Speaker 1 (08:16):
Them, which is when they get very hard and uncomfortable.
Speaker 2 (08:19):
Often encapsulation is the formation of height or thick scar
tissue around the implant. It's the body's response to the implant.
It's tissue. It's not part of the implant, it's the
patient's own tissues. When that gets hard, then that scar
tissue will have to be released or removed in many instances,
(08:45):
and so the implant has to be replaced another operation.
The problem is that once encapsulation forms, an individuals prone
to have it occur again. There's just no guarantee that
it won't come back. As implants a oftentimes the tissues
overlying them thin, and implant imperfection such as implant edge
(09:05):
and implant rippling becomes more apparent. And so for cosmetic reasons,
particularly if we have a better quality implant that's been
developed since the implant was first placed, for cosmetic reasons,
we may want to replace the implant. So rupture, encapsulation
of scar tissue, and cosmetic modifications, those are all reasons
(09:27):
that an implant might be maintained. Use of your own
tissue is associated with a permanent reconstruction. It will droop
a bit over time, just like a normal breast, but
it's not going to encapsulate and it's not going to
rupture because it's your own tissue. Now, if you have
(09:54):
a young individual who's in wonderful shape and putting a
scar on the tummy is not going to be an
acceptable option. We have to really consider whether we should
do that.
Speaker 1 (10:18):
Like you said, everybody's different. There are people that have
had the same implants for twenty twenty five years and
that when that scar tissue started forming, their doctor and yes,
you know, it doesn't necessarily feel good, but pushes and
breaks that scar tissue and go in over and over
(10:39):
and over again until that scar tissue forms way outside
of the implant. So it is possible. And I know
that you've done implants where it's possible. And so there's
the positive side of the implants and you get exactly
the size that you want and everything else, and there's
minimal scarring. Like you said, it's contained to like the
(11:01):
chest area. And with flop surgery, the positives are everything
that you mentioned, but there are some negatives. And those
negatives are the scars, right, because you know, if you're
taking from the belly, you have a scar from hipbone
to hip bone. And sure, you know you can drop
it a little bit lower. Hopefully you can, you know,
(11:24):
keep stretching that skin and go back in and get
that scar, you know, redone to drop even lower, but
it's only going to go so so low.
Speaker 2 (11:33):
Yeah, there's there's no question Shannon that the heavier individual,
or the more weight fluctuation she's had, or the more
pregnancy she may have had, the lower you can place
that scar. It is a scar of a tummy tuck.
You have to decide, you know, if someone is thin,
the scar is going to be higher by definition because
(11:56):
you just can't get it quite as low if there
isn't the laxia of the skin, and that trade off
has to be weighed. You know, there are women who
simply would benefit asthetically in some regards from getting rid
of the excess skin and fat of the tummy, but
the scar simply isn't worth it to them. So we
always discuss that. You know, I spend typically an hour,
(12:19):
sometimes an hour and a half with patients. As you know,
there are a lot of options that are available, and
you know, it's a great honor and privilege to work
for the people that I take care of, and it's
really important that they know the options that we discuss them,
that they have an opportunity to ask questions and get
their questions answered. So those are the things we talk about.
(12:45):
You know, yes, you have this extra tissue on your tummy.
Would you tolerate a scar? You know, and that really
has to be an individual decision. A couple things that
you mentioned that are relevant the concept of the close
(13:05):
capsule otomy. I just want to mention we no longer
accept the squeezing of an implant to treat a capsule
as a generally well thought of technique.
Speaker 1 (13:20):
I'm talking about something that was done, you know, you
literally I'm in the nineties.
Speaker 2 (13:24):
Sure is still being done.
Speaker 1 (13:27):
There are doctors.
Speaker 2 (13:28):
So I'm just telling the wonderful people that are that
may be enjoying this benefiting if that suggested, avoid that option.
Speaker 1 (13:38):
Listen to the doctor, not s.
Speaker 2 (13:42):
You. I don't think you're advocating for You're saying that
it's done.
Speaker 1 (13:45):
It is done.
Speaker 2 (13:45):
Yeah, that can rupture an implant, so yes, why you Well,
you might might break the capsule, the scar tissue. You
may also break plant the plants shell. Of course, sanon
in terms of more specifically what technique is appropriate for
(14:07):
what I think it's worthwhile mentioning the effects of radiation
and reconstructions, I think that's a very important point. One
must realize that while potentially life saving, life prolonging, radiation
is a double edged sword. In that it permanently damages
(14:29):
the tissue of the chest wall. That's permanent. Someone lives
to be one hundred microscopically. You'll see the changes of
radiation in the tissues as a result. When you place
an implant beneath radiated tissues, or you radiate an implant
after implant placement, the radiation incites a more vigorous cap
(14:55):
or response, a thicker or tighter capsule formation the scar
tissue around the implant. That's what radiation does. It incites
a vigorous reaction. And so it's a very very common
happening that if you radiate the chess wall that has
an implant, the patient will within a fairly short period
(15:18):
of time say, wow, this feels really tight. This feels
tight and uncomfortable. That's not every patient, but it's very common,
and it's common enough that I tell patients an implant
beneath your radiated tissues may not be a comfortable long
(15:42):
term option. I think in many instances it's not. It
might be an acceptable option in the short term, but
I think that over time the radiation induces increasing capsule formation, tightness,
perhaps discomfort, and so it's particularly the radiated patient or
the patient that has failed an implant, who just hasn't
(16:05):
done well with implants, even in the absence of radiation.
The use of your own tissue in that setting really
is often a blessing because it brings blood supply to
those radiated tissues. We hook up those blood vessels to
transfer that tissue from that tissue that is under the skin.
(16:25):
The tissue we transfer new blood vessels grow into the
surrounding chess wall tissues. It grows from the flat the
bony ay, into the muscle, into the overlying skin and fat.
It brings new blood supply to the radiated chest wall
and improves the quality of the radiated chess wall. So
(16:47):
in the setting of someone who has had an unfortunate
thinning of tissues from multiple implant operations, because each time
you remove that capsule, the tissues overlying the implant become thinner.
So someone who has had let's see, multiple AAP selectomies
or removal of implants, they may be referred to me.
(17:08):
They may come into my office and say, look, how
you can almost see my implant through the skin. That's
a very very difficult problem that I think is generally
generally best treated with the addition of healthy tissue.
Speaker 1 (17:26):
Well, how often do you actually see that.
Speaker 2 (17:28):
It's pretty common, really, it's pretty common. Not everyone does
well with implants, and you know, again it's hard to
accept the concept that they have to be maintained. But
I think in the last ten or fifteen years we've
really come to accept that it's not often a one
(17:51):
and done operation where you put an implant in. It's
pretty common that they'll have to at some point be replaced.
And there's some people who simply just don't do well
with them. The body just doesn't seem to tolerate them.
Speaker 1 (18:05):
Right, rejects it and still identifies it as a foreign object, and.
Speaker 2 (18:09):
They get recurrent encapsulation. You get recurrent encapsulation over and
over and over. There are certain things we can try
and sometimes it's beneficial. There's a material what's called a
cellular dermal matrix. It's a skin derived product and it's
(18:32):
a hammock that you can put in under the skin
to support the breast. Many surgeons use it as a
means of potentially diminishing recurrent encapsulation. In addition to supporting
the implant, it might decrease encapsulation either the first time
(18:53):
implantation or may prevent recurrent encapsulation. Studies are ongoing, but
there a number of studies that suggest that that might
be a benefit. But despite trying everything, we know still
there are patients who simply don't accept their implants well.
And it's in that patient besides the radiated patient, or
(19:17):
use of ones on tissues maybe especially beneficial.
Speaker 1 (19:23):
So so with my surgery, you know, I had the surgery,
only one for us was removed, which is always so
funny when when you make these decisions and you think
you're making the right decision, and then later a couple
of years later, you're like, oh, I should have you know,
(19:45):
had both. And it's probably why this podcast is so
important to me, so that I can share my experiences,
the ones that I think were mistakes that still you know,
the outcome was still good, just maybe I would have
done things differently. So one of those was both breasts, goodbye,
(20:06):
see you later. And because then for my particular reconstruction
it I could have gone a lot smaller, I could
have you know, there's those things. So let's tune the
audience in for a second. And two, I had surgery,
I only had one breast, removed. And then what you did,
(20:29):
which was remarkable is you actually were in there with
again one of the best surgeons, doctor g. I remember
you did the final stitch. It was very important to
you that you did the final stitch because you like
the way that your stitches are. So you were literally
there during that entire surgery. And there's not a lot
(20:50):
of plastic surgeons for reconstruction that would actually be there
for a surgery that they don't even get paid for.
They don't have to be a part of You do that.
You're remarkable. And then you you did expanders because we
knew that I was getting chemo, and we knew that
(21:12):
I was getting radiation, and we wanted all of that
to happen right away. So you did expanders, which can
you explain exactly what an expander does? And how many
times I went back to see you and you sort of,
you know, pared them up or deflated. It's like a
(21:32):
balloon and where my breast was.
Speaker 2 (21:37):
I'm happy to discuss that an expander shan as you know,
as a temporary adjustable volume implant. It has a port
within it where with a mag that we can pass
a magnet over the skin identify the center of that
port where we can put a small needle in safely
actually into the implant, into the expander, add salt water,
(22:01):
sterile salt water, and adjust the size as the boss.
You'll tell me, Jay, I want to be a little larger.
I want to be a little smaller, but we have
the capacity to do that.
Speaker 1 (22:10):
I kept just saying I want Kate Moss boots.
Speaker 2 (22:15):
By the way, Shannon, I don't disagree with anything that
you did from from your reconstructive perspective. I think I
think your thinking was was very reasonable. Each patient has
to really do it with their with their oncologists, with
(22:36):
their their metabal oncologists, their their oncologic surgeon, geneticist really
has to do a risk assessment. It's very important as
it pertains to the other breast. If they're gene negative
and they have no family history and lack of variety
of potential risk factors, leaving the other rest, it is
(23:01):
not unreasonable. Bat breast has a nipple that has sensation
and natural feel and natural shape, it's not unreasonable. I
think that it is also reasonable sometimes to remove both breasts,
especially if there's a very strong family history. If someone
(23:22):
has a bracket gene or other genes. Their genes called
check two PLB two, a variety of other genes that
may place somewhat it significantly increased risks for cancer, and
not just the involved breast, but the other breast. So
it's not unreasonable times to do that. Do you really
have to weigh that decision. I encourage patients not to
(23:46):
act reactively where they say, we'll dog on and I
got a cancer in this breast, I'm taking them both off.
The issue at that time is the cancer in that
breast that we have to deal with. It's very reasonable
to think about the other breasts and future risk, but
before you just reactively say let's take them both off,
(24:08):
I really strongly encourage patients to do an analysis of
their actual risk. It's important to understand that just because
we elect to have a breast removed profilatically, the Good
Lord doesn't necessarily smile upon us and say we're not
going to have any issues with that breast. There won't
(24:30):
be pain in that breast, there won't be healing issues,
there won't be any situations that arise that we don't want.
That press has the same risk of having pain issues
or any other issues. There's the cancer breast, right, so
you need to have a good reason for taking it off.
That doesn't mean that there aren't good reasons. And for
(24:51):
some people the reason to do it is peace of mind.
Speaker 1 (24:55):
And I understand that right, because for some people it
becomes and even if in their heads or in reality,
like like you said, there's a lot of people with
different hereditary stuff, different genes that short, then you need
(25:16):
a double both gone, but also mentally, if it makes
you feel more secure in your future so that you're
not walking around simply scared and worried and obsessing, then
people do it for those reasons too, which is one
(25:37):
hundred percent valid absolutely.
Speaker 2 (25:40):
I mean, there are certain findings on the pathology Shannon,
in addition that aren't cancer, but they're finding something for example,
called atypical lobular hyperplasia for example, which is a number
of long words meaning not cancer, but it's a sign
(26:02):
a marker that in the course of life that individual
is it an increased risk for developing a cancer in
that breast or the other breast, that breast or the
other breast. So there's certain findings that can be found
that aren't cancer. But besides a positive gene testing one
(26:24):
can have findings in their breast pathology, it would suggest
we might consider removing the other breast. So in your situation,
you are going to have radiation. I think that with
a desire to have a patient wake up with a breast,
and I think that's really important in my way of thinking,
(26:50):
having a patient wake up and look down and say
to me, looks pretty good right away. I mean, that
really makes me happy. That's my goal. And whether we
do it by putting your tissue up there or a
tissue expander, or go directly to an implant, that's my
goal that someone wake up or leave the hostel at
least saying okay, you know, I can't can see where
(27:12):
this is going to look pretty good?
Speaker 1 (27:13):
Yeah, because having cancer is traumatizing enough. Absolutely, there are
some of us, me specifically, that the idea of waking
up with no breast at all and just this sort
of horizontal scar that was really I thought for me
(27:35):
it would mentally be even more damaging. Absolutely, and there's
probably large percentage of women out there who who feel
that way.
Speaker 2 (27:45):
So in your situation, we were able to preserve the tissues,
nipple skin by using that expander and even though we
knew that the radiation acts almost like a shrink wrap
up on the tissues, it would tighten that the fact
that the expander was in there to hold the mold,
(28:06):
so to speak, to hold a position of the soft tissues.
I then knew that after initial healing from the radiation,
usually wait at least six months. You waited a little longer,
which it was even better, but at least six months
typically after the final radiation treatment, when the tissues are
(28:27):
a bit more normalized. I knew then that we could
take out that expander, take out the capsule, put in
your own tissue to bring new blood supply and a breast.
It would much better match the opposite lifted breast than
an implant. I will tell you that your own tissue
(28:49):
will virtually always match an opposite breast of normal tissue
than an implant. There is no implant that looks exactly
or feels exactly like one zone tissues. So if someone
makes the decision based upon analysis of their risk factors,
their own worries, their concerns, that they're going to keep
(29:11):
the opposite breast, and again, in many instances, it's entirely reasonable.
I feel that your own tissue in that setting will
typically match much better than an implant. Okay, let's talk
a little bit about scarring. Let's talk let's talk about
incisional approaches. And I think that's really important. You really
(29:32):
touched upon something that was so important. I've spent many
years of my practice analyzing incisional approaches. What is socially acceptable,
what is most cosmetically pleasing, and how can we use
the scars that are associated with cosmetic surgery. For example,
(29:56):
a scar that's in the fold, which is commonly done
for a breast augmentation, or the common breastlift incision. You know,
there's a scar that may go around the nipple, or
it may go under the nipple and down like an
inverted t or an anchor that we think of as
a lift scar. Lift scars are something that are somewhat
(30:17):
socially known and socially accepted. If someone has a droopy breast,
I'll often try to simulate the scar of a breast
lift to do the mastectomy. And oftentimes we can lift
the nipple that we keep by using certain nuanced techniques,
I think we can we can get the nipple into
(30:38):
a more youthful position save the nipple in many instances
and do the whole procedure, the mestetomy and the reconstruction
through incisions that in many ways mimic traditional known cosmetic approaches,
and that's that's always my approach. In the now fairly
(31:02):
rare situation where we have to remove the nipple, sometimes
I will do that again using the breastlift incision and
make the nipple on the top of that of that
inverted T shaped scar. That breastlift scar will make the
nipple on the top of that so that it looks
like the patient had a lift or a reduction. If
(31:24):
the nipple has to be removed in a transverse fashion
because we can't use the breastlift scar because she doesn't
have droopy skin of the breast, the scar can be
limited in its inner extent, keeping the scar whenever possible,
off the ascetically important duclette area, the center area that chose.
So I think it's very important that we as surgeons,
(31:48):
cosmetic surgeons, discuss with our patients a variety of incisional
approaches and arrive at the one that, while being oncologically sound,
is most cosmetically pleasing. I think that's very important.
Speaker 1 (32:03):
I mean it for sure. Is because again I don't
I don't think women really want a lot of scars.
And when we put on a bikini or when we
find some one worthy of seeing as nude, we don't
want them to focus on scars all over the body.
And so it is important to think of those scars
(32:24):
and where they are hidden. In my case, you did
the expanders. I was able to heal from radiation, and
then you did in the breast that was still left
that didn't I just you know, didn't get chopped off
by doctor g it. You know, we didn't you do
(32:46):
a little bit of a reduction and a lift so
that it would match. So, guys, I I obviously had
the flap surgery. So he took fat and tissue from
my stomach and created a breast out of that. He
didn't you also take a blood vessel from there? Absolutely, yeah,
(33:10):
in order to pump sure blood like we talked about.
Speaker 2 (33:13):
Right, So we use the techniques of microsurgery where we
identified an artery in vein going to that and you
didn't have a lot of fat. We had to really
kind of work hard. That defined the sufficient volume fortunately,
you know, yeah, just so that was helpful too. We
identified an artery in vein that went to that fat.
(33:37):
We took that up off the tummy. Normally that tissue
and a tummy tuck would just be discarded. Because we
had that artery in vein going to that tissue. We
could plug that artery and vein into an artery and
vein on the chest wall, and we would have, as
you mentioned earlier, blow into that tissue and flow out
(33:58):
of It's just like a normal organ that.
Speaker 1 (34:02):
So the tissue didn't die.
Speaker 2 (34:04):
Yeah, it's remarkable.
Speaker 1 (34:05):
The skin didn't die nothing.
Speaker 2 (34:07):
It's remarkable. You know. Having done this now for so
many years, I still am excited by the amazing nature
of that technology. It's really it's really something amazing. The thing,
as we were talking about incisional approaches, one thing that
(34:27):
I want people to be aware of about women to
be aware of, I want colleagues to be aware of,
is that if a woman has had previous surgery around
her nipple or around her areola, that doesn't necessarily preclude
the saving of a nipple at the time of the mastectomy.
(34:49):
Unlike twenty years ago, the concept of preserving the nipple
at the time of mastectomy is now quite quite often
done you know, if the tumor is a prophylatic setting,
or the tumor is remote sufficiently remote from the nipple,
(35:11):
we often save the nipple, which is really really an
aesthetic benefit.
Speaker 1 (35:17):
Can I interrupt you? I feel like this is going
to become a drinking game with this, with this episode,
where every single time you say nipple, somebody's going to
take a drink.
Speaker 2 (35:27):
It's part of dress surgery. What can I tell you?
Speaker 1 (35:29):
I know, right, I'm like.
Speaker 2 (35:30):
That it's an integral and important part of the break.
It is an important part of the brains and.
Speaker 1 (35:37):
So well, you saved mine.
Speaker 2 (35:39):
Yes, there there are times when if there's certain techniques,
there's something called a nipple delay, the E l A
Y E E l A Y procedure delay procedure, we
are ten to fourteen days before the mass stectomy, we
divide some of the underlying blood supply to the nipple
(36:00):
so that that which remains gets heartier. Okay, that's just
the concept. And so patients who have had radiation or
prior surgery around the nipple and still often keep their nipple.
It's really very valuable. So I just mentioned that, so
(36:22):
that if people are told that their nipples have to
come off because they've had a previous breast lift or
a previous breast reduction, that may not necessarily be true.
And so just just be aware of that.
Speaker 1 (36:35):
Right, maybe go see another doctor get a.
Speaker 2 (36:38):
Second opinion of their opinions in that regard.
Speaker 1 (36:54):
I mean, I think that that's what I sort of
encourage on the podcast and on my Instagram is it's
the white coat does not always know everything absolutely, and
it's really important to go get a second opinion, even
a third opinion. I mean, you weren't you weren't I
met with I think four different plastic surgeons, just like
(37:15):
I met with multiple oncologists. I don't think doctor G
was my only meeting for you know. I just always
thought I need to meet different people, see what different
people say, and also find the person that I connect
the most with.
Speaker 2 (37:31):
Absolutely, I couldn't agree more with that, And I think
that unlike many areas of medicine, and medicine is an art,
but sixth surgeon really is an art. And what you
said about connecting, yeah, that's true. I mean the surgeon
should be able to show you examples of his or
(37:52):
her work, some examples, you know, I mean, just to
get a sense of do you like they're aesthetic? Do
you like what they see as beautiful? You know, there's
some people, for example, who surgeons and find surgeons who
(38:14):
like placing very large implants, so that.
Speaker 1 (38:19):
It's the same thing with you, like with people who
do facelift. I mean, I know you do facelift. But
there's this doctor that several women I personally know have
gone to and they all look the same because that's
his aesthetic. So you know, the mouth is always, you know,
a little bit wider, it's a very specific eyebrows are
(38:45):
and I see them and I'm like, uh huh, Okay,
that's who your surgeon is.
Speaker 2 (38:49):
So you may not feel that that was that's how
you're aesthetic, right, I mean that's important to they look beautiful,
but but that beauty may not be optimal beauty for you, correct,
And so that's what that's what I think has to
be determined. And I think that if if the plastic surgery,
I think that if someone can't show you their results,
(39:10):
that's of concern. That's that to me. I think of
as if you were to work with an artist and
you said, I'm going to commission you to make a
beautiful painting. You'd have to see their work to some.
Speaker 1 (39:29):
Extent for sure. Are they impressionists? Are they modern? Of
course you want to know.
Speaker 2 (39:35):
Now, with that said surgeon may show you pictures and
should show you pictures that get you some sense, give
you some sense of what she he or she does.
That obviously doesn't say that you're going to get that
same result. Each patient is different, the body is different,
(39:57):
the situation is different. At least she have the opportunity
to get a sense of the artistry of that individual.
I really think that's what you're doing. You're getting a
sense of the artists the individual. Do you like the individuals?
It's someone you can get along with.
Speaker 1 (40:15):
It's also somebody you want to find a surgeon who
adjust to your desires, right because one of the plastic
surgeons I met with for reconstruction was a big boop guy.
He put big implants in and I'm five to four
(40:39):
and one hundred and four pounds. I can't like big
huge knockers. Is not my personal sthetic. Other people, it
looks great on do whatever pleases you. I'm all for it.
But for me, and it didn't really matter how much.
I just kept on showing him a picture of Kate Moss, like,
(41:00):
do you see how small her boobs are? Like? This
is perfection to me.
Speaker 2 (41:04):
He it.
Speaker 1 (41:07):
Just wasn't resonating with him, and whereas with you. You know,
maybe that's not even your personal style. Outher but you
looked at me and you said, beautiful breast, let's try
to get as close as possible. Just you know, because
I opted to only have one removed, it was you know,
(41:32):
you're still working with a real one. There's got to
be symmetry, because that's what I would want. So ultimately,
did I get tiny A's No? Am I happy or
that I didn't? Yes, Like, I'm pretty happy with your work.
Speaker 2 (41:50):
It's important to determine if the surgeon hears you.
Speaker 1 (41:55):
Yeah.
Speaker 2 (41:55):
I mean, I'm sure that surgeon who made the large
rest he or she might have been of find. But
if he didn't hear what you were saying, you know
that that's more of an issue. I think that the
plastic surgeon, after a message a reconstruction, tends to follow
you the most, you know, certainly among the surgeons. The
(42:17):
general surgeon does his job or job, then the plastic
surgeon really has to help you with the healing process
and follow scars and uh, you know, make certain that
you maintain a good path, you know. So I think
it's important to like your doctor.
Speaker 1 (42:37):
I mean, well, you've visited me over the weekend at
my house. You would drive all the way out to
Malibu and you would check the drains see how much
was draining before we could actually take the drains out.
You you just you wanted to make sure the skin was,
you know, staying alive, that there was no issues there.
(43:01):
And you were really really very very very hands on.
And I know that some people who have heard conversations
between myself and my doctors have made a comment of well,
you know, you're Shannon Doherty, so you're getting special treatment
(43:22):
or maybe it's your insurance. And I'm just going to
tell you guys that I know that doctor J does
this for every single one of his patients. It doesn't
matter if they're famous or not. You do this for
every single one. And to just chalk off sort of
my experience as well, you're famous, so you get extra
(43:44):
it's incredibly unfair. It's not unfair to me because I
don't really care what people say. It's unfair to my
doctors because I know for a fact that you are
this meticulous and hold your every single one of your patients.
You literally hold our hands through all of this. And
(44:08):
even after I was totally cleared by you, everything was fine.
You know. We went to the Greek theater together with
my mom and your wife jo Lynne, like you know,
and then we went to the Italian place together. It's
a relationship. You build relationships with your patients and you
(44:30):
constantly check in with them, even years and years and
years and years later, like when was when were we
probably done with everything? Like twenty seventeen?
Speaker 2 (44:40):
I think I think that's I think it's about right.
Speaker 1 (44:44):
We still check in and there's a true you just
you care. And it goes back to that story you
told in the beginning. It does of seeing that young
woman and wanting to help her and what that did
to you mentally, that you want people to at least
(45:05):
have as good of an experience through something like this
that they possibly can.
Speaker 2 (45:12):
Thank you, Shan. I appreciate your kind words. Yeah, I think,
you know. I often often tell my staff that we're
we should be like like family for as long as
we're needed, you know. And I had a young patient
recently who I had wonderful young woman who I had
(45:38):
reconstructed her breasts, who had a bad congenital problem which
was born with very very asymmetric press and she she
had she had her reconstruction completed, was thrilled, thankfully thrilled.
And she said, so, so am I going to see
(45:59):
you guys anymore? And I joked it, I said, no, no,
we're done, and she started crying, you know, I mean,
it was like and I said, of course you're going
to see this. You'll see us for as long as
you need us, and we're going to continue to make
sure your scars you know well that everything is great,
you know, in the coming months and years. I said,
You're never done with us, you know, we're always here
(46:21):
for you. But it made me feel great because you know,
I tell my staff, look, as long as they need us,
as long as they want us as both part of
their extended family, as people who are really meaningful in
their lives, that's a blessing. And when they're happy and
we no longer hear from them, that also means we've
(46:44):
done our good job because they no longer need us,
you know, And so it's a very wonderful opportunity to
help people. I every day in my life. I feel
immensely grateful and honor to do what I do. It's
really a privilege. And yes, Shannon, I mean, you're very important.
(47:06):
You're a very wonderful person. I have so many patients
who are also wonderful people who I deeply care about,
and that's just the way it should be. You know,
Medicine is it's very different, I think than anything else
in society that near their job, so to speak. I
(47:26):
think it's very different. And I grew up in a
family of doctors, and you know, my dad instilled in
me the concept that what we do really is a
privilege and an honor, and I've never not felt that.
That's always been my feeling from day one. And once
(47:48):
I saw that patient and directed my life's professional path
where I wanted it, it's really been just such a
privilege and great honor to hear from people that I
made a positive difference, you know, Shanneon we don't always succeed.
We're not perfect, We certainly are not perfect, but by
(48:13):
when we do succeed, it's the greatest feeling in horror.
Speaker 1 (48:17):
Right, Yeah, I know, I'm sure, I'm sure that feels
amazing There's a lot more you guys with Doctor j Oranger,
so stay tuned for part two.
Popular Podcasts
1. Stuff You Missed in History Class
Join Holly and Tracy as they bring you the greatest and strangest Stuff You Missed In History Class in this podcast by iHeartRadio.
2. Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations.
3. Crime Junkie
If you can never get enough true crime... Congratulations, you’ve found your people.