Peter Barry is a Consultant Surgeon at the Breast Unit, Royal Marsden in London. He focuses on breast oncoplastic techniques and reconstructive options following cancer surgery, as well as preventative surgery for high-risk women. He was a guest speaker at our 2024 Annual Scientific Meeting and we spoke to him about selecting patients for volume replacement therapy.
“We are trying to improve aesthetic outcomes for women who survive their breast cancer treatment and make surgery less of a challenge. In terms of cosmetic deformity, pain and other issues that can follow on from surgery. And so, we’re trying to sort of reduce the extent of surgery. So, reduce rates of mastectomy, that is breast removal.
“One of the methods of doing this is by actually filling the breast, especially when it’s a smaller breast, with tissue from either just beyond the breast or using fatty tissue, if there’s spare tissue around the body.”
“We can do what commonly people know as liposuction, but we do it in a way that harvests the fat to then actually transplant it into the breast and so rejuvenate and reshape the breast by using those techniques.”
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We spoke with Dr Peter Barry about selecting patients for volume replacement therapy.
How do you work out who will be a good candidate for volume replacement surgery?
“Look, that’s a really good question. So, in the primary breast cancer scenario, we have women with either very extensive breast cancer where the volume of the actual cancer removal is quite large in comparison to the volume of the breast.”
“Often women with smaller breasts, where there’s less drop to the breast, that sort of thing, they’re the ideal candidates. And especially if they’ve got a little bit of spare tissue around the sides or underneath the breast, where we can then transplant that tissue and move it into the breast.”
“So, we rebuild the breast by removing tissue from outside and around the breast, or indeed other parts of the body using the fat, as I mentioned. So again, it just reduces the rate of women having to undergo very complex breast removal, mastectomy, and then more complex reconstruction procedures.”
What are the benefits of this procedure?
“These women will need to then undergo radiotherapy to the breast generally as part of the overall treatment, and possibly other treatments as well, drug treatments. And it just means these procedures are all day surgery treatments, so they’re in and out of the hospital in the same day.”
“The recovery is very quick. They’re relatively painless compared to some of the more extensive procedures, and they wake up with a pretty good cosmetic outcome. You might say, well, why not just use a breast implant for reconstruction? That’s pretty simple too, and sort of overnight hospital stay.”
“But breast implants will cause more general problems, complications, infections can happen. And there’s always some ongoing maintenance with implants. Whereas this is pretty well a one-step procedure, that’s robust and will last a long time, because it uses the patient’s own natural tissue, so that’s the key.”
“So, in fact, I know we do reconstruction using the patient’s own tissues, from the lower abdomen, the tummy tuck, if you like, or from the thighs or around other areas of the patient’s body where you can move bulk tissue. This removes tissue and replaces it just from around the breast.”
“So, it’s in the vicinity of the breast, so the downtime for the patient is much less. For example, with the tummy tuck procedure, these days, hospital stays are getting shorter. So, there might be three to five days, where there used to be seven to ten days in hospital. But often they can’t do heavy lifting, they can’t run and get back to their normal daily activities for probably six weeks or so.”
“Whereas with this procedure, they might have a little bit of restriction in their shoulder movement with the arm on that side for a couple of weeks. But, because we don’t use muscle in the procedure, that recovers very quickly. So, they’re not losing power or strength and generally, recovery is quick in comparison.”
“There are always risks with fiddling with small blood vessels. So, it does take training and we’ve done a sort of global study looking at training needs. This is probably considered a more advanced procedure for the breast surgeon. And so, we’re doing a lot of workshops to train people in the technique, so it becomes more widespread.”
“It’s certainly available in the larger centres around Australia as well and so it’s just a matter of asking, you know, what the options are and who can do this. Usually in one centre there’s at least one or two surgeons that will undertake this. Yeah, so probably about one in two hundred risks of part of the flap or the tissue dying off.”
“That can happen before or even after radiotherapy because radiotherapy will always stress the tissues. And so sometimes patients end up with a little area of hard tissue. Now that can happen with any breast reconstruction procedure using the patient’s own tissues. But it’s relatively easy to treat.”
“It can be a bit painful, but you can suck that out through liposuction or even local anaesthetic, and you can replace it with new fat from around the body. So, it’s pretty treatable and there shouldn’t be many complications.”
“Yeah, so I think particularly in the realm of fat transplant or what we call fat grafting or lipo-filling, these are all synonymous terms. Many people have heard of liposuction, which is a cosmetic procedure for some patients who want to get rid of sort of unsightly or excess fat in the body.”
“This now takes that procedure, which is quite a traumatic procedure if you’re just removing it. But we’ve adapted the procedure over many years, and there are several machines developed for this. Which actually treat the fat super gently. We remove it in a very gentle way because this fat is literally like liquid gold now, we want to put it back to make sure it survives, and we traumatize it as little as possible. The body basically will sort re-adapt itself to take that fat on board, and then new blood vessels can be formed, and the fat then regenerates.”
“It’s shown to also improve the tissues after radiotherapy, which damages the normal tissues, and so it can reduce scar formation and tissue distortion after radiotherapy, so it’s a great procedure.”
“Alot of people are using it in many different cases, not just with breast conservation, but even over breast implant reconstruction. We’re even reconstructing whole breasts using fat grafting. The downside of fat grafting is you need to do multiple procedures, although each procedure is about 60 to 90 minutes. But you often need to do a repeated procedures a few months apart. So, it’s a process.” It’s often not one single procedure unless it’s just a tiny cosmetic thing you want to fix. But really, this is part of regenerative medicine and it’s a very exciting area. So, I think that technology is going to only improve with time.”
“To say that with the lipo filling fat transfer aspects of it, we are using what we call stem cells. The fat tissue in our body has an abundance of stem cells. In fact, maybe most of the body’s soft tissue stem cells are actually found with the fat. And so, we know which part of the tissue that we take out when we take fat out through these small needles.”
“One of the advantages is the scars are very tiny because we use two, three, four-millimetre needles to harvest the fat. But part of that fatty tissue is what we call the adipose derived stem cells. And those stem cells, if you just inject those back, particularly just under the skin, can rejuvenate scars, they reduce further scarring and they can make the body tolerate much more trauma, like radiotherapy and other issues. And it lasts a long time as far as we can tell.”
“We can also always, also use the patient’s own blood and extract what we call platelet rich plasma. And that also has regenerative qualities and people are trying different ways of enriching the fat so that more of it takes and the results are better with fewer procedures. So, it’s a really exciting area in development.”
What is the role of the patient and how can they keep informed about their treatment?
“Yeah, it’s a really good question because I mean for breast surgery in particular, we talk about the concept of shared decision making. And this is exemplified in breast cancer surgery because, I mean the very initial decision is sort of mastectomy, removing the breast versus keeping part of the breast and conserving the breast.”
“This was something that was established years ago that either alternative is as safe in terms of the cancer outcomes. And in fact, we have a lot of data now, probably over a million patients, although it’s sort of data looking back at large patient databases. And we are asking maybe it’s even safer to not remove all the breast tissue.”
“This is something we’re a little bit circumspect about, but we know it’s at least as safe to keep some of the breast and perhaps there’s some immune local and microenvironment in the breast tissue that we left behind that might even protect the patients against cancer cells going to other parts of the body and setting up camp in different sites, which is obviously metastatic disease, and that’s what we’re trying to prevent.”
“So, there are some signals that that might be beneficial, but in terms of overall shared decision making, we’re really just trying to help the patient make decisions depending on their own priorities. So, if their priority, for example, is to have chemotherapy, as soon as possible after surgery, because that’s really important for their disease control and prevention of further disease, then we want to get them, get them recovered as quickly as possible, get them out of hospital as quickly and get on with their lives.”
“Some women have young children and so they don’t want to be burdened by a big abdominal scar where they can’t carry their child for several weeks. With some of these other procedures they can immediately use their arms, do lifting, that sort of thing.”
“So, there are many different aspects that we need to tell patients about. Again, depending on what they do with their arms and hands in their occupation and life, sort of the general lifestyle, we try and guide them as to what might be the best thing. At the end of the day, the patients will try and choose and trade off what works for them the best in the long run.”
“Often, you’ve got to guide patients a little bit because they’re initially so scared about the cancer. Often women will come and say, look, just chop off my breasts because, you know, they’re in total shock.”
“But we’ve got to look forward. Survival’s so good nowadays that we’ve got to look forward to survival issues. And we know that as women go forward one, two, three years beyond their surgery, they’re going to be more concerned about their aesthetic outcomes and their functional outcomes. So, this is really important to try and bring the patient back to that scenario early on.”
“Whilst you’re of course treating the cancer in the optimal way, you want to improve all those other outcomes for the longer term as well.”
“I want to mention the lymph nodes in the armpit, just for a moment if I could because it’s such an important area. It’s probably, arguably, much more a morbid issue than the breast itself for many patients because they can get lymphedema of the arm, shoulder stiffness, pain, and all that sort of issue.”
“I’m involved with a couple of trials including one based in the UK, called Tadpole, that’s sort of still in development, but coming along soon. We’re going to randomize patients between what we call a targeted axillary dissection, which is this removal of two or three lymph nodes, when one or two lymph glands are involved, versus taking all the lymph glands to try and prevent that sort of knee jerk reaction of taking all the lymph glands when often it’s just one or two that need to be removed.”
“So, we’re trying to refine that surgery better. And then on the other side, there is a worldwide trial called Sentinel 2, led from Sweden by a colleague of mine. And that’s where we use a particular magnetic liquid that we inject at the time of surgery for pre-cancerous change.”
“In about a fifth of those patients, they’ll come back with actual fully formed invasive cancer where we then need to go back and remove one or two lymph glands. And in this patient cohort, we never know up front whether we should remove the lymph glands, because what if we find invasive disease? Whereas with this, the actual trace that we inject at the time of initial surgery marks the lymph glands for one or two months even.”
“And so, we can then avoid taking the lymph glands if they don’t need to be taken. The pathology comes back as invasive cancer. We can then go back selectively in those 20-25% of patients and just pick out the one or two lymph glands there.”
“All of this research is aimed at reducing unnecessary axiliary surgery or armpit surgery on the lymph glands. So, I think that’s a really exciting development that’s happening as well worldwide.”
Where do you see research going in the future?
“I think in general, the first thing is to raise the level of technical ability for surgeons, so that we increase what’s on their tool belts, to give patient options like the reduction of the breast mammoplasty, as well as volume replacement techniques, which originally were thought to be more plastic surgical treatments.”
“But often, especially in Australian remote areas, patients don’t have access to plastic surgical resources as much as they might, in the big cities. And so, it’s really important to equip surgeons to offer these various options.”
“That’s one thing. And on the other hand, I think with the armpit surgery, to try and just reduce the extent of armpit surgery. Many of us still feel very twitchy about leaving lymph glands behind because we think somehow the cancer’s going to come back, whereas we know it’s really just, if you like, a surrogate marker of the potential for cancer to go to other sites.”
“We really believe increasingly that the lymph node is not the source of the spread to other body sites. It’s more that it’s just a marker of risk. And so, we need to just remove the involved lymph glands obviously, but we don’t need to remove all the lymph glands. So, I think many of us are doing this already, but I think if we can just spread the word and make sure that treatment’s more homogenous across the board, doing less for patients, I think the patients will benefit just by reducing the morbidity.”
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