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Interviewer: As technology and practices have improved, more people than ever are receiving joint implants. In fact, "The Journal of Rheumatology" projects as many as 600,000 joint replacements in the U.S. by the year 2030.

With more folks receiving an implant, how do you take care of it and ensure that it lasts as long as possible? To answer those questions, today, we are joined by Dr. Mike Archibeck. He is an associate professor with the Division of Adult Reconstruction at University of Utah Health.

Now, Dr. Archibeck, for someone who has just barely received a replacement joint, whether it be a knee or a hip or something like that, what do they need to know about taking care of it for, say, the first year after surgery?

Dr. Archibeck: Yeah. So I think I'm primarily going to talk about total knees and total hip replacements. That's kind of the purview of the Adult Reconstruction Division in the Department of Orthopedics. So we do total knees and total hips as well as revision total knees and total hips.

And so there are a few things that are generic in regards to how to maximize your recovery early after surgery. Most would consider the first year as kind of the recovery period. It's been shown that both hips and knees generally do improve over that year, even though the vast majority of the improvement is in the first few months.

And during that first year, there are a few things you can do to kind of maximize the outcome and protect it from the dangers. Early after surgery, one of the most common complications is a blood clot in the leg or something that we call a deep venous thrombosis. So, usually, patients are prescribed some form of blood thinner. It could be aspirin. It could be something stronger. So being sure to do bed exercise during the day, get up about every hour or so, and go for a short walk.

You also want to be sure that the wound heals. So one of the concerns early after surgery is infection. Try not to overdo it such that the knee or hip area becomes too swollen, that can slow or compromise wound healing, and being sure to avoid any other types of infections that you might get early after surgery, like a urinary tract infection or a skin infection.

So if any of those things develop, or dental issues, you want to touch base with your surgeon and be sure those are treated so they don't potentially get into the bloodstream and make it to the hip or knee replacement.

And then recovery-wise, some patients participate in formal physical therapy. And more commonly now, more and more patients are doing kind of directed physical therapy, but working on whatever the tasks might be that the therapists direct you to do.

So with a knee, early after surgery, one of the high priorities is working on range of motion. A hip, less of a concern range of motion, but with both, starting to work on gait training initially with a walker, and then subsequently, weaning to a cane, and gradually off. Usually, that process is coached by the therapist or the surgeon and his team.

And trying to avoid overdoing it. Like I mentioned, you can really set yourself back if you do too much too soon. You can get swollen, wound healing can be slower, and it can just be more painful and kind of slow the recovery process.

So, again, the main things to be careful about are watch for the signs of blood clot, which would be significant swelling in that leg that does not respond to elevation, protecting the wound from infection, and just being an active participant in your recovery and physical therapy.

Interviewer: For someone who has received a joint replacement or is about to have joint replacement surgery, the recovery takes anywhere from 10 months to a year. So when will they see the most improvement? I mean, when will they start walking again?

Dr. Archibeck: Yeah. So, with both, you'll really be walking the day of surgery, obviously to a limited degree, and you'll be using a walker typically. But with both, you're generally able to place as much weight on that implant or that extremity as you want.

But like you mentioned, the first few months, the improvement is very rapid. So week to week, you see a significant improvement.

The improvement after those first few months is a little more subtle. So you may not notice dramatic changes like you do early after surgery, but it will continue to improve, and you gain more confidence in it, and you think about it less as time goes by.

But most people kind of describe the first six weeks as the majority of the recovery, so that's really the time frame when the focus is on avoidance of complications. So blood clot, infection, things like that.

Interviewer: Wow. So after the first year, the body is healed up, we've made sure that the wounds are not getting infected, we're not getting clots, etc., but now we have a piece of hardware in our body. What do we have to do to make sure that we're taking care of the implant and make sure that we get as long of a use out of that implant as possible?

Dr. Archibeck: There are several things that are important to know. So one is how do these things fail? And there's a little bit of a difference with knee replacement and hip replacement, but in general, they can still fail by infection. So, obviously, that's a life-altering event if it occurs.

And generally, it's felt that that is caused by a remote infection that then enters the bloodstream and finds its way to the joint replacement. So, unfortunately, a chunk of metal like a hip and knee replacement is always more susceptible to infection than a native healthy joint.

So you just want to take generally good care of yourself. Keep your dental work up to date. That can be a potential source of infection.

Interviewer: Really? Dental work?

Dr. Archibeck: Yeah. In the past, they used to recommend antibiotics prior to any dental work, and that still is a bit of a controversial topic, but that's not felt to be absolutely necessary unless you're high risk or have multiple joint replacements. But again, that's a topic you'll get different opinions about.

Any other bacterial infections, so common ones would include urinary tract infection, skin infections on that leg or other areas, obviously sinusitis, pneumonia. As you typically would if those things develop, you just want to be diligent about getting them looked at and treated, and more so if you have prosthetic joints.

I mean, obviously, we're talking about hip and knee, but there are elbow replacements, ankle replacements, and others. So any bacterial infection can potentially go to those areas. So just kind of taking good care of yourself like you generally would.

Implants can wear out. So, luckily, hip and knee replacements, the materials that we use have significantly improved over time over the last couple of decades. And so, even at 20 years, most are still functioning well, but they do wear and tear.

So a few things you can do in that regard. It's generally recommended that you avoid repetitive, high-impact activities, such as running, for exercise or aggressive cutting and pivoting sports. Things like walking, hiking, biking, swimming, golfing, dancing, most people feel like skiing is fine, are all activities that are absolutely fine to do and don't need to be limited at all. You can do as much as you want.

Then there are those in-betweeners, like tennis, pickleball, skiing, where some of those the risk is more the risk of a fall. But generally speaking, those activities are felt to be okay too, just avoiding the really high-intensity cutting and pivoting type things.

The other thing that can help add to the longevity of an implant is maintaining a good body weight. So it's been shown that the risk of wear and tear . . . and by that, I mean the plastic can wear or parts can loosen. The risk of those issues arising increase a bit as your BMI, or body mass index, increases. So trying to maintain a good body weight is helpful. Avoiding high-impact activities.

And then another rare cause of failure would be an injury of some type. So the implants themselves are very durable. But obviously, the bone adjacent to the implant can be susceptible to fracture or injury.

Especially as you get into your advanced years, being careful to avoid situations that might put you at risk for a fall or an injury, making sure your home is safe in regards to no obstacles on the floor or edges of rugs, and just kind of doing your best to minimize the risk of a fall. A fracture around an implant obviously is considered a failure and typically requires surgery to correct.

With that being said, though, like I mentioned, when patients ask, "How long do these things last?" we give a relatively simple answer, like, "Hopefully 15 to 20 years." But to be honest, even at those intervals of time, the vast majority are still functioning well. Yeah, they're pretty durable implants.

Interviewer: What I'm hearing is after you get your joint replacement, if you take care of your body, your health, your weight, and so on, that your implant can last as long as 15 to 20 years?

Dr. Archibeck: Yeah, I think that's fair to say. The other thing that I should mention is that even if a joint replacement is functioning well, it's wise to see your physician. And recommendations vary, but I would say probably about every five years.

So the first year, there's a regimen of post-op visits. Usually two weeks, six weeks, maybe three months, a year. After that, though, we usually let patients go for a while. And it's wise, though, to return and get an X-ray and be evaluated, I would say, anywhere from every five to ten years.

The reason being is that there are things that can occur with the hip replacement or knee replacement that aren't always painful. So if you get a little bit of plastic wear, that might be something that we would be able to see on X-ray, but may not be a painful problem.

And sometimes, if caught early enough, the solution to that issue is relatively simple. If caught late, when it's maybe resulted in loosening of an implant, it can be a much more problematic issue to correct.

So routine follow-up, even after that first year, is wise. Especially as you get to the 15- to 20-year interval of time since surgery, then it becomes even more important because that's about when our concern kind of increases a little bit in regards to the risk of some of these wear-and-tear type mechanisms of failure.

The other thing that's worth mentioning is beyond just having it last a long time, obviously all patients want it to be as comfortable and functional as possible. And it's true that a hip replacement and a knee replacement probably will never feel like a totally normal joint, but the closer we can get it to that, the better.

And typically, hip replacements, for whatever reason, seem to approximate a normal hip more closely than a knee replacement. In other words, it's much more common to have some residual symptoms with a knee replacement.

But the most common reasons we see patients back who maybe had a knee replacement or a hip replacement five years ago, 10 years ago, and just somehow, again, feel concerned that it's not as comfortable as possible, or as they were hoping it would be, include weakness.

So that early post-op time frame, like we mentioned, it's important to work on strengthening. Maintaining that strength is equally as important to allow that hip or knee to function as good as it possibly can.

Again, maintaining a good body weight. It's been shown that if your BMI kind of creeps up a little bit, sometimes the patient's satisfaction level with their replacement decreases. So even though it's not intuitive that that would be the case, maintain a good body weight, maintain good strength.

And obviously, if it really seems like something is wrong, if it's painful and it seems to be not resolving or worsening, then you definitely want to see your physician to kind of rule out any concerning findings.

But again, continuing with those strengthening exercises, maintaining a good body weight, those things can help the joint replacement function most effectively for a long period of time.

Interviewer: Now, going back to that idea of satisfaction, if a patient gets a replacement and is able to take care of it for those 15, 20, or more years, what kind of improvements in quality of life can they expect after receiving a joint replacement?

Dr. Archibeck: That's a good question. The good news is that the vast majority of patients, even though they may have some residual symptoms, feel as though they're dramatically improved when compared to their status preoperatively.

So like I mentioned, it's often the younger patients that maybe notice the limitations or the shortcomings of joint replacement because of maybe their demands of it or their expectations of it.

Because they're just by nature more active, they may notice those limitations a little more than a very elderly patient that maybe isn't as active. Those patients often feel like, "Hey, this does feel pretty normal to me," whereas, maybe the younger, more active patient feels that they're still a little limited by it.

But like I mentioned, most patients, younger or older, generally feel significantly improved after surgery.

And as I mentioned earlier, they should expect to be able to participate in those activities that I mentioned without significant pain: walking, hiking, biking, swimming, things like that. The more demanding activity is, so things like stairs, squatting, walking up or downhill, long hikes, it's not uncommon to still maybe develop a little fatigue or a little ache in the joint. And those things, unfortunately, may persist.

So, with knee replacement, it's been estimated that about 15% to 20% of patients continue to have some degree of what they describe as pain, even though most patients are still very satisfied. Hip replacements, it's a little less. So maybe 5% to 10% of patients still have occasional pain. So, yeah, unfortunately, not a totally normal joint, but definitely typically a significant improvement.

Although the things that I mentioned, like infection or injury, are extremely scary and worrisome, they are very, very rare. And most people do very well after hip or knee replacement in regards to a significant improvement in their quality of life, both in regards to the level of pain that they have as well as their level of function and the activities that they're able to participate in.

If you are considering having breast implants, for whatever reason, how do the new FDA guidelines on breast implants affect you and your decision?

Breast augmentation is near the top of the most cosmetic surgical procedures. Although the number of women who had breast implants fell by one-third in 2020, probably related to COVID-19 pandemic, still 200,000 people had breast implants in the U.S. in 2020, down from the usual 300,000 implants per year. About 75% of the implants are for cosmetic reasons, and the rest are part of reconstruction after breast cancer surgery.

Recently, the FDA took some new steps to improve and strengthen the information guidelines about implants and short- and long-term consequences.

It's hard to know how women want to receive information about the risks of breast implants. They believe that they know the benefits, at least for the persons they believe themselves to be right now. They can't really assess the benefits to the woman they will be at, let's say, 60. However, the assessment of benefits is a completely personal process and will be different from woman to woman. And this includes trans women making the decision to have breast implants.

The risks are harder to communicate. Language is often very medical, numbers are hard to process, and some people don't even want to know the risks.

There are data from a randomized trial of information giving that women who received more information were happier with their decision, were less likely to experience preoperative anxiety, and were less likely to experience postoperative regret. So in the information era, I think more is better.

So what are the new components of these new FDA guidelines? First of all, they aren't exactly new. They've been worked on for several years now, and they went out for public comment and were published back in 2020. However, they became more official in the fall of 2021.

Firstly, the boxed warning, the ominous black box that comes on some package inserts of medications and devices that actually nobody really reads unless you stick it on their nose.

I'm going to quote here the example from the FDA with my own asides put in. "Warning," and this is in a big black box, "breast implants are not considered lifetime devices. The longer people have them, the greater the chances are they will develop complications, some of which will require more surgery.

"Breast implants have been associated with the development of a cancer of the immune system called breast-implant-associated anaplastic large cell lymphoma. This cancer occurs more commonly in patients with textured breast implants than smooth implants. Although the rates are not well defined, some patients have died from this." Okay, that's number two.

Three, "Patients receiving breast implants have reported a variety of systemic symptoms, such as joint pain, muscle aches, confusion, chronic fatigue, autoimmune diseases, and others. Individual patients' risk for developing the symptoms has not been well-established. Some patients report complete resolution of the symptoms when the implants are removed without replacement." Okay, that's the black box.

Well, I would want to know more about the phrase that the implants are not considered lifetime devices. There are no recommendations that breast implants be removed after some certain years, not like IUDs that have a finite effectiveness with recommendations for removal at a certain time.

Eighty percent of women who've had an implant placed still have it at 10 years. Of course, the woman that you are at 25 will not be the woman that you are at 55, and neither are your breasts, as all of us know.

"The chance of complication increases over time." What does that mean? Your surgeon should explain those complications, what they are, how often they happen, and what can be done about them.

The common ones are hard fibrous walls around the implant that can be unnatural-looking and feeling, or rupture of the implant capsule.

The uncommon one is the cancer that's associated with the certain kind of implant with a textured, not a smooth, outer covering. That cancer, which is mentioned in the black box, is called breast-implant-associated anaplastic large cell lymphoma. This is a mouthful, but is lymph cancer that arises over time, rarely.

The incidence in women who have these textured implants is 1 in 3,000 to 1 in 30,000. So it's not common. We have a great interview with Dr. Jay Agarwal on this kind of cancer and breast implants. You can find this interview at The Scope if you want to know more.

"Breast implants have been associated with these systemic symptoms." What does that mean? Some women have experienced symptoms such as pain, autoimmune symptoms, chronic fatigue. In the past, this has been somewhat ignored. But there are some women who've had fewer symptoms after their breast implants are removed. This isn't very well understood, but here it is in the black box.

To help understand the black box warning about breast implants, the FDA has created a model patient decision checklist. I think this is really great if it's given to the woman well in advance so she has time to read it or have someone read it to her and explain it to her. This isn't something to be handed out in the pre-op visit just to sign, the way you sign your permissions to your software like Google or your phone. This should actually be read word for word.

The FDA created this checklist to add to that surgeon's counseling. It is meant to be a springboard for discussion, and the patient will read and check off that they've read it and understood it.

It is long, multiple pages, with places for the patients to sign at the bottom of each topic. It includes who shouldn't have implants, at least at the moment: women who have an infection, women who are pregnant or breastfeeding, women who are having chemotherapy or have a suppressed immune system. It includes more information about the rare lymph cancer and about long-term systemic symptoms.

Actually, the example in the FDA guidelines is a really, really good one. If you're an information junkie like me and you read at, at least, the 12th-grade level, it's great.

The long-term risks of complications are spelled out. The frequency at which these things happen are attached, such as painful scar tissue around the implant reported in 51% of patients, rupture or leaking of the implant 30%, need for reoperation 60%. But those are just the biggies.

It's a really great document. It's what your surgeon should have been telling you anyway, but in the heat of the moment in the office, they might not take the 30 minutes to talk to you about this. And you might not remember. This is a great chance to take it home and read it carefully and bring it back with your questions.

And with the FDA guidelines, there's an updated suggestion about management of breast implant rupture or leakage, that 30% of the time it happens.

And last but not least, there's a card for the patient to keep forever in her wallet or personal records about what kind of implant she has, what it's made from, and when it was placed.

Now, you think you'll remember all this stuff, but you won't. And maybe you'll have them still at 80 and your memory is fading. Your surgeon may have retired or gone on to surgeon heaven. Your medical records may be lost. But at least you have a document about what is existing in your body.

If I had implants, I would laminate mine and put it next to my driver's license or my organ donation card.

I think these are really good steps in the right direction in patient information and decision-making. I know you just want what you want and you wanted it yesterday, but it's a long-term decision with long-term consequences, some good, some not so good. You should take your time and try to get it as right as you can.

Thanks for joining us on the "7 Domains of Women's Health" at The Scope.

Dr. Jones: So you've been very successful at achieving your weight loss goal. Congratulations. But you don't fill out your bra anymore. What is that about?

Most women who undertake a significant weight loss through diet or through weight loss surgery are hoping to lose fat. That's the part of the body that we don't need so much. We don't want to lose a lot of muscle when we do a weight loss thing. But some parts of our body are mostly fat, and that would be our breasts, and weight loss may lead to a body change that isn't welcome. So what can we do about that?

Today, in the virtual Scope Studio, I'm talking with Dr. Cori Agarwal. She is a plastic surgeon who specializes in aesthetic and reconstructive surgery at the University of Utah, and she has an interest in helping women find the body that they're looking for.

So I have some questions about this, because this is a really interesting topic for people who have really undergone a basic transformation of their body, whether it was 30 or 50 pounds, or they lost baby weight and the baby and then they nursed and so their body isn't the same. After substantial weight loss, women may find their bodies change in ways that they hadn't anticipated. Can you talk about weight loss and how it affects breast structure?

Dr. Agarwal: I think that's a really overlooked conversation when people set out to lose weight. They're really focused on health and kind of the getting back to feeling more active. And sometimes it's a surprise when there's this negative effect on specifically the breasts.

The breasts, as you mentioned earlier, are made up of quite a bit of fatty tissue, and that really varies person to person. But I'd say most women, especially as we age, the breasts become more and more percentage of fat. So when you lose weight all over your body and you lose fatty weight, naturally some amount of that is going to come off of the breasts. And you don't always know until you're there. So, for some women, it's just a minor effect. And for some, it's completely deflated after the weight loss.

Dr. Jones: Oh, deflated. I mean, it's hard enough getting older and if you've had babies, but to have . . . even that word deflated, that would have me rushing to you to get some help.

Dr. Agarwal: Well, I was going to say the deflation, it's really important to think of it in two areas. There is the loss of volume, so the loss of this fat where you really just lose the size of your breast. And then there's the deflation, the sagging of the skin where the nipples kind of point down and everything stretches down.

And those two we really think of separately and independently. When we talk what options there are for rejuvenating and filling the breasts, we really think of the sagging and the loss of volume separately, because not every individual has as much sagging or as much loss of volume.

Dr. Jones: When you said there are really two parts to two different kinds of changes that happen with weight loss, there's sagging and then volume, what are you going to do? What are the procedures here that you're going to undertake with this woman?

Dr. Agarwal: There are really two main objectives. And one is to fill the volume to the size that was lost. And for some women, they want to be a little bit smaller than they were to start. Some want to be a little bit bigger. And to fill that volume back, to restore that deflated volume, the mainstay operation is a breast augmentation, and that's placing an implant in the breast usually behind the muscle to regain the volume.

However, if the skin has at the same time sagged, which it usually does, in the process, there needs to be a skin tightening procedure done at the same time. And that's called a mastopexy or breast lift.

Now, these can be done independently. Someone may just want the lift. They might like the size that they've ended up, but everything's just droopy. So we'll just do the breast lift. And then more commonly, we will offer and recommend a lift with an implant, because in most people, I think both of those processes are happening. That's something that's very individualized, but I think it's important to think of those two separately, the lift and the augmentation.

Dr. Jones: And so, rather than some people thinking they're just going to have a little incision somewhere and something is going to be slipped in and pumped up or something, you're really going to have to remove some skin and maybe lift the nipple.

Dr. Agarwal: Right. I think that's often a surprise for women because they think, "Well, this is just like a deflated balloon. I'm just going to fill up the balloon," but they haven't really noticed how far things have stretched. And we really have to have an honest conversation about what it will look like with just the implant, or if you really want or would recommend a lift along with that implant.

Dr. Jones: So what are the options for women who would choose breast surgery? Do you call it aesthetic or cosmetic, or in this case, is it really reconstructive and is it paid for by insurance?

Dr. Agarwal: That's a really important thing, and so many things are blurred in the world of plastic and reconstructive surgery. A lot of things that we do that are reconstructive really are also cosmetic, and there is a blurred line, especially when it comes to the breast.

So when we talk about the words cosmetic and reconstructive, what we're usually getting to is "Will insurance pay for it?" Because if insurance sees it as cosmetic, then even if we think it's really truly a reconstructive thing, building your body back, we have to call it cosmetic. And the sad truth is that for most breasts that have sagged or lost volume almost all the time will be considered cosmetic by insurance companies and is not covered.

Dr. Jones: Well, for women who part of their weight loss journey has been becoming really active, and now they have breasts that don't want to stay where they want to put them, that ends up getting in the way of their being the physically active person that they have to be if they're going to maintain their weight loss.

Dr. Agarwal: Right. And we do try to make those arguments to insurance, but I think that it's just outside the scope of what we can declare medically necessary for the breast. Breasts sag for so many reasons. Pretty much anyone who has gone through a pregnancy and nursed a baby, even just age, breasts just sag almost 100% of the time. And so I think that's just beyond what we can argue for insurance to cover.

Dr. Jones: Knowing that many people who lose weight gain it back again, is there any recommendation about waiting for weight to stabilize for a while before considering breast augmentation? I mean, we've all watched the successes and failures on "The Biggest Loser," and some people are back right where they started from within a year or two. So how do you counsel people in terms of when they should consider this reconstruction?

Dr. Agarwal: I think as a general rule of thumb after a lot of weight loss, we'd like people to maintain their weight for about six months. If it's just a quick diet that's severe and maybe they're going to bounce right back in a couple of months . . . but by six months of sustained weight loss, most people are pretty steady in their weight. So that's the general recommendation, but of course, it's very individualized.

Dr. Jones: Right. And can this surgery be part of a larger surgery? So you certainly know people who have maybe had bariatric surgery and they lost 150 pounds, and now they have sagging not just in their breasts, but throughout skin, all over their body, which becomes a significant issue in just terms of staying healthy. Can you do redundant skin reduction at the same time that you do a breast surgery, or are these staged at different times?

Dr. Agarwal: I think both are true for each individual. When we're thinking about doing reduction of skin, tightening of skin after a lot of weight loss, safety is the main priority. We want to limit the amount of time under anesthesia for any individuals. So if they came in and said, "I want my breasts and my belly and my thighs and my back," we really have to slow it down and say, "Okay, what's the most important thing here? Can we combine it with something else?"

We try to limit the surgery time somewhere between three and six hours. And so we can do sometimes breast work with something else, but depending on what other areas are the priorities, it's very common to stage this.

But that's the conversation we have after we get to know the patient and see how healthy they are, how prepared they are for a long recovery. So it can go both ways.

Dr. Jones: So when you say how healthy they are and how emotionally prepared, it's hard when you have just a few minutes to get to know someone. And I know that sometimes before people undergo bariatric surgery, they might actually see a behavioral psychologist. But how do you get to know people to know that this is the right thing for them to do and they're not just seeking something that's really unobtainable? How do you set realistic expectations about what they're hoping for?

Dr. Agarwal: This is really important. We spend a lot of time . . . I'd say the first visit is usually about an hour. And during that time, a portion of it is talking about the surgery and evaluating them. But a big part of it is talking about how they've gotten to that point, how they feel, what their expectations are, and then their social support. I think social support is critical when you talk about getting through a big surgery like that. And so we'll make sure that they've really thought through who needs to help them, someone to help with the children, someone to help with themselves and their work. So that first visit, we do a fair amount of that really trying to get to know someone.

And you're right, it's only one visit, but usually we have another one or two visits after that before surgery and really get to these critical questions of whether they've thought this through and have the support on the other side. Some will have to really set realistic expectations, that you will not have a 20-year-old body after this, but you will have this and you won't have that. So we try to be really realistic and not try to sugarcoat it or make it seem better or easier than it will be.

Dr. Jones: Right. Well, I would think that most people having gone through . . . particularly if it was significant weight loss, they've been with this body for a while and they know what they're looking for, and I bet you they're mostly pretty realistic. They're not coming in with perfect breasts hoping for more perfect breasts.

Dr. Agarwal: I wish that was the case in everyone. I think there are certainly a lot of women who are exactly in that category, but there are a lot of people who still . . . maybe it's a lot of the TV shows out there, but there is an idea that there's some magic that happens and some Photoshopping. I do think we have to ground them sometimes if maybe what they've been seeing isn't realistic, because . . .

Dr. Jones: I've seen some of those YouTube videos, the befores and the afters, and I look at the afters and say, "How can she have lost 150 pounds and have breasts and legs that look like that? Is that real?"

Dr. Agarwal: Exactly. So you have to take a lot of it with a grain of salt, and so that's the job. I think that that's the consultation. You're not going to know that before really meeting with your surgeon and understanding what can be achieved.

Dr. Jones: I want to thank you because I hadn't really thought about this one. Certainly I've had patients over the years who were thinking about bariatric surgery, and I didn't really take them through all the steps that this will happen when you get there. You will get there, but then this may happen. It may not. So I want to thank you for giving us some insight.

And for women who've taken the big steps to make a big positive change in their body through weight loss, there are sometimes still steps to take to feel like yourself again. You're not alone and there are options and procedures that can help.

I want to thank you, Dr. Agarwal, for joining us. And thanks for everyone who's listening on The Scope.

Dr. Jones: Disfigured, mutilated. These are words that are the way some women feel after mastectomy, the extensive surgery for breast cancer. What can we offer women who have had this surgery, to help them recover their self-image?

Dr. Jones: About a quarter of a million women will be diagnosed with invasive breast cancer in the US this year. Some will choose a smaller operation, a lumpectomy, but many will choose a larger surgery in their hope for a cure. And the percent of women choosing mastectomy is increasing. Although we're grateful for the treatments that can cure breast cancer, mastectomy can leave a woman and her body image profoundly changed. The Scope's Seven Domains of Women's Health team is in the office. I've Dr. Agarwal, a breast reconstructive surgeon at the Huntsman Cancer Institute, and we're going to talk about breast reconstructive surgery. So, Dr. Agarwal, tell us a little about your training. How is it different from a breast cancer surgeon, the person who did the mastectomy?

Dr. Agarwal: Well, I'm a plastic and reconstructive surgeon so my role is to try and rebuild. After a patient undergoes a mastectomy by the breast cancer surgeon, I work with the patient to try and then rebuild the breast. And this can be really any part of the body. As a reconstructive surgeon, our goal is to try and restore form and function for a patient.

Dr. Jones: Can you do the reconstruction at the time of the mastectomy, or are there advantages of doing it immediately versus delayed?

Dr. Agarwal: You can do the reconstruction at the time. We often, in fact, start the reconstructive process on the same time, in the same operative setting as the mastectomy surgery. Sometimes, it's a staged operation in which the first stage is started at the time of mastectomy and then the subsequent stages occur in the future. And sometimes, you can complete the entire reconstruction all in one setting.

There are advantages and disadvantages to doing it all at once. Some patients like the idea of just having one operation or, at least, having one operation where the majority of the surgery is done. Some patients like waking up from the operating room with the start of a creation of a breast, rather than waking up with a flat chest. The downsides are it does add surgery time and does add recovery time to the operation, but, in general, we're starting to see an increase in the number of patients that are having reconstruction that is initiated at the time of mastectomy.

Dr. Jones: Right. So women actually use to think of reconstruction as something that came to them six months or a year later when they felt like they were cured of their cancer and they were really ready to go on with the next step of their life. But now I think women are expecting to walk out knowing that they're going to feel a little bit more like themselves.

Dr. Agarwal: I think that's true. I think, in the past, reconstructive surgery was often considered something that was not part of the cancer care process of a patient. And today, reconstructive surgery and the role of a reconstructive surgeon are really integral into the entire comprehensive care of a cancer patient.

Dr. Jones: Right. So what's changed with our new tissues, new materials?

Dr. Agarwal: The types of surgeries we do and the technologies that we have have improved. We don't quite have the 3D printing of a breast down yet, although we may get there in the near future. But the quality, the implants, the implant material, and the ability to use tissues from different parts of the body has really improved dramatically over the past 15 years.

Dr. Jones: So we're using some of the woman's own tissues for some of the breast, and some implants, or combinations?

Dr. Agarwal: Both scenarios. So patients can have implants only, their tissue only, or a combination of implant and their own tissue. And that sort of depends on their body, their choices, and what may be the best option. And that often requires a discussion with their surgeon.

Dr. Jones: Well, honestly, Dr. Agarwal, as a woman, my personal fear about mastectomy, with or without reconstructive surgery, would be that I would be asymmetrical, that I'd have one normal breast and one plastic breast, and I just wouldn't be balanced. And I feel that breast had betrayed me already, and I wouldn't want to have breast cancer in the other breast. So I might ask you as if I were your patient to just do them both, so make them, when we're done, they can both look the same and be the same. Are you getting more requests? Does this sound crazy?

Dr. Agarwal: This isn't crazy. In fact, we're getting an increasing number of requests for bilateral mastectomy and reconstructions. And it's a very personal choice, it's not a choice that every woman makes, and it's not an easy choice. I think there are a lot of factors that go into it. Fear is, by far, the biggest factor. Patients exactly like you said, patients are worried that they might develop cancer in their other breast, or they're always going to be nervous and can't sleep at night and so they want to be free of that fear. And that's a real consideration when we consider doing a bilateral mastectomy.

I will say, though, just like any surgery, you have to be prepared that the more surgery you do, the more recovery, the more potential for a problem. So think carefully, talk to your surgeon, talk to your family before you make these decisions.

Dr. Jones: Fears of cancer and fears of disfigurement may lead women to avoid mammograms or seeking medical help if a lump is noticed. There are many more options for women as they face the challenges of breast cancer, and challenging, and living after a breast cancer treatment. Dr. Agarwal, thanks for helping us and think about our options, and thank you for joining us on The Scope.

updated: June 17, 2021
originally published: October 22, 2015

Dr. Jones: When women have had breast cancer surgery, the major surgery such as a mastectomy, they are often looking forward to living their lives and getting their body back. What are the new steps and what are the things that we have here at the Huntsman that will really help them make this difficult decision? How do we make the decision, and who is the team involved?

We are in the office of Dr. Agarwal here at the Huntsman Hospital with a beautiful view out the back door of people living their lives. I want to talk about how women who have had mastectomies make the decision to live their lives going forward as they make the transition from a cancer victim to a cancer survivor. We're talking about breast reconstruction here with Dr. Agarwal, plastic surgeon and reconstructive surgeon here at the Huntsman Hospital.

Let's talk a little bit about women who request the bilateral mastectomy. Of course, there are women with BRCA mutations, mutations that increase their risk of cancer. They don't have cancer yet, but both of their breasts are going to be involved so that's pretty easy to understand. How about if a woman has breast cancer on one side and wants the other one done? Does insurance pay for that?

Dr. Agarwal: Not always. We're seeing an increased demand, if you will, in patients who want to have the contralateral breast removed. A lot of times, this is driven by fear of developing cancer in the other breast. Oftentimes, it's driven by the desire to have symmetry and it's not a guarantee that your insurance will pay for this. More and more, we're seeing that insurance wants to really focus on the breast that has cancer and may not always pay for removal and reconstruction of the other breast.

But any time a patient has these concerns or desires to have both breasts removed, it requires a good discussion with their doctors, their oncologists, their surgeons because while things like symmetry may be improved in some cases, there are also potential consequences to having your other breast removed. You lose sensation of an otherwise normal and healthy breast. Just like with any other surgeries, there is the risk of potential complications by adding more surgery time or more operations.

Dr. Jones: And if women are young enough that they might want to consider having children if they get past their diagnosis and are cured, then they couldn't breastfeed if they have bilateral reconstruction and that has to be discussed. There is so much on the Internet about the pros and cons, but are there other women that someone can talk to? Do you have support groups of women who have made decisions and how they worked through their decisions? How do women go about finding out more information?

Dr. Agarwal: There are definitely support groups here at the Huntsman Cancer Hospital. There are teams of patients who have offered their services to other patients because they've gone through this process in the past and they give the whole picture, the good and the bad of going through this process. Throughout the Salt Lake community, there are organizations that provide a lot of information to patients, including Susan Komen's Foundation. So there are definitely support groups. I think that it is a very personal decision in the end and I think that a frank conversation with your medical team and your family is important when finally making these types of decisions.

Dr. Jones: Let's talk briefly about nipple reconstruction. I've heard that you have an amazing tattoo artist here at the Huntsman who might be able to even tattoo a nipple or are you using other tissues for nipple reconstruction?

Dr. Agarwal: First of all, we do have a great tattoo artist here at the University of Utah and Huntsman Cancer Hospital, but there are different ways of reconstructing a nipple. We can actually use some of a patient's own tissue to create the nipple itself and then tattoo the areola around it. And another option is to purely use tattooing. Some of the tattoo artists can create 3D tattoos of a nipple, which looks amazing. They look like real nipples that have projection even though they're flat on the surface of the skin.

Dr. Jones: That must be very gratifying to have the ability to give a woman that gift, not only as a reconstructive surgeon to give the gift of having symmetry and a self-image that will carry her forward as she works through her recovery but even having the ancillary staff that can help her through that like the tattoos and the counselors and therapists and all of the people, a whole team that can take care of people.

Dr. Agarwal: It's absolutely gratifying to see a patient go through this process and come out feeling whole again and feeling like they can get past or move beyond their initial diagnosis of cancer, and that's really the goal is to help them move forward in life.

updated: June 8, 2021
originally published: October 22, 2015

Gretchen: A breast cancer diagnosis can feel like a body blow to anyone. Kimberly Myers, PhD, from the Penn State College of Medicine is here to tell us why one of her first responses to her own diagnosis was to meet with a professional photographer to document her body. That's coming up on The Scope.

Announcer: Medical news and research from the University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Gretchen: Hi, I'm Gretchen Case from the Division of Medical Ethics and Humanities at the University of Utah School of Medicine, and I'm here with Kimberly Myers. So my first question for you is why did you want to meet with a photographer? Why was that one of your first thoughts?

Dr. Myers: I think when one gets diagnosed with breast cancer one's mind goes just goes blank in many ways. But one of the things I did know was having had no photographs of my breasts, I wanted to know what I would look like after surgery. I knew that I had a very short window of time in which to get photographs, if I were going to do that. A friend of mine suggested Wendy Palmer, a professional photographer.

Gretchen: So you wanted to be able to remember with photographs what your body had looked liked before you moved on.

Dr. Myers: Yes, because I was convinced that I wanted bilateral mastectomy.

Gretchen: So when you met with Wendy, what was that experience like?

Dr. Myers: It was a bizarre experience. Wendy and I had never met in person and I was going to her studio for the photo shoot. She had said, "Bring scarves and jewelry and bring music. I'd like for you to dance. We won't pose this." And so it was three hours of, first of all, meeting someone completely new and then going through various stages of undress to the point of being completely nude and having oneself photographed. It's something I would never have expected that I would do and she got some amazing photographs.

Gretchen: And then you had an idea about where this might go further. Can you talk about that?

Dr. Myers: Right. So I had a partial mastectomy and then went to chemotherapy. I had decided that one of the things I wanted to do with Wendy's photographs is to go through them and select one to have made into a portrait. Wendy and I, again, after I was into and almost through with chemotherapy, we got together and we looked through the 440 photographs that she had taken that afternoon, and I was struck with the range of emotions that she had captured. She's a phenomenal artist and I thought, I mentioned to her that so many of these feelings and moods were things that perhaps other people could relate to in their breast cancer experience.

We began a conversation about what we might want to do and that's when we decided that she would at least come and photograph subsequent stages of the process so that we would have the primary material if we wanted to do anything with it.

Gretchen: So what you ended up with is a series of photographs that goes from just days after your diagnosis all the way through your surgeries, your treatments, and your reconstruction.

Dr. Myers: Right.

Gretchen: Can you tell us how you went from taking these pictures for yourself to creating an exhibit that has gone around the country and is likely to go around the world?

Dr. Myers: It's strange when you put something out in the universe what happens sometimes. I think many, many people who go through breast cancer have this commitment to do absolutely whatever they can to help other women. Education has always been my passion and so my great desire going through this experience was to do whatever I could to help educate and encourage women about this.

We selected photographs that captured different moods and different dimensions, different parts of the process of reconstruction. It's a 30 piece exhibit and it's paired with verbal reflections that are very, very brief, like verbal snapshots that complement the visual images and those were added when I was looking back at the images. So it was well after the fact, months after the fact, when I was looking at the images and remembering what I would have been feeling like in those particular shots.

Gretchen: And what do you hope for someone to see or to take away from this exhibit? What do you want people to take away?

Dr. Myers: The main thing I want people to take away is a feeling that a diagnosis of breast cancer is not a death sentence necessarily, and it's certainly not something that will make a person into a monstrosity. I think many women are very concerned about losing a vital part of their femininity and aren't really aware that the cosmetic result can be really wonderful. That said, I also would never want to imply that my experience or the results I was fortunate enough to have would be the same experience and results that other women would go through. I think it's very individual.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.