Episode 29: Breast Reconstruction – The Art of Plastic Surgery

Dr. Franco: Welcome back to “Plastic Surgery Untold,” the greatest podcast in the world as voted by us. I’m Dr. Johnny Franco, also known as Austin Plastic Surgeon, and I have the pleasure of having our celebrity cast and special guest Dr. Adam Weinfeld joining us today. We’ll get to him in a minute and why he’s joining us today to talk about breast reconstruction, The Art of Plastic Surgery. But before we get to that greatness, let’s talk about “Celebrity anesthesia” what’s going on in your life. What’s new? I know you’re trying to sell a house, I know you’re making some big moves. What’s going on with you?

Dr. Osborne: Yeah, man, trying to make some big moves. We got a house that is almost finished, we should finally be moved in December 1st. So before the end of the year, any, you know, prayers would be appreciated because this thing has drug out for an extra year than it was supposed to. So yeah.

Dr. Franco: But you’re selling the house too.

Dr. Osborne: We’re selling a house too.

Dr. Franco: Well, you’re welcome to come sleep on my couch anytime you need.

Dr. Osborne: I appreciate that. Yeah, selling a house and all the headaches that come along with that, just little ins and outs and needs to be, you know, fixed or remedied before we put the house on the market. We had a handyman come over and he was supposed to fix some stuff. We had an entire 10 hour day of work for him. And I get a text at 9:00 in the morning when he’s supposed to be there at 09:30, “Hey, my car won’t start.” And then I got ghosted the rest of the day. I felt like Johnny over there like Tinder ghosted.

Dr. Franco: I was gonna say just like G-Berto and those Tinder dates, you know. They’re there and then they’re gone and you just don’t know what happened.

Dr. Osborne: So I basically, you know, shirt came off how to run to Home Depot, get some paint to stain the back fence, and me and Mary out there, at your training therapist shirt off, staining the fence.

Dr. Franco: Well, I’m just not clear… Wait, Mary didn’t have a shirt on either?

Dr. Osborne: Oh, did I say that out loud?

Dr. Franco: This is a family show right now. I don’t wanna get banned on iTunes. But why does the shirt have to come off to stain the back of the wall there? I don’t understand.

Donald: What are you talking about? I have to argue with him to put a shirt on to come in here.

Dr. Franco: That’s interesting. And then we got producer Donald who’s filling in for one G-Berto. He had a hair appointment, so I’m sure he’ll be back later. But appreciate you stepping in while G-Berto is getting his hair done and his nose powdered for the next episode, which is a little plug for what we’re gonna be talking about on the next episode.

Dr. Osborne: Like what you did there.

Donald: Yeah, that’s good.

Dr. Osborne: That was really good. I was a little late. It took me about five seconds to figure that one out

Donald: Yeah, no, I’ve been busy, the past couple of days definitely recuperating from your birthday, Johnny, you know, had a good weekend with you and, you know, trying to get back into the land of the living after all that.

Dr. Weinfeld: My feelings aren’t hurt by the way that I wasn’t there. [crosstalk 00:02:38].

Dr. Franco: Yeah, I know. We had to do a little COVID limit, you know. Celebrity didn’t make the cut either. You know, just it’s a tough line to draw in the sand.

Donald: Yeah, there was like three blood tests and, you know, it was crazy.

Dr. Osborne: Can I point out.

Dr. Weinfeld: I’m just happy to be here.

Donald: It’s okay.

Dr. Osborne: Can I point one thing out before we continue? Johnny is the only guy that I know that gets a birthday month. My wife gets a birthday month. Johnny’s the only man that I know that gets a full birthday month. October is his…

Dr. Franco: Well, the month is not over yet. You talking like this is past tense right now.

Donald: We have to support the ego, you know.

Dr. Osborne: Yeah, that’s right.

Dr. Franco: Well, let’s jump in. Dr. Adam Weinfeld’s nice enough to join us today talking about breast reconstruction. And he’s a plastic surgeon here in Austin, Texas. And it’s funny we’ve talked on other episodes about how many extremely skilled and subspecialty physicians there are here in town and you know, some of your subspecialties and correct me if I’m wrong, microsurgery and cranial facial and are two things that are your babies that I know you do a ton of. And so we thought we’d bring you in to talk a little bit about breast reconstruction, which is a wide variety of stuff, things that I don’t do as much in my practice anymore but do miss. And so tell us a little bit about you and your life and what you do.

Dr. Weinfeld: Yeah, so yeah. So Adam Weinfeld, and I’m a plastic surgeon here in Austin. I originally grew up in Maryland and made my way to Texas to go to medical school where I stayed for my residency. I think one thing that’s unique about me among plastic surgeons is I knew very early that I wanted to be a plastic surgeon I knew at the age of 12 that I wanted to be a plastic surgeon. People often ask me, you know, “How is it you knew at the age of 12?” And I saw this program or documentary about microtia reconstruction. Microtia reconstruction is reconstructing someone’s ear when they were born without an ear and that’s kind of what drew me to it.

Dr. Franco: And that’s kind of one of the fine arts of plastic surgery is recreating an ear. It seems subtle, but it’s probably one of the hardest things to do in plastic surgery.

Dr. Weinfeld: Oh, it really is. It’s such a complex structure, three dimensions, multiple different tissue types, skin, cartilage. So yeah, it’s a very tough procedure to do. You know, it’s what drew me to plastic surgery. I actually didn’t learn a lot about it until I went into practice and a good friend of mine from Houston when we recognized here we had the need in Austin to perform these kinds of surgeries, a friend of mine, Sean Boutros in Houston came out taught me what I know now and continue to work at it. It’s not a big part of my practice, because it’s not…microtia is not that common but it’s very rewarding part of my practice.

Dr. Osborne: That’s cool.

Dr. Franco: It’s interesting because there’s always the things that we love to do and the things that we do every day. And so, ears are just such an interesting one. I had the fortune to be part of a couple of surgeries when I was a resident, nothing I’ve ever done in practice, but definitely a very humbling procedure for sure.

Dr. Weinfeld: Without a doubt.

Dr. Franco: But let’s talk a little bit, if you don’t mind, we’ll jump into it, a little bit talking about breast reconstruction, this is Breast Cancer Awareness Month. So, “Celebrity Anesthesia” had the idea if we could bring in a specialist like yourself to talk about plastic surgery, aspects of breast cancer awareness, breast cancer reconstruction. And, you know, I feel like we get involved at different aspects because a lot of times during our workup before a breast reduction, before other stuff, a lot of times we do some screening, exams and so forth and then end up sending people to the breast surgeon if there’s something that they were worried about on a mammogram or exam. But the flip side is what happens when somebody gets a breast cancer and whether it’s a lumpectomy, mastectomy, how they get involved? And I was gonna see if maybe you could start from the very beginning because I think people don’t realize that now, at many centers like the one you’re at, patients actually get sent to you before they ever have their breast cancer surgery. Correct me if I’m wrong.

Dr. Weinfeld: Yeah, without a doubt. Yeah, there was a major shift, probably in the ’80s and ’90s, where two things happened, and that was that the medical community recognized that doing a breast reconstruction at the time of the mastectomy, did not prevent good screening for recurrence. And that was a major hurdle in terms of doing what we call immediate reconstruction, which is reconstruction at the time of the mastectomy. And then also, there were a lot of studies that came out, this is kind of the second thing that led to what we are doing now, is there a lot of studies that demonstrated the emotional benefit, as you can imagine, it goes without saying, have been able to reconstruct a woman’s breast or at least starting to reconstruct a woman’s breasts at the time of the mastectomy. So yes, nowadays, what happens is, you know, a family practice doctor ,ob-gyn, internal medicine doctor does a screen mammography, the diagnosis is made and, you know, unfortunately, breast cancer. That patient then gets sent to a breast surgeon. And it’s that breast surgeon in conjunction with a medical oncologist who starts to discuss with the patient, what is gonna need to be done to treat the breast cancer effectively. And often or I should say almost always surgery is a part of that plan, and the surgery can take a couple of different forms. One as I had mentioned lumpectomy. And a lumpectomy is where the breast surgeon removes a small segment of the breast that contains the cancer and healthy tissue around it so that you don’t have the risk of recurrence. Or a mastectomy, mastectomy being the second major way of treating breast cancer and that’s where the entirety of the breast tissue, the skin, the fat, the glands, the ducts is removed, leaving behind nowadays, fortunately, most of the skin. And it’s when that discussion with the patient occurs about what surgically is gonna need to go on, that the breast surgeon then refers the patient to me to discuss how I’m gonna help the breast surgeon, help the patient restoring the patient’s breast to the sort of pre-cancer state to restore their sense of confidence, to give them the ability to look in the mirror after all of the treatment, and kind of essentially forget that they had breast cancer. After all, that’s really the goal of what we do together.

Dr. Franco: And I don’t think people realize how big of a team effort this is because there’s so many different kinds of algorithms and paradigms and other directions that you can go depending on each of these. Because there’s pluses and minuses and there’s no absolute that somebody gets a lumpectomy, mastectomy, nipple-sparing mastectomy, prophylactic mastectomies. I mean, I don’t want to get too far off tangent, but all those things are stuff that you take into account in discussion with the patient, the breast surgeon, and helping guide them to the best treatment for them.

Dr. Weinfeld: Absolutely. Yeah, touching upon two things that you hinted at is that, you know, the word we use for that is multi-disciplinary and definitely, the care of breast cancer nowadays is perhaps one of the best examples of multi-disciplinary care where you do have a breast surgeon who’s gonna be doing the lumpectomy or the mastectomy, the medical oncologist who will help decide and administer…decide if chemotherapy is needed, and then administer it and monitor and deal with any side effects that can occur with that radiation oncologist. Radiation is another adjuvant or addition to cancer care, that helps decrease the risk of recurrence. And then, of course, there’s counselors and physical therapists and nutritionists and then, you know, last but not least, the plastic surgeon. So definitely multi-disciplinary and like, you said, there are so many factors that go into the decision making for what is the most appropriate method of breast reconstruction for any particular patient. You know, the size of their breast, the size of their body, medical conditions such as diabetes, or the need for steroids, whether or not they’re gonna get radiation, what they want, what they want their recovery to be like, whether they’re gonna get chemotherapy before or after, all these things have to go into the decision making. It’s very complex. I kind of liken it to a game of chess, actually. And when I get to know the patient a little bit better, I describe it to them as such. It’s not the best thing to tell a patient right off the bat, because you don’t want them to hear, game, right, you know, obviously a very serious thing. But really, there are so many different moves, and you have to anticipate ahead and start to think about, you know, well, if they’re gonna get radiation, what does that mean, in terms of what we should do upfront? You know, and we’re gonna talk about some of the methods of reconstruction later. And maybe I’ll leave that as like a little bit of a, you know, a little teaser, yeah.

Dr. Franco: A little teaser. I see what you did there. This guy I mean, his [crosstalk 00:10:53].

Dr. Osborne: His learning.

Dr. Weinfeld: I learned when you talk about the nose. Yeah, I’m going.

Dr. Franco: Because it’s a process, and I think that’s the only thing for people to understand, is it that it’s a process that you’re gonna get them through. And it kind of leads to my first question is, who’s a good candidate? And it sounds to the stuff you’re alluding to, most people are a candidate for something.

Dr. Weinfeld: Yeah.

Dr. Franco: Not everyone but most people.

Dr. Weinfeld: Yeah, no, I totally agree with you. There are very few patients we would ever tell that they’re not a candidate. There may be some patients that we would say you’re not a candidate right now but later, you probably can be. A great example of that is someone who has a bad breast cancer and has to have a mastectomy soon, but they have really bad uncontrolled diabetes. And you just know that the additional risk that the reconstruction brings to their care, it’s probably not worth it now. But most people with bad diabetes can be made better with weight loss with, you know, changing their medications. So that’s the kind of patient you say, “Hey, listen, have the mastectomy. Get over that. If you need chemotherapy, have that and then come back to me once we get your diabetes controlled better.” Frankly, that’s one of the only examples that we deal with frequently, you know, in terms of who is not a candidate. So that leaves like, all ages and, you know, all sorts of different things that patients bring to the table, you know, in terms of medical problems. There’s rarely a medical problem other than that, that prevents us from doing surgery to reconstruct the breast.

Donald: [crosstalk 00:12:24].

Dr. Franco: Go ahead.

Donald: I was just gonna say like, so we’re talking about, you know, who is a candidate and things of that nature. But at the end of the day, we’re also talking about plastic surgery, which can be considered an elective surgery. So there’s like, insurance usually play nice with this, or is this something that like, you know, insurance may not cover?

Dr. Weinfeld: Yeah, no, that’s such an important question. And it’s a question surprisingly, that patients who have already met with the breast surgeon and sometimes medical oncologist, and clearly they’ve done a lot of research, they still come to me with some concerns that breast cancer or breast reconstruction for breast cancer is not gonna be covered. But actually, there was a law passed, a federal law in 1998, called The Women’s Health and Cancer Rights Act, which basically says that if insurance is gonna cover your cancer care, the ablative part, ablative meaning removing the cancer, the lumpectomy, the mastectomy, then the insurance company has to. It’s a mandate. They have to cover whatever is necessary for breast reconstruction, including symmetry procedures for the other side. Not all women have, in fact, the majority of women don’t actually have surgery on the other breast, the non-cancer breast. But often, the breast cancer management is gonna create a change in the final result on the cancer side, and to create symmetry, you need to do something on the other side, a reduction or a breast lift. And that law also says that those symmetry procedures have to be covered as well. So they’re very, and rightfully so. They’re very…women who have breast cancer are very privileged in that regard. It’s almost never the case that something gets rejected by insurance.

Dr. Franco: And I think there’s two important parts to this and to some of the stuff you alluded to earlier. This becomes a whole multidisciplinary team to help guide people through some of this process. The first part is, what you alluded to is that there’s a couple of things a huge majority of patients will get their reconstructive surgery process at least started at the same time of their cancer reduction. So you and the breast surgeon will work, hand in hand. Both of you will see the patient ahead of time before the surgery. Stop me if I’m wrong or misleading people.

Dr. Weinfeld: Yeah, no.

Dr. Franco: Ahead of time. And then typically the day of the surgery, you both see them, mark them have a plan. You may come in and start some portion, the breast surgeon do their portion, come back, but it’s really this back and forth and then taken over so that they at least have some process started on that same day.

Dr. Weinfeld: Yeah, there’s, I mean, there’s so much in what you said to unpack it a little bit. We definitely meet with the patients in advance because you really got to start to work through that process of figuring out what the patient’s gonna be happy with, what, you know, their medical conditions can allow them to have done and then to make sure what the plan is gonna jive with what’s important to the radiation, oncologist, the medical oncologist, breast surgeon. And then also one of the important things you alluded to you used the word start and that implies that it’s a multi-stage process, the breast reconstruction is and that’s definitely the case. It is almost never the case that a woman goes in has a mastectomy, we do the reconstruction, the wake-up, and that is the breast they have forever. It’s almost always the case that we’re starting something. You know, in the example, and we’ll probably talk about this in a little bit more detail, but like an implant-based method of breast reconstruction, it starts off with at the time of the mastectomy, we put a tissue expander, which is kind of like an empty implant that we can later in our office with different techniques, fill with saline, fill it, create a space, put an implant there. So that’s an example of two parts of that multi-stage process. But it often takes, that’s just a little bit of it. Like if they want a nipple, then you got to make a nipple later. So it’s always kind of starting, just like you said.

Dr. Franco: And then the other part that I think people forget, and I had a personal experience with this with my own aunt who had had a mastectomy, just and hers was she just wasn’t emotionally ready to do anything else. She just wanted out, wanted to be done. And then, about 10 years later decided, “Hey, you know, I do wanna reconstruct this breast. I do wanna do something.” And I think to Donald’s point, in your point, you know, one, you know, it’s still something that can be covered by insurance even if she doesn’t get it done at the exact same time or whether it’s for health reasons, for just kind of emotional, you know, mental reasons. And then two, you know, from a physical plastic surgeon standpoint, that’s still something you can address, depending on the circumstances.

Dr. Weinfeld: Yeah, both of the things you said are true and important. Yes. So if you didn’t have a mastectomy at the time…excuse me, if you’d have a reconstruction at the time of the mastectomy, insurance will still cover the reconstruction no matter when it is done, unless the laws change, which I don’t anticipate will happen. And, yes, I mean, physically it can be done. And frankly, some of those are our most happy patients, because they’ve lived without a breast. And so they really have a good sense of what the alternative is and they’re most tolerant of some of the challenges that we have in terms of achieving perfection. We always aim for perfection, of course, but, you know, as we all know, there are some limitations. And so the patients who have lived without a breast for some time, they’re kind of like our ace in the hole, we know that they’re going to be happy because they really have a sense of what it’s like not to have breast.

Dr. Franco: I just think it’s so important because I don’t want people to feel like, “Oh, I missed out, you know, there’s no going back.” That’s not true. And I’m sure some of our listeners have been like, “Oh, I didn’t know I could still do this.”

Dr. Osborne: Yeah, that’s right.

Dr. Weinfeld: I’ve reconstructed breasts on women who were 70 years old and they had mastectomies when they were 50 and for whatever reason, they chose not to have a reconstruction, and all of a sudden, at 70, they decided that it’s the right thing for them.

Dr. Franco: I feel like even though as hard as we work, depending on where people are, sometimes people just for some reason escaped through the system. When I was still doing breast reconstruction when I was in Miami, I would get random people who would come into the office and for some reason didn’t know that it was an option. And some…I don’t know how that still skips through the system occasionally but it does.

Dr. Weinfeld: I think the answer is obvious, this podcast didn’t exist back then.

Donald: Nice.

Dr. Franco: Exactly.

Dr. Osborne: Now they know. Doc… Oh.

Dr. Franco: Go ahead. No, “Celebrity,” don’t let me interrupt you. Go ahead. Please.

Dr. Osborne: I was just gonna say, would you mind explaining to or walking us through kind of the different options that you have for reconstruction?

Dr. Weinfeld: Sure.

Dr. Osborne: I know, that’s a huge question and it involves a lot.

Dr. Franco: And some of the stuff in seven minutes. Go.

Dr. Weinfeld: Yeah. I was just laughing because I feel like I’ve been like, you know, just exploding with speech. And so do you mind? Of course, I don’t mind. You know, like, I just talk all the time. Just ask my wife.

Donald: You know what, though? I will say this, though. I think this is just a big educational point for not only us but also for our listeners as well, like, a lot of this stuff I didn’t know coming into this to this podcast. So yeah, I appreciate you talking excessively or a lot. I don’t know how it wouldn’t end up.

Dr. Franco: Because, you know, a lot of people find information in different places. And, you know, Instagram and other stuff are A source, you know, depending on which ones but it’s sometimes the medical stuff gets lost for all the big butts and other things. And so I think it’s great to have some information for things that people medically really need, and it’s a benefit. So, appreciate it.

Dr. Weinfeld: Yeah. Well, let me break it down for you the way that I do with patients. So, first of all, I think it’s important to talk about the fact that even if someone is having a lumpectomy, so they’re not having the whole breast removed, there are still surgical options designed to get the best result for them. And what do I mean by the best result? So it used to be the case probably about 10 years ago that if a woman had a lumpectomy, again, that is removing the small bit of breast tissue, sometimes a larger bit of breast tissue that has the breast cancer, they’d have that lumpectomy, and then for reasons that we won’t discuss right now, almost everyone who gets a lumpectomy they get radiation. So they’re having a lumpectomy, which is removing breast tissue, and then, unfortunately, what happens is the outer surface of the skin sinks into that space where the lumpectomy removed the tissue, and then radiation kind of sears, if you will, that tissue together and it really pushes that skin and it shrinks it, and it creates an obvious difference in the breast so the breast that didn’t have the breast cancer… When I’m with patients, I do the same slips too where I can’t say breast, it’s like you get a little tongue-tied. But with the radiation and lumpectomy, you’ll have a difference between the non-treated breast and the treated breast, and that difference is that the breast that’s been irradiated will shrink. So it’ll get smaller, tighter, more compacted actually just a little bit lift with some patients like and that dent that’s created can be very obvious.

Well, there are ways that we can prevent that from happening now. And I should actually say that most breast surgeons do that now and they’re called oncoplastic techniques. But sometimes breast surgeons who don’t do that will get plastic surgeons involved to help with that. So what is oncoplastic surgery? That’s at the time of the lumpectomy, a breast surgeon or a plastic surgeon will take the breast parenchyma, which is like the breast tissue, the fatty and breast tissue underneath the skin and they’ll make some other incisions in it and push it together to fill in the space that was vacated by removing the breast cancer, and then they’ll smooth out the skin around it either by just kind of re-draping it or sometimes making the incisions that we make to do a breast lift or a breast reduction in order to create a nice, tidy, smooth, breast-like package that once it goes on to get radiation may still get that shrinkage, but and that tightening effect, but won’t see that permanent dip that dump…dump, that dip, that concavity that occurs with the radiation. And often you have to operate on the other side because if you’re gonna do a lift, let’s say on the breast cancer side, you’re gonna have to do a lift on the other side so that after radiation, you have as much symmetry as possible. So that’s oncoplasty for a lumpectomy.

Dr. Franco: And that’s somewhere where especially with radiation and other things, where is a perfect example of where you may need to do something now, but then again later. Because, radiation is one of these weird things that can have lasting effects and changes from time to time.

Dr. Weinfeld: Yeah, and as good at oncoplastic I mean, you know, dovetailing off what you’re saying. As good as oncoplastic is and it often sets the stage for good symmetry but sometimes not for perfect symmetry. And so often we do find ourselves having the patients come back and perhaps fat grafting the, you know, if they do still have a little bit of a concavity, a little bit of a dip in the skin, doing some fat grafting there. Something I think you know a little bit about. Is that true?

Dr. Franco: It’s one of my favorites. And fat grafting adds some volume, but also has some skin kind of healing other properties that may be beyond what we can talk about today. But it’s kind of cool stuff.

Dr. Weinfeld: Without a doubt, it definitely helps treat some of the negative changes that occur with radiation. And then also we, you know, after surgery, sometimes we haven’t got the contralateral side as high as it could potentially be or as small. And so sometimes we’re doing some adjustments on the other side. Now, moving on to mastectomy. So mastectomy is where the entirety of the breast is removed, often nowadays, leaving behind much if not all of the skin. So, Johnny, I’m sure you remember when we were training, almost nobody was getting a nipple-sparing mastectomy.

D.Franco: Mm-hmm.

Dr. Weinfeld: Yeah.

D.Franco: That was like this new thing. And it was, you know.

Dr. Weinfeld: Controversial.

Dr. Franco: Controversial and you had to meet 5,000 criteria to even be a candidate and some of the people doing it were considered rebels and.

Dr. Weinfeld: Without a doubt probably looked down upon. So you know, again, the mastectomy part of the surgery is removing the breast tissue and it used to be in the past that the breast tissue and most of the breast skin, was removed, and you can imagine how difficult it would be to reconstruct a breast if you have to create more skin and create a breast mound with whether it be an implant or tissue. So then the next sort of step, the next advance was what they called a skin-sparing mastectomy in comparison to a radical mastectomy. And a skin-sparing mastectomy is where the nipple and the areola was removed, leaving behind all of the skin and then also removing the breast tissue. That made breast reconstruction so much easier because you no longer had to worry about bringing in a bunch of skin. It was really just about how do you use that skin? How do you…whether it be using an implant or using one’s own tissue, fill that space to create a breast mound and then later reconstruct a nipple. And that created really great results. But in the last probably five to 10 years, nipple-sparing mastectomy has become a huge deal and it’s really to the patient’s advantage because using incisions at the inframammary incision where we place implants for breast augmentation, I should say you do, I don’t do as many, but, or other incisions elsewhere on the breast which are pretty well hidden and quite small was able to remove the breast tissue and leave behind all the skins that’s leaving behind the nipple. And just, no matter how we reconstruct the breast to have all of that natural skin left behind, it’s such an asset. So…

Dr. Franco: And just so people know that these changes happen, because just like anything, you know, we’re only scratching the surface of what we know. And it’s exciting to see what’s gonna happen 10, 15 years from now. We used to think that to cure people of breast cancer to treat them appropriately, you had to do these massive resections where you’re taking skin, muscle, other stuff, when you go back to the Halstead, you know, mastectomies and so forth. An,d you know, we’ve been able to now risk stratify people, and that’s why ,you know, what treatment they can or can’t get. Because the goal is, obviously, right, to treat people for their breast cancer, make sure that we’re not doing anything to decrease their survival or reoccurrence rate. But the less trauma we can do, and still keep those same, you know, great rates, that’s where these changes have happened.

Dr. Weinfeld: Yeah, without a doubt. I mean, it’s so fascinating, just, I mean, this is true for medicine, and definitely for plastic surgery. Just when you thought that we had really perfected things and we thought that we understood it, we thought we were doing things really well, someone pushes just outside the envelope and it’s like a paradigm shift and everything changes and for the better for patients and it makes it more exciting and fun for us. And breast reconstruction is a great example of that but it’s not the only one by any stretch of the imagination. But yeah, and what makes breast reconstruction interesting is that it’s not just the innovations and the changes that occur in plastic surgery, but it’s also the innovations that occur in all those other disciplines, in particular, breast…what the breast surgeons do the mastectomies because, you know, it was a major game-changer to be able to leave behind the nipple and areola and it just allowed, you know, our cream floated to the top of their cream, and it was just really, really a fantastic change. And again, you know, the women really benefit from it, we’re able to do breast reconstructions now, where, you know, they look like just breast augmentations. They’re really incredible. And it’s the presence of that nipple at the apex of that breast mount that really brings that about.

Dr. Franco: Can I… I’m sorry. Can I jump into a couple of things? Because there’s a couple of things that you do that are really cool that was just starting to take off when I was leaving residency. And so, you know, there’s basically two big groups of breast reconstruction. There’s the tissue expander implant, so the same breast implants would use for a breast aug, and then there’s, you’ve alluded to it a few times, using people’s own skin and tissue. And, you know, I do this for my butt augmentations or I do fat transfer, you know, in a breast where you have a tight skin and not a lot of space to do something, you got to find skin and fat from somewhere else. Can we maybe touch basically on the tissue expander breast implant for a minute? And then I want you to jump in on the DIEP flaps and other really, really cool innovations that have happened over the last gosh, even just five, seven years that these have become common practice. It hasn’t been that long.

Dr. Weinfeld: No. Yeah. Really, like you said last sort of 10 years or so. Yeah. So when I explain…

Dr. Franco: I was trying to make us feel a little younger, you know, my last three years they did.

Dr. Weinfeld: Well, yeah. So there are two main categories of reconstruction. The first category is where the breast mound is made by a breast implant, and like you said, they’re the same implants for the most part that we use for breast augmentation. And the way that we do that is we first place a tissue expander underneath the skin at the time of the mastectomy, and we have it filled in a sort of a variable fashion. We let the skin heal around it, we then later fill up the tissue expander and then later, come back, remove the tissue expander and place an implant. So that’s sort of a quick sort of thumbnail sketch of it, adding a little bit more detail. So it used to be… Well, how about this. Why a tissue expander? Why not just go straight to the implant? Which some surgeons do. I don’t care for it.

Dr. Franco: That’s a great argument all the time in a meeting.

Dr. Weinfeld: All the time. Yeah. And just as, you know, a quick jab at those who do that, they always are talking about how great it is, yet they always talk about how they have their radiologists or interventional radiologists on speed dial so they can drain seromas. That’s like a little inside thing. You know, so I don’t care for it, and frankly, it’s a great way of doing things and there are some people who do it really well. I think the conditions for a direct implant have to be perfect and you have to feel super comfortable with it. I’m a little bit more cautious and so I like to do the “Two-step” reconstruction [crosstalk 00:29:25].

Dr. Franco: And limit the size. And you got to be careful about the size.

Dr. Weinfeld: Without a doubt. And then, you know, and they, and the people who do that type of reconstruction, they always say they have to come back and do fat grafting or maybe change the implant size later anyhow, so you’re already two steps, it’s just, you know, they’re two different steps. I think that’s how it sort of shakes out. But with the two-step that I do it not the one-step really two-step procedure that other people do, you know, we place a tissue expander first and the reason that we place a tissue expander is because, a tissue expander you can place in the breast scan, which is very fragile at the time of the mastectomy, and not have it stretched out that far and thus, you don’t stress out the skin that much. So, you know, if a woman’s breast is like yay big, and… That’s kind of big, isn’t it? If a woman’s breast is like yay big and you do a mastectomy and you put an implant in there right away or tissue expander that filled all the way right away, that really stresses out skin that has been, you know, naturally traumatized by the mastectomy. But if you place a tissue expander that allows the skin to kind of shrink back half of its previous volume capacity, it lets those damaged blood vessels still transmit blood all the way to the ends of the skin and allows it to heal. And then later what happens there’s a little valve in the tissue expander, they come back to our office, and over a series of different expansion processes, a needle goes into that expander and we fill it with saline solution and fill it until it’s the size that the woman wants, which can be slightly smaller, same size, or even slightly bigger. And then later, usually about four to five months later, we remove the tissue expander almost always through the same incision that was placed, but not always and then replace it with an implant. And at the same time that that’s done, we often are doing the process of fat grafting. Again, it’s something you know about right?

Dr. Franco: I love it.

Dr. Weinfeld: And we use the fat grafting to fill in parts of the breast, usually it’s the upper outer part of the breast where the round implant doesn’t fill it in to give a natural teardrop shape of the breast reconstruction. If they had a nipple reconstruction…excuse me if they had a nipple-sparing mastectomy at the time of the breast cancer management, then they may be done. You know, if they didn’t have a nipple-sparing mastectomy, if they had a skin-sparing mastectomy, then later usually about three months later, we either tattoo on a three-dimensional appearing nipple with a tattoo, or we make a nipple and then they later come back and have that tattooed.

Donald: That’s what I was gonna ask about, like the nipple reconstruction options, like I’ve heard of tattooing before, but I’ve never heard of like, making a new nipple-areola complexes.

Dr. Weinfeld: Yeah. And I think it’s a very gratifying procedure for both for me and the patient, I feel like it is really kind of completes the breast reconstruction. I always tell patients, you know, and I should say, some women choose not to. I think that’s great. And then there’s some women who ask me what do I think, and I always encourage them to consider nipple reconstruction. Because I think that, you know, if you think about it, we’re mammals, right? Like, we like, suck on nipples when we’re young to get nourishment. It’s like this schema that’s like primal in our brain to like, see, you know, a fleshy blob with a dark spot on it. And I don’t think we see a breast as a breast until there’s a nipple on it.

Dr. Franco: I couldn’t agree more with you. I, when I used to do more, I used to push people I was like, even if you don’t do the fancy flap, if you just even get the tattooing, it makes such a huge difference.

Dr. Weinfeld: It does.

Dr. Franco: There’s some completion. I tell people, it’s like making a cake and not putting icing. It’s just not done. It just looks like a mound and when you do this it’s like, “Oh.” It’s like “What?”

Dr. Weinfeld: And I have to respect it when women don’t want it. You know, I like, because I can never obviously I’m not a woman like, you know, and then those decisions that they make are very personal, and I think they’re the absolute right decisions that, you know, any decision a woman makes about her breast reconstruction is the right decision, you know, I mean, so long as we’re steering them away from things that are going to create complications. But when they ask me what do I think I say, “It’s so rare that I kind of nudge someone in a direction, but with this, I really think you’ll be much happier because it camouflages the scars, it really completes that that really primal schema that I think we have in all of our brains about what a breast is.” And so I’m a big fan of nipple reconstruction.

Dr. Franco: And especially because if you’ve got just tattooing or a lot of little flaps, we can even do in our office depending on what you’re doing, it’s such a small procedure for I feel like such a big emotional gain.

Dr. Weinfeld: I agree with you. I couldn’t agree more. Yeah.

Dr. Franco: Can we jump into because and I know you just scratched the surface because we could spend hours just talking about tissue reconstruction…tissue implant reconstruction, and we skipped the AlloDerm the meshes and above below the muscle type stuff. But you do a really cool thing called DIEP flap.

Dr. Weinfeld: Yes.

Dr. Franco: For people that don’t know this, this again goes to the whole evolution of breast reconstruction because then in the old days and old days, even when I trained and I feel like we’re not that old, you know, people still did TRAMS, where you would take a skin, you’d keep it attached to the muscle, tunnel it underneath the skin, you’d have this big bulge because you’re trying to like fold these pedicles up. And now, you can actually go into the belly like we would do a tummy tuck, find the very specific little blood vessels, track them down, and just take that skin and fat which is exactly what you’re trying to replace and that one long little blood vessel.

Dr. Weinfeld: Yeah. So you spoke of the DIEP flap. A lot of people think it’s D-E-E-P, but it’s D-I-E-P. Some people pronounce it DIEP, but that’s the wrong way to pronounce it. It’s DIEP flap.

Dr. Franco: Great. I got lucky there because I had no idea.

Dr. Weinfeld: No, you know, I think it’s honestly, I think I don’t know where that’s like a regional thing.

Donald: Is it like a gif and a jif?

Dr. Weinfeld: I think so yeah, and I don’t know if it’s like West Coast versus East Coast, or what most people say deep but there is a small contingent of surgeons who do this procedure who call it a DIEP. And again, I don’t know why. But it’s…so DIEP it’s an acronym that stands for Deep Inferior Epigastric Perforator Flap. And so flap in plastic surgery is kind of a funny term, that just means a chunk of tissue that you’re transferring from one place to another, containing its own blood supply. And as Johnny spoke of, when we’re doing a DIEP flap we are, what we’re doing is we’re taking that tummy tuck tissue, the tissue, the excess skin, and fat that exists between the belly button and the pubic hairline, out to each hip. We’re taking that tissue away from the body, based on one or two little blood vessels, an artery, and a vein with a connection or two to that tissue, and we’re disconnecting it from the blood vessels that supply it in the pelvis, and we’re reconnecting it to blood vessels in the chest, so that we can kind of go from alive in the belly to temporary, you know, not alive just for an hour or two and then make it re-alive sort of like a Frankenstein sort of fashion on the breast. Meaning, you know, like it for a moment, it wasn’t really alive when it was disconnected from the blood supply. And it’s really a miraculous surgery.

Donald: It is cool.

Dr. Weinfeld: And Johnny was talking about the evolution of breast reconstruction of tissue-based breast reconstruction. And what he was talking about was a TRAM flap, which was really sort of the predecessor to the DIEP flap, there was one iteration in between, which was the free TRAM. But a TRAM flap is the Transverse Rectus Abdominis Myocutaneous Flap. And that Myocutaneous word means that it was a flap, again, a tissue chunk of tissue that’s transferred from one part of the body to the other. But it involved a muscle and that muscle was kind of a bridge that took the blood supply that originated in the upper part of the abdomen and went down into the tissue that we were transferring. That was kind of left there as a conduit or like a pipe, bringing blood in and out of it, as that tissue was disconnected from the same locations and reposition to the chest to make the breast mount. But that muscle had to stay there stay intact. And he had to take that muscle out of its normal location and fold it up, as he said, creating bulges so that it could reposition that tissue and supply it when it rested in the chest. But the big problem with that is that you know, that rectus abdominis that’s your six-pack muscle. And so that you know, you’re robbing a woman of a lot of our core abdominal strain, which makes it more difficult for them to return to normal activities. And it is because you’re cutting into the fascia, that thick, strong layer of tissue above the muscle, you’re increasing the potential that the patient is gonna have a hernia. That was a big complication associated with that type of reconstruction but it was still wonderful.

Dr. Franco: And even if not a true hernia, they would get that bulge. Yeah, you know, it’s like, “Oh, I got a better breast. But now I got this big.” Because that fascia is what we tied in for those of you who are familiar with like our tummy tucks, you know, when we do our internal core set, or we tighten the belly, it’s that specific fascia you’re talking about.

Dr. Weinfeld: That’s exactly fascia, but then you’ve kind of taken that muscle out behind it, so it doesn’t have the same strain. And you know, and so if you take one of those muscles, if you’re doing a unilateral reconstruction, they can usually compensate pretty well. But if you have to take both of those muscles, because you’re doing a bilateral reconstruction, that’s a really big hit to the core abdominal muscles. And so DIEP flap, as I said, there was a small…or wasn’t small, there’s a period of time when we did what was called a free TRAM. Where we took a little chunk of muscle, so you’re taking the whole muscle, and that chunk of muscle contained the blood vessels that went to the tissue that you’re transferring the skin and the fat. And so that decrease the risk of hernias and bulges, but they still existed. So the DIEP flap the real innovation there, this guy by the name of Bob Allen, kind of came up with this, I don’t know what like 15 years ago, and it didn’t popularize until 15, 20 years ago. But what he realized was that you could take one or two of those little blood vessels that went through the muscle and separate the muscle around them. And snake the main blood vessel that’s coming from the pelvis and those two little blood vessels, one or two that go into the tissue. And you can pull that blood vessel through the muscle, put the muscle back together, fascia back together, almost as strong as it was before the surgery. And after a period of healing in a functional standpoint, basically, as strong as they were transferred the tissue, they can go back to all their normal activity. So it’s a really huge step ahead.

Dr. Franco: The one thing that I think is crazy, and you know, this shows you how much we’ve learned and how much we have to go. That this is basic anatomy that we are only, you know, still learning and understanding, you know, because we used to think that you needed this entire muscle to make that survive. And now we know that these tiny little blood cells sometimes just one, one little perforator can do the entire thing you’re gonna do for the whole breast. And being able to do that, it’s just it’s mind-blowing that we’re still learning basic anatomy.

Dr. Weinfeld: Yeah, well, it man. It is really amazing. And I think, you know, some of these pioneers have big kahunas, you know, like, they were like willing to really push the limits. And I think we’re all grateful and we’re allowed to say kahunas, right?

Dr. Franco: I think so.

Donald: That’s a medical term, right?

Dr. Weinfeld: Yeah, absolutely.

Dr. Franco: But all this stuff just makes it better for patients. And we talked to one of our other segments about how many great plastic surgeons are in Austin in this innovation and people like yourself. Because DIEP flap is probably the most common of this specialty micro reconstruction but not the only one. Because not everybody, somebody may have already had a tummy tuck, somebody may not have enough tissue, and we won’t get into the weeds, but there’s like four or five other options you have if that’s not available for people.

Dr. Weinfeld: Yeah, I would feel remiss if I didn’t say kahunas one more time, only to say that without a doubt, I think is an important thing to say. Because without a doubt some of the pioneers or the pioneers for this procedure were men, but actually a lot of the advances now and some of the best surgeons, both in our town and across the nation are women. And the person that I first learned this procedure from Aldona Spiegel in Houston. And she actually went and spent time with Bob Allen. So she kind of learned from the master I was able to learn from her. So I think it’s important to mention, you know, I use that word, but it’s really important to mention that this is plastic surgery is becoming you know, there’s more and more representation by women and especially in breast reconstruction. There are fantastic things that I’m learning from all surgeons, you know, men and women. So it’s important to put that here.

Dr.Franco: Surgery is one of the forefronts of women being in surgery compared to other surgical fields. Plastic Surgery is almost even if you look at resonance, right, and it’s been the last few years, which obviously it takes time to filter all the way through because surgeons never retire. We don’t know what else to do. But it’s nice to see that at least in training, those numbers are even.

Dr. Weinfeld: Yeah, you know, my father’s an ob-gyn. And when he started in residency, all males when he started to practice all males, by the time he retired 50/50 are probably more women than men. And frankly, I think we’re gonna see that in plastic surgery. I mean, given the fact that most of our patients are females, you know, and so I think by the end of our career too easily is gonna be 50/50, or maybe a discipline where there are actually more women than men.

Dr. Osborne: Okay, can I give a quick shout out to the hospital-based anesthesiologists and CRNAs around the country that take care of these patients on a daily basis is, these are not easy cases. When you spoke up the DIEP flap, and TRAM flap, I have some experience doing those when I was hospital-based in Arizona, and those are not easy patients to care for. A lot of restrictions, a lot of changes in technique and evolution on different techniques that we do anesthesia wise. From lack of using vasopressor medications to shrink those arterioles and arteries and veins, because we want to get as much perfusion to that tissue as possible. So those are not easy cases to manage. And a lot of those patients, they’re not as a one, you know, easy, young, healthy patients, like we’re doing breast augs on. They are oftentimes riddled with comorbidities, and also, you know, have issues related to the chemo and radiation that we have to look out for as well. So just can’t say enough good things about those providers that take care of those patients.

Dr. Franco: Yes. And those surgeries are longer.

Dr. Osborne: They are not short.

Dr.Franco: They’ve got a lot…the DEIP flaps have gotten a lot better. But when people first started doing them 12 hours was not un…

Dr. Weinfeld: Unheard of at all, even for unilateral. Yeah, I mean, going back to Travis’s point, that’s you know, while there’s only two, you know, kind of two teams, from a professional standpoint, the anesthesia team and the plastic surgery team during a DEIP flap. But really it is that’s also a multidisciplinary event. I mean, we have a lot of dialogue with our anesthesia providers about you know, what’s going on? What do they need to know from us? What do we need to know from them? You know, we’re asking them about the blood pressure, they’re telling us what they can do to, you know, keep it where we need it to be. So there’s a lot of dialogue going on. And I agree. And having great anesthesia providers definitely makes their job easier.

Dr.Franco: Anything else and from an anesthesia standpoint of breast reconstruction that you’d like to hit on a “Celebrity?” Because I think that was a good point of some of the more complexities some of the patients are, you know, in the hospital, because this isn’t a breast aug where we, you know, sometimes, even if it’s not the breast reconstruction part. You know, you had mentioned uncontrolled diabetes, hypertension, there’s only so long you can delay a breast cancer. And so our anesthesia colleagues sometimes have to help us to make sure that we can at least get that first phase done in a safe manner.

Dr. Weinfeld: Sure. Without a doubt.

Dr.Osborne: So.

Dr. Weinfeld: Oh, sorry. Go ahead.

Dr. Osborne: No, touching on that. It’s just optimizing the patient, even if I only have, you know, a couple of hours to optimize that patient. If I know that they’ve announced the night before or I see that patient, I can get their glucose, their blood glucose under control before we rollback. We can regulate that hypertension before we go back. Those things can be addressed day of surgery. Dr. Weinfeld was speaking to uncontrolled diabetes, things like that we normally work with their primary care physicians or their oncologist to try to optimize those numbers. And to get them medically managed before we do those cases.

Dr.Franco: Or the hospital.

Dr. Osborne: Or the hospitals, absolutely, if they’re inpatients. Another thing you know, we’ve been playing with techniques here for the past, you know, probably 10, 15 years in anesthesia and longer. But made some real advancements in the past 10 or 15 years with doing thoracic epidurals for these cases, trying to promote this EROS or early recovery or enhanced recovery after surgery. Anything we can do to increase perfusion to those areas, decrease the amount of narcotics were given to these patients. And really decrease the amount of vasopressors we have to use to keep their blood pressure up all help that tissue live is as long as easily as possible.

Dr. Franco: Yeah, no, no, I think it’s always interesting because people don’t realize how many people are involved, especially in some of these more complex situations to make sure that everything comes out as good as possible.

Dr. Weinfeld: Yeah, without a doubt, I mean, what’s done with the patient under anesthesia can have a really significant role in terms of their recovery. And so I think one of the Trav’s talked about this, but one of the really important things is how do you keep the blood pressure up without having to flood them with fluids because that does make it difficult for the patients to recover. And, you know, I don’t know if when you were doing this in a hospital-based setting, whether plastic surgeons were kind of allowing if you guys will you guys use pressors. But actually, we allow the anesthesia staff to use pressors nowadays, and there’s, I don’t know why it’s escaping me. But there’s one that’s actually really good for flaps. And so we let them use it. This kind of sounds weird to let them we encourage them, please use that I’m actually telling them often, “Please use this,” I can’t remember, I don’t know why. Because especially if it allows you to limit fluids a little bit because having a patient who wakes up and isn’t you know full of fluid, they’re gonna be able to get up and recover quicker. They’re gonna breathe better, they’re gonna be out of bed quicker, it just works out really nicely. Do you know what it is Travis, what’s the one we like?

Dr. Osborne: It was either a Levophed or…

Dr. Weinfeld: Levophed.

Dr. Osborne: Yeah, Levophed has some good action. One thing about Levophed that’s different from some of the other concentrate…the other blood pressure, increasing medications is it’s not just working on the arterioles and arteries to vasoconstriction. But it’s also actually giving you some beta agonism. So you’re increasing the squeeze the heart, you’re getting some minor trophy from the heart, you’re increasing the heart rate with that as well. So you’re increasing cardiac output and perfusion distally just by augmenting the heart rate and in how much squeeze you have on the heart. So that’s what we like that medication over some of the others that are strictly alpha.

Dr.Franco: I think I learned so much from you damn.

Donald: Yeah.

Dr. Osborne: You guys don’t hear me using those kinds of words I’m just doing plastics now.

Dr. Franco: I got to do a fact check on that. Can we…Any other nuggets that you think take-home stuff that patients should know? You know, I think one if somebody doesn’t bring up the topic of breast reconstruction, and you’re having, you know, mastectomy, lumpectomy, something that the patient should at least feel comfortable about asking. And besides that, any other things that our patients should know?

Dr. Weinfeld: Well, I think I think having realistic expectations as is true for all of the plastic surgery is really important. And one of the best ways to set reasonable expectations is to show patients photographs of patients who are of similar age, similar body size, breast size, same skin color. All of those can really help a patient understand what they’re looking at in terms of a final result. That’s kind of creating a book of results is something that has been really beneficial for us to help patients know what they’re gonna get and feel good about it. Because they had a good mental image of it before they went into the surgery.

Dr. Franco: I think that’s super helpful. And then yeah, I know, I didn’t give you a heads up on this, but we like to do a little segment we call behind the bogey. So if there was something in the world of breast reconstruction that patients would know nothing about that you think would be a cool little nugget for them to know. What would be a great little like behind-the-scenes nugget?

Dr. Weinfeld: Gosh, I’m really stumped. Give me a second to think.

Dr.Franco: Because one that I think is and you could tell me if this is still true or not, but for a lot of these micro breast reconstructions, there’s actually two surgeons. Like a lot of times, you’ll have a second surgeon just for time and kind of ease and stuff is that still something that happens or?

Dr. Weinfeld: Without a doubt when we’re doing the DIEP flaps we always have a second guy you know, or gal, but yeah, sort of like a silent partner back there helping out but they’re playing an equal role in surgery. And sometimes when we have time we introduce the patient, you know, like if the surgeons are there we introduce them before the case. But sometimes they ever meet someone who is like 50% of you know, what’s their amazing results. So yeah, that’s a great one.

Dr. Franco: And just so patients don’t get confused. You’re doing this because you’re trying to keep the surgery shorter. Also, from a micro standpoint, if you have somebody sitting across from the microscope from you that really knows each other really well, the success is much higher.

Dr. Weinfeld: Yeah, absolutely, to have two surgeons, they’re really cuts out probably, you know, three to four hours of time, if you…I mean, it could easily take twice as long to do the surgery without a second surgeon. And in fact, you had mentioned him as a real technical point. But you had mentioned having another surgeon across the microscope from you. Nowadays, we don’t do that almost all the time we’ve done this first flap. So we’ve taken that disconnect from the body, I hand it up to my partner who’s doing the anastomosis or the blood vessel connection in the chest. And while he’s doing that, I’m moving on to the second flap dissecting that out. So when he’s finished, I’m then passing it up. So it’s like a leapfrog process. And it really cuts down on time. And then while he’s doing the second, anastomosis I’m starting to get the belly closed, you know, so it saves a ton of time. That’s a great movie. Thank you.

Dr.Franco: That’s a good one.

Dr. Osborne: Not to mention, in that instant, time is tissue, right?

Dr. Weinfeld: Yeah. Without a doubt and recovery, you know.

Dr.Franco: Because we talked about it in our static surgeries all the time. Where we try and limit how long you know, we sometimes don’t have a choice in cancer surgeries, but nuggets like this make their outcomes better the recovery better.

Dr. Weinfeld: No doubt. Yeah, you know, one quick thing. And this is sort of like an insider type of thing. One of the things that we’ve done, because these are long surgeries, the lungs do kind of collapse a little bit during surgery. And it’s challenging for patients right after surgery, to start to take those deep breaths, we started to put that incentive spirometer in their hand in the recovery room. And that’s where it’s really helpful to have an anesthesia provider who can wake that patient up and have them be like, conscious right away, but not in pain. And we’ve worked with some really skilled nurse anesthetists who have them like awake, not in pain. And I pop that thing in their hand in the recovery room. They’re starting to blow on that or suck on that incentive spirometer open up those lungs. And they’re the patients the next day who are like in the chair they’re O2 sad off of oxygens it’s like 99. They’re getting up walking around. It’s really impressive stuff.

Dr. Franco: That’s incredible.

Dr. Osborne: That’s awesome.

Dr. Franco: Can we do a little quote of the day to get us down the homestretch here?

Dr. Osborne: Yeah, I’ve got one right here. We touched a little bit on innovation and changes in technique during this podcast, and I thought this one was great. This is from Peter F. Drucker. “If you want something new, you have to stop doing something old.” I think that’s like, you talked about the guys with the kahunas, if you will, to step out and really try something that was innovative. Not necessarily being Cowboys, but doing something that was evidence-based and doing something innovative and pushing the envelope a little bit for better patient recovery…for better patient outcomes and better recovery.

Dr. Franco: It’s hard because you know, it’s sometimes scary to do something, especially when it’s something that it works. And you’re like, you know that there’s something better but it’s tough to kind of take that leap. And I don’t want people to think that we’re just doing something cowboy-ish way out in the left field, but it’s typically a little baby step in the right direction. Well, I think that’s about it. Unless any other take-home messages for the day as we wrap up here.

Dr. Weinfeld: No, that was wonderful. And I mean, I guess you know, we started off with this, but yes, insurance covers all breast reconstruction and symmetry procedures. And really, it’s never too late to have a breast reconstruction. So I think if that’s the only thing that women and their partners take away from this podcast, then we’ve done a lot.

Dr. Franco: And if somebody had questions if they want to follow you on Instagram, what what’s a good handle for you?

Dr. Weinfeld: Instagram, @happinessplasticsurgery.

Dr. Franco: And then you have a website as well.

Dr. Weinfeld: Yeah, drweinfeld.com, which right now does not include breast reconstruction but within two to three months it will.

Dr. Franco: You’re a busy man. And this was such a vast topic if the crew will allow us I’d love to have you back again because I feel like we only scratched the surface of some of the stuff. We nibbled on fat transfer and some of the other exotic stuff but there’s so many things you didn’t even touch nuances to it.

Dr. Weinfeld: Yeah, so much to delve too. Yeah, I’d love to without a doubt.

Dr. Franco: Well, I appreciate you having you appreciate the rest of our cast coming in and hanging out. So don’t forget “Plastic Surgery Untold.” You can download us anywhere we get your favorite podcasts, iTunes, iHeart, Spotify, Pandora, and you can even find us on YouTube. So thanks, guys, the greatest podcast in the world as voted by us. We’ll see you guys. Bye.

Together: Bye.

Dr. Osborne: Thanks, guys.