Dr. Baltrusch (00:00):
My name is Kyle Baltrusch. I am a plastic surgeon at Portland Plastic Surgery Group in Portland, Oregon.

Eva Sheie (00:05):
Okay. So you go from diagnosis to oncology and then oncology very quickly sends you to the plastic surgeon depending on which path they think you should go down. How often is the mastectomy and reconstruction happening at the same time?

Dr. Baltrusch (00:22):
So I do a two stage reconstruction with my mastectomy patients, and so at the time of the mastectomy, I am putting in tissue expanders, and then sometimes I also perform breast lifts in different variations to establish or cosmetic breast mound. And then about four months later, I do the second stage reconstruction where I take the tissue expander and put in their permanent implant. So the second stage reconstruction I don't do at the hospital, I do at our surgery centers. So it's another whole team of doctors. So we work with the same nurses and anesthesiologists at the surgery centers as well. So there's the hospital-based team, the office-based team, and the surgery center team.

Eva Sheie (01:02):
Can you give us some more detail about the tissue expander process and what that looks like and feels like? And are you, they're called expanders for a reason. Are they getting bigger over that four months or however long that is?

Dr. Baltrusch (01:15):
Yeah, so part of the consultation with the patient is to establish their goals. If they are moving forward with mastectomies, then the discussion is, are you having a unilateral meaning one-sided or bilateral, both sided mastectomies. And so if a unilateral procedure is performed, then obviously the non-cancerous breast acts as a template for reconstruction of volume. If they're having bilateral, then the discussion is what size do you want to be? I certainly have patients who want to have smaller breasts after reconstruction, and I've had patients that want to increase their breast size after reconstruction. So you have to establish a patient's goal. So which tissue expander to be putting in at the time of mastectomy. And so a tissue expander is just a temporary silicone shelled saline implant. A little bit firm, but it's anatomic in form. So it sits in the chest cavity. When it's a certain position, it's sutured to the fascia, so it holds it in position. And then after mastectomy, there's a very significant decrease in sensation of the chest wall. And so it makes it very easy for us in clinic to locate the port of that tissue expander and just kind of pop a needle into it through the patient's skin. And then we slowly expand the breast back out to size or out to goal when that's done, starting at three weeks after surgery. And we meet patients every week or so until they're at their goal size.

Eva Sheie (02:29):
Do you have any idea what that feels like to have the tissue expander in and constantly expanding your tissue?

Dr. Baltrusch (02:36):
I personally don't, but patients tell me that the tissue expanders are uncomfortable. They can kind of feel the edges of them. They can even cause muscle spasm the pec muscle. And so they're not the most comfortable. And I just remind patients that they're a temporary device and most patients are very excited to get the tissue expander out and get the permanent implant in place.

Eva Sheie (02:56):
I know the purpose is in the name of the device. What is the purpose of the tissue expander? What are you trying to achieve?

Dr. Baltrusch (03:04):
Yeah, it's a placeholder. So if you did a mastectomy and you didn't do any sort of reconstruction, those tissues would scar down. And so basically the tissue expander is a placeholder. It's keeping the domain of the breast. It allows us to maintain shape and better cosmesis overall. And so it expands preferentially the lower pole of the breast for a more anatomic slope. I do all my reconstruction on top of the muscle, and so basically just replaces where the glandular tissue was.

Eva Sheie (03:33):
So they're coming in about every week for is usually about four months before they're ready.

Dr. Baltrusch (03:38):
It's roughly every two weeks. If I need to get a patient expanded quicker because of radiation, I do like the tissue expander to be at full volume before the patient gets radiated. And so the radiation oncologist do want to get patients in before three months. So starting at three weeks, I do start the expansion process. And then it kind of just depends on future management. It may only be a few expansions before then the patient just gets a big break from me and I see them at their preoperative appointment for their second stage reconstruction. But yeah, it's every few weeks until we're expanded.

Eva Sheie (04:14):
Do they come to your office or are they seeing you at the hospital?

Dr. Baltrusch (04:17):
The expansions are done here in our office. My PA, as well as my nurse also perform expansions. Sadly, we have a lot of women coming in with tissue expanders, and so we need multiple people in our office to be able to perform those.

Eva Sheie (04:30):
So do you get to be friends with all of these patients as they're kind of coming and going?

Dr. Baltrusch (04:34):
Yeah, actually. I really enjoy catching up with all of my patients on such a frequent basis. And what I love about cancer reconstruction is you're really helping someone through a very difficult time in their life and they become lifelong patients of mine. So once I have an implant in a patient that's a yearly follow-up until we discuss exchanging that implant in roughly like 12 years or so.

Eva Sheie (04:57):
On this podcast, we bring you directly to the doctors who are where before meets after. Links to our guest's website and contact info are in your show notes. Follow us on Instagram @wherebeforemeetsafter. Where Before Meets After is a production of The Axis, the podcast agency for aesthetics, theaxis.io.