He’s the man of the hour, but Beverly Hills plastic surgeon Jay Orringer, MD, is not one for seeking the spotlight. Orringer performed actress and advocate Angelina Jolie’s breast reconstruction surgery earlier this year, yet he is only officially coming forward now.BRA DAY logo hi res

Jolie, an Academy Award winner, mother of six, and human rights advocate, underwent a preventive mastectomy to reduce her risk of breast cancer after gene testing. She opened up about her experiences in a New York Times Op-Ed piece that got the world talking about breast cancer risk. Jolie’s mother, actress Marcheline Bertrand, died from ovarian cancer in 2007, at the age of 56.
Jolie tested positive for the BRCA1 gene, and her doctor said she had an 87% chance of getting breast cancer and a 50% risk of developing ovarian cancer in her lifetime.

Orringer’s name was bandied about in the days and weeks after Jolie’s announcement, but it remained a fairly well-kept secret. So why are we hearing from Dr Orringer now? The answer is simple. October 16, 2013, marks the second annual breast reconstruction awareness day USA also known as BRA Day USA.

“Angelina Jolie is an extremely brave and benevolent individual who truly wants to help people, and her coming forward has already saved, I believe, a significant numbers of lives,” he says. “I have already heard of women who said that, ‘As a result of her coming forward, I got tested, and my life or that of my daughter might have been saved,’ ” he says.

BRA Day helps raise awareness so all women faced with a breast cancer diagnosis or those, like Jolie, who are at high risk for the cancer, will understand their choices as well.

This year’s BRA Day theme is the importance of the breast care team—which all women are entitled to have and should seek.

“The patient is the captain, and we are her co-captains,” Orringer says. “The breast care team involves not just the general breast surgeon, but also the plastic surgeon, medical oncologist, radiation oncologist, personal physicians, psychotherapist, physical therapist, and others.” Support groups are also important. “Woman who have been through this are a great source of support and information for others,” he says.

Where does the plastic surgeon fit in? “Members of the American Society of Plastic Surgeons are trained to reconstruct the breast and to treat the implications of radiation on the breast—not just the mastectomy deformity.”

The choice of a lumpectomy and radiation or mastectomy will have ramifications down the road, he says. This aspect may get overlooked during the time of breast cancer diagnosis.

Of course, when given the choice, many women will want to save their breast, but they need to know what this really means, Orringer says. “Radiation and the effects of radiation are permanent in nature and often difficult, if not impossible, to correct,” he says. “Should you develop a second cancer in that breast or the other breast, the fact that you have had radiation will adversely affect the quality of a subsequent reconstruction,” he says. “This doesn’t mean that reconstruction can’t be done, but prior radiation will affect it,” he says.

This needs to be considered so that the patient can make a best-informed decision. “Otherwise, years later, there may be women saying, ‘Now I need a mastectomy, but had I known that my radiation would adversely affect my reconstruction option, I may have chosen a different option.’ “

Or maybe she would have done the exact same thing. Orringer is only advocating for education about the options because no woman can make an informed choice without understanding all the variables.

“Early on, a woman will say, ‘I just want to live,’ and that is absolutely the highest priority,” he says. But fast forward 5 years, and picture life in remission where you are doing well and the fear of cancer starts to abate. “This is when it will matter a great deal how you look in the mirror,” he says. “The risks of a less-than-optimal outcome will be significantly increased because of the effects of the prior radiation.”

The onus may fall on the diagnosed to add a plastic surgeon to the team. “Say to your oncologist or surgical oncologist that you would like to have a plastic surgeon included on the team,” he says. “Assemble your team early, and have that team include a plastic surgeon.”

Breast Reconstruction 2.0

Reconstructions look different today than ever before. Shaped implants, of which there are now three manufacturers with federal Food and Drug Administration approval, are improving outcomes for some reconstruction patients. “While still a good option for some, the traditional round implants tend to have more visible rippling than the shaped devices. The shaped implants, however, are inherently firmer in nature,” he says. “We trade greater firmness for less rippling … and if someone desires a more natural shape with less fullness above, the shaped device makes sense. It is an individual choice.”

Fat grafting to the breast is also becoming an option in breast reconstruction, particularly for upper chest wall post-mastectomy hollow, where it may fill the defect to some degree.

There are some technical issues with fat grafting, including the possibility of developing benign small cysts or lumps, for which further testing may be needed. Fat grafting results are difficult to entirely predict. “Nevertheless, it is a procedure gaining increasing popularity, and even in the post-radiation setting, many people believe the injected fat may improve the health of the radiated chest wall,” Orringer says. This may be related to stem cells and other factors in the liposuctioned fat.