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16 T M C N E W S . O R G Reconstructing Breasts with a Dermal Bra Plastic surgeon uses her sewing savvy to improve post-mastectomy reconstructions E leanor "Blitz" Hoppe was 18 when an at-home genetic test revealed that she carried the BRCA1 gene mutation. This means one of her genes that is supposed to help prevent breast cancer is damaged, leaving her more likely to develop breast cancer at a younger age. "I don't think it affected me in any way, shape or form when I found out. I'm good at compart- mentalizing things and I think I put that in a vault and moved on," Hoppe said. "There was a lot of excitement going on in my life. I was getting ready to go to college." After graduating from Texas Christian University with a nursing degree, Hoppe was excited to start her career at Houston Methodist Hospital. Thriving, she brushed aside her knowledge of the gene mutation, but after a few months as an operating room nurse, she could no longer ignore the future of her own breast health. "I started noticing that a lot of these women [in the OR] had a history of breast cancer. Some of them were frightening. They didn't look like they were going to leave the hospital," she said. "Then, all of a sudden, the genetic testing crept its way back into my mind." Her father's battle with multiple myeloma, a blood cancer that affects plasma cells, was also a driving force. "I have a dad who has an incurable cancer. We've been dealing with that since 2012. At the time, he was on oral maintenance chemotherapy," Hoppe said. "I knew that if I ever had kids down the road, I did not want to do this to them. It's not like my dad had a choice, but I do. I have a choice." Hoppe's father, an avid football fan, nick- named her "Blitz" before she was born. A blitz is a defensive tactic used to disrupt an offensive pass—and a fitting nickname for someone trying to decide if the best way to attack her increased risk of breast cancer is an aggressive defense. "He told me, 'You either live up to the nick- name or you don't,'" Hoppe said. "This is a danger- ous cancer and I have the choice to protect myself from it. I can beat cancer before it gets its nasty hands on me." Determined, she opted for a double mastectomy. A dermal bra, sewn under the skin For women carrying the breast cancer type 1 (BRCA1) or breast cancer type 2 (BRCA2) gene— both mutations involve a flaw in the gene's ability to produce tumor suppressor proteins—one of the ways to reduce the risk of breast cancer is a prophylactic mastectomy, which involves completely removing the breasts. This procedure can reduce the risk of breast cancer by 95 percent in women with BRCA1 or BRCA2, according to the National Cancer Institute. Houston Methodist reconstructive plastic surgeon Aldona Spiegel, M.D., has developed an innovative approach to breast reconstruction that offers patients, like Hoppe, more natural-looking breasts with decreased surgery time, reduced pain and faster recovery. Spiegel had grown frustrated by the results of reconstructive surgeries that placed implants in the mastectomy pocket under the muscle. The pectoralis muscle covered the top half of the implant, while new collagen provided coverage for the bottom half. "We were able to do a very nice reconstruction and patients were happy, but unfortunately, the thing that still was a problem was the muscle that was basically causing deformity of the implant," Spiegel explained. "As you contract, that muscle pulls. It's right underneath the skin and you can see a deformity that occurs. We were challenged to figure out how we can improve this." In pursuit of a solution, Spiegel drew on her childhood in Poland, where she learned how to sew cloth- ing for her dolls. "Unlike the U.S., where you have American dolls with different outfits, that was not the case in Poland. You just had one doll, one outfit and that was it," she said. Spiegel's love of sewing dresses grew into a love for fashion. When she immigrated to Canada in 1981, she became enamored by the elegant cuts, silhouettes and embellishments on couture dresses. Although she couldn't afford to buy her own designer clothing, she was inspired by a Chanel dress with a corset in an issue of Vogue magazine and decided to replicate it for her prom. "Sewing was an experience I had that allowed me to figure out this [breast reconstruction] problem," Spiegel said. "I don't think I would have been able to figure it out easily if I didn't have that experience of realizing how to sew fabric into a bodice of a dress. That allowed me to problem-solve in this situation and figure out how to make this two-dimensional shape conform to a three-dimensional object." Spiegel created an internal dermal brassiere made of biological tissue meshes that supports and holds the implant in the same space from which the breast tissue was removed. The implants are placed over the chest muscles and underneath the skin, creating a more natural reconstruction without deform- ing the muscle or pulling on the skin. This approach also prevents capsular contracture (a hardening of a thin layer of tissue around the implant) and uses smooth implants rather than the textured implants that have been linked to a type of cancer called anaplastic-large cell lymphoma or BIA-ALCL, for short. B y S h a n l e y P i e r c e The dermal brassiere, marketed under the name FlexHD Pliable PRE by MTF Biologics, is placed over the chest muscles and under the skin. Credit: Courtesy Houston Methodist