Episode 9 – Nipples with patient Ayda Hornak

Wendy Squires (00:10):

Welcome. My name is Wendy Squires and I’ve been a journalist for more than 30 years covering women’s health issues, which is why I have the great pleasure of introducing Dr Nicole Yap, a highly respected breast doctor and surgeon. Dr. Yap is a specialist in oncoplasty, which involves removing cancers with pleasing aesthetic results for patients after training in both plastic surgery and general surgery. Dr. Yaps techniques were refined whilst working in the European Institute of Oncology in Milan, at the Royal College of Surgeons in London and working with world-renowned experts in the field in Paris and Lyon. Amongst her many accolades Dr. Yap was the deputy chair of the Victorian branch of the Royal Australasian College of Surgeons, and it’s representative on the Cancer Council Victoria medical and scientific committee. She is also Pink Hope expert advisor and vice president of the Medico Legal Society of Victoria. Today Dr. Yap is known for providing bespoke breast care. In other words, individually catering, not only to patient’s medical issues, but also how they want to look and feel after treatment, as she is adamant that one size doesn’t fit all when it comes to breasts.

Wendy Squires (01:28):

Today I’m here with Dr. Yap and her patient, Ayda Hornak, and we’re going to be talking about something that doesn’t get discussed enough in regards to the breast, and that’s a nipple and areola. Dr. Yap what can affect the nipple and areola? What sort of things do you see?

Dr Nicole Yap (01:46):

Well, a lot of people don’t present that early with problems because you can have congenital benign problems and you can have a cancer or problems associated with cancer of the breast. So with regards to the benign sorts of things, the nipple, for example, can be inverted and can be inverted at a very early age. So the reason why people don’t present at an early age with this, even though they may be embarrassed, is because I think that’s just normal for them.

Wendy Squires (02:19):

So you can tell me what is an inverted nipple? What does it look?

Dr Nicole Yap (02:22):

Well a nipple that is everted, that is out, it looks like a little so-called bump appendage on your skin, or on the areola, but an inverted one is when it’s sunk down and the surface is more or less flat and you can’t see that protrusion, but the nipple is still formed, but it’s sunken inside.

Wendy Squires (02:43):

And is that a problem?

Dr Nicole Yap (02:44):

Well, if it’s there for a long time, it’s congenitally, then probably isn’t a problem. And it’s just due to the fact of the structure of the area around it. But if it was never like that, and a specifically if it’s occurred only on one side as you get on in life, then it could be due to the fact that there could be an underlying cancer that’s pulling it down. And that’s when that’s one of the signs that you should present with, if you’re concerned about any breast disease.

Wendy Squires (03:17):

That’s fascinating, I never knew that. And what other issues can affect the nipple?

Dr Nicole Yap (03:21):

Well, the other thing is people can present with nipple discharge. So nipple discharge comes in a variety of ways, so it can be clear, it can be milky, yellow, green. These are generally benign causes, clear can be associated with a cancer that’s inside the duct. And of course, bloody discharge. Now if you have bloody discharge we are always very concerned about that, because bloody discharge can either come from an otherwise benign, but turning into a cancer papilloma. Papilloma is an outgrowth of the lining of the milk duct, okay, so if you know about having polyps in the bowel, a polyp is an outgrowth in the lining of the bowel, we always remove them because they may turn into a cancer. Well similar with papillomas. We try to remove them and they commonly present as nipple discharge, it doesn’t have to be blood. It can be just clear. And so all discharged should be checked.

Wendy Squires (04:34):

Is discharged common in a nipple?

Dr Nicole Yap (04:36):

Yes, because it can also be physiological. It can just be normal. So people can have normal, white, yellow discharge, and that can happen even after, similar to breastfeeding. But people say “I’m just still producing milk and I haven’t been breast feeding for a while.” That can be within the norm, but never assess it yourself, always get it checked, and checking requires sometimes taking a sample and checking it for cytology and definitely having a mammogram and an ultrasound and sometimes an MRI of the breast.

Wendy Squires (05:13):

I’ve heard of horrible stories regarding what happens to the nipple during cancer surgery, or even some aesthetic breast surgeries. Can you tell me, is it true that they need to be removed from the body and put on ice and all of these sorts of things that I’ve heard over time and, Ayda feel free to talk to us about your journey with your cancer surgery and what happened to your nipples in this instance, because I do know that there are some frightening stories out there, and I think it’s a great opportunity to clear the air.

Dr Nicole Yap (05:45):

Well, if cancer does involve the nipple areola, obviously that has to go, because you can’t leave cancer behind. And sometimes that also presents as an eczematous rash around the nipple areola, otherwise called Pagets disease. In patients that have the cancer closely associated, we’ll remove it. But if not, it’s not necessary to do that. And I never take it off and put it on ice, only my Dr.inks. So with these situations, I use the natural blood supply of the nipple areola to maintain that blood supply. So I will either keep it as what we call a flap, which means it maintains the blood supply, where it comes from, which is from the internal part of your chest wall. And then also sometimes I add to that some grafting. So I graft it down as well onto the underlying muscle, because you’ve done a mastectomy there will just be muscle there, not breast tissue. In aesthetic surgery it’s slightly different, I will never take them off. I will always keep them. There is no need to take them off and just use the similar techniques to maintain their viability. With Ayda though it was slightly different.

Ayda Hornak (07:04):

Yeah, well we removed the areola nipple area from one of the breasts because [crosstalk 00:07:11] which was the cancer. So we decided to do that. And Nicole reconstructed it, did such an incredible job of it. When I went home and decided I looked at both of them and thought, I kind of like what she’s done better than what I’ve got. So we went back and she made the match, didn’t you? So we actually went to the extent of redoing the other one to make it look the same.

Wendy Squires (07:36):

The healthy breast?

Ayda Hornak (07:37):

The healthy breast to make it look the same as what Nicole did. Which was fantastic because when we first started talking about it, I went through the journey of the tattooing of the areola. But after a couple of times I’ve just gone, I can’t keep this up because it keeps fading and it hurts.

Wendy Squires (07:56):

But that’s a very common first step isn’t it really, aesthetically, is to tattoo that area. Tell me Ayda was it painful?

Ayda Hornak (08:02):

Yes. Yeah, it was really painful. And Nicole was really happy that it was painful because it meant that I’ve still got sensation in that area, which is a good thing.

Wendy Squires (08:09):

Which is a great thing, because that’s another misconception, isn’t it around breast cancer and the nipple, is that you will wind up with no sensation in your nipple.

Dr Nicole Yap (08:17):

Yeah, that’s actually quite common with the majority of people, but I’ve just got a few techniques which are on the whole, not always, but we can maintain the sensation along with the vascularity, the blood supply.

Wendy Squires (08:32):

So what did you do to Ayda’s nipples?

Dr Nicole Yap (08:36):

Well on the area where she needed the reconstruction, because it was a slightly larger one on the side that had no cancer. So I did a nipple share technique. So I took some of that nipple so it looks like a real nipple. It’s not a made up nipple. And then I grafted it onto the side that didn’t have nipple areola. And around that we originally then did the tattooing. But when that didn’t work, the tattooing didn’t work, I did a definitive procedure, which is doing a split skin graft. So taking a partial skin thickness from somewhere, usually the upper inner thigh so it’s hidden, and then recreating the areola, which actually looks quite natural because the area is kind of bumpy and slightly irregular. You don’t want it to be too regular because that looks contrived.

Wendy Squires (09:29):

And how do you feel about your breasts now after everything you’ve been through?

Ayda Hornak (09:33):

I love them. They look great. They look normal.

Wendy Squires (09:35):

Better than they were at the beginning?

Ayda Hornak (09:37):

They actually are. Yep.

Wendy Squires (09:40):

And what about your journey emotionally? How did you feel going through this aesthetic part, and cancer, to come out the other end like this. What’s that meant to you?

Ayda Hornak (09:51):

Look at first it’s terrifying and it’s something that nobody ever wants to go through. So I stick with that, but there’s an amusing side to it because I’m quite frightened of surgeries and needles and things like that. So every time I went into surgery with Nicole, I’d have to have, sorry…

Dr Nicole Yap (10:12):

Valium.

Ayda Hornak (10:12):

Have Valium or something like that to calm me down before I even went into theater.

Wendy Squires (10:18):

Ayda, after this incredible ordeal you’ve been through, you are now walking around with two healthy breasts that you are happy with their appearance. Can you tell me what difference that’s made for you psychologically and emotionally?

Ayda Hornak (10:32):

It’s made a massive difference. So at the time going through the journey, it was the most frightening thing I’ve ever experienced. And me personally, I am very fearful of anything that’s related to surgery, from needles to anything really, but we went through the journey, Nicole was fantastic. She really helped me go through the whole process with a lot of information. So I was able to harness that information and empower myself and go, okay, this is what I need to do. Step by step and get through to the other end. So I think everything has a silver lining, so when you kind of reflect back and go, yes, scary as that was, I’m really glad I made the decisions that I did and have the additional surgeries and get to the point where I can actually look at myself and go, hell yeah, that looks okay. It wasn’t that bad.

Wendy Squires (11:21):

That’s wonderful. Thank you so much Ayda, all the best in the future. And I’ll see you next time Dr. Yap.