Specialist Breast Surgeon with interest in breast cancer surgery, breast implant removal and breast r
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Very calcified 40-year-old breast implants as seen on a mammogram.
The patient has severe capsular contracture, which is when scar tissue that normally forms around the implant tightens and squeezes the implant resulting in progressive hardening, distortion, and deformity of the breast. On the left side, it has resulted in implant rupture, as you can see in the irregular outline of the implant.
Needless to say, these implants are coming out 🗑
Breast implant capsules are routinely sent off to the lab for testing.
🧫 A small piece of the capsule is sent fresh to look for any growth of bacteria, mycobacteria and fungus. (picture: yellow top jar)
🔬 The rest of the capsule is sent in a solution of formalin (a type of tissue preservative) and this will be assessed by the pathologist under the microscope for the types of cells present, such as inflammatory or cancerous cells. (picture: white top jar)
Intracapsular rupture of 1️⃣4️⃣-year-old textured silicone implant. The outer shell of the implant is completely torn but the silicone remains contained within the tissue capsule formed by the body.
Implant rupture can be asymptomatic, so the breast and implant may look and feel normal.
Left alone, intracapsular rupture can progress to extracapsular rupture, meaning the silicone can break through the tissue capsule and leak into the surrounding breast tissue.
🚩 Women with breast implants are recommended to have regular reviews with their surgeon or GP for the duration of the implants. 🚩
Officially calling Central Coast home for the next little while 🏠🎉
17 years of working in the public health system, and that is it for me.
Today, I handed in the resignation letter I wrote 12 months ago.
I will always be grateful to the system that trained me, and to the department that welcomed me back as a consultant surgeon.
It has been a privilege to play a part in training future surgeons - and it always brings me joy to see a trainee progress and improve during the term.
I have always tried to give the best care to my public patients, even under challenging circumstances.
It is scary to walk away from a system that I have spent nearly half my life working in, and it is a point of no return. I have my reasons, and today I am finally at peace with my decision.
I still love surgery, and will continue private practice on the Central Coast.
Thank you to Tuggerah Lakes Private Hospital and Icon Cancer Centre for hosting the recent Wyong Breast Cancer Forum for General Practitioners. Also thank you to the other sponsors who made the event possible: I-MED Radiology, ImpediMed and Douglas Hanly Moir.
My team and I are up at Tuggerah Lakes Private Hospital twice a month, and our breast cancer patients living on the northern end of the Coast are always pleased to save on extra travel time 🚗.
This year, Professor Boyages (radiation oncologist) and Dr Bagia and Dr Nayar (medical oncologist) are also consulting regularly at Tuggerah Lakes Private Hospital.
Please let us know if you prefer to have your appointments in Kanwal, and my team will facilitate that.
From Australia 🇦🇺 to Austria 🇦🇹 for the 18th St.Gallen International Breast Cancer Conference. Really looking forward to the next 4 days of talks and discussions on the treatment of Early Breast Cancer. Treatments are changing quickly in breast cancer so it's important to remain updated. 👩🏫
Good morning from Zagreb 🧡
Looking forward to a day of exploration …
Greetings from Dubai 👋
14 hours of flying done and 7 hours more to go. I’ve been so looking forwards to my first overseas holidays since 🦠. Next few posts and stories will be about 🇦🇹 & 🇭🇷.
You can check out more medical content at The B Clinic - Specialist Breast Care page, and this month’s focus is on Breast Implant Awareness Month.
The office is open, and Katherine and Deb will still be there to assist with any queries.
Look at those smiling faces 😀 … Hugo, Archie and Louie having THE time of their lives at Doggy Daycare Adventures
Wire-free breast cancer surgery using SAVI SCOUT technology with the Gosford Private Hospital team today. I’m so grateful to have this technology available to Central Coast patients. 🙌
More about wire-free breast surgery is on the website 👉 https://www.drmaryling.com.au/wire-free-breast-surgery
The rooms have closed for this year and will re-open on the 3rd of January 2023. Emails to [email protected] will be intermittently checked.
I need a break, and so does my team. And we will be back refreshed in 2023.
I want to thank each one of you who has trusted my team and I to look after you during your time of sickness and at your most vulnerable. It means a lot to us, and we do our absolute best to care for you. We have also been so fortunate to meet a lot of beautiful human beings along the way. 💖
Happy holidays!
📸 by
WIRE versus REFLECTOR
As you may already know from the previous post, breast cancers that cannot be felt need to be marked or localised before surgery.
The WIRE (red arrows) is the traditional way. It has an external part that sticks out of the skin, and needs to be inserted on the day of surgery. The wire can course through the breast for a distance before getting to the target. It works though, and is cheap.
The REFLECTOR (blue arrow) is newer technology. It is the size of a grain of rice with no external parts, and is inserted into the tumour any time before surgery (including marking the tumour for patients needing to have chemotherapy first).
The left picture is a mammogram that shows one wire localising an area of calcification, and a wire & SCOUT reflector localising a lesion that was only seen on ultrasound.
The right picture is an x-ray of the removed specimen with wire & reflector. (oops ignore the random tumour word 😬)
Now, this patient had both a wire and reflector inserted as part of the initial trial. With all new technology, there is a learning curve for the surgeon but patient care and safety should be not compromised. The wire was inserted as a ‘back-up’.
I am pleased to report that the SCOUT technology is very intuitive to use, and to be offering wire-free breast surgery on the Central Coast in 2023. 🙌
In my practice, I am constantly looking for ways to improve the patient journey and experience. Last Thursday, I was able to trial the SAVI SCOUT technology for removing non-palpable breast lesions … and it is very promising so far.
Let me explain.
Women who need removal of a non-palpable breast lesion require localisation. This currently involves a radiologist inserting a wire into the breast to mark the location of the tumour, and then the surgeon follows the wire to find and remove the tumour.
This technique works, BUT there are problems.
❌ The wire can be dislodged as the end of it sticks out from the breast. To reduce this risk, the wire needs to be inserted on the morning of surgery and surgery performed at a hospital with on-site radiology facility. This is the reason I can only do these operations at Gosford Private Hospital on the Central Coast as it is not ideal to be traveling long distances with a wire in the breast.
❌ It can turn day surgery into an entire day. The wire is inserted on the morning of surgery, and the timing of surgery is planned for as close as possible afterward. Inevitably, there is waiting time between the 2 procedures, which can exacerbate anxiety in an already stressful time of navigating breast cancer.
The SCOUT works by placing a tiny ‘reflector’ (size of a grain of rice) into the tumour. At surgery, a probe is used to detect the reflector’s position within the breast, AND it gives the distance to the tumour allowing more precise surgery. The reflector has no ‘external’ bits and can be inserted at any time before surgery, overcoming the above problems of wire localisation.
The SAVI SCOUT is widely used in the USA, and currently on a trial basis on the Central Coast. I am grateful to everyone who has made this trial possible, including
🙂 My patient who agreed to be the first person on the Central Coast for the trial
🙂 Theatre team at Gosford Private Hospital for doing what needs to be done for the new device to be used
🙂 Patrick & Fiza from Merit Medical for providing support
🙂 for taking Instagrammable photos
More about the trial in the next post.
Thank you to Dr Ken Wong for minding Hugo whilst I did my Saturday ward round. 🙏🥰
The eligibility criteria for Medicare subsidised MRI scan for breast cancer screening has been updated today. Without Medicare subsidy, MRI breasts can cost around $700.
You may be eligible for annual MRI breasts if you meet the expanded criteria. You will still require a referral from a specialist, and the scan must be performed in an eligible MRI unit.
🙌 Thank you to Tuggerah Lakes Private Hospital for introducing the Savi Scout technology to the Central Coast. This technology allows precise removal of breast cancers (and lesions) that are not palpable, without needing wires placed into the breast on the morning of surgery. It makes life easier for the patient (and the surgeon).
"I found a breast lump. What should I do next?" ⤵️
My team and I are excited to resume consulting and operating at Tuggerah Lakes Private Hospital, starting this month! We will be there once a month on a Wednesday, so please let my team know if you prefer to have your consultation at Kanwal.
📸 Photo is from the last time I was there in 2020, pre-Covid times.
On September 8, 2022, the FDA issued a safety communication about squamous cell carcinoma (SCC) and various lymphomas in the capsule around breast implants.
Here is what we know about Breast Implant Associated Squamous Cell Carcinoma (BIA-SCC) so far …
1️⃣ BIA-SCC is not a cancer of the breast tissue, but rather it arises from the scar tissue (capsule) that forms around breast implants.
2️⃣ BIA-SCC is very rare. Only 16 cases have been reported in the published literature. It was first described in 1992.
3️⃣ BIA-SCC has been reported in patients with silicone and saline implants, smooth and textured implants, as well as in women who had implants for reconstruction and cosmetic reasons.
4️⃣ BIA-SCC appears to be a more aggressive tumour than BIA-ALCL. It can spread to local tissues such as muscle and bone, as well as to lymph nodes and elsewhere in the body (e.g. lung, liver).
5️⃣ The average length of time from initial implantation to diagnosis for BIA-SCC is about 22 years.
6️⃣ The cause of BIA-SCC is unknown, but may be due to chronic inflammation around the implants.
7️⃣ BIA-SCC symptoms are similar to those of BIA-ALCL and include
- Breast swelling
- Breast pain
- Lump in breast or axilla
- Hardening of the breast
- Large fluid collection around the implant
TAKE HOME MESSAGE:
BIA-SCC is very rare, but if you have breast implants it is important to
🛑 Remain breast aware - if you notice changes in your breasts please see your GP (and at the minimum you should have a clinical examination and ultrasound)
🛑 Have ongoing surveillance of your implants for as long as they remain in you (this should be tailored to your specific situation but may mean annual clinical examination and ultrasound)
Thank you Dr Kirsty Seward for sharing your story and raising awareness on breast implant illness.
Full article + video at 👉 https://www.news.com.au/lifestyle/beauty/cosmetic-surgery/body-image-coach-reveals-how-implants-led-to-years-of-hell/news-story/7f781019023dd0715e42d9d75f5143c7
"Join Dr Andrew Browning, the Medical Director of the Barbara May Foundation, and one of the world's leading fistula surgeons, in an inspirational luncheon event at the beautiful Avoca Beach Surf Club.
Andrew and his family moved back to the Central Coast after their return from East Africa where Andrew, and his Aunt, Valerie Browning, run a range of maternal health programs and maternity hospitals for underprivileged women from remote and regional areas with all services provided for free."
Tickets 👉 https://www.trybooking.com/events/landing/929840
8-year-old textured Silimed implants removed because of new-onset seroma (fluid) around the implants. This is concerning for the possibility of Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL).
The fluid was seen prior to surgery on ultrasound and MRI scan. The implant was not ruptured on imaging.
The implant and capsule were removed intact - total intact capsulectomy. The capsule and fluid were sent off for testing.
ABOUT BIA-ALCL
1️⃣ Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a rare cancer of the immune system that occurs only in women with breast implants. It is not breast cancer, but rather a type of lymphoma that grows in the tissue capsule which the body has formed around the implant.
2️⃣ The risk of BIA-ALCL is significantly higher for "macro" textured (e.g. Silimed Polyurethane, Allergan Biocell) compared to "micro" textured (e.g. Mentor Siltex) implants.
3️⃣ The main symptoms of BIA-ALCL are persistent breast swelling or pain. It can also present as a lump in the breast or armpit. Most cases occur between 3 and 14 years after surgery.
4️⃣ Most patients with BIA-ALCL are cured by complete removal of the intact capsule with the implant contained inside.
*️⃣ If you have textured (or recalled) implants, it is important to have regular checks for as long as the implants remain in *️⃣
More on BIA-ALCL at https://www.drmaryling.com.au/breast-implant-complications
SNOWSTORM SIGN || Silicone from ruptured implants can migrate to the lymph nodes in the armpit and can appear like a ‘snowstorm’ on ultrasound. Can you see the resemblance? ❄️❄️
Latest study on Breast Implant Illness published in BMJ Open this month. The key findings are summarised above.
Link to full article: https://bmjopen.bmj.com/content/12/6/e057159
This research was financially supported by a research grant from the government (in the Netherlands).
BREAST IMPLANT STUDY ||
For ladies who are awaiting explant surgery, I strongly encourage you to participate in this Australian study focusing on adverse events related to breast implants (including capsular contracture, rupture, BIA-ALCL and breast implant illness).
Whilst is important to raise awareness on the harms of breast implants through sharing your stories on social media, it is also critical that we have clinical data from studies and trials (that are unbiased).
The study is open to all Australian women (irrespective of who your surgeon is), and here is the link: https://saferbreastimplants.org/breast-implant-removal/
*️⃣ Please enrol before your surgery, and also let your surgeon know so that the complete pre-operative blood tests and capsule tissue testing can be performed. *️⃣
Removal of bilateral breast implants & total capsulectomy
🔹 11-year-old McGhan implants
🔹 Submuscular location
🔹 Indication: BII symptoms
It’s amazing how the body responds to foreign bodies - the textured part of the implant has been walled off by 2 layers of scar tissue (double capsule), yet the smooth part with the implant details is completely free from scar tissue (black circle).
Making the most of this sunny rain-free weekend. Hope you are too. 🌞
Removal of bilateral breast implants & total capsulectomy
🔸 14-year-old Nagor implants
🔸 Submuscular location
🔸 Indication: BII symptoms
Incidental finding of intracapsular rupture on one side. This was not picked up pre-operative ultrasound but the patient had noted a change in the shape of her breast on that side.
The risk of rupture increases with the age of implants. So it is important to have ongoing implant checks for as long as the implants remain in.
Learn more about breast implant complications https://www.drmaryling.com.au/breast-implant-complications
BII: A Man's Perspective 👨🦰🧔
EXPLANT SURGERY FAQ || How long will my scars be?
The incision will have to be longer than the ‘length’ of your implants in order to remove the implant and capsule together (total intact capsulectomy - left in picture 2). A smaller incision can be used if the implant and capsule are removed separately (total capsulectomy - right in picture 2).
This is for women who are explanting without a lift via an incision under the breast (inframammary incision).
Learn more about breast implant removal surgery at https://www.drmaryling.com.au/breast-implant-removal
Removal of bilateral breast implants & total capsulectomy
🔹 9-year-old Silimed implants
🔹 Submuscular location
🔹 Indication: BII symptoms
Silimed Polyurethane implants consist of a layer of polyurethane foam on the outer surface of the silicone envelope (black arrows). These polyurethane-coated implants, also known as furry Brazilian implants, were popular due to their low rates of capsular contracture. However, these implants also have the highest rates for Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) - estimated risk of 1 in 2000-2500.
⚠️ If you have these type of implants, please make sure you have regular breast ultrasound (yearly) to check for complications. ⚠️
Silimed implants have been suspended in Australia since 2015.
Suite 6/16 Hills Street
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What to start with ?! Thanks to The Mad Platter Avoca Beach for catering lunch for the theatre team. The mushroom cutie pies were a hit.
😘😘 Happy Mother’s Day to all the mums of the world
BUSTING THE MYTHS ON CORONAVIRUS ||
A "LIVING BRA" || Nipple-sparing mastectomy & implant reconstruction with external oblique muscle flap 🤔 Why is the external oblique muscle flap called a 'living bra'? Have a read of the article published at ➡️ https://brisbanewatersprivate.com.au/news/2020/collaborative-breast-cancer-surgery ======== Dr Mary Ling (Breast Surgeon) and Dr Mihaela Lefter (Plastic and Reconstructive Surgeon) worked collaboratively to offer breast cancer patients immediate breast reconstruction with an innovative procedure involving nipple sparing mastectomy and implant reconstruction with external oblique muscle flap. Nipple sparing mastectomy involves removing breast tissue with preservation of the entire breast skin envelope including the nipple areolar complex. Following mastectomy, the external oblique muscle, the most superficial muscle of the abdominal wall, is harvested. The implant is positioned and covered by the pectoralis muscle and the ‘turned over’ external oblique muscle. The entire procedure is performed through a single incision, hidden in the inframammary crease, and with minimal long-term morbidity. Initially described by Little in 1981 as a ‘living bra’, the external oblique muscle flap is useful in both immediate and delayed implant based breast reconstruction. Compared to the more commonly used surgical meshes that lack its own blood supply, the external oblique muscle flap can provide a more robust protection of the implants against complications (including infection, extrusion and capsular contracture) and achieve a natural breast shape (with reduced implant visibility and palpability). “Having both Dr Ling and Dr Lefter work collaboratively for this ground breaking procedure, involving intricate reconstructive surgery, is fabulous for the hospital and the Woy Woy Peninsula community,“ said Kathy Beverly, CEO of Brisbane Waters Private Hospital.
🥰 Loving this pressie
NEW YEAR RESOLUTIONS || Today is the day that you are most likely to abandon your New Year fitness goals, dubbed 'Quitter's Day'. But here is one resolution you can keep ...
MONDAY MOOD || Who's feeling a little like this? 🙋♀️🙋♂️ #MondayMood HUGO the little boss
SWIMWEAR || Pauline Campbell, professional bra fitter from Leila O'Toole, answers commonly asked questions about swimwear after breast cancer surgery.
BRAS || Pauline Campbell, professional bra fitter from Leila O'Toole, answers commonly asked questions about bras after breast cancer surgery.
EXERCISE & BREAST CANCER || Twice world age duathlon champion Margaret Beardslee OAM shares the importance of exercise during breast cancer treatment.
SURVIVAL TIPS FOR BREAST CANCER || Seven Coastie women share their survival tips for breast cancer.
KEYHOLE HERNIA SURGERY || Ever wondered what your hernia looks like from the inside? 🤔 Learn more about hernia surgery ▶️ http://bit.do/keyholeherniasurgery #TheatreThursday #Hernia #HerniaSurgery #UmbilicalHernia #RecurrentHernia #KeyholeSurgery #HerniaSurgeon #LaparoscopicSurgeon Gosford Private Hospital Brisbane Waters Private Hospital Tuggerah Lakes Private Hospital
🎥 Last year, in partnership with Lymphatic Solutions, we created a video to raise awareness that early detection & intervention is effective for preventing breast cancer related lymphoedema.
BREAST CANCER RELATED LYMPHOEDEMA || Early detection & intervention is effective for preventing breast cancer related lymphoedema.
KEYHOLE HERNIA SURGERY || Reducing a cord lipoma during keyhole inguinal hernia surgery ... one of my favourite parts of the operation! A "cord lipoma" refers to a lump of fat that is associated with the spermatic cord in the male groin. It often occurs in conjunction with an inguinal hernia or may even be mistaken for a hernia. Symptoms of a cord lipoma range from none to a sensation of pain or discomfort to a lump. Learn more about hernia surgery: https://drmaryling.com.au/procedures/general-and-laparoscopic-surgery/hernia-surgery #Hernia #HerniaSurgery #KeyholeSurgery #HerniaSurgeonCentralCoast
Dr Mary Ling is a Specialist Breast Surgeon who is passionate about delivering the best breast cancer care to maximize life after cancer. She collaborates with the local multidisciplinary team to provide a personalised and coordinated treatment plan. She is also an advocate for using the least invasive surgical techniques to achieve the best oncological and cosmetic outcome.
Dr Ling is also an experienced General Surgeon, with expertise in gallbladder, hernia, gastric band removal, melanoma and skin cancer surgery. She is accredited to perform colonoscopies by the Gastroenterological Society of Australia.
Dr Mary Ling operates at Gosford Private Hospital, Brisbane Waters Private Hospital and Tuggerah Lakes Private Hospital.
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