Microsurgery Offers Better
Breast Reconstruction After Mastectomy
Robert M. Whitfield, MDMedical College of Wisconsin Plastic Surgeon
Three new options in breast reconstruction surgery offer more choices for women who have had mastectomies. Robert M. Whitfield, MD, is one of fewer than 40 surgeons in the country who perform these new microsurgery procedures regularly. He and John B. Hijjawi, MD, also a Medical College of Wisconsin plastic surgeon, perform these complicated surgeries together as a team.
Q. What are the latest options for women needing breast reconstruction after cancer surgery?The latest options for women needing breast reconstruction after cancer include a new series of tissue flaps referred to as perforator flaps. They are all abbreviated based on the perforator blood vessels, which come up through the muscle and supply the skin and fat overlying the muscle. There’s the SIEA (superficial inferior epigastric artery) flap, and the DIEP (deep inferior epigastric perforator) flap, which is commonly featured on the Internet. Those are the two most common types and both come from the abdomen. Another less commonly used flap is the SGAP (superior gluteal artery perforator) flap, which comes from the upper buttock tissue. The advantage to the patient in each procedure is that muscles are spared because just skin and fat are used to reconstruct the breast, along with the appropriate perforator vessel to supply blood flow when the fat is transferred to the breast area.
We do all the traditional techniques as well. Because we do microsurgery, we don’t limit people to just the traditional procedures. We feel these microsurgery procedures are better.
There are two systems — the superficial and the deep. The SIEA flap is like the Ferrari of breast reconstruction because it requires no muscle dissection. It’s based on blood vessels that are superficial in the abdomen, not deep. Only about 20 percent of women have the superficial system. We always look for these vessels when Dr. Hijjawi and I do the cases, and our goal is to use them whenever they’re available, if they’re of adequate size and character. We start out by evaluating that in the operating room. If we can’t use those vessels, then we go to the deep system, which is always there.
We look carefully at all the vessels and decide which we can use. We then take them up and attach them to either the blood vessels underneath the breastplate or to those in the armpit area. With the DIEP flap, as with the SIEA flap, no abdominal muscle is taken. We do our best not to take things we don’t need to take. You don’t have to sacrifice the muscle. The patient preserves her abdominal wall; for a woman of childbearing age, that’s very important. With these procedures, patients routinely return home four days after reconstruction surgery.
The SGAP is a flap that is taken from the upper buttock. It’s also based on a perforator vessel. You don’t take any of the buttock muscle, so it’s just skin and fat. If you’ve already had surgery on your abdomen and your abdomen’s not suitable for breast reconstruction, then this is an excellent alternative. I’ve used it for women who’ve undergone bilateral (both breasts) reconstructions or have had multiple abdominal procedures and can’t have the other flaps.
Q. How readily available are these options? All of these options are available at Froedtert & the Medical College. Their availability across the country is limited by the plastic surgeons’ expertise in different communities. Both Dr. Hijjawi and I underwent additional training in microsurgery. Dr. Hijjawi is only the third American surgeon to be honored with the Kroll Fellowship to study at University Hospital Gent in Belgium, which is one of the leading DIEP flap breast reconstruction centers in the world. In Europe, these procedures are more common than in our country.
Q. Who are the best candidates for breast reconstruction?The thing that limits women for these procedures is their own tissue. It’s not age-dependent. It’s a question of whether you have enough tummy tissue or upper buttock tissue to provide a suitable amount for breast reconstruction. It’s more difficult for bilateral (both breasts) procedures, especially if you’re thinner. This is one time when it pays to have excess tummy tissue.
Q. Is breast reconstruction an option for women who have had mastectomies in the past?Women seeking delayed breast reconstruction are ideal candidates. They’ve survived their cancer, had their surgery, dealt with the finality of having breast cancer, and they’ve gone beyond that. Now they’re interested in reconstruction, and they’re maybe more psychologically ready for that.
Q. Do some women change their mind and come back later to have reconstruction?Absolutely. It may be they’re having a difficult time in the beginning because they have so many things that they’re worried about. The number one thing is to treat the cancer. Breast reconstruction is an added benefit that we can take care of at any time. Our services are not dictated by timing — if it’s one, two, five or 10 years out — every woman is eligible, depending on her anatomy.
If you came to me and wanted this done and did not know whether or not you were going to have radiation therapy, I would say you should wait. It doesn’t mean you can’t have the procedure, but I would feel better for your long-term plastic surgery result. The main thing is to get the cancer taken care of, and we can always do the reconstruction later.
Q. How does it benefit someone to use a plastic surgery program that is affiliated with an academic medical center? We’re a team-oriented system. This is microvascular breast reconstruction, and we do it as team. We have two board-certified plastic surgeons providing this service in a multidisciplinary facility with a strong history of performing breast reconstruction.
As a team, Dr. Hijjawi and I perform reconstruction surgery together. We do one or two procedures a week and do microsurgery on a weekly basis for trauma and for other forms of cancer reconstruction after tumor surgery. We also do a lot of head and neck cancer reconstruction.
Q. What are the pros and cons of breast reconstruction surgery after mastectomy?In terms of the pros and cons of breast reconstruction surgery after mastectomy, it’s clear. Women feel better psychologically and emotionally. They can wear their clothing again, and they feel comfortable and whole again. A woman’s self-esteem can change dramatically after breast reconstruction. It helps women regain a sense of body image and restore a more feminine appearance. There’s no uncomfortable prosthesis to wear under their clothing.
On the con side, these procedures are more lengthy; the time considerations are not insignificant. It doesn’t change your overall risk, but the procedure for one breast can take from four to six hours. That’s with both of us working. If we do both breasts, it’s 10 to 12 hours. It’s a lot of time, but patients who have both breasts reconstructed still leave the hospital in four days. They’re not any worse for the wear because they’ve had both breasts done. Our best advocates are our patients, who will talk to any woman considering the procedure.
Q. Is there a difference between cosmetic surgery and reconstructive surgery? The reason for the procedure may be different. Cosmetic surgery usually means an elective procedure. Reconstructive surgery can be elective and also be medically necessary. For me, there is no difference. My practice is devoted to all forms of plastic surgery, whether it’s reconstructive surgery for trauma or breast cancer or aesthetic surgery. The goals are still the same for me in every case. I want everybody to have the best outcome regardless of what I’m doing. I give the same effort in every aspect of my practice.
Q. What other programs does plastic surgery tie into? We work with everybody. We work with general surgeons, otolaryngology surgeons, head and neck surgeons, orthopaedic surgeons and neurosurgeons. There really isn’t anybody we don’t work with in surgery. It’s very important that we have good relationships with everybody. In a large academic medical center like this, it’s key and a huge advantage for patients.
Q. How long have these new procedures been around? Microsurgery has been around since the 1980s. The DIEP flap was first done in 1989 in Japan by Koshima, a famous Japanese plastic surgeon. In this country, the first one was done in 1994. It hasn’t caught on as much in this country because it takes more time and it uses a microscope. We’ve been doing them at Froedtert & the Medical College since 2005, when I joined the practice.
Source: Every Day, interview with Robert Whitfield, MD
Date: Jan. - April 2007