Thursday, July 5, 2007

Plastic Surgery - Breast Reconstructions

So my second week has been spent doing much of the same as the previous week - rounds first thing in the morning and OR cases for the remainder of the day. Rounds are starting to get less hectic and more fun because I actually know what’s going on now and can interact with the actual doctors…and the patients for that matter. The patients actually trust me and ask my opinion on medical matters, which is always interesting…

As for the OR, breast reconstructive surgery is by far the most common procedure for plastics…or at least from what I have experienced. There are probably 2-3 procedures every single day, without fail…it’s actually pretty humanizing when you step back for a second and reflect on it – for example, by writing this blog entry. I guess what I’m trying to say, is that the OR cases are the fun and exciting parts of our day (or at least mine) and we (or I) view them as just another fun spectacle; however, being in a hospital, most, if not all of these patients are here because they are really sick. Yet, as mere observers, it’s our entertainment. So, in my case, these 2-3 patients a day…yeah, they all have cancer. It really is an eye-opener. According to the American Cancer Society women in the United States have a 1 in 8 lifetime chance of developing invasive breast cancer… that is also expected to take almost 41,000 lives and much more worldwide…somehow, those numbers just seem so much more real now that I look it in the face every single day.

On the other hand. Due to advances in medicine and science, many patients with breast cancer survive AND can have breasts surgerically created to resemble a natural breast in form and appearance. I’ve heard and seen many patients first-hand that are very pleased with the results of the surgery. Anyway, I have digressed from anything remotely science oriented. I suppose I should provide some details on this procedure since it is basically all I have written about today.

Bilateral Mastectomy with Breast Reconstruction

As the name suggests, breast reconstruction is simply the surgical rebuilding of a breast to create a natural looking one, typically involving reconstructing the areola and nipple as well.

Usually the procedure starts with the general surgery team making an incision around the nipple and continuing it laterally to form enough of a hole to remove the entire breast. The underlying breast tissue (including the nipple, but usually leaving the areola) is then separated and removed from the pectoralis major via a bovie (the electric knife). Before the plastics team arrives, the removed tissue and remaining margins are probed with essentially a Geiger counter. Honestly, I’m not really sure what is a high or low number, the thing seems to go crazy no matter what. However, the removed tissue is always much higher than the remainder (obviously). They use a Geiger counter probe because the patient is injected with a radioisotope before the procedure starts. This radioisotope translocates to the lymph nodes and is imaged to show the surgeons approximately what needs to be removed. The probe is used mostly as a double check.

When the plastics team arrives there are no breasts left…just an empty cavity. However, it is their job to recreate what was lost. Unfortunately, that involves multiple operations. So, they begin by separating the pectoralis major from the underlying fascia. Next, with the aid of some wonderfully engineered biomaterials, a temporary, partially saline-filled, tissue expander is placed under the pectoralis major muscle of the chest wall. In subsequent procedures, the tissue expander is incrementally filled with more saline to sketch out the overlying tissue. This in turn, allows for enough slack to eventually surgerically insert a real silicone or saline implant, all the while subjecting the tissue to minimal tension.

Notice that many subsequent operations are needed to complete this overall procedure… such as nipple and areola reconstruction. Also, keep in mind that once the implants are secured and the wounds perfectly healed the end of the road is still up ahead. It is a common misconception that implants will essentially last a lifetime (perhaps this would be a nice invention). However, the reality is that even after all of these procedures, each woman will most likely have at least one, if not more, additional maintenance follow-up surgeries due to any number of reasons from simple aging to a failed implant. Sad.

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