Giving Cancer Patients a Whole New Look

 

At his home in Fresno, Texas, A. J. Berg often takes a ride on his Harley Davidson.

 

 

For more than a year after he lost his nose and upper lip to cancer, 69-year-old A. J. Berg hid from the public, not wanting to be seen by anyone but his family - and even that was difficult at times.

 

"It was a nightmare," he recalls. "I had to wear a bandage all the time."

 

As the owner of an automobile dealership, Berg found it hard to face his customers. "I just couldn't. I didn't want the questions or the stares," he says.

 

To keep his business going, Berg said his son did most of the outside-the-shop chores, while he worked behind the scenes, handling the business-end of things. Aside from his staff and family, he basically kept to himself.

 

Grappling with his facial deformity and lowered self-esteem, Berg was about to give up on ever looking "normal" again when he was encouraged to have reconstructive surgery.

 

Thanks to surgery and improved, life-like prostheses, Berg got a new lip and a nasal prosthesis. He also got a new lease on life. "I now can go back into public, go to restaurants and meet with customers without feeling self-conscious. It has been great."

 

 

"It's our job to restore form, contour and function of the specific part of the body that was removed so people can feel better about themselves." - Dr. Geoffrey L. Robb

 

 

For decades, plastic surgeons at M. D. Anderson have been rebuilding lives devastated by cancer.

 

"As reconstructive surgeons, it's our job to restore form, contour and function of the specific part of the body that was removed so people can feel better about themselves and re-integrate back into society," says Dr. Geoffrey L. Robb, chairman of the Department of Plastic Surgery. "It is our goal to maximize a patient's life - rehabilitating them physically, psychologically and socially."

 

With the advent of microvascular surgery in the 1980s, surgeons have been able to reshape patients' lives more than ever before. Restricted to using regional flaps in the past, they now use the microvascular method to move tissue, muscle, fat and bone, along with their vital blood vessels, as free flaps from distant parts of the body to fill a defect.

 

These free flaps, Dr. Robb explains, provide a better blood supply to the defective area than regional flaps and are a more reliable source of tissue transfer, with a failure rate of only about three percent. They also speed primary healing, which allows patients to recover more quickly and resume necessary cancer treatments, and result in better cosmetic and functional outcomes.

 

The reliability of free flaps used for wound coverage also has enabled surgical oncologists to do more extensive surgery, removing tumors that were once deemed inoperable.

 

In the future, Dr. Robb says, the use of autologous tissue may be replaced by "home-grown" tissue. Through tissue engineering, plastic surgeons have the potential to grow specific tissues for reconstruction and then apply them as free-flap transfers. This technique would eliminate the need to remove large amounts of tissue from specific donor sites, therefore reducing the morbidity of using a patient's own tissue.

 

While free flaps can be used to reconstruct any defect, they have been particularly beneficial in head and neck, and breast reconstructive surgery.

 

Just over a decade ago, the primary regional opportunity for reconstructing a head and neck defect was the pectoralis major (chest wall muscle). To fill a defect, surgeons would stretch and rotate the chest muscle up to the designated area, leaving the muscle and its blood vessels intact.

 

"Although this technique was a big advantage over what was available before, it was not particularly functional or aesthetically pleasing because it tethered a patient's head and restricted movement, and it left a bulky pedicle in the neck. In addition, the blood supply to the tip of the flap was often unreliable, resulting in complications," says Dr. Stephen Kroll, professor of plastic surgery.

 

The availability of distant free flaps, however, allows surgeons to select the most appropriate tissue(s) for specific types of head and neck reconstruction, ones that enhance appearance and optimize function.

 

Depending on the area that needs to be repaired, they may use a thin, pliable tissue like the skin beneath the forearm to reconstruct a tongue, the mouth floor, or cheek and orbital socket area. They also may use a thick tissue such as the rectus abdominis or lattismus dorsi (back muscle) to repair facial and laryngeal defects. In addition, a section of the small bowel may be used to reconstruct the cervical esophagus or the fibula and overlying skin of the leg may be used to reconstruct a jaw.

 

While plastic surgeons have limits in repairing a defect, their work often is complemented by the use of sophisticated, well-crafted prosthetic devices. "Sometimes a patient loses an eye or teeth to cancer. We can't replace those features, but we can provide a structural foundation to support certain prostheses such as dentures or an artificial eye. It takes a team effort from plastic surgeons to prosthodontists to help patients regain a close-to-normal appearance and optimal functioning," Dr. Robb says.

 

For Debbie Falgout, losing a breast to cancer was devastating. Living without a breast for more than a year after her mastectomy also was emotionally difficult.

 

"I lost a part of me," the 43-year-old says. "I didn't feel the same anymore. I felt uncomfortable around my friends and I was ashamed to wear certain clothes, particularly a bathing suit. Always outgoing, I found myself retreating from doing the things I used to enjoy."

 

After growing tired of wearing a prosthesis, Falgout decided to have breast reconstructive surgery. "I wanted to feel feminine and good about myself again."

 

Falgout is one of many breast cancer patients who has benefitted physically and psychologically from the advancements made in breast reconstruction. Microvascular surgery, immediate breast reconstruction and breast conservation all have contributed to better reconstructive outcomes and improved quality of life for women, Dr. Robb says.

 

Skin-sparing mastectomies, for instance, "have allowed us to go to the pinnacle of reconstruction because the eggshell of the breast, which was routinely sacrificed, is spared," Dr. Robb says. "This skin creates a nice envelope or 'skin brassiere' for us to fill with reconstructive tissue. With this foundation intact, we can build a more natural-looking breast and one that closely resembles the existing one."

 

While breast implants are still used today, the most popular reconstruction performed is the TRAM (transverse rectus abdominis myocutaneous) flap. Better known as the "tummy tuck," this technique involves the transfer of fat and muscle from a woman's abdomen to the chest wall. Although free flaps from the back, hip and buttocks also can be used, the TRAM flap is considered the best because the abdominal tissue most resembles the texture of a normal breast, according to Dr. Kroll.

 

"As opposed to implants, breasts reconstructed with autologous tissue will look, feel and move like a normal breast, as well as change size if a woman loses or gains weight," Dr. Kroll says. "Breast implants don't offer this same quality. Typically, they are less soft, less natural and more subject to change over time.

 

"The results we get from the TRAM flap procedure can be wonderful," Dr. Kroll adds.

 

Falgout, who had a bilateral TRAM flap reconstruction, concurs. "When I first saw my breasts after the surgery, I was totally amazed. They were beautiful. I finally felt like one of the girls again!"

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