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Restoring the body, renewing the spirit

Conquest - Fall 2012

Reconstructive plastic surgeons ready patients to face life after cancer

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By Julie Penne

Geoffrey Robb, M.D.,
chair, Department 
of Plastic Surgery
Photo: Medical 
Graphics and 
Photography

They are elegant artisans in the operating room.

Using sophisticated operating microscopes and instruments, MD Anderson’s reconstructive plastic surgeons carve bones into new structures, reattach thread-like blood vessels and transplant harvested tissue as new scaffolds for cratered parts of the body.

Back away from the complex tools, and their work reveals a new jaw, esophagus, breast, nerve graft, skin cover, eye socket or other structures to restore form and function for a patient.

Step even farther away from the scene and observe patients’ new self-assurance and outlook because of the ability to speak, swallow, attend school, return to work or continue treatment.

Since the introduction of modern microsurgery in the 1970s — that enabled blood vessels and tissue to be transferred from one part of the body to another — the Department of Plastic Surgery has become a global hub for innovation, multidisciplinary collaboration, research and training.

What distinguishes the group and its practice from the plastic surgery norm is the commitment to restoring the patient’s health, function and form — goals that go well beyond a cosmetic outcome.

“Any procedure we do will have a cosmetic element, but reconstructive plastic surgery at MD Anderson contributes to patients starting new lives after their cancer,” says Geoffrey Robb, M.D., professor and chair of the Department of Plastic Surgery. “We’re driven to constantly improve our techniques, skills and technologies but we also must be attuned to the biology and treatment of cancer so we can work alongside our colleagues, complement their work and improve outcomes.”

Research changing and influencing patient care

The number of MD Anderson reconstructive plastic surgeons has grown from 11 in 2002 to 19 in 2011. In that same period, total cases have soared from 1,505 to 4,260. Breast reconstruction is the most common procedure, with head and neck reconstruction second.

The team’s growth and expertise have fueled research, stoked the internationally acclaimed fellowship program and encouraged greater collaboration with a wide range of other disciplines.

Thomas Buchholz, M.D. (left), head of the Division of 
Radiation Oncology, and Steven Kronowitz, M.D., 
work together to fill Kristin Fenetz' expanders as she 
prepares for radiation treatment.
Photo: Wyatt McSpadden

In the coming year, reconstructive plastic surgery will be offered at the institution's regional care centers.

Through the decades, these surgeons have contributed significantly to MD Anderson’s body of research that has changed or influenced the standard of care.

Discoveries include limb-sparing surgery for bone tumors and sarcomas, a new flap strategy for pharyngeal reconstruction and clinical guidelines for determining the best approach for reconstruction on patients who have had a total or partial mastectomy and who may need radiation.

Steven Kronowitz, M.D., professor in the Department of Plastic Surgery, has led a number of the groundbreaking studies that enable more women to wake up from their mastectomies or lumpectomies with a breast.

Today, with skin-sparing breast surgery and the use of tissue expanders, breast implants are positioned at the time of a full or partial mastectomy and filled when the time is clinically appropriate, even if the patient is scheduled for radiation.

According to Kronowitz, it now is common for radiation oncologists to observe or assist with filling or deflating the expanders so the precise size will correspond with the treatment plans.

Before the research, as late as the 1970s, women would have their breast or tumor removed but often were unsure if they would need radiation later. Reconstruction often was delayed for years, so it would not hinder possible follow-up treatment.

“With this new standard of care, women don’t have to go back to the dark ages,” Kronowitz says. “They can wake up from surgery with a breast and still have the necessary follow-up care without any difference in survival.”

Kronowitz and his colleagues also are exploring new reconstruction techniques after a partial mastectomy. Though lumpectomy is common, more research is needed on maximizing the remaining tissue for rebuilding the breast.

Matthew Hanasono, M.D. (left), and Roman Skoracki, M.D., 
helped develop software that gives plastic surgeons more 
precise dimensions for creating new facial structures.
Photo: Wyatt McSpadden

3D aids precision

Another area of research is in jaw replacement and reconstruction in which Matthew Hanasono, M.D., and Roman Skoracki, M.D., both associate professors in the Department of Plastic Surgery, are collaborating.

The two have helped develop software that uses MRI or CT scans to model the patient’s jawbone and surrounding structures in 3D, providing precise measurements for surgeons in the operating room.

Using the software in their planning, the surgeons employ the model to shape the patient’s fibula (a leg bone) into a new jaw. The meticulous measurements taken in advance can reduce time under anesthesia and result in a jaw that improves the patient’s appearance and ability to chew and speak.

MD Anderson performs more jaw reconstructions than any other center in the nation, but, for now, the experimental modeling is used only in the most complex cases.

Hanasono, like Robb, trained first as a head and neck surgeon. Along with his colleagues, he now operates on patients who face severe disfigurement and function loss.

David Chang, M.D., professor in
the Department of Plastic Surgery,
emphasizes that preparation is
key for surgical cases. "If the
surgeon removing the tumor runs
into problems, how can they fix
it? If the cancer is more 
widespread than thought, what's 
the plan? What if the bone I want 
to use is not in good shape? 
Preparation and working closely 
with colleagues early on are key."
Photo: Wyatt McSpadden

“I wanted to do the most challenging reconstructive surgery and that was in head and neck,” says Hanasono, who, with Skoracki, leads the largest fellowship training program in reconstructive plastic surgery in the world. “We see patients at their best and worst, but the motivation they show is inspirational. We don’t count out anyone.”

A change in patient care

Other reconstructive plastic surgeons and their teams also have research under way on lymphedema and the use of robotics. They are also exploring new approaches for treating skin conditions, restoring erectile function through nerve reconstruction and growing tissue in the laboratory.

Randal Weber, M.D., professor and chair of the Department of Head and Neck Surgery, and Mark Chambers, D.M.D., professor in the department, say that new reconstruction techniques have changed the way they approach their patients’ care.

“Knowing that the reconstructive plastic surgeons on our team have top-level expertise and tools allows my colleagues and me to access and remove tumors we may never have tried before,” Weber says. “Knowing that patients can have quality of life after major head and neck surgery gives me additional flexibility, and that can mean a better outcome for a patient.”

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