I had the opportunity to attend the American Society of Reconstructive Microsurgeons meeting recently. As a patient advocate attending, I was particularly focused on microsurgery in breast reconstruction after mastectomy. It gave me the chance to have in depth conversations with plastic surgeons who dedicate intense hours of training to become microsurgeons. The conference attendees included medical students interested in this specialty, plastic surgeons who are currently in fellowship training for microsurgery, and those seasoned veterans sharing the latest techniques and methods of surgical skills to achieve optimal outcomes for patients.
The ASRM conference took place at a hotel with all of the sessions easily accessible. This conference felt comfortable, informal, and intimate to me. These microsurgeons reflected the feeling, this group is like a small tribe who understand the rigors of microsurgical training and how it can positively change the lives of patients.
Why Should you Find a Microsurgeon for Autologous Breast Reconstruction?
One of the unique differences between plastic surgery and microsurgery is the highly specialized training it takes to sew blood vessels, nerves, and lymphatic vessels together under high powered microscopes. Implant based reconstruction can be performed by a plastic surgeon without the use of this specialized instrumentation. As always, I encourage others to seek board certified plastic surgeons to perform their surgery.
If you are considering autologous breast reconstruction, using your own tissue, it is imperative to find a board-certified microsurgeon. The transfer of any flap tissue from one part of your body to the breast area has a blood source. It also has nerves. These blood vessels and nerves are all in areas within the tissue and must be carefully dissected out so as not to damage them when they are transferred to the breast area.
The blood vessels from the flap, typically the tummy as in a DIEP flap, are very small, as small as just a few millimeters in diameter. The thread, or suturing material, used to sew these vessels together is finer than most human hair. Attached to a needle, the microsurgeon uses instruments to hold the small, curved, needle and do what is called anastomosis, tying the vessels end to end together. This can only be done under high-powered magnification.
Perfecting the Skill of Microsurgery in Breast Reconstruction
I was fortunate to be able to experience the intricacy, and eye-hand coordination required to become a highly skilled surgeon rebuilding breasts for those who have been affected by breast cancer. At the conference, they set up a station called, “Sewing with the Masters”. It was a truly eye-opening experience for me, literally and figuratively.
Dr. David Greenspun was the surgeon who so patiently worked with me. First, I had to get used to the view under the scope. Coordinating the magnification and properly holding the instruments was my first challenge. He helped place the instrument in my hand with the fine suturing material and needle attached. I wouldn’t have been able to even master that and he knew it. This microsurgeon has the patience of an oyster, working diligently with me to reveal the pearl…getting the first surgical knot tied!
The Team Effort in Microsurgery under the Scope
Next, I sat across from Dr. Greenspun to work with him on tying the blood vessel together. If you think working alone is challenging under these high-powered scopes, try doing it with someone who is on the other side of the microscope. Whether a microsurgeon is working with another microsurgeon on his team, a PA (physician’s assistant), or training someone in their fellowship, this is team work on steroids! I know they learn to work seamlessly together but it was a quiet, slow, methodical process. Just tying the surgical knot for me was a herculean effort.
The ultimate goal is to get the end to end anastomosis done to perfection. Why? Once complete, the blood must flow through this newly formed vessel smoothly. This is what supplies the blood source to the new breast. A monitor is placed on the flap to make sure no kinks occur or blood clots form.
There are a number of other important skills microsurgeons must train for. However, perfecting the skill of the end to end anastomosis under these high-powered microscopes has to be at the top of the list in my mind.
A huge shout out to Dr. David Greenspun for his patience and guidance. Experiencing the rush of “being under the scope” gave me a great deal of understanding and appreciation for the specialty and role of microsurgery in breast reconstruction after mastectomy. Love my DIEP flap!
Thank you, Terri, for an informative article. I had this surgery in May 2019, but it was one of the 1-2 percent failures due to several infected mammary lymph nodes, which impeded the blood flow to the transplant site. My surgeon was a competent university professor, but it was something he could not have foreseen. I chose the surgery because my breast was previously radiated and an implant was risky. My advice: ask questions, expect a long recovery, and consider a latissimus flap surgery (a back muscle) which is not a transplant but swings the muscle under the armpit to make a breast.
Sheri, thank you for sharing your story. In a perfect world… right? I am sorry you experienced this. Flap failure is the biggest fear for patients, what microsugeons work hard not to have happen, but in reality, there are no 100% guarantees. As you stated, there are alternate flaps in breast reconstruction. The ravages of breast cancer treatment, radiation as you stated, have long-lasting effects on skin and underlying tissue making it very challenging for surgeons. I couldn’t agree with you more about asking a lot of questions, including, what are my alternatives if there is a flap failure? The LAT flap is a good choice for many. I wish you continued good health and again, thank you for sharing your story and comment. ~ Terri