When you have cancer, hospital gowns feel like curtains at a theater in the Twilight Zone. The drama when the curtains parted this time was not about amputating my breasts. It was about considering that another part of my body could be used to replace them.
The medical director of the Baptist Health Breast Center, Dr. Robert DerHagopian, looked at my abdomen and said, “let’s see if there is enough.” He then grabbed the excess fat that I am most ashamed of and my abdomen muscle with both hands.
“There is not enough,” said Derhagopian, also known as Dr. D. “Check again. I can assure you can find plenty of fat there,” I said jokingly. He remained serious and said, “They can also remove ...”
I couldn’t hear the rest. His voice slowed down, and all I saw was his hand pointing to my behind. I panicked.
He was referring to the use of a flap — tissue from elsewhere in the body — for breast reconstruction.
There are many different types of procedures of this kind. The TRAM (Transverse Rectus Abdominus Myocutaneous) flap procedure uses tissue from the abdomen. The DIEP (Deep Inferior Epigastric Perforator) flap uses tissue from the abdomen but preserves the muscle. The SGAP (Gluteal Artery Perforator) flap uses tissue from the buttock area. And I decided no surgeon was going to touch that.
Fear boiled into anger. I love my body. I would usually run for my life or fight if any one dared to come at me with a knife, but there was an enemy inside me, and fighting it required Derhagopian’s ability to cut and slice. It is no wonder so many breast cancer survivors in Miami love him.
Weeks after that visit, while I recovered from chemo in bed, I turned to YouTube to try make sense of the situation. Dr. Gordon Lee, director of microsurgery at Stanford Hospital, explained the procedures during a lecture earlier this year.
He described the TRAM flap procedure as being “very similar to what is done in a tummy tuck, but in a tummy tuck where the tissue is not discarded. This tissue is saved with its blood supply and transferred to the chest region to make a breast. it does rely on circulating vessels to allow this tissue to be living tissue.”
Patients who have insufficient amount of tissue in the abdomen, prior abdominal liposuction, or prior abdominal operations with excessive scars are not good candidates for the TRAM Flap. A risk with the TRAM flap is that once “the muscle is gone, it never grows back. That can lead to weakness of the abdominal wall, hernias and bulges,” Lee said.
Patients who have had abdominal surgery are candidates for the DIEP flap, but only if they have abdominal fat to spare, and they are not smokers. A good candidate must also have adequate sized blood vessels, which cannot be determined accurately before the operation. The DIEP flap procedure, which Lee referred to as “the Cadillac of all surgeries,” requires that a doctor use a microscope to hook up the blood vessels from the belly tissue to the chest.
Out of all of the other options for reconstruction, a flap “has the greatest longevity,” said Lee. “If you gain weight and you tend to gain weight in the abdomen region you will actually gain weight in your breast tissue.”
At the Miami Breast Center, Dr. Roger K. Khouri also likes the way transferred fat works on the breast. He has performed hundreds of flap procedures, but said he no longer recommends them.
“TRAM flap is a patch. TRAM flap is 20th Century surgery,” said Khouri. “You do get the benefit of an abdominoplasty, if you need a tummy tuck, but it is a huge operation with a longer recuperation.”
The procedure requires about eight hours. The patient’s hospital stay could last up to six days, and the recovery time could lengthen to about six weeks. Patients generally feel more discomfort on their abdomen than on their chest.
Khouri is training surgeons from around the world on a procedure that has not been approved by the Food and Drug Administration, but he believes is the best option for reconstruction.
“TRAM flap was good for women who didn’t want a foreign body,” said Khouri. “Now we can build an entire breast from your own fat without having to undergo a major surgery.”
Plastic surgeons Angela Fausto Souza and Patricia Breder de Barros flew from Rio de Janeiro to attend Khouri’s Micro-Fat Transfer course in Key Biscayne. They were skeptical.
“TRAM flap is the most common form of living tissue reconstruction,” said Breder de Barros. “We are having great results with it.” Her colleague Fausto Souza agreed, “it has helped a lot of women in Brazil.”
Breder de Barros said there is really not a perfect solution for breast reconstruction. Fausto Souza said choosing a method of reconstruction is a very tough decision for a woman to have to make.
“I can foresee a day when a mastectomy won’t be necessary and reconstruction can be less traumatic because of oncological improvements,” said Breder de Barros. “The day when we won’t need to be having this discussion will come.”
In the meantime, my mastectomy will happen on Thursday.