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Surgical oncology & reconstructive surgery

Our surgical oncology department

The Department of Surgical Oncology at Cancer Treatment Centers of America® (CTCA), Atlanta, provides a variety of surgical procedures to treat cancer and cancer-related symptoms.

Because many of our patients come to us with complex and advanced-stage cancers, the surgical oncology team is experienced in providing a wide variety of surgical procedures for all types and stages of disease.

Your surgical team

Your surgical oncology team includes surgical oncologists and surgeons with advanced training in various surgical techniques, as well as nurses, surgical technicians, anesthesiologists and other cancer professionals with diverse expertise in treating all types and stages of cancer. We work closely with you to find surgical options tailored to your individual needs and preferences, to help you feel confident in and comfortable with your treatment decisions. What to expect:

Before surgery, we will explain what you can expect, answer your questions and help you feel comfortable with the upcoming procedure.

During surgery, our pathologists can evaluate tissue samples as they are removed and provide pathology results immediately. This helps your surgical oncology team remove as much cancerous tissue as possible during surgery, reducing the likelihood that you will have to undergo multiple surgeries.

After surgery, your care team will work with you to help prevent and manage side effects. You may also have reconstructive surgery to restore appearance or function.

Innovations in surgery

Our experienced surgeons have performed thousands of procedures and will discuss the surgical options designed to fit your individual needs. We also provide minimally invasive surgical procedures, which may help reduce side effects and recovery time.

Whether a patient is a candidate for surgery depends on factors such as the location, size, type, grade and stage of the tumor, as well as the patient’s age, general health and other factors. The goal of surgery may be to remove the tumor (e.g., excisions, resections, debulking surgery), reconstruct a part of the body (e.g., restorative surgery), and/or to relieve symptoms such as pain (e.g., palliative surgery).

For some patients, surgery may be combined with other cancer treatments, such as chemotherapy, radiation therapy or hormone therapy, administered before or after surgery to stop cancer growth, spread or recurrence.

Early in the treatment planning process, we plan for and proactively manage side effects from surgery. Our nutritionists, rehabilitation therapists and naturopathic clinicians work together with your surgical oncologist to support your healing and quality of life. Our reconstructive surgeons perform procedures to restore the body's appearance and function, often at the time of surgery or following surgery.

The surgical oncology team at CTCA Atlanta

Led by Chief of Surgery Gary Bernstein, MD, the Department of Surgical Oncology at CTCA® Atlanta is staffed by surgical oncologists, as well as anesthesiologists, surgical technicians, physician’s assistants and wound care-certified registered nurses.

"We make sure that our patients have a full understanding of their cancer, treatment options and the surgery that they are about to have," says Dr. Bernstein. "We talk to them openly and honestly in a compassionate way and give them a full understanding of what to expect."

An individualized approach

For our surgeons, formulating an individualized treatment plan begins with a thorough review of your medical records prior to your visit to CTCA, coupled with the findings of our intake clinicians. Your surgical oncologist will also examine lab findings and imaging studies, and meet with other members of your care team.

“Our goal is to do a thorough evaluation so we can pull together the entire picture to gain an accurate understanding of the stage and complexity of the disease,” explains Dr. Bernstein. “We then use that information to make an assessment about whether surgical treatment is appropriate.”

Improving quality of life

While removing malignant tumors is the primary objective, the surgical oncology team at CTCA Atlanta also understands the importance of quality of life. Through various procedures, your surgical oncologist strives to help alleviate pain (e.g., palliative surgery), maintain your self-confidence (e.g., reconstructive surgery) and preserve normal function (e.g., limb-sparing surgery).

Throughout your treatment, you will also receive supportive care services to help reduce cancer-related fatigue, functional impairments and other side effects to help you maintain your quality of life during treatment.

The Advanced Surgical Recovery Program (ASURE) at CTCA Atlanta

Led by Surgical Oncologist Kevin Watkins, MD, and Neil Seeley, MD, Chief of the CTCA Division of Anesthesia, the Advanced Surgical Recovery (ASURE) program at our Atlanta hospital includes surgeons, anesthesiologists, nurses, physical therapists, pain management physicians, registered dietitians, naturopathic clinicians and other supportive care clinicians. “The ASURE program is designed to help patients recover from surgery faster, with shorter hospital stays and fewer complications,” says Dr. Watkins. “For cancer patients trying to complete treatment, it may also mean getting through their journey faster.”

Our Breast Surgical Oncology and Breast Reconstructive Surgery Program

Breast Surgical Oncologists Elizabeth Min Hui Kim, MD, and Anita Johnson, MD, FACS, work collaboratively with our plastic and reconstructive surgeons and the rest of the multidisciplinary oncology team to develop each patient’s surgical care plan. Plastic & Reconstructive Surgeon Fred Durden, MD, leads the breast reconstruction program at CTCA Atlanta. Dr. Durden is double board-certified by the American Board of Plastic Surgery and the American Board of Otolaryngology-Head and Neck Surgery, and completed a fellowship in microsurgical reconstruction. Drs. Kim and Johnson are fellowship-trained Breast Surgical Oncologists providing advanced surgical techniques, such as oncoplastic surgery, which combines principles of plastic surgery with cancer surgery, such as nipple-areola-sparing, areolar-sparing and skin-sparing mastectomies for cancer patients, as well as those determined to be at high-risk for the disease. Our breast surgical team also provides surgical techniques that may help reduce a patient’s risk of lymphedema and improve quality of life.

Nipple-areola sparing mastectomy: This procedure keeps intact the nipple and areola, and preserves the breast skin, but removes the breast tissue. Unlike a traditional mastectomy, it preserves a thin layer of fat and blood vessels needed to maintain adequate blood flow and protect the skin’s viability. Because most of the nerves are removed during the mastectomy, the preserved skin and nipple often become permanently numb. A nipple-sparing mastectomy, combined with immediate breast reconstruction, may produce a reconstructed breast that looks similar to the original breast, with the skin and nipple intact.

Skin-sparing mastectomy: This technique involves removing breast tissue while preserving the outer skin. This less-invasive approach to a mastectomy helps preserve the breast’s natural contour and shape while reducing the risk of scarring. Reconstruction options following a skin-sparing mastectomy include silicon or saline breast implants and autologous fat grafting or tissue transfer. While both procedures use the body’s own cells to reform the breast, fat-grafting techniques transfer fat cells from other areas of the body, while tissue transfers transplant tissue from the abdomen, back, buttocks and other regions.

Our breast center team offers a variety of techniques to help restore the appearance of the breast and nipple area. The team has expertise in the wide array of breast reconstruction techniques, including options for patients with weight concerns due to very low or very high body mass index.

Changes to your body may raise concerns about sexuality and femininity. Our goal is to provide you with an interdisciplinary team that can address non-surgical needs, as well. Our breast surgical team works closely with clinicians who offer evidence-informed therapies, including mind-body therapists, oncology rehabilitation providers, licensed dietitians, counselors, lymphedema-certified therapists and other clinicians, to offer advice, resources and therapies to support your overall well-being.

Breast ASURE: Dr. Kim and Dr. Seeley developed our Enhanced Surgical Recovery Program for breast cancer patients. This program aligns with the American College of Surgeon’s effort to provide a patient-centered, evidence-based, multidisciplinary team approach to care before, during and after surgery.

At CTCA Atlanta, we recognize that treating breast cancer patients involves more than removing the tumor. Our plastic and reconstructive surgeons work closely with our breast surgical oncologists to provide quality surgical care for our patients. Breast cancer treatments can change how patients look, feel and function. The decision to have breast reconstruction surgery is personal and involves a thorough discussion with a plastic surgeon who partners with you to achieve your goals. For many women, restoring the appearance of one or both breasts may benefit their physical and emotional recovery.

You may consider breast reconstruction:

  • To improve symmetry if only one of your breasts is affected
  • To help restore confidence in your appearance and sense of femininity
  • If you think reconstruction will give you a sense of wholeness or psychological well-being

Candidates for breast reconstruction have been:

  • Diagnosed with breast cancer and have undergone, or plan to undergo, breast conservation surgery, such as a partial mastectomy or lumpectomy
  • Diagnosed with breast cancer and had a mastectomy
  • Diagnosed with a genetic mutation or are at very high risk of developing cancer in the future, and plan to have a prophylactic mastectomy

Our breast reconstruction surgeons

At CTCA, our plastic and reconstructive surgeons will discuss your breast reconstruction options before or after a lumpectomy or mastectomy is performed, when appropriate. This conversation is designed to help you make more informed decisions about your care. Our surgeons are trained to revise misshapen breasts and/or improve breast symmetry that may result after a cancer treatment. They also treat cancer patients who have decided to postpone reconstruction after radiation therapy. Women who seek breast reconstruction typically want a natural-looking breast that is symmetrical with the unaffected breast, and reconstruction can occur immediately at the time of the cancer operation or after chemotherapy and/or radiation are complete.

Overview of breast reconstruction

Breast reconstruction options may include reshaping techniques to reduce defects or improve symmetry; implants-based reconstruction; or microsurgical procedures using the patient’s own skin and tissue (autologous techniques). Recommendations may vary based on many factors, including the location and size of tumors, body mass index, smoking status and chronic diseases such as diabetes. A consultation with a plastic and reconstructive surgeon may provide valuable insight into questions like whether you are a good candidate for the surgery, as well as details about your options and what timing is appropriate for your needs.

Types of reconstructive surgery include:

Immediate breast reconstruction: When appropriate, some women may choose immediate reconstruction of their breast(s) at the same time as their mastectomy. This is not an option for patients requiring radiation therapy.

Advantages

Disadvantages

When the breast skin is preserved, it often produces a more natural appearance.

Longer hospitalization and recovery times may result when compared to mastectomies performed alone.

It may lead to fewer surgeries.

More scarring may result than with a mastectomy alone.

Some patients report a psychological benefit to immediate reconstruction over delaying the procedure.

 


Staged breast reconstruction:
This option rebuilds the breast in several stages to reduce the risk of complications. Many women who require radiation therapy may be advised to have staged breast reconstruction, such as an immediate tissue expander instead of immediate direct implant reconstruction. Once radiation therapy is complete and the tissue has recovered, the expander used to maintain the shape of the breast is removed and replaced during final reconstruction, either with the patient’s own tissue, transplanted from a donor site or a silicone or saline implant.

Advantages

Disadvantages

Allows any needed treatment, such as radiation, to begin after mastectomy.

Waiting for reconstruction requires patients to live for a time without breasts, which may lead to self-image challenges.

Staging the surgery allows radiated tissue to heal.

Multiple procedures raise the risk of infection.

Using an expander, the surgeon is able to create a pocket to provide support for an implant.

Performing the surgeries in stages extends the total time needed for total reconstruction.

It is better to have expanders exposed to bacteria that may potentially form after a mastectomy than implants, as the expanders will be permanently removed.

 


Delayed breast reconstruction:
This is when surgical reconstruction is performed weeks, months or years after the mastectomy. Unlike staged reconstruction, delayed reconstruction is not specifically planned out at the time of a mastectomy or lumpectomy. Patients may opt for delayed reconstruction if their plastic surgeon was not involved with the mastectomy or if they needed radiation therapy after surgery.

Advantages

Disadvantages

Patients have more time to consider their options.

Waiting for reconstruction requires patients to live for a time without breasts, which may lead to self-image challenges.

Additional cancer therapies performed after mastectomy (such as radiation) do not affect the reconstruction.

Delaying the procedure extends the total time needed to complete reconstruction.

 

Waiting for reconstruction may lead to less optimal cosmetic results, depending on the amount of time between procedures.

During the breast cancer treatment planning process, a plastic and reconstructive surgeon will discuss your medical needs and goals. If you received chemotherapy prior to surgical planning, you may be at risk for side effects such as lymphedema, hair loss, nausea and pain. Our goal is to provide you with a comprehensive care plan to help support your needs at multiple levels.

Implant-based reconstruction

A common breast reconstruction procedure involves the use of saline or silicone implants. This option often occurs in two stages. The first includes inserting a tissue expander. The second stage involves removing the tissue expanders and inserting a permanent implant.

Oncoplastic reconstruction

As part of a lumpectomy or partial mastectomy procedure, various plastic surgery techniques may be used to reshape the breast and create symmetry after the cancer is removed. Oncoplastic surgery combines the principles of plastic surgery with breast surgical oncology to achieve an aesthetic result. Oncoplastic reconstruction may be recommended for patients who have sufficient breast tissue after cancer removal surgery without the use of implants or tissue transfers.

Oncoplastic reconstruction techniques include:

Corrective surgery repairs: Patients who experienced an unsatisfactory breast reconstruction that resulted in an abnormal breast appearance following a mastectomy may choose corrective surgery to restore the breast to a more natural look.

3-D nipple tattoo: Instead of using tissue to rebuild a nipple, some women choose to have a nipple tattooed on the reconstructed breast. Many 3-D nipple tattoos provide realistic results by darkening, contouring and shading the nipple area to match the opposite breast.

Autologous reconstruction

Compared to implant-based reconstruction, autologous procedures typically require more time and a longer recovery period. Because they use the patient’s own tissue, these techniques may yield more natural results. The tissue and skin may be transplanted from various areas of the patient’s body, and the area and method chosen will depend on the amount and quality of tissue available.

The tissue (called a "flap") usually comes from the belly, the back, buttocks or inner thighs to create the reconstructed breast. Autologous breast reconstruction techniques are classified based on the composition of the flaps and the source of the tissue. CTCA offers a wide array of tissue transfer procedures, including:

Deep inferior epigastric artery perforator (DIEP flap surgery): This microsurgical procedure moves fat, skin and the blood supply from the lower belly to the breast.

Stacked DIEP flap reconstruction: A newer approach to DIEP, this procedure is used to reconstruct one breast in women who don’t have adequate extra belly tissue and are therefore ineligible for standard DIEP surgery.

Transverse rectus abdominis myocutaneous (TRAM) flap surgery: This operation also uses abdominal tissue and is typically shorter in duration than the DIEP flap surgery. It is performed less often because it affects the core abdominal muscles.

Superficial inferior epigastric artery (SIEA) flap: An alternative free-flap procedure, this technique uses the skin and fat of the lower abdomen. In an SIEA flap, incisions are made in the skin and fat only, allowing the flap to be transferred based on the superficial inferior epigastric vessels. This often results in less post-operative pain and lower risk of herniation.

Transverse upper gracilis (TUG) flap: This procedure uses the gracilis muscle, located in the upper inner thigh, starting at the pubic bone and ending along the inside of the upper leg. You use the gracilis muscle to bring your leg toward your body. Patients who undergo TUG flap surgery are no longer able to use this muscle.

Superior gluteal artery perforator flap (SGAP) and inferior gluteal artery perforator flap (IGAP) flap: For patients who do not have sufficient tissue in the abdomen or thigh, the gluteal region, or buttock, may also be used to create a flap. The SGAP flap uses the upper portion of the buttock, while the IGAP flap uses the lower portion.

Rubens free flap: This procedure uses the fatty area in the region near the hip. This tissue may be harvested in a patient who has undergone an abdominoplasty or a TRAM flap in the past.

Latissimus dorsi flap: This procedure uses muscle, skin and fat from the back. Similar to implant reconstruction, it is performed in two stages.

Autologous fat grafting: This technique uses liposuction to remove fat from one area of the body, such as the belly, and transfers it to the breast, allowing surgeons to fine-tune the breast’s shape. Fat is a rich source of stem cells, which are critical to healing. Transferring fat may help nurture the formation of new blood vessels, improve skin texture and, in some cases, restore some lost sensation.