Next Generation is a BWH Clinical & Research News (CRN) column penned by students, residents, fellows and postdocs. This month’s column is written by Tatiana Kelil, MD, a third-year resident in the BWH Department of Radiology.
Most of the focus of my medical training has been on identifying a disease and providing treatment. So when an early cancer is detected on imaging before metastasis and a woman ends up cancer-free by undergoing mastectomy, I used to consider that a total triumph.
I have seen so many of these mastectomy scars across the chests of cancer survivors that come for their surveillance imaging at BWH. But I never really paused to ponder about what happens in the next chapter after beating cancer: life after mastectomy. Then I read Adventures of a One Breasted Woman: Reclaiming My Moxie After Cancer, a book that chronicles one woman’s journey after undergoing mastectomy for early stage breast cancer. As a physician, aspiring breast imager and, most importantly, as a woman, I was deeply touched by the story.
Although life-saving, mastectomy can cause tremendous distortion of body image and leave survivors feeling less feminine, undesirable and incomplete. One may assume breast reconstruction surgeries are just cosmetic, but the fact that some women would rather die than live without a breast signifies how a woman’s breasts are intricately associated with her self-image and feminine identity. Breast reconstruction is an integral part of breast cancer management and has been shown to positively impact a woman’s psychosocial adjustment and quality of life.
Seeing the Challenges of Breast Reconstruction Firsthand
At the time of reading the book, I was working on exploring utilities of 3-D printing in health care and wondered how we could use this technology to assist in breast reconstruction surgeries and achieve better outcomes. I contacted Stephanie Caterson, MD, one of the top breast reconstruction surgeons at BWH. She was excited about the idea and was as passionate as I was to improve the way breast reconstruction surgeries were currently performed.
I attended one of her autologous flap reconstruction surgeries, which took about 9 hours. Breast reconstruction involves either implants or autologous tissue flaps, in which a flap of skin, fat and sometimes muscle is excised typically from the abdomen and reattached to the chest. The long and arduous procedure presents challenges for surgeons, who lack an accurate and objective means to measure the volume of the diseased breast and match the replacement flap or implant. Finding the location and course of the dominant vessels which are used for reattachment to the chest with 2-D imaging is also a challenge for surgeons during breast reconstruction and requires a lot of back and forth between the image screen and operating table. As I watched Dr. Caterson meticulously dissect the vessels, harvest and weigh the flap and reattach the harvested tissue to the patient’s chest, I was determined to find ways to help make the procedure better for both surgeons and their patients.
Dr. Caterson and I have met multiple times since then to identify current challenges and come up with possible solutions. We also included in the effort Beth Ripley, MD, a BWH clinical fellow in cardiovascular imaging and expert in 3-D printing; Michael Steigner, MD, an attending radiologist at BWH with expertise in cardiovascular imaging and 3-D visualization; as well as Ahmed Hosny and James Weaver, PhD, from Harvard University’s Wyss Institute. They have expertise in material analytics, chemical engineering and physics.
Together, our team has been trying to determine ways of improving pre-surgical planning and operative flap harvest through the use of 3-D volume rendering of preoperative images and 3-D printing. Our hope is to accurately determine matching volumes of the breast and reconstruction flap ahead of surgery in order to minimize prolonged intraoperative tissue manipulation and yielding symmetric natural appearing breasts. This would also mean reduced operation and sedation time for the patient. To optimize symmetry, 3-D printed molds of the breast can be used as cutting guides to reshape the flap intraoperatively. Furthermore, 3-D printed models of the vessels required for anastomosis could be used to enable better visualization of the location and course of the dominant vessels aiding in dissection and minimizing unintended vessel injury during flap harvest. In addition to its uses in surgical reconstruction, 3-D printing can be used to manufacture phantoms, which better represent the realistic breast anatomy and patient variability and replace expensive cadaveric material for education and training purposes.
Technological advances such as 3-D printing and 3-D visualization that promise to enhance surgical outcomes and improve a woman’s quality of life should be embraced and further investigated. I feel very fortunate to be a resident at BWH, where such innovations are fostered. I am grateful to be part of a team of experts who are passionate about this cause.
If we are able to detect breast cancer early, provide the appropriate treatment and enable a cancer survivor to look at herself in the mirror and confidently say, “not only did I beat cancer but I look good doing it,” then I think that would be a total triumph.