Stephanie Caterson, MD, director of the Perforator Flap Breast Reconstruction Program in the Division of Plastic Surgery, received the 2017 Bernard Lown Teaching Award, which celebrates BWH physicians who are outstanding clinical teachers.
In 2007, Caterson introduced the deep inferior epigastric perforator (DIEP) flap procedure for breast reconstruction at BWH. This innovative microsurgical program has steadily expanded in the years following.
The DIEP flap is a reconstruction technique that uses a person’s own abdominal tissue to reconstruct the breast. There is no implant used. The technique is a modern twist on the TRAM flap procedure, which involves the removal of the entire rectus muscle (a core strength muscle). With DIEP, that muscle remains in place on the abdomen to do what it was meant to do. The surgeon uses just the patient’s abdominal skin and fat to reconstruct the breast, with no muscle moved. To do this, the surgeon must meticulously dissect out the dominant blood vessels from the muscle, and transfer the tissue to the chest using microsurgery.
In this Q&A with BWH Clinical Research News, Caterson shares her thoughts on her career in plastic surgery, her development of the DIEP flap program at BWH and some of her education initiatives.
What drew you to the field of plastic surgery?
SC: I was an aerospace engineer as an undergraduate, and when I went to medical school, I was not even considering surgery. I was seeking a higher-level degree so that I could apply for the astronaut program. I thought I would study emergency medicine because it would be applicable in space. But as I started my clinical rotations, I fell in love with the technical aspects and challenges of surgery.
Plastic surgery stood out to me due to the parallels to engineering. You have a set of “tools,” and you must solve the problem, which is different for each patient. During my formative years as a medical student, the most inspiring role models I came across were plastic surgeons. They loved what they did, and it was contagious.
As I completed my surgical residency, I began to question my path to the astronaut program because, as an astronaut, I wouldn’t practice any clinical medicine. In the end, the pull of plastic surgery won. I applied for a fellowship and I was lucky enough to match.
Can you briefly explain the origin and development of the DIEP flap procedure at BWH?
SC: I began the DIEP flap program at BWH in 2007. Since then, we have added other plastic surgeons to the team, and we are now able to complete over 200 DIEP flap procedures each year. Due to the high volume of DIEP flap procedures at BWH, our residents get enough experience that they could perform the procedure right after graduating from residency, without needing a microsurgery fellowship. Brigham’s support of the continued development of this program has played a huge role in its success, and it has certainly improved the patient experience overall.
The DIEP flap technique is very important for patients. In the past, we could only move skin and fat (for breast reconstruction) by also moving the underlying muscles for blood supply. The TRAM flap involves repositioning of the rectus abdominal muscle from the abdomen to the chest, where it no longer helps with muscle function. If we take both rectus muscles, most patients can’t do a sit up afterwards, because there are no other muscles that aid in the abdominal crunch maneuver. In a DIEP flap, we split the muscle and dissect out one or two dominant perforating blood vessels to move, leaving the rest of the muscle intact. It is more complicated to do the delicate vessel perforator dissection required for DIEP, but a patient’s abdominal wall function is much stronger after DIEP, compared to TRAM, with less risk of hernia or bulge.
How does DIEP flap positively impact patients seeking breast reconstruction?
SC: The DIEP flap procedure can be an excellent option because it offers patients a potential alternative to implant reconstruction. An implant breast reconstruction procedure is a smaller operation with a shorter recovery, fewer steps and less scars. However, some patients don’t want implants because they don’t like the way it looks, or they want a more natural reconstruction. Additionally, patients who have had chest wall radiation are at high risk for implant related complications (much less with the DIEP flap). Unfortunately, not all surgeons and hospitals offer DIEP flaps, so sometimes patients are only offered implants.
I see many patients who have developed significant capsular contracture [an immune response to an implant that can cause pain and disfigurement and scar tissue around their implant, because a body that has undergone radiation treatment often “rejects” implants. It’s painful, it doesn’t look good, and the patient feels helpless about improving their reconstruction. But, with the DIEP flap procedure, we can take the implant out and replace it with their own tissue that is soft, warm and not painful.
It is rewarding for us as surgeons to be able to give these patients hope and improve their way of life with a modified reconstruction.
Patients can sometimes be hesitant to choose the bigger flap operation because there is a lot of recovery and it is more invasive upfront. But there are long-term benefits to having a healthy flap with its own blood supply, like not having to worry about implant rupture, leakage or scar tissue formation. The DIEP flap gives the patient all those benefits of being able to avoid an implant, without the downside of moving the core-strength rectus muscle.
To help calm the nerves of patients about to undergo DIEP flap surgery, our program started a preoperative education class for patients who are preparing for DIEP flap surgery, as well as their families. We host the class in the hospital on the floor where the patients will be staying post-operatively. They get a tour of the facilities; then we demonstrate the medical equipment we will be using during their care. Patients gain a better understanding of the day-to-day hospital recovery, meet caregivers from the surgical team who will be caring from them, and have an opportunity to meet others about to undergo the same procedure. At the same time, I am learning what concerns patients may have pre-operatively, which allows me to improve my consultations. Overall the response has been tremendously positive for patients and caregivers alike.
Can you tell us about any teaching initiatives that amplify your practice in microsurgery at BWH?
SC: I am working with my new partner, Lydia Helliwell, MD, and the STRATUS Center to develop a skills lab on microsurgery, or surgery that requires the use of an operating microscope. DIEP flap is a microsurgery procedure. We will be teaching microsurgical skills to plastic surgery residents before they ever enter the operating room. Honing their technique in a non-invasive environment benefits everyone.
I usually have conversations with residents during a procedure about their prior experience with microsurgery, and that is how I calibrate my teaching to their appropriate skill and experience level. But the use of this microsurgery lab would help us solidify a common knowledge base outside of the operating room and would enhance efficiency of teaching during the actual procedure. We have an amazing faculty at each institution, so in the future we could potentially develop a Harvard-wide programmatic approach to teaching microsurgery. We are looking forward to this next adventure!