Decades' Worth of Reconstruction Advancements Have Transformed the Lives of Many Patients Who Underwent Debilitating Cancer Treatments

CURE, CURE Spring 2022,

Aesthetic appearances, according to an expert at the UCSF, are often important for patients following the surgical treatment of cancer. Advancements in this space over the past 20 years have allowed many to patients to look as normal as possible.

After cancer treatment, some patients may have to undergo some form of reconstruction. This can include the removal of a limb after sarcoma resection, grafts after skin cancer removal, fat and skin grafts for breast reconstruction and even prosthetics to address urinary incontinence in prostate cancer. Regardless of what type of reconstruction a patient may require, advances in this area over the past two decades have furthered what surgeons can do for patients to restore as normal an appearance as possible.

As surgical techniques, prosthetics and even conversations about reconstruction have improved over time, patients and their cancer teams can feel more comfort-able and confident about what they want to achieve with these procedures to address expectations.

An evolution has occurred in the cancer treatment reconstruction space regarding where tissue can be taken from and placed during surgery. The improvements allow tissue to be moved from one part of the body to the other with less trauma to patients, such as decreased scarring and decreased manipulation of the anatomy. In patients undergoing breast reconstruction, for example, tissue connected to skin and fat can be taken from anywhere on the body — including the buttocks, belly and thigh — as long as it is connected to an artery and vein. Although similar procedures were performed 20 years ago, they were not nearly as widespread as they are now.

“Not everyone was that good at it, and people were not as efficient at it,” said Dr. Justin M. Sacks, Shoenberg Professor and chief of the Division of Plastic and Reconstructive Surgery at Washington University School of Medicine in St. Louis, in an interview with CURE®. “Nowadays, we can do flaps called perforator flaps, where we stick skin, fat and blood vessels without cutting in or taking the muscle and transplanting it to the chest wall. It happens routinely on a daily basis at private and academic medical centers all over the country.

A similar technique can also be used for patients requiring head and neck reconstruction after treatment. Surgeons can use soft tissue and bone from another part of the body and transfer it to the jaw and tongue, enabling people to eat, speak and smile. This procedure has also become less traumatic for patients.

Many of these techniques were made possible by advancements in microvascular surgery — the ability to connect blood vessels that are 1 to 3 millimeters in diameter together. These advancements have also allowed surgeons to perform better facial nerve resections, which can restore a patient’s ability to express emotions on their face. Twenty years ago, if a patient with cancer had part or all of their facial nerve removed, half their face or their entire face would be paralyzed, leaving them unable to blink their eyes or breathe through their nose and causing them to drool while eating. Nowadays, surgeons can move a few nerves in the face, depending on what functional issues a patient has. For example, the temporalis muscle can be moved to help a patient smile again, and the master nerve can be repositioned to restore chewing.

In the prostate and testicular cancer space, the quality of pros-thetics and an understanding of what they can achieve have also improved. For example, the surgery to place a prosthetic in patients with testicular cancer is cleaner, which leads to fewer infections. Additionally, prosthetics are now more widely available in hospitals than they were previously, when surgeons would sometimes have to wait until they were in stock, sometimes after a patient had undergone an orchiectomy (the surgical removal of one or both testicles).

Infection prevention also has come a long way in reconstruction for patients with prostate cancer, especially with the introduction of prosthetics coated in antibiotics. These can reduce the frequency of infections.

Technologies such as 3D printing and artificial intelligence have also played a critical role in virtual surgical planning. For example, if a patient required head/neck cancer reconstruction that focused on their jaw, surgeons could map out the surgical resection, create the bony segment that needed to be recon-structed and customize the plate formation that would eventually be the metal plate holding the bone in place.

“It’s been done for extremity reconstruction for cancer, sarcoma — the upper extremity (and) lower extremity,” Sacks said. “Utilizing overlaying technology onto typical surgical procedures allows us to be more efficient and (produces) better outcomes.”

Advancements have been made not only in surgical techniques and prosthetics, but also in the conversations patients have with their cancer team before, during and after these surgeries.

A major difference is in our focus on the patient’s voice, (on their) goals and desires in the reconstruction,” explained Dr. Michele Manahan, a professor in the Department of Plastic and Reconstructive Surgery at Johns Hopkins University School of Medicine in Baltimore, in an interview with CURE®. “While the surgical techniques have evolved somewhat, as you would expect over the course of time, we’ve had more of a tidal wave shift toward making sure that we have a deep, rich conversation with each new patient who comes to us. (This is) so we can ... really understand, out of this wide menu of options that we have, what might work better or worse for any patient based on where they want to go with things."

IMPROVING THE LIVES OF PATIENTS WITH CANCER

Advancements in reconstruction and prosthetics have improved the lives of patients with cancer in several ways, such as by minimizing the impact on other parts of the body where skin and other structures may be taken from.

“If we can minimize the disruption (to) another area of the body ... then the patient may be able to get back to more normal exercise more quickly or eventually maintain the level of exercise they had before surgery rather than worrying about sliding backwards,” Manahan said.

Further, more medical centers across the United States are offering these reconstruction procedures, many of which can now be performed more quickly and efficiently. This can speed up recovery and lead patients to “have better function both in the head and neck and in the extremities,” Sacks said.

Not only can advancements improve recovery and function, they can also bring back certain actions that people often take for granted, such as speaking naturally or even smiling. “People who had bone resections and people that had radiation therapy ... were significantly worse off in terms of the psychosocial and aesthetic outcome measures,” Dr. P. Daniel Knott, a professor and director of the Division of Facial Plastic and Reconstructive Surgery in the Department of Otolaryngology-Head and Neck Surgery at the University of California, San Francisco, told CURE®. “Being able to replace bone accurately and appropriately allows the patients to then feel and look normal. It allows them to bite correctly. Because the teeth have to meet — for example, both the upper and lower jaws — it allows them to have the correct contour of the cheeks. It allows them to have the ability to speak naturally, because the mouth opens and closes naturally. It has just tremendous improve-ments in quality outcomes and patient satisfaction."

WHAT’S NEXT?

Although a lot of progress has been made over the past 20 years, patients should look for more innovation during the next 20 years (or even sooner). For example, Sacks said, surgical simulation with virtual reality may aid surgeons by enabling them to visualize the tumor in real time, removing it and performing the reconstruction even before the patient is in the operating room. Sacks also hopes that soft and hard tissues can be engineered in a laboratory setting rather than being taken from a patient’s body.

“The future is for us to be able to help reconstruct the human form using synthetic and biological constructs that reduce morbidity (in) patients so that we don’t have to cut them in another part of the body to help reconstruct them,” Sacks said.

3D cameras may also be used during surgery to help guide surgical resections, allowing surgeons to perform precise surgeries with real-time imaging. Previously, patients would undergo a CT scan or an MRI and those images would be shown to surgeons, which they would use to base their surgeries on. Real-time imaging can help surgeons know exactly what they’re doing as they’re doing it.

The use of robotic technology may also be on the horizon, which may allow surgeons to enter the body through natural orifices such as the mouth, nose and ears to perform surgeries deep within the body.

Smart devices may have a place in the penile and incontinence prosthetic space, which would help those patients who have dexterity and hand strength issues due to their age. In particular, incontinence prosthetics and penile prostheses are pump controlled, with pumps implanted in the scrotum. If updates occur in the future, such devices may be controlled via app or remotely to simplify their use.

“Especially in elderly patients and the frail elderly, if you can reduce incontinence in them, it does help prevent things like falls at night, which could lead to ... fractures, hospitalizations and (so on),” Dr. Christopher E. Wolter, an assistant professor of urology at Mayo Clinic in Phoenix, Arizona, told CURE®. “They’re not having to rush to go to the bathroom in the middle of the night or trying to keep their bladder empty so they don’t leak so much.”

Some developments may focus on techniques rather than the devices themselves. For example, Manahan explained how she and her colleagues are striving to refine techniques, minimize scars and potentially minimize the disruption of tissue.“

Those are all things that we think of as natural evolution,” she added. “It’s something that everybody doing these surgeries is working toward every day. But when we step back, how do we make (these surgeries) OK and ease the process when (patients are) facing it?

“We know what we know now, but we learn more over time and we progress over time,” she said. “I think we will always strive to know more and do better in the future, as our techniques, tools, technology, etc., develop. We’re working to the best of our abilities where we are now, but we always want to keep an eye on the future and look to make it better.”

FEELING EMPOWERED WHILE MAINTAINING GOALS

For patients, it can be overwhelming to navigate the area of reconstruction and prosthetics, especially in light of so many advancements. Experts advise patients to have in-depth conversations and consultations with their cancer surgeon and plastic/reconstructive surgeon to learn as much as they can about what they might undergo, but also to understand that curing their cancer comes first and foremost. Once that has been achieved, a conversation about reconstruction can begin.

"My advice to you, as a cancer patient, is that we are going to restore form, function and dignity at the same time, and that you should seek consultation with a plastic and reconstructive surgeon so that you can have that form, function and dignity restored to you,” Sacks said. “It’s not a death sentence if you have cancer, and it shouldn’t change necessarily the way you look, function or feel over time. You will be changed, but you will be cancer free and you will be reconstructed.”

Throughout this conversation, it is important for the cancer team to address the patient’s needs, no matter how unique those may be.

“(I urge patients) to maintain their individual goals (and) to share with their care team those goals,” Manahan said. “Patients feeling empowered to really share what they truly believe and think and their reactions to the facts that are delivered is important; and then asking questions — that’s part of the whole thing about having an open conversation. It’s a partnership, so you want to feel comfortable in your partnership.”

Wolter mentioned that men with testicular cancer are often younger — in their late teens to mid-30s — and may be somewhat more self-conscious about how they look. This highlights the importance of patients knowing their options immediately, especially as it is much easier to place an implant at the time of the orchiectomy because the space has already been created.

In contrast, patients with prostate cancer have a little bit more lead time into the discussion about if and when reconstruction and prosthetics may be needed. These patients should know that although there is a chance they may lose urinary control and the ability to have erections, treatments exist that can serve as solutions down the road.“

(Patients) knowing that, yes, (they are) incontinent is obviously life altering,” Wolter said. “It can lead to increased rates of depression, isolation, those kinds of things. But knowing that there would be an end to that in sight, ... something that you can almost place on the calendar when you would be experiencing that relief from that problem, is very, very encouraging to patients.”

Although functional outcomes are a critical component of this process, patients are also allowed to focus on appearance-related outcomes.

“After surgery, those aesthetic things are important,” Knott said. “It’s hard to go back and change what’s already been done. You’d want to make sure that for patients that do (place) an element of aesthetic importance on their tumor resections, (you) choose the reconstruction wisely; that will enable them to look as normal as possible.”

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