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Restoring the Body

Master plastic surgeon pioneers breast reconstruction technique

February 2003

by Will Sansom

Plastic surgeons take their name from the Greek word plastikos, which means "to remold or reshape." Abhay Gupta, M.D., assistant professor of surgery at the Health Science Center, is a master at moving skin, fat, bone, muscle, nerves and blood vessels from one part of the body to another part that needs to be reconstructed. "We literally work from head to toe," he said, "whether the problem is skin cancer, upper or lower extremity deficits, the breast, you name it."

He recently helped a 4-year-old San Antonio boy who lost half his foot in a lawn mower accident. Dr. Gupta, chief of reconstructive microsurgery in the division of plastic and reconstructive surgery, moved skin and fat from the boy’s back to replace some of the foot. The youngster faces further surgery when the family is ready.

He also helped a woman who lost half of her jawbone due to infection. An oral surgeon referred her to Dr. Gupta, who removed part of the fibula in her leg to replace the jawbone deficit. To provide a blood supply for the bone graft, he used a microscope and tied vessels from the bone to a branch of the carotid artery and to the jugular vein, employing sutures about half the size of a human hair. "Now she has a normal jawbone and can chew," he said.
Traditional Surgical Procedure
Dr. Gupta also has treated a woman with a large burn scar on the front of her neck. Having difficulty fully extending her neck and self-conscious about the appearance of the scar, the woman often wore turtlenecks and held her face down to cover it. Dr. Gupta removed the neck scar tissue and transplanted tissue from her back to form a new neck that is cosmetically appealing and fully functional.

Dr. Gupta has developed a unique procedure to help women who need breast reconstruction. He has done 10 cases and recently presented his experience to an international society of microsurgeons meeting in Hawaii.
"The women are very pleased with the results," he said. He is in the process of publishing this work, and it will be the first description of the new procedure in the medical literature to date.
Less-Invasive Procedure
Dr. Gupta uses skin, fat, and nerves from redundant abdominal tissues to mold a new breast. In a key finding, he discovered he could establish circulation to the new breast by connecting its blood supply to small blood vessels near the surface of the chest (above the ribs and pectoral muscle). Conventional surgeries require cutting out a 1½-inch segment of rib to expose larger blood vessels, the internal mammary vessels, which are underneath the rib cage. Exposing the vessels through the rib increases the risk of hernias, pain, permanent chest weakness and lung injury, he said. “The smaller blood vessels, which are called the anterior thoracic perforators, are offshoots of the internal mam

Estella Grajeda, 50, of San Antonio says Dr. Gupta "has angel hands." A routine mammogram in February 2002 revealed a mass in her breast. A biopsy confirmed the results and Ms. Grajeda was given several options, one of which was breast removal and reconstruction, followed by chemotherapy. An active woman who works for a company that cleans homes during the construction and move-in phases, she selected the aggressive approach. In a single surgery March 26, 2002, at University Hospital, Morton Kahlenberg, M.D., assistant professor of surgery at the Health Science Center, removed her breast and Dr. Gupta performed the reconstruction. "I was very surprised when I woke up," Ms. Grajeda said. "I had my breast again."

Drs. Gupta and Kahlenberg are among the increasing number of physicians who perform breast removal and reconstruction during the same operation. "Dr. Kahlenberg refers patients to me and we plan the surgery," Dr. Gupta said. "It saves an extra operation, but far beyond that, it spares a woman the anguish of having no breast. Reconstructing the breast during the same surgery does not make it harder to detect cancer recurrence, which was the argument for doing the surgeries separately."

Breasts may be reconstructed using the patient’s own tissue (as in Ms. Grajeda’s case) or breast implants. After swelling subsides, a second operation is performed to reconstruct the nipple – which is removed in case it contains cancer cells – and tattoo the areola, or dark circle around the nipple.

After six years of plastic surgery training in Canada, Dr. Gupta completed a one-year fellowship in reconstructive microsurgery at The University of Texas M.D. Anderson Cancer Center in Houston prior to joining the faculty at the Health Science Center. Only 1 percent to 2 percent of the world’s plastic surgeons are fellowship-trained microsurgeons. These super-specialists use large operating room microscopes to painstakingly tie and retie blood vessels in graft areas. The microscope magnifies the surgeon’s view of the operating field up to 25 times. "The anterior thoracic perforators, which I’m utilizing in breast reconstruction, are only 1.5 millimeters in diameter, but the microscope enables me to see them easily," Dr. Gupta said.

"He did a perfect job. He is a wonderful doctor," Ms. Grajeda said. "So is Dr. Kahlenberg. They are No. 1 for me." She has resumed her work and her hobbies, such as needlepoint, reading and cutting the grass at her house. "Some women panic when they hear the word cancer," she said. "Thank God I am very easy. When the doctor told me what my problem was, I was okay. It didn’t make me crazy. I think it’s normal for people my age to have one thing or another. My thing was cancer, but I am in God’s hands."

She is whole again, thanks to Dr. Gupta’s skillful "angel hands."


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