Dr. Robert Whitfield (MD) describes decades of experience in breast cancer reconstruction, emphasizing autologous tissue techniques—particularly the DIEP (deep inferior epigastric artery perforator) free flap—and related procedures (ALT flap, lymphatic reconstruction, fat grafting). He explains rationale for perforator flaps (muscle preservation for core strength), reports high microsurgical success (>95%), and discusses converting implant-based reconstructions to autologous reconstructions or performing explant/aesthetic-flat closures for capsular contracture, implant complications, radiation injury, animation deformity, or suspected breast implant illness. He notes he's no longer performing microsurgery but continues explant and fat-transfer work and perioperative inflammation-reduction programs for cancer patients.
Questions this video answers
Over 95% success rate.
2012.
2019.
Fellowship in 2004–2005 (learned ALT flap technique).
Approximately 100–150 fat transfers per year.
Chapters
All right, so we're going to talk about breast cancer reconstruction. This is what I did mainly for almost two decades was cancer reconstruction, predominantly breast, because that's the most prevalent form of cancer in the United States. One in eight women will get breast cancer. And so my niche was to take their own tissue. Think of like the tummy tuck tissue. So the tissue below the belly button all the way out to the hip bone and down towards the groin area, pubic area, that kind of swath of tissue you could take out, but you could take it out and leave it attached to the blood vessels. The blood vessels are found in the six pack muscles that run down the abdomen. So why is that important? Well, you want to preserve the muscle and the nerves that go to those muscles so that the abdominal wall will work. So you could do a crunch, a sit up, whatever you want. Think of it like that, maintain the core strength. And so we know that if you preserve even one of those muscles completely, there's much better recovery. There are studies done throughout the world about that. And that was really what got me interested in how to do the perforator flap is what that's called. It's called the deep inferior epigastric artery perforator flap. And basically it's just following the anatomy, which was always, you know, just the most incredibly interesting thing to me as a surgeon in training was how you could follow the anatomy and perform these flap reconstructions for tumor infection, traumatic area of injury all over the body. And so when I was finishing my plastic surgery training, this type of reconstruction was really starting to get elevated around the United States and around the world. So I was super interested in and wanted to do more and more reconstruction with this type of technique. And when I started academic practice, I did hundreds of lower leg reconstructions with what's called the anterolateral thigh perforator free flap. And I had learned that in my fellowship serene in 2004,05 with a now a surgeon who's deceased, Dr. Kevon Chiabani, great surgeon. And I was allowed to do more and more free flap breast reconstruction because of my mentor, Dr. Bill Zamboni, and my mentor in surgical training, plastic surgical training, was Dr. Coleman. So those I owe them, you know, a huge debt of gratitude because they allowed me to express myself and learn those techniques. And then I went on and I taught those techniques to residents and fellows and the most complicated reconstructions you could come up with from our surgical oncologists that I worked with orthopedic surgical oncologists doing Sarcoma care, very difficult cases, head and neck cancer cases where you had to reconstruct the jawbone using the lower leg bone with or without skin. And then throat cancer cases where you'd use the ALT flap and make a tube that still, that was my preferred technique. I really enjoyed reconstruction with that flap and then of course doing DIEP free flap breast reconstruction, which when I transitioned out of academic practice and came to Austin, Texas in, in 2012, that was what we did predominantly was dip free flap breast reconstruction. I still did all the sarcomas in Austin and I still did in conjunction with other surgeons. The majority, they had neck reconstruction in Austin. And so really the breast cancer reconstruction led to all the explant surgery I did. Patients who had developed problems with their breast implant reconstruction, they could be capsular contracture, they could be infection, they could be skin problems, they could have went on and had radiation injury. They may have what's called an animation deformity, where the implants of course, would have been an animation deformity. The cause is it's behind the muscle and when they, they move their torso or they're working out, it creates an abnormal appearance that bothered them. So there are a host of reasons why people get referred to me with an implant based reconstruction that then I would convert to an autologous or their own tissue reconstruction. And my preferred technique was the dip perforator flap or the deep inferior epigastric artery perforator flap. And the, the outcomes provided, everything went well with the microsurgical aspects of it, which we had a success rate over 95%. And I had, you know, really honed in on that flap reconstruction as well as other things to help cancer patients like lymphatic reconstruction. I was the first to do that in Austin, Texas. And now, now it's becoming more common to do lymphatic reconstruction. But we had been advancing that really since 2000, probably 1516 after going to a meeting in Taiwan. And those were extremely rewarding cases. But going back to breast cancer reconstruction, you know, I get asked routinely now, can we take down a reconstruction and perform aesthetic flat closure for somebody with chronic inflammation, breast implant, capsular contracture, breast implant illness symptoms. And so now I don't do microsurgery anymore. So don't ring up the office desiring a flap based reconstruction. There are plenty of people around the country doing that. You want to have somebody who's done several hundred, if not thousand free flap breast reconstructions. Don't go to anybody who hasn't. That's not advisable. And then, you know, for us, I get asked, can we do fat transfers? Of course. I mean, I did hundreds of fat transfers every year for breast cancer patients from the time I started in 0405 until the time I stopped doing reconstruction 2019, we would do 100, 150 a year. And now obviously have people fly from all over the United States, Europe, Asia, to come here and get explants and have fat transfers at the same time. For cancer patients, it's just different. We have to be just looking at all the factors that they're going through. I recently had a consultation with somebody from the western United States who had a very complicated cancer case. That definitely is not for every provider to take care of. So with cancer, there are obviously special circumstances that we take into consideration when providing surgical treatment plans for them, but we definitely provide consultations and guidance. My sharp process can be used by any of those patients who are trying to get prepared for or just lower inflammation prior to surgery and after surgery. It's a very, very good program. So that is one of the ways that we interact with our breast cancer patients. And I think that will grow more and more as patients just resolve themselves to either not wanting the reconstruction or providing themselves with a fat transfer for contour and adding volume, but obviously it'll be a smaller amount of volume.
