Plastic Surgery Q & A

I NTRO:  PS stands for “Plastic Surgery” or “Reconstruction” if you have had a mastectomy.  At first I was leery of this profession and even considered not having reconstruction, thinking it was vain or self-serving.  But when I was personally affected by DCIS and as I met others, I have come to realize how much of a woman’s identity and even self-confidence is found in her breasts.  Believe me, having one cut off is no picnic and a double mastectomy with reconstruction is major surgery. Every woman has a right to their own feelings and  for me undergoing reconstruction is worth it.

My PS, Dr. James Ferlmann,  agreed to be interviewed and we hope this helps you get a better understanding of what is entailed with reconstruction options.  I’ll also insert his hand drawings (I have to find a scanner) – I really like them and requested them especially for you.

Here are the questions for you to do a quick review.  I’m sorry you can’t just click on the question you are interested in, but you can scan them to see what is covered to save time.

1. What types of breast surgery do you perform?

2. What are the percentages for the different reconstructive surgery types that you perform?

3. What are the plastic surgery ways to approach DCIS for breast cancer reconstruction?

4. Tell me more about a fat graft. Wouldn’t fat in your breast be affected if you were planning on losing weight?

5. How do you see the doctor-patient relationship from your perspective?

6. In a perfect world, what role do you see yourself as having with DCIS/breast cancer patients?

7. How can medicine and physicians in general adapt to better serve the patient?

JAMES FERLMANN, M.D. 

Q & A INTERVIEW WITH DR. JAMES FERLMANN, PLASTIC SURGEON –

June 23, 2011

INTRODUCTION:

Dr. James Ferlmann is Board Certified, American Board of Plastic Surgery, a Member of American College of Surgeons, Chief of Staff at Rush-Copley and a Castle Connelly Top Doc for the past eight years. Here are some of his other awards. I just can’t keep up.

Compassionate Doctor Recognition, 2010
Patients’ Choice Award, 2010
Awards:
Compassionate Doctor Recognition2009
Faculty Member at Rush-Presbyterian-St. Luke’s Medical Center
Patients’ Choice Award2008 — 2009
Associations:
American Society of Plastic Surgeons
Member

1. Britta’s Question:  What types of breast surgery do you perform?

Dr. Ferlmann’s Answer:  There are two categories:  cosmetic and reconstructive.  For DCIS and breast cancer there are three reconstructive surgery types:  tram flap, latissimas flap, tissue expander reconstruction and the fourth is immediate reconstruction where you go right to implant.  That is a reconstruction where you just pop in the implant with someone who has larger or droopy breasts where there is plenty of skin. When there is not ample skin, we do a tissue expander.  When there is a post partum droopy breast that wants to go from a C down to a full B is perfect for single stage reconstruction.  We don’t have to stretch out any skin, there is more than enough there.  Tram flap is one he loves to do. Lat flap is a lifeboat procedure.  There are other procedures like micro or the DIEP flap or free trams where you take the gluteal muscles and gracilas muscle for reconstruction.  These procedures are done at larger hospitals with more experienced teams and specialized equipment.

Tram flap requires that the volume of tissue between the belly button and pubic hair line has to match the volume of the breast you need to match.  Grab the breast, grab the fat, if there is an equal amount, you are a candidate for this procedure.  This moves skin and fat along with the muscle that contains the artery that is needed to keep the keep the skin alive. The muscle is cut and acts as a conduit to keep the skin alive. When you do a micro tram, where you are taking this off, its blood supply comes from a vessel that goes down into the groin and the muscle is attached to that.  It is called a “free tram” and the advantage is that you don’t have to harvest or sacrifice the muscles.

Dr. Ferlmann is also an artist and draws simplified pictures that give a patient a good idea of what each procedure is on a level they can understand.

2. Britta’s Question:  What are the percentages for the different reconstructive surgery types that you perform?

Dr. Ferlmann’s Answer:  20% tram, 10% lat flap, 70% tissue expander implants plus a newer and growing market for immediate construction.

3. Britta’s Question:  What are the plastic surgery ways to approach DCIS for breast cancer reconstruction?

Dr. Ferlmann’s Answer:  From my perspective, since we are in the Midwest, everything that happens here is later than on either coast. As far as a lumpectomy, I do not see or treat DCIS.  Plastic surgery is very limited after lumpectomy, especially for patients with a small breast. Fat grafting can be done or bilateral augmentation as well or a patient can decide to live with some asymmetry. Anything that is treated with an elective mastectomy, then the patient comes to me for reconstruction.

4. Britta’s Question: Tell me more about a fat graft. Wouldn’t fat in your breast be affected if you were planning on losing weight?

Dr. Ferlmann’s Answer:  Typically a fat graft comes from parts of the body where weight comes off last, like the abdomen and the hips.  Your body doesn’t take fat from these areas and your fat in these areas is different than in other areas of your body.  Even though you take fat from your hips and place it in the breast, your body still thinks it is hip fat.

5. Britta’s Question:  How do you see the doctor-patient relationship from your perspective?

Dr. Ferlmann’s Answer:  It’s a team.  Family members and the patient and I do not believe in being the only decision maker in the process. I think the patient needs to be invested in the end result and all along the way I need the patient’s input and where do they think their ideal end point should be and I’ll do everything I can do to get them there.  I’ll give recommendations, I’ll tell them what’s possible, I’ll tell them what’s reasonable and try to make sure that if I ask them what their ideal outcome is that I’ll get them there.

6. Britta’s Question:  In a perfect world, what role do you see yourself as having with DCIS/breast cancer patients?

Dr. Ferlmann’s Answer:  After a year or however long it takes the patient to be done and oncologically clear, I want the patient to be able to go to the beach and put on any outfit, go out socially and both in and out of clothes, and not feel self conscious about themselves and feel whole.  That is my goal with every procedure. And possibly even look better if they were too big, too small, too uneven, where they can go out in public in a nice revealing white tight blouse and have a friend say, “I thought you had cancer…I thought you had a problem,” and you can raise your eyebrows and say “well….and pass the butter.” That’s the whole idea, to have the patient’s get their life back and not have them wake up every morning and be reminded of what they went through.

7. Britta’s Question:  How can medicine and physicians in general adapt to better serve the patient?

Dr. Ferlmann’s Answer:  It would help if the docs were patients at some point and went through surgery.  Docs are the worst patients. That not being an overall possibility, it should start in medical school where they work on empathy training.  The old style method is not as conducive to seeing things from the patient’s point of view.  I think there are some docs that can’t be improved upon.  You can’t teach charm or sympathy.  You can’t but wish you could.  Some people would say I don’t care if he is Satan himself if I can get the best result.  Others would say, ‘part of my healing is going to be dependent on my liking the docs that I am going to deal with.’

Britta’s takeaway from this question:  Don’t just go to the doctor you are sent to.  Seek out a doctor whom you can relate to – whether there are male-female issues, cultural issues, or arrogance.

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