It’s just after dawn on a Wednesday morning as breast reconstruction specialist Keith E. Brandt, M.D., and his surgical team of residents, fellows and nurses prepare a patient for reconstructive breast surgery.
An iPod loaded with more than 500 classic rock songs plays lightly in the background as the team begins the procedure. Years ago at another hospital, the patient received a breast implant that has since leaked, causing the breast to scar and deform. The team will remove the implant and then recreate a natural breast from the patient’s tissue.
By the close of the seven-hour operation, Brandt, associate professor of plastic and reconstructive surgery, and his team will have built a new breast from the tissue, arteries and veins of the patient’s abdominal wall.
The technique, called the traverse rectus abdominus myocutaneous (TRAM) flap procedure, allows reconstructive surgeons to use the patient’s tissues to recreate a natural breast.
“Losing a breast after a mastectomy can take a heavy emotional toll on a woman,” Brandt says. “As reconstructive surgeons, sometimes our job is to ‘fill holes’ resulting from trauma or tumor resection. But in breast reconstruction, we have the opportunity to rebuild part of the patient. It’s very rewarding to help patients get back to normal again.”
During the procedure, Brandt removes an oval section of skin, fat and muscle from the lower abdomen wall, along with the arteries and veins that supply those tissues. The blood vessels are reattached by using a microscope to sew the tiny, delicate parts into place and restore the blood flow. Finally, the tissue is shaped into a natural-looking breast.
As Brandt sews the transplanted tissue to the patient’s chest, he explains that the patient can opt for nipple reconstruction a few months later. Skin from the breast is used to create a nipple and then colored with a tattoo technique.
Although this patient is being reconstructed with the TRAM technique years after her mastectomy, Brandt explains that ideally the procedure is performed immediately at the time of mastectomy.
“When the two procedures are done simultaneously, the patient is rid of her cancer while being spared the emotional trauma of being without a breast,” he says. “In one fell swoop, you can get rid of the disease and get a completely natural reconstruction along with a free tummy tuck.”
Although the 1998 Federal Breast Reconstruction Law requires insurance providers to pay for reconstruction in connection with mastectomies, only 15 percent of American women have reconstructive procedures following mastectomy, according to the American Society of Plastic Surgeons (ASPS). And the numbers drop significantly for African-American, Hispanic and Asian women.
A recent ASPS study reported that whether a woman chooses to have breast reconstruction following mastectomy is largely influenced by the patient’s race, geographic location and stage of the disease.
“The low numbers are largely attributed to the lack of availability of reconstructive surgeons,” Brandt says. “Unlike at the School of Medicine, most of the time there isn’t a plastic surgeon next door that can run over and perform the reconstructive procedure.”
Fortunately, at the University — one of the few places in the state that offers immediate breast reconstruction at the time of mastectomy — 60 percent of breast cancer patients have reconstructive procedures.
Brandt works side-by-side with surgeons at the Siteman Cancer Center. While the oncologic surgeons perform a mastectomy, Brandt steps in and harvests the tissue of the TRAM flap, which will be used to create a natural breast.
“There are many options for breast reconstruction, and women can count on Dr. Brandt to educate them on their various options and always do what is best for them,” says Susan E. Mackinnon, M.D., the Sydney M. Shoenberg Jr. and Robert H. Shoenberg Professor of Plastic and Reconstructive Surgery and head of the department.
“Keith is probably the most compassionate surgeon I’ve known — and what a tremendous quality that is for someone treating women with breast cancer.”
Superb patient care
When Mary Kay Gaydos-Gabriel was diagnosed with bilateral breast cancer three years ago, she was shocked because there was no family history of the disease. Her oncologic surgeon, Virginia A. Herrmann, M.D., professor of surgery, introduced her to Brandt, who explained reconstructive options.
At first she was hesitant about letting a stranger rearrange her body. But that quickly changed.
“I knew when I first spoke with Dr. Brandt that he’s not your typical surgeon who just wants to get in and get out,” she says. “He spent a lot of time talking with me and my husband and made us feel very comfortable. He is so open, accessible and accommodating. I really think of him more as a friend and peer instead of my surgeon.”
Gaydos-Gabriel is thrilled with the results of the reconstructive TRAM flap procedure and feels like she was spared much of the psychological trauma that accompanies breast cancer.
“I think I was really saved from a lot of the emotional ordeal that results from losing my breasts,” she says. “I love that the results are so natural. And Dr. Brandt is a perfectionist — he’s not done until he thinks it’s absolutely perfect.”
Herrmann agrees that Brandt has a special gift for making patients feel comfortable — and hopeful — about reconstructive surgery.
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Keith E. Brandt Hometown: San Antonio Years married: 18. He met his wife, Tina, a retired surgical nurse, in the OR. “The surgeon was 80 and the patient was 79, and the case lasted for 10 hours,” he says. “She left after a few hours and it took me three weeks to track her down. But it was worth it!” Family: Brandt is an assistant scoutmaster for his sons’ — Taylor, 13, and Travis, 10 — Boy Scouts troop. Brandt — an Eagle Scout himself — has been camping 28 nights this past year. |
“Dr. Brandt is one of the most compassionate and kind physicians, and he has the ability to put patients at ease even though they are facing a difficult diagnosis and surgery,” she says. “His patience and willingness to listen distinguish him as a reconstructive plastic surgeon. He has excellent insight and is interested in the whole patient, not just the reconstructive surgery.”
Incredibly dedicated
While attending the University of Texas Medical School at Houston, Brandt was drawn to plastic and reconstructive surgery after participating in a toe-to-thumb transplant.
“The ability to rebuild things was too cool,” he says. “I was hooked after that.”
After medical school, he completed general surgery training at the University of Nebraska Medical Center and then did a plastic surgery residency at the University of Tennessee.
In 1991, he came to Washington University for a hand and microsurgery fellowship, followed by a peripheral nerve and brachial plexus fellowship under Mackinnon.
When the Siteman Cancer Center became an NCI-designated center in 2001, Mackinnon knew her former fellow would be the perfect person to head up the division’s section of cancer reconstruction. Brandt left the M.D. Anderson Cancer Center to come to Washington University in 1999.
Since then, he’s become the program director of the Plastic and Reconstructive Surgery Residency program and the Hand Surgery Fellowship Program.
Brandt’s new role as program director of the residency and fellowship programs also resulted in a new hobby: running marathons.
“I started training four years ago, and there are six residents that are still alive today because I run,” he jokes. “I take out all of my frustrations on the ground instead of on them.”
In the past two years, Brandt has competed in seven marathons, including the Chicago Marathon, and he’s training to qualify for the Boston Marathon.
“Dr. Brandt brings the same steady, even pace to patient care and the OR that he uses as a marathon runner,” says resident Elizabeth Sieczka, M.D. “He is a dedicated teacher and serves as a guide for the residents as we go through our training.”
Herrmann says what she admires most about Brandt is his humility and dedication to patients and willingness to pass his knowledge on to residents and fellows.
“His focus is always on what is best for patients,” she says. “He selflessly gives his time and energy to patients and to the residents and students who are lucky enough to work with him.”