Practice News

New Jersey-Based Reconstructive Plastic Surgeon Dr. Andrew Elkwood Performs “Miraculous” Complex Hand Surgery

“I figured this is as good as it gets,” thought Kaelen Green at age 16, after six long years of therapy for a nearly paralyzed right arm and hand. But then, at age 28, she was inspired by a spiritual teacher to “take action and achieve more healing” in her life. She Googled paralysis treatment and The Institute for Advanced Reconstruction popped up. She had found the place, and the man, who would change her life: Dr. Andrew Elkwood.

Green’s story starts in Santa Fe, New Mexico when at 10 years old she lost control of her bicycle. Thrown from the bike, she suffered a massive brain hemorrhage that paralyzed the right side of her body. The damage was so severe that she had to re-learn how to walk and talk. Her parents dismissed the doctors’ claims that Kaelen would be in a wheelchair, and instead began what would be a steady stream of consultations with a slew of both traditional and alternative therapy practitioners.

Green, who was right-handed before the accident, also had to adapt to using her left hand—a tall order considering that at that young age she already was inclined toward drawing and painting. “’Necessity is the mother of invention’,” she says of her ordeal. “My right hand and arm were limp and floppy in the beginning, and then my hand balled up into a solid fist with my wrist bent forward. I spent six years in physical therapy and a good portion of my adolescence in hospitals.” By 16, Green figured she had reached the limit of what could be done, stopped her therapy, and went to art boarding school.

She ultimately majored in painting in college and went on to develop an artistic style she calls magical realism—an all-pencil approach she does left-handed. Seventeen years after her fall and countless sessions of physical therapy, her life took a turn.

“I went to the (Institute for Advanced Reconstruction) site and read about the amazing things they were doing for paralysis and that Dr. Elkwood was on the cutting edge in this area. I was hesitant to resort to surgery, so I wanted the very best doctor and had the gut instinct that he was ‘the one,’” says Green, right then deciding to fly across the country from Santa Fe to New Jersey to see him.

Her instinct proved correct. Thirty seconds into her consultation with Dr. Elkwood, he offered his expertise, theorizing that a muscle in her arm was confused neurologically and in a perpetual spasm causing her hand to close. He proposed a complex reconstructive surgery on her right hand and forearm that would excise the muscle spasm, fuse joints, and cut and lengthen tendons and re-attach them to different muscles. Green underwent the two-and-a-half-hour surgery on October 26, 2010 at Jersey Shore University Medical Center. After a tough bout with pain medications following her procedure, she returned home to recover and begin six months of physical therapy. The results since then have been what she describes as “miraculous.”

“I can open my hand for the first time in 18 years and have a lot more function overall. I also have better balance, and my fine motor skills and dexterity have improved,” reports Green, who now swims twice a week and is once again fully involved in her art. “I feel really grateful to have my hand back in a way I never thought I would, and am constantly surprised at what I can accomplish.”

Says Dr. Elkwood, “Kaelen is inspirational to me as a surgeon in many ways.  Her drive, determination, and spirit have no peer, and clearly, attributed strongly to her final result.  Her case also brings up a great frustration.  There are so many patients out there with similar medical circumstances that can be helped, if only they and their caregivers knew about further options.  Too often patients with certain types of paralysis are maximally rehabbed, then given a pat on the back and a pep talk; yet, sometimes more can be done.  Our goal is not to give patients false hope but rather, to maximize their potential function.  Sometimes that means small gains, sometimes -as in Kaelen’s case- the gains can be life-altering.”

Green is considering a second surgery, but in the meantime she is concentrating on a writing and drawing project and enjoying the community of artists with whom she recently hosted an open house at the New School Studios on Upper Canyon Road in Santa Fe. Of her experience with Dr. Elkwood and the staff at The Institute for Advanced Reconstruction, she says “They were great to me–always my ally and constantly advocating on my behalf with my health insurance.  As for Dr. Elkwood? I trust him implicitly and know that I’m in very good hands.”  Hands that now function on a whole new level, thanks to Dr. Elkwood.

By Russell Ashinoff, M.D.

Breast reconstruction after breast cancer surgery is one of the most commonly performed procedures at The Institute for Advanced Reconstruction.   Traditional mastectomy procedures involve removing the breast tissue and the nipple, which is  usually followed by the first step of the breast reconstruction process.  The process culminates with a separate procedure to reconstruct the nipple and areola up to one year later.  A recent study reported in ScienceDaily (Oct. 27, 2011) suggests that some women undergoing a mastectomy may be eligible for a nipple sparing procedure. This eliminates the need for an additional procedure to reconstruct the nipple and areola and expedites the reconstructive process.

Nipple sparing mastectomy (NSM) involves the removal of the breast tissue while leaving the breast skin and nipple areola complex, which includes the nipple and darker pigmented circle of skin that surrounds it. The incision is usually make on the edge of the areola, to camouflage the scar.  The breast is usually reconstructed at the time of mastectomy. In the past, there was concern that leaving the nipple intact increased the risk of local cancer recurrence.

To examine the effectiveness of NSM, surgeons conducted a review of patient records for all women receiving the surgery at Georgetown University Hospital (GUH) between 1989 and 2010 including surgeries to either prevent or treat breast cancer. The results are published in the November issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons.

Of the 162 surgeries performed, doctors found no cancer recurrences and no new cancers in those receiving NSM. However, careful selection of appropriate patients for NSM is important for the success of this procedure.

To read more about this study, go to http://www.sciencedaily.com/releases/2011/10/111027083037.htm

The surgeons at The Institute for Advanced Reconstruction are active in the area of breast cancer awareness and education, as well as experts in all advanced techniques of breast reconstruction surgery following cancer, which they perform at their New Jersey surgical facility.  During a breast reconstruction consultation at their New Jersey practice, the doctors extensively review options with patients to determine which method is most appropriate based on their needs and goals. One of those surgeons is Dr. Tushar Patel. The Institute for Advanced Reconstruction at the Plastic Surgery Center recognizes breast cancer awareness month with various initiatives, including this discussion with Dr. Patel.

Q: You trained in breast cancer reconstruction at the prestigious MD Anderson Cancer Center in Houston. What has this experience enabled you to provide your patients in terms of advanced techniques and aesthetic expertise?

The MD Anderson Cancer Center is the largest cancer hospital in the country. They have a large department that deals with breast reconstruction. What I benefitted from in training and rotating in that center is seeing how they use a multidisciplinary approach to treating breast cancer. From the start with being diagnosed, having biopsies done, meeting with oncologists, plastic surgeons, social workers and psychologists all in one center, I was exposed to the entire aspect of that multidisciplinary approach. The Cancer Institute of New Jersey, where I am involved, is also an NIH-funded facility where they closely mimic the approach of MD Anderson. The patients can meet most of their healthcare professionals and have their treatments performed at one institution.

This is rare. There are similar centers across the country, but most places don’t have a comprehensive center like this. The main benefit is convenience, because when a patient gets diagnosed with breast cancer there are lots of questions and issues that may arise. There are so many physicians she has to see–ranging from the breast surgeon to the radiation and medical oncologist to the reconstructive surgeon. This involves the psycho-social aspects as well, including meeting with psychologists and genetic counselors. If you’re telling a patient she has to see five or six different specialists, and they are all located in different places, it’s tough to navigate through all that. It’s nice having a comprehensive center where most of those facets are contained in one place.

Q: You offer various options for breast cancer reconstruction: pedicled TRAM flap, free TRAM flap, latissimus dorsi flap, DIEP flap and implant reconstruction. What factors determine which approach you would recommend to a patient?

It’s all individually patient-based, and there are a number of factors involved—such as smoking, diabetes, other illness, the age of patient, along with the need for post-operative radiation therapy. One thing often not sufficiently taken into account is the psychological well-being of the patient. She’s been diagnosed with cancer; she has multiple different doctors to see, and she may not be ready to discuss and ultimately undergo some of the more involved types of breast reconstructions. I take all this into account, and then offer the patient the most reasonable reconstructive option for her.

Q: Can you outline the basic details of breast reconstruction surgery?

The different types of breast reconstruction are basically broken down to a minimum of three procedures. The first surgery is at the time of the mastectomy, which may include placement of a tissue expander/implant or reconstruction with a flap. Once the patient has healed from this initial surgery, then the next stage involves placing permanent implants, when appropriate, along with symmetry procedures on the cancer-free side if needed. The third stage involved is creating a nipple and subsequent areola around the nipple. The first is the most comprehensive, while the final two are usually done in an outpatient setting.

There are two main categories for breast reconstruction. One is using synthetic compounds, such as implants and tissue expanders. The other is using the body’s own tissue. Within those two categories, there are different available options. The implant procedures are the easiest to recover from, as they involve the least amount of surgery with a quicker overall recovery. However, we do sometimes compromise symmetry and more natural results with the synthetics. Also, if the patient is going to receive radiation afterwards, implant-based reconstruction may not fare well. The benefits of one’s own tissue are a more natural looking breast, and one that will tolerate radiation better when needed. The down side is that these are more involved operations. The surgery takes longer, as does the recovery.

There is probably a 50/50 percent division between the two main types of surgery I perform. Sometimes there is a combined approach, such as a latissimus dorsi flap with an implant underneath one’s own tissue to reconstruct the breast.

Q: What makes a patient a good candidate for breast cancer reconstruction, and why are some patients better suited for immediate vs. delayed reconstruction?

In my practice, roughly 80 percent of the time I try to do immediate reconstruction. The benefit of immediate reconstruction is being able to salvage one’s own native breast skin which often will maintain sensation. Also, when women wake up from anesthesia they have a breast mound present, which is psychologically very important. In the delayed option, a patient wakes up with no breast, and over time that skin shrinks and is not able to be utilized as efficiently for the reconstruction. In these patients, we must take skin from the belly or the back, which will be insensate.

Those who undergo delayed reconstruction are often not psychologically prepared to absorb all the reconstructive options to make informed decisions at the time of their cancer diagnosis. Others have very aggressive breast cancers whom we know will need radiation and chemotherapy afterwards; we tend to concern ourselves with doing reconstruction later. With each reconstructive procedure, there is a four to six week recovery time, during which a patient cannot receive chemotherapy or radiation.

Obviously, taking care of the cancer comes first (such as chemotherapy and/or radiation); therefore,  the reconstructive procedures sometimes may be delayed until the cancer is treated fully and effectively.

Q: Breast cancer reconstruction not only has a great physical impact on the patient, but an emotional one as well. How would you describe your treatment approach?

The office visit is where it all starts, and at the Institute for Advanced Reconstruction, we don’t put a restriction on how much time we spend. Sometimes it is a half-hour, sometimes an hour or 90 minutes, and often multiple consultations are needed before all the questions are answered and all options explored. The main goal from my viewpoint is to make the patient feel comfortable. As a reconstructive plastic surgeon I am usually the last on a patient’s list of doctors to see. By that time, she is fairly exhausted—from the shock of her diagnosis to seeing all her physicians. I try to make it simple for her. I explain the main types of reconstruction available, and the pros and cons of each. And I recommend an option based on her individual case.

Overall, nationally, studies show breast reconstructive surgery is underutilized. Statistics show that almost 70 percent of women who are eligible for breast reconstruction following cancer surgery aren’t well informed of their options for it.

In our practice, the number of women who at least explore reconstruction is fairly high, because at facilities like the Cancer Institute of New Jersey, every woman undergoing breast cancer surgery is informed of her breast reconstructive options.

Q: What is on the horizon in terms of innovations in breast reconstruction?

The implants are improving. We have silicone (as opposed to saline) implants which provide better aesthetics (they look and feel more natural); they may tolerate radiation a little better. We have various techniques that make the flap surgeries more elegant. There’s a whole area of fat grafting, in which we use fat from different parts of the body to help give the reconstruction a more uniform, asthetically pleasing appearence. Although fat grafting is not entirely where we want it yet, it is evolving.

Q: What’s the end goal of breast reconstruction surgery?

I’ve been performing these surgeries for many years. I tell all my patients that the main goal of breast reconstruction at the very minimum is to be able to look and feel as normal as possible in clothes.

Q: What inspires you about breast reconstruction surgery?

What really stands out is the younger patients in their early or mid-30s, who have breast cancer or have the genetic mutation for breast cancer requiring the removal of their breasts. They are early in their adulthood, with a lifetime ahead of them. These are patients for whom we are providing a service they will appreciate for the rest of their lives.

Questions to ask your plastic surgeon

It is very important that you get all of your questions answered by your plastic surgeon before having breast reconstruction. If you don’t understand something, ask your surgeon about it. Here is a list of questions to get you started. Write down other questions as you think of them. You may want to record your talks with your surgeons or take notes. Some people bring a friend or family member with them to the doctor to help remember what was said. The answers to these questions may help you make your decisions.

• Can I have breast reconstruction?
• When can I have reconstruction done?
• What types of reconstruction could I have?
• What is the average cost of each type? Will my insurance cover them?
• What type of reconstruction do you think would be best for me? Why?
• How many of these procedures have your (plastic surgeon) done?
• What results can I expect?
• Will the reconstructed breast match my other breast?
• How will my reconstructed breast feel to the touch?
• Will I have any feeling in my reconstructed breast?
• What possible problems should I know about?
• How much discomfort or pain will I feel?
• How long will I be in the hospital?
• Will I need blood transfusions? If so, can I donate my own blood?
• How long it take for me to recover?
• What will I need to do at home to care for my incisions (surgical wounds)?
• Will I have a drain (tube that lets fluid out) when I go home?
• How much help will I need at home to take care of my drain and wound?
• When can I start my exercises?
• How much activity can I do at home?
• What do I do if my arm swells (this is called lymphedema)?
• When will I be able to go back to normal activity such as driving and working?
• Can I talk with other women who have had the same surgery?
• Will reconstruction interfere with chemotherapy?
• Will reconstruction interfere with radiation therapy?
• How long will the implant last?
• What kinds of changes to the breast can I expect over time?
• How will aging affect the reconstructed breast?
• What happens if I gain or lose weight?
• Are there any new reconstruction options that I should know about?

(Source: American Cancer Society)

THE SOLOIST OF BRACHIAL PLEXUS INJURY TREATMENT

Dr. Andrew Elkwood of The Institute for Advanced Reconstruction is a renowned expert in the treatment for brachial plexus injury. In his nearly 20 years of medical practice, he has successfully treated countless patients with brachial plexus injuries, including the most complex cases. Dr. Elkwood is the founder and Chairman of the Center for the Treatment of Paralysis and Reconstructive Nerve Surgery at the Jersey Shore Medical Center, which was established to deal with brachial plexus and other nerve injuries. Dr. Elkwood and his colleagues at The Institute for Advanced Reconstruction are among the few or only experts nationally and worldwide to perform all aspects of reconstructive procedures.

In addition to conducting both surgical procedures and research, the mission of the Center is to apply these same techniques to other nerve injuries, such as those to the spinal cord and those resulting from stroke.  Physicians at the Center also perform Bell’s palsy treatment, radial and ulnar nerve surgery, foot drop treatment, and an entire range of other nerve reconstruction procedures.

What is brachial plexus injury?

The brachial plexus (brachial means arm; plexus means communication or meeting point) refers to the nerves that exit the cervical spine and pass down to the shoulder and arm. This network of nerves conducts signals from the spinal cord to the shoulder, arm and hand. Brachial plexus injuries are caused by damage to those nerves. These injuries are not uncommon in adults, and are mostly due to trauma. However, there are other injuries similar to, but not necessarily to the brachial plexus. Brachial plexus is the procedure for which we have received the most attention, but my focus is all peripheral nerve injuries—from the face down to the toes.

Can you explain the various procedures you do for brachial plexus treatment?

Depending upon the seriousness of the injury, treatments for brachial plexus injury range from a “wait and see approach,” with physical therapy, to complex surgical reconstruction. At the Institute for Advanced Reconstruction, we also perform nerve transplant surgery to help patients who have suffered massive injuries to the brachial plexus, or other types of paralysis.

Can you clarify the various procedures?

Technically, transplant is transferring something from one place to another. (In reality, the medical profession considers transplant taking from one person to another.) Taking something from within the body and putting it somewhere else actually is considered grafting. A transfer is taking a nerve from the general locale and using it within that locale, without completely disconnecting that nerve. I perform all of these procedures.

A patient’s surgical treatment regimen needs to be personalized, as it is often a complex, multi-step undertaking. Some patients are not candidates for nerve surgery, and some patients have maximized the benefits from nerve surgery, but if necessary, the plan should not end there. There are many procedures that can be undertaken to help. Muscle transfers, tendon transfers, muscle flaps, and joint fusion are some of the procedures that may also benefit patients with paralysis.

What advice would you give to those seeking treatment for brachial plexus injury?

As with any illness or injury, the type of treatment selected is potentially a very emotional topic. Because of the complexity of the treatment, I believe the most important aspect of a search for care is to consider a complete approach to a solution, rather than a solely compartmentalized one.

Using a true team approach to care is the hallmark of our practice. You need a team to integrate all the modalities I have described. There are very few institutions that truly use this approach. I consider myself a “soloist” in brachial plexus and peripheral nerve surgery procedure. I personally perform all of these procedures with my team’s support. By being the lead surgeon in each of these modalities, I can best integrate an overall care plan for the patient. This is very critical and counter to those who advertise the “team approach,” but merely hand the patient off from one team member to another.

You call yourself a “soloist” of brachial plexus surgery. What exactly do you mean?

I know of no other surgeon that performs all aspects of this type of surgery. There are a number of steps and surgeries I explore with every patient, and I don’t quit until every treatment or surgical option has been considered and, if relevant, performed.

You referred to the various surgeries you perform for brachial plexus injury. What are they necessary?

There is a hierarchy of care. Ideally, I want to get the patient as close to the way God designed him or her as possible. Sometimes, additional nerve surgeries are necessary. Often I do muscle transfers, tendon transfers, muscle flaps, and joint fusion.

In the majority of cases, I have to go beyond the first and most obvious step to ensure the best possible results. One procedure results in improvement, but to maximize results, a patient often requires a multi-faceted approach. It’s a process, not an event. There are multiple goals: One goal is to return movement; then, another goal is to restore feeling.

The most important goal, which is often overlooked, is to decrease pain. Paralysis can be very painful.  Most patient complaints aren’t the paralysis, it’s the pain. You know the feeling when you hit your funny bone and that initial pain takes your breath away. Imagine hitting your funny bone and living with that initial pain 24/7. Alleviating that agony alone is huge.

With so many possible procedures, how do you define success?

The way I define success is that patients are happy they had surgery. If they don’t need to take narcotics for pain, if they gained movement—they’re happy. If there is an improvement in their quality of life—they’re happy.  I am proud to say that the vast majority of my patients are glad that they had surgery and would do it again.

Can you give a specific example of what sets you apart in your approach to brachial plexus surgery?

I treated a college student from North Carolina with a gunshot wound who had previously undergone a vascular reconstruction of his right arm. The fact the doctors kept his arm alive was fantastic. However, his arm was limp, basically useless. His doctors, who had after all saved his arm, doubted there was anything else that could be done. Unfortunately, this is what often happens. He was referred to me through his neurologist. I did an initial surgery and about 80% of the nerve damage was improved. But I realized more could be done (he still did not have the use of his hand).  I went through the hierarchy, and performed several surgeries. He got back the use of his hand. This was a young man who need not have “settled” for a partial cure, or get sent on his way because a surgeon couldn’t advise him beyond that person’s specialty.

Why did you take on the aspect of multi-level care of this injury?

I see, and treat, these procedures from “soup to nuts.” It’s just the way I see the world.  That’s why, for example, in addition to my medical training, I went to Columbia University to get my MBA—to perfect my understanding of health policy issues. As remarkable as it may seem, nerve surgery can be unsophisticated in a certain sense. These days, medical professionals tend to be specialized, so often the care is not particularly integrated. Very few want to take on complex, multi-layered procedures. My interest is in system accessibility: filling the gaps.

Is there a final message you want to communicate?

From the least to most complicated cases, I am dedicated to return patients to the best quality of life possible. I have devoted my career to this specialized surgery, and hope that this explanation will assist those who require brachial plexus treatment. I particularly pride myself in taking care of patients who have been told that nothing can be done, or that they have maximized their treatment, but I can take them to the next level. It’s rare that I see someone that I say there is nothing I can do. I’m going to get them better than they were—that’s my obsession.

What a year it has been for Kathy Leonard! The pharmacist technician from Neptune City had decided to move ahead with a breast reduction to relieve her increasing back, collarbone and shoulder pain. She was referred to Dr. Russell Ashinoff at The Institute for Advanced Reconstruction and had her first consultation in early summer 2010. A second consultation followed and Kathy underwent surgery that August.

When breast tissue is removed during surgery, it is analyzed by a pathologist. In Kathy’s case, this proved life-saving. Breast cancer was detected in the samples.

“It’s kind of hard to describe. If my sister wasn’t with me to also hear it, I wouldn’t have believed it,” says Kathy of her diagnosis. While she does have a family history (her now deceased paternal grandmother had a mastectomy 20 years ago), Kathy has had regular mammograms, none of which detected any cancer. “My breast reduction was a blessing that saved my life. My oncologist told me that if I hadn’t had it, by the time my cancer would have been found, it would have been Stage 4.”

Things moved swiftly, and one week after receiving her diagnosis she underwent a bilateral mastectomy with Dr. Jarrod Kaufman, followed by immediate breast reconstruction. She has since completed the second stage of the reconstructive process with Dr. Ashinoff and expects to complete the third, and final, stage by spring 2012. She sees Dr. Ashinoff every six weeks for monitoring to ensure she is healing properly.

“Today I’m feeling great and my shoulders and back feel fine,” remarks Kathy, whose treatment and recuperation period were strained by the loss of her father to rectal cancer and her nephew in an automobile accident. “Sometimes I get a little emotional. I’m a single parent with an 18-year-old daughter, so I’ve had to focus on keeping my job and health insurance. It definitely has been hard, but I’m grateful to be alive.”

“Kathy is one of my favorite patients. She brings a smile to my face every time I see her,” says Dr. Ashinoff. “Her bravery in the face of a number of very difficult trials this year has impressed and inspired me. She is a great example for other patients in similar situations.”

“Dr. Ashinoff called me personally the night after he told me I had cancer,” Kathy says. “Every single time I’ve had surgery, he’s been phenomenal. I’ve seen him just before having anesthesia and he’s always made me feel relaxed, comfortable and confident that I’d be fine.

“I’ve recommended him and his staff at the Institute for Advanced Reconstruction to so many people. I can’t say enough how special and caring he is. I’ve never felt this way about a doctor before. He’s really touched my life.”