Active smokers have a marked impaired ability to heal and increased risk of poor healing with the mastectomy and the reconstruction. With implant surgery smokers are at higher risk of implant infection, mastectomy flap necrosis, and reconstructive failure. With abdominal flap surgery smokers are at higher risk of infection and delayed healing of the abdomen. Smoking does not increase the risk of total reconstructive failure. Nicotine replacement therapy (patches, e-cigarettes, gum) also have a poor effect on wound healing and are not much better than smoking. It is encouraged to be off of all nicotine products four weeks prior to surgery.
Patients known to be requiring radiation therapy after mastectomy present a complicated reconstructive scenario. If implant reconstruction is performed and then radiation is given, there is a higher rate of aggressive scarring around the implant which can cause pain and deformity. This is called “capsular contracture.” There is also a higher rate of implant based infection which can lead to removal of the implant and reconstruction failure. If a woman wants abdominal tissue reconstruction, performing it prior to radiation therapy can lead to unpredictable shrinkage of the reconstruction. For most women who are known to need radiation therapy after mastectomy, our general recommendation is to wait on any reconstruction until after the radiation therapy is completed. In some select patients, especially thin women with smaller breasts, initial reconstruction might be considered prior to radiation, but needs to be discussed with both the surgical oncologist and plastic surgeon.
In general, previously radiated tissue has impaired healing with surgical procedures and doesn’t stretch well because of scarring. Implant based reconstruction after radiation has a higher rate of delayed healing, infection, and reconstructive failure. Because of the tight radiated skin, it is very difficult to get an adequately sized implant reconstruction. Abdominal tissue breast reconstruction in a previously radiated area generally involves replacing much of the radiated tissue with healthy, non-radiated skin and fat. Because new non-radiated skin is used to replace the radiated skin on the chest, an adequate amount of breast can be created at the time of surgery. Timing is generally 3-6 months after completing radiation.
The location of the abdominal incision varies between patients based on location of the perforators needed for the reconstruction. High perforators (generally above the umbilicus) result in a high scar, where’s lower perforators can allow for planning of a lower scar. In general, the scar is slightly higher than the location of a true ‘tummy tuck’ scar. In some cases the scar can be lowered as a secondary procedure at time of revision.
Women who are thin, normal weight, or slightly overweight and have small to moderate breast size (A or B cup), who are having both breasts removed, and do not need radiation therapy usually do best with implant reconstructions. Implants look most natural when they are not too big and are placed on a women with a thin frame.
Women who are mildly or slightly overweight with some extra tissue in their abdomen and are having one or both breasts removed are ideal candidates for DIEP flap reconstruction. The DIEP flap has a better chance of matching the appearance of the other breast, and removing tissue from the lower abdomen can give a “tummy tuck” effect that will improve the body contour.
Many women will have multiple options for breast reconstruction, including implants or DIEP flap reconstruction. Only a thorough evaluation of a patient’s goals, physical status, and clinical history can help decide which type of reconstruction would be best.
In the setting of radiation therapy, implants have an increased risk of infection, capsular contracture, tightness, pain, and implant extrusion compared to women who have not had radiation therapy. Since DIEP flap reconstruction uses your own tissue, it can heal to radiated tissues better and has a much lower complication rate than implant based reconstruction.
A flap is a portion of tissue (usually skin and fat) that has an artery and vein providing blood supply to the tissue to keep it alive. The flap can be rotated or transplanted from one part of the body to another to help reconstruct a defect caused by cancer, trauma, or infection.
Microsurgery is a technique used by Plastic Surgeons to transplant tissue from one part of the body to another. It involves using a high powered microscope to connect the millimeter sized arteries and veins together.
DIEP stands for Deep Inferior Epigastric Perforator flap. The deep inferior epigastric blood vessels supply the circulation to the DIEP flap.
The DIEP and TRAM flap use the same skin and fat from the lower abdomen, but the TRAM flap will remove the six pack muscle from the abdomen. The DIEP flap separates the blood vessels from the six pack muscles, leaving the muscle in the abdomen. Sparing the muscle with a DIEP flap leads to less pain, quicker recovery, and less risk for hernia after surgery.
For reconstruction of one breast the surgery is usually 3- 4 hours, for reconstruction of two breasts the surgery is usually 5-6 hours.
Patients will spend 2-3 nights in the hospital, and will generally stop taking pain pills within 1-2 weeks. At 3-4 weeks most women who have light duty careers (no heaving lifting) can consider resuming work.
Once you go home you can start walking and going up and down stairs. Lighter aerobic exercises like stationary bicycle and elliptical trainer can be started within 3-4 weeks. In order to prevent injury to the abdomen, we ask that no strenuous lifting or core exercises (yoga, pilates, weight training) be performed for 12 weeks.
Yes. Once you have finished the recovery period, there will be no limitations to your activites. DIEP flap surgery has been performed on high level tennis players, professional dancers, yoga instructors and other very active women with complete recovery.
After DIEP flap surgery most patients will require only nipple reconstruction and areolar tattooing. Some patients may have some asymmetry after the initial surgery which could require an out-patient revision surgery. Since every case is unique and some reconstructions are more challenging than others, your doctor can estimate the likelihood that you would require a revision surgery. Our goal is to try to get every woman completed with as few procedures as possible.
The more experience the surgeon has, the lower the failure rate generally is. Our group has a greater than 99% success rate.
Our group routinely performs over 10 flaps per week and 600 flaps per year.
These procedures are best performed with two surgeons and an assistant. Having two experienced microsurgeons present creates efficiencies that allows our operative times to be as short as possible.
Absolutely. Most patients appreciate talking to other patients who have been through the surgery, and we have patients who are willing to share their experiences. It is best to talk to someone who best matches your clinical situation.
Yes. All cases will go through normal pre-authorization with your insurer, the same process that your Surgical Oncologist would do for the mastectomy. Normal deductibles and co-payments apply and patients are encouraged to meet with the practice billing specialist to clarify or estimate out of pocket expenses.
There are so many insurance companies out there that it is simply impossible to participate in all plans. If our group is out of network for your insurance plan, we will work on a case by case basis with your insurer to assure coverage.
For the majority of women, the answer is yes. This is very dependent on the timing of events. In general, we make every attempt to get as much of the reconstruction performed in one procedure. Frequently the only remaining procedure to perform is nipple reconstruction, which is done 3 months after the initial DIEP flap surgery.
Yes. We never want financial considerations to prevent a woman from undergoing breast reconstruction. Our patient coordinator can help you understand the different financial options available.