Archives for October 2018

Q: How is natural breast reconstruction done and what is the cost? Also, how long is the recovery period? 

A: Thanks for your question, my name is Audrey and I am one of the Physician’s Assistants with the Center for Natural Breast Reconstruction. I will try to give you some basic information and please email or call if you have more.

There are three common options for natural reconstruction—DIEP, PAP and GAP:

• DIEP stands for Deep Inferior Epigastric Perforator, and the tissue comes from your abdomen, like a tummy tuck. We never take muscle—only the fat and skin—and then we close up the abdomen similar to the closure for a tummy tuck. The tissue is detached from your body and then placed in the breast pockets. The blood supply to this flap is traced out and dissected, and then the tissue is transplanted into the breast skin envelope. To keep the flap viable, microsurgery is performed to restore its blood supply by attaching its blood vessels to recipient blood vessels in the chest. This flap requires specialized operating room equipment and postoperative personnel. Some skin on the flap is kept as a skin paddle to allow us to monitor the flap’s color, temperature and vessel signals. That skin paddle may be removed at a subsequent stage of surgery in certain patient situations. DIEP is the most commonly performed free flap reconstruction and has the highest success rate.
• PAP stands for Profunda Artery Perforator. The procedure is the same as above, but it uses tissue from the thighs instead of the abdomen. Often, it is taken from the back and/or inner thighs, and we typically take a small amount from each thigh to make either one or two breasts. The recovery takes a little more time since you would have two donor sites instead of one—but it is very achievable. The risks are the same as with DIEP as is the procedure of connecting the blood vessels through microsurgery.
• GAP stands for Gluteal Artery Perforator, and the donor site is the buttocks. Depending on whether you need one breast or two, we take only fat and skin from each side of the buttocks to make into breast mounds using the same process as the DIEP. This also has the same risk, can have more than one donor site, and requires repositioning during surgery since we are working on each side of your body.

For each of these procedures, the surgery time is anywhere from 5 to 10 hours with an average of about 7 to 8—it depends primarily on whether you need mastectomies; whether you have had previous reconstruction procedures; and on your personal anatomy in terms of how difficult it is to find and connect your blood vessels. We keep patients in the hospital for three-four nights. Out-of-town patients are asked to stay in the Charleston area for a full week following surgery so we can check in on them, and hopefully remove breast drains, which prevent blood and lymphatic fluid from building up under the skin, before you head home. We provide a list of hotels that offer medical rates to help you control lodging costs. Patients have one drain per breast and then one drain at each donor site. Breast drains are removed within 6-7 days post-op and the donor site drains are in for 2-4 weeks, depending on the site. We require a special MRI called an MRA (magnetic resonance angiography) of the donor area before surgery to look for where your blood vessels are located. We request this be done at Imaging Specialists of Charleston as they have the right equipment and outstanding radiologists who use a specialized protocol to read the MRA and know exactly what to report to our surgeons.

If only a cancer-side mastectomy was completed, the other breast may also require augmentation, lifting, reduction or some combination thereof to establish symmetry.

Breast reconstruction is a staged process with a minimum of two surgeries, with each subsequent surgery getting smaller, and requiring less recovery time. The first stage requires three-four nights in the hospital, and subsequent surgeries typically require a one-night hospital stay. Second stages can be a minimum of three months after the previous surgery (often six months after if you have had radiation), or can be spread out further as needed to fit in with your schedule. The recovery is about six-eight weeks, and requires you to keep your arms close to your sides, no heavy lifting and no high-impact activities. You will, however, be up and walking around and able to do most basic activities with some restrictions. Driving is not allowed for at least the first few weeks. Some patients can go back to work after six to eight weeks—maybe sooner—depending on the job they have.

As follow-up appointments go, within a week to 10 days after the first surgery, you are typically cleared to head home and need not see us again until right before your next surgery stage. If you have a local breast surgeon or plastic surgeon close to home, we recommend following up with them, and we do frequent telephone/email/patient portal outreach to check in. We are always happy to see you in the office if you wish to make the trip.
Our office also does expander/implant reconstruction, but it is harder for patients out-of-state because of the number and frequency of follow-up appointments needed in the first few weeks to months after surgery. If you are interested in hearing more about this option, please let me know.

I hope this information helps to answer your questions and give you a better idea of your natural breast reconstruction options. We are happy to continue answering questions via email or phone calls, and we would love to set up a consult for you to come meet us in the office at a time convenient for you. We often like to gather more health information before you make the trip to make sure that one of these options could work for you. That information includes:

• Breast cancer details (which breast, when were you diagnosed, what type of cancer is it, do you need radiation?)
• Mastectomy/reconstruction details (have you had lumpectomy, mastectomy, was it skin/nipple-sparing, did you have any reconstruction done already?)
• Abdominal surgeries (have you had any major surgeries with large scars across your belly, do you have enough tissue to use?)
• Medical history (any history of clotting disorders, DVT/PE blood clots, problems with anesthesia, diabetes, obesity, etc?)

Once you have a breast cancer diagnosis, insurance is supposed to cover the cost of breast reconstruction. We have no control over your personal deductibles or out-of-pocket maximums—everything is billed as reconstruction through your insurance. Using your own tissue for reconstruction is not a simple or low-cost procedure; however insurance typically makes it affordable. We are in-network with most major insurers and can usually negotiate a one-time contract with those we are not.

If you want to provide your insurance information, we’re happy to investigate your benefits for you and assure your insurance will cover any procedure you choose. Our office manager, Gail, could give you detailed information about the costs and once we have more information from you.

Please call us or email any questions you have with information/details from above. We look forward to speaking with you soon. Thanks and have a great day!

Audrey Rowen, PA-C
East Cooper Plastic Surgery
The Center for Natural Breast Reconstruction,
Phone: (843) 849-8418
Fax: (843) 849-8419

1300 Hospital Drive, Suite 120
Mount Pleasant, SC 29464

Q:  
I have an implant from reconstruction 7 years ago. I do not have breast symmetry as the other breast was a TRAM flap reconstruction. I would, however, like to have symmetry – how can this be achieved?

A:
Great question! You have several options to improve breast symmetry. We could simply “fat graft” the TRAM flap reconstruction to improve the size and enhance the shape of the breast mound. In fat grafting, fatty tissue is removed from other parts of your body – usually your thighs, belly and buttocks – by liposuction. The tissue is then processed into liquid and injected into the breast area to recreate/enhance the breast. This technique is especially helpful when trying to improve the symmetry between an implant reconstruction and autologous reconstruction.

If your implant is currently under the muscle, this can be revised. The implant can be re-placed in front of the muscle with a full ADM (Acellular Dermal Matrix, specially preserved cadaver skin – AlloDerm® is most commonly used brand) wrap. This allows much better control of implant position, and often helps create better projection and shape. The main complication is that you can sometimes see more rippling of the skin than you typically do with an under-the-muscle implant, but not necessarily. It is also possible that simply revising your current implant reconstruction could produce improvement, but we have less control with that method. 

Finally, it may be possible to have the implant replaced with your own tissue. You might consider using another area of the body, such as the buttock or thigh, to replace the implant completely. One option would be the SGAP (Superior Gluteal Artery Perforator). Breast reconstruction with the GAP flap involves moving a segment of skin and fat from the buttock to recreate a breast mound shape after the removal of the breast tissue (i.e., mastectomy defect). This involves the disconnection of the tissues from the gluteal muscles and surrounding gluteal tissue. (We DO NOT take the muscle.) The tissue is then transplanted into the breast skin envelope. To keep the flap alive, its blood supply must be restored by microsurgery, a procedure that attaches its blood vessels to recipient blood vessels in the chest. 

I hope this information helps. Please let me know if you have any further questions. 
 
Lindsey Weaver, FNP-C
East Cooper Plastic Surgery

The Center for Natural Breast Reconstruction

Phone: (843) 849-8418

Fax: (843) 849-8419