Ask the Doctor: Flap Surgeries

natural breast reconstructionQuestion: 

I had a bilateral mastectomy last December after chemotherapy for stage 3 breast cancer in my right breast and lymph node removal. Expanders were inserted, and I had radiation treatment that ended in the spring. I am now ready to get rid of these expanders and have reconstructive surgery. I am confident I want an autologous tissue surgery. I am on my third plastic surgeon and I have concerns about going forward with this doctor since he has not shown me any pictures and does not talk about a “team” approach.

I was interested in the PAP flap surgery since I have large hips and thighs, but he has only talked about doing the DIEP flap surgery or implants. He has other plastic surgeries (not breast reconstruction) he specializes in at his practice. I have never considered going out-of-state for medical treatment, and my work schedule is a concern.

I just want to know your thoughts about my situation and if I should go forward with my current doctor. I have found your website to be a great source of information and encouragement. God bless you for all your doing to help!

Answer: 

Thanks for reaching out to us.

The PAP is our 3rd line flap (after DIEP and SGAP). It is ideal in some situations, and yours may well be one of them, but it does have a few potential downsides:

  1. In MOST people, the flaps are fairly small, typically 200-300 grams (but you may be an exception);
  2. The profunda artery perforator, while usually present, is occasionally absent or very small. The preoperative MRI angiogram will determine this; and
  3. If you have a donor site complication, such as dehiscence (ruptured wound along a surgical incision), it can be difficult to manage due to the location and motion in the area.

One good thing about the PAP in contrast to the TUG (which we do not use) is that it involves few if any lymph nodes, and thus the risk of lower extremity lymphedema is minimal. We usually recommend the DIEP if you have a good donor site, but many people do not. Our DIEP success rate (after around 1350 flaps) is 99.0 percent.

The SGAP, our next choice, is an extremely good flap, although the dissection is difficult, which is why it is not routinely performed in most places. This flap can be quite large, occasionally in excess of 1000 grams in certain individuals. We have completed about 270 of these flaps, most simultaneous bilateral, with a success rate of 94.8 percent. We firmly believe in the team approach, which was taught to us by Dr. Allen, and we would not have the results that we do without it.

At The Center for Natural Breast Reconstruction, we never do flaps without two equally competent microsurgeons present.

Thank you again for your inquiry. Please contact us if you need anything, and we would be happy to speak with you by phone, or see you in-person for a consultation at any time.

Richard M. Kline, Jr., MD, 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, S.C. 29464.

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