Ask the Doctor: Q&A

Q:
I recently completed chemo for stage 3 IDC (invasive ductal carcinoma) in my left breast. I have chosen to have a bilateral mastectomy because I’m 44 and my oncologist recommended it. I’m scheduled for radiation after surgery. I was hoping to have immediate DIEP flap reconstruction but the plastic surgeon I spoke to today said he doesn’t recommend it until after radiation. I had originally consulted with an out-of-state plastic surgeon who said they perform the mastectomy and immediate reconstruction with skin flaps but they don’t recommend it with implants. My radiation oncologist even told me that statistically, women are more satisfied with immediate reconstruction. I’m very confused and if I can avoid having two surgeries, I would prefer that. Any advice would be greatly appreciated!

Thanks,
Angie

 

A:
Hi Angie,
I’m sorry you are going through this, but your question is an excellent one, and has been asked by many patients.
We try not to radiate natural tissue (flap) reconstructions, which includes DIEP flaps. As a rule, at best, the radiation will “shrivel up” the flap about 25% and make it firmer; at worst, it will shrivel it up to almost nothing. While some plastic surgeons don’t seem to mind these odds, we feel that in general, we do patients a disservice if we recommend radiating flaps. Additionally, if the flap is delayed until AFTER the radiation, it is usually the IDEAL method of reconstruction, and its success is not at all affected by the fact that the breast area has been radiated.
On the other hand, implant-based reconstructions, while faring more poorly when radiated than when not radiated, at least do not place priceless irreplaceable natural tissue at risk of loss. When we know or strongly suspect that a patient is to need post-operative radiation, we often recommend placing temporary tissue expanders
in front of the muscle at the time of mastectomy(ies). After the radiation is complete, the expander is removed, and reconstruction with natural tissue (such as DIEP flap or sGAP flap) is performed. It is not absolutely necessary that a temporary tissue expander be placed, but it serves the dual purposes of providing a temporary breast mound, and often preventing excessive wrinkling and contraction of the remaining breast skin until reconstruction with your own tissue can be done.
I would be happy to chat with you by phone or see you in person to discuss your situation further, if you wish. We have performed more than 1400 DIEP flaps with a 99% success rate, and we are happy to share what we have learned in the process.

Thanks,
Dr. Richard M. Kline Jr., M.D.

Dr. Kline trained in microsurgery with Dr. Robert Allen, who was pioneering the DIEP, SIEA, and GAP flaps.

Comments

  1. Hello,
    I had a left mastectomy with axilla lymph node resection in 2004. Afterwards I had chemo in 2004 and again in 2005.I did not have radiation. I am interested in a flap reconstruction on left side. I know there would be better visual results with bilateral flap reconstruction but don’t want to give up sensation and natural breast on right side for appearance. I am “A” cup on right side. How hard is it to ‘match up’ reconstructed with existing smaller breast? I’ve heard patients say they were strongly encouraged to have bilat due to symmetry and appearance. How far off are results when it’s unilateral? Also – I’m in triangle area (Raleigh NC), how many trips would this take? I’m 65 yrs old. What do you recommend for presurgical prep to ‘get in shape’ for a major surgery? Thank you.

    • Thank you for your question.

      Generally speaking, it is much easier to match a remaining normal breast with your own tissue than it is with an implant. If you are an “A” on the other side and want your reconstruction to be the same size, that can probably be accomplished with a flap, although it may be necessary for technical reasons to first make the breast a little larger than you want, then reduce it later to the appropriate size. If you want to be larger on both sides than you are now and don’t mind using implants, then an implant could be added to the right side with a reasonable expectation (but no guarantee) of retained sensation. If this was your preferred approach, then you might get better overall symmetry by undergoing an implant reconstruction in front of the muscle on the left side, although I would hesitate to make a firm recommendation before evaluating you in person.

      If you have flap reconstruction, the normal sequence of surgeries is as follows:

      1) Big surgery to transfer the flap, (3-4) days in the hospital
      2) (3 months or more later) much smaller surgery, open revision breast flap and donor site to improve appearance, 1 night in hospital
      3) (3 months or more later) free fat grafting to improve breast symmetry and further refine donor site, 1 night in hospital.

      Of course, you are in the “driver’s seat,” and we only to proceed to each subsequent phase of surgery if that is what you want at the time. However, most patients find that this sequence gets them the most favorable results for the long term.

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