When is the Ideal Time for Reconstruction Surgery?

Some breast cancer patients require a mastectomy, the removal of a breast affected with cancer. Many choose to then have reconstruction surgery in an attempt to rebuild the breasts back to a normal look and shape. But when is the best time to have this surgery – at the same time you are having your mastectomy or at a later time?

Well, it depends on a variety of factors.

During the Mastectomy

Ideally, reconstruction begins at the same time that you have the mastectomy. This is especially important for earlier stage breast cancers. There is an advantage to having immediate reconstruction: Breast cancer patients do not have to wake up to the stark change of a removed breast. Instead, the reconstructed breast is already in place. This often helps with the breast cancer patient’s self-esteem and recovery.

Months After the Mastectomy

However, breast cancer patients who must undergo chemotherapy or radiation may choose to delay their breast reconstruction. Breast reconstruction cannot be performed until around six months after a patient’s final radiation treatment. However, chemotherapy varies. Some women have mastectomy and reconstruction immediately and do not start chemotherapy until after that is completed. Some women have to do chemotherapy first and then have mastectomy and reconstruction. Others have their mastectomy, have chemotherapy and wait to have reconstruction. Planning and timing is based on the type of cancer, pathology, oncology recommendation and the patient preference.

You might also decide to have reconstruction at a later time because, as a breast cancer patient, you are also dealing with a lot and may just want some time to make this decision and prepare for the surgeries.

Preparing for a Delayed Reconstruction

For those who do choose delayed reconstruction, the surgeon can put expanders in during the mastectomy that will help to keep the skin preserved to accommodate an implant or autologeous breast flap at a later time.

There are many decisions to make when you are undergoing breast cancer treatment and possible reconstruction. Patients and their team must consider timing and which reconstruction procedure is best. The patient can choose from implants or autologous breast procedures. Autologous breast reconstruction uses the patient’s own body tissue to recreate the breast. The tissue can come from the belly, buttocks or thigh.

It is important to note that if radiation therapy is indicated it’s best that occur before undergoing autologous breast reconstruction. Whether you decide to have autologous breast reconstruction or implant reconstruction will also depend on several factors, including your age, health status, location of the tumor, previous surgeries and the availability of extra tissue in your body. There are pros and cons of each procedure, so it’s important to talk to your doctor about which one is best for you.

The Center for Natural Breast Reconstruction believes in good health for everyone. If you or someone you know is in need of breast reconstruction, contact them at NaturalBreastReconstruction.com or toll-free at 866-374-2627.

Know the 5 Steps of Breast Reconstruction Before Your Mastectomy

 

If you’ve been diagnosed with breast cancer and will have a mastectomy, your doctor has probably discussed what comes next. Often, if you choose breast reconstruction, the process starts at the time of your mastectomy, but it can also be done at a later time – even years later.

Once the reconstruction process starts, it’s typically two or three stages – restoring the breast, refining the shape of the reconstructed breast and then reconstructing the nipples if desired. But every breast reconstruction procedure should start with a consultation with your physician.

Step One: Consultation with Your Team
Not every woman chooses to have reconstruction after mastectomy, so it’s important to weigh your options with your team, which should include your breast surgeon, plastic surgeon, radiation oncologist, medical oncologist and anyone else who is part of your treatment.

If you do choose reconstruction, your physician should discuss whether you will have your procedure at the same time you are having your mastectomy or at a later time. Your physician may recommend delaying your breast reconstruction based on the course of your treatment. Sometimes chemotherapy and radiation can delay the ability to have immediate reconstruction. Your surgeons should discuss the risks and benefits associated with all breast reconstruction procedures to allow you to make the choice that is best for you as well as helping you understand when the right time is for you to successfully complete the procedure of your choice.

Step Two: Mastectomy and Reconstruction

Choosing immediate reconstruction, at the time of mastectomy, is a great choice if it’s possible for the patient to do so. Those who opt to have breast reconstruction at a later time and have their mastectomy completed first can still choose from the wide variety of breast reconstruction procedures offered to all patients. At the time of mastectomy, tissue expanders can be inserted to help preserve the shape of the breast and conserve breast skin should definitive reconstructive surgery be scheduled for the future.   

Step Three: Restoring the Breast

Now it’s time to rebuild your breast. The two most common reconstruction procedures are autologous breast reconstruction and implant reconstruction. During autologous reconstruction, a plastic surgeon uses your own tissue, skin and fat from another place on your body – typically from your buttock, abdomen or thigh – to recreate your breast mound. Should you choose implant reconstruction, our surgeons at The Center for Natural Breast Reconstruction utilize the most state of the art techniques to achieve the most natural result. Direct to implant and above the muscle implant reconstruction with acellular dermal matrix are examples of the procedures we offer. 

Step Four: Refinement
Sometimes the shape of the reconstructed breasts need to be refined a bit, so another surgical procedure might be necessary. Some patients also choose to have the unaffected breast modified to achieve even closer symmetry, and that can be done at this stage.

Step Five: Nipple Reconstruction

If you have chosen to have a nipple-preserving mastectomy, you may only need one or two stages of surgery to complete the restoration process. However, if you need nipple reconstruction, it can be done either during Stage Two or Three. We typically like to wait at least three months between all procedures if possible to allow for healing before making further modifications. A few months after the nipples are reconstructed, you may also undergo a tattooing procedure to add more natural coloring to the nipple. Some women choose only 3-D tattooing as their definitive choice for nipple reconstruction.

Recovery time will vary from patient to patient. Your individual surgery timeline may also differ depending on your particular needs.

The Center for Natural Breast Reconstruction believes in good health for everyone. If you or someone you know is in need of breast reconstruction, contact them at NaturalBreastReconstruction.com or toll-free at 866-374-2627.

Ask the Doctor: Q&A

Q:

I am interested in DIEP and live in N.C., but before I go any further, I have questions. I’m a healthy, 43-year-old female; married with children; I work, and I’m a non-smoker. I was recently diagnosed with multi-centric DCIS in my right breast. MRI enhancing revealed a left breast lesion, and a biopsy will be scheduled soon. Genetic testing came back negative. A local plastic surgery consult indicated sufficient abdominal tissue to create a breast mound. My first question — who are the breast surgeons that your office works with? Would they do a sentinel node biopsy as my surgeon has recommended? Second, could the mastectomy and DIEP occur during a single surgery? Third, do you coordinate care with my current breast surgeon? I anticipate that if the lesion on the left is also DCIS, I would opt for a lumpectomy and radiation on that side since the area is small, and do it locally with my current breast surgeon. Finally, how would I start the process of moving forward with a consult with your office for DIEP?

A:

Hi, Kay,

Thank you for your question, I am sorry you have to go through surgery. It seems you have already gotten a lot of good information about your possible treatment and reconstruction. Our practice has specialized in breast reconstruction using natural fatty tissue and procedures such as the DIEP flap since 2002. My partner and I have performed nearly 2000 breast reconstructions using natural tissue with an overall success rate of 99%. We work with several breast surgeons who we collaborate with on every patient. We are also accustomed to patients having to travel to us from out of state and have had patients come from 48 of the 50 states. We understand the difficulties associated with what you are going through and our mission is to help people in your situation. You have some excellent questions so I will answer them in list format. 

1. Who are the breast surgeons that your office works with?

We work with multiple breast surgeons who we are familiar with and collaborate with to offer our patients the options that are best for each individual situation.  Drs. Megan Baker, Jennifer Fiorinni, and Jennifer Beatty are excellent breast surgeons who we work with. Would they do a sentinel node biopsy as my surgeon has recommended I have done? Yes, they would and frequently do prior to mastectomy to determine if radiation is needed after mastectomy.

2. Could the mastectomy and DIEP Flap occur during a single surgery?

Yes, absolutely! We feel this is very important to get the best result and to minimize the number of surgeries needed.

3.  Do you coordinate care with my current breast surgeon? I anticipate that if the lesion on the left is also DCIS that I would opt for lumpectomy and radiation on that side since it is a small area and would do that locally with my current breast surgeon.

Yes, we coordinate with our patient’s home breast surgeons. For what treatment is best we also rely on the opinion of the breast surgeon here. In your situation it may be best to consider possibly having both breasts removed and then reconstructing both at the same time with the same technique. That approach allows us to achieve better symmetry between the breasts. Sometimes after a lumpectomy and radiation, the breast can develop an abnormal shape that is not desirable and difficult — if not impossible — to match with the opposite breast. The problems might not surface until after radiation and are then nearly impossible to repair. When we use the DIEP flap, it is often available for each breast and therefore makes for a great match. We can discuss this more if you like.

4. How would I start the process of moving forward with a consult with your office for DIEP?

Just let me know if you would like to see me for a consult in person or make an appointment to talk over the phone. Most of the time, we can plan and answer questions before an actual visit in person. My staff can contact you to schedule an appointment and gather additional information.

I hope that I have answered your questions, let me know if you have other questions.

Thank you,

James Craigie, MD

CNBR

Finding the Right Surgeon

5 Key Attributes to Look for in a Plastic Surgeon

 

You’ve been diagnosed with breast cancer and had a mastectomy. Now you’ve made the important decision to have reconstructive surgery to rebuild your breast. Your next important decision is to make sure you have the right plastic surgeon to do the job.

Finding the right surgeon isn’t always easy. But you need to put the same time and effort into it that you would put into hiring a real estate agent to find you a home or finding the right school for your children. After all this is your health we’re talking about and you deserve the best.

So what should you look for when choosing a surgeon?

1. Make Sure the Plastic Surgeon Specializes in Your Procedure

Some plastic surgeons specialize in implants, while others do tissue flap procedures, such as TRAM or the newer microsurgical procedure, the DIEP flap. Perhaps you already had a reconstruction procedure and need it revised. You need someone who has extensive experience with revision surgery.  Ask how many procedures the surgeon has performed and the success rate for the specific procedure you are considering.

2. Make Sure They are Board Certified and Well Trained.

Plastic surgeons are certified by the American Board of Plastic Surgery (ABPS)  which means that they have completed residency training specifically in Plastic and Reconstructive Surgery at an accredited institution.  They have passed comprehensive written and oral examinations covering all plastic surgery procedures. You can visit the ABPS website to find out if your plastic surgeon is an up-to-date certified member.  Fellowship training in a specialized field such as Breast Microsurgery is desirable if you are considering muscle sparing autologeous reconstruction procedures such as DIEP, GAP, PAP etc.

3. Make Sure the Surgeon’s Record is Clean

There are licensing boards for each state where you can check a surgeon’s background for any malpractice judgments or disciplinary actions. Visit the Federation of State Medical Boards’ website for more information.

4. Make Sure You are Comfortable

Once you find a plastic surgeon that specializes in your chosen breast reconstruction procedure, make sure to meet and ask a variety of questions. For example, how many procedures have you performed? What is your success rate? What is your background? What will the surgery entail and what is recovery going to be like?

Even if you have done your research and know the answers, see if you are comfortable with how the doctor communicates with you during this meeting. Does the surgeon answer your questions thoroughly and address your concerns?  If the answers are off-putting or you feel uncomfortable in any way, that surgeon may not be the one for you.

5. Make Sure They Take Your Insurance

It might sound like an obvious thing to ask, but some surgeons will require that you pay out-of-network fees. You don’t want to be surprised with a big bill at the end of the procedure, so make sure that your plastic surgery procedure and the surgeon’s fees are covered at in-network rates by your insurance plan. Work with the surgeon and their staff to make sure everything is covered and you know all of the out-of-pocket costs prior to the procedure.

The Center for Natural Breast Reconstruction believes in good health for everyone. If you or someone you know is in need of breast reconstruction, contact them at NaturalBreastReconstruction.com or toll-free at 866- 374-2627.

Ask the Doctor: Q&A

Q: I had a lumpectomy and radiation for breast cancer. I would like to know if I can get reconstruction surgery.

Sincerely,

Ms. Jones

A: Ms. Jones,
Thank you for your question. You can absolutely get reconstruction after lumpectomy and radiation. Some of your options depend on the extent of deformity/radiation damage and asymmetry between breasts, and whether you want to proceed with a complete mastectomy.
If you are looking to just improve the appearance of your radiated breast, different things that can be done to adjust that breast to achieve a better cosmetic result and symmetry. Often modifying the non-cancer breast with a reduction and/or lift can create better symmetry.

With true breast reconstruction, you need a complete mastectomy for an implant or your own tissue to replace the breast mound. Implants are often not recommended for and do not work the best in a radiated breast, but it is not impossible. Having had a lumpectomy with radiation has no effect on your ability to have the breast reconstructed with your own tissue by using your abdomen, buttocks or thighs as the most likely donor sites.

We work with multiple excellent breast surgeons in our area who could do the mastectomy immediately followed by reconstruction in the same surgery. Depending on your overall risk and preference, you could also have the non-cancer breast removed and reconstructed, but we leave that decision up to you and your oncology team.

Our reconstruction procedures are most commonly a staged process that involves at least two surgeries to achieve something close to a satisfying result. We would be happy to meet you in the office for a consult with one of our surgeons, Dr. James Craigie or Dr. Richard Kline, to discuss your best options and give you more information on the different procedures. If you live out of town, we can often offer a phone consult first to help you better understand the process before you make a long trip here. We also can set up a meeting for you with a local breast surgeon on the same day as your consult with us if you are interested. Please let us know how we can best help you, and we look forward to hearing from you.
Sincerely,

Audrey Rowen, PA-C

Autologous vs. Implant

Benefits of Autologous Breast Reconstruction vs. Implants

 

If you had a mastectomy as part of your breast cancer treatment, you may be considering reconstruction to get back the look and feel of your natural breast. The two reconstruction options that patients normally choose between are autologous breast reconstruction and implant reconstruction.

Autologous breast reconstruction involves using your own tissue to recreate your breasts and can be done either when you have your mastectomy (immediate reconstruction) or at a later time (delayed reconstruction). Autologous breast reconstruction typically involves multiple stages; however, implant reconstruction often requires several stages as well.

With autologous reconstruction, a plastic surgeon uses the tissue from another place on your body (called a donor site) — typically from your abdomen, buttocks, or thighs – to recreate natural looking (and feeling) breasts. Using microsurgery, the surgeons attach vessels from the donor site to vessels in your chest to provide adequate blood flow to your new breasts.

Many patients who undergo autologous reconstruction, after having implants placed previously, state that their new breasts look and feel more like their old breasts compared to when they had implants.

Women who need radiation therapy before or after their mastectomy may also want to consider autologous breast reconstruction instead of implants because of the higher rate of failure associated with placing an implant under radiated skin and tissue. However, it is important to note that radiation must occur before undergoing autologous breast reconstruction.

Whether you decide to have autologous breast reconstruction or implant reconstruction depends on several factors, including your age, health status, location of the tumor, previous surgeries, and the availability of extra tissue in your body. There are pros and cons of each procedure, so it’s important to talk to your doctor about which one is best for you.

Implant reconstruction carries its own unique set of risks. Risks include inflammatory reaction, leaks, and mechanical implant failures.  There is also a chance that excessive scar tissue can form around the implants (capsular contracture) and cause pain and malposition necessitating removal or revision of the reconstructed breast. Due to these possibilities, implants may have to be surgically replaced or exchanged at a later time.

The Center for Natural Breast Reconstruction believes in good health for everyone. If you or someone you know is in need of breast reconstruction, contact them at NaturalBreastReconstruction.com or toll-free at 866- 374-2627.

Ask the Doctor: Q&A

Q:
Hello,

I had a double mastectomy on June 5, 2018, for breast cancer. I finished chemotherapy on November 28th, 2018. I am interested in having the DIEP done and I read information about the ReSensation™ option and am very interested. I live in Aiken, S.C. and would love to get an appointment scheduled.

Thanks,
Erin

 

A:
Hi Erin,

I’m sorry you have had breast cancer, but we would be delighted to help you. We have done about 1,400 DIEP reconstructions over the last 15 years, with a 99% flap survival rate (plus about 300 other perforator flaps for breast reconstruction, mostly sGAPs and PAPs). We have been using ReSensation™ to improve the chances of restoring sensation since October 2017.

While there is not yet definitive published data proving that the nerve grafts help restore sensation, there are some promising early results. We have had some difficulty with certain insurance companies refusing to pay for the nerve grafts, but we would of course address that with them prior to your surgery. I would be delighted to see you in consultation at a time convenient for you. I typically see new patients on Tuesdays and Fridays, but I can often see patients on other days if it works better for you. Thanks for your inquiry, and have a great day!

Best,
Richard M. Kline Jr., M.D.

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

Breast Cancer and Younger Women

Most breast cancer is found in women who are over 50 years old, but lately it is becoming more common for younger women to be diagnosed with the disease. As a matter of fact, the Centers for Disease Control and Prevention (CDC) states that about 11 percent of all new cases of breast cancer in the United States are found in women who are younger than 45 years of age.

Young women who have been diagnosed are often confused and angry. Here are some stories from younger women (their last names have been withheld to protect their anonymity).

Jamie always felt like she had a higher risk of breast cancer, but never thought she’d be diagnosed at 38. “I thought if I ever got cancer it would be much later in life – when I was in my 60s or 70s,” she says.

Sarah was diagnosed two weeks shy of her 37th birthday. An otherwise healthy young woman, she was angry when the doctor told her she had breast cancer at such a young age.

Anna was diagnosed when she was only 34-years-old and, as a young mom to a 17-month-old daughter, she felt like her future family plans were quickly fading away.

Kristen has a three-year-old daughter, but her breast cancer diagnosis and chemo treatment wiped away her dreams of having another child. “This is the time when all my friends who had babies at the same time as me are having their second child,” she says.

According to the CDC, younger women are at a higher risk for breast cancer if they have close relatives who have also been diagnosed at a younger age, if they have the BRCA1 and BRCA2 gene, are of Ashkenazi Jewish heritage or have been treated with radiation therapy to the breast or chest in childhood or early adulthood. If they are diagnosed, the breast cancer is often found to be at a later stage and more aggressive.

Once diagnosed, younger women must make a variety of decisions concerning their treatment and their future. That includes decisions to have a mastectomy and reconstruction surgery, as well as deciding about childbirth. That is because some breast cancer chemo treatments might damage the ovaries, which can sometimes cause immediate or delayed infertility.

Dana says the hardest part of being a young breast cancer patient was going into the chemo room where the average age of the patients was about 60. “They look at me with such pity and said, ‘At least I’ve had a long life, saw my kids and grandkids grow up,’” she says. “But I will survive and will also see my kids grow up.”

The Center for Natural Breast Reconstruction believes in good health for everyone, regardless of their age. If you or someone you know is in need of breast reconstruction, contact them at NaturalBreastReconstruction.com or toll-free at (866) 374-2627.

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.

Love Yourself

February is the month of love! As we celebrate Valentine’s Day and show those who are special to us how much we love them, why not do the same for yourself? As a breast cancer patient, you’ve been through diagnosis, surgery, treatment and possibly reconstruction and, of course, all the emotional ups and downs that have gone with it. This month, make sure you take some time to love and pamper yourself because you deserve it!

Love Your Bod

With breast cancer comes scars, hair loss, weight fluctuations and other changes to your body. Sometimes they are hard to accept, so the best way to start off a month about loving yourself is by loving your body and how it looks now. Yes, it’s changed, but it is hard at work fighting a disease, so be more confident about how beautiful you look. Maintain your beauty routine if it makes you feel good, accept compliments and wear clothes and hats that make you look and feel better.

Indulge

This month, millions of Americans will buy heart-shaped boxes of chocolates and indulge on rich desserts. It’s OK for you to indulge, too. If that occasional decadent dessert, piece of chocolate or dinner out makes you feel better, enjoy it!

Go Outside

In some parts of the country, it’s too chilly to take a walk, but if you can get outside for a bit, go for a walk. Many cancer patients stay inside during treatment and recovery and can suffer from winter blues. Going outside for some fresh hair and daylight can help your body to fight depression, sleep better and feel better. Even 15 minutes can make a difference.

Relax

Sometimes loving yourself means shutting out the world and enjoying your version of relaxation. Maybe it’s putting on your favorite music or romantic comedy movie. Perhaps it’s a long hot soak in a tub, reading a New York Times best-selling novel or filling in their crossword puzzle. Whatever it is, take time to do it. Your body and mind will appreciate it.

Pamper Yourself

Loving your bod, indulging and relaxation are all ways of pampering yourself, but if you need a few more ideas, how about a day at the spa? Buy that dress you always wanted or, depending on how you feel, take a quick weekend getaway from the hustle and bustle of tests and doctor appointments.

Breast reconstruction after mastectomy has been proven to help women feel better emotionally and physically. If you’ve recently gone through breast reconstructive surgery, loving yourself will help you to feel better about your breast cancer journey and how you look and feel. Also, talking to others who have gone through the process before you will also help.

Buddha once said, “You yourself, as much as anybody in the entire universe, deserve your love and affection.”

The Center for Natural Breast Reconstruction believes in good health for everyone, regardless of the season. If you or someone you know is in need of breast reconstruction, contact them at NaturalBreastReconstruction.com or toll-free at (866) 374-2627.