Question: 

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.

Question: Hello! I’m currently seeking a surgeon for phase 2 DIEP. My plastic surgeon
here did a great job for phase 1, but doesn’t seem interested in correcting what I think is
a problem for phase 2. My breast size is currently a DD and I do not like the size. They
are heavy and my back hurts by the end of the day. I’m seeking a C cup. Also, my
abdomen is hard and bloated from underneath the breasts to just below my bellybutton.
This hardness makes it difficult to breathe. Is this something you have seen, and
something you could fix?

Answer: For one reason or another, we routinely work with patients who have had
phase 1 DIEP elsewhere, but end up coming to us for the “finishing” work. Of course,
we are delighted to help, no matter who has operated on you, and no matter what
condition you are in. Breast size certainly can be reduced; symmetry often can be
improved; and the donor site usually can be optimized. It is important to remember that
to obtain the optimal result, several procedures are commonly necessary. Typically,
each subsequent procedure decreases in length and complexity as the process
progresses. An average stage 2 scenario would include open revisions of the breast
mounds and donor site, and stage 3 would involve free-fat grafting to further refine the
shape of the breast mounds and lower body. While the initial flap transfer is obviously
the “big procedure,” we believe that the subsequent procedures are absolutely essential
to getting the results most patients to feel confident and pain-free.

Q:  I am weeks out from a unilateral DIEP flap procedure on my right side. Regarding the tightness and cramping in the abdominal area, is there any type of stretching or massage that can be done to speed healing and/or alleviate discomfort? Also, when can I begin to use moisturizers for scar reduction, and what type would you recommend?

A:  Good afternoon, thank you for reaching out to us. Those are great questions! Who was the plastic surgeon who did your DIEP procedure? It might be best to reach out to your surgeon about these questions since every practice has different recommendations. We tell our patients to leave the abdominal incision alone – to let it heal on its own – so we often discourage patients from doing any serious stretching or massage until a few months after surgery. It is OK to try standing up a little straighter each day, but you never want to force it. The tightness and discomfort will resolve on its own over time with little intervention. As far as the scars go, a lot depends on whether your surgeon feels you would benefit from having the abdomen redone at a later stage to remove scar tissue, lower the incision or remove extra skin for an aesthetically pleasing result. If you have the incision reopened, there is no reason to worry about the scars now. If you do not intend to revise the abdominal incision, then we recommend waiting closer to at least 2-3 months post-op before using any scar products.

I hope this was helpful. Please let us know if we can answer additional questions for you and we wish you the best in your recovery. 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, S.C. 29464.

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

Posted Question:
I had a Latissimus dorsi double mastectomy reconstruction in 2013. I have since lost a lot of weight – about 50 pounds – and I now feel that my breasts are too big. I feel really self-conscious. Is it possible to have a reduction after this type of surgery?

Dr.’s Answer:
Yes, it is usually possible to do a reduction in some fashion. Latissimus flaps are commonly used with implants, and it’s possible your implants could just be downsized. Alternatively, it may be better or necessary to remove some flap tissue as well. It would be difficult to make more specific recommendations without doing an actual exam and getting a few more details, but I’m willing to bet you have some good options.