The below question is answered by Christina Hobgood Naugle, PA-C, of The Center for Natural Breast Reconstruction.

Christina Hobgood Naugle, PA-C

What are the stages involved in DIEP / GAP free flap breast reconstruction?

The stages of breast free flap reconstruction at our facility can vary depending upon what time in the treatment process we initially meet the patient. The best scenario occurs when the treatment is mastectomy, alone. In those patients, we are able to discuss a skin and possible nipple-sparring mastectomy. This approach means that there is a possibility that the patient would only require one step, although most women are not opposed to a second stage when liposuction, “body contouring,” is involved. Many patients do not have this opportunity, so for them, this process usually involves three stages.

The first stage, being the most involved, is the “technical” stage—the microsurgery element.  After meeting with one of our physicians and discussing the best donor site tissue (tummy, buttocks or inner thigh) the process begins and we relocate the tissue to form a new breast mound. Only the donor site fatty tissue and the blood vessels that nourish that tissue are removed. NO muscle is sacrificed. This blood supply is separated from the body and reconnected to the vessel in the chest wall that once nourished the native breast.

Since the new breast mound is solely relying on the tiny vessels we reconnected initially, we keep you in the hospital for four days to monitor the blood flow into the relocated tissue. This stage of the procedure can require about a six to eight week recovery period, depending upon healing. It varies greatly when women are feeling well enough to return to work or resume the activities they enjoyed prior to surgery.

About three months after Stage One, we may begin discussing each specific patient’s Stage Two.  Three months is the minimum amount of time that we allow. In some cases, we recommend waiting slightly longer than three months (example: radiated tissue, healing issues, or unilateral reconstruction).

Stage Two could be described as the “plastic surgery” side of the breast reconstruction. This is the stage where we fine tune everything that was accomplished in the first procedure, and attempt to improve upon your concerns and how clothes fit. During the first stage, we try our best to achieve symmetry between the two breasts, but sometimes the doctors are limited on the shaping that they are able to accomplish because of the microsurgery portion. Stage Two is about improving symmetry between the two breasts, re-building a nipple if needed, and improving the donor site. This is usually an outpatient hospital procedure but, on the rare occasion, the patient may need to stay overnight.

The procedures performed during this stage vary from person to person, according to their needs. Recovery time varies, too. It could be as little as a day or two weeks, according to the procedures that need to be performed to achieve your desired result.

Three months after your second stage, it is time for your areola tattoo, Stage Three. Women who were able to save their nipple / areola complex at Stage One do not require this stage and are complete at Stage Two. The tattoo is performed in the office under local anesthesia. There is really nothing to this phase. You may drive yourself to the office and expect to be out in one to two hours. It’s really a lot like a social visit and other than exposing your newly tattooed area to public bodies of water like swimming pools, lakes or beaches, there is not much aftercare to speak of. Simple local wound care is all that is required. The risks are minimal and infection and complications are rare.

Many women think of the tattooing as the final hurdle. The best comment I’ve heard was from a woman who stated that after the tattoo healed, she got out of the shower one day and upon looking in the mirror, felt like everything was behind her.

A few other things to keep in mind:

• Scars look their worse at about three to six months, from that point they should steadily lighten and become less noticeable. It’s hard, but be patient. It takes a while for scars to fully mature and everyone is different.

• You’ll meet with your surgeon and discuss the best case scenario for you and how to get your breast reconstruction accomplished in as few steps as possible. It is important, even though you are plagued with so many other physicians and concerns, to meet with your surgeon before you have your mastectomy to keep the surgical stages to a minimum. At this point, we’re able to discuss with you your breast surgeon incision site techniques and helpful concepts to improve you final outcome. We also ask your surgeon to weigh the amount of breast tissue removed. It helps for our reconstructive surgeons to know how much breast tissue was removed with your mastectomy and use that number to work toward  rebuilding your new breast, hopefully achieving a symmetrical result earlier in the process to minimize the number of surgical stages.

• Most patients after the first stage have breast mounds and feel comfortable in clothing. If they must delay State Two of their procedure to undergo chemotherapy, build up time off from work, or just desire time with their family, they are not on a time restriction. (Do keep in mind your deductable.)

• Vanity is not even a consideration in the breast reconstruction process and these surgeries are not cosmetic plastic surgical procedures. It all comes down to trying to get your body back together and make you as happy as possible, so you can move forward with your life and not have the reminder of everything that you have been through and overcome.

• Procedures in the breast not affected by breast cancer are insurance covered reconstructive procedures, too. When patients have unilateral reconstruction, achieving symmetry is a little bit more complicated. We have to let the newly relocated tissue settle and heal. The second stage surgical procedures in this case can include, breast lift, reduction, and / or minor procedures to fine tune and attempt to achieve symmetry between the native and reconstructed breast.

We like our patients to discuss with us the things that bother them about their reconstructive result. There are usually things we can improve upon, whether it’s a local procedure in our office or an additional stage. The three stages described in this piece are an outline to the overall process.

Breast reconstruction cases vary and affect each individual differently based upon a number of factors. Some people require one stage and others two or three outpatient or minor procedures to return their bodies back to where they are comfortable and confident.  After you overcome the first stage, the rest are just fine tuning by standard outpatient procedures and local procedures. It is all about making you as comfortable and confident as possible.

—Christina Hobgood Naugle, PA-C