Flap Reconstruction Surgery: Important Stats and Abstract Information

If you’ve had breast cancer and are considering reconstruction surgery, it’s possible that one of the options you may be looking into is flap reconstruction surgery.

Breast reconstruction utilizing “flap” techniques are procedures where body tissue is used to reconstruct the shape of your breast after surgery. While it’s a relatively common type of reconstructive surgery these days, we feel it’s important that you should learn as much as possible about the benefits and risks, and discuss them with your doctor before you have the procedure.

That’s why we at The Center for Natural Breast Reconstruction are always looking for better ways to educate and inform our patients before a decision.

One way we ensure our patients have access to the latest in medicine and medical technology is to have our surgeons and staff constantly learning, researching, and writing about their findings.

In fact, some of our latest research on reconstructive flap surgery was recently submitted to the American Association of Plastic Surgeons by our Dr. Kline. This specific abstract documented the success rate of our reconstructive flap surgeries with regard to the role of autogenous microvascular breast reconstruction in the community.

Check it out…

Abstract

PURPOSE: To present the continuing role of autogenous microvascular breast reconstruction in the community

METHODS: 1393 free perforator flaps for breast reconstruction were performed by two surgeons from October, 2003 to October, 2016. All flaps were performed in two community hospitals. Types of flaps included DIEP unilateral (122 flaps), DIEP simultaneous bilateral (866 flaps), DIEP bipedicle (106 flaps), sGAP unilateral (55 flaps), sGAP simultaneous bilateral (202 flaps), iGAP unilateral (2 flaps), iGAP simultaneous bilateral (18 flaps), PAP unilateral (5 flaps), PAP bilateral (10 flaps), SIEA unilateral (3 flaps), SIEA simultaneous bilateral (2 flaps), and TFL perforator (1 flap). The series includes a large number of both immediate and delayed reconstructions, prior failed reconstructions, and patients with a history of radiation.

RESULTS: Overall flap survival rate was 98.2%. DIEP survival rate was 99.1%. sGAP survival rate was 95.7%. No primary unilateral flaps were lost, and no bilateral losses occurred. Including those patients whose initial flaps failed, 99% of patients were ultimately successfully reconstructed with autogenous tissue.

CONCLUSION: Implant-based reconstruction is an appropriate initial choice for many patients, but autogenous microsurgical reconstruction still remains an excellent option, whether as an initial choice, or for patients with a prior history of failed reconstruction. With proper preparation and institutional support, perforator flap breast reconstruction can be performed with a high degree of success in a community hospital setting.

On top of the abstract, our physicians—Richard M. Kline Jr., M.D. and James E. Craigie MD—also wrote the chapter on GAP (buttock) flaps for the book Perforator Flaps for Breast Reconstruction.

Check out the book chapter here.

As we mentioned earlier, we are passionate about continuing to learn, receive training, and interact with the scientific community to ensure we provide our patients with the safest, most advanced care.

And, while we’re doing our job to make sure we’re properly training our staff and staying up-to-date with the latest in medical technology, there’s one thing we encourage you to do as well—always ask for medical procedure stats.

Much like the abstract we provided above, your doctor should be able to provide you with stats on the procedures he or she conducts.

When patients come to us and ask questions on success rates, we can happily tell them the different percentage rates of success for the various procedures we provide. Equipping our patients with this information empowers them to make wise, educated decisions about their own health.

So, please, before you move ahead with a specific procedure, ask your doctor for the stats. If they have a high success rate with their surgeries, then you’re in the right place. If they don’t, it’s time for you to find another doctor.

We wish you the best as you move forward with any new procedure you may need!

Did you find the book chapter insightful? Let us know what you learned and what you thought was helpful to know in the comments below!

Ask the Doctor: Lymphedema and Lymph Node Transfer

<alt="3 pink roses"/>This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your question.

QUESTION: I’ve had breast cancer and developed lymphedema after my mastectomy.  I recently heard about Lymph Node Transfer surgery.  Does it work?  I’m scheduled for a DIEP breast reconstruction, can it be done at the same time?

ANSWER: Lymphedema is a very difficult problem that results when a patient has had breast cancer and has to undergo surgical removal of the lymph nodes under the arm as part of their surgical treatment for breast cancer. There are other causes of lymphedema but our specific interest has been in patients who have had breast cancer.

Lymphedema can be a very debilitating process; it remains a terrible problem worldwide, for all types of reasons. There is still much to be learned about why some people develop lymphedema and others do not. It appears that lymphedema is directly related to several factors in our breast cancer patients. It is directly related to having the lymph nodes removed from under the arm and seems to develop from the scarring that occurs under the arm following mastectomy and / or axillary dissection.

Undergoing radiation of the arm or axilla increases this risk. However, there are many people who undergo removal of the lymph nodes and radiation that do not develop lymphedema. There are also people who have mastectomy, have lymph nodes removed followed by radiation, and don’t develop lymphedema until many years after their surgery. That is the main reason that patients are warned to pay particular attention to their arm if they have had removal of any lymph nodes.

It is also possible that someone could get lymphedema even after simply having a sentinel node removed. A sentinel node procedure (lymphadenectomy) is a way to examine the lymph node without having to remove more than one or two. The whole idea of examining only the sentinel node is to lower the risk for lymphedema, but even with the sentinel node procedure, there is still a chance of developing lymphedema. Our practice became interested in options to help breast cancer patients with lymphedema as we see many who are suffering from the symptoms of this process while undergoing breast reconstruction.

Our practice specializes in microsurgical free flap breast reconstruction utilizing skin, underlying tissue, and microscopic blood vessels that transport life-giving blood to the reconstructed breast. This procedure is commonly referred to as the DIEP if using the abdomen or a GAP if using the buttock tissue. The muscles of the abdominal wall are left intact as it is the removal of the muscles of the abdominal wall that can lead to problems in the donor area, like hernias and bulging, as well as a more involved extended recovery. The lower tummy wall is the most common area that we transfer and it’s also an area where lymph nodes are present. Therefore, over the first decade this surgery was being done, we would encounter lymph nodes in the area of the blood vessels, as well as fatty tissue.

It became obvious that we could transfer lymph nodes on the blood vessels as we refine our technique for microsurgery. Due to the lack of effective treatment for lymphedema, for years surgeons doing perforator flaps have taken on this challenge and are trying to come up with ideas and techniques to treat it. We began doing an extensive amount of research, spanning the globe, looking for information on procedures that may help these patients. In 2005, we formed a group known as the Group for the Advancement of Breast Reconstruction, known as GABRs, and we included members throughout the world who had had a unique experience with our type of breast reconstruction.

We encountered one individual who had 15-years of experience with what is now known as “vascularized lymph node transfer” for the treatment of lymphedema. Initially, Dr. Robert Allen had attempted lymph node transfer during breast reconstruction and the biggest concern was how to transfer lymph nodes from one area of the body to treat lymphedema but not to create lymphedema in the donor area. In 2006, the GABRs met in Beijing, China and invited Corrine Becker, a surgeon from France who had a long history of experience with vascularized lymph node transfer.

She presented her work and through communication and travel to Paris to work with her, members of the GABRs group began to gain experience and learn more of her technique. The biggest hurdle that we were able to overcome was learning how to select the lymph nodes that could be removed as the donor lymph nodes and use those for breast reconstruction without causing lymphedema of the leg. We spent an extensive amount of time discussing her techniques and reviewing her results, as well as her publications.

We then made arrangements for her to travel to South Carolina and actually performed surgery on our own patients with her as an assistant surgeon. Since that time we have been very encouraged by the results with vascularized lymph node transfer as an effective treatment for reduction of the symptoms of lymphedema. We feel very excited but yet are very cautious about all results. It is important that patients realize that this procedure is still evolving and that there are risks involved, but to date we have had very good results and no serious complications.

Improvement of symptoms with vascularized lymph node transfer can occur immediately; however, they also may take up to 2 years to be appreciated. In most of our patients, the indicators of success are different. For the majority, the goal was to improve the edema, lessen the need to wear compression garments on a regular basis, and to eliminate the risk for frequent infections, which are the typical problems that those affected by lymphedema experience.

In order to lower the risk for complications and to closely study our results in conjunction with other colleagues who perform this procedure, we prefer to perform vascularized lymph node transfer as an isolated procedure. It can be done at the time of breast reconstruction; however, there is a chance that some people with mild lymphedema who undergo breast reconstruction may have improvement without lymph node transfer. Therefore, in order to closely study our results, we perform the breast reconstruction first followed by vascularized lymph node transfer as the second step. When the results are complete, we can determine whether it was the reconstruction or the transferred lymph nodes that gave the end result. It is important again to reemphasize that the main risk for of the surgery is that the transfer may not work. It is possible that if the transfer did not work resulting in more scar, the lymphedema could worsen.

Thankfully, to date, we have not experienced this complication. Other complications are damage to the blood vessels under the arm or the nerves under the arm. Therefore, our preference is to have an oncologic surgeon, who performs axillary dissection, release the scar under arm.  At the same surgical setting, after the scar is released, we perform the transfer by removing very specialized lymph nodes from the outer and lower abdominal wall or outer upper leg. We preserve the lymph nodes of the inside leg. These are the ones that drain the lower extremity and therefore, we feel that the risk for lymphedema of the donor area is reduced.

At this point, we have received some very exciting results along with some mixed results and continue to follow our patients very closely. We have had no patients with any serious complications and no patients at this point with lymphedema of the donor site. We are hopeful that the future holds vascularized lymph node transfer as an effective option for people with lymphedema following breast cancer surgery.

We plan to continue to devote and focus our energies on a surgical solution while simultaneously not exposing people to excess risk of additional problems. Once again, we do have to admit that the surgery, although giving some promising results, is  still evolving at this point and we choose to proceed with caution in the best interest of our patients.

— James Craigie, M.D.

Have a question about breast reconstruction or post-surgical care you’d like answered from our surgical team? Just ask us!

Ask the Experts: Dr. James Craigie

Dr. Craigie  of the Center for Natural Breast Reconstruction was recently featured on Channel 4, representing East Cooper Medical Center. Check out his video here!


Ask the Experts: Dr. James Craigie

 

Have a question about breast reconstruction you’d like answered from our surgical team? Just ask us!

Your DIEP Reconstruction Recovery Process Question Answered

diep questionsThe below question is answered by Charleston breast surgeon, Dr. James E. Craigie. of The Center for Natural Breast Reconstruction:

I still feel tightness in my chest and stomach after DIEP reconstruction, when can I expect that to improve?

Tightness in the donor site area or tummy depends on how much tissue was taken to rebuild the breast and how much loose tissue was there to begin with.  The scar that results after the healing process can take approximately 6 months to relax and mature.  Therefore, during recovery, the tissues will be stiff for approximately 3 months and as you begin to do more and exercise more, the areas should slowly become less tight, less swollen, and more natural.  Regarding tightness in your chest, it would be unusual for tightness to exist for very long after having reconstruction with your own tissue.  Usually a new healthy breast made from your own tissue will improve tightness or scarring particularly if someone has had reconstruction with implants prior to using their own tissue.  However, if you have had radiation, those changes can be permanent and there may be residual stiffness, but it is very unusual for people in our practice to complain of tightness in the chest area once everything has healed approximately 3 to 6 months after surgery.

-Dr. James E. Craigie

Share this post with your followers on Twitter and Facebook. And if you have a question for our breast surgeons, submit them here!

Your Questions about Natural Breast Reconstruction and Implants Answered

implantsThe following submission below is answered by Dr. James E. Craigie, of The Center for Natural Breast Reconstruction.

I had breast reconstruction in 2009 with implants and am unhappy with the result.  How hard is it to go back and do reconstruction with your own tissue?  What is the recovery time and does insurance give you a hard time if you need to do this?

Sorry that you are having so many problems with your implants, here are several things you need to know.  First of all, if someone required a mastectomy and their insurance company offers coverage for mastectomy; there is a federal law that mandates that insurance company to cover breast reconstruction.  If one technique did not work for you or failed, you are still eligible for another technique.  In our practice, 30% of our patients who undergo reconstruction with their own tissue have had failed implants.  Implant failure can be many different things.  Some people lose their implants because of infection; some have had radiation effects that contributed to rejection of the implant or hardness, while others simply have a result that is not satisfactory to them.  Other factors such as problems with implant itself or leakage can be reasons for implant failure as well.  Depending on exactly what your situation and original surgery was, the challenges of reconstruction following implants can include repair of the chest muscle, removal of leaking silicone, or removal of Alloderm if that product had been used during the initial reconstruction.  All of these things do make the reconstruction more challenging, but certainly our most successful technique to solve this problem is to remove the implants, any leaking implant material, the Alloderm, and the hard capsule that had formed around the implant and replace all of this with your own healthy living tissue.   Our preferred way to do this utilizes muscle-sparing techniques such as the DIEP or GAP, using just your fatty tissue to replace the implants.  Compared to someone who has not had failed implants, you may require an additional one or two revision stages of surgery and may require more time to allow the results to settle and overcome the effects of the previous surgeries.  These issues do make the process more complex, but the success rate among our patients is very high and the completed result is permanent and natural feeling which our patients who have had implant failures report to be their main goal. The recovery time for these types of surgeries is always patient dependent and generally longer than surgeries utilizing implants but our patients are usually back to work anywhere between 4 to 6 weeks.  I hope this has answered your questions and if you have any others I can answer, please feel free to forward them to us.

Do you have a question about breast implants or natural breast reconstruction? Submit your questions here to be answered by our team!

 

 

Breast Cancer Survivor Shares Reconstruction Success Story

according to shirleyWe are so happy to share with you another In Her Words post, this time with Shirley Trainor-Thomas, a breast cancer survivor, Hodgkin’s lymphoma survivor, and reconstruction success story!

Shirley was a patient of ours at The Center for Natural Breast Reconstruction and we are delighted to share her story with you.

See below for the interview (*Don’t forget to download a copy of According to Shirley, a short story / information booklet written by Shirley about her breast reconstruction experience):

When you were diagnosed with breast cancer in your left breast, you chose to have a double mastectomy. What influenced this decision? In other words, what factors did you consider when deciding whether or not to have a double mastectomy?

“It’s not good, princess.” Those were the exact words Dr. Bob Flowers used when he called to tell me the results of my biopsy. I promptly informed him that it was not the right answer! And after I caught my breath, I asked what we were going to do about it. He said he would get me to a surgeon that very day. True to his word, my husband and I were in Dr. Stan Wilson’s office that afternoon and we started discussing options. I was a bit of a difficult case because many years ago I had Hodgkin’s lymphoma and radiation to my entire torso—which is what likely caused my breast cancer. There was a lot of discussion among physicians and tests that were taken to make sure we had all of the information we needed to make the best decision.

The waiting to get answers and opinions that would lead to a plan was excruciating. All I could think about was breast cancer and I spent endless hours on the Internet trying to learn everything I could about my diagnosis and choices. My husband and I were in a fog.

Long story short, it appeared that chemo and mastectomy was my option. But, Dr. Wilson wasn’t totally convinced chemo was the really indicated and sent my tissue to have the Oncotype test.   As we waited on those results, we were moving forward with the chemo option. On a Thursday evening, I was preparing for surgery to take place the next morning to have a port put in—and at 8:00 pm, Dr. Wilson called with the Oncotype results—they were great. We opted to not have chemo.

Because other cells in my breasts were described as “busy” by the pathologist, I knew there was a chance of cancer striking my other breast. Given the painful waiting and emotional impact we went through, my husband and I said that we need to eliminate the chance of having to go through this again. Playing into that decision was that I was aware of the DIEP reconstruction option. I’m lucky, not everyone knows about that option and most people have to do a lot of research to find it or the right surgeon. I knew right out of the gate that the only person I would allow to do this procedure was Dr. Richard M. Kline, Jr. of The Center for Natural Breast Reconstruction.

2. What type of reconstruction surgery did you have and how do you feel about the results? Would you make the same decision again if you could go back?

I had DIEP. The great thing for me is that I went into surgery with bosoms and came out with bosoms—and a flat tummy. Bi-lateral mastectomy and reconstruction were done in one surgery.

Recovery was frustrating. As Dr. Kline kept telling me, “It’s a process.” No matter what he told me, I was convinced I would be back to normal in just a few weeks. Okay, so it took longer.  I got tired easily and couldn’t stand up straight for a while because of the stomach incision. But, my job requires travel and I was able to get on an airplane six weeks after surgery and get back to work.

My energy level took some time to return—it’s a big surgery. But, if faced with the same decision today, knowing what I know, I absolutely would do it again.

My bosoms are perfect.

Unfortunately, I didn’t have enough tummy fat to make them bigger than they were (my one chance—had I known, I would have eaten a lot more over the years!). Even my oncologist has marveled at how real they look and feel. But I would only allow Dr. Kline and Dr. Craigie to do it. I’ve read some horror stories online about women who went to surgeons who either weren’t trained properly or didn’t have the skill level needed for microsurgery. I actually communicate with women around the country to share my experience and to alert them that they really need to investigate their surgeon’s success record.

3. You decided to write a short story / information booklet about your breast reconstruction experience titled According to Shirley. Why did you choose to write this book and what do you hope readers will get from reading it?

I love Dr. Kline and his entire staff. But, when planning for surgery they gave me a booklet of what to do and expect. After going through the experience, I let them know they left A LOT of information out! It was written by medical professionals who never actually experienced the procedure. When I told them that the information was technically good, but needed to include more practical information, they said fine—write one. So I did. It’s really meant to give women a better idea of what to expect throughout the process and to keep positive about the experience.

4. What advice would you give to women who have undergone a mastectomy or double mastectomy and are unsure about natural breast reconstruction?

Research, research , research. Unfortunately, not all plastic surgeons will present options that they are not capable of providing, such as DIEP. Talk to several surgeons and get a feel for the success rate of the surgeon. Talk to their patients. It’s a major procedure. Women need to know how many procedures the surgeon has done and what his or her success rates are.

Have you downloaded your copy of According to Shirley? If not, click here.

What Are My Options If I Develop Lymphedema?

I’ve had breast cancer and developed lymphedema after my mastectomy.  I recently heard about Lymph Node Transfer surgery.  Does it work?  I’m scheduled for a DIEP breast reconstruction, can it be done at the same time?

Question answered by Dr. James Craigie:

Lymphedema is a very difficult problem that results when a patient has had breast cancer and has to undergo surgical removal of the lymph nodes under the arm as part of their surgical treatment for breast cancer. There are other causes of lymphedema but our specific interest has been in patients who have had breast cancer.

Lymphedema can be a very debilitating process; it remains a terrible problem worldwide, for all types of reasons. There is still much to be learned about why some people develop lymphedema and others do not. It appears that lymphedema is directly related to several factors in our breast cancer patients. It is directly related to having the lymph nodes removed from under the arm and seems to develop from the scarring that occurs under the arm following mastectomy and / or axillary dissection.

Undergoing radiation of the arm or axilla increases this risk. However, there are many people who undergo removal of the lymph nodes and radiation that do not develop lymphedema. There are also people who have mastectomy, have lymph nodes removed followed by radiation, and don’t develop lymphedema until many years after their surgery. That is the main reason that patients are warned to pay particular attention to their arm if they have had removal of any lymph nodes.

It is also possible that someone could get lymphedema even after simply having a sentinel node removed. A sentinel node procedure (lymphadenectomy) is a way to examine the lymph node without having to remove more than one or two. The whole idea of examining only the sentinel node is to lower the risk for lymphedema, but even with the sentinel node procedure, there is still a chance of developing lymphedema. Our practice became interested in options to help breast cancer patients with lymphedema as we see many who are suffering from the symptoms of this process while undergoing breast reconstruction.

Our practice specializes in microsurgical free flap breast reconstruction utilizing skin, underlying tissue, and microscopic blood vessels that transport life-giving blood to the reconstructed breast. This procedure is commonly referred to as the DIEP if using the abdomen or a GAP if using the buttock tissue. The muscles of the abdominal wall are left intact as it is the removal of the muscles of the abdominal wall that can lead to problems in the donor area, like hernias and bulging, as well as a more involved extended recovery. The lower tummy wall is the most common area that we transfer and it’s also an area where lymph nodes are present. Therefore, over the first decade this surgery was being done, we would encounter lymph nodes in the area of the blood vessels, as well as fatty tissue.

It became obvious that we could transfer lymph nodes on the blood vessels as we refine our technique for microsurgery. Due to the lack of effective treatment for lymphedema, for years surgeons doing perforator flaps have taken on this challenge and are trying to come up with ideas and techniques to treat it. We began doing an extensive amount of research, spanning the globe, looking for information on procedures that may help these patients. In 2005, we formed a group known as the Group for the Advancement of Breast Reconstruction, known as GABRs, and we included members throughout the world who had had a unique experience with our type of breast reconstruction.

We encountered one individual who had 15-years of experience with what is now known as “vascularized lymph node transfer” for the treatment of lymphedema. Initially, Dr. Robert Allen had attempted lymph node transfer during breast reconstruction and the biggest concern was how to transfer lymph nodes from one area of the body to treat lymphedema but not to create lymphedema in the donor area. In 2006, the GABRs met in Beijing, China and invited Corrine Becker, a surgeon from France who had a long history of experience with vascularized lymph node transfer.

She presented her work and through communication and travel to Paris to work with her, members of the GABRs group began to gain experience and learn more of her technique. The biggest hurdle that we were able to overcome was learning how to select the lymph nodes that could be removed as the donor lymph nodes and use those for breast reconstruction without causing lymphedema of the leg. We spent an extensive amount of time discussing her techniques and reviewing her results, as well as her publications.

We then made arrangements for her to travel to South Carolina and actually performed surgery on our own patients with her as an assistant surgeon. Since that time we have been very encouraged by the results with vascularized lymph node transfer as an effective treatment for reduction of the symptoms of lymphedema. We feel very excited but yet are very cautious about all results. It is important that patients realize that this procedure is still evolving and that there are risks involved, but to date we have had very good results and no serious complications.

Improvement of symptoms with vascularized lymph node transfer can occur immediately; however, they also may take up to 2 years to be appreciated. In most of our patients, the indicators of success are different. For the majority, the goal was to improve the edema, lessen the need to wear compression garments on a regular basis, and to eliminate the risk for frequent infections, which are the typical problems that those affected by lymphedema experience.

In order to lower the risk for complications and to closely study our results in conjunction with other colleagues who perform this procedure, we prefer to perform vascularized lymph node transfer as an isolated procedure. It can be done at the time of breast reconstruction; however, there is a chance that some people with mild lymphedema who undergo breast reconstruction may have improvement without lymph node transfer. Therefore, in order to closely study our results, we perform the breast reconstruction first followed by vascularized lymph node transfer as the second step. When the results are complete, we can determine whether it was the reconstruction or the transferred lymph nodes that gave the end result. It is important again to reemphasize that the main risk for of the surgery is that the transfer may not work. It is possible that if the transfer did not work resulting in more scar, the lymphedema could worsen.

Thankfully, to date, we have not experienced this complication. Other complications are damage to the blood vessels under the arm or the nerves under the arm. Therefore, our preference is to have an oncologic surgeon, who performs axillary dissection, release the scar under arm.  At the same surgical setting, after the scar is released, we perform the transfer by removing very specialized lymph nodes from the outer and lower abdominal wall or outer upper leg. We preserve the lymph nodes of the inside leg. These are the ones that drain the lower extremity and therefore, we feel that the risk for lymphedema of the donor area is reduced.

At this point, we have received some very exciting results along with some mixed results and continue to follow our patients very closely. We have had no patients with any serious complications and no patients at this point with lymphedema of the donor site. We are hopeful that the future holds vascularized lymph node transfer as an effective option for people with lymphedema following breast cancer surgery.

We plan to continue to devote and focus our energies on a surgical solution while simultaneously not exposing people to excess risk of additional problems. Once again, we do have to admit that the surgery, although giving some promising results, is  still evolving at this point and we choose to proceed with caution in the best interest of our patients.

—James Craigie, M.D.

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