The DIEP flap procedure has rapidly become the “gold standard” in breast reconstruction today. While not every woman is a candidate for DIEP flap surgery, many are turned away when in fact they needn’t be. The most common areas of confusion include:
1) Previous Abdominal Surgery
While some types of previous abdominal surgery can make the DIEP flap procedure impossible to perform, most of the time previous abdominal surgery really isn’t an issue.
Many women these days have had a previous c-section or hysterectomy. It is possible for these procedures to cause damage to the blood vessels needed for DIEP flap surgery, but this is rare. A previous c-section, hysterectomy, or tubal ligation is not a contra-indication to having the procedure.
If your surgeon is worried about potential damage from previous surgery then certain tests can be performed to examine the anatomy more closely. This can include a simple doppler ultrasound exam in the office or a more involved test like a CT angiogram.
So which previous surgeries DO cause a problem? Women that have had a previous TRAM flap, tummy tuck or very extensive abdominal wall surgeries (like complex repairs of huge hernias) cannot have a DIEP or SIEA flap reconstruction because the lower tummy tissue that is needed has already been removed, disconnected or moved around.
While previous abdominal surgeries may not prevent DIEP flap reconstruction, women that have had multiple previous abdominal procedures are at increased risk of abdominal complications like bulging and even hernia after DIEP flap surgery when compared to women that have never had prior abdominal surgery.
2) An Umbilical Hernia
It is very unlikely that an umbilical hernia would prevent DIEP flap surgery. Most umbilical hernias are small. A very large umbilical hernia can make the surgery harder but even this is not usually a contra-indication to having the procedure.
3) Previous Chest Radiation
One of the most important things for the reconstructive surgeon to achieve is to replace the damaged, firm irradiated tissue with normal, healthy, soft tissue. If the irradiated tissue is not healthy enough to be used as part of the reconstruction (as is the case in many instances), it will be removed and replaced by the healthy (DIEP) tissue.
I have visited with a fair number of patients who have previously been told they are not candidates for DIEP flap reconstruction because they received chest radiation after their mastectomy. I do not share this opinion.
Most of the time this advice seems to stem from fear that the radiation may have caused damage to the internal mammary vessels in the chest. These are the blood vessels that are usually used to connect the DIEP flap to the chest. In reality it is exceptionally rare for us to find these blood vessels are damaged and cannot be used.
4) Not the Right Amount of Tissue
You don’t need to be overweight to be a candidate for a DIEP flap. What matters is the distribution of the fat. We have performed DIEP flaps on smaller breast, thin women with a BMI (body mass index) of 20 (and even less) because the fat that they did have was “in all the right places”. Having said that, there is an upper limit beyond which the risks of surgery outweigh the benefits - At PRMA we set an upper BMI limit of 40 as we have found that performing the procedure on women with BMIs greater than this significantly increases the rates of complications (especially wound healing problems).
I’ve spoken to several ladies recently who have had the same misconception about DIEP flap surgery. They were scared they were “too skinny”. The truth of the matter is that you don’t need to be overweight to be a candidate for DIEP flap surgery. What matters is the distribution of the fat that you do have. Unfortunately that can’t be determined over the phone. Sometimes it can’t even be determined by emailing pictures.
I can say that we have successfully performed DIEP flap reconstructions on women with BMI’s of 20 and even less. In instances where the reconstruction ends up too small, many women are candidates for autologous fat grafting. This involves liposuction of fat from another part of the body, purifying this fat, and then re-injecting it into the reconstructed breast for additional volume.
We used to occasionally place a breast implant under the DIEP flap in women who needed more volume. Unfortunately the patient is then exposed to the risks of breast implants like capsular contracture (hardening of the implant and breast) and even deformity.
Fat is not free of issues either though - some of it can become reabsorbed or form little pea-sized areas of hardening (fat necrosis), especially if the fat grafting is not performed in a meticulous way. There were fears for a while that the injected fat could cause calcifications on a mammogram that could look like or even mask a new breast cancer. Several studies have since proven that fat grafting is safe though some plastic surgeons are still reluctant to perform the procedure because of these previous fears. Even though fat grafting may not be 100% predictable, it has served our patients very well and we now prefer it to implants in these situations.
If you’d like to know for sure whether you’re a candidate for a DIEP flap please visit with an experienced DIEP surgeon. It’s the only way to really be sure.
The two most common questions among breast cancer patients considering breast reconstruction are “how much does breast reconstruction cost?” and “will my insurance cover it?”. The good news is that even though breast reconstruction is performed by plastic surgeons, it is NOT considered cosmetic surgery.
If the mastectomy is for breast cancer then the law states it must be covered by insurance. If the mastectomy is covered, the reconstruction will be too. The bad news is that even though insurance covers breast reconstruction, there are still some costs that the patient will be responsible for. Patients much research this ahead of time to limit the risk of a nasty financial surprise down the line.
While the degree of coverage varies based on the insurance plan, there are some things that are pretty standard. Effective June 1, 2010 even Medicaid will provide a benefit for breast surgery to the unaffected breast for symmetry, providing certain criteria are met. Breast reconstruction after prophylactic (preventive) mastectomy is usually covered as long as the patient is deemed to be high risk for breast cancer (significant family history or BRCA gene positive).
Even though insurance companies are mandated to cover reconstruction, breast reconstruction insurance laws do vary by state. The amount each insurance pays can also vary a great deal.
It is important to make sure your surgeon is in-network for your insurance plan if at all possible. This will limit your costs to whatever you’ve agreed to pay under the terms of your insurance plan (such as your deductible, co-pay and out of pocket expense). Using an out-of-network surgeon will likely subject you to other costs such as “balance billing”. This is when the surgeon essentially sets his/her price (just to use an example let’s say $1,000), receives whatever the insurance plan pays (let’s say $600) and then asks the patient to pay the remainder (ie the “balance” of $400). This example is based on relatively small dollar amounts but you can see how this could add up to tens of thousands of dollars of additional bills for a major surgical procedure, and that’s just for the first procedure.
Whether or not you can find an in-network, experienced surgeon depends on the procedure you’ve decided to have. If you’ve decided to have an implant reconstruction then you may have several doctors to choose from. Implant breast reconstruction is technically not as challenging as other options and most plastic surgeons perform the procedure.
On the other hand, if you’re more interested in an advanced reconstructive procedure that not many surgeons offer (like a DIEP flap), you’re likely to have a harder time finding an experienced surgeon to perform your surgery who is in-network. Most patients will unfortunately have to travel for their surgery because of this. Even though this may now add the cost of airfare and hotel stays, these costs are typically significantly less than a “balance bill” from an out-of-network surgeon.
Some breast centers even offer special arrangements to traveling patients such as significantly discounted hotel charges to help ease the financial burden.
After deciding to pursue immediate breast reconstruction I went online and requested information from the PRMA website on a Saturday. By Monday morning Mistie (the nurse) called me back to see what information I needed. She was so kind and nice. She really listened to what I was saying and took my medical information and then verified my insurance. After I gave Mistie my medical information, the ball started rolling in the right direction. Mistie spoke with Dr. Chrysopoulo directly about my case and an appointment was scheduled. Once I met him I had an incredible peace about the whole thing. I knew that I found the right doctor and the right place to have my surgery.
When I arrived for my initial appointment, Dr. Chrysopoulo made me feel at ease immediately. He was kind, compassionate, and knowledgeable. He spoke with complete sincerity and he also had a great sense of humor, which helped to make me smile and made me feel at ease. It was also wonderful getting to meet Mistie in person after talking to her on the phone several times.
I had initially wanted to do reconstruction with implants thinking that my recovery time would be quicker. Dr. Chrysopoulo spoke to me about the pros and cons of implants verses DIEP flap reconstruction. Once it was laid out in front of me, it made complete sense to have the DIEP flap procedure rather than reconstruction with implants. The DIEP procedure would use tissue from my stomach to reconstruct my breasts and Dr. Chrysopoulo would begin the reconstruction as soon as the general surgeon completed the mastectomy - while I was still asleep. I would not have to return for reconstruction surgery later. That sounded great to me.
Dr. Chrysopoulo was preparing me for what might be ahead after surgery by saying that when I woke up, I would feel like I had been hit by an 18-wheeler but it would get better. He said that by a week later I would feel like I had been hit by a mini-van. I knew other women who had breast augmentation who said when they woke up; it felt like they had a Buick parked on their chest, so I knew that there would be pain following such major surgery. I prepared myself for whatever was ahead mentally. (Actually, my personal experience with pain following my surgery was so much less than what I mentally prepared for.)
Dr. Chrysopoulo also told me that my instructions following my surgery would be to basically ?live in a recliner for 3 weeks getting up only to walk?. I knew that walking was going to be a big part of recovery, but that it would be important to take it a little easy as well.
Every woman has a right to breast reconstruction surgery after breast cancer. This has been a federal mandate for some time and insurance companies have to pay for breast reconstruction surgery by law. There is no age limitation for breast reconstruction and there are many different options available.
When the breast reconstruction is performed at the same setting as the mastectomy it is referred to as “immediate” reconstruction. The biggest advantage of immediate reconstruction is that the patient wakes up from the surgery still “whole” and completely avoids having to live without a breast. Other advantages include shorter scars and, generally speaking, a better cosmetic result.
In some instances immediate reconstruction is not recommended or is not possible and the reconstruction is performed several months after the mastectomy. This is called “delayed” reconstruction. Women with more advanced disease are usually not candidates for immediate reconstruction because of the need for radiation therapy after the mastectomy. While some plastic surgeons still perform immediate reconstruction in these cases, most prefer to delay the reconstruction until a later date to allow the tissues to recover.
The most common breast reconstruction procedure performed by American plastic surgeons utilizes implants to restore the breast shape and form. These can be either saline or silicone. Implant reconstruction is typically performed as two separate surgeries. The first involves placing a tissue expander (temporary implant) under the skin and pectoral muscle. This is used to expand the skin to the required size. The expander is later replaced by the permanent implant at a second surgery. A few surgeons prefer using a one-stage approach and place the permanent implant at the same time as the mastectomy. While not all patients are candidates, this is a very attractive option for many women because they avoid the entire tissue expander phase of the reconstruction.
Implant reconstruction can be the best option for some patients. However, reconstruction with expanders and breast implants are associated with more complications than cosmetic breast augmentation. Complications following radiation therapy are also higher with implants compared to reconstructions using the patient’s own tissue.
The Latissimus procedure uses muscle (latissimus dorsi), fat and skin from the back (below the shoulder blade) that is brought around to the chest to create a new breast. Many patients also need an expander or implant to obtain a satisfactory result in terms of size. Patients typically have a scar on their back that can be seen with some low-cut clothing. Women who are very active in sports may notice some strength loss with activities like golf, climbing, or tennis.
Tissue can also be taken from the lower abdomen to create the new breast. The TRAM flap uses the same tissue that is removed by a tummy tuck. This skin and fat is transferred along with variable amounts of the rectus (sit-up) muscle. This tissue can be tunneled under the upper abdominal skin (pedicled TRAM), or disconnected from the body and reconnected to the chest using microsurgery (free TRAM). All forms of TRAM flap can improve the abdominal contour just like a tummy tuck. Unfortunately, women can notice loss of abdominal muscle strength due to the sacrifice of the rectus muscle. There is also a risk of bulging of the tummy and even hernia.
Over the last decade or so, the TRAM has been replaced by the DIEP flap as the new breast reconstruction gold standard. The DIEP provides a natural, warm, soft reconstruction together with an improved abdominal contour, just like the TRAM flap. However, unlike the TRAM, the DIEP flap spares the abdominal muscles completely. The tissue is disconnected from the body completely and reattached at the chest using microsurgery. This makes the post-op recovery easier and also significantly decreases the risk of abdominal bulging and hernia.
There are a handful of other tissue options available for women who are not candidates or prefer to avoid using their abdominal tissue. These include the inner, upper thigh (TUG flap), lower buttock crease (IGAP), and upper buttock (SGAP). The best tissue option will depend on a number of factors, primarily the patient’s body habitus.
Microsurgical breast reconstruction procedures like the DIEP, TUG and GAP flaps are not offered routinely by many American plastic surgeons. There are many reasons for this, primarily the complexity of the surgery and the need for additional training. Unfortunately most patients seeking one of these breast reconstruction options after mastectomy will be forced to travel to specialized centers for their surgery.
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Dr Chrysopoulo and his partners are board certified plastic surgeons specializing in advanced breast reconstruction techniques after mastectomy. All PRMA surgeons are in-network for most US insurance plans. PRMA Plastic Surgery is located in San Antonio, Texas. (800) 692-5565.
A new form of breast reconstruction that allows women to grow new breasts from their own fat cells after a mastectomy could be offered to British and Australian breast cancer patients for the first time in 2010.
A human trial of the new technique is being planned by plastic surgeons at a London hospital. The trial will study whether fat cells can be induced to multiply and fill a breast-shaped mold implanted under the chest skin to recreate a breast after mastectomy. Australian scientists also recently announced that they would start similar treatments on women within six months, following animal studies involving mice and pigs that successfully re-grew breasts from fat.
If the human trials are as successful, this new technique could transform breast reconstruction surgery, offering an alternative to breast implant reconstruction and more complex tissue transfer techniques requiring significant down-time.
The technique is expected to take about eight months to grow a breast. Initially it will only be used to reconstruct breast cancer patients who have been cancer-free for at least 2 years. Eventually it may also be used for cosmetic breast augmentation allowing women to achieve a significantly larger breast size without needing saline or silicone implants.
The Australian team is led by Professor Wayne Morrison of the Bernard O?Brien Institute of Microsurgery in Melbourne. After a decade or so of working on this project he has now obtained ethical approval for a trial involving a handful of women.
I had the pleasure of listening to a presentation by Dr Morrison at the American Society for Reconstructive Microsurgery in 2008. The technique involves using liposuction to remove some of the woman?s own fat cells. The concentration of stem cells within this fat is then boosted in the laboratory. A biocompatible scaffold is then implanted under the patient?s skin, to create a cavity that matches the shape of her remaining, natural breast. The stem cell-enhanced fat solution is then injected into the scaffold. Over time, the scaffold is filled by the multiplying fat cells which obtain the necessary nutrients from blood vessels surgically wrapped around the scaffold.
The first trials will likely require that the scaffold is removed at the end of the reconstruction process though there is some talk of making the scaffold absorbable in the future so this extra step can be avoided.
Right now the focus remains on growing a breast made completely of fat, without breast glandular tissue, milk ducts or nipple-areolar tissue. The nipple and areola will therefore still need to be reconstructed as an additional step.
These developments are very exciting. I am sure this is the direction breast reconstruction is going in. The most advanced techniques currently available, like the DIEP flap for instance, already use the patient’s own fat to recreate a very natural breast. In the case of the DIEP flap, this tissue (fat and skin) is taken from the lower abdomen, providing the benefit of a tummy-tuck at the same time.
While DIEP flap breast reconstruction only takes a few hours (as opposed to eight months), it does involve major surgery and the creation of scars on another part of the body (lower abdomen). In addition, women still need a second surgery for “fine tuning” and nipple reconstruction. In essence then, the reconstruction process can still be fairly drawn out and take several months. I am sure many women will be eager to avoid major surgery and scarring for what could be a very similar end result once this new technique is optimized.
My name is Tammy and I was diagnosed with Ductal Carcinoma In Situ (DCIS) in June 2009. I underwent bilateral mastectomy and immediate reconstruction with DIEP flaps.
I believe it is important to share my story on how I made my decision because when I was looking for information on other women?s experiences, it was hard to find. If I can help even one woman feel peaceful about making her own decision, then it was worth it all. That?s part of this process? reaching out and helping others who are behind us in the journey.
My nature is to research things completely so that I can make informed decisions. I am the mom to a severely brain injured little boy who is now 12 years old and I?ve spent lots of time over the years looking for information on how to help him to get better and have spent more than 20 years in the medical field as well.
My diagnosis came as a complete shock to me. I am sure it?s a shock to anyone who hears it for the first time, but somehow I never thought I would be hearing those words associated with me. I just remember how numb I felt when I heard the ?C? word? CANCER.
I had no signs or symptoms to indicate that there was any type of problem. I went in for my routine annual mammogram and they asked me to return for an ultrasound of my breast. Having me return was not an unusual request because I have had fibrocystic breast tissue and it had almost become routine for me to have to return. They would always do an ultrasound where they could see the cysts and then I would then be sent on my merry way.
This year was different.
They called me back for the ultrasound but also wanted to do some spot compression views so they could look more closely at an area of my breast where they wanted to see more detail. The doctor told me that radiologists are trained to look for microcalcifications when they view mammograms. My mammogram showed some microcalcifications and this time I was told to follow up in 6 months to see if there were any changes in my breast during that time.
My gut feeling told me that I didn?t want to wait 6 months, so my physician sent me to a local surgeon and he decided to do a stereotactic breast biopsy right away. The results were back quickly and I was diagnosed with ductal carcinoma in situ (DCIS). I had breast cancer.
While this may sound extreme to many of you, this would happen if comparative-effectiveness research rules that the benefits of the surgery for the average breast cancer patient just don’t justify its price tag, especially when compared with yesterday’s treatments (like tissue expanders for example).
Unfortunately, medical advances and “cutting-edge” procedures do come at a price. Though this does mean certain procedures are more expensive, it has also ensured the United States has stayed at the leading edge of health care in the world, at least until now.
In an enormous break with tradition, such cost considerations based on averages will be factored into medical practice guidelines. These will function as an invisible hand that puts a brake on the more expensive procedures even though they benefit certain patients.
Standardized practice guidelines will be evident everywhere, even embedded into your doctor’s government-certified computer: as described in the Obama budget, computer pop-ups will appear to help your doctor make decisions. (And through the same systems, his or her choices can be monitored for consistency with the guidelines.)
More uniform care will certainly improve weak performing doctors, but many experts worry about intruding on the seasoned judgment of the good physician. It remains to be seen how government micromanaging?if not rationing?of care, driven by reasons other than patient well-being, will go down,? particularly when that patient has a face.
Traditional medical opinion states that women with metastatic breast cancer are not candidates for breast reconstruction. Once metastases are diagnosed (stage 4 breast cancer), attention turns solely to aggressive medical treatment to prolong life. Breast reconstruction is no longer discussed as an option.
At least that was the consensus up until fairly recently.
Opinions have started to change over the last few years.
While we are still losing the battle with stage 4 breast cancer and most women will die from their disease, who are we to decide that these women should not be made “whole”? Why should any women interested in breast reconstruction die breastless?
As long as patients interested in reconstruction are medically stable and passed “fit for surgery”, the psycho-social and quality of life benefits that breast reconstruction can provide should not be ignored. While the priority must always remain “life over breast”, breast reconstruction should be discussed with patients regardless of the stage of the disease.
Radiation therapy is often recommended as part of breast cancer treatment. Patients undergoing lumpectomy receive radiation routinely once they’ve healed from surgery. Some mastectomy patients also need radiation after surgery depending on the characteristics of the tumor.
I think it is fair to say that most reconstructive breast surgeons, myself included, are not particularly fond of radiation because of the way it impacts the patient’s tissues (and breast reconstruction in general.) Nonetheless, it is important to remember that “life comes before breast” and in certain situations there is a definite benefit for the patient in having radiation therapy.
So what’s the problem with radiation therapy (from a plastic surgeon’s perspective)? For starters it can cause toughening (fibrosis) and shrinking (contracture) of the patient’s tissue which makes the tissue lose its elasticity and become more tough and rigid. Skin color changes are common, red at first turning more brown over time. Radiation can also cause burn injuries as well as damage to underlying organs such as the lungs and heart. Anyone who is facing radiation therapy must discuss all the potential risks with their their radiation oncologist beforehand.
Women undergoing lumpectomy are often told that most of their breast will be preserved and that radiation is given “as insurance” to decrease the risk of cancer recurrence. What many women don’t appreciate is that the breast can end up looking vastly different once the treatment is done because of radiation changes, even though they underwent “breast conservation”. Many women end up going to see a plastic surgeon anyway to fix this unforeseen problem, which ironically can include the same reconstructive procedures as for mastectomy.
Radiation after a tissue reconstruction (eg tram flap, diep flap) can cause the reconstructed breast to shrink and harden. Unfortunately, this is a fairly common scenario. Less frequently (with heavy radiation doses), new wounds can develop in the reconstructed breast which need wound care. Patients facing radiation after flap breast reconstruction should know that there is a risk of needing further reconstructive surgery to correct changes caused by the radiation therapy. One study found a re-operation rate of almost 30% in patients receiving radiation after TRAM flap reconstruction.
Tissue expander / implant reconstructions fair even worse with radiation. The complication rates in this setting are much higher than with tissue reconstructions, including complete failure of the reconstruction altogether (and removal of the implant). Some surgeons routinely offer implant reconstructions to patients that are either facing or have already had radiation therapy. There are even articles published in the plastic surgery literature supporting it. I have to respectfully disagree (strongly). In my experience mixing implants with radiation typically ends badly. I will only do this in the very rare instance that there is absolutely no other option.
So what’s the take-home message?
1) “Breast conservation” can fall short of the patient’s cosmetic expectations.
2) breast implants and radiation do not mix well.
3) If you’re facing radiation after mastectomy think twice about insisting on immediate reconstruction. You may be lucky and things may work out just fine. However, there’s also a good chance you’ll be signing up for more surgery than you bargained for.
