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.
Despite the increase of breast reconstruction procedures performed after mastectomy in 2008, nearly 70 percent of women who are eligible for the procedure are not informed of the breast reconstructive options available to them, according to a recently published report. Newly released statistics by the American Society of Plastic Surgeons (ASPS) shows there were more than 79,000 breast reconstruction procedures performed in 2008 - a 39 percent increase over 2007. But in spite of this, current research suggests that many breast cancer patients are missing out on a key conversation that should take place at the time of diagnosis.
“Women need to understand all of their options to make an informed decision,” said ASPS President John Canady, MD. “Those who are diagnosed should be immediately referred to a full team of physicians that can provide breast care, and plastic surgeons need to be included as part of that treatment team.”
Taking the position that every woman deserves the right to choose which, if any reconstruction option is best for her after a mastectomy, the ASPS is launching an ongoing effort to bring public awareness to breast reconstruction issues, including education, access, and a team approach. Because early involvement by plastic surgeons and other physicians can allow development of an optimum treatment plan for each individual patient, collaboration amongst specialties is essential. As such, ASPS suggests that primary care, general surgery, radiology, pathology, oncology, gynecology, and plastic surgery be available from the onset of treatment to ensure the greatest possible outcome for the patient.”
It is also important that patients actively participate in their treatment. Though a common misconception, eligible patients should not assume that anyone other than a board-certified plastic surgeon affiliated with an accredited facility is qualified to perform breast reconstruction after mastectomy. While technology has made breast cancer diagnosis, treatment, and reconstruction better than ever, it does not negate the need for medical expertise within each specific area of care.
Among the factors contributing to patient awareness and understanding, specific education regarding the options for breast reconstruction is often lacking. Therefore, in the coming months, ASPS will reach out to women through a variety of materials, ranging from information cards and online videos, to an ad campaign featured online and in the waiting-room publication produced by the American College of Obstetricians and Gynecologists.
“We know that there are many issues surrounding breast reconstruction and that addressing them all will take time, but this is a very important first step,” said Dr. Canady. “Our goal is to make sure that those women who are not getting breast reconstruction are doing so of their own accord and not because they are uneducated or uninformed about their options.”
“Do I still need to have mammograms after my mastectomy and breast reconstruction?”
I’m asked this question quite often.
The truth is there’s a lot of ongoing debate about this.
Some doctors feel that since there is no “natural” breast tissue left, there is no need to continue monitoring patients. I disagree with this strongly.
Breast cancer can come back after mastectomy - there’s a 6.7% chance in fact. Breast reconstruction does not increase or decrease the risk of recurrence at all - the recurrence rate is the same whether women have reconstruction or not.
Since the risk of breast cancer recurrence is a real one, surely we need to continue some sort of monitoring?
Self breast exam is a no-brainer. It’s relatively easy to perform and it’s dirt-cheap (free). The issue of mammograms is less clear-cut.
The appearance of the mammogram changes completely after breast reconstruction. Even if the breast looks very natural and similar to the way it did before the mastectomy on the outside, the inside of the breast is completely different.
Let’s take the following example: a woman who undergoes a skin-sparing mastectomy and tissue (flap) reconstruction like a DIEP flap may look like she has natural breasts that have merely been “lifted”. In reality her breast tissue has been completely replaced by tummy fat. Fat and breast tissue look completely different on mammograms so the post-reconstruction mammograms cannot be compared to any taken before the mastectomy. You’re essentially starting from scratch as far as the mammograms go.
Some surgeons feel that patients should have 1 mammogram after the reconstruction has been completed just to get a new “baseline”. If the regular self breast exams reveal anything new of concern then the mammogram can be repeated. At least now the new mammogram can be compared to the baseline mammogram.
Other breast surgeons take it a step further and recommend a baseline MRI once the reconstruction is completed instead of a mammogram. MRIs are much more sensitive and the information they provide is also more specific. Again, if self breast exam reveals a new area of concern in the future the MRI can be repeated to see if anything has changed.
Yet one more viewpoint is that any new breast lumps that appear in the future are going to require a biopsy anyway so what is the point of getting a “baseline” MRI or mammogram at all?
I understand this point of view but don’t agree with it. Tissue (flap) breast reconstructions can occasionally develop something called “fat necrosis”. These are areas of fat in the new breast that become hard and create “lumps”. While a biopsy may indeed be planned anyway, there is a lot to be said for the physician and patient knowing this “lump” has been there all along (on the MRI) and the chance of this representing a new cancer is extremely low. The additional peace of mind and information a baseline MRI provides in this situation alone warrants it in my opinion.
What do I recommend? At least a baseline mammogram and self breast exams. If it was my wife she’d get a baseline MRI 6 months after the breast reconstruction and continue monitoring herself with monthly self breast exams.
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.
San Antonio, TX (PRWEB) February 23, 2009 — Plastic, Reconstructive & Microsurgical Associates (PRMA) of South Texas, a leading breast reconstruction surgery practice in San Antonio, is now offering women the Transverse Upper Gracilis (TUG) flap procedure to restore their breasts after mastectomy. PRMA plastic surgeons specialize in breast reconstruction after breast cancer, with particular expertise in advanced microsurgical techniques using the patient’s own living tissue.
“Increasingly, women facing mastectomy prefer new breasts sculpted from their own skin and fat, thereby avoiding the problems that often occur with implants,” says Dr Chrysopoulo. Breasts shaped from living tissue have a natural look and feel that can’t be achieved using implants or temporary prostheses. “While most patients prefer the Deep Inferior Epigastric Perforator (DIEP) flap technique which uses a woman’s lower abdominal tissue, it is a technique that may not be an option for those who have had previous tummy tucks, who don’t have adequate abdominal fat, or who prefer not to scar their abdomens. TUG flap surgery is a viable option for these women; a way to restore their natural breasts with excellent results.”
Both the TUG and DIEP flap procedures are complex, technically demanding microsurgical procedures requiring special skill and experience. During the TUG procedure, surgeons transplant a flap of skin, tissue and muscle from a woman’s upper thigh to her chest. The process has distinct advantages compared to other types of natural tissue breast reconstruction: thigh tissue has superior contour, shape and projection; loss of the muscle does not inhibit an individual’s mobility or function; scarring is not easily visible, and the procedure produces a cosmetic thigh lift as well as a new breast.
“TUG flap surgery allows a woman to come out of the operating room the same way she went in,” says Chrysopoulo. “With nice-sized natural breasts in place.” The TUG flap is an excellent post-mastectomy option for women who have mastectomy to either treat or prevent breast cancer.
Candidates for the TUG are women who:
? have small to medium-sized breasts.
? want to avoid an abdominal scar.
? lack sufficient abdominal tissue for DIEP breast reconstruction.
? have had a previous tummy tuck or other abdominal surgery.
PRMA board-certified surgeons routinely offer both reconstructive and cosmetic breast procedures, and perform more than 400 microsurgical breast reconstructions annually for patients from Texas and across the U.S. PRMA surgeons are in-network for most U.S. insurance plans. Visit www.prma-Enhance.com or contact 800-692-5565 to schedule a consultation or for more information about the TUG flap or any other reconstructive breast procedure.
