Doctor Advice For Breast Reconstruction

Reconstructing Breasts with Sensation – 86th Edition

Posted on Dec 31, 2011 under Doctor Advice for Breast Reconstruction | No Comment

Most women facing mastectomy and breast reconstruction want to know what kind of feeling their new breast(s) will have.

Unfortunately mastectomy leaves many women with very little feeling long term (if any), regardless of whether they have breast reconstruction or not.

There is some good news though…. Most women undergoing DIEP or SIEA flap breast reconstruction are also candidates for reconstruction of the sensory nerves in the breasts that provide feeling. The feeling in the new breast won’t be as good as what Mother Nature provided but it’s certainly a lot better than the alternative. A nice bonus at the very least.

Once the tummy tissue (flap) is moved up to the breast, a sensory nerve in the flap is connected microsurgically to a breast nerve in the chest that was cut by the mastectomy. New nerve cells grow from the chest nerve into the flap nerve over time allowing the reconstructed breast to develop feeling.

If you’re feeling brave, here’s a short video clip of how the two nerves are connected. You can also see the pulse in the blood vessel connections to the new breast:

I hope this info helps.

Dr C

*****

PRMA Plastic Surgery specializes in advanced breast reconstruction including DIEP flap, SIEA flap, GAP flap, TUG flap and Alloderm One-Step. In-Network for most US insurance plans. Patients routinely welcomed from across the USA. Please call (800) 692-5565 or email patientadvocate@PRMAplasticsurgery.com to learn more about your breast reconstruction options. Connect with other breast cancer reconstruction patients at www.facebook.com/PRMAplasticsurgery.

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Questions To Ask Your DIEP Flap Surgeon – 85th Edition

Posted on Mar 20, 2011 under Doctor Advice for Breast Reconstruction | No Comment

If you are considering DIEP flap breast reconstruction finding the right surgical team is key. Before choosing a DIEP flap surgeon be sure to ask the following questions:

Are you certified by the American Board of Plastic Surgery? Your surgeon should be a board certified plastic surgeon.
Do you have extensive experience with this type of surgery – How many have you performed? Preferably your surgeon will have performed over 100 DIEP flap procedures.
What’s your success rate? Top specialist centers boast a success rate of at least 98%.
How long does the surgery take? This will vary between institutions based on experience. The most experienced surgeons typically take between 3-6 hours depending on whether one or both breast are being reconstructed (not including the mastectomies).
How often do you plan to perform a DIEP flap but end up changing the procedure to a free TRAM flap during the surgery? The “conversion rate” to a free TRAM flap should be low.
How many microsurgeons will be performing the surgery? Since the DIEP flap procedure is so technically demanding and long, it is preferable to have two microsurgeons performing the surgery rather than just one. Not only will this ensure you benefit from the expertise of two specially trained surgeons, but it will also significantly cut down the length of the procedure and anesthesia.
Do you have residents or fellows? Will they be performing any of my surgery? Some centers have surgeons-in-training known as “residents” or “fellows” that may be helping with your surgery or even performing part of it. This may or may not be something you are comfortable with considering the complexity of the surgery.
Do you “balance bill”? Centers that are in-network for most insurance plans will ask the patient to pay ONLY what’s laid out by the patient’s insurance plan (ie copay, deductible, etc). Other centers “accept insurance” and will often help the patient get money back from their insurance company – however, the patient is still expected to provide the difference between what the insurance pays and the doctor’s fee. This is known as “balance billing“. While many centers do this, some DO NOT balance bill. Make sure to ask ahead of time to avoid nasty financial surprises down the line.
Do you have Insurance Specialists on staff? Unfortunately, some patients will face difficulties in gaining access to DIEP flap specialists even though insurance companies are federally mandated to pay for the cost of breast reconstruction. Here again it pays to seek out centers that specialize in these procedures as typically an insurance specialist is available to help patients with insurance issues. Again, this can prevent a nasty financial surprise after your surgery.

Hope that helps!

Dr C

*****

PRMA Plastic Surgery has successfully performed over 3,000 DIEP flap breast reconstructions. We specialize in advanced breast reconstruction procedures that use the patient’s own tissue. Procedures offered include the DIEP flap, SIEA flap, GAP flap, and TUG flap. We are In-Network for most US insurance plans. Patients are routinely welcomed from across and outside the USA. Connect with other breast cancer reconstruction patients at www.facebook.com/PRMAplasticsurgery.

*****

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Breast Reconstruction: New Video Discusses Latest Breast Reconstruction Options – 84th Edition

Posted on Sep 27, 2010 under Doctor Advice for Breast Reconstruction | No Comment

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TRAM Flap vs DIEP Flap: What’s the Difference? – 83th Edition

Posted on Aug 21, 2010 under Doctor Advice for Breast Reconstruction | No Comment

Up until a few years ago, the TRAM flap was the gold standard in breast reconstruction after mastectomy. The TRAM has now been surpassed by the DIEP flap for that honor. For patient’s researching their reconstructive options after mastectomy, it is important to understand the concept of TRAM surgery and how it has evolved into today’s cutting edge DIEP procedure.

There are three main forms of the TRAM flap operation commonly performed by plastic surgeons:

1) The Pedicled TRAM flap: this was the first operation to describe use of one of the rectus abdominus muscles (sit-up muscle) for breast reconstruction. The surgery begins with an incision from hip to hip. Then, the lower abdominal tissue below the belly button (skin, fat and one of the abdominal muscles) is tunneled under the upper abdominal skin to the chest to create a new breast.

Recovery from the surgery can be difficult and painful. Long-term, the patient has to adapt to the loss of some abdominal strength (up to 20%). As with any surgical procedure there is the possibility of complications. These include delayed healing, fat necrosis (part of the tissue turns hard due to poor blood supply), abdominal complications such as bulging and/or hernia, and loss of the reconstruction altogether (rare).

2) The Free TRAM flap: this procedure uses the same abdominal tissue as the pedicled TRAM except that the tissue (“flap”) is disconnected from the patient’s body, transplanted to the chest, and reconnected to the body using microsurgery. Advantages over the pedicled TRAM include: improved blood supply (and therefore less risk of healing problems and fat necrosis), and less muscle sacrifice (so the abdominal recovery is a little easier, potentially more strength is maintained long-term, and the risk of bulging and hernia formation is lower).

Since the tissue is disconnected and transplanted to the chest, there is also no tunneling under the skin as there is with the pedicled procedure and no subsequent upper abdominal bulge around the ribcage area (which is typically seen with tunneling).

3) The Muscle-Sparing Free TRAM flap: this operation is associated with all the benefits of the free TRAM but has significantly fewer abdominal complications and side-effects (pain, bulging, hernia, strength loss) because the vast majority of the abdominal muscle is spared and left behind. The amount of muscle taken is typically very small (postage-stamp size). We will opt for this version of the TRAM only in the rare event that the patient’s anatomy does not allow for a DIEP or SIEA flap.

4) The DIEP flap: This is the most advanced form of breast reconstruction surgery available today. Like the muscle-sparing free TRAM, the DIEP uses the patient’s own abdominal skin and fat to reconstruct a natural, soft breast after mastectomy. Unlike the TRAM however, all the abdominal muscle is preserved. Only abdominal skin and fat are removed similar to a “tummy tuck”. Patients therefore experience less pain after surgery, enjoy a faster recovery and maintain their abdominal strength long-term. Since the abdominal muscles are saved, the risk of complications like abdominal bulging and hernia are also significantly lower. Please visit our gallery to view DIEP flap before and after photos.

*****

Dr Chrysopoulo is a board certified plastic surgeon specializing in the latest breast reconstruction techniques including DIEP flap surgery. He and his partners perform over 500 DIEP flap procedures per year and are In-Network for most US insurance plans. Learn more about your breast reconstruction options and connect with other breast reconstruction patients here. You can also follow Dr C on Twitter!

*****

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Are you a DIEP Flap candidate? – 82th Edition

Posted on Jul 20, 2010 under Doctor Advice for Breast Reconstruction | No Comment

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).

*****

Dr Chrysopoulo is a board certified plastic surgeon specializing in the latest breast reconstruction techniques . He and his partners are in-network for most US insurance plans. Learn more about your breast reconstruction options and connect with other breast reconstruction patients here. You can also follow Dr C on Twitter!

*****

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Impact of Radiation on Breast Reconstruction – 70th Edition

Posted on Jul 08, 2010 under Doctor Advice for Breast Reconstruction | No Comment

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.

Dr C

******

Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient’s own tissue. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

******

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Breast Reconstruction in Metastatic Breast Cancer Patients – 71th Edition

Posted on Jul 08, 2010 under Doctor Advice for Breast Reconstruction | No Comment

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.

Dr C

******

Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient’s own tissue. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

******

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Mammograms after Mastectomy and Breast Reconstruction – Are They Really Needed? – 72th Edition

Posted on Jul 08, 2010 under Doctor Advice for Breast Reconstruction | No Comment

“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 (sometimes over sensitive though) 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.

The issues with MRIs are (1) the additional cost compared to a mammogram, and (2) sometimes they see things that really aren’t there – for example, something that is benign is interpreted as worrisome. This in turn leads to further investigations and biopsies that may never have really been needed.

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? 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 the test in some physicians’ opinions.

What do I recommend? At least a mammogram 6 months after the breast reconstruction is completed to get a new baseline and regular self breast exams.

Dr C

******

Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient’s own tissue. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction at The Breast Cancer Reconstruction Blog. Please also Follow Dr C on Twitter.

******

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Breast Reconstruction – Breast Cancer Patients Denied Right To Choose – 73th Edition

Posted on Jul 08, 2010 under Doctor Advice for Breast Reconstruction | No Comment

Despite the increase of breast reconstruction procedures performed in 2008, nearly 70 percent of women who are eligible for the procedure are not informed of the 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, 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. 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.”.”

******

Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient’s own tissue. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction at The Breast Cancer Reconstruction Blog. Please also Follow Dr C on Twitter.

******

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Breast Cancer Reconstruction And Health Care Reform – What Does It Mean For You? – 74th Edition

Posted on Jul 08, 2010 under Doctor Advice for Breast Reconstruction | No Comment

By Sharon Lacey

What does health care reform mean for patients with breast cancer and how will it affect you?

Well, it could mean…

Even though you or your loved one could benefit from advanced breast reconstructive surgery after mastectomy (like the DIEP flap procedure for example), your plastic surgeon might well have to say “no”.

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 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.

*****

Keep up to date with the latest news in breast reconstruction at The Breast Cancer Reconstruction Blog. Also follow us on Twitter.

*****

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Archive for Doctor Advice for Breast Reconstruction

Reconstructing Breasts with Sensation – 86th Edition

Questions To Ask Your DIEP Flap Surgeon – 85th Edition

Breast Reconstruction: New Video Discusses Latest Breast Reconstruction Options – 84th Edition

TRAM Flap vs DIEP Flap: What’s the Difference? – 83th Edition

Are you a DIEP Flap candidate? – 82th Edition

Impact of Radiation on Breast Reconstruction – 70th Edition

Breast Reconstruction in Metastatic Breast Cancer Patients – 71th Edition

Mammograms after Mastectomy and Breast Reconstruction – Are They Really Needed? – 72th Edition

Breast Reconstruction – Breast Cancer Patients Denied Right To Choose – 73th Edition

Breast Cancer Reconstruction And Health Care Reform – What Does It Mean For You? – 74th Edition

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