Analysis of Sensibility in the DIEP breast reconstruction

The DIEP flap has been considered by many authors as "the definitive standard in breast reconstruction" due to its "achievable shape and consistency, permanence of static and dynamic symmetry, and aesthetic and functional gain in the donor site". One question regarding this most-innovative type of breast reconstruction such as the DIEP and other free tissue transfer breast reconstructions is the amount of sensation that is restored postoperatively.

Although I, as well as several of the few other surgeons who perform such microsurgical flaps, spare the nerves, there have been no publications to specifically look at the sensibility in breast reconstruction with the non-reinnervated DIEP flap. A recent study followed 30 consecutive women following DIEP flaps and studied the sensation. They found that "for immediate breast reconstruction undergoes satisfactory progressive spontaneous sensitive recovery at 6 and 12 months after surgery" This may significantly save intraoperative time for this already complex procedure and hopefully improve the overall postoperative wellness of the patient with a shorter anesthetic time. Overall, the DIEP flap has become a bright spot in breast reconstruction!

October

October is National Breast Cancer Awareness month!

Nipple-Areolar Complex Reconstruction

The final stage of the breast reconstruction is the reconstruction of the nipple-areolar complex (NAC). Usually, this is performed after the nipple reconstruction, however, it may be done without it as well. While some women opt not to have anything further done after the breast reconstruction, as discussed in the last post, these relatively benign procedures are simple and easy to perform, and "complete" the breast reconstruction.

I usually perform a nipple reconstruction first if one decides to proceed with the NAC. If one foregoes the actual nipple reconstruction and only have a NAC recreated, options for such are skin grafts and tattoos. The same techniques are used if a nipple reconstruction is performed as well.

Skin grafts are usually taken from the medial thigh or groin area as the skin is typically darker in color and the donor site is hidden. The skin graft recreates a great appearance to the areola. This procedure is tolerated very well and may be done via local anesthesia or general/sedation. Little recuperation time is required afterwards.

The other popular technique is areolar repigmentation. This is done via tattoo under no or local anesthesia. Often times the NAC area is still insensate from the previous surgery, and the tattoo needle is tolerated very well. As with a tattoo, pigmentation (instead of ink), is injected into the superficial dermis to repigment the area. This, as well, gives a great appearance to the areola. This is my preferred method. I perform this with only topical anesthetic in the office as a short procedure. It also avoids another "surgical procedure".

Both techniques are very simple to perform, benign procedures with little down-time and few complications, and give excellent appearance to a reconstructed NAC.

Nipple Reconstruction

Many people have asked about what happens with the nipple and areola after the reconstruction. I do have a post on nipple-sparing mastectomy. However, if the nipple-areolar complex (NAC) is removed during the mastectomy, there are several different procedures to reconstruct the NAC to complete the breast reconstruction. I usually wait approximately 6-12 weeks after the implants are placed in order to allow the swelling to subside as well as to allow the implants to settle into their formed pockets.

There are several techniques to reconstruct a nipple. All are very effective, and basically comes down to surgeon preference. The main goal of the nipple reconstruction is to provide the appearance of a nipple as well as give the projection of the nipple. It is a very simple procedure, which usually is performed under local anesthesia alone, often times in the office in less than an hour. Downtime is minimal and local care to the incisions is all that is needed. The biggest problem with nipple reconstruction is loss of projection, usually quoted as about a 30-6-% shrinkage from immediate postoperative appearance. Various things surgeons have tried are to add a filler (e.g., fat, dermis, cartilage, or other material), in order to support the nipple and decrease the amount of postoperative shrinkage. Overall, is is a very safe and easy procedure; most women in my practice opt to undergo NAC reconstruction, as it truly "finishes" the breast reconstruction.

After these incisions are completely healed, there are various techniques to reconstruct the areola, including tattoos and skin grafts. This will be discussed next.

Wellness Center

Come listen to the presentation on advances in breast cancer and screening/diagnostic technology by the Wellness Center Thursday 6/30 - Phoenix, A. Breast mammographers, breast surgeons, and myself will be there to disucss.

Operation Smile

Sorry for the absence...

Medical mission in Zhengzhou, China. Looking to screen ~200 children with cleft lips and/or palates and operate on ~170.

Operation Smile

www.operationsmile.org

Back soon :)

Nipple-Sparing Mastectomy and Reconstruction

Nipple-sparing mastectomy has been a controversial topic in breast cancer and its treatment. Not all women are candidates for this procedure for treatment, and it is necessary to discuss with your general/breast surgeon on your candidacy. In general, women who may fall into this category include those women who do not have cancer at the present time (genetically positive), and low-risk for recurrence of the cancer within the ductal elements (those that lead to the nipple). So, those very early/small tumors that are remote from the central area and do not have a significant ductal component may be candidates. Having said that, it is important to discuss with your general/breast surgeon regarding the oncologic aspect of sparing the nipple, as well as the risks and complications involved with this procedure.

On a reconstructive standpoint, nipple-sparing mastectomies could give an excellent aesthetic appearance, as the natural nipple-areolar complex remains intact, and often times, the incisions are in a remote location from the central area of the breast. Again, it will be important to coordinate the planning with your surgeon and plastic surgeon for optimal treatment, planning, and results. Both immediate implant-based and flap-based procedures have been performed with excellent results. Filling in the volume that is lost during the mastectomy with either an implant or tissue from your own body can produce a superb reconstruction.

Such a procedure is not without its risks, including a significant rate of necrosis of the spared nipple, due to inadequate blood supply to the area. Especially if an implant lies beneath the area, an open wound could potentially seed an infection to the prosthetic device, warranting antibiotic therapy or potential further procedures and/or removal of the threatened implant. Flap-based procedures give the advantage of bringing in a robust blood supply from a remote area that increases the vascularity to the mastectomy flaps. The normal sensation and erectile function of the nipple will be lost, as a nature of the mastectomy. In addition, for women with significant ptosis (sag) of the breast needing repositioning of the nipple-areolar complex to a more appropriate position, a staged procedure may be appropriate to first reposition and then reconstruct the breast, or vice versa. A recent article in the Plastic Surgery Journal reports good results with banking of the complex for use at a later date.

For those who can perform such procedures, the microsurgical flaps (e.g., DIEP, SIEA, TUG, ALT, SGAP, etc) are great ways to reconstruct the breast after a nipple-sparing mastectomy. I have had phenomenal results with these as it recreates the breast with like-tissue as well as having excellent vascularity, thus recreating the most realistic, natural-appearing and feeling reconstructed breast with a real nipple-areolar complex.

DIEP or SIEA Flap Candidate?

Many women have asked if they are good candidates to undergo such a complex procedure as the DIEP flap for breast reconstruction. Many have been denied by other surgeons for various reasons. I have been asked if I would share some thoughts on who would be the ideal candidate for this type of microsurgical breast reconstruction.

In a nutshell, every woman is a candidate for breast reconstruction. Specifically, there are several types of microsurgical, muscle-sparing, perforator flaps that may be used to obtain an aesthetically pleasing breast reconstruction. Not only is there the DIEP flap and the SIEA flap (which are flaps obtained from tissue from the lower abdomen), but there are also the SGAP/IGAP flap (gluteal tissue), TAP flap (back tissue), ALT flap (lateral thigh tissue), TUG flap (groin tissue), and other donor sites that are continually being found. Certainly these microsurgical, muscle-sparing, perforator flaps are highly complex procedures that usually requires specialized training due to their complexity, and, since they have recently gained in popularity and prowess for their minimal donor site morbidity, decreased complication rate, muscle-sparing nature, robust blood supply, and aesthetic results, very few surgeons have the training and skill to perform such procedures. Many surgeons may not offer, let alone discuss, such types of reconstructive options, which are certainly at the forefront of breast reconstruction today. Certainly there are some risks and potential complications that may occur with such a complex procedure, which should be discussed with your plastic surgeon, but with the advent of these procedures, they should be included in any discussion about breast reconstruction.

You do not have to be overweight to be a candidate for the DIEP flap. This procedure has been successfully performed in women of all Body Mass Indices (BMI's). Gaining weight will not increase the success rate or the result obtained. In fact, sometimes it makes it more difficult. What is known is that the overall risk for surgical complications increases with BMI >35 and significantly increases with BMI >40.

Medical comorbidities, such as heart and lung problems are also a major concern. Your primary physician should medically clear you for the surgical procedure prior to undergoing such a lengthy procedure to maximize your health prior to, and after your surgical procedure. Diabetes also increases the risk of small-vessel disease, wound healing complications, and infection. Great success has been obtained in diabetics after achieving stable glucose control with minimal increased complication rates. Smoking also does the same and cessation should be done at least 6 weeks prior to any surgical procedure. Your overall health will be considered by your plastic surgeon.

Previous abdominal surgery has not significantly increased failure rate, with few exceptions. Women who have previously had an abdominoplasty (tummy-tuck) are not candidates for this procedure. The perforating vessel which would have been used to sustain the flap, have unfortunately been cut already, making this flap unusable. The same holds true for those who have previously had a DIEP/SIEA or TRAM flap procedure in the past. I co-authored a paper while at the Mayo Clinic which looked at success rates of the DIEP flap after laparoscopic gynecologic procedures. There were no increased failure or complication rates to those who did not have ay such procedure performed in the past. Hernias, unless massively large with multiple complex abdominal repairs and/or abdominal wall reconstructions, also have not been shown to preclude one from a DIEP flap. Previous appendectomy, hysterectomy, c-section also are still viable candidates. Another paper through the Mayo Clinic, we looked at obtaining CT angiograms prior to the DIEP flap for evaluation of the vasculature as well as surgical planning. This will certainly help if there is any question regarding viability of the flap for use. We utilize this imaging routinely.

Previous chest irradiation also has not hampered the success rate of any microsurgical breast reconstruction. In fact, it has ameliorated it. Bringing in such a robust blood supply from this microsurgical flap helps the irradiated tissue of the chest. Also, we have not seen any increased damage to the vessels that we utilize in the chest to perform the microsurgery. Several papers have shown this to be true. As discussed before, a flap procedure is the wisest thing to do if previous radiation therapy was done.

Overall, the DIEP/SIEA flap is a great option for breast reconstruction. All women are candidates for breast reconstruction and a thorough conversation with your plastic surgeon should be done to determine WHICH procedure would be the best for YOU...which should include a discussion about microsurgical flap procedures. This should answer many of the questions about candidacy for the DIEP flap or SIEA flap. Even if you may not be a candidate for abdominal tissue procedures, there are other flaps which may be considered as discussed above.

Women have sought the DIEP flap from all over the Phoenix, Scottsdale, Tucson area and Southwest have had great results with our DIEP flap. We have had women travel from throughout the United States to have the DIEP flap, SIEA flap, SGAP flap, and other microsurgical reconstructive procedures.

Additional information

Happy New Year! Wishes for a happy, healthy, and joyous 2011!!!

Lumpectomy (aka: tylectomy) is a common surgical procedure designed to remove a discrete lump, usually a benign tumor or breast cancer, from an affected man or woman's breast. As the tissue removed is generally quite limited and the procedure relatively non-invasive, compared to a mastectomy, a lumpectomy is considered a viable means of "breast conservation" or "breast preservation" surgery with all the attendant physical and emotional advantages of such an approach.

If you are reading this, you’ve probably already started to consider having breast augmentation or reconstruction surgery. Maybe you are dissatisfied with the size of your breasts, or perhaps one breast is sized differently than the other. Sometimes there is a reduction in breast size after pregnancy to be corrected, or you may need a breast reconstruction after a mastectomy.

Additional information regarding breast reconstruction and augmentation can be viewed on the website and on previous posts. Thank you for visiting!