DIEP candidate with previous abdominal procedures

There have been much interest in a woman's candidacy for abdominal flap procedures if previous abdominal surgery has been done.  Especially with c-sections, many women have been told that they are not candidates for the DIEP flap.  Often times with low-transverse incisions (Pfannenstiel) incisions, the Superior Inferior Epigastric Artery (SIEA) has been transected. 

A recent study has looked at DIEP flaps being performed after such incisions.  While, if in fact the SIEA has been cut, it has actually improved circulation to the Deep Inferior Epigastric Artery Perforator (DIEP) system and augmented its vascularity and survival rate.  Unfortunately, there are rare instances that the DIEP artery system has also been transected, such as in the aforementioned cases, appendectomy, hysterectomy, exploratory laparatomy, cholecystectomy, etc.  These should be assessed on an individual basis and discussion/tests performed prior in order to speak abou the DIEP flap.  Physical examination, Doppler ultrasound, and CT angiograms can help to visualize the vascularity of the abdominal flaps prior.

All in all, abdominal procedures are not a contraindication to abdominal flap breast reconstructions such as the DIEP, but should be assessed by a skilled surgeon in such flaps.  "Flaps raised from these abdomens are not only safe, but may be better vascularized".

Breast Reconstruction with Fat Grafting/Transfer

One of the newest techniques for breast reconstruction involve utilization of the exciting benefits of fat grafting. Much research has been put forth into plastic surgery for harvesting of fat and its potential as stem cells. Fat grafting and transfer has been utilized both for breast augmentation but also in breast reconstruction for contouring of the breast after implant-based and flap-based reconstruction with excellent results.

After a lumpectomy or mastectomy, an innovative technique which has been implemented is performing this fat grafting and transfer technique to completely reconstruct a breast. This would involve no other scars or incisions, no foreign bodies or implants, and no complex flap procedures. Plus, additional benefits to the breast reconstruction include as close to normal sensation of the breasts along with the benefit of liposuction to harvest the fat from wherever there is spare fat!

Working with your breast surgeon during the oncologic procedure for your breast, some fat is harvested during the same surgery, which in turn is placed back into the breast area. This will give a small breast mound immediately after the procedure. An external expander device is then used for several weeks after the initial procedure while you are sleeping. The expander will have the same benefits as the internal tissue expander, however it is simply worn on the outside as a vest, without having an implanted prosthetic.  It has been shown to increase vascualrity, increase blood supply (important for radiated breasts especially), as well as expand the breast framework for which the fat will be placed in the future.

Once adequate expansion has been obtained after several weeks of wearing the external expander vest, a simple outpatient procedure will be performed in which liposuction will be performed from areas where you have excess fat. Instead of wasting this fat, it will be harvested, washed, and then transferred back directly into the breast to give the additional volume to reconstruct the breast. The liposuction may be performed from the abdomen, flanks, hips, thighs, buttocks, etc., until enough fat has been obtained to give adequate volume for your reconstructed breast. Multiple micro-fat grafts will then be placed throughout the expanded breast framework within its well-vascularized bed. Sometimes this will take a few small outpatient procedures, separated by several weeks, to obtain the results. Fat grafting allows precise placement of where the fat should go in order to perfectly contour the breast shape.

The newly-reconstructed breast mound has now been recreated with the use of only your own fat via liposuction with the hopes for a breast mound that looks and feels much like a "normal" breast. The results thus far have been superb and patients have raved about their overall results.

Happy New Year!

Happy New Year to all!

I hope that much of the information has been helpful to you.

Please continue to follow as I look forward to continually adding information on the subject this coming 2012 and into the future!

To a healthy & happy 2012!!!

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.