Breast Reconstruction Options At A Glance

Here's a great infographic summarizing the breast reconstruction options available these days:

Some additional important points:

"Immediate" vs "delayed" breast reconstruction simply describes when the breast reconstruction process begins. Most approaches require more than 1 surgery and the whole reconstruction process can take several months to complete regardless of when it starts. The benefits of immediate reconstruction (same time as the mastectomy) include avoiding the experience of living without a breast, less scarring and better cosmetic results (especially when combined with nipple-sparing mastectomy). You can see patient before and after pictures here.

Many of the above procedures are often combined. For example, tissue expanders or implants can be used in conjunction with flaps. The most common combination is a tissue expander with a latissimus ("lat") flap. Fat grafting is also frequently used in combination with any of the above techniques to address contour deformities, hide implant rippling, add volume, or simply make the results more "natural".

Unfortunately, many of the above procedures are not offered by all plastic surgeons. I encourage all of you to do your own research, ask questions, and if at all possible, consult with plastic surgeons experienced in all types of breast reconstruction before making a final decision.

Dr C
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Dr Chrysopoulo is a breast reconstruction surgeon in San Antonio, TX, specializing in the DIEP flap and other state-of-the-art breast reconstruction procedures. In-network for most US insurance plans. Patients are welcomed from across and outside the US. Please call (800) 692-5565 or email patientadvocate@PRMAplasticsurgery.com to learn more about your breast reconstruction options. Connect with Dr C on Twitter and Facebook.

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What Does Flap Breast Reconstruction Involve?

If you're considering breast reconstruction using your own tissue (a "flap" procedure), it's important to know that achieving the best results usually involves several stages and takes time.

BEFORE skin-sparing mastectomies and DIEP flaps

AFTER skin-sparing mastectomies and DIEP flaps

The patient in the pictures above required the following stages to complete her breast reconstruction:

Stage 1: The Initial Breast Reconstruction

Whenever possible, breast reconstruction should be performed at the same time as the mastectomy. This is known as "immediate breast reconstruction". This allows for less scarring because the natural breast skin envelope can usually be preserved ("skin sparing mastectomy"). Only the nipple, areola and breast tissue under the skin is removed. The patient above had bilateral skin-sparing mastectomies and DIEP flap reconstruction using tissue from her lower abdomen.

In some cases, the nipple and areola can also be preserved. This is called a nipple-sparing mastectomy.

Immediate reconstruction enables the patient to wake up from the surgery "complete" and avoid the experience of a flat chest altogether. Most women with early breast cancer (stage I or II) are candidates for this approach.

If immediate reconstruction isn't an option, or the patient prefers to wait, the reconstruction can be performed "delayed", any time after the mastectomy. Patients having radiation are often advised to delay reconstruction. Other reasons for delaying reconstruction include advanced breast cancer (stage III or IV) and lack of access to a specialist surgeon.

Stage 2: Revision
This is the "fine-tuning" phase and is usually performed as an outpatient procedure. This stage involves shaping the breasts and making them as symmetric as possible. Fat injections can be used to address any contour deformities and make the breasts look and feel even more natural. The donor site scar (scar from where the flap tissue was taken) is revised to make the area look as good possible. Nipple reconstruction is also usually performed at this stage if the patient did not have a nipple-sparing mastectomy.

Stage 3: Micro-pigmentation/Tattooing
This office procedure applies the "finishing touch". Color is added to the reconstructed nipple-areola complex to make the results even more natural. Women now also have the option of a 3D tattoo which can look very life-like, with or without a surgically reconstructed nipple-areola.

Each stage is performed 3 months apart which means that the entire reconstructive process can take several months. Insurance authorization is also required before each stage.

I hope this info helps.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon in San Antonio, TX specializing in the DIEP flap and other state-of-the-art breast reconstruction procedures. He and his partners at PRMA are In-Network for most US insurance plans. Patients are welcomed from across and outside the US. Please call (800) 692-5565 or email patientadvocate@PRMAplasticsurgery.com to learn more about your breast reconstruction options. Connect with others touched by breast cancer on Facebook.

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Prophylactic Mastectomy - is it right for you?

Having prophylactic mastectomy is a very personal choice. There is no "right answer", only what you consider is best for you.

Women who are at high risk of developing breast cancer have the option of prophylactic (preventive) mastectomy as a way of decreasing their risk. Factors that increase a woman’s chance of developing breast cancer include:

1. a genetic predisposition to breast cancer e.g. BRCA+, Cowden's Syndrome, Li-Fraumeni Syndrome
2. a strong family history of breast cancer
3. a breast cancer diagnosis at a young age
4. abnormal breast cells on biopsy that increase the risk of breast cancer, e.g. LCIS
5. a history of previous chest radiation, e.g. treatment for Hodgkin's Lymphoma

Prophylactic mastectomy decreases the risk of future breast cancer by 97-99%. Since the breast tissue is removed, the surgery also removes the need for regular screening mammograms/MRIs and preventive drugs like tamoxifen.

Surgery is not the only option however. Many women prefer close monitoring and preventive drugs (known as "chemoprophylaxis").

Regardless of other choices, all women should modify their diet wherever possible to decrease their risk. It is vital you discuss all your options and the pros, cons, and risks of each before making the best decision for you.

If you choose prophylactic surgery please remember that you can also have breast reconstruction at the same time as mastectomy. There is no need to experience having a flat chest unless you specifically decide you wish to remain without breasts.

You have several reconstructive options and the results can be very natural and cosmetic. If you choose to undergo breast reconstruction at the same time, a "skin-sparing" mastectomy is usually performed. This saves all the breast skin envelope which significantly adds to the cosmetic results without increasing your risk of cancer. In many cases, the nipple-areola can be saved too. This is known as a "nipple-sparing" mastectomy.

Thankfully, most insurance plans cover the cost of prophylactic mastectomy and reconstruction in high risk patients but you will have to check with your individual plan to make 100% sure.

I hope this info helps.

Dr C

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PRMA Plastic Surgery specializes in state-of-the-art breast reconstruction including DIEP flap, SIEA flap, GAP flap, TUG flap, Alloderm One-Step and fat grafting. We are In-Network for most US insurance plans and routinely welcome patients 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 patients at facebook.com/PRMAplasticsurgery.

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Nipple Delay Surgery

Angelina Jolie recently shared her BRCA+ diagnosis and brave decision to undergo prophylactic nipple-sparing mastectomy and immediate breast reconstruction. As part of her surgery, she underwent a nipple delay procedure.

So what is a "nipple delay"?

Most patients do not need a delay procedure. It's actually performed quite rarely. It can however be a good option for patients who want nipple-sparing mastectomy but are at high risk for nipple necrosis. High risk patients include smokers, patients with moderate to significant breast ptosis (sagging), and patients with a history of previous breast surgery (eg breast reduction or lift).

Nipple delay is usually performed 7-21 days before the nipple-sparing mastectomy. The nipple-areolar complex and a rim of surrounding breast skin is elevated off the underlying breast gland. This disconnects all the ducts connecting the breast tissue to the nipple and also cuts off the blood supply to the nipple and areola from the underlying breast tissue. At this point, the nipple-areolar complex is only kept alive by the blood supply from the surrounding skin.

Over the next 1 - 3 weeks, this remaining blood supply becomes much more robust and the blood flow to the nipple-areola from the surrounding skin increases. This improved blood supply makes the subsequent nipple-sparing mastectomy safer and decreases the risk of nipple-areolar necrosis (tissue death) and wound healing complications.

The procedure is combined with a subareolar biopsy to ensure there are no cancer cells involving the nipple-areolar complex. If the subareolar biopsy reveals malignancy, the nipple and areoala are removed at the time of mastectomy. Sentinel lymph node biopsy is also usually performed at the same time as the nipple delay procedure if it is indicated.

Nipple delay does not decrease the risk of future breast cancer. As long as the subareolar biopsy is negative, the risk of future breast cancer is very low and is the same as with standard nipple-sparing mastectomy.

Nipple delay is usually covered by insurance if it is medically justified and the mastectomy is covered.

I hope this info helps.

Dr C

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PRMA Plastic Surgery specializes in advanced breast reconstruction including DIEP flap, SIEA flap, GAP flap, TUG flap, Alloderm One-Step and fat grafting. We are In-Network for most US insurance plans and routinely welcome patients 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 patients at facebook.com/PRMAplasticsurgery.

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Breast Reconstruction Timing: Immediate vs Delayed Reconstruction

With so much to think about after a breast cancer diagnosis, many patients facing mastectomy do not fully understand how the timing of breast reconstruction influences how the reconstructed breasts will ultimately look.

Breast reconstruction can be performed at the same time as the mastectomy ("immediate reconstruction") or a while after mastectomy ("delayed reconstruction").

When the mastectomy and reconstruction are performed at the same time, a skin-sparing mastectomy can usually be performed which saves the majority of the natural breast skin envelope (except for the nipple and areola). Only the actual breast tissue under the skin is removed. The reconstruction then "fills" this empty skin envelope. In some select cases the nipple and areola can also be saved. This is known as a nipple-sparing mastectomy.

Skin-sparing (or nipple-sparing) mastectomy and immediate breast reconstruction produce the most "natural" results with the least scarring. Skin-sparing mastectomy and immediate reconstruction is therefore preferred whenever possible and should be the goal for breast cancer patients with early disease (stage I or II).

Delayed reconstruction unfortunately leaves more scarring (typically) and the final breast is less likely to look like the breasts Mother Nature provided. Common reasons to delay reconstruction include advanced breast cancer (stage III or IV), inflammatory breast cancer, the plan for radiation therapy after mastectomy, and lack of access to a reconstructive surgeon.

The difference in scarring between immediate and delayed breast reconstruction can be seen in these breast reconstruction before and after photos.

Ultimately the priority must always be "life before breast" - obviously the breast cancer treatment comes first in terms of priority. However, all other things being equal, there will sometimes be a choice to be made between having the reconstruction performed with the mastectomy or some time after the mastectomy. Whenever possible, I encourage women to seek immediate reconstruction for the best cosmetic results.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in the latest breast reconstruction techniques including the DIEP flap procedure. 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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