Should I have Breast Reconstruction Now or Later?

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. This should therefore be the goal for breast cancer patients with early disease (stage I or II) whenever possible.

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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Nipple-Sparing Mastectomy

Nipple-sparing mastectomy in conjunction with immediate breast reconstruction is becoming more and more popular so I thought a blog post about it was in order...

What is a nipple-sparing mastectomy?

A nipple-sparing mastectomy preserves the nipple,  areola and all the surrounding breast skin which is then used for the breast reconstruction. Unlike the traditional "modified radical mastectomy", nipple-sparing mastectomy only removes the breast tissue ("parenchyma") under the skin.

What are the benefits?

Studies show that nipple-sparing mastectomy provides the same level of surgical treatment as a modified radical mastectomy in appropriate candidates. Preserving the nipple-areola complex adds to the quality of the reconstruction making the results even more "natural". It also means the patient avoids having to go through the additional steps of nipple reconstruction and tattooing.

Who is a candidate?

Nipple-sparing mastectomy is an option for many patients with a small cancer located several centimeters away from the nipple-areola complex. Patients with ductal carcinoma in situ (DCIS) can also be candidates, again depending on the location and distance from the nipple-areola.

During the surgery, a biopsy ("frozen section") is taken from behind the nipple-areola complex and sent to pathology to make sure there is no cancer under the nipple or areola. If this biopsy is negative then the area can be preserved. If it is positive for cancer cells, the nipple and areola are obviously removed.

Patients at high risk of breast cancer (eg BRCA+, strong family history, Cowden's syndrome) choosing to undergo prophylactic (preventive) mastectomy and immediate breast reconstruction are the best candidates.

Patients who do not need a signficant breast lift will have the best cosmetic results.

What are the risks?

Nipple sensation is usually significantly reduced. Sometimes feeling is lost completely. Even in cases where some nipple-areola sensation is maintained, it is very unlikely the feeling will be as Mother Nature provided.

The underside of the nipple and areola is "shaved down" to remove as much of the breast tissue as possible. This can sometimes compromise the blood supply to the tissue which can then cause healing problems. If the blood supply is damaged too much by the mastectomy, part or all of the nipple-areola can die. Thankfully this is uncommon.

At PRMA we check the blood flow intra-operatively to ensure the nipple-areola will survive. In the unlikely event that the nipple-areola cannot be saved, it is removed to prevent wound healing complications and a new nipple and areola are reconstructed at a later time.

Where will the scars be?

This depends on the size and shape of the breast, whether a small "lift" is needed, patient preference and surgeon preference. Scars can be placed around part of the areola and extended outwards or downwards, or completely away from the areola at the breast crease ("inframmamary fold incision").


I hope this info helps!

Dr C

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Dr Chrysopoulo specializes in advanced breast reconstruction including DIEP flap, SIEA flap, GAP flap, TUG flap, Alloderm One-Step and fat grafting. He is in-Network for most US insurance plans. Patients are 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 patients at facebook.com/PRMAplasticsurgery.

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Who is NOT a DIEP flap candidate?

With more women becoming aware of DIEP flap breast reconstruction as an option, the question of who is and who isn't a good DIEP flap candidate is coming up more often.

As a general rule, women that have had extensive abdominal surgery like a previous TRAM flap, tummy tuck or a complex hernia repair cannot have a DIEP or SIEA flap breast reconstruction. This is because the lower tummy tissue that is needed has usually been removed or moved around, and the necessary blood supply has been disrupted.

Having said that, most of the time previous abdominal surgery isn't an issue in experienced hands.

Many women these days have had at least one previous c-section or another gynecologic procedure like a hysterectomy. It is possible for these procedures to cause damage to the blood vessels needed for DIEP flap surgery but fortunately this is unusual. A previous c-section, hysterectomy, or tubal ligation is not a contra-indication to having a DIEP or SIEA flap. Previous liposuction is not usually a problem either unless this was extensive.

If your surgeon is worried about potential damage from previous surgery then certain tests can be performed to evaluate your anatomy more closely. This can include a simple doppler ultrasound exam in the office or a more involved test like a CT angiogram. Unfortunately, the CT scan does involve radiation.

While previous abdominal surgeries may not prevent you having DIEP flap reconstruction, women that have had multiple previous abdominal procedures are at increased risk of abdominal complications like bulging and hernia after DIEP flap surgery when compared to women that have never had prior abdominal surgery, even though the abdominal muscles are preserved. This is because the fascia (the strong layer of tissue over the muscles) has already been weakened by the previous surgeries.

Some medical issues can make any form of microsurgical breast reconstruction (like the DIEP flap) more difficult and they can also increase the risk of complications like flap loss. These include disorders that make the blood clot more easily (eg Factor V Leiden).

I hope this info helps.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon in San Antonio, Texas specializing in state-of-the-art reconstructive breast surgery. He and his partners at PRMA are In-Network for most major 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 other breast cancer patients on Facebook.

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Breast Reconstruction Before and After Pictures

As this video of before and after pictures shows, breast reconstruction has come a long way over the last few years. When breast cancer is diagnosed at an early stage and immediate reconstruction is an option, the results can look very natural indeed.

Thanks to all the PRMA breast reconstruction patients that contributed their before and after photos to make this video possible!

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. 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 patients at facebook.com/PRMAplasticsurgery.

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My DIEP Flap Journey - Why I traveled from California to San Antonio for my Breast Reconstruction

A big "thank you" to Sharon Pira from Monterey, California for sharing her DIEP flap journey with us....

"I was diagnosed with breast cancer in September 2011 and underwent the whole routine of chemo-therapy, radiation and a full mastectomy of my left breast in March 2012. After all of my treatment was complete I began looking into my options for breast reconstruction.  My local doctor advised against an implant (because of the effect of radiation on the area) so he suggested the TRAM flap as the best option for me which I agreed.

In May 2012 I attended a women's conference in Scottsdale, AZ which was life-changing in itself, however I had no idea just how incredible this trip was going to turn out. On Sunday I got on a shuttle to the Phoenix airport along with another woman and as the driver pulled away I turned to her and asked, "Were you here for the women's conference?"  She said, No, I am a breast cancer surgeon from San Antonio, TX and was here for a breast cancer symposium. I removed the hat I was wearing to reveal my still very bald head and she proceeded to ask me questions about my treatment. She asked what kind of reconstruction I was having and I told her about the Tram flap. She asked if I knew about the DIEP flap? I explained that I had a friend in San Jose who was having the DIEP flap operation but that no one in my area performed this procedure. She gave me her card with the info about PRMA and said I should at least check out their website. We hugged at the airport and I thanked her for the info!

When I returned home I went online to the PRMA website and was amazed by the before and after pictures and actually found a picture of a woman who looked just like me and I could not get over how great she looked one year later. So I called the clinic and scheduled an appointment...

After sending my paperwork for insurance approval I was able to schedule my surgery for August. Everything from beginning to end went incredibly smooth and I am so grateful to the staff of PRMA for their amazing support and care during my hospital stay and my follow up appointments. I feel so blessed... and am thrilled with my results! It feels so good to have my new breast created from my very own body and my friends are all jealous of my incredible tummy tuck - Wow, what a bonus!"

Thanks again Sharon!

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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. 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 patients at facebook.com/PRMAplasticsurgery.

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BRA Day SA - Join us!

I have to say, it's about time. Finally, there is a national push to increase awareness about breast reconstruction.

For years I have had to console ladies who were upset they weren't offered reconstruction at the time of their mastectomy. To this day, 70% of women facing mastectomy for breast cancer are not informed about their reconstructive options. Many have lived for years without a breast only to find out much later that they could have avoided the psychological and social impact of living without a breast altogether.

Now, the American Society of Plastic Surgeons (ASPS) is trying to change that terrible statistic with a national Breast Reconstruction Awareness campaign centered around "BRA day" on October 17th.

Thank you ASPS!

We'll be doing our utmost to help out... PRMA will be hosting the first ever "BRA Day SA" on October 17th at the Witte Museum. It's going to be a phenomenal event full of fun, food, and of course the latest info on breast reconstruction. 

Admission is free and all proceeds will go to WINGS, a 501(C)(3) charity which provides comprehensive breast cancer treatment services to uninsured women in Texas. 

Please join us! More details here.

Hope to see you there!

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. 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 patients at facebook.com/PRMAplasticsurgery.

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One-Step Breast Reconstruction with Implants and Alloderm

Implant breast reconstruction is the most common method of breast reconstruction currently performed in the US. There are two main approaches: the "Alloderm one-step" (also referred to as "single stage" or "direct to implant" reconstruction), and the two-stage reconstruction with tissue expanders. To easier explain the ins-and-outs of the one-step procedure, I first need to summarize the more traditional two-stage approach...

Tissue expanders essentially act as "spacers". They can either be placed at the same time as the mastectomy or some time later. They are inflated with saline injections to recreate the desired breast size. This expansion process can take several weeks depending on the amount of expansion required to reach the optimal cup size. Once the expansion process is completed, the tissue expanders are removed and the final implants are placed. Reconstruction with breast implants is therefore usually performed as a multiple-step process and can take several months.

Alloderm One-Step / Single Stage / Direct to Implant Reconstruction

Some patients are candidates for a "One-Step" procedure whereby the permanent implant is inserted at the time of the mastectomy. A cadaveric implant known as Alloderm is also used to provide extra implant coverage and support. By going direct to the final implant in a single stage, the patient has only one procedure and avoids the use of a tissue expander (and the whole expansion process) altogether. The scar can also be placed in the inframammary fold (at the breast crease) which makes it much easier to hide. The One-Step procedure is also referred to as "direct to implant" or "single stage" reconstruction.

This procedure is obviously very appealing to many women, including those that may not be candidates for perforator flaps. The down time in terms of recovery is also much shorter than most of the alternatives (2-4 weeks).

There are some caveats though.... I used to offer this procedure to most patients. Some One-Step surgeons still do. Personally, I don't anymore - "the perfect candidate" for the procedure has evolved in my eyes. Experience (and grey hair) has a tendency of doing that.

So who is the "ideal candidate"?

1) Patients that do not have a current breast cancer diagnosis

2) Patients that are having prophylactic mastectomy only, e.g. for BRCA1 or BRCA2

3) Patients that are having nipple-sparing mastectomy

4) Patients that do not need a significant breast lift

5) Patients that have not had previous breast/chest radiation


By limiting the procedure to women who fulfill these strict criteria the surgical results are far more predictable and very cosmetic. The risk of further revision or "touch up" procedures is also very low.

PRMA patient Mrs Michelle Coben kindly shares her experience with the One-Step procedure in the video below. You can also see before and after pictures here.

I hope this info helps.

Dr C

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Dr Chrysopoulo specializes in advanced breast reconstruction techniques including perforator flaps, Alloderm One-Step and fat grafting. He is In-Network for most US insurance plans. Patients are 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 patients at facebook.com/PRMAplasticsurgery.

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BRCA Testing: What it means for you

By: Brandy Korman

If you have a family history of breast cancer, chances are that you have been BRCA tested or are considering it.

BRCA is an acronym for BReast CAncer. Carrying the BRCA 1 or BRCA 2 gene mutation can ultimately help determine a woman’s lifetime risk of developing breast or ovarian cancer. The likelihood that a breast and or ovarian cancer is associated with a BRCA 1 or 2 gene mutation is highest in families with a history of multiple cases of breast cancer.

Being a carrier of BRCA 1 or 2 however does not always mean that a woman will develop cancer, although research has shown that chances are five times higher in women who do carry the mutation. According to estimates of lifetime risk, about 12 percent of women (120 out of 1000) in the general population will develop breast cancer during their lives compared to about 60 percent of women who have inherited a BRCA 1 or 2 mutation.

BRCA testing is performed by blood tests which look for changes in DNA, as well as changes in proteins produced by these genes. Positive results generally indicate that a person has inherited a known harmful mutation and therefore has an increased risk of developing an associated cancer.

If you have received a positive BRCA test, you may be looking into options to help prevent cancer. Surveillance is extremely important even if you have not received a positive test result. Staying on top of mammograms and self-screening is crucial.

Some women may opt for prophylactic surgery which involves removing any at-risk tissue in order to reduce the chance of developing cancer. The option for immediate breast reconstruction has made prophylactic mastectomy a more desirable choice for some women.

Another option may be chemoprevention which essentially involves taking medication to reduce the risk of developing cancer. For example, the drug Tamoxifen has been shown in clinical trials to reduce the risk of developing breast cancer by about 50 percent in women who are at increased risk of developing cancer.

If you have tested positive for BRCA, or are interested in receiving more information on genetic testing, please visit www.cancer.gov. Learn more about reconstruction after prophylactic breast surgery here.

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Thank you Brandy for this excellent article. Some great info here.

I'd like to add a couple of points...

BRCA gene mutations are associated with other forms of cancer too, not just breast and ovarian. Affected women can also have an increased risk of developing melanoma as well as cervical, uterine, pancreatic, gallbladder, stomach, and colon cancer (depending on the type of mutation).

BRCA gene mutations can also affect men and increase the risk of breast cancer, pancreatic cancer, testicular cancer, and prostate cancer. When it comes to testing other family members, I strongly recommend the men/boys are BRCA tested too.

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. 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 facebook.com/PRMAplasticsurgery.

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Abdominal Muscle - Why Save It?

Most women that have looked into breast reconstruction know about the TRAM flap. The TRAM uses lower abdominal skin, fat, and varying amounts of abdominal muscle to reconstruct a "natural", warm, soft breast after mastectomy. The TRAM used to be the gold standard in breast reconstruction, but not anymore.

Over the years, the TRAM flap procedure has evolved into two more advanced procedures that decrease the risk of abdominal complications: the DIEP flap and the SIEA flap. Both use the same lower tummy skin and fat but unlike the TRAM, both SAVE all the abdominal muscle and leave it in place.

The SIEA flap differs from the DIEP flap only in terms of the blood vessels that supply the tissue. While the surgical preparation is slightly different, both procedures spare the abdominal muscle completely and only use the patient's skin and fat to reconstruct the breast. 

All three procedures provide the added benefit of a flatter abdomen with results that mimic a “tummy tuck”. However, because the TRAM flap sacrifices abdominal muscle, the risk of a hernia or abdominal bulging is signifantly higher than with the DIEP or SIEA procedures.

Since the DIEP and SIEA flaps preserve all the abdominal muscles, patients experience less pain than after TRAM flap surgery, enjoy a faster recovery and also maintain their abdominal strength long-term.

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. 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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Fat Grafting in Breast Reconstruction - What's the Scoop?

Fat grafting has been in the news a fair amount so I thought I'd give you a brief run-down of what's involved....

Fat grafting is a fairly new technique in breast surgery. Fat is liposuctioned from one part of the patient's body, purified and then injected into the breast.

Fat grafting can be used to fill-in partial breast defects after lumpectomy. It is also frequently used after mastectomy, usually in conjunction with other reconstructive techniques, to optimize the breast contour and improve overall cosmetic results.

There are several fat grafting techniques that are used by plastic surgeons. There is no "set way" that has been shown to be the best in terms of long-term results. However, studies have shown that regardless of the technique used, the collection, storage, and transplantation of the fat cells (and fat stem cells they contain) must be optimized to obtain the best long-lasting results.

Studies have also shown that once the injected fat "takes", it can also help improve the thickness and quality of radiation-damaged tissue and skin.

Regardless of technique, some of the injected fat will be reabsorbed over time but this can vary depending on the exact clinical situation. Patients must therefore be prepared to require more than one procedure for the best results.

As for the risks.... For women still undergoing regular mammograms, it is also important to know that fat grafting can also cause calcifications known as "MACRO-calcifications". As many of you have already unfortunately experienced, breast cancer can also cause calcifications, known as "MICRO-calcifications". According to the American Society of Radiology, these different types of calcifications are easily distinguishable. Having said that, I still tell my patients that fat grafting can lead to the recommendation for further tests in the future because of this calcification issue.

Injected fat can also become firm or create "oil cysts". Fortunately these are becoming much less frequent as techniques are refined but again, both of these can cause "unnecessary" stress.

Several independent studies that have evaluated patients over a few years after the procedure have shown that fat grafting is safe. However, because the technique is fairly new, no long-term safety data is currently available.

Unfortunately not all insurance companies cover the cost of fat grafting so the procedure can involve out of pocket expenses for some patients.

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. 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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