Do you need a CT angiogram before DIEP flap breast reconstruction?

If you've had several previous abdominal surgeries and are considering DIEP flap breast reconstruction, a CT angiogram may be recommended by your plastic surgeon.

A CT angiogram (CTA) is a special type of CT scan that examines the blood vessels in the abdomen to determine if they are intact and able to be used for DIEP flap reconstruction. It can also provide a "road map" for the surgeon and help locate the largest blood vessels ("perforators").

Sometimes the vessels needed for the DIEP flap may have been damaged by previous abdominal surgery. Although the majority of previous abdominal surgeries are not a contraindication for DIEP flap reconstruction (except a tummy tuck), there is a small chance that the blood vessels may be damaged in patients that have had multiple previous abdominal surgeries or certain procedures.

While some surgeons obtain CT angiograms on their patients routinely before DIEP flap surgery, in our opinion not all patients need the study. A very good example is patients who have never had abdominal surgery. Much depends on surgeon preference and experience.

It is also important to realize that the test exposes patients to radiation; in many cases, patients have already had more than their fair share of radiation as part of their breast cancer treatment! At PRMA, we usually only recommend a pre-operative CTA in patients that have had multiple previous abdominal surgeries and there is a question about the vascular anatomy.

There is no doubt, despite the radiation exposure, a CTA can be an excellent planning tool when needed. Be sure to discuss any concerns you have regarding previous abdominal surgeries and the need for a CT angiogram with your plastic surgeon.

I hope this info helps!

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 others touched by breast cancer on Facebook.

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What is a Microsurgery?

Microsurgery is a very intricate, specialized type of plastic surgery performed using delicate instruments, sutures finer than human hair and high powered magnification provided by either a microscope or high-powered loupes. Microsurgeons can repair and reconnect very small blood vessels and nerves less than 1mm in diameter.

Microsurgery has allowed significant advances in many surgical fields. Breast reconstruction has been transformed completely.

We can now replace tissue removed by a mastectomy with the patient's own tissue transplanted from another part of their body. Unlike conventional tissue reconstruction techniques (like the TRAM flap), the latest microsurgical techniques ("perforator flaps") carefully preserve the patient's underlying muscles. The tissue is disconnected from the body, transplanted to the patient's chest and reconnected using microsurgery.

Preserving underlying muscles lessens postoperative discomfort making the recovery easier and shorter. It also helps the patient maintain muscle strength long-term which is particularly important for active women.

Below is a video of microsurgery performed during a DIEP flap breast reconstruction. Here we are connecting the DIEP flap artery to the internal mammary artery in the chest under the microscope:

I hope this info helps!

Dr C

*****

Dr Chrysopoulo is a board certified plastic surgeon in San Antonio, Texas and an active member of the American Society for Reconstructive Microsurgery. He specializes in DIEP flap breast reconstruction and other state-of-the-art breast reconstruction procedures. He is 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 schedule a consultation.

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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

*****

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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Are you a BRCA Patient Interested in Prophylactic Mastectomy & DIEP Flap Breast Reconstruction?

Angelina Jolie's decision to have prophylactic mastectomies and immediate breast reconstruction earlier this year has prompted women across the country to look into their hereditary breast cancer risk.

We're kicking off Breast Cancer Awareness month on Wednesday, October 2nd with a live tweet event about this very topic.

One of our BRCA+ patients has kindly agreed for our staff to tweet during her surgery - bilateral prophylactic mastectomies and immediate DIEP flap breast reconstruction.

Please join us live in the OR to learn more about these procedures!

You can learn more about the Live Tweet Event here.

Dr C

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Dr C is a board certified plastic surgeon and microsurgeon specializing in state-of-the-art breast reconstruction. 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.

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Vascularized Lymph Node Transfer for Lymphedema

Vascularized lymph node transfer is the latest surgical option for the treatment of lymphedema. The procedure was first described several years ago and has continued to evolve since then. It is now gaining popularity for the treatment of arm lymphedema in breast cancer survivors that do not respond to conservative (non-surgical) therapy. The results have been quite exciting.


In the case of arm lymphedema caused by breast cancer surgery or radiation, a vascularized lymph node transfer moves healthy lymph nodes, usually from the upper-outer groin, to the underarm area (axilla). These healthy nodes compensate for the lymph nodes removed or damaged by the breast cancer treatment.

The lymph nodes from the upper-outer groin can be transplanted connected to a DIEP flap at the same time as breast reconstruction, or as a separate piece of tissue if DIEP flap breast reconstruction is not being performed at the same time. These lymph nodes are more superficial than the deeper groin lymph nodes that are important for lymphatic drainage of the leg.


Lymph node transfer is not the only surgical option for lymphedema. Other surgical options include soft tissue resection, liposuction, and lymphatico-venous or lymphatico-venule anastomoses (connecting the lymphatic system to the venous system to encourage drainage).

Of all the procedures described to treat lymphedema, vascularized lymph node transfer is showing the most exciting results in terms of decreasing swelling, preventing infections and reducing the need for compression therapy. Patients can experience improvement in their symptoms very quickly after surgery though it can take several months in some cases.

As with all surgery, there are risks too. In addition to the risks of any surgery (bleeding, infection, wound healing issues), the lymph nodes may not survive and the lymphedema can worsen because of further scarring created by the surgery. There is also a risk of creating leg swelling if deep groin lymph nodes are taken. Thankfully, the risk of these complications is very low.

Only patients that have exhausted all conservative therapy by certified lymphedema specialists are considered candidates for vascularized lymph node transfer.

Unfortunately, most insurance companies still consider the procedure experimental and do not currently cover the cost of lymph node transfer.

I hope this info helps.

Dr C

*****

Dr C is a board certified plastic surgeon and microsurgeon specializing in state-of-the-art breast reconstruction. In-Network for most US insurance plans. Patients 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.

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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.

*****

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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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!

*****

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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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

*****

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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Reconstructing Breasts with Sensation

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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DIEP Flap Breast Reconstruction

Here's a short video about DIEP flap breast reconstruction after mastectomy.... details about the procedure and why it has become the gold standard in breast reconstruction.

Hope you find it useful.

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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Breast Reconstruction Makes Breast Cancer Patients Whole Again After Mastectomy

Alarmingly, 70% of American women facing surgery for breast cancer are not told about the option of breast reconstruction.

Perhaps one of the best things about breast reconstruction is that it can be performed at any time….  you can never “miss the boat” so to speak. Regardless of the timing of the procedure, breast reconstruction enables women to feel whole again, not just physically but also emotionally.

There are several reconstructive options ranging from breast implants to using the patient’s own tissue. Tissue (or “flap”) procedures recreate a “natural”, warm, soft breast and are associated with fewer complications than breast implants.

Breast reconstruction can be performed at the same time as the mastectomy ("immediate reconstruction") or any time 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 most of the natural breast skin envelope. Only the actual breast tissue under the skin is removed. The reconstruction then "fills" this empty skin envelope. In some cases nipple-sparing mastectomy can be performed. This preserves the nipple and areola as well as all the breast skin.



Skin-sparing (and nipple-sparing) mastectomy and immediate breast reconstruction produce the most "natural" results with the least scarring. Patients undergoing immediate reconstruction also avoid the experience of a flat chest altogether. Immediate reconstruction is therefore preferred whenever possible and should be the goal for patients with early breast cancer (stage I or II).

In some cases breast reconstruction cannot be performed at the same time as the mastectomy. Reasons 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 plastic surgeon.

As I already mentioned at the beginning of this post, most women unfortunately are not made aware of their breast reconstruction options. I therefore encourage all women interested in breast reconstruction to research their options and seek a referral or consultation with a plastic surgeon specializing in breast reconstruction.

You can see real patient results after immediate and delayed breast reconstruction in our photo gallery here.

Dr C


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PRMA Plastic Surgery specializes 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 reconstruction. 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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Finding the Best DIEP Flap Surgeon for You

If you are considering DIEP flap breast reconstruction, finding the right surgical team is key. Before deciding which surgeon is the best DIEP flap surgeon for you, consider asking the following questions:

1. Are you certified by the American Board of Plastic Surgery? Your surgeon should be a board certified plastic surgeon with extensive training and experience in microsurgery.
2. How much experience do you have with this type of surgery - How many have you performed? It is preferable that your surgeon has successfully performed over 100 DIEP flap reconstructions.
3. What's your success rate? Top specialist centers boast a success rate of at least 98%.
4. 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).
5. 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 very low.
6. How many microsurgeons will be performing the surgery? Since the DIEP flap procedure can be so technically demanding, 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 time.
7. 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. 
8. Do you "balance bill"? Centers like PRMA 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". Make sure to ask ahead of time to avoid nasty financial surprises down the line.
9. 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 several thousand microsurgical breast reconstructions, and typically performs over 500 DIEP flaps per year. 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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Texas Bill Mandates Breast Reconstruction Discussion Before Breast Cancer Surgery

Currently only 30% of breast cancer patients are informed of their breast reconstruction options before mastectomy or lumpectomy.

New legislation is being proposed in Texas that aims to significantly improve that abysmal statistic for breast cancer patients. Texas House Bill 669 would mandate that doctors inform all breast cancer patients about their breast reconstruction options BEFORE having surgery for breast cancer. The bill was drafted based on similar legislation in the state of New York.

PRMA Plastic Surgery is proud to announce that a former patient, Tammy Carrington, is the team leader behind this Bill.  She proactively sought out her state representative, James White, to begin drafting proposals.  The Bill was drafted and submitted January 14, 2011.  If approved, this statute will take effect the following year.

Tammy Carrington knows firsthand what it’s like to be diagnosed with breast cancer and receive limited treatment options.  After being diagnosed in June of 2009, Tammy was given two options: a lumpectomy with radiation or a unilateral mastectomy.  Tammy didn’t want either.

Tammy wanted to decrease the risk of breast cancer in the future in the other breast too. After intensely researching her options on her own she learned she could have bilateral mastectomies and immediate reconstruction. Ultimately she traveled to PRMA in San Antonio and underwent bilateral mastectomies with immediate DIEP flap breast reconstruction using her own abdominal tissue.  All the procedures were covered by her health insurance.

Not surprisingly, Tammy feels very strongly about this Bill since she so easily could have chosen something she feels would have been the wrong option for her.

"My nature is to research things completely so that I can make informed decisions. I am the mom to a severely brain injured little boy… I’ve spent lots of time over the years looking for information on how to help him get better… After getting over the shock of hearing the 'C' word,... I went into research mode”, Tammy recalls.

“HB 669 isn’t mandating any particular treatment. It's not mandating any surgery. It's just mandating education. Women have the right to be told about their options so they can make truly informed decisions about their own health. Unfortunately, right now only 30% are even told breast reconstruction is an option”, she says.

PRMA Plastic Surgery is proud to support HB 669 and is calling on breast cancer patients, physicians, and all those touched by breast cancer throughout the state of Texas to offer their support by calling their representatives.

Please call your State Legislator and urge them to co-author HB 669. Your state representative’s contact information can be found HERE.

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PRMA Plastic Surgery in San Antonio, Texas, specializes in advanced breast reconstruction using 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 Texas, out-of-state, as well as from outside the USA. Connect with other breast cancer reconstruction patients at www.facebook.com/PRMAplasticsurgery

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Breast Reconstruction With Tummy Tissue (Abdominal Flaps)

DIEP flap? TRAM flap? SIEA flap? With so many breast reconstruction options available these days it's difficult to understand what these terms really mean and what the differences are between all these "tummy flap" procedures.

It is important for women considering these reconstructive options to realize that not all tummy tissue options are created equal. For example, a DIEP flap is not the same as a TRAM flap just because both provide the benefit of a tummy tuck.

Many women are now rejecting breast implants preferring to use their own abdominal tissue for reconstruction after mastectomy. A breast that has been reconstructed with the patient's own tissue typically looks and feels more natural than an implant reconstruction, will last longer without the long-term complications that can be associated with implants, and will also age like a natural breast. Women wanting to use their abdominal tissue have 3 reconstructive options: TRAM flap, DIEP flap, or SIEA flap.

The TRAM flap is a very common breast reconstruction technique that requires the sacrifice of at least a portion of the rectus abdominus (sit-up) muscle. There are 3 different types of TRAM flap ("pedicle", "free", and "muscle-sparing free"): the exact type is defined by the amount of abdominal muscle removed. Unfortunately, TRAM surgery can be associated with significant post-operative pain, prolonged recovery and a host of abdominal complications such as loss of abdominal muscle strength (up to 20% or more), bulging (or "pooching"), and even abdominal hernia.

The DIEP flap procedure is similar to the TRAM flap except that it spares the rectus abdominus muscle completely. Only skin and fat are removed from the abdomen. This tissue is disconnected from the body completely, transplanted to the chest and re-connected using microsurgery to create the new breast. As the sit-up muscle is saved completely and left behind in its natural place, the risk of abdominal complications is much less than with a TRAM. There also tends to be less pain and a quicker recovery time because the abdominal muscles are preserved and left in place.

Like the DIEP flap, the SIEA (Superficial Inferior Epigastric Artery) flap completely preserves the abdominal muscles. The main difference between these two procedures is the artery used to supply blood flow to the newly reconstructed breast. The “SIEA” blood vessels are generally found in the fatty tissue just below skin whereas the “DIEP” blood vessels run below and within the abdominal muscle (making the DIEP more technically challenging). Recovery from the SIEA flap is even easier than the DIEP since the abdominal muscles are not disturbed at all during the surgery.

Despite the similarities between these two surgeries the SIEA flap is used much less frequently than the DIEP flap because less than 20% of patients have the appropriate anatomy. Unfortunately, there are no pre-operative tests to reliably show which patients have the appropriate anatomy and the decision as to which procedure to perform is made intra-operatively by the plastic surgeon based on the anatomy found at the time of surgery.

Since the TRAM, DIEP and SIEA procedures all use the patient's lower abdominal skin and fat, all these abdominal flap options provide the added benefit of a tummy tuck at the same time as the breast reconstruction.

There are many plastic surgeons in the US offering TRAM flap reconstruction. Unfortunately, very few centers in the US routinely perform the advanced microsurgical procedures like the DIEP and SIEA flap. Many patients will therefore have to travel for these procedures.

When considering a reconstructive surgeon, ensure he/she is a plastic surgeon certified by the American Board of Plastic Surgery that has extensive experience with this specific type of surgery. Also ask about the success rate in their hands - most specialists boast a flap survival rate of 97% to 99%+.

The 2 websites below list surgeons that offer DIEP and SIEA flap reconstruction and serve as a good starting point when researching surgeons:

www.diepbreastreconstruction.org and www.breastrecon.com

*****

Dr Chrysopoulo is a board certified plastic surgeon at PRMA Plastic Surgery. PRMA specializes in microsurgical breast reconstruction including the DIEP flap procedure. PRMA has performed thousands of DIEP flaps and is In-Network for most US insurance plans. On Facebook?.... Connect with other breast cancer patients in our FB Breast Cancer Reconstruction Community.

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TRAM Flap vs DIEP Flap: What's the Difference?

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.

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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?

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).



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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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How Much Does Breast Reconstruction Cost?

The two most common questions among breast cancer patients considering breast reconstruction are "how much does breast reconstruction cost?" and "will my insurance cover it?". The good news is that even though breast reconstruction is performed by plastic surgeons, it is NOT considered cosmetic surgery.

If the mastectomy is for breast cancer then the law states it must be covered by insurance. If the mastectomy is covered, the reconstruction will be too. The bad news is that even though insurance covers breast reconstruction, there are still some costs that the patient will be responsible for. Patients much research this ahead of time to limit the risk of a nasty financial surprise down the line.

While the degree of coverage varies based on the insurance plan, there are some things that are pretty standard. Effective June 1, 2010 even Medicaid will provide a benefit for breast surgery to the unaffected breast for symmetry, providing certain criteria are met. Breast reconstruction after prophylactic (preventive) mastectomy is usually covered as long as the patient is deemed to be high risk for breast cancer (significant family history or BRCA gene positive).

Even though insurance companies are mandated to cover reconstruction, breast reconstruction insurance laws do vary by state. The amount each insurance pays can also vary a great deal.

It is important to make sure your surgeon is in-network for your insurance plan if at all possible. This will limit your costs to whatever you've agreed to pay under the terms of your insurance plan (such as your deductible, co-pay and out of pocket expense). Using an out-of-network surgeon will likely subject you to other costs such as "balance billing". This is when the surgeon essentially sets his/her price (just to use an example let's say $1,000), receives whatever the insurance plan pays (let's say $600) and then asks the patient to pay the remainder (ie the "balance" of $400). This example is based on relatively small dollar amounts but you can see how this could add up to tens of thousands of dollars of additional bills for a major surgical procedure, and that's just for the first procedure.

Whether or not you can find an in-network, experienced surgeon depends on the procedure you've decided to have. If you've decided to have an implant reconstruction then you may have several doctors to choose from. Implant breast reconstruction is technically not as challenging as other options and most plastic surgeons perform the procedure.

On the other hand, if you're more interested in an advanced reconstructive procedure that not many surgeons offer (like a DIEP flap), you're likely to have a harder time finding an experienced surgeon to perform your surgery who is in-network. Most patients will unfortunately have to travel for their surgery because of this. Even though this may now add the cost of airfare and hotel stays, these costs are typically significantly less than a "balance bill" from an out-of-network surgeon.

Some breast centers even offer special arrangements to traveling patients such as significantly discounted hotel charges to help ease the financial burden.

Find answers to frequently asked breast reconstruction insurance questions here.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in advanced breast reconstruction surgery. 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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Too thin for a DIEP flap?

I've spoken to several ladies recently who have had the same misconception about DIEP flap surgery. They were scared they were "too skinny". The truth of the matter is that you don't need to be overweight to be a candidate for DIEP flap surgery. What matters is the distribution of the fat that you do have. Unfortunately that can't be determined over the phone. Sometimes it can't even be determined by emailing pictures.

I can say that we have successfully performed DIEP flap reconstructions on women with BMI's of 20 and even less. In instances where the reconstruction ends up too small, many women are candidates for autologous fat grafting. This involves liposuction of fat from another part of the body, purifying this fat, and then re-injecting it into the reconstructed breast for additional volume.

We used to occasionally place a breast implant under the DIEP flap in women who needed more volume. Unfortunately the patient is then exposed to the risks of breast implants like capsular contracture (hardening of the implant and breast) and even deformity.

Fat is not free of issues either though - some of it can become reabsorbed or form little pea-sized areas of hardening (fat necrosis), especially if the fat grafting is not performed in a meticulous way. There were fears for a while that the injected fat could cause calcifications on a mammogram that could look like or even mask a new breast cancer. Several studies have since proven that fat grafting is safe though some plastic surgeons are still reluctant to perform the procedure because of these previous fears. Even though fat grafting may not be 100% predictable, it has served our patients very well and we now prefer it to implants in these situations.

If you'd like to know for sure whether you're a candidate for a DIEP flap please visit with an experienced DIEP surgeon. It's the only way to really be sure.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in advanced breast reconstruction. 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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Tammy's Breast Reconstruction Journey. Part 3 - Finding My Surgeon

By Tammy Carrington

After deciding to pursue immediate breast reconstruction I went online and requested information from the PRMA website on a Saturday. By Monday morning Mistie (the nurse) called me back to see what information I needed. She was so kind and nice. She really listened to what I was saying and took my medical information and then verified my insurance. After I gave Mistie my medical information, the ball started rolling in the right direction. Mistie spoke with Dr. Chrysopoulo directly about my case and an appointment was scheduled. Once I met him I had an incredible peace about the whole thing. I knew that I found the right doctor and the right place to have my surgery.

When I arrived for my initial appointment, Dr. Chrysopoulo made me feel at ease immediately. He was kind, compassionate, and knowledgeable. He spoke with complete sincerity and he also had a great sense of humor, which helped to make me smile and made me feel at ease. It was also wonderful getting to meet Mistie in person after talking to her on the phone several times.

I had initially wanted to do reconstruction with implants thinking that my recovery time would be quicker. Dr. Chrysopoulo spoke to me about the pros and cons of implants verses DIEP flap reconstruction. Once it was laid out in front of me, it made complete sense to have the DIEP flap procedure rather than reconstruction with implants. The DIEP procedure would use tissue from my stomach to reconstruct my breasts and Dr. Chrysopoulo would begin the reconstruction as soon as the general surgeon completed the mastectomy - while I was still asleep. I would not have to return for reconstruction surgery later. That sounded great to me.

Dr. Chrysopoulo was preparing me for what might be ahead after surgery by saying that when I woke up, I would feel like I had been hit by an 18-wheeler but it would get better. He said that by a week later I would feel like I had been hit by a mini-van. I knew other women who had breast augmentation who said when they woke up; it felt like they had a Buick parked on their chest, so I knew that there would be pain following such major surgery. I prepared myself for whatever was ahead mentally. (Actually, my personal experience with pain following my surgery was so much less than what I mentally prepared for.)

Dr. Chrysopoulo also told me that my instructions following my surgery would be to basically “live in a recliner for 3 weeks getting up only to walk”. I knew that walking was going to be a big part of recovery, but that it would be important to take it a little easy as well.

(more to follow on The Breast Cancer Reconstruction Blog)

Tammy's Breast Reconstruction Journey. Part 1 - My Breast Cancer Diagnosis

Tammy's Breast Reconstruction Journey. Part 2 - Making The Decision

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Keep up to date with the latest news in breast cancer reconstruction at The Breast Cancer Reconstruction Blog. Also join us on Facebook and Twitter!

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Breast Reconstruction Surgery Options After Mastectomy

Every woman has a right to breast reconstruction surgery after breast cancer. This has been a federal mandate for some time and insurance companies have to pay for breast reconstruction surgery by law. There is no age limitation for breast reconstruction and there are many different options available.

"Immediate" breast reconstruction is performed at the same time as the mastectomy. Advantages include: preserving most of the patient's breast skin, a shorter/less obvious mastectomy scar and waking up with the new breast already in place (and avoiding the experience of a flat chest). It also generally provides the best cosmetic results particularly when combined with nipple-sparing or skin-sparing mastectomy.



"Delayed" reconstruction generally takes place after the mastectomy has healed. Many times patients required to undergo radiation following their mastectomies are advised to delay reconstructive surgery in order to achieve the best results. It is common to wait several months after the last radiation therapy session before proceeding with reconstruction to allow the soft tissues to recover completely from the radiotherapy.

Tissue expander reconstruction is the most common method of breast reconstruction in the United States. Most plastic surgeons perform this as a two-stage procedure. The expander is used to stretch the skin envelope and create the size of breast the patient and plastic surgeon desire. The expander is replaced by a permanent breast implant (saline or silicone) at a separate procedure some time later.

Some patients are candidates for one-step implant reconstruction (without expanders): a permanent breast implant is inserted immediately without going through the whole expansion process. In the one-step implant reconstruction the implant is completely covered by the pectoralis muscle and an acellular dermal graft (like Alloderm or FlexHD). These grafts are tissue implants that provide support and increase the amount of padding over the implant.

Implant reconstruction can be the best option for some patients. However, reconstruction with expanders and breast implants are associated with more complications than cosmetic breast augmentation. Complications following radiation therapy are also higher with implants compared to reconstructions using the patient’s own tissue.

The Latissimus procedure uses muscle (latissimus dorsi), fat and skin from the back (below the shoulder blade) that is brought around to the chest to create a new breast. Many patients also need an expander to obtain a satisfactory result. The expander is replaced by a permanent implant at a second procedure down the line. Patients typically a scar on their back that can be seen with some low-cut clothing. Women who are very active in sports may notice some strength loss with activities like golf, climbing, or tennis.

TRAM flap surgery is a common procedure that uses skin, fat and varying amounts of the sit-up muscle (rectus abdominus) from the lower abdomen. The tissue (or flap) is then relocated to the chest to create the new breast. This procedure also results in a tightening of the lower abdomen, or a "tummy tuck." Unfortunately, sacrifice of all or part of the abdominal muscle can result in bulging (or “pooching”) of the abdomen and even a hernia. Up until a few years ago, this was the gold standard in breast reconstruction.



DIEP flap breast reconstruction has replaced the TRAM flap as today's gold standard in breast reconstruction. The DIEP flap uses only skin and fat. This is disconnected from the lower abdomen and reconnected to the chest area using microsurgery to create a new breast. Since all the abdominal muscles are saved, patients do not have to sacrifice their abdominal strength. They also experience less pain and have a quicker recovery than TRAM patients. The risk of abdominal bulging and hernia is also very small. The SIEA flap is a variation of the DIEP flap. It is associated with an even easier recovery and a 0% hernia risk but requires specific anatomy which not all patients have. Like the TRAM, the DIEP and SIEA procedures also provide a simultaneous tummy tuck.

Women who do not have enough abdominal tissue for reconstruction may be eligible for the GAP (buttock) or TUG (upper inner thigh) flap procedures. The resulting scars are generally easily hidden by most underwear.

Like the DIEP flap, the GAP and TUG flap procedures are unfortunately not offered by most plastic surgeons as they require advanced training in microsurgery and reimbursement is very low. Only about 40 surgeons in the US perform these advanced procedures routinely.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction including advanced techniques like the DIEP flap procedure. Keep up to date with the latest news in breast cancer reconstruction at The Breast Cancer Reconstruction Blog, on Facebook and on Twitter!

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