Q: Any Recommendations for the Best Reconstructive Plastic Surgeons Who Do DIEP?

A: Find a plastic surgeon who has done a fellowship in microsurgery and/or who currently does high volume reconstructive microsurgery.

You can usually find a small number of plastic surgeons in a major city, often times at an academic medical center, who perform the DIEP operation or other complex microsurgical procedures on a regular basis.   Having a microsurgery fellowship means that the plastic surgeon spent an additional year (after their usual 6-8 years of training) performing high volume, complex microsurgical cases.  Very often, these reconstructive microsurgeons are members of the American Society for Reconstructive Microsurgery (ASRM) in addition to the American Society of Plastic Surgeons (ASPS)
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It is very rare when a DIEP cannot be performed, but it is ultimatley an intraoperative decision as to whether you end up with a DIEP or some variance of a TRAM.   New imaging modalities with CT Angio or Duplex ultrasound can help "map" these vessels and delineate the anatomy better, but there is no guarantee.   Your surgeon will always perform the operation that best suits you and your anatomy, to give you the safest and best result.

The best plastic surgeon for you is the one who is qualified and who understands your individual needs and presents the best options for you.   I welcome you to contact our office at 415 933 8330 to discuss DIEP breast reconstruction, and/or other autologous (self) tissue options.

Do Breast Reconstruction Tissue Expanders Cause Pain As They Expand?

A: Tissue expansion can be uncomfortable, but should not be painful

Tissue expansion of any type can cause some amount of discomfort and is highly dependent upon the volume and the rate of the expansion.    Pain should be a guide as to when the expansion should stop and allow your tissues catch up to the amount of expansion that can be tolerated.  50cc is an average volume of expansion for breast expanders and is usually well tolerated.

Q: Mastectomy and Breast Reconstruction - Can the Procedures Be Combined

A: Combined mastectomy and breast reconstruction is possible

This is similar to the idea of "immediate vs. delayed breast reconstruction."

The combined procedure is possible, and often times, the preferred method of breast reconstruction.   This "immediate" reconstruction allows for the best aesthetic result because the skin of the breast is saved and an implant or "self tissue" (DIEP, TRAM, etc) can be placed inside the original breast pocket.   The general surgeon and plastic surgeon work together with the first surgeon removing the breast tissue and the second surgeon reconstructing the breast in a single stage.  This is the key advantage.  The disadvantage can be wound issues from thin mastectomy flaps and/or unresolved oncologic issues at the time of reconstruction. 

Can Inverted Nipple After Lumpectomy Be Repaired?

A: An inverted nipple can be corrected

The short answer to your question is yes.  Nipple inversion can occur for several reasons after your lumpectomy.  This includes the "inner" scarring that occurs that likely brough part of the nipple with it, causing an inversion.  To fix this, it is important to figure out which parts of the breast caused this:  loss of skin, skin contracture, fat necrosis, infection, radiation, etc.   Once this has been evaluated, then the principle of treating any nipple inversion are used:  release the scar, add more tissue, etc.   Recurrence can be common, so it is best to see a plastic surgeon with significant experience in this area.

Radiation Wounds & Injury around the Breast for Cancer

Radiation treatment (RT) is a double edge sword in the treatment of cancers.  Just as with chemotherapy, it attacks the cancers cells, but also damages normal cells.   This is quite evident when the "marks" of radiation are left behind on the skin in the form of a tattoo, and more seriously, as a radiation wound that may ulcerate or turn into cancer.  RT is a common treatment for breast cancer, especially for "breast conservation" techniques and to treat the local area for possible recurrence even after mastectomy.

Despite advanceces in RT, long-term complications of radiation injury are still quite common, in the range of 20%,  Depending upon the cycle and total dose, the body's response to radiation is similar to a "burn."  There is soft tissue fibrosis and decreased blood flow which can lead to ulceration, tissue necrosis, infection, chronic wounds, and sometimes, cancer.  This may not be apparent for many years, but it is often a slow, progressive injury with difficult treatment options.   .

RT makes wound healing extrmely difficult because of the tissue"fibrosis" and decreased blood flow. Once a wound forms in a radiated area, it is often a sign of more serious injury deep below the skin, including muscles, bones, cartilage, blood vessels and nerves.   Typical "wound care" with dressings are usually not enough to heal this damaged area.   Hyperbaric oxygen (HBO) may help in these circumstances, but ultimately, the radiated wound needs additional blood flow and cleaning out of the damaged and/or necrotic/infected tissue.  Additional oxygen with HBO can only do so much when blood flow has already been reduced by the RT.     

In select wounds, especially around the breast, the best form of treatment to heal radiation damaged breast tissue is with new, non radiated tissue that is brought to the area with additional blood flow, in the form of a "flap."   This reqiures careful assesment and planning and is the gold standard by which a complex wound can be healed.    Fortunatley, around the breast, there are many options to bring new tissue from the abdomen or back to treat the damaged area.    The breast can be completely reconstructed at the same time as the wound with designer flaps such as the DIEP or SIEA perforator flap in a single procedure.

Most importantly, the health practitioner must recognize when the current treatment of an irradiated breast wound is not working.   Far too often, I have seen patients who have had over 100 treatments with HBO, or years of a chronic, nonhealing wound, or with recurrent implant/tissue expander infections/capsular contracture.    3 months is the maximum time that a wound should be treated in the same manner with minimal progress;  it is at this time that a higher, expert level of assesment must be performed to determine further treatment options.  

What is the difference between "Immediate" and "Delayed" Breast Reconstruction?

This is "surgical" terminology to describe the timing of breast reconstruction in either the "immediate" situation after mastectomy, or in a "delayed" fashion, after many months or years after the mastectomy.  So the key difference is months, not hours.
There are advantages and disadvantages to each "timing" method.  First, the advantage of "immediate" reconstruction is that breast reconstruction and mastectomy are performed in 1 operation.  One does not have to wait for the "healing" after the mastectomy (typically 3-6 months), and wait for another operation to reconstruct the breast.  In terms of aesthetics, if a "skin sparing" mastectomy can be performed, the breast shape can be excellent and the overall result of the breast reconstruction can be superb.   The "skin sparing" techninque allows the surgeon to use the remaining skin as a cover over the flap (DIEP, SIEA, TRAM) or implant/tissue expander that will help shape the breast into a more natural mound.

The disadvantage of the "immediate" technique lies with the potential oncologic issues that can occur if the cancer issues are not fully eradicated, and the breast has been reconstructed with the possibility that cancer cells may come back to recur in the reconstructed breast.  The other concern is radiation therapy.  In the immediate reconstruction, radiation can adversely affect the outcome of the breast reconstruction (shape, healing, capsular contracture, etc).

The "delayed" technique is still the safest.  It provides the optimum time for healing after mastectomy, addresses issues of "recurrence," and allows the operation to be split in 2 stages allowing the patient to recover from the initial mastectomy and then address the reconstruction later.  The cosmetic result can still be excellent, with the "immediate" reconstruction having a slight advantage in overall shape.

The choice of "immediate" versus "delayed"  is not an easy one.  The overall team that is available is critical in choosing either method.  This includes the general surgeons, plastic surgeons, oncologists, and nurses.