Plastic Surgery

There are many different materials that are given to patients regarding Breast Reconstruction. Some are form the plastic surgeon's office, some are from the implant company, others are from our society ASPS. Some patients receive all types. There is not a requirement to give out the booklets from the company but it may be helpful. There are many different materials that are given to patients regarding Breast Reconstruction. Some are form the plastic surgeon's office, some are from the implant company, others are from our society ASPS. Some patients receive all types. There is not a requirement to give out the booklets from the company but it may be helpful.

I am about 4 weeks post op today. I went out on 11/13 and will return to work on 1/23. I'm a nurse and I work in a busy psych clinic. I was active and in good health prior to surgery, but there is no way I could return to work yet. I believe that I will need the full ten weeks to recover.

There is a big psychological component that needs to be processed during this time. It is a time to be gentle with yourself, I believe it is important to give yourself enough time to heal both physically, and emotionally. I usually recommend that patients take one month off from work to fully recuperate. Depending on what they do, how quickly they heal, and how motivated they are to get back, this can be variable. The only absolute restrictions are no heavy lifting or rigorous activity for 4 weeks. After that, there are no restrictions. After DIEP patients are walking on the first day after surgery, and discharged on the 4th. By that time they can do whatever they need to take care of themselves, like shower, walk stairs and drive a car.

I had a diep flap done on 11/15. Double mastecomies with reconstruction lasted 15 hours. Unfortunately, the flap on my rt side failed, so a decision was made to place an implant on the rt side. I like the look of the flap, and the feel. The flap feels more natural...the implant feels numb and tight.

The surgery was no joke, very intense. I was in the hospital for five days, and needed a lot of help for about ten days beyond hospitalization. I came home with 5 drains. I also needed a blood transfusion.

Make sure you consult with more than one plastic surgeon. Make sure you also have a plan B...what will be done if the flap fails. I don't have regrets about my choice, but I do wish I had 100% success. Reconstruction of one breast with a DIEP usually takes 4-6 hours, and reconstruction of both breasts usually takes 6-8 hours. The individual patient’s anatomy accounts for most of the variability. The surgery is usually followed by a 4-day stay in the hospital. Just in case you meant "last" as in will you have to have it redone like with implant reconstruction, the answer is .....a successful DIEP breast reconstruction is designed to "last" a lifetime. You may desire aesthetic improvements over time as your reconstructed breasts will behave much like your natural breasts.

Richard M. Kline Jr., M.D.

Patients can have radiation therapy if they are getting breast reconstruction. This holds true for use of autologous tissue transplants such as DIEP flaps or TRAM flaps, or for tissue expanders, and implants (saline or silicone). The timing of radiation therapy with reconstruction depends on many factors and is coordinated with the radiation oncologist and the breast surgeon, reconstruction surgeon, and medical oncologist. Patients can have radiation therapy if they are getting breast reconstruction. This holds true for use of autologous tissue transplants such as DIEP flaps or TRAM flaps, or for tissue expanders, and implants (saline or silicone). The timing of radiation therapy with reconstruction depends on many factors and is coordinated with the radiation oncologist and the breast surgeon, reconstruction surgeon, and medical oncologist.

Great question. I also have silicone gel implants. I only had a single mastecomy but also got implant/lift on the other one for better symmetry (and remember, insurance is required to pay for that!)My plastic surgeon told me they felt more natural than saline and let my husband and me hold them.

I decided on implants pretty quickly; I figure less is more when it comes to surgery. The tissue flap surgery sounded pretty complicated, and my plastic surgeon told me the aesthetic results are not as good. He also told me the silicone implants don't really have leaking issues; they're more like a gummy bear. He told me none of his patients have had problems or needed replacements. I'm three-plus years out and haven't had any problems. But one tip I learned that may be helpful was to make sure the facility that does mammograms has experience with implants, and I learned that mine does. (I still get mammograms on the augmented/non-mastectomy breast.)

I'm also part of an ongoing implant study to help other women, and that's kind of interesting. I take a phone or online survey every year and I have occasional follow ups with my plastic surgeon as part of that. I have silicone implants. I believe this is a very personal choice and my decision was made based on a few factors. One reason I chose silicone was the fact that when I held both of them, I found the silicone to have the feel of a natural breast as opposed to the saline ones. Safety was a concern too. Based on the current research available about the silicone implant, they do not appear to have long-term health risks.

After my reconstruction surgery I had significant pain for almost three years. I finally helped alleviate it with a proper fitting bra. My guess is that since you are having the pain at night, you are not wearing a bra, which helps support the implants and the muscles holding the implants.

Part of my problem was that I couldn't find a bra at all that would work for me because I'm a B cup in projection, but a D cup in width, so I just went with very tight camisoles. That wasn't enough support and the pulling (although I didn't know I had pulling at the time) was stretching the tissue and nerve endings. I have found a great bra from Victoria Secret that has no underwire and a light padding to help fill in the projection problem.

I suggest you try wearing a bra at night and see if that helps. If not, an additional MRI to rule out any residual problems is warranted.
Hi, I am so sorry for you pain. I had reconstructive surgery in May of 2010 and then again in September of 2010. I still have quite a bit of pain (although just recently it has lessened). I was told it is nerve pain and pain from the scars. It is getting better. I had excruciating pain also - shooting sharp pains and also a pretty constant ache all over. But, in particular, I would (and still do, just not as much) get very sharp, stabbing pains at and around the scars (incision sites).

I guess you can say I feel your pain. I don't know if that is what you have been experiencing. But, I finally just a couple of months ago broke down in front of my doctor, cried my eyes out, told him that I was in constant pain and got very little sleep. He suggested that we get the sleep under control as it might help with some of the pain I was experiencing. (I would wake up from the pain, have trouble getting to sleep because of the pain etc.). So, he gave me something for sleep. I think it is making a big difference for me because I definitely notice a big difference in my pain level after a full night's sleep - much less pain. When I have a night where I get interrupted, or very little sleep, I wake up with a lot of pain.

I don't know if this could be a possible help to you or not. And, I didn't get this intervention until very recently so I am not 100% sure if it is the sleep or just the fact that time has passed. But, my doc made a good point (I think) and that is that our bodies need rest to recuperate and that lack of sleep will interrupt our healing and can add to our pain.

I don't tolerate pain meds very well (pretty much all of the pain meds make me really sick). But, when I was having really excruciating pain that my surgeon thought was nerve pain from the surgery - they put me on something called Nuerontin (sp?) I do think it helped. But, like I said, I would get sick from the pain meds, still this one did seem to help me deal with the really bad nerve pain post op.

I am so sorry for your pain. I hope you get a resolution soon.

I have never tried it, but, have heard accupuncture is very helpful.

All the best,
Lisa

The nipple reconstruction was a piece of cake. This was done with a local and I was actually able to walk into the OR. I would have to go back and look up the exact procedure to get the details right, but my plastic surgeon used the star flap technique to create a nipple mound. All I felt was a little tugging as he was suturing. I actually watched him do it. I looked up and could see what he was doing reflected in one of those overhead lights and commented on it. One of the nurses freaked out and said "We can move the light" and I said " I can also close my eyes" but I didn't because it was too interesting. Something I never would have imagined myself doing, but I guess that's what five surgeries in eight months can do for a person :) I couldn't resist making a joke when he finished, I waited a half a beat and said "I think you need to move it a little more to the left."

I was able to go back to work the next day, and for the next couple-three weeks he had me wear an eye patch (oval gauze pad they give you afer eye surgery) with a hole cut in the middle to cushion the fake nipple. After it healed I got the areola color tattooed in, which I was able to do over a lunch hour. I'm very pleased with the results. I know women who have skipped this step but I would have felt unfinished. It's a much better match with the other breast, the color in particular is just about perfect. No one looking closely at it would mistake it for the real thing but the only people in that camp are my husband and me and we both think it looks pretty good. I'm very satisfied with my overall reconstruction. The nipple reconstruction was a piece of cake. This was done with a local and I was actually able to walk into the OR. I would have to go back and look up the exact procedure to get the details right, but my plastic surgeon used the star flap technique to create a nipple mound. All I felt was a little tugging as he was suturing. I actually watched him do it. I looked up and could see what he was doing reflected in one of those overhead lights and commented on it. One of the nurses freaked out and said "We can move the light" and I said " I can also close my eyes" but I didn't because it was too interesting. Something I never would have imagined myself doing, but I guess that's what five surgeries in eight months can do for a person :) I couldn't resist making a joke when he finished, I waited a half a beat and said "I think you need to move it a little more to the left."

I was able to go back to work the next day, and for the next couple-three weeks he had me wear an eye patch (oval gauze pad they give you afer eye surgery) with a hole cut in the middle to cushion the fake nipple. After it healed I got the areola color tattooed in, which I was able to do over a lunch hour. I'm very pleased with the results. I know women who have skipped this step but I would have felt unfinished. It's a much better match with the other breast, the color in particular is just about perfect. No one looking closely at it would mistake it for the real thing but the only people in that camp are my husband and me and we both think it looks pretty good. I'm very satisfied with my overall reconstruction.

I’m sorry that you are experiencing a rare, but, unfortunately, persistently recurring, complication – not specifically of breast reconstruction surgery, but of any surgery.

Any time skin or other body structures are cut, myriad nerves, a few named, most unnamed, are unavoidably divided, or at least damaged. Most of the divided or damaged nerves “wither away,” and cause no problem. A very few of the damaged nerves stay “irritated,” and some of the divided nerves form “neuromas,” or very tender balls of nerve tissue. These account for much of the chronic pain which some people experience following surgery. Why this occurs when it does, and how to predict or prevent it, are questions all surgeons would love to know the answer to. It is not preventable – the best a surgeon can do is warn patients that it could happen.

As a practical matter, re-operating for painful scars may not be very productive. When our patients have chronically painful surgical sites, we refer them to pain management specialists for treatment. Usually this involves injections of local anesthetics, steroids, or other agents. We have generally been pleased with the results we have seen from this.

If there are other reasons to revise your surgical site, it is not completely unreasonable to think that more surgery may favorably affect the pain, and we wish you the best of luck in that scenario.

Richard M. Kline Jr., M.D.
The Center for Natural Breast Reconstruction
www.naturalbreastreconstruction.com I’m sorry that you are experiencing a rare, but, unfortunately, persistently recurring, complication – not specifically of breast reconstruction surgery, but of any surgery.

Any time skin or other body structures are cut, myriad nerves, a few named, most unnamed, are unavoidably divided, or at least damaged. Most of the divided or damaged nerves “wither away,” and cause no problem. A very few of the damaged nerves stay “irritated,” and some of the divided nerves form “neuromas,” or very tender balls of nerve tissue. These account for much of the chronic pain which some people experience following surgery. Why this occurs when it does, and how to predict or prevent it, are questions all surgeons would love to know the answer to. It is not preventable – the best a surgeon can do is warn patients that it could happen.

As a practical matter, re-operating for painful scars may not be very productive. When our patients have chronically painful surgical sites, we refer them to pain management specialists for treatment. Usually this involves injections of local anesthetics, steroids, or other agents. We have generally been pleased with the results we have seen from this.

If there are other reasons to revise your surgical site, it is not completely unreasonable to think that more surgery may favorably affect the pain, and we wish you the best of luck in that scenario.

Richard M. Kline Jr., M.D.
The Center for Natural Breast Reconstruction
www.naturalbreastreconstruction.com

Unfortunately, the best time to do that is at the time of the reconstruction.

The nerve to the muscle can also be cut at the time of the reconstruction so that the muscle no longer "flexes". This does also cause the muscle to partially waste away though and lose bulk. For this reason, many surgeons don't cut the nerve routinely.

Dr C
http://www.PRMA-enhance.com
Unfortunately, the best time to do that is at the time of the reconstruction.

The nerve to the muscle can also be cut at the time of the reconstruction so that the muscle no longer "flexes". This does also cause the muscle to partially waste away though and lose bulk. For this reason, many surgeons don't cut the nerve routinely.

Dr C
http://www.PRMA-enhance.com

Absolutely.

Nipple-sparing mastectomy can be performed in conjunction with any type of breast reconstruction.

Dr C
http://www.PRMA-enhance.com
Absolutely.

Nipple-sparing mastectomy can be performed in conjunction with any type of breast reconstruction.

Dr C
http://www.PRMA-enhance.com

There are several ways to reconstruct a nipple. I prefer to rearrange tissue that is already in the area. The tissue (skin and a little fat) is lifted and twisted into a small cylinder to resemble the natural nipple. A couple of my patient's have described it as being "a bit like Origami"! The nipple and new areola are then tattooed at a later date to recreate the normal pigmentation.

Some surgeons prefer to use grafts from other parts of the body such as the labia, groin crease, or remaining nipple.

Dr C
http://www.PRMA-enhance.com There are several ways to reconstruct a nipple. I prefer to rearrange tissue that is already in the area. The tissue (skin and a little fat) is lifted and twisted into a small cylinder to resemble the natural nipple. A couple of my patient's have described it as being "a bit like Origami"! The nipple and new areola are then tattooed at a later date to recreate the normal pigmentation.

Some surgeons prefer to use grafts from other parts of the body such as the labia, groin crease, or remaining nipple.

Dr C
http://www.PRMA-enhance.com

Absolutely.

We commonly perform DIEP flap reconstruction in patients that have undergone radiation as part of their breast cancer treatment.

It is very rare for the internal mammary vessels to be damaged to the point where they are not usable.

In the rare event that they are too damaged, there are other vessels we can use in the chest or armpit.

I hope that helps.

Dr C
http://www.PRMA-enhance.com

ps. Congratulations on the 2 years!! Absolutely.

We commonly perform DIEP flap reconstruction in patients that have undergone radiation as part of their breast cancer treatment.

It is very rare for the internal mammary vessels to be damaged to the point where they are not usable.

In the rare event that they are too damaged, there are other vessels we can use in the chest or armpit.

I hope that helps.

Dr C
http://www.PRMA-enhance.com

ps. Congratulations on the 2 years!!

Absolutely.

We commonly perform DIEP flap reconstruction in patients that have undergone radiation as part of their breast cancer treatment.

It is very rare for the internal mammary vessels to be damaged to the point where they are not usable.

In the rare event that they are too damaged, there are other vessels we can use in the chest or armpit.

I hope that helps.

Dr C
http://www.PRMA-enhance.com

ps. Congratulations on the 2 years! Absolutely.

We commonly perform DIEP flap reconstruction in patients that have undergone radiation as part of their breast cancer treatment.

It is very rare for the internal mammary vessels to be damaged to the point where they are not usable.

In the rare event that they are too damaged, there are other vessels we can use in the chest or armpit.

I hope that helps.

Dr C
http://www.PRMA-enhance.com

ps. Congratulations on the 2 years!

The biggest misconceptions in my experience are:

1. "The only option is reconstruction with breast implants": Not true. Women have many options including using their own tissue (flaps), breast implants, and fat grafting.

2. "Reconstruction has to be performed at the same time as the mastectomy": Not true. Reconstruction can be performed at the same time as the mastectomy ("Immediate reconstruction"), or any time (even years) after the mastectomy ("delayed reconstruction").

Dr C
http://www.PRMA-enhance.com The biggest misconceptions in my experience are:

1. "The only option is reconstruction with breast implants": Not true. Women have many options including using their own tissue (flaps), breast implants, and fat grafting.

2. "Reconstruction has to be performed at the same time as the mastectomy": Not true. Reconstruction can be performed at the same time as the mastectomy ("Immediate reconstruction"), or any time (even years) after the mastectomy ("delayed reconstruction").

Dr C
http://www.PRMA-enhance.com

You're right, it can definitely be a struggle.

In terms of the results and the psycho-social benefits, reconstruction at the same time as the mastectomy is generally considered to be better than delayed reconstruction, hence the push.

Immediate reconstruction enables the patient to wake up from the surgery "complete" and avoid the experience of a flat chest completely. It is also generally associated with more natural results, and less scarring than delayed reconstruction.

Having said all that, I do agree with your point. Some women have so many other decisions to make at the time of diagnosis that they're simply not ready to consider immediate reconstruction. I do hope that women in that situation also realize that breast reconstruction can be performed at any time after the mastectomy, even years later, so the option is always there.

Dr C
www.PRMA-enhance.com
You're right, it can definitely be a struggle.

In terms of the results and the psycho-social benefits, reconstruction at the same time as the mastectomy is generally considered to be better than delayed reconstruction, hence the push.

Immediate reconstruction enables the patient to wake up from the surgery "complete" and avoid the experience of a flat chest completely. It is also generally associated with more natural results, and less scarring than delayed reconstruction.

Having said all that, I do agree with your point. Some women have so many other decisions to make at the time of diagnosis that they're simply not ready to consider immediate reconstruction. I do hope that women in that situation also realize that breast reconstruction can be performed at any time after the mastectomy, even years later, so the option is always there.

Dr C
www.PRMA-enhance.com

In terms of the results and the psycho-social benefits, reconstruction at the same time as the mastectomy is generally considered to be better.

"Immediate reconstruction" is the term used when the reconstruction is performed at the same time as the mastectomy. "Delayed reconstruction" usually takes place several months after the mastectomy but there is no set time limit..... Reconstruction can be performed literally years after the mastectomy.

Immediate reconstruction enables the patient to wake up from the surgery "complete" and avoid the experience of a flat chest completely. Most women with early breast cancer (stage I or II) are candidates. Immediate reconstruction is generally associated with more natural results, and less scarring.

Patients having radiation may be advised to delay the surgery for the best cosmetic results. This is because radiation can sometimes damage the reconstruction if the reconstruction is performed first. This also allows the chest tissues to heal as much as possible after the radiation. Other reasons for delaying reconstruction include advanced disease (stage III or IV), lack of access to a reconstructive surgeon, or patient preference.

I hope that helps.

Dr C
http://www.PRMA-enhance.com In terms of the results and the psycho-social benefits, reconstruction at the same time as the mastectomy is generally considered to be better.

"Immediate reconstruction" is the term used when the reconstruction is performed at the same time as the mastectomy. "Delayed reconstruction" usually takes place several months after the mastectomy but there is no set time limit..... Reconstruction can be performed literally years after the mastectomy.

Immediate reconstruction enables the patient to wake up from the surgery "complete" and avoid the experience of a flat chest completely. Most women with early breast cancer (stage I or II) are candidates. Immediate reconstruction is generally associated with more natural results, and less scarring.

Patients having radiation may be advised to delay the surgery for the best cosmetic results. This is because radiation can sometimes damage the reconstruction if the reconstruction is performed first. This also allows the chest tissues to heal as much as possible after the radiation. Other reasons for delaying reconstruction include advanced disease (stage III or IV), lack of access to a reconstructive surgeon, or patient preference.

I hope that helps.

Dr C
http://www.PRMA-enhance.com

There is no set rule to be honest. Like all reconstructive options, it depends on the patient's clinical situation and wishes, as well as the surgeon's preference and expertise.

Fat grafting is also often used in conjunction with another reconstructive technique.

Sorry I can't be more specific.

Dr C
http://www.PRMA-enhance.com There is no set rule to be honest. Like all reconstructive options, it depends on the patient's clinical situation and wishes, as well as the surgeon's preference and expertise.

Fat grafting is also often used in conjunction with another reconstructive technique.

Sorry I can't be more specific.

Dr C
http://www.PRMA-enhance.com

Fat grating involves taking fat from one part of the patient's body using liposuction, purifing the fat and then injecting into the breast. It is also known as "lipofilling".

Fat grafting is usually performed to fill in contour defects after lumpectomy. It is a particularly good option for small contour defects that involve less than 25% of the overall breast size. More than one fat grafting procedure may be required for best results as some of the fat typically gets reabsorbed. The likelihood of needing multiple fat grafting procedures increases as the size of the defect increases.

Fat grafting is also being used by some plastic surgeons to reconstruct the whole breast in conjunction with a breast device known as Brava. The device is worn in place of a bra for several hours a day. Brava essentially expands the breast by external suction. A series of fat injections is performed to fill in the breast as it expands, typically over a period of a few weeks/months (depending on the number of injections required).

Fat grafting is accepted as safe but more studies are needed. Like all surgical procedures, there are known risks. These include re-absorption, oil cysts, and firm areas.

From a breast cancer perspective, you must also know that fat grafting can cause calcifications on mammograms though these are generally easily differentiated from the microcalcifications associated with breast cancer. Also, while early studies are encouraging, there are no long-term studies that have looked at fat grafting and the risk of breast cancer recurrence.

I hope that helps.

Dr C
http://www.PRMA-enhance.com Fat grating involves taking fat from one part of the patient's body using liposuction, purifing the fat and then injecting into the breast. It is also known as "lipofilling".

Fat grafting is usually performed to fill in contour defects after lumpectomy. It is a particularly good option for small contour defects that involve less than 25% of the overall breast size. More than one fat grafting procedure may be required for best results as some of the fat typically gets reabsorbed. The likelihood of needing multiple fat grafting procedures increases as the size of the defect increases.

Fat grafting is also being used by some plastic surgeons to reconstruct the whole breast in conjunction with a breast device known as Brava. The device is worn in place of a bra for several hours a day. Brava essentially expands the breast by external suction. A series of fat injections is performed to fill in the breast as it expands, typically over a period of a few weeks/months (depending on the number of injections required).

Fat grafting is accepted as safe but more studies are needed. Like all surgical procedures, there are known risks. These include re-absorption, oil cysts, and firm areas.

From a breast cancer perspective, you must also know that fat grafting can cause calcifications on mammograms though these are generally easily differentiated from the microcalcifications associated with breast cancer. Also, while early studies are encouraging, there are no long-term studies that have looked at fat grafting and the risk of breast cancer recurrence.

I hope that helps.

Dr C
http://www.PRMA-enhance.com

Yes it is. Generally speaking, as long as there are no medical reasons that would make general anesthesia or surgery unsafe, you can have breast reconstruction at any time, even years after the mastectomy.

Make sure you also discuss this with your oncologist. It is important to keep your cancer doc in the loop and to get their "ok". It's also crucial you research all your options to make sure you choose the procedure that's best for you.

I hope that helps.

Dr C
http://www.PRMA-enhance.com Yes it is. Generally speaking, as long as there are no medical reasons that would make general anesthesia or surgery unsafe, you can have breast reconstruction at any time, even years after the mastectomy.

Make sure you also discuss this with your oncologist. It is important to keep your cancer doc in the loop and to get their "ok". It's also crucial you research all your options to make sure you choose the procedure that's best for you.

I hope that helps.

Dr C
http://www.PRMA-enhance.com

I'd like to add to the great tips from Dr. Kline

#Talk with other women about their procedures and ask for "show and tell." You'll find out things that only a person who has experienced a certain procedure can tell you. You will also hear of difficult situations and bad results as well. I believe it is important to weigh everything.

#Fitness is essential. I can not emphasize this enough. Start walking as soon as possible and immediately after you return home. It doesn't have to be far. Every step forward helps. If there is one free prescription that accelerates almost every aspect of treatment it's exercise.

#Know yourself. Surgery using flaps (whether attached or detached) are not simple procedures. You will have different incision sites and multiple drains. Recovery takes time, attention and numerous follow-up visits. Knowing all this in advance helps you plan and prepare for the best possible outcome.

I had a delayed reconstruction with a free-flap almost a year after my mastectomy. I was very pleased with the result but the entire process took the better part of a year.

#1 Positive attitude! Patients who are excited about their reconstruction frequently do very well , and tolerate any “bumps in the road” much better.
#2 Education. Try to become very familiar with your desired type of reconstruction, both through reading and discussing it with patients who have been through it already. Knowing what to expect allays fears and makes everything easier.
#3 If time permits, maximize your body’s fitness through diet and exercise, to the extent that you are comfortable doing so.

Richard M. Kline Jr., M.D.