November 2003: Breast Reconstruction

Feelings about silicone implants?

Question from Chris: What is your feeling about silicone implants? Are they safe? If the unaffected breast is augmented for symmetry, does that make it difficult to obtain an accurate mammogram? I am finding it very difficult to make a decision re: reconstruction.

Answer —Maurice Nahabedian, M.D.: As far as the safety of silicone gel implants, obviously that's been a real controversial issue for the past 10 or 11 years. During that time, there has been a lot of research and investigation regarding the safety of silicone. All of the major centers have essentially concluded that there are no adverse health effects related to silicone implants. Recently, the Physician's Advisory Board convened before the FDA and voted 9 to 6 to recommend that silicone implants again be brought back into the open market.

As far as augmenting the opposite breast for symmetry and whether or not that will affect mammography, I don't believe that it will, as long as the mammographer is aware there's an implant in place. There are well-defined techniques that will allow them to visualize the breast tissue using those mammographic techniques. MRI scanning is great for really looking at the breast tissue as well as the integrity of the implant.

Screening after lift or reduction?

Question from Marietta: If you decide to have a reduction or lift on the other breast, does it make it harder to catch the start of a tumor on that breast?

Answers —Maurice Nahabedian, M.D.: The answer would be no. I generally recommend a mammography four to six months after I do a reduction or a lift, and that will establish a new baseline for the breast so that the mammographers will be able to pick out any changes. Interestingly, there was one study that came out in the plastic surgery literature two to three years ago that demonstrated a reduced incidence of breast cancer in women who have had breast reduction surgery. I think probably the reason why is that you're removing a well-defined amount of breast tissue, so you're eliminating some of that tissue that could potentially become cancerous. Still, I wouldn't rely on this as a method of reducing your risk.

Marisa Weiss, M.D., president and founder: If your plastic surgeon removes tissue from the other breast when doing a "lift," make sure that piece of breast tissue is sent to the pathology lab for tissue evaluation to make sure there is no sign of any unexpected cancer cells in there. Also, in general, after a breast lift, the scar tissue improves and eventually stabilizes on serial mammograms. This is different from a cancer-like process that increases over time.

Reconstruction after treatment for stage IIIA?

Question from Dani: I had stage IIIA breast lobular breast cancer. I had a mastectomy and radiation. What would be the best option for reconstruction for me, and how long should I wait before reconstruction?

Answers —Maurice Nahabedian, M.D.: In general, for a IIIA breast cancer (which is a relatively large tumor) and after having had radiation, I would tend to wait about one year to make sure that there is a safe, disease-free interval. Then, generally, I would recommend performing some type of reconstruction utilizing one's own body tissues.

I generally do not recommend implant reconstruction after a mastectomy and radiation, primarily because there are some associated complications, such as infection, hardening of the breast, and distortion that can occur.

Marisa Weiss, M.D., president and founder: What if this woman had a tissue expander placed at the time of original mastectomy and it is now expanded to the size of the new desired breast? If she had no problems with that expander in place for one year, is an implant an OK option for her?

Maurice Nahabedian, M.D.: Yes. Once the skin has been expanded and then radiation therapy started, the process is much better tolerated. Then I will usually go ahead and do an implant exchange as I would normally do. During that implant exchange, I would release some of the scar tissue that has formed and position the implant in an optimal location. Also, in patients who've had radiation to implants, I recommend an aggressive massaging protocol to help maintain the soft consistency of the reconstructed breast.

Marisa Weiss, M.D., president and founder: Can you explain what you mean by this massage protocol?

Maurice Nahabedian, M.D.: I recommend they use some sort of a moisturizing lotion and massage the breast two to three times a day to retain the moisture and also to help control the amount of scar tissue that forms around the implant/expander.

Marisa Weiss, M.D., president and founder: If a woman has a big cancer and her doctor recommends delayed reconstruction after her chemo and radiation is finished, do you think it's wise to place an expander at the time of initial mastectomy? The reason would be to keep that space between the skin and the chest wall, regardless of the type of final reconstruction (implant or tissue flap)?

Maurice Nahabedian, M.D.: In somebody with an advanced breast cancer who we know will be receiving adjuvant treatment, in those situations I assess whether the patient is interested in their own tissues or implant reconstruction. If they are interested in reconstruction using their own tissues, then I would more than likely recommend that they not do any expander at the time of the mastectomy.

However, if the patient is not a candidate for using her own tissue or is primarily interested in implant reconstruction, then I don't see any harm at placing an expander at the time of mastectomy to maintain an adequately stretched breast skin envelope. This will improve the future implant reconstruction.

Too old for reconstruction?

Question from BlueEyes: I'm 68 and had a mastectomy 8 years ago. Am I too old to have reconstruction?

Answers —Maurice Nahabedian, M.D.: Absolutely not. The oldest woman I've done a reconstruction on was 77 and I did that using her own tissues, in a micro-vascular reconstruction. I can tell you that the longest time interval from mastectomy to reconstruction was 25 years, so my answer would be you're never too old, and it's never too late.

Marisa Weiss, M.D., president and founder: As women, we lead very interesting and complicated lives. Our needs and our wants change over time. I have a number of patients I've taken care of who chose no reconstruction up front because they were dealing with too many cancer treatment-related decisions or they simply weren't interested. But then, years later, their lives changed or they thought about their options in a different way, and decided to seek out reconstruction.

Unsuccessful nipple reconstruction?

Question from Debby: I had reconstruction done approximately two years ago. At that time the surgeon said he did all he could to give me nipples and it just hasn't worked, so I gave up. I hate my breast now - no feeling AND no nipples. Is it really hopeless that I can't have nipples? He never took skin from any other area.

Answers —Maurice Nahabedian, M.D.: Most surgeons now who do nipple reconstruction create nipples by rearranging some of the local tissue on the breast. One of the down sides of these techniques, and there are probably about seven or eight of them, is that the nipples will sometimes flatten too much, and occasionally the nipple reconstruction will have to be repeated. In my practice, this rate is approximately 10%.

In situations where I do have to redo a nipple reconstruction in order to create more projection, I will sometimes use some semi-synthetic material to place within the substance of the nipples to maintain that projection, and this seems to work reasonably well.

Marisa Weiss, M.D., president and founder: What kind of material do you use?

Maurice Nahabedian, M.D.: I like to use AlloDerm. It's essentially human collagen that's been processed and created in various size sheets. You can pick small segments and insert them between small skin flaps. It creates more scar tissue within the nipple to give it some more long-lasting projection.

Marisa Weiss, M.D., president and founder: By projection, we mean to give the nipple height. If you want to get nipples overnight, you can actually purchase latex "nipples." There are several companies that make them. You can go to a specialty shop to find them. Nordstrom's department stores carry a full line of all kinds of prostheses for the whole breast as well as just for the nipples.

Advantage of SIEA vs. DIEP?

Question from Swall: What is the advantage of SIEA vs. DIEP?

Answers —Maurice Nahabedian, M.D.: The SIEA is an acronym that stands for superficial inferior epigastric artery flap. This is a flap that utilizes skin and fat from the abdominal area. The DIEP is an acronym that stands for deep inferior epigastric artery perforator flap. This flap also utilizes skin and fat from the abdominal area.

The difference between the two is that the DIEP flap requires a small incision to be made in the supportive layer of the abdomen as well as the rectus abdominis muscle. (That is the muscle that allows you to perform sit-ups). It runs from the rib cage down towards the pelvic bone. The SIEA flap does not require that these additional incisions be made. Both flaps have the advantage that no muscle is removed.

Marisa Weiss, M.D., president and founder: Do you perform both of these procedures, and if so, which one do you prefer?

Maurice Nahabedian, M.D.: I perform the DIEP flap. I do not perform the SIEA flap. The SIEA flap can only be performed in about 20 to 30% of patients because the blood supply to this flap is extremely variable and poorly developed in the majority of women.

Marisa Weiss, M.D., president and founder: How does DIEP compare to the TRAM flap?

Maurice Nahabedian, M.D.: TRAM is also an acronym that stands for transverse rectus abdominis muscle flap. This was the original flap that was described in 1982. This flap is capable of forming a very nicely shaped breast. However, it has the disadvantage of utilizing the entire rectus abdominis muscle on one side. In some women this may compromise their abdominal strength or ability to perform sit-ups. The recovery phase for this operation is generally about 6 weeks. The amount of discomfort experienced following this operation is generally higher than that associated with the DIEP or SIEA flaps, primarily because with the latter two flaps, there are less structures that are violated.

Marisa Weiss, M.D., president and founder: With the TRAM, you move the muscle with its blood supply up to the new location, but with the DIEP, don't you actually cut the blood supply and reattach it in the new location? Does the cutting and the attaching of the blood supply make the final tissue flap more vulnerable?

Maurice Nahabedian, M.D.: The DIEP and SIEA flaps require micro-vascular surgery because, in essence, these are tissue transplants. We utilize a microscope to reattach the small artery and vein that supply these tissues to an artery and vein in the vicinity of the mastectomy site.

This micro-vascular technique can be complicated by the formation of blood clots, which can jeopardize the success of these operations. In general, the success rate with these micro-vascular procedures (the DIEP and the SIEA procedures) is in the range of 97 to 98%. The success rate with the TRAM is approximately 99%.

Bulge following TRAM flap?

Question from MegWI: It's been 2 months since my TRAM flap breast reconstruction and I am starting to have a bulge around my abdomen where the cut was made. Should this be taken care of or do I have to live with the bulge? It doesn't hurt but is aesthetically not pleasing to me.

Answer —Maurice Nahabedian, M.D.: A bulge following TRAM flap reconstruction represents a weakness in the supportive structures of the abdominal wall. Unfortunately, this will not go away on its own. Fortunately, there is a surgical procedure that we perform that can repair this bulge. It requires that we reopen the abdominal incision, tighten the supportive layer, and reinforce this layer with a synthetic material known as Marlex mesh. This is a highly successful procedure to improve abdominal contour.

Bulge and hernia are actually different and it is important to differentiate between the two. It is much more common following the TRAM procedure to develop a bulge rather than a hernia. A hernia actually represents a defect in the supportive layers of the abdominal wall, whereas a bulge represents a laxity or weakness of the supportive layer. With the hernia, there's actually a hole in the fascia and the intestines can migrate through the hole. With the bulge, it represents a weakness and the intestines don't really go through anything; they just push out on it because it's weaker. It's an area of low resistance.

In general, if a woman comes to me and is dissatisfied with her abdominal contour, then I will recommend that a repair be performed. Most women choose to have the repair performed because the abdominal appearance is bothersome to them. If it's a true hernia, then, without question, I will recommend a repair. With a bulge, a woman has more of a choice whether or not she wants it repaired.

Long-term effects of TRAM flap?

Question from PatJ: Have there been any studies about the long-term effects of the TRAM flap—i.e. strength, mobility or effects on other parts of the body such as the back or the knees?

Answer —Maurice Nahabedian, M.D.: Excellent question! There have been studies that look at abdominal functions and how these altered functions will affect other parts of the body. It is well known that one of the ways to improve lower back pain is to do more abdominal exercising, and in cases where those muscles have been removed, this becomes difficult. Some comparative studies in which DIEP and SIEA flaps have been performed have demonstrated a superiority in maintaining abdominal and back strength in order to minimize future problems with this.

How long does reconstruction surgery take?

Question from Swall: How long does the surgery usually take?

Answer —Maurice Nahabedian, M.D.: The length of operation is variable depending upon the type of reconstruction that is selected. In general, a tissue expander requires 30 to 45 minutes to complete. A pedicled TRAM (the type of TRAM in which the muscle and fat tissues remain attached to the blood supply and are moved from the abdomen to the breast area) will require about 2-1/2 to 3 hours to complete. The free TRAM (in which the muscle and fat tissues are removed from the abdomen and need to be re-attached to a blood supply in the breast area) and the DIEP flap will require in the range of 4 to 6 hours to complete, depending on one's level of skill.

Reconstruction increases lymphedema risk?

Question from Chris: I am small-breasted (34 B) and had a left-sided mastectomy 11 months ago. My oncologists think that there is the possibility of some remaining breast tissue that should be removed. It makes sense to do reconstruction at the same time. TRAM vs. implants vs. nothing? Does additional surgery increase the chance of lymphedema? Psychologically, do women do better with reconstruction? Is it unusual to be so confused?

Answers —Maurice Nahabedian, M.D.: It's not unusual to be confused, primarily because there are so many decisions, and complicated ones, to be made. As far as requiring secondary procedures, the risk of lymphedema can increase if those procedures involve structures near the lymph node basin in the armpit. As the number of lymph nodes that are removed increases, or as scar tissue that develops near those lymph nodes increases, the risk of lymphedema will increase. This generally ranges at about 20% for women who've had most of the lymph nodes removed from the armpit area.

Marisa Weiss, M.D., president and founder: The bottom level (level I) of the underarm lymph nodes live right next to and beneath the top of the breast area. Surgery to the breast and to the lymph nodes overlaps in this region and can affect the fluid retention around the soft tissues in the armpit and in the breast area. Radiation to the breast area can increase fluid and, often, lymph fluid in the area of the breast and armpit as well, separate from "lymphedema" or swelling of the arm.

Reduction of other breast?

Question from Chemo: What are the pros and cons of having the other breast reduced after a one-sided mastectomy?

Answers —Maurice Nahabedian, M.D.: The primary benefit of having the opposite side reduced is that there will be an improvement in overall symmetry. The risk is that there will be additional scars on that breast that is otherwise healthy. The incidence in my practice of having to perform surgery on the opposite breast is about 15 to 20%.

Marisa Weiss, M.D., president and founder: The implication of that is you're able to achieve an acceptable level of symmetry without doing surgery on the other breast.

Maurice Nahabedian, M.D.: Yes.

Marisa Weiss, M.D., president and founder: What about potential loss of nipple sensation on the other breast when you do a lift? Can you explain where the nerve supply to the nipple comes from and how can the surgeon protect sensation of the nipple during such a procedure?

Maurice Nahabedian, M.D.: The nerves that supply sensation to the nipples actually come from a variety of nerves and in a variety of directions. They can target the nipple from the lateral (side) aspect as well as from underneath the nipples. There's a lateral and medial division that will supply the sensation to the nipple as well as some nerves that come up directly from the chest wall to the nipple.

Following breast reduction, there is a 40 to 50% incidence of temporary altered sensation and a 10% risk of permanently altered sensation of the nipple-areola complex. Following a lift (or mastopexy), the incidence of altered sensation is much less because many of these nerves do not require division.

Marisa Weiss, M.D., president and founder: Can a woman breast-feed after a breast lift?

Maurice Nahabedian, M.D.: A woman can breast-feed after a breast lift so long as the ducts to the nipple are not divided. In general, they do not require division during a lift procedure. However, during a breast reduction, many of these ducts are divided and breast-feeding can be compromised.

Will sensation return after reconstruction?

Question from Judy: Will normal sensation return after reconstruction, if two years have already gone by and the numbness is still there?

Answers —Maurice Nahabedian, M.D.: In general, in women who have reconstruction using their own tissues, there will be a return of sensation in about 50% of patients by one year. If the sensation has not returned by two years, it would be very unlikely that any sensation will be restored. The reason for this is that the sensory nerves to the breast have the potential to regenerate and grow into the newly constructed breast. The rate of nerve growth is extremely slow and generally progresses at the rate of one inch per month. Usually this process is completed by one year's time.

Marisa Weiss, M.D., president and founder: It's possible that for women who've also had a lot of chemotherapy and radiation that the time for nerve regrowth might be somewhat slowed. For women whose breast area remains numb, some women have been able to fantasize and imagine breast and nipple sensation in a way like they used to experience. This may take some practice and maybe even lessons on visualization or meditation...and maybe even help from erotic literature. Sometimes it's fun to be resourceful and experiment a little.

Reconstruction using back muscle?

Question from Peaches: What are the advantages and disadvantages of reconstruction using back muscle?

Answers —Maurice Nahabedian, M.D.: The back muscle, also known as the latissimus dorsi flap, can provide an excellent method of breast reconstruction. This technique has the advantage of being very reliable and is most useful for women who are not good candidates for abdominally based flaps. It often requires the use of an implant in order to create a breast of sufficient size. I typically use this flap in about 4 to 5% of my reconstructions. However, there are others around the country who use this method almost exclusively.

Marisa Weiss, M.D., president and founder: Why is there so much variability around the world from plastic surgeon to plastic surgeon regarding the options s/he presents? For example, in Pennsylvania, I am not aware of any surgeon who is doing the DIEP procedure. Why is this?

Maurice Nahabedian, M.D.: Most surgeons will tend to perform reconstructions that they learned during their years of training. Over the years, newer techniques have evolved that are more complicated, but many surgeons are reluctant to perform some of these more complicated techniques. I think that all of these reconstructive options are capable of providing excellent outcomes. I think that as long as a surgeon is comfortable with the method he or she uses, then a patient will be well served by that surgeon.

Replacing old implants?

Question from Dorothy: What happens if my nine-year-old breast implants need replacing? Is it recommended to take them out and not replace the implants, since this would require opening the breast near the cancer site?

Answer —Maurice Nahabedian, M.D.: If an implant requires replacement due to rupture or hardening or some other circumstance, we usually recommend implant replacement. If, after nine years, a cancer has not recurred, the chances of recurrence are significantly less over time, and I feel that a replacement can be safely performed without putting the breast at risk.

Port-a-cath after reconstruction?

Question from El: Can a port-a-cath be inserted following reconstructive surgery?

Answers —Maurice Nahabedian, M.D.: A port-a-cath can be inserted. Usually they're inserted into one of the large veins near the clavicle or collarbone, and this is usually far enough away from the reconstruction that it will not hurt the reconstruction.

Marisa Weiss, M.D., president and founder: A port-a-cath is a device used to deliver medication and to withdraw blood for testing. It is usually a plastic tube-like thing that sits under the skin and goes into a blood vessel.

Are uncomfortable expanders normal?

Question from Milissa: My expanders are too high and uncomfortable all the time, especially the two weeks after chemo. Is this normal?

Answers —Maurice Nahabedian, M.D.: It is not uncommon for the temporary tissue expander to be positioned higher on the chest wall than we would like. This is usually a consequence of the action of the muscle and the ensuing scar tissue that forms. When the temporary expander is removed and a permanent implant is inserted, the implant can then be placed in an ideal location.

Marisa Weiss, M.D., president and founder: Sometimes the discomfort associated with a tissue expander comes from pressure put on the chest wall beneath it. This discomfort will also improve once the expander is replaced with the implant.

Scar tissue around implants?

Question from Trudy: I had my implants for a year-and-a-half and then had to have them replaced because so much scar tissue built up and they moved. What are the chances of this happening again?

Answer —Maurice Nahabedian, M.D.: Answering that question depends on an understanding of why all that scar tissue formed. Some women naturally form more scar tissue than expected. In some women, scar tissue can form because of small infections, a small amount of old blood that may have remained following the reconstruction, or following radiation treatment.

If somebody has developed an abnormal amount of scar tissue around an implant, it would be OK to perform a procedure to remove or release some of that scar tissue. This would require another operation, but it usually is successful in improving the overall outcome.

Saline or silicone implants?

Question from ClareK: Is saline or silicone the most popular choice for implants for breast reconstruction?

Answers —Maurice Nahabedian, M.D.: Saline implants are still the most commonly selected implants. I think that this choice by women to continue with saline is based primarily on fear of silicone and the result of all the negative publicity related to silicone. Silicone implants can provide an excellent quality reconstruction, but I think it will probably take more time for the public to become more accepting of silicone gel implants.

Marisa Weiss, M.D., president and founder: What about oil implants?

Maurice Nahabedian, M.D.: I don't use any of the oil implants, but I do frequently use the combination of saline and silicone gel implants. I've found this implant to be very useful because it provides women with the feel and consistency of the silicone gel and provides the surgeon the ability to adjust the volume of the implant because of the saline chamber.

Marisa Weiss, M.D., president and founder: So the saline chamber has a port on it?

Maurice Nahabedian, M.D.: Yes, the saline chamber is connected to a remote port that I will place on the side or bottom of the reconstructed breast. The implant itself has equal amounts of silicone gel in the outer chamber and saline on the inner chamber.

Tightness after physical activity?

Question from Betsy: I had a saline implant after a mastectomy 1-1/2 years ago. When I go kayaking, do yard work or anything that uses the chest muscles, I feel the implant is getting pushed into my armpit. Afterwards, I have a tightness in the chest muscles on the mastectomy side. Can I do any exercises before or after kayaking, gardening, etc., to reduce this discomfort?

Answers —Maurice Nahabedian, M.D.: That's a difficult question to answer, because it may be that the implant is firmly adherent to the chest wall muscle because of the capsule or scar tissue that has formed. The motion of the implant with that chest wall motion may be responsible for this discomfort and the positional changes that may be occurring. In order for me to fully understand why this is occurring, I would have to do a physical examination.

Marisa Weiss, M.D., president and founder: When the surgeon places the implant into position, is there a way to fasten the implant in place or not? To keep it from migrating?

Maurice Nahabedian, M.D.: When the implant is inserted, it's important to create a pocket underneath the chest wall muscle that is of sufficient size to accommodate the implant. I generally do not create a pocket that is too large or too small, in order to allow for optimal implant positioning and appearance.

Reconstruction after lumpectomy?

Question from Kathy: This year was my third bout with BC. I have had a lumpectomy and lymph node removal in both breasts. I asked my surgeon about a referral for reconstruction. He said that breast reconstruction referrals are not made when a lumpectomy is performed, only when a complete mastectomy is done. Does this sound right? Any suggestions on how I should proceed?

Answers —Maurice Nahabedian, M.D.: I can say that probably 95% of women who have lumpectomies will not require any type of reconstruction. However, there are about 5% of women who have significant contour abnormality of the breast following lumpectomy. If this has occurred, there are reconstructive techniques to improve the contour of the breast. These techniques can include use of the latissimus dorsi flap, TRAM flap, or implants.

Marisa Weiss, M.D., president and founder: The procedure of taking part of the latissimus dorsi muscle laparoscopically and flipping it into place—is this a reasonably manageable procedure that has a high success rate?

Maurice Nahabedian, M.D.: The latissimus dorsi flap is occasionally performed now using laparoscopic techniques. This can be useful in certain situations where a small portion of the breast needs to be reconstructed, rather than the entire breast. The laparoscopic techniques will be somewhat limited in their ability to harvest large amounts of skin, fat and muscle.

Marisa Weiss, M.D., president and founder: Plastic surgical reconstruction of a breast really is a marriage between fine medicine, surgery, and artwork. Also, there is only one of each of you, and each of you has her own self-image and set of expectations and desires. Reconstruction is such an individualized process. In order to get the best results, there has to be good communication with your doctor. You can really help your doctor help you if you put your concerns and expectations "on the table."

Unhappy with reconstruction results?

Question from ABC: I've already had reconstruction and am not happy with the results. My doctor is recommending not doing over. I disagree. What are my options?

Answer —Maurice Nahabedian, M.D.: I would have to know what type of reconstruction. If a patient is dissatisfied with an implant reconstruction, there are a variety of options that can be considered. This includes redoing the reconstruction with an implant or using her own tissues. If the reconstruction that she is dissatisfied with utilized her own tissues, those options can only be performed once and an unsatisfactory result may require the use of an implant to correct. It's important to realize that any reconstruction that utilizes the abdominal skin and fat—TRAM or DIEP or SIEA— can be performed one time only, because those are all abdominal-based.

Second reconstruction options after TRAM flap?

Question from Sue: If you have a TRAM flap for one breast, what options do you have if you need to have the other breast removed at a later time?

Answers —Maurice Nahabedian, M.D.: Unfortunately, the TRAM flap or any abdominally based flap can only be performed one time. Should the opposite breast require reconstruction, our options would be to use an implant or to use the latissimus dorsi muscle. A third option that we have not yet discussed would be to use the upper buttock skin and fat, which is known as the SGAP flap. This is an acronym for superior gluteal artery perforator flap.

Marisa Weiss, M.D., president and founder: If someone feels that they have a really big rear end and would love to make it smaller, would she ever consider this as a primary option for reconstruction?

Maurice Nahabedian, M.D.: The SGAP flap is probably the most difficult type of reconstruction to successfully perform. Women who are interested in this flap must be carefully selected and counseled. If there is an excessive amount of buttocks skin and fat, this flap would, unfortunately, not be a very safe option. However, in the slender woman who is interested in using her own tissues and who has insufficient quantities of abdominal skin and fat, this is a good option.

Marisa Weiss, M.D., president and founder: What options does a woman have for reconstruction if she is a significant smoker?

Maurice Nahabedian, M.D.: Women who use tobacco are generally counseled to avoid cigarette smoking. The pedicled TRAM flap is the reconstructive technique that is most adversely affected by tobacco use. This is because the blood supply to the flap is most compromised with this form of reconstruction. In addition, the use of tobacco can adversely affect the healing of the abdominal incision, especially if there has been a large amount of undermining that is commonly associated with the pedicled TRAM flap.

With the DIEP or the free TRAM flap, the effects of tobacco use have not been associated with adverse outcomes. This is primarily because of the robust blood supply associated with these flaps. In patients who use tobacco and who are going to have a pedicled TRAM flap, there are techniques available that can improve the blood supply to the flap and minimize the untoward feeling associated with tobacco use. These techniques involve staging the reconstruction into two phases. The first phase is known as a delay procedure, which stresses the blood supply and allows it to acclimate to adequately supply the flap.

Traveling for DIEP reconstruction?

Question from WynnME: What are the issues one must address if one wants a DIEP reconstruction and you have to go many miles away from one's home to a city where they perform the surgeries (i.e. Johns Hopkins)?

Answer —Maurice Nahabedian, M.D.: Unfortunately, there are very few surgeons in the U.S. that routinely perform the DIEP flap. They are located throughout the United States but only in a few cities. This means that many women will have to travel to these cities in order to receive this type of reconstruction. This procedure is actually performed with greater frequency in the European countries. However, in the U.S., many surgeons are reluctant to perform this type of reconstruction.

In my practice, I see many patients who travel great distances in order to have this procedure performed. What I request is that these patients be prepared to stay in Baltimore for a period of 7to 10 days following the reconstruction. After that, they are free to go back home and then return for scheduled follow-ups at 6 weeks and 3 months following the procedure.

Issues with insurance companies?

Question from CB: Have any of your patients experienced trouble from their insurance company over which kind of tissue reconstruction is done, such as not wanting to pay for a procedure that is longer, and I assume, more expensive?

Answer —Maurice Nahabedian, M.D.: That has been an issue for a couple of my patients. Most insurance companies are willing to pay for whatever type of reconstruction is desired. However, there have been some instances where coverage is denied for these microvascular procedures on the grounds that there are surgeons within their particular plan that may be capable of providing the conventional reconstructive options, such as the pedicled TRAM or implants.

Gaining weight after TRAM flap?

Question from BJW: If you have a TRAM done and normally gain weight in your belly, will you then gain it in your new breasts? Or is this an "urban legend" of the breast cancer world?

Answers —Maurice Nahabedian, M.D.: Actually, because we are transplanting skin and fat from one part of the body to the other, if you gain or lose weight, the reconstructed breast will also increase or decrease in size or have the ability or potential to increase or decrease in size.

Marisa Weiss, M.D., president and founder: What role does liposuction have in terms of building up soft tissue or removing excess soft tissue from an area of tissue reconstruction?

Maurice Nahabedian, M.D.: Liposuction is a very effective means of contouring a reconstructed breast in order to obtain better symmetry with the opposite side. It is a safe and relatively easy technique that can be performed with minimal patient discomfort.

Marisa Weiss, M.D., president and founder: Can it be used to bring softness to the area?

Maurice Nahabedian, M.D.: In general, liposuction is only going to be effective if the fat being removed is soft. If there are areas of firmness within the breast, then liposuction will not be as effective in removing those firm areas. Those areas must be surgically excised. The fat that is removed from liposuction can be used in other areas of the body. However, it is not used in other parts of the breast routinely because of the potential for additional firmness. Fat grafting is not successful in the breast.

Marisa Weiss, M.D., president and founder: Can you explain what fat necrosis is and how it can affect the way the tissue-reconstructed breast can feel?

Maurice Nahabedian, M.D.: Fat necrosis occurs because of insufficient blood supply. This insufficient blood supply causes the fat that is starved of blood to become firm or hard. This is known as fat necrosis. This can occur spontaneously; however, it generally requires a few years to occur.

Fat necrosis can be palpable and a source of dissatisfaction. When it does occur, one option is to surgically excise the areas of firmness. The incidence of fat necrosis generally ranges from 5 to 10% of patients and usually involves only 1 to 2% of the actual breast tissue. In other words, it's usually the size of a marble or walnut.

Marisa Weiss, M.D., president and founder: Your doctor will follow you over time and is usually able to easily distinguish a lump from fat necrosis vs. a lump from a cancer recurrence. Fat necrosis stays the same or gets better over time in terms of size and consistency, whereas recurrence after mastectomy is likely to get bigger without treatment.

Maurice Nahabedian, M.D.: An easy way to distinguish the two, if there is some ambiguity, is to do a fine needle aspiration.