Surgeons Answer Your Breast Reconstruction Questions
Can implant surgery be revised with DIEP flaps years later?
Can implants be replaced years after the initial reconstruction with DIEP flaps under the spared skin? Can nipple reconstruction be preserved in this case?
Yes. It is quite common for women to have implants replaced with their own tissue. They may desire this for a number of reasons, including capsular contracture, in which the tissue around the implant becomes tight and uncomfortable. They may not like the feel, the size, the position, or the shape of the implant. In these cases, the implants and any associated capsular contracture can be removed and replaced with their own healthy natural fatty tissue all while sparing the abdominal muscles in the case of the DIEP flap. If a successful nipple reconstruction has already been performed, it can often be preserved.
— Craig Blum, MD, FACS
Am I too old for reconstruction using my own tissue?
I had a lumpectomy and radiation 2+ years ago. My skin did great during the radiation — no burns, just a bit of redness — and no chemo. I recently discovered that for genetic reasons I should have a prophylactic mastectomy. I have read up on implants and am clear that I don't want them. I live in a major city where they do both DIEP and SIEP. I want SIEP if I can have it. I have plenty of belly fat to use so no issues there. My breast surgeon has retired so I looked for recommendations for a plastic surgeon as I consider their work the most important since I don't currently have BC. The first office I called the nurse was very negative because I am 60 years old. It never occurred to me that I wouldn't qualify for a tram flap due to my age. I am healthy but sedentary. I do take blood pressure and cholesterol medication, but they keep things under control. The concern is apparently because it is a long surgery. Am I too old for this procedure?
We do not have a specific age cutoff for surgery. We prefer to evaluate each patient independently, and determine if breast reconstruction is a safe option based on their overall health. We have performed breast reconstruction on patients well into their 70s safely and with excellent outcomes. Prior to surgery, each patient’s medical history is discussed amongst our team of well-trained nurses, surgeons, and anesthesiologist. If any concerns arise, we may ask the patient to see their medical physician prior to surgery to address these concerns in order to make the surgery as safe as possible.
— Craig Blum, MD, FACS
Can a DIEP flap and fat grafting be performed at the same time to create a breast?
I’m wondering can you do a DIEP flap and fat grafting to make a full breast at same time during same surgery procedure?
Generally, we will perform the DIEP flap first and allow the patient to heal and recover. Then we can re-evaluate the volume and projection of the breast. The reconstructed breast may need a breast lift at the time of revision, which will certainly improve the projection of the breast, making it appear more full and youthful. Fat grafting may be used in addition to add volume and smooth out any contour irregularities to make the best possible result.
— Craig Blum, MD, FACS
Can post-surgical adhesions be fixed?
I was wondering if anything can be done about post-surgical adhesions. My lovely surgeons did multiple surgeries (for my mastectomy and subsequent reconstruction) as I threw a hematoma after my lumpectomy. They were trying to limit how many scars I ended up with, so they used the same incision site for my drain tube for each surgery. What I've ended up with is a scar that has adhered to the tissue underneath and, so, the skin doesn't move freely or lay flat. This leaves me with a bunch of skin and tissue that sort of sticks off the right side of my chest close to my armpit and looks pretty funny with any sleeve-less top/tank top or bathing suit. Can anything (short of an additional surgery) be done? Thanks so much!
There are some things that can be done that can improve scar tethering/adhesions short of surgery. First-line treatments can include silicone gels and sheeting for the external feel/appearance. Combine this with massage to the area to improve the mobility of the scar. Physical therapy can help to improve range of motion to the shoulder as well as alleviate some of the discomfort. However, I suspect that you would do best with an additional surgery. We often extend incisions towards the armpit and bra line to remove excess axillary skin and refine the outer breast shape. If you have cording (bands extending from the arm to the chest wall) the cords can be released at the same time. Drain sites can be excised and resutured to correct tethering as well. Seek out reconstructive surgeons specializing in breast reconstruction and offering implant and autologous/flap reconstructions.
— M. Whitten Wise, MD
I had radiation and my surgeon says I can’t have implants. Is flap surgery my only option?
I have had 16 rounds of chemo, three chemo medications, and 35 rounds of radiation. I’m triple-negative, BRCA-positive. Bilateral mastectomy removed two metaplastic sarcoma tumors with good margins and no spreading to lymph system. I’ve had a complete hysterectomy post treatment to prevent recurrence.
I have had three fat grafts with not-so-great results on my affected side (radiation). I do not want any flap surgery. I’m only interested in fat grafts. I asked my surgeon if a very small implant could be done. I have been advised by my plastic surgeon I cannot have implants after 35 rounds of radiation without a flap surgery (skin cooked and too thin)... is there any option for women like me other than the extreme flap surgery?
I am glad you have done so well. With triple-negative breast cancer and a BRCA genetic diagnosis, we would also have recommended bilateral/double mastectomy. Post-mastectomy radiation does indeed make implant reconstruction very difficult. Implants in the setting of radiation are prone to capsular contracture (painful scar tissue around the implant), infection, and extrusion (the implant actually coming out of the incision).
Alternatively, we would love to believe that fat grafting (fat injections) alone can rebuild a breast, but it is almost universally unsuccessful. Breasts rebuilt from fat grafting alone are firm, fibrotic, and filled with oil cysts and half-dead fat. This is even worse in the setting of radiation. In addition, it takes multiple sessions/operations to see even modest results. The best answer for you and most patients is autologous breast reconstruction (flap surgery). I can tell that you are apprehensive about flap surgery. However, it should not be considered “extreme.” Some plastic surgeons portray it as such because it is time-consuming and technically difficult for them. However, the results are almost invariably better than implant reconstructions. The surgery takes a bigger up-front commitment, but the results are worth it.
Flap surgeries require less frequent long-term surgeries than both implants and fat grafting. The results both feel and look more natural. The reconstructed breasts will age naturally as you age. Flaps are definitely the best option for you. Seek out a group that specializes in breast reconstruction and offers both implant and flap reconstructions. Specifically, you want to see a group that does perforator flap breast reconstruction (the names of those procedures are DIEP flaps, GAP flaps, PAP flaps, TDAP flaps). Experienced reconstructive surgeons will work with you to pick the ideal donor site for your body shape and desired breast size.
— M. Whitten Wise, MD
How difficult is it to “go flat” after implant surgery?
I had bilateral mastectomy with implant reconstruction about a year ago. The implant exchange was done 3 months ago. I am very unhappy with the silicone implants, although they look fine and healed well.
My question is: If I choose to have the implants removed and to “go flat,” how difficult is that surgery? Will the function of the pectoral muscles ever be back to normal? Are the Alloderm grafts removed? How is the excess skin/tissue handled?
My plastic surgeon has never removed implants and so can't answer these questions.
I’m sorry that you are having difficulties with your implant breast reconstruction. We see a large volume of patients who have a variety of symptoms from implant reconstructions. Some report “animation” where the breast moves around when they contract their pectoralis muscle. Others report discomfort, tightness, cold feeling, and other problems related to the shape or size of the implants. Many of these problems can be improved with a revision. Alternatively, many of our patients seek to have their implants out and replaced with autologous/flap reconstruction. Invariably the flap reconstructions look and feel more natural. The implants are removed, the pectoralis muscle is returned to its natural position and the reconstruction is done in the same location that the breasts were prior to the mastectomy — above the muscle.
However, if you want to “go flat,” that is easily accomplished. The implant and cellular dermal matrix (Alloderm) are easily removed. Some of the excess skin is removed as well. The muscle is returned to its natural position and function should improve. Seek out a reconstructive plastic surgeon specializing in breast reconstruction and offering both implant and autologous perforator flap breast reconstruction.
— M. Whitten Wise, MD
Why is implant reconstruction usually not recommended after radiation therapy?
Why do a lat flap and not just implants? Can radiated skin/area not “hold up” the implants? I'm going with a C cup so I'm really confused. I have lots more questions to ask my plastic surgeon. Just thought I'd try another opinion. I was now told she wants to do the lat flap on my right and implant on my left. Not happy about going through that surgery if I don't have to. Thank you.
Thank you for your question… I’ll start out by stating that, BY FAR, the most important factor determining outcomes in implant-based breast reconstruction is quality of the mastectomy and, thus, quality of the post-mastectomy skin. ANY implant placed in the human body — from joint replacements to breast implants — is only as good as the tissue and skin that covers it. With respect to implant breast reconstruction, the implants are separated from the outside world by a very thin layer of breast skin. Post-mastectomy skin is always “stressed out” to some degree as its primary source of blood flow — your breast tissue — is removed and, thus, requires the small vessels and capillaries under your skin to survive.
Even in the highest-quality mastectomies, other variables, such as:
prior or impending radiation
quality of the breast skin (amount of stretch marks)
size of the breast
amount of ptosis, or “sagging”
other medical issues (diabetes, smoking)
play a tremendous role in determining the ultimate ability of the breast skin to support an implant both in the near- and long-term.
With that being said, and specific to your question, the relationship between radiated skin and breast implants is rocky at best. Permanent, progressive, and irreversible stress is being added to already stressed skin. Further, capsular contracture of varying degrees of severity is the norm with implants in a radiated field.
Based on your surgeon's recommendation, it sounds as if she is anticipating a thinner skin envelope on the side with the cancer and/or is anticipating radiation therapy post-operatively. In this situation, the addition of additional vascularized tissue, such as a latissimus flap, is used to better protect and completely cover the implant. While implants are usually placed underneath the pectoralis muscle, it is not complete coverage. At most, two-thirds of the implant is covered by the pectoralis and, more often than not, over time there is retraction or “window shading” of the pectoralis over the implant and often leaves only one-third of the implant covered in the long-term.
The latissimus flap is a very common flap performed in this setting. It is safe, technically easy to perform with high success rate, and has a relatively straightforward recovery. The major drawback is that the operation involves sacrifice of a large trunk muscle and increases the animation deformity (when you move or strain, the breast will distort significantly until muscles are at complete rest) due to action of both the pectoralis and latissimus over the implant. The donor sites can also be difficult, as risk of a seroma — fluid collection — at the donor site is high and there is obvious difference in appearance of the back on the side with latissimus versus the side where the latissimus flap was taken from. Further, the degree to which losing the normal function of the latissimus muscle affects daily life is controversial and is often individual-dependent based upon line of work and hobbies, but is a legitimate concern.
Taking all of this into consideration, while I agree that likely adding your own tissue is necessary in your situation and reduces risk of implant-related complication, there are other reliable options that do not involve sacrifice of muscle and have more favorable donor sites such as the DIEP, SGAP, and TUG flaps. These options involve microsurgical transfer of fat from areas of natural excess, while sparing muscle. While these options may have slightly longer recoveries, the trade-off is permanence. The DIEP flap, for example, is regarded as the “gold standard” for tissue restoration of the breast. Outcomes relative to these options are optimized in centers that perform large volumes of microsurgical procedures using organized and experienced teams and, thus, it is not uncommon for people to travel for these procedures. It’s worth learning about these options as they are frequently used in situations where there is dissatisfaction with implant-based results, or failed implant reconstructions due to exposure, severe capsular contracture, or need for many revisions over time.
In any case, I commend you for sharing your concerns and advocating for yourself regarding these complex issues. You should be informed of ALL options available to you in an environment where questions are welcomed and shared decision-making between you and your surgeon is valued. I encourage you to seek more than one opinion and wish you all the best.
— Chris Trahan, MD, FACS
— Last updated on February 9, 2022, 8:32 PM