So how do I choose the “right” perforators and minimize fat necrosis? I use an acoustic Doppler to identify the perforators and mark their location on the skin the night before surgery. I use the results of a CT angiogram to understand the size, course and communication with other vessels to further narrow down my perforator selection. Lastly, I use my clinical judgment. Having performed over 1000 DIEP flap breast reconstruction procedures, I have an understanding of the anatomy, interrelationships, and artistry to harvest a DIEP flap with an excellent blood supply to create a soft, natural breast.

The new U.S. Preventative Services Task Force guidelines recommend that women of average risk for breast cancer wait until age 50 to begin getting regular mammograms, and that they do so biannually instead of annually. Their research concludes that there isn’t a clear benefit to earlier or more regular screening for women in their 40s. They also recommend that screening stop after age 74.

However, in response to these guidelines, the American Cancer Society, the American College of Radiology, and the Society of Breast Imaging have announced that they will continue to advise women to begin screening at age 40 and to have annual mammograms after that. They believe that early screening saves lives because the earlier the disease is diagnosed, the more effectively it can be treated.

If you are at high risk for breast cancer or have a history of the disease in your family, screening should begin much earlier, and it might also involve other imaging or diagnostic procedures. Your best course of action would be to begin discussing breast health with your doctor when you are in your 20s.

Here’s the bottom line: if you’re concerned about breast cancer, you should discuss your situation with your doctor or other health care provider, who can help you determine your risk factors and customize a personal plan for you.

1. Will breast reconstruction hide other tumors that may later appear in the breast tissue?
2. Will breast reconstruction encourage the growth of new cancerous cells?
3. Should I continue with regular mammograms and breast self-exams?

Does breast reconstruction hide subsequent tumors?

During a mammogram, implants can occasionally interfere with obtaining a good picture, so your technologist must be trained at positioning the implant to enable the best possible image. In a flap reconstruction, the mammogram image may reveal surgical clips or scars, or the breasts might appear fatty, but an experienced technologist will be able to detect any abnormality. Breast reconstruction rarely, if ever, hides a return of breast cancer, so you shouldn’t consider this a significant risk when deciding to have breast reconstruction after mastectomy.

Will breast reconstruction encourage the growth of new cancerous cells?

No research has shown that reconstruction, either with implants or tissue flaps, increases the risk of the breast cancer returning or of a new cancer forming.

What about mammograms and breast self-exams?

After your reconstruction, whether it involves implants or tissue flap reconstructions, it is important to have regular mammograms at an experienced facility. I also encourage you to keep performing breast self-examination on both breasts as soon as you are fully healed from your surgery. This will enable you to notice and report any changes you feel. You should expect your reconstructed breast to feel different, and your doctor or nurse can help you understand the changes.

If you or a loved one has been diagnosed with breast cancer, I encourage you to participate in a support group because doing so can benefit your mind, body, and spirit. Research has shown that those who actively pursue the companionship of others with breast cancer can decrease stress levels and boost their immune system.

In a support group, you will learn about and from others’ experiences, discussing everything from mood swings to side effects, sleep disturbances to alternative and advanced therapies. Most importantly, you will discover that you’re not alone.

Support groups can meet in person or online. To locate a group in your area, contact local hospitals or breast cancer clinics, or one of the following organizations:

• The National Cancer Institute’s Cancer Information Service, 1-800-4-CANCER (1-800-422-6237)
• Local chapters of the American Cancer Society and Susan G. Komen for the Cure

For those who live in remote locations or prefer an online support group, many resources are available, including the Breast Cancer.org discussion forums. If you are considering mastectomy, the DIEP Sisters Web site provides an excellent resource for support. It also discusses alternative methods of breast reconstruction after mastectomy, focusing on the DIEP flap.

In my own office, the DIEP Flap Support Group was formed over 13 years ago because many patients had a difficult time finding other people to talk to who had undergone the same surgery. Meetings are held once a month, in a very positive mood and setting. Most members are willing to speak to patients considering the DIEP flap for breast reconstruction, so if you’re interested, phone my office at (516) 482- 1100.

One year ago DIEP flap breast reconstruction became available at Huntington Hospital when Drs. Keller and Yoon-Schwartz joined the staff. DIEP flap breast reconstruction utilizes sophisticated microsurgery to reconstruct the breast after a mastectomy from excess abdominal fat. As a side benefit, the patient also ends up with a tummy tuck. The result is the most natural and soft breast reconstruction available. Unlike other techniques, the abdominal muscles are not sacrificed. Dr. Keller has been a pioneer in this type of reconstruction and has been performing DIEP flap breast reconstruction for over 15 years.

There are very few places in the country where this type of reconstruction is available. Huntington Hospital is now on that list and is the only hospital in Suffolk County where this procedure is available. Huntington Hospital has made the commitment to support this service by purchasing a new operating microscope that is ideal for successfully performing this procedure.

Flap Procedure Basics

Flap-type procedures (unlike implant-and-expander surgery) use your own skin, muscle, and fat to reconstruct your breast. The tissue can be taken from different areas of the body (the abdomen, back, or buttocks), but the biggest difference between flap procedures lies in how the surgeon will supply this “flap” of tissue with blood flow to keep it healthy.

• With TRAM flap procedures the breast reconstruction surgeon removes or repositions a piece of upper-abdominal muscle tissue containing blood vessels to divert blood flow to the tissues.
• With DIEP flap procedures no muscle is removed; the surgeon only takes a few blood vessels from the lower abdomen and uses microsurgery to connect the tissues to a healthy blood supply.

TRAM vs. DIEP: How They Measure Up

1 - Tissue health:

This factor is absolutely essential for good results; in order for your new breast tissues to live, they need a healthy blood supply to nourish and maintain the cells.

• TRAM flaps usually use upper-abdominal muscles that aren’t ideal to nourish the flap. Taking the muscle along with the vessels makes this procedure faster, but it also means the surgeon is taking blood vessels that carry less blood, which can make it more difficult for the flap tissues to thrive.
• The DIEP flap utilizes blood vessels from the lower abdomen, and connects them to the flap’s own blood vessels through microsurgery. This takes a bit of time, but it means better blood flow, better tissue health, and lower complication risk.

2 - Muscle functionality:

Your abdominal muscles help hold your internal organs in place. Removing part of this muscle sometimes may cause your internal organs to press forward through the gap in the muscle (a hernia), making a bulge that looks (and feels) uncomfortable.

• TRAM flaps, especially the Free TRAM Flap, pose a clear risk of hernia. Healing times are also longer and less comfortable, since the surgeon has to cut into muscle directly.
• The DIEP flap addresses only the skin, fat, and blood vessels while leaving the muscles intact, so recovery is fast and there’s no risk of hernia.

Most of the time I will be able to recognize from the beginning when a patient will need to have the other breast lifted or reduced so that both breasts match each other as well as possible, but sometimes I won’t know for sure until she has healed. Here are a few of the most common reasons why you may need follow-up surgery:

• Larger, saggier breasts: Women with very large breasts will often need to have their natural breast reduced. I am able to get very good results matching even larger breasts during breast reconstruction surgery in New York. Sometimes thinner women with larger breasts pose a particularly challenging case, and I may recommend a reduction or a lift with reduction to ensure balance following their procedures.
• Small or unevenly positioned breasts: Many women are happy with a reconstruction procedure that matches a smaller breast, but some will choose their reconstruction as an opportunity to fill out their breast volume on both sides. I have found that the results are usually much better when the patient receives the breast augmentation at the same time as her breast reconstruction on Long Island, New York.
• Downward-pointing nipples: Unless you received a nipple-sparing mastectomy, your initial surgery probably left you without either nipples or areolas on that breast. I can place the reconstructed nipple and areola at any position, but in most cases patients will want some lift to give both breasts a more shapely and perky appearance.

Implants vs. Flap Procedures: The Facts

To the body, breast implants are still a foreign substance, and they just can’t integrate with your body the way the fat and muscle used in flap procedures would. Complications of implants include:

• Capsular contracture - the body forms an unusually thick layer of scar tissue that squeezes and puts pressure on the implant
• Rupture of the implant shell
• Development of problems like the “bottoming out” and the “double bubble” deformities

Breast reconstruction surgery using implants can also pose extra challenges that some surgeons just aren’t used to dealing with. A mastectomy is bound to leave behind scar tissue, and in many cases will remove part of the pectoral that normally helps cover the implant and help it keep its position. Patients frequently come to my Long Island, New York practice to revise failed implant-type reconstruction, and in many cases part of the problem stemmed from the fact that their surgeons were not using techniques that take into account the special needs of reconstructive patients.

Flap-type breast reconstruction surgery, such as the DIEP flap procedure, avoids these problems because there is no implant, and the tissues used in the reconstruction are your own. Breasts reconstructed using this method look and feel like natural tissue because they are natural tissue.

… So, Why Aren’t All Breast Reconstructions Flap Procedures?

The basic answer is that these procedures are highly complex.

Flap surgeries require a high level of skill to perform correctly, and most surgeons’ training and experience leans much more heavily toward implant procedures. With flap surgery, the biggest challenges are to shape the breast in ways that balance well with the patient’s body, and to create a reliable blood supply to keep the reconstructed breast tissues healthy.

From a surgeon with genuine experience and authority in this area, this isn’t a problem – I’ve never had a patient go home from the hospital and experience flap failure. However, these aren’t surgeries that any “average” plastic surgeon can perform.

Helpful Resources:

• Questions to ask your New York breast reconstruction surgeon
• Details about breast reconstruction
• More information and case studies on implant-type breast reconstruction after mastectomy

In my experience there are a few clear advantages to having your breasts reconstructed immediately, but there are also plenty of benefits for women who choose delayed reconstruction, and there is no reason to worry that you’ve somehow lost out on your opportunity to benefit from breast reconstruction just because you waited.

Immediate Reconstruction: The Advantages

For most patients, the biggest benefit of having breast reconstruction immediately after mastectomy is that you will wake up from surgery and still have breasts. For most women this benefit alone is a significant reason to have immediate reconstruction, but as a recognized authority on breast reconstruction procedures I can tell you that breast reconstruction has plenty of other benefits even if you wait years for your procedure.

Look at the Bigger Picture

No matter what your age, your breasts can have a profound impact on your self-image and sense of femininity, and that relationship doesn’t change just because your body does. Studies have found that both immediate and delayed breast reconstruction can benefit women in areas such as:

• Body image
• Self image
• Mood, emotion, and positivity
• Sexual satisfaction

Ultimately, the choice to undergo breast reconstruction after mastectomy on Long Island, New York should be yours and yours alone. But I think it’s important for patients not to feel that they have “missed out” on their chance to gain better self confidence and complete the healing process just because it’s been some time since their mastectomy.