Can the mastectomy be carried out by a Plastic Surgeon or another surgeon?

The mastectomy can be carried out by the general surgeon (senologist), gynecologist or by the plastic surgeon, but always with some adequate oncological criteria.

Is it advisable to do mastectomies for fibrocystic mastopathy¿

Nowadays, mastectomy is considered the last therapeutic resource. Therefore, it is indicated in breast cancers or in women with high risk of suffering these tumors, and not in the case of an isolated fibrocystic disease without risk of malignancy.

What percentage of women with breast cancer decide to rebuild the mastectomized breast?

Studies done a few years ago numbered 15 percent mastectomized women that finally decided to rebuild her breast. This low percentage is explained by the limited information, and sometimes misguided, that patients received during the treatment of breast cancer.
However, more and more women are now requesting breast reconstruction because it is easier to find reliable information.

Can you know in advance how the breast will be after the reconstruction?

As a rule, the specialist allows patients to see their (anonymous) case file in which they look for “before and after” reconstruction photographs in patients with similar body characteristics.
However, these images can give an approximate idea of ​​the results of a reconstruction, but each patient is physically different, experience in its own way the evolution and treatment of cancer and its tissues also behave in a different way.

Is it usually necessary to do surgery the contralateral breast?

With reconstructive surgery we look for the best result for the whole breast and the figure of the woman. This is why it is often advisable to reduce breasts, to practice a mastopexy (to give the breast a younger appearance) or even increase the other breast. In any case, when it is entrusted to expert hands, this procedure is usually carried out at the same time as the reconstruction to avoid subjecting the patient to further surgeries in the future.

Can a reconstruction of the two breasts be carried out in the same surgery?

In the case of DIEP generally yes if we have enough tissue in the abdomen

Is Liposuction used in Breast Reconstruction?

No. It can only be used as a technique to refine the remodeling of the new breast and, furthermore, sometime after the reconstruction. It can also be used to improve the abdominal contour even if the reconstruction is done with the DIEP technique.

Can the reconstructive surgery be carried out if you have the period?

Normally yes. Many patients – due to their personal or professional agenda, travel to get the surgery …- and have the surgery during their period. In that case, we must take into account the hormonal shifts during the menstrual cycle. Often the stress and natural nervousness is a reason for having an early period.

Which are the specific risks in the tissue expander plus implant technique in the reconstruction with latissimus dorsi muscle in the DIEP reconstruction?

The common risks of the three techniques used are : Skin sensivity change, abnormal healing that would require a posterior surgical correction, breast asymmetry and cutaneous necrosis.

In procedures that involve implants, it is more difficult for the breasts to remain symmetrical, as weight changes over time will cause variations between the unreconstructed and implanted breast.

In the tissue expansion technique it is possible to get an implant extrusion (of the expander or the posterior silicone implant) because of the lack of a linen of the tissue or an infection. The extrusion of the implant through the skin requires surgery to remove it completely. There may also be intolerance to the material.

In reconstruction with latissimus dorsi recovery could be slow and, the absence of this muscle may impede the sports practice or exercises that require active and important movement of the arm involved. In addition, necrosis of the total or partial flap may occur. However, the most frequent complication is the formation and accumulation of sterile liquid (seroma) in the donor area (the back), which can become infected and / or cause suffering in the overlying skin, so it will have to be drained as many times as possible through a puncture.

As for a DIEP, the specific risks are the possible alterations in the abdominal sensitivity, as well as the pathological healing of the abdomen. As a more serious risk – although unlikely, less than 1 percent, if a proper study is done – appears the necrosis of the transplanted tissue, with partial or total loss of the breast.

In addition, all three techniques will require nipple and areola reconstruction. In this case, the specific risks of this technique are the scar abnormal alteration, the nipple necrosis and the areola pigmentation alteration.

Which is the possibility of having cancer in the reconstructed breast?

Cancer recurrence depends on the type of tumor, its size and the number of affected nodes. Therefore, reconstruction does not interfere with the type of treatment or its evolution, and it has not been found that it can delay the detection of a recurrence.

Should mammograms of the reconstructed breast be done?

It is not necessary since there is no breast tissue. If there is not clear if some breast tissue remains, it is always possible to perform them.

When can the areola and nipple be rebuilt?

The reconstruction of the areola and nipple (Areola nipple complex), as well as any other modification or refinement in the size or shape of the reconstructed breast, should be performed when the reconstructed breast tissue has stabilized in its new location. Therefore, it depends on the evolution and recovery of each patient, but usually happens between four and six months after the reconstruction. The procedure is performed on an outpatient basis and under local anesthesia.

Since when is this type of surgery done?

In Spain, and thanks to the pioneering team of Dr. Jaume Masià, we began to practice the DIEP technique in the Planas Clinic and the Sant Pau Hospital in Barcelona in 1999. Since that date, more than 150 plastic surgeons from fourteen different countries have spent training periods with Dr. Masià to learn this type of techniques. Worldwide, the team of Dr. Robert Allen (USA) began to apply it for breast reconstruction in 1994.

What teams develop this type of surgery in Spain?

Progressively the DIEP technique is becoming more prevalent in most hospitals where quality plastic surgery is performed. Despite this, the implantation is slow because this technique requires a long and complex learning by the facultatives

Are there other doctors who do DIEP reconstructive surgery outside Spain?

In most specialized and prestigious centers in the world, this intervention is the first option for breast reconstruction. This is the case of some of the most reputed european hospitals, such as the University Hospital of Ghent (Belgium) or the Canniesburn of Glasgow (United Kingdom), or of North American plastic surgeons such as Robert Allen, Geoffrey Hallock or Peter Neligan.

Why DIEP has more benefits than the breast Reconstruction with Implants?

Implants can always suffer capsule contracture which, depending on the degree, would require removal of the implant because it would be altering the shape of the breast and / or cause discomfort. In addition, a breast reconstructed with implants does not evolve throughout the patient life as it would do a breast reconstructed with living tissue, something that happens in the case of DIEP. The breast reconstructed with autologous or own tissue increases and decreases in size just like normal breast: that is, it follows the habitual body fluctuations that anyone experiences during the life.

You should also keep in mind that implants are not a lifelong solution: most of them suffer a certain wear, it is recommended to change the implants every fifteen years. In contrast, DIEP offers lasting results, forever.

Is a DIEP a painful intervention?

Most of the patients stop taking analgesics three to four days after the operation. The discomfort is basically due to the fact that the patient cannot sleep on her stomach during the first weeks of the postoperative period, as well as the initial abdominal tightness.

Is a DIEP used in any other reconstructive procedure apart from the breast?

Yes, it is also used in reconstructive surgery of numerous pathologies such as Poland’s syndrome, head and neck reconstructive surgery, complex reconstructions after resection of tumors, to deal with important trauma, etc.

Who is able to reconstruct her breast through the DIEP technique?

Most mastectomized women may be suitable candidates for a DIEP, a breast reconstruction through skin and fatty tissue -nourished by arteries and veins- obtained from the patient’s own abdomen. Only a plastic surgeon with experience in this type of surgery can assess if there is enough abdominal tissue available. Often ignorance of this technique can lead to incorrect indication.

Virtually any woman is a candidate for the reconstruction of the breast through the DIEP technique or, alternatively, through cutaneous and fatty tissue of the gluteus (called SGAP). In fact, most women have enough abdominal tissue to rebuild the breast. In addition, most surgeries performed previously on the abdomen do not prevent the use of this area of ​​the body.

In which time should the DIEP intervention be done?

This type of breast reconstruction can be done at the same time as conservative breast surgery or mastectomy (immediate reconstruction) or at a later date (delayed breast reconstruction). Choosing one or another option will depend on the type of tumor and the indication of the oncologist or the specialist, as well as the decision that each patient makes about it. Age does not involve any limitation, only medical history.

The patient is free to decide whether she wants to live with or without a breast after a mastectomy, regardless of her age. The desire to rebuild the breast may also appear years after the mastectomy.

How long should I wait to perform a DIEP after the mastectomy?

It depends on the cancer treatment taken before. In complementary chemotherapy treatments, reconstruction can be performed within 6 months after finishing it. In case of radiotherapy, patient must wait between eight and twelve months. Patient’s wellness is mandatory, so it is always important to seek for the right moment.

Can this procedure be done in women with a previous implant reconstruction?

Yes. In fact, DIEP is especially recommended for patients who have received radiotherapy since, as this surgery provides healthy vascularized tissue (with blood vessels), it substantially improves the area affected by radiation.

If treated with radiation therapy, how long after the last dose can be the DIEP done?

Between eight months and a year. An immediate reconstruction can also be done and later radiotherapy.

Can this procedure be done in women with a previous prosthetic reconstruction?

Yes. Anyone with a previous silicone implant reconstruction can benefit from the DIEP. The implant is removed and the abdominal tissue is transferred with microsurgical techniques, the same way that would be done in a patient without previous reconstruction. The whole process takes place during the same surgical phase. In fact, this gets frankly spectacular results, which achieve the naturalness that patients yearn for their new breast.

Which effect has the DIEP on a hypothetical pregnancy?

Any. Pregnancy will not be conditioned in any way after this surgery. The non-operated breast physiology will remain the same. During the reconstruction process, the only treatment that can alter pregnancy is antihormonal medication prescribed by the oncologist. Any possible doubts about it should be asked to this professional.

In which cases is a DIEP contraindicated?

There are only two absolute contraindications.

The first is being an important active smoker, so the patient who wish to be operated with this technique must quit smoking fat least six weeks before the intervention. And the second is having undergone some previous surgical intervention in the abdomen that would have damaged the vascularization of the abdominal wall. This second assumption is very rare, since most abdominal interventions (gall bladder, hysterectomies, appendicitis …) do not damage the abdominal vessels.

So, do you have to quit smoking to undergo a DIEP?

Patients must quit smoking completely six weeks before surgery. Substances that are absorbed by smoking, especially nicotine, are extraordinarily harmful in this type of surgery. Nicotine is a vasoactive substance that causes the blood vessels to close.

What are the differences between a DIEP and a TRAM (Tranverse Rectus Abdominis Musculocutaneous)?

In short, TRAM involves destroying abdominal wall muscles, while DIEP only uses excess fat and skin from the abdomen. Therefore, the DIEP has all the advantages of TRAM but, in addition, it brings the benefit of not injuring the patient’s abdominal wall. For this reason, DIEP avoids possible future problems of hernia, pain and physical incapacity due to abdominal weakness. In addition, the postoperative recovery is faster, which implies fewer days of hospital stay.

How does the DIEP technique accompany the abdominal tissue of blood vessels if the musculature of this area is not used?

Deep blood vessels have vascular branches that traverse, from deep to superficial, the abdominal muscles and, ultimately, reach the adipose tissue and the skin of the abdomen. The DIEP technique consists in following these perforating vessels, from the surface to the depth and through the muscle, with microsurgery techniques to respect this muscle and its innervation (distribution of the nerves).

This way deep vessels are reached without injuring the abdominal wall. Deep vessels (in this case inferior deep epigastric vessels) will be dissected with the perforating vessels, the skin and fat tissue and then attached to vessels of equal diameter in the thorax. These deep vessels are totally dispensable since the rest of the deep and superficial vascularization of the body will supply their lack to perfection.

If a TRAM has already been done and the patient has experienced complications, what type of reconstruction can she undergo?

A DIEP cannot be performed because the patient’s abdomen has been altered in the previous TRAM, but there are many alternative techniques for this type of patient. Possibly one of the most suitable would be the SGAP of the gluteal region.

How much abdomen’s tissue is used to reconstruct the breast through a DIEP?

Only skin and abdominal fat are transferred, so the patient’s abdomen looks like if an aesthetic corrective abdominoplasty had been done (to obtain a flatter and firmer belly). No muscle structure is transferred.

Is it possible to transfer tissue from one person to another to make a new breast?

No, it would work only if the other person was identical twin and after having done a previous genetic study. In the United States, Dr. Robert Allen, a pioneer in this type of reconstruction, has performed some tissue transfer interventions in twins to reconstruct the breast.

Which are the exact steps that should be followed immediately after DIEP surgery?

After reconstructive surgery, the patient will be transferred to the postoperative observation room or, as in the most cases, she will be taken directly to the room. There, a postoperative control procedure can be installed while the patient is better attended and accompanied by her loved ones.
The patient will rest at the room for two or three days, when all the drains will be removed and she will be discharged.
After a week, a check at the specialists’ office will be made.

Does the new breast have sensitivity?

In more than a quarter of the patients (25 percent) spontaneous reinnervation occurs. This means that sensitive nerve endings are developed at the reconstructed breast. When is technically possible, and with he aim to increase the quality of reconstructed breast sensitivity, the fourth intercostal nerve (main nerve in the sensitivity of the nipple) is connected to a sensory nerve of the abdominal flap.

Will the rebuilt breast change if there is a weight gain or loss?

Perforator flaps follow the volume variations of the rest of the body and, more importantly, follow a symmetrical course with the other healthy breast.

Which immediate complications can occur in DIEP surgery?

There is the possibility to have to check the flap in the operating theater within 24-48 hours after the reconstruction (5 percent) or experiencing flap loss (1 percent). The most common cause of these complications is usually an hematoma that compresses the blood vessel which nourishes the tissue.

Which is the possibility of having an abdominal hernia after surgery?

The incidence of herniation in the DIEP is 1 percent and in the TRAM from 8 to 30 percent, even though a mesh has been placed in the abdomen.

Which are the long-term effects on the abdomen?

A slight alteration can be manifested on the abdominal musculature.

How long it will take to hide the scars and the new breast look natural?

It takes about six weeks to achieve an acceptable aesthetic result. When the weeks go by, it will improve in a slower rhythm. Finally, after six or eight months is when the new breast will have a natural appearance.

When will I be able to sunbathe and / or UVA in the operated area?

Two months after the reconstruction, but only with extreme sun protection. If this extreme protection is not used, you must wait one year.

Do the scars allow wearing a bikini?

Yes

Can we improve the scars appearance with some complementary technique?

The final result depends on each skin. But there are silicone bandages that can improve the scars final appearance when applied on the scars through presotherapy. Likewise, there are cosmetics, oils and creams that can facilitate this process. In addition, laser techniques can be applied to clarify the scar color.

To sum up: compression, cosmetics and lasers – used according to each case evolution – provide a very good aesthetic result in the vast majority of cases, making the scars stabilized in about a year.

Physical activity is essential for some women. Do I have to rest for a long time after reconstructive breast surgery?

In certain cases, women with a high level of physical activity may resume their normal life within three weeks after being discharged. The intervention does not change the muscle function, so you can even practice intense physical exercise with the time. It is always advisable to perform physical exercise progressively and with caution.

Can I sleep on my stomach?

You can sleep on your stomach one month after he chest area is already healed. Anyway, the body will mark the rhythm of the movements during the night’s rest.

When can the axilla be waxed?

From the first month.

When can I wear a bra after DIEP?

The second day after the intervention. During the first two or three weeks you must use a sports bra and even sleep with it. After this time, and for a limited period, you can start using other models without ring or seams. Finally, you can choose the underwear that you prefer.

How many days should I wait before traveling?

For long trips, three or four weeks after the surgery. For short and non-heavy journeys, you can travel as from the week after surgery.

How many days should you wait to drive or lift weights?

Between two and three weeks.

Can I take a shower or a bath during the first few days after the intervention?

Quick shower is recommended, without fear of wetting the wounds.

Planas Clinic

Advanced Unit of
Breast Reconstruction

Pere de Montcada 16
08034 Barcelona

Tel.: (+34)932032812
www.clinicaplanas.com

Sant Pau Hospital

Reconstructive and Plastic
Surgery Unit

Sant Antoni Mª Claret 167
08025 Barcelona

Tel.: (+34)935565693
www.santpau.cat

Puigvert Foundation

Advanced Unit of
Breast Reconstruction

Cartagena 340- 350
08025 Barcelona

Tel.: (+34)934169700 / (+34)934169707
www.fundacio-puigvert.es

Del Mar Hospital

Plastic Surgery Unit

Passeig Marítim 25-29
08003 Barcelona

Tel.: (+34)932483000
www.parcdesalutmar.cat/hospitals/hospital-del-mar