The Breast Cancer Reconstruction Blog

Tammy's Breast Reconstruction Journey. Part I - My Breast Cancer Diagnosis

noreply@blogger.com (Dr C) — Mon, 09 Nov 2009 18:08:56 PST

By Tammy Carrington

My name is Tammy and I was diagnosed with Ductal Carcinoma In Situ (DCIS) in June 2009. I underwent bilateral mastectomy and immediate reconstruction with DIEP flaps. I believe it is important to share my story on how I made my decision because when I was looking for information on other women’s experiences, it was hard to find. If I can help even one woman feel peaceful about making her own decision, then it was worth it all. That’s part of this process… reaching out and helping others who are behind us in the journey.

My nature is to research things completely so that I can make informed decisions. I am the mom to a severely brain injured little boy who is now 12 years old and I’ve spent lots of time over the years looking for information on how to help him to get better and have spent more than 20 years in the medical field as well.

My Breast Cancer Diagnosis:

My diagnosis came as a complete shock to me. I am sure it’s a shock to anyone who hears it for the first time, but somehow I never thought I would be hearing those words associated with me. I just remember how numb I felt when I heard the “C” word… CANCER.

I had no signs or symptoms to indicate that there was any type of problem. I went in for my routine annual mammogram and they asked me to return for an ultrasound of my breast. Having me return was not an unusual request because I have had fibrocystic breast tissue and it had almost become routine for me to have to return. They would always do an ultrasound where they could see the cysts and then I would then be sent on my merry way.

This year was different.

They called me back for the ultrasound but also wanted to do some spot compression views so they could look more closely at an area of my breast where they wanted to see more detail. The doctor told me that radiologists are trained to look for microcalcifications when they view mammograms. My mammogram showed some microcalcifications and this time I was told to follow up in 6 months to see if there were any changes in my breast during that time.

My gut feeling told me that I didn’t want to wait 6 months, so my physician sent me to a local surgeon and he decided to do a stereotactic breast biopsy right away. The results were back quickly and I was diagnosed with ductal carcinoma in situ (DCIS). I had breast cancer.

Time to get over the shock…

(more to follow on The Breast Cancer Reconstruction Blog)

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Keep up to date with the latest news in breast cancer reconstruction at The Breast Cancer Reconstruction Blog. Also join us on Facebook and Twitter!

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Scar Healing - Tips For "Invisible" Scars

noreply@blogger.com (Dr C) — Sun, 01 Nov 2009 15:54:23 PST

Scar healing is the result of biologic wound repair and is a complex process. With the exception of minor lesions, every skin wound causes some degree of permanent scarring.

My breast reconstruction patients often ask for advice on how to improve their scars. While expecting 100% invisible scars may not be realistic, it is possible to influence the body's scar healing mechanism to improve scar appearance and texture significantly.

The word "scar" comes from the Greek word "eschara", meaning "place of fire." Scar tissue is different from normal skin. It is inferior both in appearance and function. For example, scars are much less resistant to the sun's ultraviolet rays and more prone to sunburn. Scars also lack a blood supply or sweat glands, and they never grow hair.

Complete scar healing can take up to 2 years. Scars continue to soften, flatten and fade during this time. Unfortunately, some scars become more problematic over time by:

- Growing larger or more raised
- Causing itching
- Becoming painful
- Becoming permanently pigmented (dark red/brown)
- Restricting motion

Various factors influence the way scars heal:

1) Age - younger skin is more prone to abnormal and exaggerated scarring. This can lead to hypertrophic or keloid scars. Older skin takes longer to recover.

2) Skin type - scar healing is typically worse in people with darker skin types. African and Hispanic ancestry is associated with a higher risk of developing hypertrophic or keloid scars.

3) Genetics - abnormal scarring can be inherited.

4) Location - Movement of scars over joints can make them wider.

5) Infection - Infected wounds do not heal well. The final scar may be raised, wide, uneven and abnormally red or dark.

6) Poor nutrition - not eating healthily can deprive the body of much needed nutrients (like protein), vitamins (like vitamin C) and minerals (like copper and zinc) that are needed for optimal wound healing.

7) Smoking - components of cigarette smoke cause blood vessels to clamp down and decrease blood flow. Wounds that do not receive enough blood are more prone to poor wound healing and worse scarring.

8) Sun exposure - exposing fresh scars to the sun can cause permanent redness which makes the scar more obvious.

So what can you do to improve scar healing?

1) Keep fresh wounds clean. Don't be afraid to wash your wounds but use a skin-friendly soap like Dial. Also keep fresh wounds covered to prevent dirt and bacteria entering and increasing the risk of an infection.

2) Eat healthily.

3) Don't smoke.

4) Protect scars from the sun. Cover them with clothing initially and use sunblock as soon as the scar is healed enough.

5) Scar massage - firm massage of the scar for several minutes, multiple times a day has been shown to help soften and flatten scars.

6) Use a scientifically-proven scar treatment - there are plenty of options out there but most promise much and deliver little. Commonly recommended therapies include onion extract (like Mederma skin care) and vitamin E. Multiple clinical studies have shown that neither of these are beneficial for scar healing. Vitamin E actually causes contact dermatitis in up to 33% of users!

Scientifically proven scar treatments to look for include dimethicone silicone sheeting or gel (soften scars), topical vitamin C (lightens darks scars and promotes healthy collagen), and some (all-natural) botanicals like licorice extract (lightens dark scars) and aloe vera (anti-inflammatory). Whichever scar treatment you choose, start using it as soon as initial scar healing has taken place and continue using it until no further improvement in scar appearance is seen.

I encourage everyone to become familiar with the scientific evidence behind common scar treatments and to carefully examine product labels before buying.

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Dr Chrysopoulo is a board certified plastic surgeon with a special interest in scar healing and breast cancer reconstruction. He is also Chief Science Officer of C&H Scientific, makers of the scar treatment InviCible Scars. Follow us on Twitter and join us on Facebook for more scar treatment tips!

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Links for 2009-10-21 [del.icio.us]

Thu, 22 Oct 2009 00:00:00 PDT

Get Rid of Dark Scars & Brown Spots - InviCible Scars™
Get rid of dark scars and brown spots. Advanced Scar Treatment diminishes scars and dark pigmentation. Hypo-allergenic. No parabens, fragrances or harmful D4/D5 silicones.
Scar Treatments - Products Compared
Scar Treatments Comparison - The science behind common scar treatment ingredients like silicone, vitamin E and onion extract. What really works?
Scar Healing Treatments
Scar healing treatments - factors that influence the way scars heal and how to improve scar healing.
Scar Therapy Safety
Scar Therapy Safety - Which scar treatments are scientifically proven, safe, and effective?
Vitamin C For Scars
Vitamin C fades scars and lightens dark scars and brown spots. Backed by independent scientific studies.
Does Vitamin E fade Scars?
Vitamin E for scars. What do the scientific studies show? Does vitamin E really fade scars?
Scar Silicone Treatment
Scar silicone treatment with Silicone gel or sheeting fades and softens scars, and improves scar elasticity. Backed by independent scientific studies.
Topical Steroids For Scars - Do they work?
Steroids for scars. What do the scientific studies show? Do topical steroids really fade scars?

Can Breast Cancer Be Found Early?

noreply@blogger.com (Dr C) — Sun, 04 Oct 2009 18:31:53 PDT

Breast Cancer Screening Recommendations from the American Cancer Society

Screening refers to tests and exams used to find a disease, such as cancer, in people who do not have any symptoms. The goal of screening exams, such as mammograms, is to find cancers before they start to cause symptoms. Breast cancers that are found because they can be felt tend to be larger and are more likely to have already spread beyond the breast. In contrast, breast cancers found during screening exams are more likely to be small and still confined to the breast. The size of a breast cancer and how far it has spread are important factors in predicting the prognosis (survival outlook) for a woman with this disease.

Most doctors feel that early detection tests for breast cancer save many thousands of lives each year, and that many more lives could be saved if even more women and their health care providers took advantage of these tests. Following the American Cancer Society's guidelines for the early detection of breast cancer improves the chances that breast cancer can be diagnosed at an early stage and treated successfully.

American Cancer Society recommendations for early breast cancer detection

Women age 40 and older should have a screening mammogram every year and should continue to do so for as long as they are in good health.

Current evidence supporting mammograms is even stronger than in the past. In particular, recent evidence has confirmed that mammograms offer substantial benefit for women in their 40s. Women can feel confident about the benefits associated with regular mammograms for finding cancer early. However, mammograms also have limitations. A mammogram will miss some cancers, and it sometimes leads to follow up of findings that are not cancer, including biopsies.

Women should be told about the benefits, limitations, and potential harms linked with regular screening. Mammograms can miss some cancers. But despite their limitations, they remain a very effective and valuable tool for decreasing suffering and death from breast cancer.

Mammograms for older women should be based on the individual, her health, and other serious illnesses, such as congestive heart failure, end-stage renal disease, chronic obstructive pulmonary disease, and moderate-to-severe dementia. Age alone should not be the reason to stop having regular mammograms. As long as a woman is in good health and would be a candidate for treatment, she should continue to be screened with a mammogram.

Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a periodic (regular) health exam by a health professional, at least every 3 years. After age 40, women should have a breast exam by a health professional every year.

CBE is a complement to mammograms and an opportunity for women and their doctor or nurse to discuss changes in their breasts, early detection testing, and factors in the woman's history that might make her more likely to have breast cancer.

There may be some benefit in having the CBE shortly before the mammogram. The exam should include instruction for the purpose of getting more familiar with your own breasts. Women should also be given information about the benefits and limitations of CBE and breast self exam (BSE). Breast cancer risk is very low for women in their 20s and gradually increases with age. Women should be told to promptly report any new breast symptoms to a health professional.

Breast self exam (BSE) is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away.

Research has shown that BSE plays a small role in finding breast cancer compared with finding a breast lump by chance or simply being aware of what is normal for each woman. Some women feel very comfortable doing BSE regularly (usually monthly after their period) which involves a systematic step-by-step approach to examining the look and feel of their breasts. Other women are more comfortable simply looking and feeling their breasts in a less systematic approach, such as while showering or getting dressed or doing an occasional thorough exam. Sometimes, women are so concerned about "doing it right" that they become stressed over the technique. Doing BSE regularly is one way for women to know how their breasts normally look and feel and to notice any changes. The goal, with or without BSE, is to report any breast changes to a doctor or nurse right away.

Women who choose to do BSE should have their BSE technique reviewed during their physical exam by a health professional. It is okay for women to choose not to do BSE or not to do it on a regular schedule. However, by doing the exam regularly, you get to know how your breasts normally look and feel and you can more readily detect any signs or symptoms if a change occurs, such as development of a lump or swelling, skin irritation or dimpling, nipple pain or retraction (turning inward), redness or scaliness of the nipple or breast skin, or a discharge other than breast milk. Should you notice any changes you should see your health care provider as soon as possible for evaluation. Remember that most of the time, however, these breast changes are not cancer.

Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15% to 20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%.

Women at high risk include those who:

have a known BRCA1 or BRCA2 gene mutation

have a first-degree relative (parent, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation, but have not had genetic testing themselves

have a lifetime risk of breast cancer of 20% to 25% or greater, according to risk assessment tools that are based mainly on family history (see below)

had radiation therapy to the chest when they were between the ages of 10 and 30 years

have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes

Women at moderately increased risk include those who:

have a lifetime risk of breast cancer of 15% to 20%, according to risk assessment tools that are based mainly on family history (see below)

have a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH)

have extremely dense breasts or unevenly dense breasts when viewed by mammograms

If MRI is used, it should be in addition to, not instead of, a screening mammogram. This is because while an MRI is a more sensitive test (it's more likely to detect cancer than a mammogram), it may still miss some cancers that a mammogram would detect.

For most women at high risk, screening with MRI and mammograms should begin at age 30 years and continue for as long as a woman is in good health. But because the evidence is limited regarding the best age at which to start screening, this decision should be based on shared decision making between patients and their health care providers, taking into account personal circumstances and preferences.

Several risk assessment tools, with names such as the Gail model, the Claus model, and the Tyrer-Cuzick model, are available to help health professionals estimate a woman's breast cancer risk. These tools give approximate, rather than precise, estimates of breast cancer risk based on different combinations of risk factors and different data sets. As a result, they may give different risk estimates for the same woman. Their results should be discussed by a woman and her doctor when being used to decide whether to start MRI screening.

It is recommended that women who get screening MRI do so at a facility that can do an MRI-guided breast biopsy at the same time if needed. Otherwise, the woman will have to have a second MRI exam at another facility at the time of biopsy.

There is no evidence right now that MRI will be an effective screening tool for women at average risk. While MRI is more sensitive than mammograms, it also has a higher false-positive rate (it is more likely to find something that turns out not to be cancer). This would lead to unneeded biopsies and other tests in many of these women.

The American Cancer Society believes the use of mammograms, MRI (in women at high risk), clinical breast exams, and finding and reporting breast changes early, according to the recommendations outlined above, offers women the best chance to reduce their risk of dying from breast cancer. This combined approach is clearly better than any one exam or test alone. Without question, breast physical exam without a mammogram would miss the opportunity to detect many breast cancers that are too small for a woman or her doctor to feel but can be seen on mammograms. Although mammograms are a sensitive screening method, a small percentage of breast cancers do not show up on mammograms but can be felt by a woman or her doctors. For women at high risk of breast cancer, such as those with BRCA gene mutations or a strong family history, both MRI and mammogram exams of the breast are recommended.

Mammograms

A mammogram is an x-ray of the breast. A diagnostic mammogram is used to diagnose breast disease in women who have breast symptoms or an abnormal result on a screening mammogram. Screening mammograms are used to look for breast disease in women who are asymptomatic; that is, they appear to have no breast problems. Screening mammograms usually take 2 views (x-ray pictures taken from different angles) of each breast. For some patients, such as women with breast implants, more pictures may be needed to include as much breast tissue as possible. Women who are breast-feeding can still get mammograms, although these are probably not quite as accurate because the breast tissue tends to be dense.

Although breast x-rays have been done for more than 70 years, the modern mammogram has only existed since 1969. That was the first year x-ray units specifically for breast imaging were available. Modern mammogram equipment designed for breast x-rays uses very low levels of radiation, usually a dose of about 0.1 to 0.2 rads per picture (a rad is a measure of radiation dose).

Strict guidelines ensure that mammogram equipment is safe and uses the lowest dose of radiation possible. Many people are concerned about the exposure to x-rays, but the level of radiation used in modern mammograms does not significantly increase the risk for breast cancer.

To put dose into perspective, if a woman with breast cancer is treated with radiation, she will receive around 5,000 rads. If she had yearly mammograms beginning at age 40 and continuing until she was 90, she will have received 20 to 40 rads.

For a mammogram, the breast is pressed between 2 plates to flatten and spread the tissue. Although this may be uncomfortable for a moment, it is necessary to produce a good, readable mammogram. The compression only lasts a few seconds. The entire procedure for a screening mammogram takes about 20 minutes. This procedure produces a black and white image of the breast tissue either on a large sheet of film or as a digital computer image that is read, or interpreted, by a radiologist (a doctor trained to interpret images from x-rays, ultrasound, MRI, and related tests).

Some advances in technology, such as digital mammography, may help doctors read mammograms more accurately. They are described here.

What the doctor looks for on your mammogram

The doctor reading the films will look for several types of changes:

Calcifications are tiny mineral deposits within the breast tissue, which look like small white spots on the films. They may or may not be caused by cancer. There are 2 types of calcifications:

Macrocalcifications are coarse (larger) calcium deposits that are most likely changes in the breasts caused by aging of the breast arteries, old injuries, or inflammation. These deposits are related to non-cancerous conditions and do not require a biopsy. Macrocalcifications are found in about half the women over 50, and in about 1 of 10 women under 50.

Microcalcifications are tiny specks of calcium in the breast. They may appear alone or in clusters. Microcalcifications seen on a mammogram are of more concern, but still usually do not mean that cancer is present. The shape and layout of microcalcifications help the radiologist judge how likely it is that cancer is present. If the calcifications look suspicious for cancer, a biopsy will be done.

A mass, which may occur with or without calcifications, is another important change seen on mammograms. Masses can be many things, including cysts (non-cancerous, fluid-filled sacs) and non-cancerous solid tumors (such as fibroadenomas), but they could also be cancer. Masses that are not cysts usually need to be biopsied.

A cyst and a tumor can feel alike on a physical exam. They can also look the same on a mammogram. To confirm that a mass is really a cyst, a breast ultrasound is often done. Another option is to remove (aspirate) the fluid from the cyst with a thin, hollow needle.

If a mass is not a simple cyst (that is, if it is at least partly solid), then you may need to have more imaging tests. Some masses can be watched with periodic mammograms, while others may need a biopsy. The size, shape, and margins (edges) of the mass help the radiologist determine if cancer is present.

Having your previous mammograms available for the radiologist is very important. They can be helpful to show that a mass or calcification has not changed for many years. This would mean that it is probably a benign condition and a biopsy is not needed.

Limitations of mammograms

A mammogram cannot prove that an abnormal area is cancer. To confirm whether cancer is present, a small amount of tissue must be removed and looked at under a microscope. This procedure, called a biopsy, is described here.

You should also be aware that mammograms are done to find breast cancer that cannot be felt. If you have a breast lump, you should have it checked by your doctor and consider having it biopsied even if your mammogram result is normal.

For some women, such as those with breast implants, additional pictures may be needed. Breast implants make it harder to see breast tissue on standard mammograms, but additional x-ray pictures with implant displacement and compression views can be used to more completely examine the breast tissue.

Mammograms are not perfect at finding breast cancer. They do not work as well in younger women, usually because their breasts are dense, and can hide a tumor. This may also be true for pregnant women and women who are breast-feeding. Since most breast cancers occur in older women, this is usually not a major concern.

However, this can be a problem for young women who are at high risk for breast cancer (due to gene mutations, a strong family history of breast cancer, or other factors) because they often develop breast cancer at a younger age. For this reason, the American Cancer Society now recommends MRI scans in addition to mammograms for screening in these women. (MRI scans are described below.)

More information on these tests is available here and the separate American Cancer Society document, Mammograms and Other Breast Imaging Procedures.

What to expect when you have a mammogram

To have a mammogram you must undress above the waist. The facility will give you a wrap to wear.

A technologist will be there to position your breasts for the mammogram. Most technologists are women. You and the technologist are the only ones in the room during the mammogram.

To get a high-quality mammogram picture with excellent image quality, it is necessary to flatten the breast slightly. A technologist places the breast on the mammogram machine's lower plate, which is made of metal and has a drawer to hold the x-ray film or the camera to produce a digital image. The upper plate, made of plastic, is lowered to compress the breast for a few seconds while the picture is taken.

The whole procedure takes about 20 minutes. The actual breast compression only lasts a few seconds.

You will feel some discomfort when your breasts are compressed, and for some women compression can be painful. Try not to schedule a mammogram when your breasts are likely to be tender, as they may be just before or during your period.

All mammogram facilities are now required to send your results to you within 30 days. Generally, you will be contacted within 5 working days if there is a problem with the mammogram.

Only 2 to 4 mammograms of every 1,000 lead to a diagnosis of cancer. About 10% of women who have a mammogram will require more tests, and the majority will only need an additional mammogram. Don't panic if this happens to you. Only 8% to 10% of those women will need a biopsy, and most (80%) of those biopsies will not be cancer.

If you are a woman aged 40 or over, you should get a mammogram every year. You can schedule the next one while you're at the facility and/or request a reminder.

Tips for having a mammogram

The following are useful suggestions for making sure that you will receive a quality mammogram:

If it is not posted visibly near the receptionist's desk, ask to see the FDA certificate that is issued to all facilities that offer mammography. The FDA requires that all facilities meet high professional standards of safety and quality in order to be a provider of mammography services. A facility may not provide mammography without certification.

Use a facility that either specializes in mammography or does many mammograms a day.

If you are satisfied that the facility is of high quality, continue to go there on a regular basis so that your mammograms can be compared from year to year.

If you are going to a facility for the first time, bring a list of the places, dates of mammograms, biopsies, or other breast treatments you have had before.

If you have had mammograms at another facility, you should make every attempt to get those mammograms to bring with you to the new facility (or have them sent there) so that they can be compared to the new ones.

On the day of the exam don't wear deodorant or antiperspirant. Some of these contain substances that can interfere with the reading of the mammogram by appearing on the x-ray film as white spots.

You may find it easier to wear a skirt or pants, so that you'll only need to remove your blouse for the exam.

Schedule your mammogram when your breasts are not tender or swollen to help reduce discomfort and to ensure a good picture. Try to avoid the week just before your period.

Always describe any breast symptoms or problems that you are having to the technologist who is doing the mammogram. Be prepared to describe any medical history that could affect your breast cancer risk -- such as surgery, hormone use, or family or personal history of breast cancer. Discuss any new findings or problems in your breasts with your doctor or nurse before having a mammogram.

If you do not hear from your doctor within 10 days, do not assume that your mammogram was normal -- call your doctor or the facility.

Help with mammogram costs

Medicare, Medicaid, and most private health insurance plans cover mammogram costs or a percentage of them. Low-cost mammograms are available in most communities. Call 1-800-227-2345 for information about facilities in your area.

Breast cancer screening is now more available to medically underserved women through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). This program provides breast and cervical cancer early detection testing to women without health insurance for free or at very low cost. Although the program is administered within each state, the Centers for Disease Control and Prevention (CDC) provide matching funds and support to each state program. Each state's Department of Health has information on how to contact the nearest program.

The program is only designed to provide screening. But if a cancer is discovered, it will cover further diagnostic testing and a surgical consultation.

The Breast and Cervical Cancer Prevention and Treatment Act gives states Medicaid funds to pay for treating breast and cervical cancers that are detected through the NBCCEDP. This helps women focus their energies on fighting their disease, instead of worrying about how to pay for treatment. All states participate in this program.

To learn more about these programs, please contact the CDC at 1-800-CDC INFO (1-800-232-4636) or online.

Clinical breast exam

A clinical breast exam (CBE) is an exam of your breasts by a health care professional, such as a doctor, nurse practitioner, nurse, or doctor's assistant. For this exam, you undress from the waist up. The health care professional will first look at your breasts for abnormalities in size or shape, or changes in the skin of the breasts or nipple. Then, using the pads of the fingers, the examiner will gently feel (palpate) your breasts.

Special attention will be given to the shape and texture of the breasts, location of any lumps, and whether such lumps are attached to the skin or to deeper tissues. The area under both arms will also be examined.

The CBE is a good time for women who don't know how to examine their breasts to learn the proper technique from their health care professionals. Ask your doctor or nurse to teach you and watch your technique.

Breast awareness and self exam

Beginning in their 20s, women should be told about the benefits and limitations of breast self-exam (BSE). Women should know how their breasts normally look and feel and report any new breast changes to a health professional as soon as they are found. Finding a breast change does not necessarily mean there is a cancer.

A woman can notice changes by being aware of how her breasts normally look and feel and by feeling her breasts for changes (breast awareness), or by choosing to use a step-by-step approach (see below) and using a specific schedule to examine her breasts.

If you choose to do BSE, the information below is a step-by-step approach for the exam. The best time for a woman to examine her breasts is when the breasts are not tender or swollen. Women who examine their breasts should have their technique reviewed during their periodic health exams by their health care professional.

Women with breast implants can do BSE, too. It may be helpful to have the surgeon help identify the edges of the implant so that you know what you are feeling. There is some thought that the implants push out the breast tissue and may actually make it easier to examine. Women who are pregnant or breast-feeding can also choose to examine their breasts regularly.

It is acceptable for women to choose not to do BSE or to do BSE once in a while. Women who choose not to do BSE should still be aware of the normal look and feel of their breasts and report any changes to their doctor right away.

How to examine your breasts

Lie down and place your right arm behind your head. The exam is done while lying down, not standing up. This is because when lying down the breast tissue spreads evenly over the chest wall and is as thin as possible, making it much easier to feel all the breast tissue.

Use the finger pads of the 3 middle fingers on your left hand to feel for lumps in the right breast. Use overlapping dime-sized circular motions of the finger pads to feel the breast tissue.

Use 3 different levels of pressure to feel all the breast tissue. Light pressure is needed to feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel the tissue closest to the chest and ribs. It is normal to feel a firm ridge in the lower curve of each breast, but you should tell your doctor if you feel anything else out of the ordinary. If you're not sure how hard to press, talk with your doctor or nurse. Use each pressure level to feel the breast tissue before moving on to the next spot.

Move around the breast in an up and down pattern starting at an imaginary line drawn straight down your side from the underarm and moving across the breast to the middle of the chest bone (sternum or breastbone). Be sure to check the entire breast area going down until you feel only ribs and up to the neck or collar bone (clavicle).

There is some evidence to suggest that the up-and-down pattern (sometimes called the vertical pattern) is the most effective pattern for covering the entire breast, without missing any breast tissue.

Repeat the exam on your left breast, putting your left arm behind your head and using the finger pads of your right hand to do the exam.

While standing in front of a mirror with your hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin. (The pressing down on the hips position contracts the chest wall muscles and enhances any breast changes.)

Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and makes it harder to examine.

This procedure for doing breast self exam is different from previous recommendations. These changes represent an extensive review of the medical literature and input from an expert advisory group. There is evidence that this position (lying down), the area felt, pattern of coverage of the breast, and use of different amounts of pressure increase a woman's ability to find abnormal areas.

Magnetic resonance imaging (MRI)

For certain women at high risk for breast cancer, screening MRI is recommended along with a yearly mammogram. It is not generally recommended as a screening tool by itself, because although it is a sensitive test, it may still miss some cancers that mammograms would detect.

MRI scans use magnets and radio waves (instead of x-rays) to produce very detailed, cross-sectional images of the body. The most useful MRI exams for breast imaging use a contrast material (gadolinium) that is injected into a vein in the arm before or during the exam. This improves the ability of the MRI to clearly show breast tissue details.

Although MRI is more sensitive in detecting cancers than mammograms, it also has a higher false-positive rate (where the test finds something that turns out not to be cancer), which results in more recalls and biopsies. This is why it is not recommended as a screening test for women at average risk of breast cancer, as it would result in unneeded biopsies and other tests in a large portion of these women.

Just as mammography uses x-ray machines that are specially designed to image the breasts, breast MRI also requires special equipment. Breast MRI machines produce higher quality images than MRI machines designed for head, chest, or abdominal scanning. However, many hospitals and imaging centers do not have dedicated breast MRI equipment available. It is important that screening MRIs be done at facilities that can perform an MRI-guided breast biopsy. Otherwise, the entire scan will need to be repeated at another facility when the biopsy is done.

MRI is more expensive than mammography. Most major insurance companies will likely pay for these screening tests if a woman can be shown to be at high risk, but it's not yet clear if all companies will do so. At this time there are concerns about costs of and limited access to high-quality MRI breast screening services for women at high risk of breast cancer.

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Keep up to date with the latest news in breast cancer reconstruction at The Breast Cancer Reconstruction Blog. Also follow us on Twitter!

*****

Breast Reconstruction Report: "I wanted to heal my way"

noreply@blogger.com (Dr C) — Sun, 04 Oct 2009 15:44:14 PDT

By Lisa Bernhard

I was 29 years old when my gray-haired surgeon looked at me from across his desk and said, "I'd recommend a mastectomy." My dad, seated to my left, exhaled hard. To my right, my mom sat in silence. Family history had repeated itself: My grandmother underwent a mastectomy at age 39. Now it would be me. But in the four days since my diagnosis, I had researched and stumbled upon a choice my grandmother never had.

"It's OK," I said to my dad. "They can rebuild me."

They did. In one nine-hour procedure, a cancer surgeon performed a skin-sparing mastectomy, removing the nipple and tissue inside my right breast but leaving most of the skin intact. Then a plastic surgeon performed a free-flap reconstruction, extracting a portion of my stomach skin and fat and microscopically reconnecting it to my chest. Later, he reconstructed the nipple. The result was a breast that looks and feels like...my breast.

In the 14 years since, my reconstructed chest has seen me through highs and lows: confident in an evening gown while reporting from the Oscars as a TV correspondent; sorrowful, at times, when standing naked under bright bathroom lights, the faint scars tracing my areola reminders of invading disease and scalpels. Yearly screenings send my heart pounding, but my surgery has helped me be hopeful about the future.

Of course, some women don't want any kind of reconstruction, sometimes due to health reasons or as a matter of preference. But women who do choose it report significant, lasting psychological benefits, in a way that transcends physical beauty, according to a study by Amy K. Alderman, M.D., assistant professor of plastic surgery at the University of Michigan Medical School in Ann Arbor. "Women tell me they feel whole again and more able to put cancer behind them," she explains.

Which is why I'm alarmed that many women don't know that options like the one I selected exist. Nearly 70 percent of women eligible for reconstruction aren't informed of their reconstructive options, according to a 2007 study by Dr. Alderman. Almost 65 percent of general surgeons said they believe patients lack interest in reconstruction, and less than one in four consistently refers breast cancer patients to plastic surgeons.

Meanwhile, plastic surgeons often limit the time they devote to cancer patients, because they tend to lose money treating them. Insurance reimbursements—which are roughly based on what Medicare pays—are paltry. In the case of free-flap surgery, plastic surgeons can charge $7,000 to $25,000 per breast; the average Medicare reimbursement in 2007 was $1,737. As a result, some doctors won't accept insurance for reconstructive surgeries, forcing patients to pay out of pocket. Others steer patients toward more profitable types of reconstruction, regardless of what's best medically, says Mark Sultan, M.D., my reconstructive surgeon and chief of the division of plastic surgery at St. Luke's-Roosevelt Hospital Center and Beth Israel Medical Center in New York City. Insurers reimburse implant reconstruction at roughly the same level as a flap, but surgery takes only about an hour. "Doctors may think, Why do a six-hour operation when I am paid the same amount for a one-hour implant?" Dr. Sultan says. "They may convince themselves, consciously or unconsciously, that the patient is a better candidate for an implant."

Comment by Dr C:

I completely agree with Dr Sultan and I strongly encourage all women considering breast reconstruction to research all their reconstructive options. Unfortunately, some patients will have to consider traveling for some of the more advanced procedures. A major consideration for most people is obviously cost. Patients must be aware of the practice of balance billing which can add thousands of dollars to the out-of-pocket expenses.

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Keep up to date with the latest news in breast reconstruction at The Breast Cancer Reconstruction Blog. Also follow us on Twitter!

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CNN Airs News Story on Male Breast Cancer at Camp Lejeune

noreply@blogger.com (Dr C) — Wed, 23 Sep 2009 06:26:49 PDT

By Pam Stephan, About.com Guide to Breast Cancer

Mike Partain, male breast cancer survivor and former resident of Camp Lejeune, is back in the news again. Tune in to CNN on Thursday and Friday night (September 24th and 25th) at 8 p.m. EST. That's when you can see a two-part special about the 22 men who developed male breast cancer - most likely as a result of having lived at and consumed water from the base's supply from 1957 to 1987.

Now I would think that the Marines would protect their own water supply, wouldn't you? But during the time in question, dry cleaning chemicals were dumped into at least two water distribution systems at Camp Lejeune. Many Marines, Sailors, their families and civilian employees have been affected by the contamination. We're talking about drinking water that contained Tetrachloroethylene, Trichloroethylene, Vinyl Chloride, Benzene, Toluene, Ethylbenzene, and Xylene. I wonder how anybody could stand to drink it, but perhaps it was a matter of people becoming accustomed to it over time. Trichloroethylene is used to degrease metal parts - my husband used to use it to clean broken tape recorders and VCRs when he worked in a repair shop. Benzene is used for lots of industrial processes, including petrochemical production. Xylene is a cleaning solvent - I used it to clean photostencils off of silk screens in college art classes. Toluene is used to make benzene and urethane - stuff that is used in paint, rubber, insulation, and golf balls. These things are commonly used in dry cleaning, and they do not belong in anyone's drinking water!

The Marine Corps still hasn't notified everyone who drank that water at Camp Lejeune - but the people who developed many kinds of cancer - including male breast cancer - as well as birth defects and miscarriages need to know, and to have their rights protected. These Marines are the folks that go out into danger to protect and defend this country - they should also be protected and treated well, and given the whole truth about their health risks.

Men have only a small amount of breast tissue, especially compared to women, so a man's lifetime risk of developing breast cancer is quite rare. In fact, only about 1% of all breast cancer cases are diagnosed in men. When men are diagnosed with breast cancer, it's usually later in life, not when they are just 39 - like Mike Partain - and not in clumps of 22, as at Camp Lejeune. We know that cancer gets started as the result of mutated DNA, but we don't always know what breaks a person's DNA, and why it doesn't repair itself. Our modern diet, lifestyle, and environment seems to play a part in contributing to a rise in cancers of all types. But what if all the people that were exposed to the water at Camp Lejeune could be identified, informed, and surveyed - so the full extent of the effects of this health disaster could be properly studied? Would it lead to a new discovery about the development of cancer?

Mike Partain learned of the water contamination almost by accident, after his diagnosis. Turns out the Marine Corps had known about these chemicals in the base water supply since 1980. Mike parents were consuming the contaminated water in 1967, when they were expecting him. He was a small baby, born with a persistent skin rash, and developed other health problems as he grew up. His parents, along with many other base residents, have developed more than the average number of health problems. Camp LeJeune's water supply was contaminated for 30 years. This preventable water problem and the resulting health disaster may have affected an estimated 800,000 to 1 million former Marines and their families. It takes my breath away!

To learn more about this, tune in to CNN on Thursday and Friday night (September 24th and 25th) at 8 p.m. EST to hear Campbell Brown reporting on this story.

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Keep up to date with the latest news in breast reconstruction at The Breast Cancer Reconstruction Blog. Also follow us on Twitter.

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Breast Cancer Reconstruction And Health Care Reform - What Does It Mean For You?

noreply@blogger.com (Dr C) — Mon, 03 Aug 2009 20:01:19 PDT

By Sharon Lacey

What does health care reform mean for patients with breast cancer and how will it affect you?

Well, it could mean...

Even though you or your loved one could benefit from advanced breast reconstructive surgery after mastectomy (like the DIEP flap procedure for example), your plastic surgeon might well have to say “no”.

While this may sound extreme to many of you, this would happen if comparative-effectiveness research rules that the benefits of the surgery for the average patient just don't justify its price tag, especially when compared with yesterday's treatments (like tissue expanders for example).

Unfortunately, medical advances and "cutting-edge" procedures do come at a price. Though this does mean certain procedures are more expensive, it has also ensured the United States has stayed at the leading edge of health care in the world, at least until now.

In an enormous break with tradition, such cost considerations based on averages will be factored into medical practice guidelines. These will function as an invisible hand that puts a brake on the more expensive procedures even though they benefit certain patients.

Standardized practice guidelines will be evident everywhere, even embedded into your doctor's government-certified computer: as described in the Obama budget, computer pop-ups will appear to help your doctor make decisions. (And through the same systems, his or her choices can be monitored for consistency with the guidelines.)

More uniform care will certainly improve weak performing doctors, but many experts worry about intruding on the seasoned judgment of the good physician. It remains to be seen how government micromanaging—if not rationing—of care, driven by reasons other than patient well-being, will go down,… particularly when that patient has a face.

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Keep up to date with the latest news in breast reconstruction at The Breast Cancer Reconstruction Blog. Also follow us on Twitter.

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Breast Reconstruction - Breast Cancer Patients Denied Right To Choose

noreply@blogger.com (Dr C) — Wed, 15 Jul 2009 06:37:56 PDT

Despite the increase of breast reconstruction procedures performed in 2008, nearly 70 percent of women who are eligible for the procedure are not informed of the reconstructive options available to them, according to a recently published report. Newly released statistics by the American Society of Plastic Surgeons (ASPS) shows there were more than 79,000 breast reconstruction procedures performed in 2008 - a 39 percent increase over 2007. But in spite of this, current research suggests that many breast cancer patients are missing out on a key conversation that should take place at the time of diagnosis.

"Women need to understand all of their options to make an informed decision," said ASPS President John Canady, MD. "Those who are diagnosed should be immediately referred to a full team of physicians that can provide breast care, and plastic surgeons need to be included as part of that treatment team."

Taking the position that every woman deserves the right to choose which, if any reconstruction option is best for her, the ASPS is launching an ongoing effort to bring public awareness to breast reconstruction issues, including education, access, and a team approach. Because early involvement by plastic surgeons and other physicians can allow development of an optimum treatment plan for each individual patient, collaboration amongst specialties is essential. As such, ASPS suggests that primary care, general surgery, radiology, pathology, oncology, gynecology, and plastic surgery be available from the onset of treatment to ensure the greatest possible outcome for the patient.."

It is also important that patients actively participate in their treatment. Though a common misconception, eligible patients should not assume that anyone other than a board-certified plastic surgeon affiliated with an accredited facility is qualified to perform breast reconstruction. While technology has made breast cancer diagnosis, treatment, and reconstruction better than ever, it does not negate the need for medical expertise within each specific area of care.

Among the factors contributing to patient awareness and understanding, specific education regarding the options for breast reconstruction is often lacking. Therefore, in the coming months, ASPS will reach out to women through a variety of materials, ranging from information cards and online videos, to an ad campaign featured online and in the waiting-room publication produced by the American College of Obstetricians and Gynecologists.

"We know that there are many issues surrounding breast reconstruction and that addressing them all will take time, but this is a very important first step," said Dr. Canady. "Our goal is to make sure that those women who are not getting breast reconstruction are doing so of their own accord and not because they are uneducated or uninformed about their options."."

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient's own tissue. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction at The Breast Cancer Reconstruction Blog. Please also Follow Dr C on Twitter.

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Mammograms after Mastectomy and Breast Reconstruction - Are They Really Needed?

noreply@blogger.com (Dr C) — Sun, 04 Oct 2009 15:43:21 PDT

"Do I still need to have mammograms after my mastectomy and breast reconstruction?"

I'm asked this question quite often.

The truth is there's a lot of ongoing debate about this.

Some doctors feel that since there is no "natural" breast tissue left, there is no need to continue monitoring patients. I disagree with this strongly.

Breast cancer can come back after mastectomy - there's a 6.7% chance in fact. Breast reconstruction does not increase or decrease the risk of recurrence at all - the recurrence rate is the same whether women have reconstruction or not.

Since the risk of breast cancer recurrence is a real one, surely we need to continue some sort of monitoring?

Self breast exam is a no-brainer. It's relatively easy to perform and it's dirt-cheap (free). The issue of mammograms is less clear-cut.

The appearance of the mammogram changes completely after breast reconstruction. Even if the breast looks very natural and similar to the way it did before the mastectomy on the outside, the inside of the breast is completely different.

Let's take the following example: a woman who undergoes a skin-sparing mastectomy and tissue (flap) reconstruction like a DIEP flap may look like she has natural breasts that have merely been "lifted". In reality her breast tissue has been completely replaced by tummy fat. Fat and breast tissue look completely different on mammograms so the post-reconstruction mammograms cannot be compared to any taken before the mastectomy. You're essentially starting from scratch as far as the mammograms go.

Some surgeons feel that patients should have 1 mammogram after the reconstruction has been completed just to get a new "baseline". If the regular self breast exams reveal anything new of concern then the mammogram can be repeated. At least now the new mammogram can be compared to the baseline mammogram.

Other breast surgeons take it a step further and recommend a baseline MRI once the reconstruction is completed instead of a mammogram. MRIs are much more sensitive (sometimes over sensitive though) and the information they provide is also more specific. Again, if self breast exam reveals a new area of concern in the future the MRI can be repeated to see if anything has changed.

The issues with MRIs are (1) the additional cost compared to a mammogram, and (2) sometimes they see things that really aren't there - for example, something that is benign is interpreted as worrisome. This in turn leads to further investigations and biopsies that may never have really been needed.

Yet one more viewpoint is that any new breast lumps that appear in the future are going to require a biopsy anyway so what is the point of getting a "baseline" MRI or mammogram at all? Tissue (flap) breast reconstructions can occasionally develop something called "fat necrosis". These are areas of fat in the new breast that become hard and create "lumps". While a biopsy may indeed be planned anyway, there is a lot to be said for the physician and patient knowing this "lump" has been there all along (on the MRI) and the chance of this representing a new cancer is extremely low. The additional peace of mind and information a baseline MRI provides in this situation alone warrants the test in some physicians' opinions.

What do I recommend? At least a mammogram 6 months after the breast reconstruction is completed to get a new baseline and regular self breast exams.

Dr C

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Links for 2009-07-05 [del.icio.us]

Mon, 06 Jul 2009 00:00:00 PDT

Breast Reconstruction Surgery, Texas - Austin, Dallas, Houston, San Antonio
Breast Reconstruction in Austin, Dallas, Houston, and San Antonio - PRMA Plastic Surgery specializes in advanced breast reconstruction techniques. Patients welcomed from across Texas (including Austin, New Braunfels, Dallas, Fort Worth, Houston, Arlington, El Paso, Corpus Christi, Laredo, San Angelo, Temple).

Breast Reconstruction in Metastatic Breast Cancer Patients

noreply@blogger.com (Dr C) — Thu, 21 May 2009 21:36:18 PDT

Traditional medical opinion states that women with metastatic breast cancer are not candidates for breast reconstruction. Once metastases are diagnosed (stage 4 breast cancer), attention turns solely to aggressive medical treatment to prolong life. Breast reconstruction is no longer discussed as an option.

At least that was the consensus up until fairly recently.

Opinions have started to change over the last few years.

While we are still losing the battle with stage 4 breast cancer and most women will die from their disease, who are we to decide that these women should not be made "whole"? Why should any women interested in breast reconstruction die breastless?

As long as patients interested in reconstruction are medically stable and passed "fit for surgery", the psycho-social and quality of life benefits that breast reconstruction can provide should not be ignored. While the priority must always remain "life over breast", breast reconstruction should be discussed with patients regardless of the stage of the disease.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient's own tissue. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

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Impact of Radiation on Breast Reconstruction

noreply@blogger.com (Dr C) — Wed, 08 Apr 2009 19:52:13 PDT

Radiation therapy is often recommended as part of breast cancer treatment. Patients undergoing lumpectomy receive radiation routinely once they've healed from surgery. Some mastectomy patients also need radiation after surgery depending on the characteristics of the tumor.

I think it is fair to say that most reconstructive breast surgeons, myself included, are not particularly fond of radiation because of the way it impacts the patient's tissues (and breast reconstruction in general.) Nonetheless, it is important to remember that "life comes before breast" and in certain situations there is a definite benefit for the patient in having radiation therapy.

So what's the problem with radiation therapy (from a plastic surgeon's perspective)? For starters it can cause toughening (fibrosis) and shrinking (contracture) of the patient's tissue which makes the tissue lose its elasticity and become more tough and rigid. Skin color changes are common, red at first turning more brown over time. Radiation can also cause burn injuries as well as damage to underlying organs such as the lungs and heart. Anyone who is facing radiation therapy must discuss all the potential risks with their their radiation oncologist beforehand.

Women undergoing lumpectomy are often told that most of their breast will be preserved and that radiation is given "as insurance" to decrease the risk of cancer recurrence. What many women don't appreciate is that the breast can end up looking vastly different once the treatment is done because of radiation changes, even though they underwent "breast conservation". Many women end up going to see a plastic surgeon anyway to fix this unforeseen problem, which ironically can include the same reconstructive procedures as for mastectomy.

Radiation after a tissue reconstruction (eg tram flap, diep flap) can cause the reconstructed breast to shrink and harden. Unfortunately, this is a fairly common scenario. Less frequently (with heavy radiation doses), new wounds can develop in the reconstructed breast which need wound care. Patients facing radiation after flap breast reconstruction should know that there is a risk of needing further reconstructive surgery to correct changes caused by the radiation therapy. One study found a re-operation rate of almost 30% in patients receiving radiation after TRAM flap reconstruction.

Tissue expander / implant reconstructions fair even worse with radiation. The complication rates in this setting are much higher than with tissue reconstructions, including complete failure of the reconstruction altogether (and removal of the implant). Some surgeons routinely offer implant reconstructions to patients that are either facing or have already had radiation therapy. There are even articles published in the plastic surgery literature supporting it. I have to respectfully disagree (strongly). In my experience mixing implants with radiation typically ends badly. I will only do this in the very rare instance that there is absolutely no other option.

So what's the take-home message?
1) "Breast conservation" can fall short of the patient's cosmetic expectations.
2) breast implants and radiation do not mix well.
3) If you're facing radiation after mastectomy think twice about insisting on immediate reconstruction. You may be lucky and things may work out just fine. However, there's also a good chance you'll be signing up for more surgery than you bargained for.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient's own tissue. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

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Texas Plastic Surgeons Offer Innovative New TUG Flap Procedure to Recreate Natural Breasts After Mastectomy

noreply@blogger.com (Dr C) — Tue, 03 Mar 2009 20:34:16 PST

San Antonio, TX (PRWEB) February 23, 2009 -- Plastic, Reconstructive & Microsurgical Associates (PRMA) of South Texas, a leading breast reconstruction surgery practice in San Antonio, is now offering women the Transverse Upper Gracilis (TUG) flap procedure to restore their breasts after mastectomy. PRMA plastic surgeons specialize in breast reconstruction after breast cancer, with particular expertise in advanced microsurgical techniques using the patient's own living tissue.

"Increasingly, women facing mastectomy prefer new breasts sculpted from their own skin and fat, thereby avoiding the problems that often occur with implants," says Dr Chrysopoulo. Breasts shaped from living tissue have a natural look and feel that can't be achieved using implants or temporary prostheses. "While most patients prefer the Deep Inferior Epigastric Perforator (DIEP) flap technique which uses a woman's lower abdominal tissue, it is a technique that may not be an option for those who have had previous tummy tucks, who don't have adequate abdominal fat, or who prefer not to scar their abdomens. TUG flap surgery is a viable option for these women; a way to restore their natural breasts with excellent results."

Both the TUG and DIEP flap procedures are complex, technically demanding microsurgical procedures requiring special skill and experience. During the TUG procedure, surgeons transplant a flap of skin, tissue and muscle from a woman's upper thigh to her chest. The process has distinct advantages compared to other types of natural tissue breast reconstruction: thigh tissue has superior contour, shape and projection; loss of the muscle does not inhibit an individual's mobility or function; scarring is not easily visible, and the procedure produces a cosmetic thigh lift as well as a new breast.

"TUG flap surgery allows a woman to come out of the operating room the same way she went in," says Chrysopoulo. "With nice-sized natural breasts in place." The TUG flap is an excellent post-mastectomy option for women who have mastectomy to either treat or prevent breast cancer.

Candidates for the TUG are women who:
• have small to medium-sized breasts.
• want to avoid an abdominal scar.
• lack sufficient abdominal tissue for DIEP breast reconstruction.
• have had a previous tummy tuck or other abdominal surgery.

PRMA board-certified surgeons routinely offer both reconstructive and cosmetic breast procedures, and perform more than 400 microsurgical breast reconstructions annually for patients from Texas and across the U.S. PRMA surgeons are in-network for most U.S. insurance plans. Visit www.prma-Enhance.com or contact 800-692-5565 to schedule a consultation or for more information about the TUG flap or any other reconstructive breast procedure.

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Breast Reconstruction After Mastectomy - Dr Chrysopoulo Radio Interview

noreply@blogger.com (Dr C) — Tue, 10 Feb 2009 18:30:04 PST

It was an absolute pleasure to talk to DeLeon and Travis on "DeLeon Dialogue" last night.

Breast cancer survivor DeLeon and cervical cancer survivor Travis talk frankly with their guests about quality of life as cancer survivors in remission. They discuss side effects, spirituality, mastectomy, sexuality, health and wellness, self-esteem, food, exercise, relationships, and everything else in between.

Last night the one-hour show was about "breast reconstruction after mastectomy". We managed to cover a lot of ground - we talked about the various cutting edge breast reconstruction options currently available, breast implants, the impact of radiation therapy on reconstruction, recovery from surgery, and insurance coverage for reconstruction. Please click on the link below to listen to the show:

Breast Reconstruction after Mastectomy - Dr Chrysopoulo on DeLeon Dialogue

I hope you enjoy the show as much as I did!

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient's own tissue (including DIEP flap and TUG flap procedures). PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

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Links for 2009-02-03 [del.icio.us]

Wed, 04 Feb 2009 00:00:00 PST

Breast Reconstruction Blog
Breast Reconstruction Blog on Wellsphere.com

When is Prophylactic Mastectomy The Right Choice?

noreply@blogger.com (Dr C) — Mon, 02 Feb 2009 20:18:02 PST

Having breast cancer in one breast increases a woman's chances of getting breast cancer in the second breast at some point in her lifetime. A study in the March issue of Cancer addresses a question which women facing mastectomy for breast cancer have been asking doctors for years.... should I have my other ("good") breast removed as well to decrease my risk of future breast cancer in the other breast? Here's the study abstract....

"Predictors of contralateral breast cancer in patients with unilateral breast cancer undergoing contralateral prophylactic mastectomy."
Min Yi, Funda Meric-Bernstam, Lavinia P. Middleton, et al. CANCER Print Issue Date: March 1, 2009

BACKGROUND:
Although contralateral prophylactic mastectomy (CPM) reduced the risk of contralateral breast cancer in unilateral breast cancer patients, it was difficult to predict which patients were most likely to benefit from the procedure. The objective of this study was to identify the clinicopathologic factors that predict contralateral breast cancer and thereby inform decisions regarding performing CPM in unilateral breast cancer patients.

METHODS:
A total of 542 unilateral breast cancer patients who underwent CPM at The University of Texas M. D. Anderson Cancer Center from January 2000 to April 2007 were included in the current study. A logistic regression analysis was used to identify clinicopathologic factors that predict contralateral breast cancer.

RESULTS:
Of the 542 patients included in this study, 25 (5%) had an occult malignancy in the contralateral breast. Eighty-two patients (15%) had moderate-risk to high-risk histologic findings identified at final pathologic evaluation of the contralateral breast. Multivariate analysis revealed that 3 independent factors predicted malignancy in the contralateral breast: an ipsilateral invasive lobular histology, an ipsilateral multicentric tumor, and a 5-year Gail risk 1.67%. Multivariate analysis also revealed that an age 50 years at the time of the initial cancer diagnosis and an additional ipsilateral moderate-risk to high-risk pathology were independent predictors of moderate-risk to high-risk histologic findings in the contralateral breast.

CONCLUSIONS:
The findings indicated that CPM may be a rational choice for breast cancer patients who have a 5-year Gail risk 1.67%, an additional ipsilateral moderate-risk to high-risk pathology, an ipsilateral multicentric tumor, or an ipsilateral tumor of invasive lobular histology.

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So what does all this mean?

This study basically concludes that prophylactic (ie preventive) mastectomy should be recommended to breast cancer patients in the following situations:

1) the breast cancer is particularly aggressive or invasive

2) the biopsy pathology report shows high risk histology (such as "invasive lobular" disease)

3) there are multiple tumors in the same breast

4) a 5-year Gail risk of at least 1.67 - The "Gail risk" assesses a woman's risk of developing breast cancer by looking at a number of health factors including her medical history, race, age and more.

5) age 50 or older at the time of the first breast cancer diagnosis

This study is helpful. I'd like to expand a little on the effect age has on risk of future disease. Many doctors (including myself) recommend prophylactic mastectomy to young women, particularly if they have a family history of breast cancer, as these women have the highest overall risk of getting another cancer in their lifetime. Previous studies have shown that breast cancer patients have close to a 1% risk of another cancer per year. This risk is cumulative, in other words, it adds up: 1 % risk after 1 year, 10% risk after 10 years, 30% after 30 years, and so on. This cumulative risk is important to remember.

While I applaud this study and think it's results are very useful, I also think it is imperative that doctors remember the primary indication for prophylactic mastectomy: the patient's wishes. Breast cancer is such a devastating disease both physically and emotionally. We can educate our patients all we want about study results but we must not forget the erosive nature of anxiety over the possibility of a second breast cancer in the future. If one of my patients wants a prophylactic mastectomy even after discussing the studies, that's good enough for me.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in "natural" breast reconstruction surgery after mastectomy using the patient's own tissue (including DIEP flap reconstruction). PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

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Links for 2009-01-16 [del.icio.us]

Sat, 17 Jan 2009 00:00:00 PST

Breast Reconstruction Surgery - Part I - Tissue Expanders, Breast Implants and Alloderm
This the first of a 3-part series on breast reconstruction surgery discussing the reconstructive options available to women facing mastectomy for breast cancer.
Breast Reconstruction Surgery - Part II - Muscle Flap Reconstruction
This the second of a 3-part series on breast reconstruction surgery discussing the reconstructive options available to women facing mastectomy for breast cancer.
Breast Reconstruction Surgery - Part III - Perforator Flap Reconstruction
This the third of a 3-part series on breast reconstruction surgery discussing the reconstructive options available to women facing mastectomy for breast cancer.

Breast Reconstruction Surgery - Part I - Tissue Expanders, Breast Implants and Alloderm

noreply@blogger.com (Dr C) — Sun, 04 Jan 2009 20:27:26 PST

This posting is the first of a 3-part series on breast reconstructive surgery discussing the reconstructive options available to women facing mastectomy for breast cancer.

Every woman has a right to breast reconstruction. This has now actually become a federal mandate and insurance companies are required to pay for all types of breast reconstruction by law. Having said that it is also important to remember that it’s not up to the health insuranc carrier to decide which reconstruction a patient receives. That’s determined by the patient and her surgeons.

Breast reconstruction is not a form of cosmetic surgery – it restores something that nature has provided but cancer has taken away. There is also no age limit – as long as there are no medical conditions that render the surgery unsafe and the breast cancer is diagnosed at an early enough stage, most women are candidates.

Breast reconstruction can be performed as an “immediate” or “delayed” procedure. As the term implies, immediate reconstruction is performed immediately after the mastectomy while the patient is still under anesthesia. Once the general surgeon has completed the mastectomy the plastic surgeon begins creating the new breast. Advantages of this approach include the option of preserving most of the breast skin (“skin-sparing mastectomy”) and a shorter scar. The patient also wakes up “complete” and avoids the experience of a flat chest. Immediate reconstruction generally provides far superior cosmetic results.

Delayed reconstruction generally takes place several months following mastectomy. Patients required to undergo radiation after mastectomy may be advised to delay reconstruction in order to achieve the best results. This delay may last several months in order to allow the tissues to recover as much as possible from the radiotherapy.

There are several reconstructive options for women to choose from, ranging from breast implants to “autologous” techniques using the patient's own tissue to recreate a more “natural”, warm, soft breast. The nipple and areola can also be recreated.

Tissue Expanders and Breast Implant Reconstruction

This is the most common method of reconstructive breast surgery currently being used in the United States. Most surgeons perform this is a two-stage procedure. The tissue expander is essentially a temporary breast implant which can be placed either at the same time as the mastectomy or after the mastectomy has healed. The expander is used to stretch the skin envelope and recreate the size of breast the patient wants. The expander is ultimately replaced by a permanent implant (saline or silicone) at a separate procedure several months later.

Some patients undergoing immediate breast reconstruction are candidates for one-step breast implant reconstruction whereby a permanent implant is inserted at the time of the mastectomy and the patient avoids going through the whole expansion process. In the one-step implant reconstruction the implant is completely covered by the pectoralis muscle and Alloderm (a cadaveric acellular dermal graft). This is specially treated skin from a cadaver that is used to provide a sling and coverage of the lower part of the implant.

Two types of implants are available to patients: saline and silicone. There are many opinions regarding both types of implants and it is advised that you speak with your surgeon as to which implant would be best for you. Patients who undergo implant reconstruction should be aware that their breast implants may need to be replaced at a future date.

Implant reconstruction can be the best option for some patients. However, tissue expanders and implants can be fraught with complications long-term, particularly if the patient has had or is going to have radiation therapy as part of her cancer treatments. For these reasons, many surgeons and patients prefer autologous reconstruction, i.e. reconstruction using the patient's own tissue taken from another part of the body. These will be discussed in upcoming posts.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in reconstructive breast surgery after mastectomy. Techniques offered include Alloderm one-step reconstruction and DIEP flap reconstruction. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

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Breast Reconstruction Surgery - Part II - Muscle Flap Reconstruction

noreply@blogger.com (Dr C) — Sat, 10 Jan 2009 09:43:38 PST

Women interested in breast reconstruction after mastectomy have several reconstruction options to choose from. In Part I of this series we discussed tissue expanders, breast implants and Alloderm.

Though implant reconstruction remains the most common method of breast reconstruction in the US, many women are now steering away from this option, opting instead to use their own tissue for more “natural” results. Muscle flaps have, until fairly recently, been the only choice available for these tissue reconstructions. The most commonly offered muscle flaps are the latissimus and TRAM flap procedures.

Latissimus Dorsi Flap:

The latissimus procedure uses muscle from the back of the shoulder blade which is brought around to the breast mound to help create a new breast. During the procedure a section of skin, fat and muscle is detached from the back and brought to the breast area.

Many patients also need a tissue expander placed under the muscle flap in order to obtain a satisfactory result. The expander is replaced by a permanent implant at a second procedure down the line.

Patients will have a scar on their back shoulder region that can sometimes be seen through a tank top, swimsuit or sundress. The upper back can be numb or sore for a few following this procedure until the nerves grow back and the incisions are completely healed.

Women who are very active in sports should know that this procedure can reduce ability to participate in activities like golf, climbing, swimming, or tennis.

TRAM (Transverse Rectus Abdominis Myocutaneous) Flap:

The TRAM flap was the first procedure to describe use of one of the rectus abdominis muscles (sit-up muscles) for breast reconstruction. This procedure begins with an incision from hip to hip rather like a “tummy-tuck”.

A "flap" of skin, fat and one of the patient's abdominal muscles is typically tunneled under the skin to the chest to create a new breast. This is known as a pedicled TRAM flap. Recovery from the TRAM flap procedure can be difficult and painful and there is a risk of abdominal bulging (or “pooching”) and even hernia. Long-term, the patient has to adapt to the loss of some abdominal strength (up to 20%) which most active patients will notice.

In cases where both breasts are being reconstructed, both abdominal muscles are sacrificed and transferred to the chest (one for each breast). The loss of abdominal strength in these situations is far greater and very significant.

Over the years and with the introduction of microsurgery, the procedure has evolved several times with each modification preserving more and more abdominal muscle. This has made postoperative recovery a little easier and has decreased the potential for abdominal complications somewhat.

The latest evolution in breast reconstruction is “perforator flap surgery”. These techniques use skin and fat from various parts of the body. Since no muscle is sacrificed recovery is much easier and muscle strength and function are preserved long-term. These techniques will be discussed in Part III of this breast reconstruction series.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction after mastectomy including the DIEP flap and Alloderm one-step procedures. In-network for most US insurance plans. Toll Free (800) 692-5565. Latest news in breast reconstruction surgery and research available at The Breast Cancer Reconstruction Blog.

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Breast Reconstruction Surgery - Part III - Perforator Flap Reconstruction

noreply@blogger.com (Dr C) — Fri, 16 Jan 2009 08:52:05 PST

The ideal breast reconstruction technique is one which allows reconstruction of a “natural”, warm, soft breast with the least impact on the patient’s body. While breast reconstruction with stem cells may not be too far off, until it becomes a reality we are limited to using the patient’s own tissue to achieve these goals. As discussed in the previous posts in this breast reconstruction series, until fairly recently the only “tissue reconstruction” options involved sacrificing muscle. This made recovery from the surgery difficult and painful, not to mention the risk of long-term muscle function loss and weakness.

Perforator flap techniques use skin and fat from various parts of the body. All muscles are preserved. Since no muscle is sacrificed recovery is much easier and muscle strength and function are preserved long-term. The downside to these procedures is that they are technically much more demanding than other breast reconstruction techniques and require microsurgical expertise. For this reason they are not offered by many plastic surgeons and patients must be prepared to travel when choosing these procedures.

DIEP (Deep Inferior Epigastric Perforator) Flap

The DIEP flap is the latest evolution of the TRAM flap (discussed in Part II) and represents today's gold standard in breast reconstruction. The DIEP flap procedure is similar to the TRAM flap but only requires the removal of skin and fat. NO MUSCLE is sacrificed. The blood vessels required to keep the tissue alive lay just beneath the abdominal muscle. Therefore, a small incision is made in the abdominal muscle in order to dissect the vessels and microsurgery is required to reattach the blood vessels to the chest area.

Even though an incision is made in the abdominal muscle NO abdominal muscle is removed or transferred to the breast in the DIEP flap procedure. As a result, patients do not have to sacrifice their abdominal strength and they experience less pain and a much quicker recovery. The risk of abdominal bulging and hernia is also very small.

The DIEP flap was first described in the early 1990's but has remained much less popular than the TRAM flap among plastic surgeons, presumably because of the increased complexity and difficulty of the procedure compared to the TRAM.

So the advantages of the DIEP flap are multiple: it uses living tissue to recreate a breast that often looks and feels like a normal breast; abdominal strength is not affected; the risk of bulging or hernias is significantly reduced; and, like the TRAM flap, the patient benefits from a simultaneous “tummy-tuck”.

The DIEP flap is a very technically demanding operation but the benefits are tremendous for the patient, especially when performed at the same time as a skin-sparing mastectomy.

SIEA (Superficial Inferior Epigastric Artery) Flap

The SIEA flap procedure is very similar to the DIEP flap procedure. The main difference between the SIEA and DIEP is the artery used for blood flow supply to the reconstructed breast. The SIEA arteries are generally found in the fatty tissue just below skin.

As in the DIEP the SIEA flap reconstruction does not sacrifice the abdominal muscle and only uses the patient's skin and fat to reconstruct the breast. While the SIEA flap procedure is similar to the DIEP it is used less frequently since less than 20% of patients have the anatomy required to allow this procedure.

GAP (Gluteal Artery Perforator) Flap

Women who do not have an adequate amount of abdominal tissue for reconstruction may be eligible for the GAP flap. This procedure uses excess skin and fat from the gluteal or buttock region. Fat and skin from either the upper or lower buttock region can be used and microsurgically transplanted to the chest.

Once again, no muscle is sacrificed. Incisions can generally be hidden by most underwear. If a patient requires a bilateral reconstruction with GAP flaps most surgeons prefer to only perform one side at a time. It is important to discuss this possibility with your surgeon.

Advantages of the GAP flap include: a scar that is generally hidden with underwear or swimsuits, and no loss of muscle function or strength.

Other Breast Reconstruction Options:

TUG (Transverse Upper Gracilis) Flap

Like the GAP flap, the TUG flap is an option in cases where there is not enough lower abdominal tissue to reconstruct the breast(s). The TUG procedure uses the upper part of the inner thigh; skin, fat and a small amount of muscle are disconnected and transferred to the chest to create the new breast. The patient benefits from a simultaneous inner thigh lift. Once again, this procedure is not widely available due to its complexity and need for microsurgical expertise.

It is important to realize that whichever method of reconstruction is used, the vast majority of women will require 2 or even 3 procedures for the optimal cosmetic result. Each procedure is typically separated by several weeks. The entire reconstructive process, regardless of the method of reconstruction, can therefore take several months to complete. However, breast reconstruction does NOT typically complicate or delay cancer treatment such as chemotherapy.

With all this in mind and also remembering the superior cosmetic results associated with immediate breast reconstruction (reconstruction performed at the same time as mastectomy), it is recommended that women discuss their reconstructive options with a plastic surgeon specializing in breast reconstruction before undergoing mastectomy whenever possible.

For more information about breast reconstruction options please visit www.prma-Enhance.com. For the latest news and developments in breast reconstruction please also visit The Breast Cancer Reconstruction Blog.

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Dr Chrysopoulo, board certified plastic surgeon, PRMA Plastic Surgery, San Antonio, TX. Specializing in breast reconstruction surgery after mastectomy for breast cancer. Over 350 DIEP flaps performed yearly. In-network for most US insurance plans. Toll Free (800) 692-5565. www.prma-Enhance.com. Latest breast reconstruction news available at The Breast Cancer Reconstruction Blog.

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Breast Reconstruction With Tissue Much Safer Than Implants When Radiation Planned After Mastectomy

noreply@blogger.com (Dr C) — Mon, 29 Dec 2008 15:14:25 PST

A study published in the November issue of the International Journal of Radiation Oncology*Biology*Physics examined the effect of radiation therapy on different methods of immediate breast reconstruction surgery. For breast cancer patients who receive radiation therapy after a mastectomy and immediate breast reconstruction, autologous tissue reconstruction (ie reconstruction using their own tissue) provides fewer long-term complications and superior cosmetic results than breast reconstruction with a tissue expander and subsequent breast implant.

Many women choose to undergo breast reconstruction surgery at the same time as their mastectomy procedure (under the same anesthetic). This avoids many of the psycho-social issues women face when dealing with a flat chest after mastectomy alone. However, frequently radiation can negatively affect the outcome of reconstruction and increase the risk of long-term complications.

Radiation therapy is increasingly becoming the standard of care for high-risk breast cancer patients after mastectomy in an attempt to decrease local cancer recurrence. However, this can cause a problem for both patients and their radiation oncologists.

Researchers at the Department of Radiation Oncology at Long Island Radiation Therapy in Garden City, N.Y., the Department of Surgery at Long Island Jewish Hospital in New Hyde Park, N.Y., the Department of Surgery at North Shore University Hospital in Manhasset, N.Y., and the Department of Surgery at Winthrop University Hospital in Mineola, N.Y., looked at whether the type of reconstruction performed in women receiving radiation after a mastectomy had an impact on their long-term outcomes.

Two general types of breast reconstruction are available for patients facing mastectomy for breast cancer: autologous tissue reconstruction utilizing the patient's own tissue (eg DIEP flap, GAP flap, TRAM flap, or latissimus flap) transferred to the chest to recreate the breast(s); and tissue expander/implant reconstruction which involves placement of an inflatable tissue expander (temporary saline implant) and exchange for a permanent implant (saline or silicone) at a separate procedure later on.

This study involved the largest reported series of patients who sequentially underwent mastectomy, immediate reconstruction and postmastectomy radiation therapy. Ninety-two patients were observed for a period of 38 months following breast reconstruction and radiation therapy.

Researchers found that autologous breast reconstruction is better tolerated by breast cancer patients because it is associated with fewer long-term complications and better cosmetic results than tissue expander/implant reconstruction.

None of the 23 patients reconstructed with their own tissue required further surgery while 33% of tissue expander/implant patients needed surgery to correct a problem with their reconstruction. Eighty-three percent of autologous reconstruction patients reported acceptable cosmetic results, as opposed to only 54% of implant patients.

"This study is useful for patients who are candidates for either [method of reconstruction] and are making a decision with regards to reconstruction technique," Jigna Jhaveri, M.D., lead author of the study and a radiation oncologist at Advanced Radiation Centers of New York in Hauppauge, N.Y., said. "Our study provides evidence that patients who undergo autologous tissue reconstruction and radiation therapy have fewer long term complications and better cosmetic outcomes than those who undergo tissue expander/implant reconstruction and radiation therapy."

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Here's my take....

While some plastic surgeons will disagree with this statement I strongly believe that breast implants and radiation therapy do not get along (at all). I feel the complication rate in implant-reconstructed women receiving radiation therapy is very high, particularly long-term. The handful of women that "do fine" in the short-term will very frequently end up with hard, uncomfortable breasts as the irradiated tissue firms-up over time and squeezes down on the implant. In my opinion the re-operation rate is too high for tissue expander/implant reconstruction to be offered as a routine option when radiation is on the table. This study confirms that breast reconstruction using the patient's own tissue is far safer than tissue expander/implant reconstruction in women facing radiation therapy after mastectomy.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy, particularly advanced perforator flap techniques such as the DIEP flap procedure. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following The Breast Cancer Reconstruction Blog.

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Breast Cancer Recurrence Not Related To Method Of Breast Reconstruction

noreply@blogger.com (Dr C) — Mon, 22 Dec 2008 08:12:25 PST

One of my breast cancer patients called me today. She recently underwent bilateral mastectomies and immediate breast reconstruction with DIEP flaps. She recovered very well from the surgery but unfortunately her pathology results showed that she had cancer extending almost to the edge of the mastectomy specimen. The exact medical jargon used by the pathologist was.... "invasive carcinoma extending to 1mm from the margin". She also had DCIS (ductal carcinoma in situ) "extending to 0.2mm from the margin."

From a purist's perspective, these results still represent "clear margins". In other words, no tumor was found at the edge of the mastectomy specimen so there is no reason to believe there is any cancer left in my patient's breast. BUT, it's very close and that is certainly worrisome.

She called me today because she visited with her oncologist (cancer doc) and a radiation oncologist (cancer doc specializing in radiotherapy) and radiation therapy was recommended (in addition to the planned chemotherapy).

She explained to the radiation oncologist that she was worried the radiation therapy would ruin her DIEP flap reconstruction. She is right to be fearful of this - patients undergoing radiation therapy after an autologous reconstruction (ie a reconstruction using their own tissue) have a 28% risk of needing further surgery to correct asymmetry caused by the radiation changes (usually firming and shrinking) of the irradiated breast.

The response she received from the radiation oncologist baffled me (and is actually the reason behind this blogpost)...... "DIEP flap? What's a DIEP flap?.... if you'd had a TRAM flap then you wouldn't be needing radiation".

What?

This is a ridiculous statement. Let me clarify why...

This lady is being recommended radiation therapy as an insurance policy to decrease the risk of local recurrence (cancer coming back in the same breast). This is a consequence of her "near margins" which in turn are a result of the mastectomy specimen. Obviously the mastectomy was completed before the reconstruction was even started. If this lady had only had the mastectomy (without reconstruction) the margins would be the same. The breast reconstruction, and moreover, the type of breast reconstruction has absolutely nothing to do with it. The margins, the pathologist reading and the recommendation for radiation therapy would have been exactly the same whether reconstruction was performed or not.

So what's the take home message if you're considering breast reconstruction surgery? Choose whichever method of reconstruction is best for you. Your decision will not influence the likelihood of your cancer coming back in any way. The risk of cancer recurrence is related to the characteristics of the cancer itself and the mastectomy margins, not the method of reconstruction.

Dr C

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Dr Chrysopoulo is a board certified breast reconstruction surgeon specializing in DIEP flap breast reconstruction surgery. He and his partners perform over 350 DIEP flap procedures each year with a success rate of over 99%. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Cancer Reconstruction Blog.

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Avoiding Denervation of Abdominal Muscles during DIEP Flap Breast Reconstruction Surgery

noreply@blogger.com (Dr C) — Mon, 22 Dec 2008 08:13:42 PST

The following interesting article was published in the "Plastic and Reconstructive Surgery" journal this month.....

Avoiding Denervation of Rectus Abdominis in DIEP Flap Harvest II: An Intraoperative Assessment of the Nerves to Rectus
by Rozen W, Ashton M, Kiil B, et al.
Plastic and Reconstructive Surgery:Volume 122(5) November 2008 pp 1321-1325.

Background: The deep inferior epigastric artery perforator (DIEP) flap aims to reduce donor-site morbidity by minimizing rectus muscle damage; however, damage to motor nerves during perforator dissection may denervate rectus muscle. Although cadaveric research has demonstrated that individual nerves do not arise from single spinal cord segments and are not distributed segmentally, the functional distribution of individual nerves remains unknown. Using intraoperative nerve stimulation, the current study describes the motor distribution of individual nerves supplying the rectus abdominis, providing a guide to nerve dissection during DIEP flap harvest.

Methods: Twenty rectus abdominis muscles in 17 patients undergoing reconstructive surgery involving rectus abdominis (DIEP, transverse rectus abdominis musculocutaneous, or vertical rectus abdominis musculocutaneous flaps) underwent intraoperative stimulation of nerves innervating the infraumbilical segment of the rectus. Nerve course and extent of rectus muscle contraction were recorded.

Results: In each case, three to seven nerves entered the infraumbilical segment of the rectus abdominis. Small nerves (type 1) innervated small longitudinal strips of rectus muscle, rather than transverse strips as previously described. There was significant overlap between adjacent type 1 nerves. In 18 of 20 cases, a single large nerve (type 2) at the level of the arcuate line supplied the entire width and length of rectus muscle.

Conclusions: Nerves innervating the rectus abdominis are at risk during DIEP flap harvest. Small, type 1 nerves have overlapping innervation from adjacent nerves and may be sacrificed without functional detriment. However, large type 2 nerves at the level of the arcuate line innervate the entire width of rectus muscle without adjacent overlap and may contribute to donor-site morbidity if sacrificed.

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Here's my take....

The long and the short of it is that for DIEP flap surgery to be considered successful several things need to happen (in my opinion):

1) the tissue (flap) transferred to the chest to create the new breast must survive. ie the new breast must live. Obvious.
2) the patient must not suffer any ill-effects from removal of the tissue ("flap") from the abdomen. This is what we call in the trade "donor-site morbidity". Abdominal bulging, hernia and significant muscle strength loss fall in this category.
3) the patient must be happy.

Number 1 is obvious.

This article addresses number 2. Ideally, other than the scar, the patient's abdomen must recover completely from the surgery and suffer no long-term problems for the surgery to be deemed a full success.

It does not matter how much muscle is left behind if the nerves supplying it have all been cut. A muscle without a healthy nerve supply will lose it's tone, strength and function. If the DIEP surgeon does not take great care to identify and preserve the majority of the nerves supplying the abdominal muscle then the benefits of the DIEP are potentially lost.

I feel it is important for me to make an additional point..... I'm going to take it for granted that you have chosen an experienced DIEP flap surgeon. I have heard of some patients (indeed some of mine too) entering the consultation with their DIEP flap surgeon having already decided they will be getting a DIEP flap and nothing else. This is a dangerous game to play and I'm going to explain why.

I'd like to think that most breast reconstruction surgeons would spend the required time with their patient discussing the differences between saving ALL the abdominal muscle (a DIEP flap) and having to sacrifice a very small amount (a muscle-sparing type 2 free TRAM).

The truth is this.... in some (very few) instances, patient's do not have the appropriate anatomy to allow for a DIEP flap. Though this happens rarely in our practice, it does still happen on occasion. Trying to "force" a DIEP flap out of a patient who does not have favorable anatomy requires more muscle dissection and will significantly increase the risk of nerve damage to the abdominal muscle. The potential resulting loss of tone, strength and function will place the patient in a much worse position than if she'd had a muscle-sparing type 2 free TRAM flap to begin with (postage-stamp sized piece of muscle sacrificed).

Please do not be adamant going in to the consult about which procedure you're to receive. As long as you have chosen an experienced microsurgeon specializing in these procedures chances are that you will indeed get a DIEP flap. BUT, your anatomy is the deciding factor. Your surgeon didn't give that to you, he just has to work with it.

Dr C

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Dr Chrysopoulo is a board certified breast reconstruction surgeon specializing in DIEP flap breast reconstruction surgery. He and his partners perform over 350 DIEP flap procedures each year with a success rate of over 99%. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Cancer Reconstruction Blog.

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Links for 2008-12-13 [del.icio.us]

Sun, 14 Dec 2008 00:00:00 PST

New Technology Improving Breast Reconstruction Surgery
PRMA Plastic Surgery in San Antonio, Texas is one of only two breast reconstruction facilities in the country routinely offering new "SPY" technology to improve breast reconstruction surgery.

Share your Stories of Hope, Celebration and Remembrance.

noreply@blogger.com (Dr C) — Sat, 06 Dec 2008 08:21:42 PST

From Susan G Komen, San Antonio Affiliate.

November is a time of thanksgiving.

We are very thankful for our many Komen friends and would like to share your stories of hope, celebration and remembrance. Beginning in January and leading up to Race, Komen will feature stores of breast cancer Survivors and Co-Survivors (family, friends, health care providers and colleagues who lend support). If you'd like to share your story, please email info@sakomen.net the following:

Name and age

Survivors: Brief background and how long you've been a survivor

Co-Survivors: Relationship to survivor with brief background

What advice would you give someone who is or knows someone going through the battle with breast cancer?

What inspired you?

Were there positive outcomes dealing with breast cancer?

Thanks.

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Keep up to date with the latest breast reconstruction news by following The Breast Cancer Reconstruction Blog.

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Links for 2008-11-15 [del.icio.us]

Sun, 16 Nov 2008 00:00:00 PST

DIEP Flap Breast Reconstruction
DIEP flap breast reconstruction surgery after mastectomy for breast cancer - the gold standard in breast reconstruction. Website devoted to the DIEP flap procedure.

Plastic Surgeon using New Technology in Breast Reconstruction Surgery

noreply@blogger.com (Dr C) — Sat, 18 Oct 2008 10:02:58 PDT

Wendy Rigby- KENS 5 Eyewitness News

San Antonio's Methodist Hospital is one of only two facilities in the country offering a new technology to help in breast reconstruction surgery — a system that gives doctors a more precise way to see what they are operating on.

Plastic surgeon, Dr. Minas Chrysopoulo is a man on a mission. He wants more breast cancer patients to know that when they face a mastectomy, they can have their breast reconstructed at the same time. Dr. Chrysopoulo performs the new procedure at the Methodist Hospital.

It's a specialized form of breast reconstruction surgery called the "DIEP flap", where doctors take skin and fat from the patient's abdomen, and use it to form a natural-looking breast by using Novadaq's new imaging system called "SPY…" the doctor is able to preserve stomach muscles, while transferring skin and fat. The key is a special dye — a fluorescent agent injected into the body during the four hour operation.

"It's a bit like an angiogram but without exposing the patient to radiation," said Dr. Chrysopoulo. "The dye travels through the bloodstream and basically lights up the blood vessels. It provides a bit of a road map for us, and it helps us identify these vessels a little bit quicker. It helps us formulate the best surgical plan so that we can preserve the patient's abdominal muscle."

Dr. Chrysopoulo and his partners have used the SPY system on about 150 patients since February with great success. After time, the resulting breast is natural looking, and for the patient, a natural feeling.

While the abdomen is scarred like after a tummy tuck procedure, the abdominal muscles and core strength can be preserved. This tedious microsurgery is on the cutting edge of breast reconstruction. Doctors say waking up from cancer surgery with a new breast can make a big difference on a woman's outlook.

"Psycho-socially, it's a huge deal to wake up without a flat chest," Dr. Chrysopoulo said.

Only about 40 plastic surgeons in the country are using this particular procedure routinely. Patients come to San Antonio from all over the United States and even from some foreign countries to have the operation that promises less pain, a shorter hospital stay and a faster recovery.

Dr Chrysopoulo and his partners are breast reconstruction specialists and perform hundreds of DIEP flaps every year. Learn more about DIEP flap breast reconstruction surgery here.

Watch the KENS 5 feature video clip here.

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Comparison of Abdominal Donor-Site Morbidity of SIEA, DIEP, and Muscle-Sparing Free TRAM Flaps for Breast Reconstruction.

noreply@blogger.com (Dr C) — Tue, 23 Sep 2008 18:29:23 PDT

A study published in September's edition of Plastic and Reconstructive Surgery examined the abdominal recovery rates and patient satisfaction after breast reconstruction with different abdominal flaps: the DIEP, SIEA and muscle-sparing free TRAM. The SIEA (superficial inferior epigastric artery) flap is the least invasive method of lower abdominal flap breast reconstruction; however, there are no published reports comparing the donor-site morbidity of SIEA flaps to that of TRAM (transverse rectus abdominis myocutaneous) flaps or DIEP (deep inferior epigastric artery perforator) flaps. A description of how these abdominal flap breast reconstruction procedures differ is available here.

The authors of the study used a 12-question patient survey and retrospective chart review to compare donor-site (abdominal) function, pain, and aesthetics in 179 patients who had unilateral or bilateral breast reconstruction with 47 SIEA flaps, 49 DIEP flaps, and 136 muscle-sparing free TRAM flaps during a 5-year period.

Unilateral SIEA flap patients scored higher on 10 of the 12 survey questions compared with unilateral muscle-sparing TRAM flap patients, including reporting significantly better postoperative lifting ability. Abdominal pain also seemed to lessen sooner in the unilateral SIEA group (though this was not statistically significant) when compared to the muscle-sparing free TRAM group. Bilateral breast reconstruction patients with at least one SIEA flap scored higher on all 12 survey questions, including reporting significantly better ability to get out of bed (sit-up motion) compared with patients with bilateral muscle-sparing TRAM or DIEP flaps. The greatest benefit of the SIEA flap occurs in cases of bilateral breast reconstruction where at least one of the flaps used is an SIEA flap. There were no differences between patients that had undergone reconstruction of only 1 breast (unilateral) with an SIEA flap versus those that had had a DIEP flap.

The authors' conclusions were that breast reconstruction using SIEA flaps results in significantly less abdominal donor-site issues than DIEP flaps in bilateral cases and free muscle-sparing TRAM flaps in both unilateral and bilateral cases. The authors felt that these differences were "clinically relevant" and recommended that SIEA flaps be used whenever possible in preference to DIEP or muscle-sparing free TRAM flaps for breast reconstruction.

These findings are not surprising to me at all. They make a lot of sense considering that the SIEA flap procedure requires the least amount of surgical dissection while the muscle-sparing free TRAM is the most invasive (due to removal of some of the rectus abdominis muscle). One would expect recovery to be easiest in patients that undergo the least invasive surgery and this is essentially what this study has shown. Interestingly though, in patients undergoing unilateral breast reconstruction (one breast only), DIEP flaps are just as good as SIEA flaps in terms of recovery and patient satisfaction even though the DIEP procedure is slightly more invasive.

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Dr Chrysopoulo is a board certified breast reconstruction surgeon specializing in breast reconstruction surgery after mastectomy for breast cancer. He and his partners perform hundreds of microsurgical breast reconstructions with perforator flaps each year including the DIEP flap procedure. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Cancer Reconstruction Blog.

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Christina Applegate Mastectomy Calls Attention To Need For Team Approach To Breast Cancer Reconstruction

noreply@blogger.com (Dr C) — Tue, 16 Sep 2008 07:19:04 PDT

Actress Christina Applegate’s public disclosure of her breast cancer, her decision to have a double mastectomy, and plans to go forth with breast reconstruction surgery, calls attention to the need for a medical “team” approach in the treatment and recovery from breast cancer.

“A decision to have breast reconstruction is a decision to have plastic surgery. And, that ought to be done by a plastic surgeon. This is what we train for and do everyday. Plastic surgeons have pioneered and refined all of the state-of-the-art techniques in breast reconstruction including implant approaches and autologous tissue (natural) transfers,” said Richard D’Amico, MD, president of the American Society of Plastic Surgeons (ASPS).

The methods for treating women with breast cancer have evolved and we are seeing scientific advancements in the treatment of this disease. These improvements can be attributed to a strong collaboration between medical specialties, in particular radiologists, pathologists, psychologists, general oncologic surgeons, medical oncologists, and plastic surgeons.

The ASPS says breast cancer patients should insist that their treatment be handled by a “team” of physicians, including plastic surgeons, with the appropriate expertise for each procedure and level of care. This, in turn, gives the breast cancer patient the best chance for positive outcomes.

“ASPS Member Surgeons are carrying out the cutting-edge research for constant outcomes improvement. Our members have the foremost training, education and experience in breast reconstruction, and should be a part of every breast care team,” said Dr. D’Amico.

Patients should not assume that anyone other than a board-certified plastic surgeon affiliated with an accredited facility is qualified to perform breast reconstruction. While technology has made breast cancer diagnosis, treatment, and reconstruction better than ever, it does not negate the need for medical expertise within each area.

According to a recent breast reconstruction study published in the Journal of Plastic and Reconstructive Surgery, 98 percent of elective mastectomy patients would have breast reconstruction again.

“That’s a success and satisfaction rate that should not be compromised,” said Dr. D’Amico.
According to ASPS statistics, more than 57,000 breast reconstruction procedures were performed in 2007.

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Dr Chrysopoulo is board certified in Plastic and Reconstructive Surgery and specializes in breast reconstruction surgery after mastectomy for breast cancer. He and his partners perform hundreds of microsurgical breast reconstructions with perforator flaps each year including the DIEP flap procedure. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Cancer Reconstruction Blog.

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98% Of Mastectomy Patients Would Have Reconstruction Again, Study Says

noreply@blogger.com (Dr C) — Sun, 21 Sep 2008 19:10:08 PDT

Satisfaction Rate 94% - 100%

Women who have breast reconstruction after an elective mastectomy are satisfied with their decision, have low complication rates and 98 percent would do it again, reports a study in July’s Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS). In addition, breast reconstruction after preventive mastectomy was as safe as or safer than reconstruction in women with breast cancer and had excellent cosmetic results.

“Breast cancer is a terrible diagnosis and decisions regarding treatment are never easy. This study shows that women with cancer in one breast who choose to have their other breast removed as a preventive measure are happy with their decision and a high percentage would do it again,” said Scott Spear, MD, study co-author and past ASPS president. “More remarkable is the 100 percent satisfaction level, as well as the 100 percent willingness to have breast reconstruction again, for the women who chose to have both breasts removed.”

The study examined 74 women who had preventive mastectomies and subsequent breast reconstruction between 2000 and 2005. Forty-seven patients had breast cancer in one breast and elected to surgically remove their other breast (unilateral prophylactic mastectomy). Twenty-seven patients did not have breast cancer, but chose to surgically remove both breasts due to a high-risk of developing breast cancer (bilateral prophylactic mastectomy). The cosmetic outcome was scored by 14 surgeons who looked at post-reconstruction photos and evaluated the result on a 1 to 4 scale (4 being an “excellent” result).

The study found that women who had a bilateral prophylactic mastectomy were 100 percent satisfied with their breast reconstruction and 100 percent of them would have the surgery again. Ninety-four percent of women who had unilateral prophylactic mastectomy were satisfied with their reconstruction and 96 percent of them would have reconstruction again.

The complication rate for reconstruction in women who had bilateral prophylactic mastectomy was 3 percent and 10 percent for those who had unilateral prophylactic mastectomy. Additionally, the study noted the cosmetic assessment for all patients was a score of 3 out of 4.

“These women look and feel the same or better and their risk of cancer has been taken off the table,” said Dr. Spear. “For women who know they are at risk, this option gives them the opportunity to be active about their health and appearance rather than reactive. They can have excellent cosmetic results, low surgical risk and a high level of satisfaction with their breast reconstruction. This is empowering for women.”

According to ASPS statistics, more than 57,000 breast reconstructions were performed in 2007, up 2 percent since 2006.

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Dr Chrysopoulo is board certified in Plastic and Reconstructive Surgery. He is a breast reconstruction surgeon offering all types of breast reconstruction surgery after mastectomy for breast cancer. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Reconstruction Blog.

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Immediate Breast Reconstruction After Mastectomy is Safe, ASPS Study Says

noreply@blogger.com (Dr C) — Tue, 16 Sep 2008 07:30:28 PDT

Breast Reconstruction Does Not Impede Chemotherapy, Recovery or Diagnosis of Breast Cancer Recurrence.

Debunking the myth that women with locally advanced breast cancer must wait until after chemotherapy to have their breast reconstructed, a study presented at the Annual ASPS/PSEF/ASMS Meeting found that immediate free flap breast reconstruction for women with breast cancer is safe and psychologically beneficial.

The study, which followed 170 patients with locally advanced breast cancer, found that immediate reconstruction did not delay post-operative chemotherapy, prolong recovery or hinder the diagnosis of local cancer reccurrence.

"Losing a breast is traumatic," said ASPS Member James Watson, MD, and participating surgeon in the study. "As a board-certified plastic surgeon, I wanted to ensure that immediate breast reconstruction was safe for my patients and would make the healing process easier. The findings in this study will allow women to start healing sooner psychologically, knowing that their decision will not impede their physical progress against breast cancer."

The paper states that women participating in the study were pleased with their immediate reconstruction experience, indicating an immeasurable emotional benefit patients gain by having the reconstruction right away.

According to the findings, the majority of patients were either satisfied or very satisfied with their reconstruction and, if they had to, would have it done immediately after their mastectomy again. Also, the majority of women agreed they would recommend immediate reconstruction to a friend or colleague.

Through the study, Dr. Watson found that immediate free flap reconstruction - where the patient's own tissue is removed from the abdomen, buttocks or thigh regions and reattached in the breast using microsurgical techniques - resulted in similar complications and delays of post-operative chemotherapy to patients who delayed reconstruction. The most common postponement for patients was waiting for the wound to heal. However, the maximum delay was only three weeks, which did not have significant oncological impact on their post-operative therapy.

Also, while there were local recurrences of the cancer, physicians were able to diagnose the cancer's return quickly, resulting in no delay for additional treatment. Most local recurrences were located at the mastectomy scar or in the mastectomy flaps, which could be diagnosed by a physical exam and biopsy.

"An added benefit to reconstructing the breast immediately is that it's easier for the oncology surgeon to complete the mastectomy. Often, the breast cancer is so large or involves so much skin that the surgeon has to remove additional skin in the region, making it difficult to reserve enough tissue to close the wound," stated Dr. Watson. "With immediate reconstruction, the oncologic surgeon can eliminate more breast skin to ensure the cancer is removed and use the skin from the free flap procedure to close the wound."

According to ASPS 2001 statistics, more than 190,000 women were diagnosed with breast cancer and more than 80,000 women opted for breast reconstruction following a mastectomy.

Access to breast reconstruction following a mastectomy has increased due to the passage of the Women's Health and Cancer Rights Act 1998, proudly supported by ASPS, which mandated insurance coverage for breast reconstruction and the alteration of the opposite breast for symmetry for women who have undergone a mastectomy.

"With the finding that reconstruction right after mastectomy is safe, women can maximize their opportunity to not only heal physically but also psychologically right away," said Dr. Watson. "Before, women had to wrestle with their changed body image after losing a breast while physically recovering from their battle with cancer. Now, they don't have to delay the psychological healing process of beating breast cancer and celebrating that victory."

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Dr Chrysopoulo is board certified in Plastic and Reconstructive Surgery and specializes in breast reconstruction surgery after mastectomy for breast cancer. He and his partners perform hundreds of microsurgical breast reconstructions with perforator flaps each year including the DIEP flap procedure. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Reconstruction Blog.

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