As recent articles in the media have stressed, successful breast cancer treatment and reconstruction involves close collaboration among all those treating the patient. Angelina Jolie and her plastic surgeon have been very public about her mastectomies and reconstruction and have helped shine a light on the importance of a close, collaborative relationship among the doctors and patients. We couldn’t agree more.
We are fortunate to have such a team here in Lawrence, and have recognized the importance of this team approach for many years. Even before establishing the Breast Center around 10 years ago we were already working closely with our general surgeons, oncologists, pathologists, and others to begin planning a treatment strategy for the patient shortly after the diagnosis of cancer was made. As reconstructive surgeons, we often meet with patients early in the process to discuss available options and make suggestions as to the most appropriate reconstructive approach and timing (immediate or delayed). Most importantly, we have often already been in communication with your other providers before we even meet you for the first time and continue to work closely with them throughout your treatment. Even if a patient chooses not to undergo reconstruction at the time of her mastectomy, we can help her make this informed decision and even become involved in the mastectomy planning, so that incisions are placed to make reconstruction easier in the future if the patient should change her mind.
Breast reconstruction should not be seen as an isolated procedure but part of a collaborative effort to treat the breast cancer patient and restore her to physical and emotional health. Communication is an old fashioned, low-tech approach that consistently makes our advanced treatments work better.
We don’t do the DIEP flap at Lawrence Plastic Surgery for several reasons. A recent article in our local paper discussed this procedure being performed at a nearby teaching hospital and pointed out they were the only ones performing this procedure within “several hundred miles”. Although this procedure was first being performed almost 20 years ago, it has not gained widespread popularity. Here’s why:
- It requires a much longer operating time than other techniques, especially if both breasts are reconstructed immediately after mastectomy. In the same recent article the patient mentioned her “14.5 hour surgery”. This is significantly longer than a traditional TRAM flap operation or tissue expander/implant reconstruction. Longer operations, as you can imagine, are harder on patients than shorter ones.
- The post-operative stay is significantly longer after this surgery as compared with a tissue expander/implant reconstruction. Most of our immediate reconstruction patients are discharged the day following surgery when we use a tissue expander reconstruction as opposed to several days after a DIEP flap. The time to return to normal activities, including work and exercise, is much longer with a DIEP flap.
- The advantages of a DIEP flap over a pedicle TRAM flap (which we perform) are still debated in the plastic surgery community. As we only utilize a portion of the abdominal muscles in a pedicle TRAM, functional muscle loss is usually not significant in most patients.
- Tissue expander/implant reconstruction is getting better all the time. The use of skin/areola/nipple sparing techniques along with the use of acellular dermal matrix products (Alloderm, etc.) and better implants has given us much better results than even just a few years ago.
- Many patients are simply not good candidates for a DIEP flap due to inadequate tissue, body habitus, or other medical problems.
- The available abdominal tissue in a DIEP reconstruction determines the size of the reconstructed breasts. With tissue expander/implant reconstruction, a patient has more options in determining the final size of her breasts.
While we admire those surgeons who are performing the DIEP flap, and many patients can attest to their good results, we still have misgivings about performing this procedure, as do many other plastic surgeons involved in breast reconstruction. There are more than 10 times as many breast reconstruction operations performed with tissue expander/implant techniques than the DIEP flap. We believe there is a good reason why the number of tissue expander/implant reconstructions continues to increase year after year while the number of DIEP flaps performed has remained relatively flat over the years despite initial enthusiasm about this procedure.