Breast Reconstruction FAQs
Get Answers to Frequently Asked Questions from Christine Fisher MD in Austin, TX
I am an active smoker. I know I should quit for my health, but what are the risks of smoking with breast reconstruction?
Active smokers have a marked impaired ability to heal and increased risk of poor healing with the mastectomy and the breast reconstruction. With implant surgery, smokers are at higher risk of implant infection, mastectomy flap necrosis, bleeding after surgery requiring reoperation, and either early or late reconstructive failure. With abdominal DIEP flap breast reconstruction surgery, smokers are at higher risk of infection, breast skin healing problems, and delayed healing of the abdomen. In summary, smoking increases the risk of total breast reconstruction failure, wound healing problems or infection. Nicotine replacement therapy (patches, e-cigarettes, gum) also have a poor effect on wound healing and are not better than smoking. It is encouraged to be off of all nicotine products six weeks prior to surgery and six weeks after surgery to reduce these risks.
I am going to need radiation therapy after my mastectomy. How will this affect my decision for breast reconstruction?
Patients planning to undergo radiation therapy after mastectomy present a complicated reconstructive scenario. If breast implant reconstruction is performed and then radiation is given, there is a higher rate of aggressive scarring around the implant, which can cause pain and deformity. This is called "capsular contracture." There is also a higher rate of implant-based infection, which can lead to removal of the implant and breast reconstruction failure. If a woman wants abdominal DIEP flap breast reconstruction, performing it prior to radiation therapy can lead to unpredictable shrinkage of the reconstruction. For most women who are known to need radiation therapy after mastectomy, we generally recommend either placing a temporary breast shaped device to hold the shape of the breast as a "babysitter" of the skin or delaying the breast reconstruction until after the radiation therapy is completed. If a "babysitter" device (tissue expander) is placed during radiation, the patient completes a DIEP flap breast reconstruction six months later to create a soft, healthy breast that will have optimal healing and a long lasting natural result. In some select patients—especially thin women with smaller breasts—initial reconstruction might be considered prior to radiation but needs to be discussed with both the surgical oncologist and plastic surgeon.
I have had previous mastectomy and radiation therapy and now want to have breast reconstruction. What is my best option?
In general, previously radiated tissue has impaired healing with surgical procedures and doesn't stretch well because of scarring. Implant-based reconstruction after radiation has a higher rate of delayed healing, infection, and reconstructive failure. Because of the tight radiated skin, it is very difficult to get an adequately sized, long-lasting breast implant reconstruction. Abdominal tissue DIEP flap breast reconstruction in a previously radiated area generally involves replacing much of the radiated tissue with healthy, non-radiated skin and fat. Because new, non-radiated skin is used to replace the radiated skin on the chest, a soft healthy breast can be created at the time of surgery. Timing is generally six months after completing radiation.
I'm planning a DIEP flap breast reconstruction; where will my abdominal incision be placed? If it's higher than desired, can it be revised in the future?
The location of the DIEP flap breast reconstruction abdominal incision varies between patients based on location of the perforators needed for the breast reconstruction. High perforators (generally above the umbilicus) result in a high scar, whereas lower perforators can allow for planning of a lower scar. In general, the scar is slightly higher than the location of a true "tummy tuck" scar. In some cases, the scar can be lowered as a secondary procedure at the time of the breast reconstruction revision surgery.
FAQs: Implant Breast Reconstruction vs. Free Flap Breast Reconstruction
Who is the best aesthetic candidate for implant-based breast reconstruction?
Women who are thin, normal weight, or slightly overweight; have small to moderate breast size (A or B cup); are having a mastectomy of both breasts; and do not need radiation therapy usually have the highest satisfaction with implant-based reconstructions. In studies of patient satisfaction, women who chose an implant reconstruction of one breast are less satisfied than patients who have a bilateral breast implant reconstruction. Implants look most natural when they are not too big and are placed on a woman with a thin frame.
Christine Fisher, M.D.
- Known for natural-looking aesthetic results in breast reconstruction and cosmetic surgery.
- Elected by her peers for inclusion in Texas Monthly's Texas Super Doctors®: Rising Stars listing.
- Reconstructed over 1,500 patients, including more than 500 DIEP flap reconstructions.
- 4.9-star average rating over hundreds of reviews for cosmetic surgery.
Who is the best aesthetic candidate for DIEP flap breast reconstruction?
Women who are thin or medium build with some extra abdominal skin and fat and are having only one breast removed are ideal candidates for DIEP flap breast reconstruction. Women with a medium or heavy build or have loose abdominal skin after weight loss or pregnancy may be candidates for DIEP flap breast reconstruction of both breasts and can achieve a C cup breast size. Women with a slim build can have DIEP flap breast reconstruction of both breasts to achieve a more petite breast size which can be enlarged in a second step with fat grafts, injectables or breast implants. The DIEP flap breast reconstruction has a better chance of matching the appearance of the other breast, and removing tissue from the lower abdomen can give a "tummy tuck" effect that will flatter and improve the aesthetic contour of the abdomen.
I do not fit into either of the above scenarios. What type of breast reconstruction will be best?
Many women will have multiple options for breast reconstruction, including breast implants or DIEP flap breast reconstruction. Only a thorough evaluation of a patient's goals, physical status, and clinical history can help decide which type of reconstruction would be best.
I have had radiation therapy previously in my breast. Is implant or DIEP flap breast reconstruction better?
In the setting of radiation therapy, implants have an increased risk of infection, capsular contracture, tightness, pain, and implant extrusion compared to women who have not had radiation therapy. Since DIEP flaps use your own tissue, it can heal to radiated tissues better and has a much lower complication rate than implant-based breast reconstruction.
FAQs: DIEP Flap Breast Reconstruction
What is a flap?
A flap is a portion of tissue (usually skin and fat) that has an artery and vein providing blood supply to the tissue to keep it alive. The flap can be rotated or transplanted from one part of the body to another to help reconstruct a defect caused by cancer, trauma, or infection.
What is microsurgery?
Microsurgery is a technique used by plastic surgeons to transplant tissue from one part of the body to another. It involves using a high-powered microscope to connect the millimeter-sized arteries and veins together.
What does DIEP flap stand for?
"DIEP" stands for Deep Inferior Epigastric Perforator flap. The deep inferior epigastric blood vessels supply the circulation to the DIEP flap.
How is a DIEP flap breast reconstruction different from a TRAM flap breast reconstruction?
The DIEP and TRAM flap use the same skin and fat from the lower abdomen to replace the volume that a mastectomy removes from the breast, but the TRAM flap will remove the rectus muscle from the abdominal wall. Removal of the rectus muscle can weaken the core muscles and cause a bulge in the abdominal wall. The DIEP flap separates the blood vessels from the rectus muscles, leaving the strength layer in the abdomen. Sparing the fascia and muscle with a DIEP flap leads to less pain, quicker recovery, and less risk for hernia after surgery.
Download Our Breast Reconstruction Post-Operative Care Guides
We've compiled detailed post-operative care instructions to best equip our breast reconstruction patients throughout their recovery process. To ensure the best and safest recovery, your plan encompasses appropriate prescriptions and clear directions towards maintaining your comfort to get you back to normal life and activity as soon as possible. Individual patients respond uniquely, and the type of procedure may differ, but these basic guidelines will help you along your journey.Download Post-Operative Care Guides
How long does the DIEP flap breast reconstruction surgery take?
For breast reconstruction of one breast, the surgery is usually three to four hours. For reconstruction of two breasts, the surgery is usually six to seven hours.
What is the expected recovery time after DIEP flap breast reconstruction?
Patients will spend two to three nights in the hospital after breast reconstruction using DIEP flap and will generally stop taking pain pills within one to two weeks. At three to four weeks, most women who have light-duty careers (no heavy lifting) can consider resuming work. No heavy lifting or high impact exercise for six to eight weeks.
When can I resume exercising after DIEP flap breast reconstruction?
Once you go home, you can start walking and going up and down stairs. Lighter aerobic exercises—like stationary bicycle and elliptical trainer—can be started in four weeks. In order to prevent injury to the abdomen, we ask that no strenuous lifting or core exercises (yoga, Pilates, heavy weight training) be performed for 12 weeks after DIEP flap breast reconstruction.
I am a very active person. Will I be able to resume all my normal activities after DIEP flap breast reconstruction surgery?
Yes. Once you have finished the recovery period, there will be no limitations to your activities. DIEP flap breast reconstruction surgery has been performed on high-level tennis players, professional dancers, yoga instructors, and other very active women with complete recovery.
How many surgeries will it take to complete my breast reconstruction?
After DIEP flap breast reconstruction surgery, some patients will require only nipple reconstruction and/or areola tattooing. In some cases a nipple can be reconstructed at the time of the first surgery. Some patients may have some asymmetry after the initial surgery, and may desire a minor outpatient revision surgery. Since every case is unique and some breast reconstructions are more challenging than others, your doctor can estimate the likelihood that you would require a breast reconstruction revision surgery. Our goal is to try to get every woman's breast reconstruction completed with as few procedures as possible.
What is the expected failure rate of DIEP flap breast reconstruction?
The more experience the surgeon has, the lower the failure rate generally is. Dr. Fisher has a greater than 99 percent success rate.
FAQs: Questions to Ask Your Surgeon
Are you specially trained in microsurgery?
All of the surgeons affiliated with Dr. Fisher are experienced in microsurgery, with a combined experience of over 2,000 cases. Dr. Fisher and her co-surgeons focus their practice on advanced microsurgical breast reconstruction and care for hundreds of patients per year. Dr. Fisher artistically designs the reconstruction plan to optimize the final aesthetic outcome. There is a skill that differentiates her results from other providers. She performs all aspects of the reconstruction operation and only does one of these cases at a time to ensure total focus on an optimal result.
How many of these surgeries have you performed?
Because a high success rate of this surgery is dependent on performing it frequently, it is important to choose a surgeon that performs this at least 50 times a year. Our group has performed more than 500 DIEP flap breast reconstructions and does two to four reconstructions a week.
Who will be in my surgery?
These procedures are best performed with two surgeons and an assistant. Having two experienced microsurgeons present creates efficiencies that allow our operative times to be as short as possible.
Can I talk to other patients who have undergone DIEP flap breast reconstruction surgery?
Absolutely. Most patients appreciate talking to other patients who have been through the surgery, and we have patients who are willing to share their experiences. It is best to talk to someone who best matches your clinical situation.
FAQs: Paying for Breast Reconstruction
Does insurance pay for DIEP flap breast reconstruction?
Yes. All cases will go through normal pre-authorization with your insurer, the same process that your surgical oncologist would do for the mastectomy. Normal deductibles and co-payments apply, and patients are encouraged to meet with the practice billing specialist to clarify or estimate out-of-pocket expenses.
I am out of state or my insurance is out of network. What options are available?
There are so many insurance companies out there that it is simply impossible to participate in all plans. If our group is out of network for your insurance plan, we will work on a case-by-case basis with your insurer to assure coverage.
I have covered my deductible for the year. Can I get breast reconstruction completed before my deductible resets?
For the majority of women, the answer is yes. This is very dependent on the timing of events. In general, we make every attempt to get as much of the reconstruction performed in one procedure. Frequently, the only remaining procedure to perform is nipple reconstruction, which is done two to three months after the initial DIEP flap breast reconstruction surgery.
I have a high out-of-pocket plan. Do you have payment plans available?
Yes. We never want financial considerations to prevent a woman from undergoing breast reconstruction. Our patient coordinator can help you understand the different financial options available.