Fat grafting has been in the news a fair amount so I thought I’d give you a brief run-down of what’s involved….
Fat grafting is a fairly new technique in breast surgery. Fat is liposuctioned from one part of the patient’s body, purified and then injected into the breast.
Fat grafting can be used to fill-in partial breast defects after lumpectomy. It is also frequently used after mastectomy, usually in conjunction with other reconstructive techniques, to optimize the breast contour and improve overall cosmetic results.
There are several fat grafting techniques that are used by plastic surgeons. There is no “set way” that has been shown to be the best in terms of long-term results. However, studies have shown that regardless of the technique used, the collection, storage, and transplantation of the fat cells (and fat stem cells they contain) must be optimized to obtain the best long-lasting results.
Studies have also shown that once the injected fat “takes”, it can also help improve the thickness and quality of radiation-damaged tissue and skin.
Regardless of technique, some of the injected fat will be reabsorbed over time but this can vary depending on the exact clinical situation. Patients must therefore be prepared to require more than one procedure for the best results.
As for the risks…. For women still undergoing regular mammograms, it is also important to know that fat grafting can also cause calcifications known as “MACRO-calcifications”. As many of you have already unfortunately experienced, breast cancer can also cause calcifications, known as “MICRO-calcifications”. According to the American Society of Radiology, these different types of calcifications are easily distinguishable. Having said that, I still tell my patients that fat grafting can lead to the recommendation for further tests in the future because of this calcification issue.
Injected fat can also become firm or create “oil cysts”. Fortunately these are becoming much less frequent as techniques are refined but again, both of these can cause “unnecessary” stress.
Several independent studies that have evaluated patients over a few years after the procedure have shown that fat grafting is safe. However, because the technique is fairly new, no long-term safety data is currently available.
Unfortunately not all insurance companies cover the cost of fat grafting so the procedure can involve out of pocket expenses for some patients.
Alloderm is now being used routinely in breast reconstruction. Here’s what you need to know…
First off, what is it? AlloDerm is derived from donated (cadaveric) human skin. It is FDA approved and is used in many different types of reconstructive surgery including breast reconstruction. Before being packaged for use, the Alloderm undergoes a multi-step process that removes all the cells that can lead to tissue rejection: even though it comes from another person, your body does not reject Alloderm because the immune cells are removed. Alloderm essentially acts as a scaffold and over time, the patient’s own cells grow into it.
Since it is a human (cadaveric) product, the U.S. Tissue Bank rigorously screens all tissue donors’ medical records. All donors must be negative for Syphilis, Hepatitis B and C, and HIV 1 and 2. AlloDerm grafts are also examined under the microscope before and after processing to rule out contamination.
Alloderm is frequently used in implant-based breast reconstruction (and has been for years). The tissue expander or implant is placed under the pectoralis (chest) muscle. The more tissue coverage over the implant, the better the results. Unfortunately, the pec muscle cannot cover the entire implant. The Alloderm is used to cover the lower part of the implant that is not covered by muscle.
Advantages:
- Stabilizes the implant in position.
- Allows for complete implant coverage.
- Can allow the creation of a full-sized breast when the tissue expander/implant reconstruction is performed at the same time as the mastectomy.
- No risk of rejection.
- Once incorporated by the body, resists infection as well as the patient’s “natural” tissue.
Disadvantages:
- Like anything that is implanted in the body, there is an initial (low) risk of infection (until it becomes incorporated).
- Can cause temporary redness in the skin over the Alloderm (“red breast syndrome”).
- Costly but usually covered by insurance.
Many plastic surgeons, including myself, use Alloderm routinely when performing breast reconstruction with tissue expanders and implants.
Did you know breast reconstruction can be performed at any time, even years after a mastectomy?
“Immediate breast reconstruction” is performed at the same time as the mastectomy and typically provides the most natural results with the least amount of scarring. Unfortunately, for many women this simply isn’t an option….
For starters, 70% of women facing mastectomy aren’t even told that reconstruction may be an option for them. They undergo surgery only to find out some time later that they could have woken up from their mastectomy with new breasts instead of having to experience a flat chest.
Of the women that are informed, some may not have access to a reconstructive plastic surgeon where they live and have to travel for reconstruction.
Other women are not candidates for immediate reconstruction because unfortunately the disease is too advanced at the time of diagnosis.
Sometimes radiation therapy is recommended as part of the breast cancer treatment. Most plastic surgeons prefer to hold off on reconstruction until the patient is several months out from her last radiation therapy. This allows the tissues to recover and soften up as much as possible to improve the results of the subsequent reconstruction.
As you can see, there are several reasons why a women wanting breast reconstruction may not be able to have it straight away, ideally at the same time as the mastectomy.
Whatever the reason for delay may be, it is important to remember there is no time limit when it comes to breast reconstruction – it can be performed at any time, even years after mastectomy.
Like immediate reconstruction, “delayed breast reconstruction” is also covered by insurance regardless of how many years have passed since the breast cancer diagnosis.
Alarmingly, 70% of American women facing surgery for breast cancer are not told about the option of breast reconstruction.
Perhaps one of the best things about breast reconstruction is that it can be performed at any time?. you can never ?miss the boat? so to speak. Regardless of the timing of the procedure, breast reconstruction enables women to feel whole again, not just physically but also emotionally.
There are several reconstructive options ranging from breast implants to using the patient?s own tissue. Tissue (or ?flap?) procedures recreate a ?natural?, warm, soft breast and are associated with fewer complications than breast implants.
Breast reconstruction can be performed at the same time as the mastectomy (“immediate reconstruction”) or any time after mastectomy (“delayed reconstruction”). ?When the mastectomy and reconstruction are performed at the same time, a skin-sparing mastectomy can usually be performed which saves most of the natural breast skin envelope. Only the actual breast tissue under the skin is removed. The reconstruction then “fills” this empty skin envelope. In some cases nipple-sparing mastectomy can be performed. This preserves the nipple and areola as well as all the breast skin.??
Skin-sparing (and nipple-sparing) mastectomy and immediate breast reconstruction produce the most “natural” results with the least scarring. Patients undergoing immediate reconstruction also avoid the experience of a flat chest altogether. Immediate reconstruction is therefore preferred whenever possible and should be the goal for patients with early breast cancer (stage I or II).
In some cases breast reconstruction cannot be performed at the same time as the mastectomy. Reasons include advanced breast cancer (stage III or IV), inflammatory breast cancer, the plan for radiation therapy after mastectomy, and lack of access to a reconstructive plastic surgeon.
As I already mentioned at the beginning of this post, most women unfortunately are not made aware of their breast reconstruction options. I therefore encourage all women interested in breast reconstruction to research their options and seek a referral or consultation with a plastic surgeon specializing in breast reconstruction.
You can see real patient results after immediate and delayed breast reconstruction in our photo gallery here.
A growing number of breast cancer patients are now choosing to travel for their care, particularly for some of the more advanced breast reconstruction procedures. Insurance may cover the health care expenses but the cost of the hotel and air fare falls on the patient.
Now, some patients may qualify for financial assistance to cover these extra expenses thanks to two special programs:
Assistance with Air Travel Expenses
The American Cancer Society (ACS) Air Miles program is a joint effort between Mercy Medical Airlift (MMA)/National Patient Travel Helpline (NPATH) and the American Cancer Society. The program is designed to help patients with the cost of air fare when traveling for cancer-related treatment. Please call the ACS at (800) 227-2345 to find out if you are eligible for help with air travel. More information regarding the Air Miles program can be found here.
American Cancer Society (ACS) Accommodation Program
San Antonio hotels have partnered with the American Cancer Society to offer breast cancer patients accommodation at either low or no charge on a space-available basis. This program is for patients who receive treatment at least 50 miles from their place of residence. One caregiver is welcome to travel with the patient At least two weeks advance notice is usually required. The program only applies to lodging Monday through Thursday. We encourage patients living more than 50 miles from San Antonio to call the American Cancer Society on (877) 227-1618 for more information and to take advantage of this opportunity.
If you are considering DIEP flap breast reconstruction finding the right surgical team is key. Before choosing a DIEP flap surgeon be sure to ask the following questions:
Are you certified by the American Board of Plastic Surgery? Your surgeon should be a board certified plastic surgeon.
Do you have extensive experience with this type of surgery – How many have you performed? Preferably your surgeon will have performed over 100 DIEP flap procedures.
What’s your success rate? Top specialist centers boast a success rate of at least 98%.
How long does the surgery take? This will vary between institutions based on experience. The most experienced surgeons typically take between 3-6 hours depending on whether one or both breast are being reconstructed (not including the mastectomies).
How often do you plan to perform a DIEP flap but end up changing the procedure to a free TRAM flap during the surgery? The “conversion rate” to a free TRAM flap should be low.
How many microsurgeons will be performing the surgery? Since the DIEP flap procedure is so technically demanding and long, it is preferable to have two microsurgeons performing the surgery rather than just one. Not only will this ensure you benefit from the expertise of two specially trained surgeons, but it will also significantly cut down the length of the procedure and anesthesia.
Do you have residents or fellows? Will they be performing any of my surgery? Some centers have surgeons-in-training known as “residents” or “fellows” that may be helping with your surgery or even performing part of it. This may or may not be something you are comfortable with considering the complexity of the surgery.
Do you “balance bill”? Centers that are in-network for most insurance plans will ask the patient to pay ONLY what’s laid out by the patient’s insurance plan (ie copay, deductible, etc). Other centers “accept insurance” and will often help the patient get money back from their insurance company – however, the patient is still expected to provide the difference between what the insurance pays and the doctor’s fee. This is known as “balance billing“. While many centers do this, some DO NOT balance bill. Make sure to ask ahead of time to avoid nasty financial surprises down the line.
Do you have Insurance Specialists on staff? Unfortunately, some patients will face difficulties in gaining access to DIEP flap specialists even though insurance companies are federally mandated to pay for the cost of breast reconstruction. Here again it pays to seek out centers that specialize in these procedures as typically an insurance specialist is available to help patients with insurance issues. Again, this can prevent a nasty financial surprise after your surgery.
Hope that helps!
Dr C
*****
PRMA Plastic Surgery has successfully performed over 3,000 DIEP flap breast reconstructions. We specialize in advanced breast reconstruction procedures that use the patient’s own tissue. Procedures offered include the DIEP flap, SIEA flap, GAP flap, and TUG flap. We are In-Network for most US insurance plans. Patients are routinely welcomed from across and outside the USA. Connect with other breast cancer reconstruction patients at www.facebook.com/PRMAplasticsurgery.
Currently only 30% of breast cancer patients are informed of their breast reconstruction options before mastectomy or lumpectomy.
New legislation is being proposed in Texas that aims to significantly improve that abysmal statistic for breast cancer patients. Texas House Bill 669 would mandate that doctors inform all breast cancer patients about their breast reconstruction options BEFORE having surgery for breast cancer. The bill was drafted based on similar legislation in the state of New York.
PRMA Plastic Surgery is proud to announce that a former patient, Tammy Carrington, is the team leader behind this Bill. She proactively sought out her state representative, James White, to begin drafting proposals. The Bill was drafted and submitted January 14, 2011. If approved, this statute will take effect the following year.
Tammy Carrington knows firsthand what it’s like to be diagnosed with breast cancer and receive limited treatment options. After being diagnosed in June of 2009, Tammy was given two options: a lumpectomy with radiation or a unilateral mastectomy. Tammy didn’t want either.
Tammy wanted to decrease the risk of breast cancer in the future in the other breast too. After intensely researching her options on her own she learned she could have bilateral mastectomies and immediate reconstruction. Ultimately she traveled to PRMA in San Antonio and underwent bilateral mastectomies with immediate DIEP flap breast reconstruction using her own abdominal tissue. All the procedures were covered by her health insurance.
Not surprisingly, Tammy feels very strongly about this Bill since she so easily could have chosen something she feels would have been the wrong option for her.
“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. I’ve spent lots of time over the years looking for information on how to help him get better. After getting over the shock of hearing the ‘C’ word,… I went into research mode”, Tammy recalls.
“HB 669 isn’t mandating any particular treatment. It’s not mandating any surgery. It’s just mandating education. Women have the right to be told about their options so they can make truly informed decisions about their own health. Unfortunately, right now only 30% are even told breast reconstruction is an option”, she says.
PRMA Plastic Surgery is proud to support HB 669 and is calling on breast cancer patients, physicians, and all those touched by breast cancer throughout the state of Texas to offer their support by calling their representatives.
DIEP flap? TRAM flap? SIEA flap? With so many breast reconstruction options available these days it’s difficult to understand what these terms really mean and what the differences are between all these “tummy flap” procedures.
It is important for women considering these reconstructive options to realize that not all tummy tissue options are created equal. For example, a DIEP flap is not the same as a TRAM flap just because both provide the benefit of a tummy tuck.
Many women are now rejecting breast implants preferring to use their own abdominal tissue for reconstruction after mastectomy. A breast that has been reconstructed with the patient’s own tissue typically looks and feels more natural than an implant reconstruction, will last longer without the long-term complications that can be associated with implants, and will also age like a natural breast. Women wanting to use their abdominal tissue have 3 reconstructive options: a TRAM flap, DIEP flap, or SIEA flap.
The TRAM flap is a very common breast reconstruction technique that requires the sacrifice of at least a portion of the rectus abdominus (sit-up) muscle. There are 3 different types of TRAM flap (“pedicle”, “free”, and “muscle-sparing free”): the exact type is defined by the amount of abdominal muscle removed. Unfortunately, TRAM surgery can be associated with significant post-operative pain, prolonged recovery and a host of abdominal complications such as loss of abdominal muscle strength (up to 20% or more), bulging (or “pooching”), and even abdominal hernia.
The DIEP flap procedure is similar to the TRAM flap except that it spares the rectus abdominus muscle completely. Only skin and fat are removed from the abdomen. This tissue is disconnected from the body completely, transplanted to the chest and re-connected using microsurgery to create the new breast. As the sit-up muscle is saved completely and left behind in its natural place, the risk of abdominal complications is much less than with a TRAM. There also tends to be less pain and a quicker recovery time because the abdominal muscles are preserved and left in place.
Like the DIEP flap, the SIEA (Superficial Inferior Epigastric Artery) flap completely preserves the abdominal muscles. The main difference between these two procedures is the artery used to supply blood flow to the newly reconstructed breast. The ?SIEA? blood vessels are generally found in the fatty tissue just below skin whereas the ?DIEP? blood vessels run below and within the abdominal muscle (making the DIEP more technically challenging). Recovery from the SIEA flap is even easier than the DIEP since the abdominal muscles are not disturbed at all during the surgery.
Despite the similarities between these two surgeries the SIEA flap is used much less frequently than the DIEP flap because less than 20% of patients have the appropriate anatomy. Unfortunately, there are no pre-operative tests to reliably show which patients have the appropriate anatomy and the decision as to which procedure to perform is made intra-operatively by the plastic surgeon based on the anatomy found at the time of surgery.
Since the TRAM, DIEP and SIEA procedures all use the patient’s lower abdominal skin and fat, all these abdominal flap options provide the added benefit of a tummy tuck at the same time as the breast reconstruction.
There are many plastic surgeons in the US offering TRAM flap reconstruction. Unfortunately, very few centers in the US routinely perform the advanced microsurgical procedures like the DIEP and SIEA flap. Many patients will therefore have to travel for these procedures.
When considering a reconstructive surgeon, ensure he/she is a plastic surgeon certified by the American Board of Plastic Surgery that has extensive experience with this specific type of surgery. Also ask about the success rate in their hands – most specialists boast a flap survival rate of 97% to 99%+.
The 2 websites below list surgeons that offer DIEP and SIEA flap reconstruction and serve as a good starting point when researching surgeons:
Great news! Well, to be honest, it’s not really “news” anymore since it happened a few of months ago but I have come across several patients that didn’t know about this so I thought I’d post about it….
PRMA Plastic Surgery and several San Antonio hotels have partnered with the American Cancer Society to offset travel expenses for breast cancer patients travelling to PRMA for their breast reconstruction.
Accommodation is now provided at either significantly reduced rates or at no charge on a space-available basis. This program is for patients who are having surgery at least 50 miles from their home. One caregiver is also welcome to travel with the patient. The program only applies to lodging Monday through Thursday (so weekends are NOT included). You also need to give advanced notice… at least two weeks advance notice is usually needed (remember this is on a space-available basis).
I encourage patients living more than 50 miles from San Antonio to call the American Cancer Society directly on (877) 227-1618 for more information and to take advantage of this great opportunity. Hotels conveniently located near PRMA can be found here.
Wounds need a lot of energy to heal well. Since energy can only come from food, it is vital that patients eat as healthily as possible especially before and after surgery. Crucial nutrients for wound healing include protein, zinc and the vitamins A and C.
So what are the best things to eat? Meats, nuts, beans and dairy products are great sources of protein. Carrots, tomatoes, sweet potatoes, spinach and apricots are great sources of vitamin A. Citrus fruits and green leafy vegetables are great sources of Vitamin C. Yogurt, green peas, beef, oysters, black beans and crab are great sources of zinc.
Patients must also stay well hydrated before and after surgery by drinking enough water. Dehydration causes the skin and soft tissues to lose moisture and become dry. Dry wounds do not heal well. A good goal is to drink eight (8 oz) glasses of water a day. Caffeinated products should also be avoided because caffeine can cause dehydration.
The importance of healthy nutrition is really emphasized by the link between obesity (Body Mass Index [BMI] over 30) and complication rates after surgery. Obese patients have much higher rates of infection, wound healing problems (breakdown of wounds), hematomas (blood collections), and seromas (fluid collections) compared to non-obese patients.
Obese patients also have a thicker subcutaneous adipose layer with a poorer blood supply. Blood flow to the healing tissues is therefore less robust and the amount of vital nutrients and oxygen reaching these tissues are far less than in non-obese patients. This poor blood flow compounds the negative effects of poor nutrition. If possible, losing weight before surgery will only decrease the risk of complications.
Smoking can also really impact healing. The nicotine in cigarette smoke causes blood vessels to shrink, so again tissues do not receive enough of the nutrients and oxygen required for healing. At best, this can cause the wound healing process to take much longer. At worst, smoking can cause wounds to breakdown. Unfortunately, many smoking-cessation products will also increase the risk of healing problems because of the nicotine they contain!
Cigarette smoke also contains carbon monoxide. This combines with your blood cells preventing them from carrying oxygen and effectively lowering the level of oxygen in the blood. Since oxygen is vital for healing, it is crucial to quit smoking before and after surgery to decrease the risk of healing complications.
Another good thing to do?… Exercise. Regular aerobic exercise improves healing after surgery and boosts the immune system. Start with walking and progressively build up to more of a sweat once given the “all-clear” by your surgeon.
