Breast Reconstruction Consult: The Physical and Technical Component
This blog discusses a breast reconstruction consult: the physical and technical component of a DIEP flap surgical visit with the plastic surgeon. I wrote part a blog dealing with the emotional and psychological aspects of a consult and another one on the abdominal examination component of a consult. A plastic surgeon will work with his nurse at this initial consult to gather all the pertinent information needed to optimize the outcomes of DIEP flap surgery.
Each of us goes to this appointment with unique circumstances in terms of both our physical structure and overall health. I will walk you through my own personal case but know yours will be exclusive to the situation you bring to the initial consult for your breast reconstruction. The hope is to give you an idea of the steps done during this consult and what the purpose of each is for your DIEP flap surgery.
My plastic surgeon asked me where I found him or who referred me to his office. This information gives them feedback and helps them understand how patients are being educated about finding a board certified plastic surgeon to perform breast reconstruction after mastectomy. Many plastic surgeons, Dr. Chrysopoulo being a leader in this effort, are very active in educating patients about all options of breast reconstruction. Read the list of questions to ask a plastic surgeon during your initial consult on my resource page under the heading, “Board Certified Plastic Surgeons By Region”.
Details of Your Diagnosis During Your Breast Reconstruction Consult
Notes will be recorded about your diagnosis. When I looked back at my report it was interesting to view the first notation in my diagnosis: “Acquired absence of breast”. My plastic surgeon never saw my “original model” and yet rebuilt my breast to look, in my humble and grateful opinion, better than the “original model”. Remember, I was delayed DIEP so all he was looking at was the after-result of my mastectomy, “acquired absence of breasts”.
It was also noted in my report I had “late effect of radiation”. Twelve years before seeing my plastic surgeon I had 6 weeks of daily radiation to my left breast. My right breast was now gone also because of a recurrence. What my plastic surgeon saw on the left side was some very uneven folds of skin and tightness affected by radiation from my first occurrence.
Does radiation complicate the work of a plastic surgeon? It certainly has the potential to complicate their work! Therefore, I always emphasize to do your homework and find a skilled, board certified plastic surgeon with a high success rate to perform your DIEP flap surgery. My plastic surgeon knew I had radiation twelve years previously and very clearly explained the possible impact and the challenges it would present both intra-operatively and post-operatively. This included thickening and shrinkage of the skin and soft tissue, fibrosis (deep scarring), changes in the ribs, cartilage, chest muscles and blood vessels. I’m happy to report the removal of radiated scar tissue by my plastic surgeon resulted in a much softer breast. The new, soft, warm tummy tissue used to reconstruct both breasts allows me to comfortably sleep on either side, something I had not been able to do on my left side in the years after radiation was administered.
Your complete health history, prior surgeries, medications you are taking, family history, alcohol and tobacco use will all be noted. Smoking and DIEP flap surgery mix like oil and water. You simply cannot be a smoker and go into this surgery. You will be asked to stop smoking before and continue cessation after this surgery. Too much is at stake. Read what my plastic surgeon’s office wrote here and read the blog about the detriment of smoking and DIEP flap breast reconstruction.
Less blood flow means less oxygen, essential nutrients and growth factors are delivered to the tissues. This increases the risk of complications like poor wound healing, infection, blood clots, and even loss of some or all of the reconstruction. Overall, smoking can increase the complication rate of surgery by up to 40-60% (UCSD Cancer Center, 2008). PRMA Plastic Surgery
Lots of Measurements Will be Taken
There will be measurements taken and recorded by your plastic surgeon. Dr. C used what resembled a ruler and placed it at my sternum over to my nipple to take measurements. It was noted in my paperwork as “sternal notch to nipple distance”. My measurements were 19 cm on the right and 18 cm on the left. Yes, uneven I was! A skilled plastic surgeon will work hard to achieve symmetry but, in all honesty, breasts are not perfectly symmetrical before mastectomy, so I wouldn’t expect them to be after breast reconstruction. His measurements were spot on because my results are those of a skilled artist and surgeon and I am very pleased with the outcomes and symmetry. I think my plastic surgeon has the keen eye of an artist. You should sense this at your initial consult with the plastic surgeon you choose. Combined with his surgical skill, I can’t help but think of Leonardo DaVinci’s Vitruvian man when I recall the moment when he was measuring my breast area.
Leonardo’s famous drawings of the Vitruvian proportions of a man’s body first standing inscribed in a square and then with feet and arms outspread inscribed in a circle provides an excellent early example of the way in which his studies of proportion fuse artistic and scientific objectives. Taken from: https://leonardodavinci.stanford.edu/submissions/clabaugh/history/leonardo.html
Skin changes will be noted as well as any scars on or around the breast area. I had a bilateral NSM (nipple sparring mastectomy). It was noted my mastectomy was performed “through IMF (inframammary fold) incisions”. He used this same scar line to place the flaps from my tummy area to insert and make the new breast mounds. Your nipple and areola complex will be examined to see if they are “viable” and have a healthy blood flow. If you will be removing your nipples, then you will discuss whether to rebuild them using your own skin or have them replaced with a tattoo. There will be a check for any lymphedema present if you have been through any treatments or prior surgeries. Your back will also be checked for signs and presence of scoliosis. Achieving symmetry is the goal and all these factors play into measurements taken at your initial consult for breast reconstruction.
You will have the all-important discussion about your desired size. This is where you must be realistic, and your plastic surgeon must be truly honest with you based on your previous size and the tummy tissue you have available to rebuild the breast mound. Some women want to “go smaller”, some bigger so the conversation needs to take place with candid sincerity.
My initial consult was a full hour plus some, 70 minutes face to face with Dr. C, to be exact. “How much time will you allow for this initial consult?” I believe this is a fair question to ask the plastic surgeon you are considering performing your DIEP flap surgery. Not only is the physical exam important but discussing the risks and complications of surgery should be part of this initial consult.
Want me to let you in on a little secret?
I’m going to tell you the final “Plan/Disposition” and the absolute best part of my report. I traveled over 800 miles for this consult and this is what I wanted to hear.
“She is a good candidate for DIEP flap breast reconstruction using her lower abdominal tissue.”
