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Updated: March 2009

Left Free TRAM Flap, Right Latissimus Dorsi and Implant

Photo of Donna's Procedure
Photo of Donna's Procedure
Before
After

This patient first required a left mastectomy with reconstruction followed by radiation. She later decided to have a right prophylactic mastectomy and reconstruction. She is seen here before and after a left free TRAM flap reconstruction and a right latissimus dorsi flap and implant reconstruction

Donna's Breast Reconstruction Story:

 

My odyssey began in August of 2004, at the age of 45, after going to my yearly gynecological visit. During my breast exam, the doctor felt a grain-like lump at the 3-o’clock position on my left breast. Although she believed it to be nothing, she recommended that I have a sonogram along with my scheduled yearly mammogram. The technician who performed my left breast sonogram believed the 3-o’clock site to be fine, but found a spot at the 12-o’clock position that looked suspicious. I was sent for a biopsy of this suspicious spot, and it was found to be malignant. It was a small tumor, and I was told that it was probably treatable with a lumpectomy and six weeks of radiation.

Unfortunately, I had watched my best friend, who lost her battle with breast cancer, deal with uncaring doctors. Now that it was me, I decided to get three opinions before choosing a breast surgeon. I needed to find a doctor who was not only on top of their game, but someone who was also caring. I really liked two of the three surgeons, but my final decision was made based on this surgeon’s strong suggestion that I have a biopsy of the 3-o’clock site, even though it looked fine on the sonogram. I liked her attention to detail, and I found her to be caring and compassionate. I thank God every day that I chose her, because this site too ended up being cancer! Removal of my axillary lymph nodes revealed that two out of 34 tested positive for cancer, making my diagnosis stage two invasive ductal carcinoma.

Because the cancer was multi-focal, my only surgical option was a mastectomy. My breast surgeon put me in contact with a plastic surgeon. I will never forget that day. I was at home with one of my daughters, and I was extremely upset. I called the plastic surgeon’s office and spoke to the surgical coordinator. She was an angel in disguise. She set me up with an appointment right away, and was so comforting and compassionate, that I actually felt better when I hung up the telephone.

After discussing all of my options with the plastic surgeon, I decided to have free flap breast reconstruction using skin, fat and muscle from my lower abdomen. In November of 2004, I had the nine-hour operation, which included my mastectomy and my TRAM free flap breast reconstruction. I remember the night before my surgery looking in the mirror at my left breast, and feeling very angry that it had betrayed me. I have never mourned the loss of that breast, and I am confident that I never will.

I woke up with four drains, but I did not feel as bad as I thought I would. Unfortunately, later that day, a nurse mixed up my pain medicine and I almost ended up in the intensive care unit. In spite of that, I was home five days later, and my healing progressed quite rapidly. To everyone's surprise, I was able to cook Christmas dinner for my family just a few weeks after surgery!

Several days after I left the hospital, my breast surgeon called me with the pathology results. Additional tumors were found during the mastectomy, and one of them was close to my chest wall. Because of this, in addition to chemotherapy, I would also need radiation. My breast surgeon strongly suggested that I consider having a prophylactic mastectomy on my right breast. I decided to wait until I was finished with all of my treatments before having more surgery.

I went back to my plastic surgeon and explained my situation. I knew that abdominal reconstruction was a one shot deal and was not available for my right breast. The other option he suggested for me was to have a latissimus dorsi flap from my back combined with an implant. This would give my right breast the natural shape that I had in my left breast.

I had surgery in November of 2005, one year after my first operation. Immediately after having a right mastectomy, I had a tissue expander placed under the latissimus dorsi flap to make room for an implant. I went home in three days with four drains. I found this surgery to be more challenging because it was hard for me to get comfortable with the pain both in the front and backof my body. I returned to work in three weeks, with one drain still in place. I visited the plastic surgeon a couple of times to have the expander filled, and I had a third operation several weeks later to insert the implant. Early in 2006, I had a revision surgery to correct dimpling on the left breast, which was a result of the radiation.

At this point, my breasts looked amazing with clothes on, and a little strange without them, because I didn't have nipples yet. The old me was a size A or B, and the new and improved me was now a size D, without sagging!!!

Late in 2006, I had a fifth procedure to create nipples. Even though I saw pictures, I wasn't sure what to expect when the bandages came off. I was not prepared for all the emotions I felt when my doctor took them off. I was relieved that I was so close to being done, and I was grateful and amazed that my breasts looked so real. I was a bit scared about how prominent the nipples appeared, but my surgeon assured me the swelling would subside in time.

I cried the first time I took a shower after the bandages were removed. I felt sexy in front of my husband again! And I remember that I wanted to show all of my friends and family how beautiful my breasts were!

In a few weeks, I will have my saline implant replaced with a new cohesive silicone gel implant, which should correct some skin rippling issues in my right breast. I assure you that it bothers my plastic surgeon more than it bothers me! Tattooing can be done in order to give my nipples a more natural color, but I am not sure if I will go through with that; perhaps, enough is enough!

I won’t lie, at times my breasts feel heavy, and I am aware of the implant. I miss the feel of my husband’s touch and hate it when I have an itch that I can’t scratch because my breasts are numb. But I am here, and grateful to be healthy!

I look back at my odyssey and wonder how I went through it all. I remind myself that I am a strong woman, who intends to live a long healthy life, and this was simply a speed bump along the way. I’m grateful that these reconstruction options were available to me. I often think of all the women in the past that woke up from breast cancer surgery with no good options for reconstruction. I feel very blessed and proud that I chose the doctors I did, and that I made the right choices for me.

 

Photos and Doctor Commentary

 

Photo of Donna's Procedure 

 

Photo of Donna's Procedure

Pre-operative markings for left mastectomy and TRAM free flap
After left TRAM free flap

Although Donna was thin and had a lower abdominal vertical scar from prior surgery, she had enough skin and fat for a TRAM free flap breast reconstruction. The distribution of her abdominal fat, and the healed scar from her prior surgery, resulted in a flap design that extended above her umbilicus. As a result, the scar on her abdomen after surgery is slightly higher than usual.

 

Photo of Donna's Procedure  Photo of Donna's Procedure

Pre-operative right mastectomy and latissimus flap implant reconstruction

 

Right latissimus flap donor site markings

 

Photo of Donna's Procedure
After right latissimus flap implant reconstruction and previous left TRAM free flap

One year later, when Donna decided to have a prophylactic right mastectomy, the abdomen was no longer available as a flap donor site for reconstruction. The right latissimus flap was designed with a skin island to mimic the left TRAM free flap skin island. The right breast reconstruction with a latissimus flap and an implant provides a better and more symmetrical result than an implant alone. Note that the left breast TRAM free flap has decreased in volume and has some scar irregularity as compared to the earlier post-operative image which followed the left mastectomy. This is because Donna required radiation to the left chest wall after her left mastectomy and reconstruction. The right side was not radiated.

 

Photo of Donna's Procedure  Photo of Donna's Procedure
Photo of Donna's Procedure
After bilateral nipple areola reconstruction

Donna is seen here after bilateral nipple areola reconstruction and additional minor revisional surgery. To improve flap symmetry and contour, Donna underwent fat injections to both breasts as well as scar revision on the left breast. If she likes, in the future she can have nipple areola tattooing to provide a darker color.