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Updated: March 2009

SIEA Flap After Skin-sparing Mastectomy

Photo of Sami's Procedure
Before
After

This patient required a left mastectomy. She is seen here before and after undergoing a left skin-sparing mastectomy and breast reconstruction with an SIEA flap.

Sami's Breast Reconstruction Story:

 

The day began as any other. I worked out at the gym and arrived home in time to get my children, ten-year-old Jeremy and seven-year-old Sydney, ready for school. I had an appointment to have additional mammography pictures taken. The day before, while reviewing my mammogram, the radiologist found suspicious areas in my left breast that required more pictures for a better look. I was told they might be calcifications.

After the pictures were taken, I waited for the results. There were three calcification spots. I was told that I should return in six months for follow-up. I got in my car and called my internist. I had felt a very small lump for one year in that same breast, but the lump never showed on a mammogram or MRI. The year before I had been told everything was clear. I met with my internist that afternoon, and we decided that I should see a breast surgeon.

Two biopsies later, I was told that I had two different types of breast cancer in my left breast. I thought that my results had gotten mixed up. I have no family history of breast cancer. I’m an active, healthy woman. In my situation there was no choice to be made; I needed to have a mastectomy.

I think I went into shock when I was told. I was afraid of dying and leaving my children without a mother. I was afraid of what I would look like, and I did not know very much about the surgical options for reconstruction. My husband was so strong for me, listening to me at all hours and handing me many tissues. He always listened, but he left the final decisions to me.

I turned to a very good friend that I grew up with. She had been diagnosed just a year before me and she was doing well. She chose to have the DIEP flap method of reconstruction. At first, I did not consider this to be an option for me. I wanted a quick recovery so that I could get back to my normal boring life. I take care of my two children, and I work while going to school for my doctorate in audiology. I didn’t have time to sit and recover.

I spoke to two plastic surgeons. As with any doctor, I looked for experience, attention to detail, and a personality that made me feel comfortable. I had to completely trust my surgeons, or nothing that they would do for me would be right. I did not want a surgeon with his own agenda, or one who pushed his method on me as the only way to do the surgery.

The first surgeon discussed his reconstruction method using tissue expanders and implants. He did not perform the DIEP flap surgery. I would have a fairly quick recovery, with post-operative visits every few weeks, and a future procedure when I was ready for the actual implant. This seemed to fit my needs. I wanted a short recovery to minimize the disruption of my children’s schedules and to allow me to return to work and school as soon as possible. In my mind, returning to my normal schedule would help my healing process.

The second plastic surgeon, asked me what type of reconstruction I was considering. Again, I thought I wanted implants. He examined me, discussed his procedure and showed me before and after pictures. I was able to see and feel what the implants were like. I left feeling that at least there would be something on that side of my chest after the mastectomy.

After giving it some thought, I contacted the second plastic surgeon again, and asked if we could talk about the DIEP flap method of reconstruction. My husband was surprised by this, since I had not seriously considered this method before. I did some soul searching and thinking. Did I want to use a method that would meet my short-term needs? What were my long-term expectations for my body? I wanted to look and feel as natural as possible. I was having a single mastectomy, not a double. I was worried that implants would never quite match my natural breast in shape and feel. I was not sure how I would feel about having something artificial in my body.

At a second consultation, I listened to the surgeon describe the DIEP method and we reviewed some before and after photographs. I became convinced that this was the reconstruction method for me. I would be able to leave the hospital looking and feeling like any other woman, even though I understood the recovery would be more difficult early after surgery. I left the plastic surgeon’s office feeling completely confident in his abilities. This was the first time since my journey began that I felt a sense of relief. The weight of the world was lifted from my shoulders. Jokingly, I told my close friends that I was having a tummy tuck and a boob job. I can’t say exactly why I changed my mind, but I can tell you that I am very pleased with my decision.

I waited four weeks for my breast and plastic surgeons to join me for this life changing surgery. In that time, I spoke to my friend and to a patient that had the same procedure performed by my plastic surgeon. This helped me to prepare myself as well as my family and home for the surgery and recovery period. Being able to prepare gave me some sense of control over my situation. I was given valuable information about how to prepare my home and what type of clothes would work best after surgery. I prepared moist bathing towels that I could heat in the microwave, and I divided my laundry detergent in advance into small amounts because I knew that I would not be able lift the heavy container after surgery.

My family and I were ready for the surgery and for the recovery. My mother watched my children at home. At the hospital I met with my surgeons and the anesthesiologist. We were set to go. My husband stayed at the hospital for the duration of my surgery. I cannot imagine how stressful that must have been for him. When I awoke in recovery, my husband was standing over me. I was comfortable, and I was given a pump to self-medicate in case of pain. I remained in recovery overnight so that the nurses could frequently check the flap and the incision sites. I had slept well the night before surgery, and then effectively I slept another nine hours during surgery. I ended up being awake most of the night in recovery.

My plastic surgeon came into the recovery room after surgery to speak with me and my husband. He told me that during surgery, when he saw my superficial inferior epigastric artery and vein, he knew that those vessels would be able to support the flap. Instead of the DIEP flap reconstruction, he did an SIEA flap. Less than 10% of patients have usable vessels to have a SIEA flap breast reconstruction. The benefit to this reconstruction was that I had absolutely no incision in my abdominal muscles whatsoever. He told me that it was the best possible scenario for both the patient and the surgeon.

The next day I spent resting in my room. I had not looked at myself yet. There were no bandages on any part of me. When the doctors came to see me and check on the incisions, I looked straight ahead at them, not down at myself. I was afraid to look. I had seen pictures of reconstructed breasts and they looked natural, with minimal scars, but I was still afraid to look. I had confidence in my surgeons, so I feel that my fear was part irrational and part my mind wandering to a dark area where I tried not to go. This fear did not last for long. I knew that I was in good hands because I felt that my plastic surgeon was looking at my breasts as an artist would admire a sculpture in progress. My breast surgeon convinced me to at least feel what my new breast felt like. I felt the side that was natural and then the new me. My new breast was warm, soft and the same size and shape as my natural side. Instantly I smiled, and then I cried. I was overcome with emotions.

The first time I got out of bed, I was amazed at how little I could straighten up. I shuffled to the bathroom, afraid that I would not make it in time. By the time I got back into bed, I was exhausted. The whole next day I sat in a chair and took very short walks. Visits from friends really boosted my spirits. I was ready to leave the hospital three days after surgery.

I had four drains that aided the healing process. A drain consists of a grenade shaped bulb attached to a thin flexible tube that is stitched into the incision. In the hospital, the drains were attached to a necklace made from gauze. Once home, I pinned them to the inside of my clothes for comfort and discretion. Each drain had a number and needed to be drained and measured twice daily. The nurses in the hospital showed my husband and I how to do this. My husband actually took care of the drains for me the first few days at home. I was told that the drains helped the healing process. I could not wait for them to be removed. I thought that would happen on my first post-operative visit. Well, not so fast. The drains became part my daily routine. My surgeon told me that the drains needed to remain until they reached a certain output level. He would not tell me the “magic number”. I think it was on my third post-operative visit that I finally had the last of the drains removed. I felt so free. It was at this visit that I was given the post-operative bra to wear. Wearing a bra never felt so good.

Standing straight was not possible for a few days. I did not experience pain, but a pulling sensation in my abdomen. I was able to climb stairs slowly, and get in and out of bed. To be comfortable in bed, I arranged several pillows of different sizes. I learned to sleep on my back, something I never thought I would be able to do.

For the first day or two after I got home, I was not ready to shower. I used good disposable bathing towelettes that I heated in the microwave. When I did shower, I used a seat for the first two days. I cried the first time I looked at myself. Within a few days, I really did not notice my new breast. It was the only time in my life that I had something in common with a Barbie doll; a breast with no nipple. I knew that having no nipple was a temporary situation, but I was a bit worried about my husband’s reaction to it and me. I think that he would tell anyone that he did not care about how I looked. He just wanted me healthy and happy.

I am normally an active person who enjoys working out, but for the first four weeks, I did little more than take short walks, sleep and study. My friends brought over meals (I did not need to cook for several weeks) and helped with my children. I started to drive and I went back to the gym one month after surgery. Slowly, I began to walk on a treadmill, use a recumbent bicycle and then the elliptical machine. I felt stronger everyday. Five weeks after surgery I returned to work. Although I was tired, it felt good to get back to my routine.

Four months after my mastectomy I had nipple reconstruction surgery. As I write this I am healing from that surgery. There may be a bit more work to be done, but every day I get one step closer to my happy, normal, boring life.

 

Photos and Doctor Commentary

 

Photo of Sami's Procedure

 

Photo of Sami's Procedure

Pre-operative

Markings for abdominal free flap breast reconstruction

Sami was marked pre-operatively for an abdominal free flap breast reconstruction.  Although she was thin, she had enough skin and fat on her lower abdomen for a unilateral free flap breast reconstruction.  In the operating room, it was determined that the abdominal flap could be elevated and transferred as an SIEA flap, avoiding incisions in the abdominal muscles.

 

 
Photo of Sami's Procedure

After left mastectomy and SIEA flap

 

Photo of Sami's Procedure
Photo of Sami's Procedure
Markings for left breast revision and nipple areola reconstruction

After the left skin-sparing mastectomy and SIEA free flap breast reconstruction, the skin island on Sami’s left breast is larger than her right areola.  Markings were made for reduction of the left areola size to better match the right side.  Also, markings were made on the hips for excision of skin to be used for her nipple areola reconstruction.

 

Photo of Sami's Procedure
Photo of Sami's Procedure
After nipple areola reconstruction and tattoo

Sami is seen here three months after left nipple areola reconstruction and two weeks after tattooing of the nipple areola. There is still a red discoloration from the recent tattooing procedure. The final color will be evident in several months.