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Updated: December 2011

Areola-sparing Mastectomies, DIEP flaps


pre-operative bilateral mastectomies tissue expander alloerm
Before
After

This patient is seen before and after bilateral areola-sparing mastectomies and DIEP flap breast reconstruction. This approach was chosen in order to preserve the natural color and texture of the areola, though remove and reconstruct the nipple to eliminate oncologic concerns about nipple preservation. Her favorable preoperative breast shape showing an appropriate position of the nipple and areola and minimal sagging made her a good candidate for areola preservation; the presence of sufficient lower abdominal tissue allowed for DIEP flap reconstruction. The flap also provided the extra skin needed to reconstruct the nipple within the preserved areola.

Karen's Breast Reconstruction Story:

 

After my annual mammography and sonogram at the end of December 2009, the Doctor came into the exam room and informed me that I needed two biopsies; left breast core needle, right breast stereotactic. I had both done on Jan 10, 2010 and five days later, I received a phone call from the radiologist with the results…left breast was benign, but the right was not. At age 45, I now had early breast cancer – 3.5 mm ductal carcinoma in situ (DCIS) and needed to see a breast surgeon and have surgery.

I had two very close friends who unfortunately had breast cancer the year before, but I was able to benefit from their advice on finding a breast surgeon, a daunting task. This was the most stressful time for me because many surgeons either did not take my insurance or, if they did, the first available appointments were five – eight weeks away. I had cancer; I did not want to wait. I actually met with only two breast surgeons and two plastic surgeons. One breast surgeon’s office was like a production line; the office staff lacked warmth and were unfriendly. While I liked this well respected surgeon, I knew this was not the place in which I wanted to be treated.

My gynecologist recommended another surgeon who was less well known and I immediately felt very comfortable with her and connected. She, like the other surgeon, was offering me a skin sparing mastectomy and seemed to be open to the different types of reconstruction. I felt somewhat conflicted in choosing between someone well known and my innate sense. There was another important piece to completing this puzzle…selecting a plastic surgeon. The minute I stepped into one of the two with whom I met, I knew he was the one. Not only did he come highly recommended, but he spent a great deal of time with me, explaining every option. He was warm and compassionate as was every staff member on his office team. It felt like home…I knew I could trust this doctor and his staff with my life. So I turned to him to help me select a breast surgeon and his advice was exactly what my gut was telling me to do!

Since my cancer was in such an early stage the first option presented to me by both breast surgeons was a lumpectomy followed by radiation with the possibility of taking tamoxifen for a few years. This was basic protocol for early DCIS….. I had already done a great deal of research, thanks to the internet, knew this option was not for me!!!! My mom was diagnosed with breast cancer when she was 46 I watched her go through hell…..6 months chemo, hair loss, appetite loss, radiation!!!! My maternal grandma also had breast cancer in her 60’s, so my sister I figured the odds were against us…one of us would inevitably end up w/ breast cancer. So, every year when my mammo results were good I was happy that I bought another year. When I heard I had breast cancer I was not shocked, I was not scared, I was relieved……I was so happy felt blessed that it was caught so early. So having a lumpectomy was not an option because with that came lots of follow up a chance of recurrence. The survival rate is practically the same but why would I want to worry about this ever again. If I had the bi-lateral mastectomy the survival rate is over 99% no chemo, no radiation, no more biopsies, no more mammo’s, no more mri’s no worry!!!!

Many options for reconstruction were presented to me by my plastic surgeon. I chose to go with Diep Flap because I wanted natural looking breasts, did not want them big since I was naturally a small breasted woman hated the pouch I had on my stomach. Yes, this surgery is much longer the recovery is much longer but I knew this is what I wanted. I was not afraid of a little pain. I also spoke to a few women who had the 2 surgeries I was considering (the other one being implants with expanders) this helped me confirm my decision. Once my decision was made, I was introduced to my doctor’s associate; together they would perform the surgery. The associate looks like a “kid” but he is one amazing Doctor I grew to love him just as much as the other half of the team. I am thankful for the surgeons I chose because they are innovative…. gave me a skin & areola sparing bi-lateral mastectomy w/DIEP flap reconstruction I have the most natural looking breasts.

The surgery was long, very long….I went in around 8 am woke up in recovery after 11:00 pm. I spent the night in recovery with an outstanding team of nurses &was moved to a room the next day. I felt ok…..must have been the morphine!!! My surgery was on Friday, by Sunday I was out of bed walking around, it wasn’t easy but I was doing great. Remember, the incision was across my abdomen from hip bone to hip bone. The worse part of this was the drains. I had 4 of them, one coming out of each breast one on each side of my abdomen. I went home a few days later was able to walk up down steps. I felt great, except for those annoying drains! The other issue was sleeping. I am a side sleeper but I couldn’t do that so I had to learn how to sleep on my back. The drains eventually came out that was the best day ever. I pushed myself a little each day; I had exercises to do tried not be lazy – walking laps around the house. It was hard for me to remember to relax; since a big part of the recovery is letting your body heal not push too much. I would say the surgery recovery were tolerable. Yes, there is some pain but mostly discomfort. While I would have liked to return to my usual activities more quickly, the abdominal recovery needed time. I was driving four weeks post op and waited 10 weeks to lift anything heavy. I had my nipple reconstruction approximately 3 1/2 months later (very simple day op) a few months after that I had them tattooed in the office…both procedures are painless!!!!!

The overall experience and process for me was more about making decisions about physicians, making appointments just getting it done! Not for one minute did I ever feel sorry for myself or feel worried about my life. Maybe for one second, I thought “what if it’s really not as early as they think”….but I put it out of my mind prayed to my parents (who both lost their lives to cancer) to give me strength to deal with whatever was coming my way. I thought of my Mom she was my inspiration. I believe her spirit strength got me thru this.

The doctors I chose and their office staff also made the overall experience as pleasant as possible. The office head nurse is the most compassionate, sweet nurse I have ever encountered. Taking out the drains stitches is not fun but she made it not so unpleasant. Additionally, having a separate staff member on the team who provides emotional support throughout this process was significant. She was so compassionate her voice words were always so comforting. Her guided imagery/relaxation therapy was a huge help I would recommend it to everyone in moving through this journey.

Now, more than a year later, I am doing great on both a physical emotional level. Physically, I still get shooting pains once in awhile in my breast abdomen but otherwise I feel great!!!!! Emotionally, I have always been ok continue to feel so blessed that my cancer was caught so early (not sure if I mentioned the biopsy of my lymph nodes was benign my cancer was gone). I just feel so lucky, especially when I see what some of my friends and other woman are going through. The love support that I received from my family friends helped me get through this!!

I will be forever grateful to them!!!

 

Photos and Doctor Commentary
 

areola sparing mastectomies DIEP flaps preop

Pre-operative photo

Karen consulted for bilateral breast reconstruction that would be performed concurrently with the scheduled bilateral mastectomy for DCIS. The patient also presents with a family history of breast cancer. On examination both breasts had no significant excess skin or sagging, and showed an appropriate position of the nipple and areola. This finding made her a good candidate for areola preservation; even though she has a thin body type, lower abdominal tissue was considered sufficient for bilateral DIEP flap reconstruction. The plan of areola-sparing mastectomies and DIEP flap reconstruction was chosen in order to preserve the natural color and texture of the areola, and at the same time remove and reconstruct the nipple to eliminate potential concerns of future cancer in the breast tissue left behind with nipple preservation.

 

 areola sparing mastectomies DIEP flaps markings

Preoperative Markings

Here is Karen laying down with her preoperative markings for bilateral skin and areola-sparing mastectomies. Only the vertical line extending from the nipple is used for the mastectomy incision. The abdomen is marked for bilateral DIEP flaps. The location of the blood vessels as predicted by the preoperative CT angiogram is indicated. The DIEP flaps also provide the skin that is used to reconstruct the nipple within the preserved areola in a second procedure.

 

areola sparing mastectomies DIEP flaps after 1st stage  

Post-operative bilateral areola-sparing mastectomies and DIEP flap breast reconstruction

Here is Karen 3 months after her bilateral areola-sparing mastectomies and DIEP flap breast reconstruction. The reconstructed breasts show good symmetry and contour. The flap skin visible in the center of the reconstructed breasts was temporarily placed between the areolar skin in preparation of the nipple reconstruction. The abdominal scar is more visible during the initial healing until it has more matured. The prior vertical abdominal scar has been eliminated with the horizontal abdominal closure. Karen is now ready for the second stage of the reconstruction.

 

areola sparing mastectomies DIEP flaps nipple preop

 areola sparing mastectomies DIEP flaps nipple first stage areola sparing mastectomies DIEP flaps nipple post-op

Before and after bilateral nipple reconstruction (left and right), compared to her preoperative appearance (top)

The DIEP flap skin island within the preserved areolar skin is folded onto itself to create the nipple. The preserved areolar skin is falling back into place. After allowing some time for healing, the reconstructed nipples are tattooed to match the areolar skin.

 

 areola sparing mastectomies DIEP flaps post-op

 areola sparing mastectomies DIEP flaps post-op  areola sparing mastectomies DIEP flaps post-op

   areola sparing mastectomies DIEP flaps post-op  areola sparing mastectomies DIEP flaps post-op  

Completed bilateral DIEP flap breast reconstruction

This is Karen’s completed breast reconstruction. She is seen 9 months after her areola-sparing mastectomies and DIEP flap breast reconstruction.