Breast Reconstruction Q&A with Scott Sullivan, M.D., F.A.C.S.: Flap Reconstruction

By on July 8th, 2015 Categories: Treatment & Side Effects

Welcome to our breast reconstruction Q&A blog series with Scott Sullivan, M.D., F.A.C.S. of the Center for Restorative Breast Surgery in New Orleans, LA. In this installment of our series, Dr. Sullivan answers your questions about using your own tissue to reconstruct a breast (flap reconstruction).

Read the Q&A with Dr. Sullivan on implant reconstruction.

Q: I am planning to have double mastectomy with immediate reconstruction, followed by radiation. I would prefer to have DIEP or SIEP flap surgery [reconstruction using an abdominal tissue flap], but will that interfere with or delay the radiation?

A: In most cases, no, it will not interfere with the radiation. It is common practice to have mastectomy with immediate flap reconstruction, followed by radiation 4 to 6 weeks later.

There can be some exceptions. If the surgical oncologist and radiation oncologist are concerned that immediate reconstruction could make the radiation less effective, this would be a reason to delay reconstruction. Obviously, the most important goal is to get rid of the cancer and not have it come back. We’ve had cases where a patient has a later-stage breast cancer that involves the skin lymphatics [lymph vessels under the skin]. The radiation therapist would rather not have a flap or an implant under there, because they want to thoroughly radiate the skin and the surrounding areas. In these cases, we suggest no immediate reconstruction, the patient to complete radiation, and then after some period of recovery the reconstruction takes place. In most cases, though, the radiation oncologist will give the OK for immediate reconstruction.

If a woman is very lean and opts for flap reconstruction, this might be another case where we’d delay the reconstruction until after radiation. Sometimes, the radiation can have an adverse effect on the flap tissue, causing it to harden and turn to scar tissue. We call this fat necrosis. The risk is fairly low — from 3 to 10% — and it can vary from surgeon to surgeon. Part of it depends upon their technique and how many blood vessels they “recruit” and reattach in the new area to make sure the flap has sufficient blood supply. In a woman who is really lean, we are concerned that if they develop fat necrosis as a result of radiation, they may not have additional options to correct it with another flap or transfer of fat tissue. Sometimes we recommend placing an implant at the time of mastectomy as a “space saver,” and then they have the radiation. Later on they can have the implant taken out and replaced with a tissue flap.

So these are the only cases where you might need to wait to have flap reconstruction until after radiation. Now, there are some plastic surgeons who always recommend using an implant as a space saver until radiation is finished, and then proceed with flap reconstruction. But there can also be complications with the implant as a result of radiation — it might get exposed to the radiation and there can be healing problems — and then it needs to come out. So you lose the advantage of it being a space saver and you can’t re-expand the skin later. That is why I generally recommend immediate flap reconstruction, unless a woman is very thin.


Q: I am considering fat grafting to fill in some concave areas after a failed TUG flap reconstruction [TUG uses a flap from the inner thigh to recreate the breast]. I’ve talked to my surgeon about taking some fat from the little pouches that have formed just in front of my underarm area since my bilateral mastectomy. Will this disturb the lymph vessels and put me at a higher risk for lymphedema?

A: So I assume this refers to the little fat pockets that are right in front of the armpit and hang out the front of your bra or bathing suit. If you had axillary lymph node dissection [removal of underarm lymph nodes] as part of your mastectomy, I would avoid taking fat from that area. It’s not likely to affect the lymphatic drainage, but it can — so to be safe, I would advise against liposuction in that area. Plus, there isn’t that much fat there anyway, and I don’t think it would be enough to fill in areas related to a failed TUG flap. There are many other parts of the body you can use as a source of fat, such as the outer thigh, back thigh, abdomen, waist, hips, and buttocks. If you did not have lymph nodes removed on that side, then it’s safe to do.


Q: How long does it take for abdominal swelling and tightness from DIEP flap reconstruction to resolve?

A: There is swelling in the abdomen and the subcutaneous tissue [tissue just under the skin] that takes about 6 to 8 weeks to resolve. Some people do retain fluid more than others, so it may take a bit longer for them.

When it comes to tightness, there are really two types: skin tightness and deeper scar tissue tightness. After we remove the flap, we have to stretch the remaining skin to cover the abdomen. So it feels tight at first, but the skin stretches and the feeling usually goes away in about 3 to 4 months. There’s another deeper tightness that results from the scar tissue that forms between the subcutaneous fat of the abdominal skin and the wall that covers the abdominal muscles. It will feel firm for about 9 months, until the scar tissue starts to soften and then that feeling will resolve.


Q: What do you tell patients about safely getting back into their exercise routines after reconstruction using their own tissue? For instance, what if you like to do yoga, Pilates, or more strenuous types of strength training such as weightlifting? How does one get back into that without any risk?

A: I tell my patients to wait 4 weeks before getting back into any exercise. Prior to that, I just want them to walk as much as they can handle, not lift anything more than about 10 or 15 pounds, and of course sleep on their backs. After 4 weeks they should be well healed, but they also need to realize there will be a period of rehabilitation as they get back into their workout routine and hobbies. They haven’t used these muscles in a long time, so there will be some weakness and normal aches and pains. As long as they listen to their bodies and they don’t go overboard with their activities on day one, they can gradually ease back into it after about a month.

Editor’s note: Anyone who’s had breast cancer surgery, with or without reconstruction, needs to be aware of exercising safely. See our Exercise section for more tips.


Q: After a flap reconstruction, is fat grafting to refine the results fairly standard? How soon after initial surgery would it occur? Is it painful, and what is recovery like? Would more than one treatment be needed in most cases?

A: In our practice, fat grafting is commonplace. Most reconstructive practices use fat grafting to refine the shape and symmetry of the breasts. We do it at the second stage — a revision stage that happens about 2 to 3 months after the first reconstruction. This delay allows the swelling in the breasts to resolve, so we can get a good idea of how they will look long-term.

For fat grafting, we use liposuction to take fat from another area of the body, collect it in a sterile way, and then process it so it can be injected into areas of the reconstructed breast that need a little more fill. It is great for adding more cleavage, filling the upper pole [upper part of the breast], creating more volume anywhere, or smoothing out any defects. If, overall, I want more volume in the reconstructed breast, I can inject it throughout the flap and go up about half a size.

Unlike a flap, though, the fat doesn’t have a blood supply right away, although it does establish one within a few days. About half of the fat that I inject will stay there permanently. This procedure isn’t painful to the breasts. The only pain comes from the liposuction that takes extra fat from another area of the body. You’re going to have a little bit of discomfort there — almost like the soreness you might feel after a very hard workout. You also might have some swelling. The discomfort lasts for about 3 to 5 days. You can have some bruising, which takes about 2 to 3 weeks to resolve. You’d wear a compressive girdle on the area for about 2 weeks. There isn’t much activity restriction after liposuction.

For most women, fat grafting is done only once because we’re using it for small volume refinement. If someone needs correction for a large portion of the flap, or for a large volume difference between the breasts, it could take a couple of sessions to graft the amount of volume desired. Most commonly, though, it’s just the one time.


Q: I just had an ultrasound to check on lumps that formed in my DIEP reconstruction. I do have some fat necrosis, but these are multiple, self-contained areas. Are these flaps prone to cysts? Needle biopsy is being recommended — is that really needed?

A: Any free flap can develop fat necrosis, whether the tissue is taken from the abdomen, as a DIEP flap is, or the buttocks, hip, or thigh. Fat necrosis happens when some of the fat inside the flap doesn’t get enough blood supply and it hardens. Sometimes you get fat necrosis from when we secure the flap to the chest wall to keep it in position. Some of the fat in the flap dies, and your body forms a wall of scar tissue around it, almost like a capsule. Sometimes a large area of fat necrosis takes on a honeycomb-like shape, with scar tissue surrounding the fat. Most often, though, fat necrosis tends to be minimal.

Oil cysts also can form in a reconstructed breast, but they are more common with fat injections than with a free flap. An area of fat can die and turn into oil, which then forms the cyst. These are more common with fat grafting because the injected fat initially does not have a blood supply; it has to establish one over time. If the fat from the injection doesn’t take, it will die and then can turn into an oil cyst.

We always recommend that patients with flaps do breast self-exams. Sometimes with fat necrosis patients will feel a little lump, like a pea-sized firmness, or maybe a larger area of hardening. Imaging is recommended, and the best tool is high-resolution ultrasound. A good radiologist can usually tell if it’s fat necrosis or a cyst versus something more concerning. If there are characteristics of the lump that raise any concern, I would say that yes, a needle biopsy is warranted — simply to make sure that it’s not something bad that’s growing.

Generally, small areas fat necrosis and cysts aren’t painful, and often they don’t have to be biopsied unless there is reason for concern and the breast surgeon or radiologist recommends it. Larger areas of fat necrosis can be painful and may be best treated by removing them.


Q: I’ve been having annual mammograms on my DIEP flaps. My plastic surgeon says it can’t hurt, and I have heard that some major medical centers recommend having mammograms or MRIs. However, I also know that many women with DIEP flaps don’t have regular imaging. What do you recommend to your patients?

A: We usually defer to the breast surgeon who is following the patient. Within our practice, though, we do not recommend routine imaging after reconstruction. As I said in my last response, we recommend seeing your breast surgeon regularly and doing self-exams, and then if you feel something unusual, such as a little lump or mass, it can be evaluated. Your fat in the flap cannot turn into breast cancer, but that doesn’t mean the risk of local recurrence is zero.  Remember, they cannot remove every breast cell with mastectomy.

Many breast surgeons do recommend a mammogram post-reconstruction, so they have a baseline image to refer to if there is a mass or lump that requires evaluation down the road. A baseline MRI is even better, since it shows more detail about the soft tissue structures, but often, insurance companies will not cover it. MRIs are definitely not needed annually.


Q: I have lymphedema in my trunk and arms after bilateral mastectomy. I am planning to have DIEP reconstruction, and I am wondering if this will help with the lymphedema — or make it worse? Given my history, am I at greater risk for lymphedema after my tissue flap is removed?

A: Lymphedema is a well-known complication of breast cancer treatment. We’ve found that when we reconstruct a breast with a woman’s own tissue, it can actually help with lymphedema in the area of the trunk and arms. When you move healthy, non-radiated tissue up to the chest area, it can help decongest the arm [getting excess fluid to move out of it]. If a patient already had radiation as part of treatment, it created scar tissue, and now they are taking that out and replacing it with normal-healing tissue with healthy vessels. The lymphedema may get somewhat better, and it’s unlikely to get worse.

It’s not likely that you will develop lymphedema in the lower extremities due to the tissue removal from the abdomen. Certainly it’s always a concern when we disrupt the lymphatic system, but the risk is considered small. There are some people who retain fluid more than others — they may have swollen ankles at the end of the day, for example — so if you think you may fall into this group, it’s worth discussing with your doctor.

Kris Conner, MA, Contributing Writer--Kris has been writing about cancer and other medical conditions since 1998. Her first assignment involved creating content for the National Cancer Institute's patient-focused web site on clinical trials--and she was hooked. Since then, she has worked on projects for several cancer centers, educational web sites, and advocacy and professional groups, and she co-authored Ovarian Cancer: Your Guide to Taking Control (O'Reilly, 2003). Kris also works on marketing and development projects for hospitals and health systems, schools and universities, and nonprofit clients.

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