Microsurgical Breast Reconstruction - San Francisco

Q: Any Recommendations for the Best Reconstructive Plastic Surgeons Who Do DIEP?

2011-06-06T10:27:00.000-07:00

A: Find a plastic surgeon who has done a fellowship in microsurgery and/or who currently does high volume reconstructive microsurgery.

You can usually find a small number of plastic surgeons in a major city, often times at an academic medical center, who perform the DIEP operation or other complex microsurgical procedures on a regular basis.   Having a microsurgery fellowship means that the plastic surgeon spent an additional year (after their usual 6-8 years of training) performing high volume, complex microsurgical cases.  Very often, these reconstructive microsurgeons are members of the American Society for Reconstructive Microsurgery (ASRM) in addition to the American Society of Plastic Surgeons (ASPS)
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It is very rare when a DIEP cannot be performed, but it is ultimatley an intraoperative decision as to whether you end up with a DIEP or some variance of a TRAM.   New imaging modalities with CT Angio or Duplex ultrasound can help "map" these vessels and delineate the anatomy better, but there is no guarantee.   Your surgeon will always perform the operation that best suits you and your anatomy, to give you the safest and best result.

The best plastic surgeon for you is the one who is qualified and who understands your individual needs and presents the best options for you.   I welcome you to contact our office at 415 933 8330 to discuss DIEP breast reconstruction, and/or other autologous (self) tissue options.

Do Breast Reconstruction Tissue Expanders Cause Pain As They Expand?

2011-06-06T10:20:00.001-07:00

A: Tissue expansion can be uncomfortable, but should not be painful

Tissue expansion of any type can cause some amount of discomfort and is highly dependent upon the volume and the rate of the expansion. Pain should be a guide as to when the expansion should stop and allow your tissues catch up to the amount of expansion that can be tolerated. 50cc is an average volume of expansion for breast expanders and is usually well tolerated.

Q: Mastectomy and Breast Reconstruction - Can the Procedures Be Combined

2011-06-06T10:02:00.001-07:00

A: Combined mastectomy and breast reconstruction is possible

This is similar to the idea of "immediate vs. delayed breast reconstruction."

The combined procedure is possible, and often times, the preferred method of breast reconstruction. This "immediate" reconstruction allows for the best aesthetic result because the skin of the breast is saved and an implant or "self tissue" (DIEP, TRAM, etc) can be placed inside the original breast pocket. The general surgeon and plastic surgeon work together with the first surgeon removing the breast tissue and the second surgeon reconstructing the breast in a single stage. This is the key advantage. The disadvantage can be wound issues from thin mastectomy flaps and/or unresolved oncologic issues at the time of reconstruction.

Can Inverted Nipple After Lumpectomy Be Repaired?

2011-06-06T09:59:00.001-07:00

A: An inverted nipple can be corrected

The short answer to your question is yes. Nipple inversion can occur for several reasons after your lumpectomy. This includes the "inner" scarring that occurs that likely brough part of the nipple with it, causing an inversion. To fix this, it is important to figure out which parts of the breast caused this: loss of skin, skin contracture, fat necrosis, infection, radiation, etc. Once this has been evaluated, then the principle of treating any nipple inversion are used: release the scar, add more tissue, etc. Recurrence can be common, so it is best to see a plastic surgeon with significant experience in this area.

Radiation Wounds & Injury around the Breast for Cancer

2011-02-20T12:30:00.000-08:00

Radiation treatment (RT) is a double edge sword in the treatment of cancers. Just as with chemotherapy, it attacks the cancers cells, but also damages normal cells.   This is quite evident when the "marks" of radiation are left behind on the skin in the form of a tattoo, and more seriously, as a radiation wound that may ulcerate or turn into cancer. RT is a common treatment for breast cancer, especially for "breast conservation" techniques and to treat the local area for possible recurrence even after mastectomy.

Despite advanceces in RT, long-term complications of radiation injury are still quite common, in the range of 20%, Depending upon the cycle and total dose, the body's response to radiation is similar to a "burn." There is soft tissue fibrosis and decreased blood flow which can lead to ulceration, tissue necrosis, infection, chronic wounds, and sometimes, cancer.  This may not be apparent for many years, but it is often a slow, progressive injury with difficult treatment options.   .

RT makes wound healing extrmely difficult because of the tissue"fibrosis" and decreased blood flow. Once a wound forms in a radiated area, it is often a sign of more serious injury deep below the skin, including muscles, bones, cartilage, blood vessels and nerves.   Typical "wound care" with dressings are usually not enough to heal this damaged area.   Hyperbaric oxygen (HBO) may help in these circumstances, but ultimately, the radiated wound needs additional blood flow and cleaning out of the damaged and/or necrotic/infected tissue. Additional oxygen with HBO can only do so much when blood flow has already been reduced by the RT.

In select wounds, especially around the breast, the best form of treatment to heal radiation damaged breast tissue is with new, non radiated tissue that is brought to the area with additional blood flow, in the form of a "flap."   This reqiures careful assesment and planning and is the gold standard by which a complex wound can be healed.    Fortunatley, around the breast, there are many options to bring new tissue from the abdomen or back to treat the damaged area.    The breast can be completely reconstructed at the same time as the wound with designer flaps such as the DIEP or SIEA perforator flap in a single procedure.

Most importantly, the health practitioner must recognize when the current treatment of an irradiated breast wound is not working.   Far too often, I have seen patients who have had over 100 treatments with HBO, or years of a chronic, nonhealing wound, or with recurrent implant/tissue expander infections/capsular contracture.   3 months is the maximum time that a wound should be treated in the same manner with minimal progress; it is at this time that a higher, expert level of assesment must be performed to determine further treatment options.

What is the difference between "Immediate" and "Delayed" Breast Reconstruction?

2011-01-10T20:41:00.000-08:00

This is "surgical" terminology to describe the timing of breast reconstruction in either the "immediate" situation after mastectomy, or in a "delayed" fashion, after many months or years after the mastectomy. So the key difference is months, not hours.
There are advantages and disadvantages to each "timing" method. First, the advantage of "immediate" reconstruction is that breast reconstruction and mastectomy are performed in 1 operation. One does not have to wait for the "healing" after the mastectomy (typically 3-6 months), and wait for another operation to reconstruct the breast. In terms of aesthetics, if a "skin sparing" mastectomy can be performed, the breast shape can be excellent and the overall result of the breast reconstruction can be superb. The "skin sparing" techninque allows the surgeon to use the remaining skin as a cover over the flap (DIEP, SIEA, TRAM) or implant/tissue expander that will help shape the breast into a more natural mound.

The disadvantage of the "immediate" technique lies with the potential oncologic issues that can occur if the cancer issues are not fully eradicated, and the breast has been reconstructed with the possibility that cancer cells may come back to recur in the reconstructed breast. The other concern is radiation therapy. In the immediate reconstruction, radiation can adversely affect the outcome of the breast reconstruction (shape, healing, capsular contracture, etc).

The "delayed" technique is still the safest. It provides the optimum time for healing after mastectomy, addresses issues of "recurrence," and allows the operation to be split in 2 stages allowing the patient to recover from the initial mastectomy and then address the reconstruction later. The cosmetic result can still be excellent, with the "immediate" reconstruction having a slight advantage in overall shape.

The choice of "immediate" versus "delayed" is not an easy one. The overall team that is available is critical in choosing either method. This includes the general surgeons, plastic surgeons, oncologists, and nurses.

A Perfect Microsurgical Anastomosis (Blood Vessel Repair)

2010-09-11T11:44:00.000-07:00

Above: Microsurgical anastomosis between the Internal Mammary Artery and Vein to the Deep Inferior Epigastric Artery Perforator (DIEP) Vessels using an Operating Microscope. Dr. Alexis Carrell from the University of Chicago (1902) proved that we can successfully reconnect blood vessels using a technique called "triangulation"--he received the Nobel Prize for his efforts. Microscopes were used in vascular surgery in the 1960s (Jacobsen) and this allowed for blood vessels to be repaired that were less than 2millimeters. This began the revolution in Reconstructive MicroSurgery, the same techniques that allow us to Reconstruct the Breast by Tissue Transplantation (from the abdomen --TRAM, DIEP--, thighs, etc) and also allows Plastic Surgeons to transplant a hand or face.

Above: Close up of the Microsurgical Anastomosis (Reconnection between blood vessels)
Note the fine black sutures and precise interspacing to allow for free flow of blood between the 2 connectected blood vessels. These sutures are finer than human hair. The top, purple vessel is the Vein; the smaller, lighter pink vessel is the Artery. Reconnecting these blood vessels takes significant skill and patience.

The temperment of a Plastic Surgeon who performs Microsurgery is different from the average surgeon. Focused intensity, absolute precision (there is little margin of error for a microsurgical blood vessel connection to avoid a blood clot), creativity and the steadiest of hands are basic hallmarks. There is a reason why Reconstructive MicroPlastic Surgeons are a rare breed.

What is an SIEA Flap?

2010-01-10T23:15:00.000-08:00

The SIEA Flap is a pure abdominal skin and fat flap. SIEA stands for Superficial Inferior Epigastric Artery. This blood vessel system comes from the same branches of the DIEP flap, however, it is more superficial. It allows the surgeons to use the skin and fat from the abdomen (tummy tuck) tissue and blood vessel without having to enter the abdominal wall fascia. It is the most IDEAL flap for breast reconstruction in terms of donor site morbidity (the process of taking from one area to fix a different area). However, not every patient has this particular blood vessel system, somewhere around 40% of the time these blood vessels exist. When the blood vessels do exist, another 20% may not be usable because of their size. The great advantage of this flap is that the abdominal wall is not "touched" and therefore the rectus muscles (six pack muscles on the abdomen), are not touched. The disadvantage is that the blood vessels can be quite small the blood flow through the tissue can be variable. The success of this flap depends upon your body's anatomy and surgeon experience and technical expertise.

We can perform a color duplex ultrasound at the initial evaluation to determine if you are candidate for this flap procedure.

Note the Blood Vessels (SIEA System) over the blue background. These are more superficial than the DIEP system.

What is a TAP flap?

2009-02-24T13:12:00.001-08:00

Pic #1: Flap Design on Chest
Pic #2: TAP flap elevated
Pic #3: Donor Site of Chest (note incision, no loss of muscle)
Pic #4: Donor Site on Back

The TAP flap is a new perforator flap that originates from the same blood vessels as the Latissimus muscle. TAP stands for Thoracodorsal Artery Perforator flap. Because of its location, it has a very nice donor site, underneath the arm pit area and back. It can be used in breast reconstruction as a local flap or free flap, giving a lot of versatility.

This flap is not as large as the abdominal tissue flaps from the DIEP, SIEA, or TRAM, but has good indications for smaller to midsize breast issues. Typically, a lumpectomy or partial mastectomy defect can leave a significant breast deformity. This flap can be "rotated" into the wound defect or deformity or microvascularly transplanted into the wound.

New treatment options for postmastectomy lymphedema

2009-02-24T00:45:00.000-08:00

Lymphedema after a mastectomy is an extremely difficult problem. The mainstay of treatment has been lymphatic massage and physical therapy. Lymphedema usually progresses over time and the tissues become more and more recalcitrant to physical therapy and massage. Because of the inadequate lymphatic flow, tissue that is lymphedematous is more at risk for infections. This sets up the extremity into a downward spiral as the remaining lymphatic vessels are further destroyed by subsequent nfections. This then causes further lymphatic obstruction and edema and causes a worsening of the inflammation and scarring process, which leads to further fibrosis of the extremity.

The only true way to treat this condition is to restore the lymphatic flow where the obstruction is sitting. Previously, this has been done by lymphovenous bypass procedures. They have been only moderately successful. This requires extremely delicate microvascular anastomoses to reconnect lymphatics to the veins so that the lymphatics have a channel to leave the swollen extremity.

A more novel approach and more anatomically correct operation would be to replace the lymphatic channels with lymph tissue, and lymph nodes to help re-create new lymphatic channels. This can be accomplished by lymph node transplantation with a vascularized skin flap. This is a cutting-edge operation and the worldwide literature is quite sparse. The preliminary findings after this operation have been extremely promising. There has been a dramatic decrease in the number of infections as well as a significant increase and the diameter of the extremity after this surgery. These results are far better than the previous lymphovenous bypass surgeries and represents a new paradigm in treating extremely difficult lymphedema. This operation will likely serve as a more permanent solution to an extremely difficult and debilitating problem.

Use of the Internal Mammary Artery Perforator, No Rib Resection

2009-02-24T00:35:00.000-08:00

The internal mammary artery has become the vessel of choice for microsurgical breast reconstruction. It has become popular because the position the of the vessel allows the flap to be positioned on the chest at a more medial position, versus the more lateral position of the lateral thoracic vessels. If you study the breast mound position, you will find that medial placement of the mound is more important than lateral placement.

The main issue with the use out of this vessel are twofold. #1. It requires removal of rib cartilage and deeper dissection into the thoracic cavity to gain access to this vessel. This sometimes leaves an indentation on the chest wall where the rib was removed. #2. The left internal mammary artery is a common source vessel for coronary artery bypass surgery to revascularize the heart. This means that in some rare cases, if this vessel has been used for breast reconstruction, it is no longer available for heart bypass surgery.

It is our philosophy that we should try to avoid use of this vessel when possible. We have been able to find, in a majority of our cases, the perforating artery and vein to the internal mammary vessel. This has shortened our operating time as well as avoiding the issues discussed above with removable are written and use of the main source vessel for coronary artery bypass surgery. We have been able to identify this vessel with ultrasound techniques as well with finesse, microsurgical dissection.

What is a DIEP Flap?

2009-02-24T00:16:00.000-08:00

DIEP stands for the Deep Inferior Epigastric Perforator flap. This block of tissue is based upon the main blood vessel which supplies vessels to the rectus abdominis muscle. This flap has become popular for breast reconstruction as the block of tissue that is transplanted to reconstruct the breast is the same tissue that is removed for a "tummy tuck." The main advantage of this procedure is that it leaves the muscle mainly intact and only uses the tissue that is required for the reconstruction, mainly the skin and fat. In this procedure, extremely fine and delicate dissection is performed to preserve the very small blood vessels which connect the skin and fat through the muscle, then finally to the main blood vessel --the deep inferior epigastric artery and vein, which then connects to the external iliac artery.

Shown above is a DIEP flap that was harvested for a recent breast reconstruction case. The 3 photos show the Flap still connected to the rectus muscle, and then the flap detached and ready for transplantation. (Surgeons- Drs. C. Lee and S. Hansen, San Francisco)

Reconstructive Breast Surgery Team

2008-12-14T17:03:00.001-08:00

We offer over 20 years of combined experience in Microsurgical Free Tissue Transfers for Breast Reconstruction.

We perform the DIEP (Deep Inferior Epigastric Artery Perforator) Flap, the SIEA (Superficial Inferior Epigastric Artery) Flap, the Gluteal Flap, and the TUG (Transverse Upper Gracillis) Flap for Breast Reconstruction. We perform these flaps in high volume, working closely with our operating room team, anesthesiologists, the ICU and floor team for postoperative care. We use the latest monitoring technologies for flap survival and the newest pain management devices for a comfortable postoperative experience.

The Team approach offers patients the highest standard of patient care for safety and high success, shortened operating times, and superb results.
Our team is comprised of UCSF (University of California-San Francisco) full time plastic surgeons and clinical faculty with significant expertise in reconstructive microsurgery.

The Team:

Dr. David Chang
http://plastic.surgery.ucsf.edu/faculty/david-chang-md.aspx

Dr. Scott L. Hansen
http://plastic.surgery.ucsf.edu/faculty/scott-hansen-md.aspx

Dr. Charles K. Lee
http://www.lplasticsurgery.com/about.html

Dr. David M. Young
http://plastic.surgery.ucsf.edu/faculty/david-m-young-md.aspx

Serving: The San Francisco Bay Area, Northern California, US, National, International, Asia

In the News: Microsurgery at St.Mary's Medical Center, San Francisco

2008-12-06T20:41:00.001-08:00

Innovative Breast Reconstruction at St. Mary's Medical Center
Business Wire, Oct 18, 2007

Microsurgical Procedure to Use Patient's Own Tissue to Construct New Breasts

SAN FRANCISCO -- The skilled plastic surgeons at St. Mary's Medical Center now offer a new breast reconstruction procedure called Deep Inferior Epigastric Artery Perforation (DIEP) flap. According to Dr. Charles Lee, director of microsurgery at St. Mary's, an upcoming surgery on November 4 will be the first time a double DIEP procedure will be performed at St. Mary's Medical Center.
This microsurgery procedure is a significant improvement because it allows surgeons to rebuild breast tissue using the patient's own skin, fat and blood vessels while preserving the abdominal muscle, which is commonly used in other types of flaps.
"Performing reconstruction with the patient's own tissue offers many advantages," said Dr. Lee. "Microsurgery means a faster recovery and the breast will look and feel more natural than with implants."
October is National Breast Cancer Awareness Month. According to the American Breast Cancer Foundation, more than 1.6 million breast cancer survivors are alive in the U.S. today. According to the American Society of Plastic Surgeons, more than 56,000 breast reconstructive surgeries were performed in 2006. DIEP flap procedures accounted for more than 3,500 of them. This is almost double the 1,909 DIEP reconstructions performed in 2005.
"Dr. Lee is one of a select number of plastic surgeons in the country performing this kind of specialized microsurgery," said Ken Steele, president of St. Mary's Medical Center. "St. Mary's has been at the forefront of medical innovation in San Francisco for 150 years and we're proud that our surgeons are continuing that tradition."
About St. Mary's Medical Center
For 150 years, St. Mary's Medical Center has provided the Bay Area with compassionate, personalized care combined with the latest advances in medical care and cutting-edge technology.
St. Mary's is a full-service acute care facility with more than 575 physicians and 1,100 employees who provide high-quality and affordable health care services to the Bay Area community. Home to advanced medical practices, such as the nation's first digital cardiac catheterization laboratory, pioneering spine surgery and comprehensive rehabilitation, St. Mary's Medical Center is one of San Francisco's leading hospitals, offering patients a full range of outpatient and inpatient services delivered with the human touch. For more information, please call (415) 668-1000 or visit http://www.stmarysmedicalcenter.org.
COPYRIGHT 2007 Business WireCOPYRIGHT 2008 Gale, Cengage Learning

What is Microsurgical Breast Reconstruction?

2008-11-29T12:51:00.000-08:00

There are several ways to reconstruct the breast after mastectomy for breast cancer. The two main categories are 1. Implant (silicone gel, tissue expansion, saline) 2. Autologous Tissue (your own body tissues). There are advantages and disadvantages with both types, however, as reconstructive plastic surgeons, we have a bias toward using your own natural tissues (Autologous Tissue) to create the most natural and long lasting breast mound. Plastic Surgery has evolved now to the point where we can take blocks of tissue from another part of the body and "transplant" them elsewhere to reconstruct another part. This ability to move these blocks of tissue hinges specifically on the ability of the surgeon to transplant this block of tissue on blood vessles and nerves, and "reconnecting" them to the new area. This is very similar to the concept of organ transplanation where the kidney or heart is reconnected to the body on their main blood vessels.
Microsurgical Breast Reconstruction is a technique that has become available in the past 20 years, and recently further refined by dedicated plastic surgeons to move highly specific blocks of tissue (mainly abdominal, butocks, and thigh--skin and fat--on an artery and vein), and transplant them to the breast area. Because of the technical expertise required to perform this operation, only a few plastic surgeons perform these operations on a regular basis.
This has created a demand to find surgeons who can provide optimal outcomes for breast reconstruction.
Microsurgical breast reconstruction has become synonymous now with the terms DIEP flap, SIEA, GAP, and TUG flaps. These are "perforator" flaps which are technical terms for the same concept of "transplanting" tissue blocks.