Whether you are undergoing lumpectomy (and saving the breast) or total mastectomy (and removing the breast) for breast cancer or other breast tumors, reconstruction at the same time as the cancer surgery is usually the best option for restoring a natural and symmetric breast to maintain your sense of wellness, natural appearance and femininity while avoiding postoperative self-consciousness about your appearance or discomfort due to asymmetry and scarring.
Dr. Oren Lerman performs all of the most advanced breast reconstruction techniques to restore the way you look and feel after breast cancer surgery.
Why should you choose Dr. Lerman for your reconstructive surgery?
Although some women choose to wear a prosthetic bra or grow accustomed to their new bust line after a mastectomy, more and more women are choosing to undergo reconstruction every year.
Weighing Your Options
As with all plastic surgery procedures, there are multiple techniques available for reconstructing the breasts after mastectomy. In helping patients to decide which technique is best suited to their particular case, Dr. Lerman takes many factors into account, such as their age, weight, lifestyle, family, and work. Each individual patient's circumstances can impact the decision as to what type of reconstruction best suits them, but the important thing to remember is that almost all woman are candidates for breast reconstruction.
In order to know what option is best for you, you must first be presented with all the options available. Because many plastic surgeons don't perform all different types of breast reconstruction, many women are only given a select few options for their reconstruction. But Dr. Lerman specializes in the most advanced methods of breast reconstruction, especially DIEP flap and other natural tissue options, so his patients get the opportunity to decide for themselves what option they prefer.
Whether you are preparing to undergo mastectomy or have already undergone mastectomy, Dr. Lerman will detail the specific advantages associated with each method of breast reconstruction and advise you as to the method that will provide the best, longest-lasting, and most aesthetically pleasing results in your particular case.
Insurance Coverage for Breast Reconstruction
The Women's Health and Cancer Rights Act of 1998 (WHCRA)
Signed into law on October 21, 1998, the Women's Health and Cancer Rights Act (WHCRA) is a federal law that requires group health plans, insurance companies, and health maintenance organizations (HMOs) that provide coverage for mastectomies to also provide coverage for reconstructive breast surgery and prostheses following the mastectomy. Patients insured under an individual plan are also protected by the WHCRA. The WHCRA is not limited to cancer patients; it also protects patients who undergo a mastectomy due to other medical reasons.
How Does the WHCRA Protect You?
If the WHCRA applies to you, and you choose to undergo breast reconstruction, insurance coverage must be provided for:
- All stages of reconstruction of the removed breast or breasts.
- Surgery and reconstruction of an untreated breast to create a symmetrical appearance.
- Prostheses, or breast implants.
- Treatment of any physical complications occurring at any stage of the mastectomy, including lymphedema.
Dr. Oren Lerman has extensive training and experience in all aspects of advanced breast reconstruction techniques that allow him to deliver beautiful results with the latest techniques offering his patients all available options so that they could choose the reconstruction method that suits their personal needs and lifestyle the best. He has advanced fellowship training in microvascular natural tissue breast reconstruction surgery and treats hundreds of patients annually performing the DIEP flap, PAP flap and other advanced natural tissue breast reconstructions routinely. Dr. Lerman is the Director of the Breast Reconstruction Fellowship at Lenox Hill Hospital in Manhattan where he teaches physicians from around the world how to perform these advanced breast reconstruction techniques. He also routinely lectures on the topic at national and international meetings.
Although most patients are candidates for natural tissue breast reconstruction they may not have been told so. If you are scheduled to undergo a mastectomy, find out if you are a candidate for one of the numerous perforator flap surgeries, including DIEP flaps, offered by Dr. Lerman. To learn more about the benefits of one of these advanced reconstructive breast surgery techniques, contact his Manhattan, NYC or Westchester, NY practice today and schedule your consultation. We also provide answers to frequently asked questions for patients to read before their visit.
Natural Tissue Flap Reconstruction
Reconstructing the breasts with a patient's own tissue delivers results that look, feel and move like natural breasts and the results last a lifetime. Tissue transfer involves moving a flap of tissue and fat from a different part of the body where there is excess (like the abdomen for a DIEP flap). The most advanced methods use microsurgery to transplant this tissue and only specialists like Dr. Lerman perform this state-of-the-art procedure. This technique can be performed at the time of mastectomy or years later to replace or correct unsatisfactory or failed implant reconstructions.
Implant Breast Reconstruction
For woman who don't want to use their own tissue or don't have the available tissue, reconstruction with breast implants is the most common choice. Implant reconstruction has changed significantly in the past few years and their are numerous options. This procedure often has multiple steps where a temporary implant called a "tissue expander" is placed first and this gradually stretches the skin over time to accommodate the final implant which is placed as a second procedure. Some patients may be eligible for a single-stage implant reconstruction.
Corrective Breast Reconstruction
Many woman are unsatisfied with their results after breast reconstruction or lumpectomy alone without reconstruction. In addition, most breast implant results look worse over time or can cause discomfort and pain. Now matter how good an implant looks when it is initially placed they do not last and need to be replaced at some point. Most patients will gain or lose weight with time and this can impact the way their breast reconstruction lasts. All of these problems may need to be addressed with revision surgery. Dr. Lerman can replace, correct or redo an unacceptable reconstruction.
Mastectomy or lumpectomy & Reconstruction
During a total mastectomy or lumpectomy the breast tissue is removed to eliminate cancerous tumors or to prevent them from developing. Mastectomy techniques have evolved to minimize loss of skin and even the nipple in order to allow for reconstruction to maintain the appearance of a normal breast. Because the mastectomy or lumpectomy technique can greatly impact the reconstruction Dr. Lerman works in a team with the oncologic surgeon to plan out the incisions and reconstruction before the mastectomy begins. This planning and coordination allows for a more natural looking, aesthetic result.
Nipple Preservation, Nipple Reconstruction & Restoring Sensation with Nerve Graft
Nipple preservation at the time of mastectomy has become routine in our practice and more woman are are candidates for this technique with the variety of options Dr. Lerman offers. When the nipple needs to be removed a new nipple is created to complete the reconstruction and minimize the 'surgical' look. Because numbness of the breast after mastectomy is routine, Dr. Lerman offers nerve grafting at the time of natural tissue reconstruction to restore sensation. Dr. Lerman is one of the few surgeons in the world who perform this advanced technique.
Natural Tissue - Flap Reconstruction
Autologous breast reconstruction, or flap reconstruction, involves transferring a flap of living tissue – which usually includes skin, and fat – from another area of the body to recreate the breast mound. There are two primary methods of flap reconstruction. A pedicled flap reconstruction involves harvesting donor tissue and tunneling it under the skin to the breast mound, while keeping the original blood vessels attached. The operation known as a pedicled TRAM flap was originally described back in 1979. Dr. Lerman prefers the more advanced method that has better outcomes called a free flap. A free flap involves completely separating the tissue from the original blood supply, and reattaching the flap to new blood vessels in the chest.
This process is called microvascular tissue transfer and it involves the use of a surgical microscope or magnifying loupes to reconnect the blood vessels. Because this advanced technique requires special training in microsurgery, free flap breast reconstruction is not as widely available. Not all free flap reconstruction is the same. Although microvascular free flap breast reconstruction has become the preferred approach because it maximizes the blood flow to the tissue, the most advanced type of free flap breast reconstruction, called a DIEP flap, also preserves the muscle from the abdominal wall. A free TRAM or muscle sparing TRAM flap does not preserve the whole muscle leading to weakness or a hernia. The DIEP flap minimizes the risk of postoperative abdominal weakness, bulge or hernia. Free DIEP flap breast reconstruction results in the most natural appearing, natural feeling, and long lasting reconstructed breast mound with a quicker recovery, less pain and lowest risk of abdominal weakness.
Types of Microvascular Natural Tissue Reconstruction
There are a number of other microvascular flap reconstruction techniques, and they differ according to the area of the body from which the tissue flap is harvested. They also differ according to whether or not muscle is transferred with the tissue. The most common flap used by Dr. Lerman for breast reconstruction is the DIEP flap reconstruction, in which fat and skin tissue is harvested from the lower abdomen to recreate the breast. This extra tissue is removed similar to patients who are having a tummy tuck. Patients that undergo DIEP flap breast reconstruction get the added benefit of an improved abdominal contour, not unlike the improvements seen with a tummy tuck.
Dr. Lerman most commonly performs natural tissue reconstruction utilizing microvascular flaps from these areas:
- DIEP flap, removing extra skin and fat from the lower abdomen.
- PAP flap, which uses tissue harvested from the upper posterior thigh.
- GAP flap, in which a flap is created using tissue from the buttocks.
- TUG flap, which reconstructs the breast using tissue from inner thigh.
- Stacked Flaps, which combine two flaps such as the DIEP and the PAP to create one breast.
Although the DIEP flap is most often the first choice due to the reliability of the tissue and the enhanced abdominal contour that our patients get as an added benefit, for those patients who do not have excess abdominal tissue the other flaps are a good option. The PAP flap is the second most common natural tissue perforator flap performed by Dr. Lerman.
Although natural tissue reconstruction is one of the most advanced techniques used for breast reconstruction it is only one of the options Dr. Lerman provides to his patients. Reconstruction with breast implants is often the best option for some patients. It is a shorter surgery with less recovery and without the need for a scar on a different part of the body. Implant reconstruction is typically performed in two stages. The first stage can occur at the time of the mastectomy, and involves placing a temporary implant called a tissue expander under the skin and muscle of the chest wall or on top of the muscle for pre-pectoral reconstruction. By gradually inflating the expander with saline over time, the skin is slowly stretched to create a pocket to hold the permanent breast implant. A saline or silicone breast implant is placed about four months later during a second surgery. It is important to consult a surgeon that offers all of the techniques available in order to decide which one best suits your specific medical needs, interests and lifestyle.
Single Stage 'Direct-to-implant' Reconstruction
Some patients may be able to skip the tissue expander process and place the final implant immediately at the time of the mastectomy in what is called 'direct-to-implant' single stage reconstruction. This innovative technique is performed immediately at the time of mastectomy, allowing the patient to avoid a second surgery. During this procedure, Dr. Lerman will place the permanent silicone or saline implant and reinforce the reconstruction with AlloDerm® Tissue Matrix, which is a type of biologic mesh that supports the implant and essentially creates an internal bra. The 'biologic mesh' is made from human skin that has been processed by a biotech firm and sterilized to remove any cells or foreign antigens creating an "acellular dermal matrix" which is acts as a scaffold to promotes tissue ingrowth and revascularization (formation of new blood vessels). It provides increased support for the implant to optimize the shape, symmetry and contour of the breast mounds. During your consultations, Dr. Lerman will work with you to determine if this approach is right for you.
Immediate versus Delayed Reconstruction and Revision
Immediate reconstruction begins on the same day as the mastectomy whether it is a breast implant or autologous DIEP flap reconstruction. Some patients never had reconstruction at the time of the mastectomy or chose to wait to have reconstruction later. These delayed reconstruction cases can occur months or even years after the mastectomy. Aesthetic outcomes are generally more favorable following immediate reconstruction. On the other hand, delayed reconstruction is sometimes necessary in order to complete all cancer treatments such as radiation before moving on with the reconstruction. Unfortunately the number of women in the United States that undergo reconstruction at the time of mastectomy is less than 40%. It is not uncommon for a woman to be told to wait until after radiation treatment following mastectomy and perform a delayed reconstruction. Dr. Lerman, however, utilizes the latest techniques that obviate the need for delayed reconstruction.
Most patients who did not undergo immediate reconstruction at the time of the mastectomy are still good candidates for "Delayed Reconstruction" and can usually have all of their options available to them including both natural tissue as well as implant reconstruction. Dr. Lerman routinely performs delayed reconstruction on patients who have had mastectomy in the past.
There are also many patients who had reconstruction in the past but have developed complications such as pain, asymmetry, discomfort, ruptured implants, visible deformities or distortions of their reconstructed breast mounds. Many woman were happy with their results at the time of the initial reconstruction but with time the implants or their bodies have changed and the breast reconstruction needs to be repaired or completely redone. These patients are usually good candidates for revision surgery. This can include changing old implants, performing fat grafting or completely redoing the reconstruction with a DIEP flap or other natural tissue.
Preventative Mastectomy and Reconstruction
Women at a high risk for developing breast cancer, whether due to a strong family history or testing positive for the BRCA gene or other genes that are associated with breast cancer may choose to have a 'prophylactic' or preventative mastectomy and reconstruction. This is an important personal decision requiring consultation with the breast surgeon, plastic surgeon, genetic counselor, ObGyn, and one's close family. Personal considerations such as lifestyle, health, age and relationships need to be taken into consideration. Patients often have ample time to consult their surgeons and other medical professionals. After becoming educated, patients often feel confident in deciding that a preventative mastectomy is in their best interest. Fortunately, with the latest techniques in breast reconstruction, mastectomy & nipple preservation it is possible to perform prophylactic mastectomy and reconstruction without the telltale scars and unnatural results that were commonplace in the past. Many patients can even look better after mastectomy and reconstruction than before.
Nipple-sparing Mastectomy & Restoring Sensation with Nerve Grafting
Many women who choose to receive a preventative mastectomy as well as many patients with breast cancer are eligible for a nipple sparing technique. This technique preserves the nipple and skin, removing only the underlying breast tissue to provide a result that often cannot be distinguished from someone who did not undergo a mastectomy. In fact, when combined with advanced reconstructive techniques, the results can look as authentic as their native breast or in some cases even better, as if they had cosmetic breast enhancement. Restoring sensation in patients with nerve grafting at the time of natural tissue reconstruction is a cutting edge technique that Dr. Lerman provides to help address numbness of the nipple that is one of the most common complaints after mastectomy.
In general the benefits of breast reconstruction after mastectomy or lumpectomy are to recreate the breast mound so that a woman can feel and look normal and whole without a permanent deformity that can impact everything from her self esteem and sexuality to her ability to exercise and participate in sports as well as wear normal clothing without the need for a external prosthesis. Although many doctors will tell you that the goal is to make you look and feel normal when you are wearing clothing, Dr. Lerman feels that the goal is to make you look and feel beautiful even when you are not wearing clothing so that even a passing glance in the mirror allows you to be happy and satisfied with your appearance and mind set. Dr. Lerman feels strongly that many woman can look even better after completing breast reconstruction than they did before.
For further information about breast reconstruction benefits, or to schedule your initial consultation with Dr. Lerman, please contact our plastic surgery practice today.
Benefits of Autologous (Natural Tissue) Breast Reconstruction
One of the preferred method of reconstructing the breasts after mastectomy among modern plastic surgeons is to use the patient’s natural tissues whenever possible. This technique offers a variety of benefits that are unique among breast reconstruction methods, including a more natural and aesthetically pleasing result.
The most advanced technique used to perform autologous breast reconstruction is the DIEP flap. Named after the deep inferior epigastric artery that supplies the blood flow to the lower abdominal skin and fat and gets transplanted during the surgery. This operation is the most advanced and current method for transplanting tissue from the lower abdomen. The older method for doing this is called a TRAM flap or muscle sparing TRAM flap. The TRAM flap cuts the muscle of the abdominal wall, whereas the DIEP flap does not. This minimally invasive procedure leads to less postop pain and recovery as well as less risk of abdominal wall weakness or hernia. The fatty tissue from the lower abdomen is remarkably similar in feel to the natural breast. Dr. Lerman transplants a flap of tissue, including blood vessels, fat and sometimes skin to the chest using and meticulously reattaches the blood vessels and then contours the tissues to produce a natural-looking and feeling breast that lasts forever. This tissue moves like natural tissue and compresses like natural tissue so when you wear clothing or lay on your side or belly it feels like your own body.
There are a number of favorable reasons to use the DIEP flap technique, including:
- It has an extremely high success rate and lasts indefinitely: The DIEP flap surgery performed by Dr. Lerman has a 99% success rate. Once healed from the surgery the reconstruction lasts a lifetime and actually tends to look and feel better as time goes on.
- It looks, feels, moves and ages like natural tissue: No other reconstructive option will give you a more natural looking and feeling result than using your own tissue. Whether you are wearing clothing or not - nothing will look more natural. When you are moving, exercising or lying down in bed it will behave like your natural breast and move with you. As you get older the tissue will even get softer. It tends to look better as time goes by as opposed to breast implants that need to be changed down the road.
- It preserves the entire abdominal wall muscle: Unlike the TRAM flap or even the msTRAM (muscle sparing TRAM flap), the DIEP flap procedure leaves the rectus abdominus muscle intact. This allows the patient to maintain the strength of the abdominal wall and lowers the risk of post-surgical hernia.
- You get the added benefit of a flatter/slimmer abdominal area: For patients with excess abdominal fat, the DIEP flap procedure is the equivalent of undergoing two procedures in one. The removal of tissue from the abdominal region leaves the area smoother and trimmer, similar to the way an abdominoplasty (tummy tuck) would.
- It minimizes recovery time: Although the DIEP flap procedure is a major surgery, it results in a shorter, more comfortable recovery period than the TRAM flap procedure, largely due to the fact that the abdominal muscles are left intact.
For patients with insufficient fat in the belly region, Dr. Lerman can harvest tissues from other regions of the body, such as the posterior upper thigh (the PAP flap method) or the buttocks (the sGAP and iGAP methods). These methods offer similar advantages to the DIEP flap method, particularly when compared to the TRAM flap method.
Benefits of Breast Reconstruction with Implants
Breast implant reconstruction remains the most common type of breast reconstruction in the United States. This operation is especially beneficial for patients who are very slim and have limited availability of natural tissue; Those who do not want additional scars of their body; and those patients who cannot or do not want to undergo the longer surgery associated with autologous (natural tissue) reconstruction. The availability of the new form-stable, highly cohesive, anatomically shaped silicone-gel-filled breast implants has changed the expectations of breast implant reconstruction. Popularly known as “gummy bear” implants, these implants allow Dr. Lerman to achieve a result that is more natural looking than traditional breast implants and Dr. Lerman uses these new implants in the majority of cases. Additionally, with new mastectomy techniques such as nipple sparing mastectomy and the use of biologic mesh (Alloderm®), we can now perform implant breast reconstruction in fewer stages with more natural results.
Some of the beneifts of breast implant reconstruction:
- Shorter Surgery and Hospitalization: Unlike autologous breast reconstruction, reconstruction with implants is a shorter surgery with a shorter hospitalization.
- Form Stable implants maintain their shape over time: Because these implants are filled with a highly cohesive gel, they hold their original shape giving a more natural 'teardrop' shape to the breast.
- Rippling and folding are less likely with Form Stable implants: Again, because the implants are filled with a highly cohesive gel that maintains its original shape over time, rippling and folding are much less likely to occur.
- The risk of leakage is extremely low: The current generation of implants has an extremely low rupture rate when compared with prior generations of implants. The FDA continue to recommend MRIs every few years to ensure that there is no rupture or leakage.
Immediate Breast Reconstruction vs. Delayed Reconstruction
The results from breast reconstruction are best if it is performed at the same time as the mastectomy, however, there are certain situations in which a woman would wait to have a delayed breast reconstruction either in order to allow them to complete their treatment or because they were undecided at the time of the mastectomy. No matter the reason, almost all woman are candidates for breast reconstruction either at the time of mastectomy or afterward.
- Immediate breast reconstruction: By undergoing breast reconstruction at the same time as mastectomy, not only do you avoid the need to come back later to have breast reconstruction at a later date, but the result tends to look more natural. The breast skin is usually preserved at the time of the mastectomy and used to recreate the new breast. In a delayed reconstruction, this skin has flattened out and needs to be replaced or re-expanded using a variety of methods which tend not to look as good as the original.
- Delayed breast reconstruction: For those woman who did not have the availability of a reconstructive plastic surgeon at the time of their mastectomy. Or who were told to wait to complete all of their treatments before undergoing reconstruction. Or for those who simply have changed their mind about wanting reconstruction, most if not all of the reconstructive options are still available to them. Delayed breast reconstruction will replace the need for an external prosthesis (padded bra) and will allow patients to go back to feeling and looking normal and beautiful both in and out of clothing.
In general, breast reconstruction candidates should be in good overall health, with no health complications that could compromise healing. There are several different methods of breast reconstruction, and each carries unique candidacy criteria. Dr. Lerman is a board-certified specialist in cosmetic and reconstructive surgery, and can help women regain their confidence and restore the shape of their bust using advanced techniques such as DIEP flap reconstruction. His goal is to help patients look and feel beautiful following the procedure. Dr. Lerman recommends breast reconstruction techniques according to a patient's goals, weight, lifestyle, age, profession, and other factors. To learn more about breast reconstruction candidacy, please schedule a consultation at his Manhattan, NY, practice.
There is a common misconception that candidates for a DIEP flap procedure must be overweight. In truth, candidates only need what can be safely considered excess tissue.
Recommending a Breast Reconstruction Method
Every breast reconstruction method carries unique advantages and requirements. During an in-depth consultation with your surgeon, he or she can recommend a procedure based on your needs and goals:
Autologous (Natural Tissue) Breast Reconstruction
Many surgeons restore the breasts using abdominal skin, fat, and muscle tissue, a technique called transverse rectus abdominis myocutaneous (TRAM) flap reconstruction. Though effective, this approach can involve a longer and more painful recovery time due to the removal of muscle tissue. Deep inferior epigastric perforator (DIEP) flap reconstruction is a newer technique that only uses abdominal skin and fat, resulting in a faster, more comfortable recovery. Only a relatively small number of surgeons, including Dr. Lerman, are qualified to perform DIEP flap reconstruction.
There is a common misconception that candidates for a DIEP flap procedure must be overweight. In truth, candidates only need what can be safely considered excess tissue. Many patients believe that the DIEP flap approach provides the most natural look and feel. Meanwhile, if a patient wishes to achieve a slimmer profile in the midsection, DIEP flap reconstruction can provide this result along with a restored bust.
Depending on your needs, goals, and your surgeon's assessment, the breasts can also be reconstructed using tissue harvested from the posterior thigh, inner thigh, buttocks, or back. In other cases, your surgeon may recommend combining grafts harvested from two different areas in a technique called stacked flaps.
Implant Breast Reconstruction
Implant breast reconstruction is a process of using breast implants to restore the bust line. Candidates for implant breast reconstruction surgery may be too slim to undergo a more extensive procedure using their own tissue, or do not wish to have any more scarring. The implant procedure is often recommended to older patients who may not have sufficient tissue for undergoing a DIEP flap reconstruction.
Corrective Breast Reconstruction
If you have undergone a breast reconstruction procedure, but feel dissatisfied with the results, you may be a candidate for a corrective breast reconstruction. Based on the results you wish to achieve, the amount of tissue that can be safely transplanted, and the extent of correction you desire, your surgeon can determine if flap reconstruction or breast implants are the best approach.
Preventative Mastectomy & Reconstruction (BRCA+)
Many women choose to undergo a mastectomy before health complications develop. Candidates for a preventative mastectomy and reconstruction procedure can include patients who:
- Have a family history of breast or ovarian cancer.
- Have breast cancer in one breast, especially if they have a strong family history of breast cancer.
- Test positive during a BRCA test, which identifies mutations to genes BRCA1 and BRCA2, which help the body fight breast cancer.
Immediate versus Delayed Reconstruction
Some patients may be good candidates for reconstruction immediately following the mastectomy. However, in other cases, patients may have to wait until radiation or chemotherapy is completed. A qualified surgeon will work closely with your oncologist and other healthcare providers to determine when it is best to proceed with breast reconstruction.
The recovery timeline following breast reconstruction will primarily depend upon whether implants or the patient's own tissue (flap reconstruction) are used to create the breast mound. An implant procedure can involve an initial recovery time of about six weeks. If a tissue expander is used, replacing the expander with an implant will require about two more weeks of recovery. A flap reconstruction procedure using microvascular techniques involves six to eight weeks of recovery. Dr. Lerman is highly experienced in this procedure, and he can help you experience a successful breast reconstruction recovery following surgery at his Manhattan, New York, practice.
Breast reconstruction patients will need to remain in the hospital for one to two days following implant reconstruction and five to six days after flap reconstruction. If your surgery is performed at the same time as a mastectomy, your doctor may recommend an additional day or two beyond the two to three days of recovery usually needed following a mastectomy.
During this time, Dr. Lerman and your nurses will encourage you to move your arms as much as possible. Regardless of the reconstruction method, the surgery significantly affects the muscles of the chest. Because many upper arm muscles are anchored in the chest, this can have an impact on arm movement. Therefore, it is important to build arm strength again slowly after surgery. However, these initial exercises will not be strenuous.
To avoid straining the chest and arms, you will need a family member or friend to drive you home after you have been discharged from the hospital.
During a consultation with Dr. Lerman, he can explain what to expect before, during, and after surgery.
Recovering at Home
Because of the strain on the chest and arms, many find it difficult to sit down, stand up, and get in or out of bed for the first six to eight weeks after breast reconstruction. Many also report soreness, swelling, and bruising during the first two to three weeks of recovery, as well as some numbness or tightness at the surgical sites.
You will need to return to the doctor regularly for check-ups throughout this period, but the bulk of recovery will depend on self-care. You will be instructed to regularly perform special exercises to prevent stiffness and excess scar tissue in the chest and arms.
While patients can typically return to their normal routine at the end of this period, it will still be several weeks before they can engage in more strenuous exercise such as heavy lifting, running, and sexual activity.
One Year after Surgery
It can take a year or more for the tissue to heal completely and the scars to fade. Once the shape of the reconstructed breast has improved, patients may decide to undergo additional procedures such as nipple reconstruction.
Communication and Persistence with Your Insurance Company
Insurance companies are in the business of helping to meet your medical needs. Therefore, it is imperative that your surgeon's office presents thorough justification for the projected scope of your procedure. Sometimes the phrasing used to describe this scope can make the difference between approval and denial. It is important that your surgeon's office uses terms specified in the ICD-10 code, the standard system of classification used by all insurance plans.
Even after presenting a meticulously planned treatment scope, there is no guarantee that the insurance company will approve coverage. Persistence is the key - you and your doctor can work together to revise the description to justify the projected scope of treatment in the eyes of the insurance company. Sometimes this can include using photos of the treatment area (excluding your face) to illustrate why the care you request is necessary.
If you have questions about insurance coverage for breast reconstruction, Dr. Lerman's compassionate and knowledgeable staff in Manhattan, NY, can provide answers. If you are interested in undergoing breast reconstruction by Dr. Lerman, his staff can speak to your insurance provider on your behalf to present thorough justification for a projected treatment scope, and to determine what your provider will contribute to the cost of his care. Expertly performed breast reconstruction can provide substantial benefits. If you are in need of a mastectomy, or if you have already undergone the procedure and are exploring breast reconstruction options please contact us today.
Insurance policies can be complicated, but you can rely on the fact that if your provider covers mastectomy, they are most likely obligated to cover breast reconstruction.
Knowing what to ask a breast reconstruction surgeon can help you decide if he or she is the right one to perform your procedure. It can also help you decide what type of reconstruction is best for you, and to understand what to expect before, during, and after your treatment. A surgeon who is willing to patiently answer all your questions and makes you feel comfortable is essential. If you are wondering what to ask your breast reconstruction surgeon, Dr. Lerman has provided a comprehensive list of suggestions.
Just because a surgeon does not recommend a procedure that interests you, it does not mean that you are not a candidate.
A surgeon’s experience and credentials play an important role in explaining what he or she can help you achieve. Some patients may feel hesitant to ask about qualifications face to face, but an experienced surgeon will expect these questions. After all, breast reconstruction requires special training and experience, and patients need to know they can rely on their surgeon.
Recommended questions include:
- Are you certified by the American Board of Plastic Surgery?
- How many procedures have you performed?
- How many were successful?
- How often do you perform breast reconstruction?
- Which types of reconstruction do you have the most experience performing?
- How often will revisions be necessary for each type of procedure?
You should also keep in mind that just because a surgeon does not recommend a procedure that interests you, it does not mean that you are not a candidate. In some cases, it may just mean that the surgeon does not offer that procedure.
You can gauge your comfort with the surgeon's recommendation by asking:
- What makes me a good candidate?
- What are the risks of this surgery?
- Will reconstruction interfere with chemotherapy or radiation therapy?
Surgery and Recovery
You should know exactly what to expect at every stage of treatment, and you can gain an understanding of your treatment timeline by asking:
- How should I prepare?
- How long does surgery typically take?
- How should my treatment be timed? Is it better to undergo immediate reconstruction, or should I delay reconstruction?
- How long does it usually take to recover? What will my recovery be like?
- How much help will I need at home?
- What kinds of exercises will I need to do after surgery?
- When can I return to work?
- When can I resume vigorous or strenuous exercise?
You are entitled to the clearest possible understanding of the results you can expect. Ask your surgeon:
- What will my breast look like after surgery?
- When will the final results be visible?
- What can I expect in terms of scarring?
- Do you have photos of results you have provided for patients undergoing this procedure?
- Will the reconstructed breast match my remaining breast?
- How will the reconstructed breast feel to the touch?
- What kinds of changes in my reconstructed breasts should I expect over time?
- If I receive an implant, how long will it last?
- Can you connect me with others who have had the same surgery?
Whether undergoing a mastectomy, lumpectomy, or requiring corrective / revision breast reconstruction most women have many options to choose from. It is important to consult with a specialized surgeon who performs all availbale techniques to determine what is most suited for them. To help patients better understand these options Dr. Lerman can discuss the most common breast reconstruction FAQs (frequently asked questions) with patients at his Manhattan, New York, office. To schedule your consultation and learn more about breast reconstruction, contact us today.
What Are My Treatment Options?
Although their are many different types of breast reconstruction options, the two basic categories of breast reconstruction to choose from are breast implants or natural (autologous) tissue reconstruction. Some patients choose natural tissue breast reconstruction, in order to achieve a breast that looks, feels, and moves naturally and lasts for the rest of their life. This option most often employs the DIEP flap or PAP flap and utilizes tissue transferred from another area of the body. The natural tissue reconstruction is the most advanced type of breast reconstruction and has numerous advantages over breast implant reconstruction. Other patients choose breast implant reconstruction which tends to be a shorter surgery without the need for a scar on a different part of the body. There are pros and cons to each type of surgery and not all patients are good candidates for both.
What Is Flap Surgery or Autologous Breast Reconstruction?
Flap surgery is a breast reconstruction technique that uses a woman's own living tissue to recreate the breast mound instead of a breast implant. Tissue for flap reconstruction is transferred from another part of the body and may be taken from the:
- Abdomen - *most common location for Autologous breast reconstruction, the most advanced procedure when taking tissue from the abdomen is the DIEP flap (deep inferior epigastric artery perforator). Older variants of this procedure include the TRAM flap (transverse rectus abdominis myocutaneous) where the muscle is cut.
- Buttocks - gluteal artery perforator (GAP) flap - can be an SGAP flap located higher on the buttocks or an IGAP flap lower down
- Posterior thigh - profunda artery perforator (PAP) flap is one of the most recent additions to the types of flaps used in breast reconstruction. Dr. Lerman is one of the few surgeons in the country offering this type of surgery.
- Inner thigh - transverse upper gracilis (TUG) flap or the diagonal upper gracilis (DUG) flap
- Back - thoracodorsal artery perforator (TAP) flap is a variant on the Latissimus muscle flap used for partial breast reconstruction.
While other surgeons are limited to performing the older TRAM flap reconstruction technique which cuts the abdominal muscles, Dr. Lerman offers his patients microvascular breast reconstruction with perforator flaps such as the DIEP flap that preserve the muscle. This advanced method maximizes blood flow to the tissue flap, while also preserving the muscle of the abdominal wall. As a result, patients experience a lower risk of abdominal weakness, bulge or hernia.
What Is Microvascular Surgery?
Using a microscope, specialized instruments, and tiny needles, a fellowship trained microvascular breast reconstruction surgeon reconnects small blood vessels, and nerves to transplant tissue from a different part of the body to reconstruct the breast such as a DIEP flap. Just like transplanting a kidney or other organ from one person to another, the 'flap' of tissue is transplanted. Unlike a kidney transplant, the tissue flap is comes from your own body and therefore cannot be rejected. Of course in order for the tissue or 'flap' to survive, the circulation must be restored by reconnecting the blood vessels. Microvascular surgeons perform free flap breast reconstruction to recreate the breast using natural tissue flaps giving the most natural looking, feeling and long lasting results.
What Is Nipple-sparing Mastectomy?
During a nipple-sparing mastectomy, the surgeon will remove the underlying breast tissue while preserving the nipple and skin. This provides a more natural-looking result that improves the overall appearance of the breast and in some cases it is hard to tell that a mastectomy was ever performed.
Who Is a Candidate for Breast Reconstruction?
Almost all women who require mastectomy or lumpectomy for breast cancer, or pre-cancerous lesions like DCIS, or those women undergoing preventative (prophylactic) mastectomy to minimize the risk of developing breast cancer such as woman who are carriers of the BRCA mutation (BRCA1+, BRACA2+) are candidates for breast reconstruction. Additionally, patients who have already undergone mastectomy or lumpectomy in the past without reconstruction or patients who need to have their reconstruction fixed are also candidates.
How Do I Prepare for My Surgery?
Most paitents will need medical clearance from their medical doctor including blood tests, EKG, chest x-ray. for patients undergoing perforator flap autologous reconstruction (DIEP, PAP, flap) a preop MRI or CT scan to look at the blood vessels will also be ordered. After determining the best treatment plan, Dr. Lerman will provide you with detailed pre-operative instructions, which might include:
- Quitting smoking
- Abstention from alcohol 24 hours before surgery
- Stopping certain vitamins or anti-inflammatory medications prior to surgery
Patients should be sure to follow all the doctor's direction carefully to ensure their safety and a smooth recovery.
What Should I Expect After the Procedure?
For the first few days after surgery, most patients will experience some discomfort, but this is minimized with our 'ERAS' - Enhanced Recovery after Surgery protocol. This protocol provides the latest in peri-operative pain management with innovative intra-operative long acting anesthetic nerve blocks as well as non-narcotic pain medications and other techniques. We will make sure you are comfortable. Although most patients worry about what to expect with postoperative pain, the vast majority find that they are surprised by how well they did after surgery.
Surgical drains are a necessary part of the recovery that often are the most challenging part of the postop routine. We will closely monitor them with you and remove them in the first couple of weeks.
We will provide you with a detailed list of instructions and you will have numerous postoperative appointments and will be in close contact with us for many weeks after surgery.
Home nursing services are routinely arranged and postoperative physical therapy is routinely prescribed. We work closely with specialized breast cancer-reconstruction-mastectomy therapists.
How Long Is the Recovery Period?
Recovery time will vary depending on the type of breast reconstruction you choose. Most patients tend to stay in the hospital for one or two days after implant reconstruction and three days after autologous (natural tissue) flap reconstruction. Most women are up walking on the very first day after surgery. Once discharged from the hospital you will need to avoid strenuous activity but will be up and about and not laying in bed. The initial recovery period where you will be out of work is bout 3-6 weeks depending on the type of surgery and your line of work or normal activities that you perform.
Learn More at Our Practice
Dr. Lerman and his team understand that the process of undergoing breast reconstruction is both emotionally and physically challenging. We are looking to simplify and guide you throughout the entire process. From the initial consultation through the recovery process, we provide detailed explanations, compassionate guidance and are happy to answer any and all of your questions and concerns. To learn more about breast reconstruction, contact our office today and schedule a consultation.
“The one thing that is most important when we're doing cosmetic surgery and aesthetic surgery of the face or the body is to make sure that the patient is happy afterwards...” Dr. Oren Lerman