Double DIEP or DIEP-GAP: How much fat is enough?

paloverde

Hello all. Newbie to the reconstruction forums here.

I had a BMX in Dec 2013 due to IDC on the left side, plus they discovered a BRCA2 mutation at that time.

I wanted immediate reconstruction, but at 5' 1" and 125 pounds I was
told by the PS that I didn't have enough ab fat for DIEP flap. Said maybe just enough
for one foob, no way for two.

I
cried! Didn't really want implants, and then the PS tried to sell me on
a bilateral LD flap, which I declined once I investigated it.

No time for multi PS opinions due to the urgency to get the BMX scheduled and align the two surgeons' surgery days.  I had an appointment with a second PS but he had to cancel. 

So I had TE's placed as a "burn no bridges" approach. Which was good,
because my little 1.5 cm bad boy of a tumor had spread to 11 of the 16
lymph nodes they removed.

So Defcon 1, do not pass go, chemo to
the max and big rads for me. I did get the TE's filled and they've had
400-500 cc apiece since mid Feb.

After I finished the chemo 2
months ago, I visited the PS again. He informed me that due to the expected rad damage (I had not started yet), there was only a 10%
chance of a successful direct exchange to implants without an
accompanying flap of some kind. I burst into tears for the second time
with this same doc, and I am NOT a big crier. He was being really
insensitive about it.

Well, his protocol is no recon for 9
months after rads. I'm finishing rads Aug 11. Supposed to see him
again after that, but am dragging my feet.

Along the way, due
to the chemopause, steroids during chemo, and how hungry the rads are
making me, I'm up around 135. And I haven't even started Tami yet.

So I'm wondering if there's a bright side to this. How do they assess
whether you have enough fat in the right places for a double DIEP with a
B cup goal, no implant?

Do they go by BMI? Mine is 25 now,
although I'd like to drop a little again after I'm done trying to help
burned tissue regenerate. Or do they take particular measurements, with
calipers or what?

I've gone over the top trying to take good
care of the breast skin. Been pounding protein and veggies (although
today and tomorrow ARE 1/2 price days at Cheesecake Factory) and
applying this PruMyx cream he prescribed, 3x per day. 20/28 treatments
and rad techs say the skin looks amazing.

But I'm stressing too
much about whether I'll make it into that 10% for direct exchange to
implant. Would rather go double DIEP - and probably with a different
doc. Do I need to put on a lot of weight? Would that even help?

Thanks for any insights!

Meow13

I was 125 pounds 5' 4" when I had my DIEP, They used almost everything for left side.

But, I had enough skin and fat I had lost 60 pounds the year before (took 6 months).

I had a very flat stomach afterwards unfortunately I have had significant weight gain from the exemestane I am taking.

I want to be 125 again! Working on it.

jbdayton

There are lots of women that were able to have flap surgeries with a low BMI.  You might check with PRMA at PRMA-enhance.com in San Antonio TX or NOLA at breastcenter.com in New Orleans.  I was amazed at how many different flaps are available, but not at all locations.  These two locations do many per week.  Good luck.  I did flaps because of rads and I did not want any type of implant anyways.  

debiann

I will be getting a bilateral mx in September with DIEP. I am 5'6' and weigh 182. I thought I had plenty of fat to make huge boobies, but he said only enough to make me a B cup, I am currently a C. When I told my son he joked "Did you turn around and show him your butt?" Lol. Anyway I will be happy with B. The PS only gave me a physical exam, no special measurements. He said they use only the fat below the belly button, half for each breast. He squeezed the fat on one side to show me how much was  available to make one breast. I had just lost 15 pounds before my dx, I'm currently doing chemo and working on gaining some back to give the PS something to work with.

Meow13

I am still a C afterwards. I think that because I was obese before I lost all the weight I think the fat tissue was still there just fattened out or shrunk down. Does anyone know if that is true?

besa

Paloverde- Would you be willing to travel for reconstruction?  Many more tissue based reconstructions (moving fat not muscle) may be available if you do.  There are skilled plastic surgeons who, as Jbdayton said, are able to use numerous donor sites  In addition some of these surgeons are able to "stack" flaps (for example combining DIEP and GAP to make 2 breasts -each reconstruction containing both DIEP and GAP flaps) - but you need to see someone who is very skilled and specializes in this.  See the list of surgeons in Kathy Steligo's web site:

http://www.breastrecon.com

(look at "finding the right plastic surgeon", then the list of ps who do tissue based reconstructions- this is a NON-VETTED list so you will need to research these plastic surgeons yourself)

Also possibly consider ordering a copy of the latest edition of Kathy Steligo's "Breast Reconstruction Guidebook" - the best I have seen on the topic.

I am about 5'5" and 130 lbs so a BMI of slightly less than 22.  I have one side DIEP (done locally) and the contralateral side is a sGAP done latter at NOLA.  I am a B/C size.  I feel that the NOLA docs (www.breastcenter.com) were able to do a much better job and offered more options than my local PS.  I wish I had know about NOLA from the start. (Just for information - I do not have stacked reconstructions.)  

Meow13-  When I gain weight I gain weight in my reconstructed breasts, when I lose weight I also lose weight in the reconstructions (not sure exactly what happens to the fat cells but your explanation sounds reasonable....probably what happens is the same as what happens when we lose or gain weight in other parts of our body :-)

paloverde

Yes, I'm within a 10 hour drive of both NOLA and Charleston and am very interested.  

I have Kathy Steligo's book on my Nook.  What's the most up to date revision?  

Thanks for the link.  

Yes, I never did want the implants in the first place, and one of the reasons was they'd never change in size as my weight varied.  Although I guess that would have been good motivation to keep the weight down.  Unless Tami has other ideas (I haven't started it yet.  Been a chicken.  Keep telling myself I want to wait till I'm done with my 7 remaining rads.)

besa

It looks like the 3rd edition is the latest edition - at least that is what Kathy's www.Breastrecon.com web site links to. Both NOLA and Charleston have great reputations. In terms of deciding what donor site to use the NOLA docs just looked at me (no actual measurements required).  Lots of women going to NOLA send photos and get a general idea of what they think in terms of donor site from that.  I flew in for a consult before I decided on surgery.  I wanted to meet the docs and see what their plan for me would be.. 

 As an aside to compare what was available to me at NOLA (Dr. Dellacroce) - I had a successful nipple sparing prophylactic sGAP reconstrucgtion at NOLA.  A well known DC ps had told me that ns after a reduction was not possible - the nipple would surely die.  The NOLA docs told me that, while they of course could not guarantee results, they were generally successful with ns after a reduction.  The very experienced high volume DC surgeons I contacted told me they were doing around 15 GAPs/year while the NOLA docs were doing 100s.  I could go on - but I felt there was a big difference between NOLA and what was available to me in the DC metro area.  

paloverde

Thanks besa.  My nipples are already gone in some hazardous medical waste dump somewhere.  I'm leaning toward paying Vinnie a visit in Balto for the 3D tattoos.  One step at a time though. 

Meow13

Good luck to you. I am so happy with my DIEP results. I could never have had implants, I think they would drive me crazy foreign objects you know. Now that my body has adjusted to the new configuration it feels great.