Struggling to decide between direct-to-implant or DIEP

rokel

Hello-

I'm 37 years old with two very young children. I was diagnosed a month ago with one small area of IDC and another area of DCIS in the same quadrant- prompting my surgeon to recommend a single mastectomy instead of lumpectomy. My surgeon does not think it has spread to lymph nodes so I may not need radiation, but obviously it's a possibility. I was being seen at Sloan Kettering but wasn't happy with the plastic surgeon I saw there and my breast surgeon strongly discouraged me from seeing other Sloan surgeons. So I got two more opinions out of Sloan- one from Dr. Constance Chen but it would have cost a lot since she's out of network and another from Dr. Andrew Salzberg who is in-network with my insurance and I think I will ultimately go with.

I am tempted to do direct-to-implant over the pectoral muscle with a nipple-sparing mastectomy because sounds the easiest to recover from. I'm wary of implants because I have autoimmune issues but I'm trying to make my peace with it. I'm an A cup and in order to achieve symmetry I will have to augment the non-cancerous breast and will probably end up a B cup. I don't really want to be any bigger- I like my small breasts- but all the plastic surgeons have said that it would be necessary.

All the surgeons have had different opinions about whether I would be a good DIEP candidate- Chen would have preferred to do PAP- but Salzberg said I have enough stomach fat for fine with DIEP and the surgeon at Sloan said she could do it but wouldn't recommend it since it's a hard surgery to recover from and I don't have a lot of fat. I'm concerned about the longer recovery and the effects it would have on my abdomen as well as the large scar. Salzberg was very reassuring about the recovery and said it would only be 2 weeks but that's not what I've heard from others. I would probably still need to augment the other breast in some way, but perhaps just a lift instead of another implant.

I'd love to hear other people's thoughts on this and how they made the decision. Anything I should consider that I haven't thought about yet? Any feedback is much appreciated.

NancyHB

rokel - it sounds like you've gotten lots of information from many sources - which can be good, but also confusing! :-) like you I wasn't excited about implants - I have sensory issues and I'm certain they would had driven me mad, so it was tissue recon or nothing for me. I can share with you what I learned from my unilateral DIEP last summer.


Maybe most importantly - you want to be certain you choose a PS who is experienced in DIEP. It's a big surgery and not everyone is skilled in the required microsurgery and asthetics. DIEP/free TRAM are my PS's specialty. I met with him once before even considering the surgery, then a second time to ask questions, and finally committed on the third appointment. I am beyond pleased with my results.

My surgeon said most patients are back to "75% energy and functioning" by 6 weeks, and that's about where I landed too. I can't imagine a 2-week recovery with DIEP, particularly with a full hip-to-hip incision and the first 5 days in the hospital - that's an unrealistic timeframe, I'm sorry. I wasn't allowed to do much of anything the first two weeks but walk gently for short distances (which was hard because I'm a runner), and I couldn't even stand up straight for three weeks.

I did, however, develop a serious infection in my breast which required two hospitalizations and home IV antibiotics. I don't say this to scare you, but just to make you aware that there are risks of infection and wound dishesence (opening) with DIEP (as with any surgery, of course). I was finally able to go back to work 10 weeks after surgery.

Know that you won't be able to save your nipple with a DIEP - that can be an important consideration for some. DIEP is also not a "one and done" surgery - there are typically at least two later "revision" surgeries required. Did a variety of reasons I have not pursued Stage 2 revisions and do not have a nipple on my left breast but if doesn't bother me.

There's a great thread on here for those going through DIEP - if you have a moment check it out and read what about others' experiences.

Good luck and I hope you find a good surgeon to help you with this decision.

NotVeryBrave

I chose the "one and done" route with skin and nipple sparing BMX. I can't imagine anyone going through even just the mastectomy (major) and being fine in two weeks! I would say I was moving more easily by two weeks but wasn't really feeling anywhere close to normal until three to four weeks. Much better by six weeks.

I was opting for the least number of surgeries and the least amount of my body being affected. I'm reasonably happy with my choice. I may or may not pursue fat grafting down the road to soften the appearance but am larger than I really wanted to be and don't need "more" there.

I can't help you on the size thing. Seems like it's hard to get exactly what you want. I would advise looking at pictures at the PS office and showing them what you like and don't like about them. I wish I had done that.

And keep in mind that you could potentially do the implant and go back to do the DIEP if not happy later.

salasila

Hi rokel. I was in the same boat as you 2 months ago. When I was first diagnosed, I met with the medical team which comprised of the radiologists, breast surgeon, plastic surgeon, oncologist, etc. all at once. It was overwhelming but I was thankful that they were in a group and talked about me at least once a week so each is updated with whatever the heck was going on. Anyway - when I met with the reconstruction team, I was given the option of implants or DIEP. I chose DIEP because a) my plastic surgeon was well-known for this procedure and he is superb (well, at least to me ) b) I did not want to mess with the TEs and then implants and then watch those implants for next 10 years or so when they would need to be replaced c) I like the look of the DIEPs than the implants - they're nicer and I felt that I deserve nice ones if I have to go through this cancer bullshit d) I get to have a tummy tuck (not important - but just nice to have).

Yes, the surgery and recovery for DIEP is longer and tougher than implants (I think). Surgery took almost 7 hours (simultaneously with the breast surgeon/breast and tumor removal - PS did my abdomen while BS did my breast and then PS moved on to reconstruct when BS got done), I had to stay in ICU for 24hrs for observation (under this silly warm electric blanket that drove me CRAZY plus I was HUNGRY and all they gave me was ice to suck on) and they kept coming in to hear if blood was flowing through the veins where the reconstruction site was (that was pretty darn cool). After that I ate and I was happy. Stayed a total of 3.5 days. Came home with 6 drains (I hated those suckers) but no pain. I didn't need to take any of the painkillers that I came home with. Be prepared to spend some sleep time on a recliner - I find that the recliner was more comfortable than my bed on some earlier days just because of the positioning and that it helped me to get up and down by myself faster than if I was lying on the bed). I live in a 2-story house with stairs and I had no problem going up and down (my master bedroom is on the 2nd floor). My drains were removed a few days later and I was up and about walking outside 2x a day. I think full recovery was at 3weeks (which included ability to driving) and I could have gone back to work then but my PS wanted me to stay rested until 4 weeks and then resume work. I started basic yoga at 5th week and started walking 4 miles a day. Honestly and truly, the abdomen incision is the worst part - it is long and ugly and I hate the feeling of numbness and the "pull" sensation sometimes. I realize that the days when I'm too tired or lazy or have no time to do my walks, I feel a tightening in my abdomen area. It relieves itself once I do light exercise or walk (I don't know if it is related to exercise but I'm just guessing).

As Nancy said: no saving of nipple here. I lost both (I did the BMX). PS will see me after chemo is done to continue with nipple and/or other "touch-up" work. He said he might give me a little lipo if I'm a good girl (kidding ... I actually asked for it and he said "ugh maybe"). I will be chasing those nips and lipo too once I'm done with my 12 weeks Taxol.

I'm not sure if I've given you any insights ... ask away if you have questions.

Lula73

I chose bi-lateral mx with immediate DIEP recon-you go in with breasts and you come out with breasts. Being an A cup it's entirely possible you could be a one and done with DIEP or SGAP as you may not need the lift later like some of us with larger cup sizes. And it sounds like even with implants you'd need a second surgery anyway. If I didn't need a lift and some revision in the hips I would be a one and done. My DH tells me all the time how great it looks. And I've really not had any complications from the surgery (treatment is another matter).

Recovery time-yes recovery time is slightly longer with natural tissue recon BUT with either surgery you will have to let someone else take the "Mom duty" reins for awhile. There's no way around it. It's hard to do but in the end you have to put yourself first so that you can go back to taking care of everyone else when you're recovered! YOU are worth the time and effort required for either surgery's recovery if it's the best choice for you personally (not because you're a busy person or busy mom and want the quickest recovery, but because that type of recon will leave you feeling as close to how you did prior to the diagnosis and surgery.)

On the nipples-you CAN definitely have nipple sparing mx with natural tissue reconstruction. I traveled to the Center for Breast Restoration Surgery in New Orleans from NCfor mine and they do nipple sparing mx with natural tissue recon all the time. Now, if your cancer is located near the nipple and shallow, you may not be able to spare the nipple no matter which surgery you choose.

Another consideration you didn't mention was uni vs bi lateral mx. It's a very personal decision and we all have different reasons for choosing each option. Some of the most common reasons in regards to recon for doing both are symmetry and when doing natural tissue recon that you only get 1 shot at any of the donor sites-so why not do both (if you choose uni and later need mx on other side you can't use the same donor site again).

Yes it's a bigger surgery with a slightly longer recovery but the results are amazing. My breasts are warm and soft, they look and feel like real breasts, the move with me like the originals did and they won't need replacing in 10-15 years, they will age with me naturally. Check out the before and after photos on this link to see what good looks like with natural tissue recon: www.breastcenter.com

Would I do it again? In a heartbeat. With the caveat that the surgeon does at least 1 natural tissue recon per week, has a flap failure rate and infection rate that is lower than the national average for flap procedures and photos of his/her work "before and after after" are representative of what I'd want to look like. If those specs aren't met, keep looking for the right surgeon-they are not all created equal.

Hope this helps! Feel free to ask any questions or PM me if you like.

rokel

That's a great idea to show them pictures of what you want- thank you.

Also good point that it might not make sense to do DIEP if I need to have the second breast removed in the future.

Thank you so much for responding. It's helpful to read everyone's experiences and how they made this decision.

Suzanne50

I will just add that I had a single right mastectomy and chose expander and implant. My left breast also needed an implant for balance. The reasons I chose this route was it was a quicker recovery mainly. I am an active person and the thought of being unable to exercise for longer than the minimum was not appealing to me. I went the simplest route. Since my expander exchange, I have needed two more outpatient surgeries to achieve symmetry but am happy with the result (now!). My only other option was the lattimus flap (or whatever it is called). I discussed with my BS and PS and it was just way too much for me. I wanted easy and done.

dtad

Hi all...I had a BMX with direct to implant reconstruction. It was one and done for sure! No complications. Happy as one can be with fake boobs...

Lula73

Rokel- glad you found the posts helpful. I guess you could take the part about unilateral mx vs bilateral mx as a reason to not do recon but I meant it as a reason to do bilateral no matter which option of recon you choose. Symmetry, identical feel and identical movement between the 2 breasts would be the reasons cited as it relates to bilateral mx benefits related to the recon no matter what type of recon you choose

NancyHB

Having had a unilateral mastectomy and DIEP I will share that my breasts look and feel almost completely identical to each other. I'm not large - B+ cup size, so maybe that makes a difference. At first my recon side was very high and firm but over the last year it's settled to the point where i see and feel minimal differences between the two. My PS was determined to achieve symmetry and, at least in my case, he did so beautifully.

rokel

If I did a bilateral mastectomy could I avoid being on Tamoxifin? I'm 80% estrogen positive. If so, I would definitely consider it.

NancyHB, were you worried about limiting your reconstruction options if you ended up needing another mastectomy? By the way, the last ps I saw said in the near future they will grow a new breasts in a lab and no longer do the fat transfer surgery so hopefully if I do get a recurrence, that will be an option by then

NotVeryBrave

Nope - any estrogen positive cancer is going to need some type of anti-estrogen therapy. Recommended anyway.

NancyHB

rokel - to be honest I never thought about it because my mastectomy and DIEP came after my second diagnosis (I had a lumpectomy the first time). I was less worried about another local recurrence than I was about a distant (metastatic) recurrence. And in my case I have other areas of tissue that could be used for future recon, so I never felt limited. It's a valid consideration, just one I never had to worry about.

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