DIEP Surgery in Seattle

Okay, I am sorry, I can't sit by and watch this last post from Miserable without saying anything. I am SORRY, but a TRAM is NOT equivelant to a DIEP. A TRAM flap utilizes the rectus abdominis for the blood supply - if not all of it, then at least a piece of it. Many plastic surgeons prefer not to do DIEP because it IS so time consuming and because the payout from insurance is generally not as high - so more work for not so great money. There is NO WAY that I would let anyone touch my abdominals. I had to argue with my insurance company about this. Will it affect your ADL's (activities of daily living) to have the rectus abdominis cut? Maybe not, if your ADL's do not consist of a lot of lifting or high activity. BUT, I like to hike, ski, bike, snowboard... etc. All of these activities require good core strength. Core strength = abdominals, back muscles... basically your "stabilizers". There have been studies regarding the risk of abdominal hernia w/TRAM flap, and yes, it is much greater with TRAM than w/DIEP. Why do you think they have to utilize a mesh cover when doing TRAM? Please go to Dr. Said. I know that the University of Washington is very much proactive regarding the DIEP - if you look on the Cancer Care Alliance website, it will tell you how much they prefer it over the TRAM. It is unfortunate that Dr. Isik has chosen this direction. It only helps the insurance companies to deny a much better procedure in hopes of paying less - how are we ever going to advance with this kind of thinking? And who loses out? The patient.

Miserable: Nordy is right on. You don't want a big ole floppy belly which you would be left with after a TRAM. Ck out this plastic surgery site; abstract regarding DIEP/TRAM:

http://journals.lww.com/plasreconsurg/Abstract/2008/07000/True_Incidence_of_All_Complications_following.3.aspx

There is a lot of information out there; just need to keep digging. Plastic surgery site has a lot of information/abstracts.

J.Seda

Dear Golfer: Do you have Grp Health or Grp Health Options with choice to go out of network. I just went through appeal with GH who initially denied Dr. Neligan doing my DIEP procedure. With letters from Dr. Neligan and myself stating this was unacceptable and reasons why (I don't know your history so can't offer info), the decision was overturned and my surgery with Dr. Neligan is going forward. In the state of Wash., medical insurance can not deny you reconstruction after breast cancer. If you can't get this done in a timely manner, citing more options for complications with delay and tissue expanders etc. Besides, a delay also adds another surgery beyond the immediate reconstruction. The costs will be much greater for GH for you to wait. Stay on them as its your body and you're paying the premiums.

Good luck

J.Seda

I didn't ask him, but his office person told me that his first opening is December 21.  FYI, I would never opt for surgery anywhere near Xmas.  It would muck up the holiday, but more importantly, you often end up with the second string (both docs and nurses) caring for you since the first and most senior string generally gets the holiday(s) off.  I worked at VM for many years and that was almost always true.  

I've interviewed several plastic surgeons.  As for the surgeries, both use lower abdominal fat and tissue to form the reconstructed breast resulting in a tummy tuck and a scar that goes from hip bone to hip bone.  The primary difference is that the Tram is done with a pedicled flap which sacrifices the rectus abdominus muscle on the affected side (of both if bilat).  The vasculature of the muscle supplies blood flow to the transplanted tissue. The muscle is cut and it and the belly tissue are moved into the proper position through a tunnel created under the skin between the abdominal donor site and the breast area which has undergone a skin sparing mastectomy.  You are generally in the hospital for 2 days.  I am told that pain in the reconstructed breast area is not a big deal, but the belly pain can be significant for a few days.  Opiates are a good thing during this period.

The DIEP is a free flap which also uses belly fat and tissue, but requires teasing blood vessels out of the rectus muscle, moving the free flap and blood vessels to the breast area, removing a portion of a rib to access the appropriate blood vessels in the chest and then sewing the very tiny artery and vein portions together with microsurgery to establish blood flow to the transplanted tissue.  It is a much more complex procedure from a surgical perspective and takes several hours longer than a TRAM, requires a 3-4 day hospital stay with the first 24 hours in Intensive Care where the flap can be frequently checked for signs of failure, and is much more expensive. It also has a higher chance of partial or total flap failure due to the potential clotting off of the newly anastomosed (connected) blood vessels.  He also mentioned that many women are not candidates for a DIEP because of other problems such as smoking, vascular disease, tiny blood vessels, too much abdominal tissue (aka belly fat), diabetes, etc., etc.  The TRAM has a reputation for a more painful recovery because of the muscle issue, but he claims that studies show that pain catheters (which are attached to pumps that allow patients to self medicate with pain meds with the push of a button) have leveled the playing field.

After years of doing both procedures and the new study I mentioned previously (which validates his observations with his patients over the last decade or so), Dr. Isik explained that he thinks it is best to "keep it simple."   He will do bilat DIEP's on some women, but not a unilateral DIEP.  Like his partner, he is also adamant that immediate TRAM or DEIP is a bad idea, resulting in a 50% complication rate.  For that reason, he normally requires his patients to wait about a month. Fortunately, his partner who does only TRAM's and implants, but who is the go-to guy in Seattle (according to many docs I know) both for TRAM flap and implant reconstruction and to correct other docs screw ups, is willing to do a TRAM in about a week,  This allows time for the path to come back before the reconstruction.

Hi miserable (I hope this names changes at some point ) - I can only talk about my DIEP experience. My PS told me he had done 200 DIEP's, mostly in the last two years, with no flap failures (he did admit it could happen at some point to him though). I asked the nurses in the hopsital what they observed in all the ladies who came in for DIEP and they said from time to time there is venous congestion which is treated with leeches (yuck, but they work) or if there is poor circulation (which becomes apparent that first 24 hours with the hourly checks), the patient goes back to surgery that day to fix the problem. I was told there is little risk of flap loss after the first few days. I was never told I could possibly have a TRAM if for some reason the DIEP didn't work. Maybe my PS was pretty confident, I don't know. I guess the message is that you need to find a PS who does this all the time and has lots of microsurgery experience. My PS also re-attaches fingers, etc so I think microsurgery is his thing. Cost is not a factor because I am in Canada.

I should add I had a unilateral DIEP and I asked what would happen if I developed BC in my other breast. I was told there would be the possibility of using the inner thigh, the SGAP and other sites could be used for a reconstruction.

I think no matter what surgeon you talk to you will get a little bit of a different story, doesn't really need to be a battle of who's right. That gets discouraging for people just beginning their journey I think

Loving the discussion regarding DIEP vs TRAM. Here's a site/study that states * in this study* no big difference in DIEP flaps vs TRAMS. http://www.eclips.consult.com/eclips/article/Breast%20Diseases/S1043-321X(08)79098-2

Again, you have to trust your surgeons and their assessment of the big picture for you, taking your health into consideration as no one else knows your situation. Anne W is correct. The preop studies give the surgeon the information he needs to make his pre-surgery plans and what is best for you. He's not going in half cocked. Trust me, they are being very careful and giving your case their ultimate scrutiny prior to. In all the medical abstracts I've read, I've not encountered anything anywhere that states there's a 50 % complication rate on immediate DIEPS. That doesn't make sense. Also, I've not ever heard, other than on this site, of a surgeon switching during the procedure from a DIEP to a TRAM. If they tell you this on your consent form, I would really question this before signing, even if I had to get another opinion. I have my PS pre surg visit next week at the U of Wash and I'm going to approach this question so will pass on what I hear as well.

We all need to do our jobs by getting in the best shape we can be in, as well as eat healthy and exercise prior to having any procedures done. Praying is good too!!

JSeda

Okay, I have only skimmed thru most of this whole thread because I saw so many things that really caused me visceral upset, and it is a holiday weekend and I want to relax! I logged out and tried to put it out of my mind, but then decided I couldn't, so I'm going to, at least, try limit how much I would usually write. I'm sorry if I rile anyone else up.

I had stacked DIEP in '06 in New Orleans. These are the most experienced doctors in DIEP in the country - probably the world - thousands of DIEPS and GAPS and all manner of stacked combinations. Their website is filled with a wealth of info. If I have to have the contralateral breast done, I would NOT get an implant, I would have another flap surgery in New Orleans - maybe a stacked GAP this time. Scars fade, but I don't want to be worrying about having to have an implant replaced at some future date. And after having the best, I only want the best again.

http://www.breastcenter.com for lots of info on reconstructive techniques and studies about outcomes.

Their failure rate is less than 1%. Anyone who quotes 50% is either ignorant or trying to instill fear about the procedure. Also, with experienced surgeons, there should never be a need to be deciding, during surgery, to do a TRAM vs. a DIEP. Never. But again, this is in the hands of experienced surgeons. If they can't offer you this guarantee, they have not had enough experience. I traveled from Minnesota to have my surgery. My insurance paid. This clinic works with many different insurance companies. Don't ever feel that you don't have a choice and that travel is not doable. Doing this was outside my comfort zone, but I'm so glad I took the leap of faith and headed south. Just consider it as an option, if it's possible for you.

We talk about the great medical care in this country. And it is great, if you have good insurance (and insurance companies are rationing care, don't kid yourself). Or if you have a job that provides insurance (and less and less can afford to do so). Or if you have a lot of money. We need to think beyond our own personal situations to all the folks who are not fortunate to have money and coverage. Preventative care sucks in this country. Our costs are higher and health outcomes are poorer. Again, I'm looking at our whole society, not just a select slice of the pie. And we all go down with this sinking ship. Fear tactics to preserve a status quo that only works for the privledged really ticks me off. No one in this country should go broke because they get sick, or not get good preventative care or be tied to a job lest they lose their coverage. And no one's job is safe in these economic times, so don't think it can't happen to you, no matter how hard you work or how deserving you think you might be. Wait 'til you have a kid graduate from college or grad school and either hasn't been able to land a job yet or gets job that doesn't provide coverage. You wouldn't believe the premiums the insurance companies are charging for healthy twenty-something kids who have to pay for their own insurance. I don't think health care should be considered a capitalistic commodity, but a right for all Americans. Now I step down from my soap box!

The particular surgeon Miserable is talking about also quoted me $50K for my bilateral delayed DIEP when I called 2 years ago, stating that they don't deal with insurance and that I would have to submit for reimbursement. 

Ladies: I agree with you that health care is too expensive. My family is in the healthcare field and we see it first hand. Its a very hard and demanding field to be in. You can make a good living but its not so easy any more with having to pay high salaries, high costs of supplies, high malpractice ins. premiums, as well as less and less reimbursement for services. That's why we're seeing more and more good docs get out as they can't afford to keep the doors open as well as way too much paperwork/regulations. I also see how much free care, we the healthcare providers, give away. We get no assistance from the gov. for this. Its out of pocket and our costs still go on. Might want to look at the facility side of healthcare as to where the monies are going. No one has had the common sense yet to put a price freeze on costs/healthcare/insurance premiums, which keep going up faster than you can blink an eye. Until this happens as well as torte reform, no system changes will work. There has to be some common sense. Also, who's going to pay for the free healthcare for everyone; our broke government. People in this country have got to learn to pay for things, not just wait around for handouts on one hand as well as demanding the best care in the world on the other. These services cost money.

 I grew up in a large family and we as kids, learned to work out buts off and if we wanted something, we earned it, and because of those basic principles, we were taught at an early age, that you don't buy what you can't afford. With that in mind, we also learned to educate ourselves about what we are after, such as med insurance, then make the best choice as well as live with the decision. We didn't learn to go out and complain everytime things didn't go our way, or, if we made a bad choice and had to buck up, learn from it, then go on. I do agree that insurance companies (own washington dc) need to pay their CEO's less and cut prices. But, we still need free choice to keep coverage and prices competitive.  I would like to see some solutions offered instead of complaints about healthcare. Its easy to complain and takes an effort to fix it. We all need to start and if you do have great ideas, write/call your congressmen/senators. Remember that old saying, ask what you can do for your country, not what your country can do for you. Its amazing how fast we forgot. Like in the past, America was known throughout the world as a leader and today, we've become followers.

We're all dealing with the field of Plastic Surgery, which is a very specialized area of healthcare. I do feel that costs do need to come down into a more realistic range. But, you also have to realize how high their malpractice insurance is as well as how many yrs of education it takes to get there. Never hurts to talk to your docs and negotiate a price prior to having procedures done. Worse case scenario, they say no, but then again, you might be surprised.

Now, I will also get off my soapbox.

JSeda

I don't have a lot of time to read these big long posts, but I don't think any of them are really helping the original question or her issue.

Me? I don't feel attacked at all, I know better than to take this personally. I was simply stating that this banter wasn't even addressing what golfer posted for her question, IMO!!

Correct me if I'm wrong but Dr. Isik's website promotes the DIEP as well as the TRAM procedure.

J.Seda

Yes Isik's website does talk about DIEP over TRAM which is a bit confusing if he has changed his policy.

 Thanks for the link!

 Jilda