Bilateral mastectomy with possible DIEP surgery vs expanders

hi Lam. I haven't had my surgery yet but recently went through the same decision making process. You'll find a lot of info on this site. You might even search here for DIEP vs implant. Outside of this site there are studies on satisfaction rates among implant patients vs DIEP patients.

For me, these were my deciding factors. Im a nipple and skin sparing candidate and dont anticipate I'll need rads or chemo, so I can do immediate recon. I didn't want to travel for treatment. I had two PS consults. The first said he only does direct to implant 20% of the time. The second surgeon never does direct to implant for cosmetic reasons - too much chance of assymettry. Tissue expanders would have been in for 3-5 months with implants. When I considered that vs DIEP recovery, I felt like the recovery wouldn't be much worse with DIEP. Both require at least a second surgery. DiEP felt like a better life long solution vs implants that may need to be replaced every 8-12y (I'm in my 40s)

If I had a surgeon near me who was very experienced at direct to implant, i would have considered that. I found a BS within an hour that has excellent DIEP experience. If I didn't have access to that, I probably would have settled for the expander/implant route. I had been leaning towards DIEP from the beginning, so I feel fortunate to have found what I did. Surgery is next week.... got to be honest, I'm a little terrified.

So true on PS steering towards what they are comfortable with! My first consult tried to steer me towards implants - he does 50 or fewer DIEPs per year, but thousands of implants. My 2nd consult painted a long TE process - he's an experienced microvascular surgeon who does DIEP and SGAP, approx 3000 at this point in career.

You almost need to decide what you want before you find and interview your PS, or at least know what they're good at going into the consult. I really viewed my consults like I was hiring an expert to do what I wanted. I took what they told me with a grain of salt when it came to the procedures they weren't renowned for and soaked in what they said about their signature procedures. If I really wanted direct to implant I would have sought out and gotten a 3rd opinion but I am at peace with my DIEP plan.

One thing to consider - you could always do implants and then DIEP years down the road if you're unhappy with implants. That option was presented to me because I don't quite have enough tissue to make my breasts as big as they are now and we all get more squishy as age.

lam38 just wanted to check back in and give you the good, bad and ugly. I'm almost two weeks out from DIEP phase 1. In the first few days after surgery I was feeling pretty bad. Visually my breasts/body looked mutilated to me. Drs, nurses and DH kept telling me everything looked great but I did not see that. The pain/discomfort for the first week is pretty intense so I think that contributed and I cried and cried. The arm pits are super sore if they do SNB and make the vessel connection there (some PS use a vessel in the chest instead but this requires partial removal of a rib on each side) also, the abdomen... wowzer. Anyone who has had abdominal surgery can attest to this. But my pity party didn't last too long.

Now that the swelling has gone down it's so much better. My nipples no longer point east/west and are centered nicely. Boobs are pretty symmetrical. My tummy is completely flat. Scar is low and thin and the soreness/swelling went down significantly after only a week. I had read that many women lose their waistline. I didn't and I was grateful because I did not have much of one to begin with. I'm built like a column, sort of athletic and short waisted with long legs. I had medium/big boobs and not a ton of body fat with a BMI of 22. Ive had 3 kids so I had a little fluff in the belly. The PS said it was just enough tissue for DIEP but fat grafting would be required.

I have to say, the boob volume is pretty close to what I had but the distribution is wider/flatter. I definitely will need fat grafting to fill out the upper and cleavage areas and I'm hoping that will work because the alternative would be small implants. I obviously don't know what implants feel like but I'm surprised that this transplanted tissue doesn't feel foreign. It mentally feels like my boobs never left... they just look different. Boobs are numb but my nipples still react to stimulus and they look like real boobs in something as skimpy as a camisole. No one would know otherwise. There are a lot of scars, so if that's something that would bother you, talk to the PS. I think some are revised in phase 2. Scars don't really bother me so I haven't asked too much about that. My niece says scars are badass, lol. If so, I might be the baddest of the asses!

I have to wear an abdominal binder 24/7. The PA said 8w, but will see what PS says at 3w apt. I understand guidelines vary. It makes the back pain from hunching better but it's a PIA to sleep in, wear clothes with, etc

Recovery wise my chest wall and armpits still feel pretty bruised but i think that is mostly mastectomy/SNB pain. I think outcomes vary greatly based on the patient's situation. Radiated skin, BMI, whether its bmx or unilateral, nipple/skin sparing vs not, etc. I think a lot can change with the phase 2 revision as well. I think the skill of the PS is also super important. I could have had this done at my local hospital with a PS who does "about one/week" but opted to go an hour away for a PS who has done thousands and came recommended by my friend who is a gynecological surgeon.

From a recovery standpoint I still am a little jealous of the ladies who had direct implant recon and didn't touch their belly, but I think I'll be happy in the long run with my choice. Best of luck to you and PM me if you have any questions.