DIEP or Latissimus and Implants? and a Bad Mastectomy

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JRNJ
JRNJ Member Posts: 573
edited January 2020 in Breast Reconstruction

I had BMx in September with TEs, had infection, TEs were removed. So I didn't like my BS, I like my PS, but there were some communication issues. I met with a new BS who I love, too late, who wanted me to see her PS and said I should go with under the muscle and agreed my former BS has a big ego and did the surgery weird, almost like a lumpectomy. PS#1 put in TE over the muscle. Never discussed with me there was any other option. But I have thick skin, so may have been ok if it worked. Tentative plan is to put TE back in between chemo and radiation, over the muscle, and wait 6 months after radiation for final implants. Originally he said I didn't have enough tummy for DIEP, but if too much skin damage from radiation, may revisit that decision. He said Latissimus is more complicated and higher rate of failure. He is overall flexible and always fit me in when necessary (due to infection) and is in-network. PS#2 said she would not put TE in, in between. She recommended waiting 6 months after radiation, doing Latissimus Flap due to skin damage from infection and probably radiation, with implants later over the muscle. While she often recommends under the muscle she said in my case over with the flap. I said why latissimus instead of DIEP? I would rather remove the fat from my stomach? I think she said OK to that, although she does not appear as flexible as PS#1. The new twist is she confirmed my fear that BS left a lot of excess tissue and she would remove that tissue during the surgery. I am told people fly from China to see her. She is booked til September for DIEP and she is out of network, but said she could get an in network exception. I think PS#1 does more cosmetic than reconstructive but I don't know for sure. I only heard good things about him and that he can do flap surgeries. I think PS#2 does more reconstruction. She told me she has done hundreds of flaps. So I'm more confused than ever. Do I stick with PS#1, try implants, delay radiation, and if they fail again go with DIEP? or do I go with PS#2, focus on treatment, than do flap with implants and have her complete my mastectomy (this is pretty important)? Why did she recommend Latissiumus before DIEP, that has me concerned?

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  • Beesie
    Beesie Member Posts: 12,240
    edited January 2020

    Your question about why the Lat Flap is a good one.

    I don't as a rule like to promote anecdotal information because it represents just one person's experience that might be way off the norm, but in this case I have to admit that from people I know who've had Lat Flaps and from reading this board, my overall impression is not positive. Complications, weird looking scars, tightness around the shoulder and back limiting activity....

    I'd suggest you do a search on this board to learn more about how other people have fared with a Lat Flap.

    As for which approach is better, I think the question is how much damage there is to your skin already as a result of the previous infection. PS#1's suggestion is what seems to be commonly done - put in the expander, then do rads, wait a bit, and then replace the expander with the implant. But there is always a risk that the skin will be compromised by the rads, impacting the results (either tightness and appearance, or failure). In your case, given the previous infection, is this risk too high? That seems to be why PS#2 is suggesting replacing the skin with the Lat Flap (or alternately, a DIEP).

    Maybe the question to PS#1 is "given the previous infection, what do you think the odds are that my skin will be fine after rads and implant reconstruction will be successful this time?". And to PS#2, "why a Lat Flap and not the DIEP?"

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  • JRNJ
    JRNJ Member Posts: 573
    edited January 2020

    Thanks Beesie! It helps to hear that. I think I already knew I didn't want Lat Flap. It leaves me questioning should I dump PS#1 for PS#2. PS#2 more conservative, won't try TE between chemo and rad. PS#2 is supposedly so great and done hundreds of Flaps, but why would she recommend Lat and everyone else is recommending DIEP? I did ask, I said why would you recommend Lat Flap over DIEP, I would rather have the fat removed from my stomach and she just said ok you can do DIEP and didn't really answer the question. MOs from Sloan and Rutgers also recommended DIEP and wanted me to see their surgeons too. I like PS#1, but am questioning his reconstructive experience now. They told me to ask how many DIEPs he as done. I was told he can do them by numerous people, so I didn't question it. I don't think he will remove my residual breast tissue, he would probably defer to breast surgeon for that who he is friends with and I dumped, so that is a confusing complication. They all have their affiliations and it is hard to change without changing the whole team. So stressful. I'm on hold with PS#2 during chemo and not seeing him. Trying to decide whether to dump him and not go back, or go back for another consultation and ask more detailed questions. I tend to be vulnerable and pick the last Dr. I see and trying to make decision based on procedures and not emotions.

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  • JRNJ
    JRNJ Member Posts: 573
    edited January 2020

    Thanks sierrahfs. I'm glad it went well for you. I'm still confused. There isn't much fat on the back either, so how does the lat flap work better? Is it because you are really skinny and they need to take muscle either way so better the muscle on your back than your stomach? What cup size did you end up with? I have an appointment with PS#1 tomorrow to get more answers. I'll ask him if he can put implants in at the same time, because PS#2 said no she would not do that.

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  • godisone
    godisone Member Posts: 100
    edited January 2020

    During implant reconstruction, an implant is inserted as an immediate reconstruction or as delayed immediate reconstruction. It is a complex procedure performed by plastic surgeons Silicone gel based and saline based implants are the two most common implants used to rebuild the breast post breast cancer surgery. The time of surgery and the healing takes less time with implant reconstruction as compared to the flap surgeries as here, there is only one surgical site rather than two. Here, a balloon like expander is inserted in the chest wall, the expander would gradually be filled with silicon or saline for the skin to stretch and expand in accordance with the contour of the reconstructed breast. It takes around 6 weeks for the surgical site to heal while the doctor would advise strictly against lifting heavy loads

    this is a piece i wrote for my blog but could never publish it. But this is true story. I hope I could help

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  • JRNJ
    JRNJ Member Posts: 573
    edited January 2020

    Thank you all for the input. I met with PS#1 today and I think I have clarity. He also recommended Lat Flap or DIEP. He would be willing to try TEs before radiation if I want, but I don't think it's the best choice now because I don't want to delay radiation by several weeks, I probably wouldn't have a full fill, and if I get another infection, it will delay radiation even more.

    I had some communication issues with his office in the past when I was in the hospital and had problems in the middle of the night, but overall I like him so I am not dumping him for PS#2. Hope I don't regret it. I feel DIEP with possible implants makes more sense for me, as I have some fat I want removed and a bad C-section scar already. And I have to wait 6 months, so if I gain enough weight I might not need implants. And I discussed the weird twist that I may have too much tissue left over from Mx and I didn't want my former breast surgeon who he is affiliated with to be involved at all. He said he would remove the tissue and if I wanted my new BS in the room that was fine. This is the only issue I am a little concerned with. I think PS#2 might remove more breast tissue. Don't know how important it is to get every piece of tissue?

    They both said with DIEP, am implant would be above the muscle and if the tumor wasn't on the breast wall, detecting a recurrence shouldn't be an issue.

    So in conclusion, I will now try and gain weight in order to have bigger boobs and possibly avoid implants and bought 2 gallons of ice cream, lol.

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  • Beesie
    Beesie Member Posts: 12,240
    edited January 2020

    An excuse to eat ice cream and gain weight, and hopefully end up with reconstruction that works and that you like.

    Sounds like a great plan! I'm glad the discussion went well and you are feeling more comfortable about everything now.

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  • Moderators
    Moderators Member Posts: 25,912
    edited January 2020

    Hi All,

    One of our writers, Cheryl, would like to talk to people who has had a great caregiver they could speak on behalf of following a mastectomy with reconstruction. OR, directly talk with the caregiver themselves. This information would be so helpful to writing the piece she is working on. Please PM us if you are interested, or your caregiver.

    Many, many thanks!

    The Mods

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  • JRNJ
    JRNJ Member Posts: 573
    edited January 2020

    I am an eternal pessimist, although I prefer the term "realist", lol, but feeling a little better with a plan. I keep second guessing every decision I make. Especially which drs. to go with actually more than the actual procedures. But time to move on. Won't have surgery til the fall now, so not an urgent matter. No bikinis for me this summer, lol, I don't wear them anyway. I can wear my stuffed sports bra.

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  • Jaybird627
    Jaybird627 Member Posts: 2,144
    edited January 2020

    JRNJ ~

    Good luck. It's normal to ask so many questions and to second guess each decision! I, too, am a realist.

    I've posted on these boards previously about my lat flap surgery. I've had no issues - so far - 6 weeks post surgery.

    I had the lat flap due to the R breast skin being radiated 15 years ago and it responding negatively to the TE after BMX.

    I had radiation on L breast while TE was in, then exchanged for silicone implant after rads. No skin issues on L breast.

    The lat flap was my only option if I wanted an implant due to the fragile skin. I did a lot of research on lat flap surgery!

    I have no belly fat/extra skin so DIEP wasn't an option. I researched TUG flap but it's not common. I like the lat flap as

    the muscle stays connected which may be a better outcome for me.

    My previously radiated skin is still being problematic but the lat flap skin is great.

    My reconstruction journey to be continued (unfortunately).



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  • JRNJ
    JRNJ Member Posts: 573
    edited January 2020

    thanks jaybird. Both my consultations recommended either lat flap or diep and didn't mention any others. I guess they are most common. Probably have to fly to NOLA for more advanced. Or I would go to Sloan or Rutgers for consult if not happy with my options as they are driveable for me. But I want diep. I think hip or butt would be my next choice as I have some fat there I'd like removed lol. I’m looking for a little bonus in this mess. Lol. Good luck with your recovery!

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  • bc6912
    bc6912 Member Posts: 3
    edited January 2020

    Never hurts to seek a second opinion! PRMA in San Antonio does specialize in DIEP flaps and they offer a free virtual consultation on their website. I would link it for you, but the forum is not letting me add links to my comments. It's worth checking out!

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  • HopeWins
    HopeWins Member Posts: 181
    edited January 2020

    JRNJ - sounds like you landed on a good plan. Just my opinion, I'd have an experienced BS remove breast tissue and let the PS stick to recon and microsurgery.

    I didn't quite have enough abdominal tissue either (bmx and DIEP in August 2019). I was a large B/small C before cancer. Was a large A/small B after initial DIEP. I strongly considered an implant after my initial surgery but fat grafting made a huge difference. I had one round in November and will have one more in March, then I'm done. No implants. I'm almost back to my original size, so no need. It's not like I had a ton of fat to spare. My bmi was 22 I think. A good PS can do a lot with good technique. First round he took from love handles and waistline. Next round will be outer thighs.

    Good luck!

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  • JRNJ
    JRNJ Member Posts: 573
    edited January 2020

    Thanks hopewins. Sounds like a good plan. I’ll revisit Fat grafting with him after surgery. I asked him about it and I think he said it was an option. And he said my new BS can be in surgery if I want. He is affiliated with my old one but is flexible. My new BS told me he showed up at their meeting because I was on the agenda. I was shocked. She thinks old BS sent him so she wouldn’t get bad mouthed lol. I’m confused which PS to pick but I think they are both good and qualified and now they are fighting over me lol. My breast surgeon sent me to her affiliate but told me she was impressed by mine at the meeting. And she called me at home at 8:00. I never got so much attention from my drs.

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