More natural look, reduced pain in new breast reconstructions

Milwaukee Journal Sentinel

(MCT)

MILWAUKEE - The two bumps that lay atop Melanie Huempfner's chest were barely recognizable as breasts when surgeons began a complex procedure last month to make their form more natural and to eliminate constant pain.

The right breast, which had been removed after breast cancer and now looked strikingly similar to a tennis ball, had become extremely hard after scar tissue encapsulated the saline implant inside.

The left breast, which had been removed as a precaution because of cancer in the right one, had an implant that was somewhat bigger, and its shape wasn't as well-rounded.

For the next eight hours, Robert Whitfield, a plastic surgeon at Froedtert Hospital in Wauwatosa, Wis., and his team of assistants would strategically remove just skin and tissue from Huempfner's abdominal area and use it to reconstruct her right breast.

The availability of this highly specialized breast reconstruction technique, called the DIEP flap procedure, has expanded the list of choices available to women after having surgery to treat cancer.

Experts say the alternative gives women more assurance that they'll be able to maintain a natural breast appearance as well as an active lifestyle.

"The important thing is that the majority of women can have this procedure as long as they have enough tummy tissue and whether or not they get radiation or already have a breast reconstruction with implants," Whitfield said. "Many women have trouble with their implants, and like our patient, have never been given the option by their doctors."

The DIEP, or deep inferior epigastric perforator flap, is so named because it transplants the "flap" of skin from the abdomen to the chest by connecting the tiny blood vessels from each area, many of which are the size of the tip of a fine ball-point pen.

The deep inferior epigastric artery and vein supply blood to and from the abdominal muscle.

Rudy Buntic, a microsurgeon at the Buncke Clinic and the California Pacific Medical Center in San Francisco, said that before the availability of the DIEP flap procedure, many women were only offered a procedure that required removal of the muscle from the lower abdominal wall to create the breast.

This procedure, called the TRAM, or transverse rectus abdominus myocutaneous flap, left women with reduced abdominal strength, back pain and hernias, he said.

Women who get the DIEP flap, which doesn't use the abdominal muscle, typically have less post-operative pain and can continue some sports, something he'd never encourage with the TRAM procedure, Buntic said.

"Women have driven this (change) a lot," he said.

According to the American Cancer Society, there will be nearly 213,000 new cases and almost 41,000 deaths from breast cancer in 2006.

There are slightly more than 2 million women living in the United States who have been treated for breast cancer, the cancer society says.

Though more women are opting for breast conservation surgeries, such as a lumpectomy or segmental mastectomy to treat their disease, many women still may require or prefer removal of their entire breast in a mastectomy.

Women who have a mastectomy, and even some who have a lumpectomy, may choose breast reconstruction surgery to maintain their natural form, said Karol Gutowski, an associate professor of surgery at the University of Wisconsin School of Medicine and Public Health in Madison.

And those who choose breast reconstruction can have it done either immediately with skin expansion, followed by an implant, or they can wait until after chemotherapy and / or radiation to have a flap procedure, said Gutowski, who practices at University of Wisconsin Hospital and Clinics.

Radiation therapy can cause complications and also less successful cosmetic results, therefore breast reconstruction isn't recommended until after the treatment has been completed, he said.

But TRAM and DIEP flap aren't the only alternatives to women.

There's also the SIEA flap, which is done the same way as the DIEP flap, but using different blood vessels called the superficial inferior epigastric arteries and veins.

The SIEA flap doesn't require muscle dissection, but studies have found that only about 30 percent of patients are candidates for the procedure, Whitfield said.

All these procedures, the TRAM, DIEP and SIEA flap, look the same superficially; their differences lie in the blood vessels dissected and whether or not muscle is included.

Huempfner, 59, was diagnosed with breast cancer in her right breast on Valentine's Day 12 years ago. A week later, on her birthday, she had a double mastectomy.

As a child, she'd watched her mom deal with breast cancer and knew she didn't want to wake up without breasts.

Huempfner had an immediate breast reconstruction with skin expanders and had implants inserted six months later.

She ended up having another set of implants placed six months after the first ones and her right one done again a year after that.

Over the years, the pain in her right side progressively worsened.

"My armpit was a big hollow and it felt like I was always wearing a sports bra that was five sizes too small," she said. "I took Tylenol PM at night just so I could sleep."

At about 8:30 a.m. on Nov. 30, Whitfield made the first incision into Huempfner's abdomen and began the diamond-shaped dissection that would span from her hip bones and around her bikini line.

At about 11:45 a.m., he detached the majority of the abdominal tissue and within two minutes, began the incision across the top right breast so that the implant could be removed.

After clearing the scar tissue that contributed to Huempfner's pain and preparing her chest to receive the flap, the abdominal section was moved to the chest area.

The team then began the tedious job of attaching the tiny abdominal arteries and veins to the internal mammary artery and vein in the chest.

By about 1:45 p.m., the job was finished and blood flowed through what would become Huempfner's new breast.

However, shaping and symmetry of her breasts would take place later, Whitfield said.

Huempfner, who loves to run and ski, was released from the hospital three days after her surgery.

She says she no longer has the unbearable pain on her right side. She's also looking forward to getting her nipples replaced next and says she'll be back to her active lifestyle soon.

Size matters in flap surgery, and people can either have too much or too little abdominal fat.

Gutowski said women who are too thin or who don't have enough abdominal tissue can get the gluteal free flaps, which uses muscle and tissue from the buttocks.

Likewise, there's also the latissimus dorsi flap, which uses tissue from the upper back, that can be used in thin or obese patients but has to be used in conjunction with an implant because only a modest amount of tissue can be transferred, Whitfield said.

Most of the procedures also have an added bonus - people who get abdominal flaps end up with a tummy tuck, while those getting a gluteal flap have a buttocks lift, he said.

Buntic's lab also offers an inner thigh flap, or TUG flap, for women who don't have enough fat to perform adequate reconstruction. This procedure is paired with the thigh lift.

Laura Crowell, 52, had a DIEP procedure in June after having a bilateral mastectomy earlier this year.

She says that she was able to play golf within six weeks and was riding her horse by three months after the surgery.

"Implants were not an option for me," she said. "I knew I wanted it fixed and that I wanted something permanent. I know what I went through and I didn't want to be reminded every time I looked at myself in the mirror."

Crowell says her breasts look and feel very natural and that her tummy has some improvements, too. She's looking forward to getting her nipples done next year.

"Looking at me, you'd never know that I had surgery," she said. "And that's how it should be."

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RETURN OF IMPLANTS

In mid-November, the Food and Drug Administration approved the use silicone gel-filled breast implants from two manufacturers, Allergan Inc. and Mentor Corp. The agency deemed them safe for use in women who are 22 and older, or those undergoing breast reconstruction surgery, but warned patients that more follow-up studies were still needed and that they probably would need at least one additional operation because the implants don't last a lifetime.

Silicone-gel breast implants first went on the market in 1962, before the FDA required proof that all medical devices be safe and effective. Thirty years later, they were banned because of concerns about their safety. Since 1992, the silicone implants had been available only as part of research studies.

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(c) 2006, Milwaukee Journal Sentinel. Distributed by Mclatchy-Tribune News Service.