Dispelling Misconceptions Around DIEP Flap Breast Reconstruction and the Thin Patient

Alison Werner 0:00
Hi, this is Alison Werner

Keri Stephens 0:01
and Keri Stevens host of the plastic surgery practice podcast. Welcome to our new season.

Alison Werner 0:06
Now before we get started, we wanted to let you know that if you previously subscribed to the Medqor Podcast Network to keep up with the latest episodes, you can now find us and subscribe to our standalone channels simply plastic surgery practice on your favorite podcast platform. Now that can be Spotify, Apple podcasts, Google or Amazon.

Keri Stephens 0:24
Now let’s get to the episode.

Hi, welcome to the plastic surgery practice podcast. I’m your host Keri Stevens. Today’s episode I’m joined by Dr. Constance chen, a New York based board certified plastic surgeon and leader in microsurgical breast reconstruction. She’s here to talk about misconceptions and breast reconstruction, which is a topic she wrote about earlier this year for PSP. Here’s my conversation with Dr. chen. Dr. Chen, thank you for joining me today. I’m so delighted to be here. Yeah, we’re excited this situation. And this This topic is very close to my heart personally, because, as I’ve talked about in the podcast, before I had breast reconstruction after mastectomy, and 2020. And one of the things I was told about when I asked about using a flap reconstruction, rather than an implant, implant based reconstruction was, Oh, you’re too thin? Well, I am a very average sized person. And so you and I had talked about that. And just you wrote a really good article about how thinner people can do flap reconstruction. So what are some of the challenges that that individuals face when it comes to breast reconstruction surgery?

Dr. Constance Chen 1:46
So I think you hit one of the nails on the head, which is if someone does want flap reconstruction, they’re automatically told by many plastic surgeons that they’re not a candidate. My own cousin had that experience she had, I may have told you about her she had breast cancer twice. And the first time she had lumpectomy and radiation the second time, when it was recurrent. She wanted bilateral mastectomy. So DIEP flap, understandably, when she was 40, she went to her plastic surgeon who told her what you just said. You said she’s very average size. She’s not, you know, super skinny, but she’s not super fat either. And he told her that she was too thin for flats for both breasts, but he could do it for one breast. So a little bit different from what you said, in which you were told, yeah, I was just flat out no, yeah. And so the long and the short of it is that it finally came out that he was just starting out, wasn’t really comfortable doing both sides and was only with one side. So I ended up doing both sides for her. And again, she was not a thin person. But I’ve also had other people such as yourself. Many who have seen multiple plastic surgeons, you know, sometimes four or five, six plastic surgeons. Sometimes people have flown around the country looking for a plastic surgeon who can do flaps for them, only to be told that they’re too thin. I had one woman who is actually a pharmaceutical rep for Allergan, who makes the breast implants. And she said that she had flown to New Orleans and Texas to well known plastic microsurgical breast reconstruction specialists who all told her she was too thin. And I thought, well, these are not fly by night micro surgeons, if they told her she was too thin, she probably is too thin. But I told her I would examine her anyway just to see. And she and she was very well educated about the subject and said, Look, I’m willing to have four flaps, I willing to basically do anything, because she had already had mastectomy and reconstruction with implants. And she really did not like her implants at all. And when I examined her, I said, Actually, I think I can do it with just two flaps. You don’t need four flaps at all. And I think you’ll be very similar to the size you are now. And I was actually really surprised that, you know, colleagues that I assumed I would have nothing more to say than what they had to say, would actually turn her down. And I think, you know, people have different criteria in terms of what they’re looking for. But and I have had patients where I thought oh, they may not have enough tissue, say in their belly, but then I’ll go to another site such as the upper inner thigh, where frankly, even I’ve had patients with a BMI of 18, 17 who are marathon runners just very, very thin. And I’ve been able to reconstruct their brests with flaps and they look actually much more natural and normal than if they had had implant reconstruction that it can be hard to tell and those people who had nipple sparing mastectomy and flap reconstruction using their own tissue, that they even had mastectomies. Even when they’re really really thin. I had one woman whose mastectomy flaps for less than 100 CC’s. So 89 CC’s on one side, or 89 grams on one side, 99 grams on the other side of the smallest implant size is 100 grams. So, you know, her the flaps that I took, were actually a little bit over 100 grams, but they really feel that her breast tissue nicely, she actually looked a little bit bigger afterward, even though I think many people would have just taken one look at her and said, No way you’re not a candidate. It’s just that sometimes when people don’t have tissue in their lower abdomen, they’ll have tissue elsewhere, for example, my second round place is basically the upper inner thigh where everybody has this little banana roll. And it may not mean that you’ll have double D breasts. But oftentimes, when you’re very thin, that would look strange on you anyway, you get proportional breasts, I always tell people that your body tends to give you what is appropriate for you in terms of just, you know, proportionality.

Keri Stephens 6:18
Well, have you noticed, because there’s been so much talk about breast implant illness that more people are coming to you postmastectomy wanting the natural flap.

Dr. Constance Chen 6:27
That definitely, that’s been happening for a while. I’m in New York. And I seem to have a steady stream of patients from one of the Sloan Kettering Cancer Center at Memorial Sloan Kettering where they do 80, 90% implants, just because of the volume of patients that they have, they can’t do as many flaps. And I’ve noticed that the nurse practitioners there have sent quite a few patients over to me for breast reconstruction when they’ve been unhappy with their implants. And, you know, I give people all of their options, meaning the option to go flat, to switch out their implants or new implants, their implants are under the muscle to go over the muscle, or to switch them out for flaps. And, you know, it’s very, very often people do choose flaps. And by and large, it’s night and day for people, it’s just a lot more comfortable for them.

Keri Stephens 7:23
I know when I looked into this, I mean, I was told I couldn’t do it based on my BMI, which to me is not that low. But I was told that also the recovery process was really hard with flap can you get into the recovery process for patients who undergo natural tissue breast reconstruction?

Dr. Constance Chen 7:41
Sure, so my patients are usually in the hospital for two or three days. It is a long operation, it’s a much bigger and more complex operation than implants. Because with implants, you’re just operating on the chest. And that’s the only place you have to worry about healing. With flaps, you have multiple surgical sites. So if you’re taking from the belly, you also have to have drains that your belly and you have to heal from that site. If you’re taking tissue from the upper inner thighs, then you have dreams there to heal from that spot too. So you’re not only healing from the chest, you’re healing from another spot as well. Overnight, you’re usually resting in bed, because we want the the tiny two millimeter blood vessels to flow well and not be jostled in the morning. Nurses help you out of bed and you start walking. And in. It’s really about eating, drinking and walking for the first you know, few days, few weeks even. It sounds very basic before surgery. But after surgery, you just need to get your strength back. And as I mentioned, people generally go home on day two or three. Versus if you have implants, it’s usually you know, if it’s above the muscle, you can even go home the same day sometimes or the next day. And so you are in the hospital for a day or two longer. And it’s just a more extensive surgery because there are more surgical sites and you have more drains to take care of and all of that sort of thing. In terms of pain. I think that when breast implants are placed under the muscle, that’s pretty uncomfortable for people and flaps are placed over the muscles. So I think that is one area where I think that pain is actually significantly from what I’ve been told by patients, it’s it can be significantly less and I’ve definitely noticed, when I used to place tissue expanders and implants under the muscle, I would forget how much it was. How much it hurt people for that to stretch out that muscle.

Keri Stephens 9:46
Hurt. Yeah, I remember.

Dr. Constance Chen 9:48
Yeah, it just, you know, it’s not anatomically correct. The breast tissue was you know, over the muscle, it wasn’t under the muscle and then when there’s that stretch all the time, it’s just not comfortable. It’s like having a rock in your shoe that you can’t get out. And so I if I put in, I do do tissue expanders and implants as well. And if I put those in, I always put them over the muscle now, because it’s just, it’s anatomically correct, I think it’s significantly more comfortable for people. So either way, I mean, if you’ve just put up whatever you’re going to use as the breast replacement over the muscle, I think it’s just going to be more comfortable. You might think that because you’re taking the tissue from the donor side that that area would be painful to. And I guess I’m thinking about it, I do think that many patients feel like their donor sites are more of an issue for them than their breasts, because I think for many patients, the breast isn’t the area that hurts. It’s, for example, when I take tissue from the belly, I usually tighten it to like people who have a tummy tuck. And so that can feel very tight for people afterward. If you’re very thin, it can, I would say that if you’re going to take it from the belly, and you’re thin, it’s probably going to hurt more than someone who is heavy because you just don’t have enough skin laxity. So it’s just going to pull more from the legs. I have a breast surgeon who commented to me some years back that she thought that people who had had flaps from their upper inner thighs, they thought she thought that their recovery seemed to go much more easily than people who had DIEP flaps. I think it’s similar, but I think it seems easier. It may just be because a lot of times when people have natural flap breast reconstruction, they are very thin and fit. And those people may just be, you know, healthier at baseline than someone who’s having a DIEP flat not always. But I think that may be why she her perception was the people who had path flaps seem to recover very easily and well. But you do have drains from the donor site, that’s a pain, those tend to stay in longer than the breast of drains, the breast drains stay in for a week or two and the other ones can stay in for two or three weeks. And it’s just annoying to have things hanging off of you and anything that you need to heal from. In general, I would say most people are feeling pretty normal at about a month. But I always tell people that even if you feel fine and you feel good. It takes six to eight weeks for the body to undergo full wound healing. So you know, I had a patient where I reconstructive she had mastectomies, nipple sparing mastectomy is and flax from her from her upper inner thigh, she was very thin, she was a marathon runner. And at about a month, she said, I don’t care what you say, I’m going to start running, I cannot lie around and do nothing anymore. And she started running long distances. To her flaps were fine. But she developed seromas, which are fluid collections at her donor sites, because even though her dreams had come out, the tissues weren’t completely healed, and that the sheer forces of that movement of running, I mean, just can’t run, you know, the miles and miles and miles that she was running. Without she, I mean, she just stirred things up. And so we had to chase after this seromas in her legs for months after that. And I think she regretted it, because you realize that, you know, even though it felt good to run, I ever she had to come in every week for me to stick a needle in there to try and draw out fluid. And then she had to wear compression around that area. I mean, it’s not something that’s dangerous, but you feel like you have a water balloon in your body. And it’s incredibly annoying and a nuisance. And so, you know, it does take six to eight weeks for full wound healing to happen in a normal healthy person, I describe it like when you go to get your nails done and you think your nails are dry, they look dry, but then, you know, if you really push down on the smear, it’s it’s kind of like that, it just takes a couple of months for things to really really stick down so that they’re confused, not not be disturbed.

Keri Stephens 14:13
So is there anyone any you know, demographic body type that is just absolutely not a candidate for natural tissue breast reconstruction.

Dr. Constance Chen 14:21
So I would say people who I would not want to do natural tissue breast reconstruction on would be for example, smokers, because smokers, the nicotine that is in cigarette and even you know some other types of things that people smoke takes up the place on the red blood cell where the hemoglobin supposed to be so your tissue oxygenation is more poor. And you don’t heal as well plus, it impairs platelet function. It makes you quite more and it also causes vasoconstriction. So it’s sort of a triple whammy. Even when you smoke in terms of flap failure, so if someone wants a flap in a smoker, they have to stop smoking for at least two months beforehand. And we will definitely do nicotine tests beforehand, just because there’s no reason for you to go through this big surgery and had a flap failure. Likewise, someone who has a lot of medical comorbidities, in other words, someone who I mean, if you have end stage renal failure and heart problems, and just a lot of medical problems, where you’re not going to be able to tolerate a long surgery, that someone who probably would not be a good candidate either. Pretty much everyone that I do the surgery on, I send them to a cardiologist, just to make sure that their heart and their lungs are good. And I’m sorry, their heart is good. And but I have operated on someone that’s older, 70 years old, who had a DIEP flap, and I was very hesitant about that. I sent her to the cardiologist like everybody else. He called and said that he didn’t see a need to do an echo because she was so healthy. I was like, Are you crazy? And I tried to explain what a big surgery this was in. So he did it. I was, you know, very apprehensive about doing bilateral DIEP flaps on a seventy year old woman but she actually healed better than some people who were 40 I had a woman who was a 40 year old triathlete who had a rough time afterward. I mean, she had urinary retention, and she swelled up and all sorts of things. But the seventy year old, she wanted to leave the hospital on day two, I showed up in her hospital room to round on her. She was in our clothes and wanted to leave. And I was like, you know, can you do me a favor, just stay one more day, I think you’re 70 years old. And she went home with nobody helping her, which I also thought was crazy. And two weeks after surgery was like nothing happened. I mean, it was it was it was crazy. And I was so nervous about operating on her. I had another woman who I just operated on was either last year, the year before, who had inflammatory breast cancer, which is a very bad breast cancer 10 years earlier, bilateral mastectomy is radiation, the radiation and chemo and everything had been such a number on her that her she needed a heart ablation through a clinical trial to get her heart working again. So I mean, basically someone who just did not seem like a great flap candidate to me. But she came to me saying no, I’ve been cleared by everybody. And I was like, I know, but do you understand this really big surgery and he had a heart ablation, just like what I’m finding now. So I put her through so many hoops to kind of dissuade her. And finally, and she jumped through all of them. So finally I said, Look, do me a favor. Something that I’ve anecdotally noticed is people who spin seem to just do better after surgery. And so she started she got on a peloton start. And you know what? That was crazy, too. She did unbelievably well, after surgery. Most people, their blood pressure drops, their heart rate is high. They just you know, many, many people, many women have low blood pressure to start out with. And so when you have these big fluid shifts from a big surgery, it just makes it worse. So for example, for myself, my blood pressure at baseline is 90 over 60. So it’s gonna drop, it’s gonna be 70 overs, which is really low. And so, and you can’t use vasopressors, or other things that anesthesiologist will do to keep your blood pressure up, because that’ll cut off blood supply to your flap. So I was you know, for this woman who had inflammatory breast cancer, I just thought to myself, this is just not going to I don’t know how to turn out. She was perfect. She was better than most people. So it’s just interesting how, you know, sometimes the people that you are the most nervous about do that, you know, sometimes I do the best. I even had a person who was a smoker, who I said, No, we can’t do this because you’re a smoker and she did stop smoking. But then she had like a, you know, she smoked at a wedding or something. And so I was like, forget it. You’re just not going to be able to stop smoking, we’re going to she had tissue expanders, I was like, we’re just gonna do implants on you But then, a couple of weeks before surgery, I saw her and she was such a perfect candidate for DIEP flaps, which she desperately wanted. I had already told her no, but she just had the tissue was perfect. Everything was just perfect. And she, you know, she claimed she hadn’t been smoking for months and months at that point. He didn’t get the team test. And I was like, I mean, I had already told her no, but I was like, All right, I gave in and she was perfect to nurses. In the recovery was like you should use her as your example of someone who was a perfect flap, because everything was so perfect after surgery. So, at the end of the day, I still would say someone who smokes. No, I mean, you have to stop smoking for a minimum of two months, and I definitely do nicotine checks. I mean, I had a patient who was young, very young, she wanted prophylactic nipple sparing mastectomy is DIEP flaps. And, you know, good health, everything. I mean, very young in her 30s Healthy basically a perfect candidate. And the Friday before her Monday surgery, we did a, I knew that she smoked marijuana. We did a spot check. And it was positive. I was like, What the heck, you know? I mean, it’s Friday, and how could this be positive if someone in my office actually tested herself because we’re like this, there’s something wrong with our test strips was negative. And so called her and I was like, this is the strangest thing, but your nicotine tests came back positive. How’s that even possible? And she said, Well, I stopped smoking no pot months ago. And I was like, well, what could it be? And she was like, well, apparently, she used chewing tobacco and, and I was like, Well, last time you use that she was like, well, Thursday night, was like, you know, that was nicotine? Obviously, it’s just like what you said no smoking. I was like, Well, no nicotine of any kind, no gum, no, like, you know, chewing tobacco. And so we unfortunately had to do implants on her, which she wasn’t really that thrilled about, but I was like, we just risk it when you have a positive nicotine test like that. So

Keri Stephens 21:45
well, how happy are patients typically

Dr. Constance Chen 21:50
thrilled. I mean, I think that what worthwhile podcast would probably be just to talk to patients, because they’re just, they’re all shouting from the rooftops about how, how it’s night and day. I think it’s just so you know, I haven’t gone through it myself, obviously. But I’ve seen enough other people go through it, I think for it’s a difference between hard breasts, that for many people have become painful. And, or Nam, or however it is something that basically feels normal. And as soft and as warm. It makes me think of another woman who she was in finance and she was sent to me by the breast surgeon for reconstruction. And she had breast cancer. And I you know, as I do with every patient, I explained all the options, including no reconstruction, every type of implant and flaps and so she wanted to get right back to where she you know, what opted for implants, which is fine. And so she underwent her nipple sparing mastectomy and put in tissue expanders, and she underwent radiation and chemo for her breast cancer. When she came back, and we were planning the next stage to put in her implant. She said, um, I actually have been rethinking everything. And I’m thinking of about flaps instead. And I was like, well, that’s interesting, why? What was what made you change your mind? And she said, Well, I am in a support group with five other women and, and five of us had implants, we’re all bitching about our implants. And one of us had flaps, and she’s doing CrossFit training. And I want to be her.

Keri Stephens 23:28
So as a final question, and I think you’ve covered a lot of this, but I really want to drive home this point, what advice would you give someone who is considering natural tissue breast reconstruction as a thin patient?

Dr. Constance Chen 23:40
Well, there’s different ways of going about it. So if you’re thin, just because you go to one person who says you don’t have enough tissue doesn’t mean that you necessarily don’t have enough tissue. How do you know, it’s real or not? I guess, you know, it’s hard to know. But if you pinch this, the tissue at your lower abdomen, that’s what becomes your breasts. And, you know, I think that the reason I get more tissue is I bevel a lot. In other words, whatever tissue you have, I also kind of take the tissue around it that’s beyond the skin. So I have discovered that I often surprise myself, because I will tell patients, you’re going to be a lot smaller than the end up being bigger. And it’s because I bevel so much. That said, there are other if the abdomen really is not a good site for you. In other words, you’re literally skin and you can you know, I’ve had patients where you can see their abdominal aorta going up and down because there’s just nothing there. There are other sites that you can take tissue from, for me, it’s most commonly going to be the upper inner thighs. And then on top of that, it’s the whole idea of this giant flap surgery, with drains everywhere kind of freaks you out, but you We don’t want your implants. Another thought, besides just going flat, is you can also do serial fat grafting, which people don’t talk a lot about. It’s kind of a slow burn type of situation. It’s where you take out your implants. And unlike a flap, where you have a breast mound right away with serial fat grafting that involves liposuction, fat grafting the process that and usually you have to undergo several rounds of that, but they’re each outpatient surgeries. I actually had someone doing that right now. And she is really happy that she’s she’s doing that instead of a flap, because even though it’s kind of a long haul type of reconstruction, every you know, every time is a outpatient, she goes back to work pretty quickly, just an easier thing to wrap her head around. She doesn’t have scars at the donor site. And that sort of,

Keri Stephens 25:56
I know myself when I have fat grafting just a lot of bruising.

Dr. Constance Chen 25:59
So yes, that’s definitely true. S

Keri Stephens 26:01
o a second part of this question, because our audience on this podcast is plastic surgeons, what advice do you want to give your fellow plastic surgeons about performing natural tissue breast reconstruction on thin patients?

Dr. Constance Chen 26:14
Well, I mean, I think it’s really about looking at additional donor sites and being creative with where you can take tissue from, I think, at the end of the day, it’s no, it’s challenging, because when you are, if you’re not a micro surgeon, you’re not going to be doing it. And if you don’t specialize in, in more creative types of microsurgery, I mean, it’s not really you do sort of have to be a specialist to to do these types of procedures. But that said, I’ll say the profunda artery perforator flap, the fat flap were taken from the upper inner supplies. That sounds intimidating. But I used to teach this procedure at the Duke perforator flap course to other plastic surgeons and other micro surgeons, both in this country and around the world. And in would show people how to do it through cadaver dissections and whatnot. And it’s not a hard flap. And it is scary to do these flaps for the first time. But it’s actually it’s not, it’s not a very difficult flap. So I think it is going to be difficult for many surgeons if they haven’t seen one in their training or ever, you know, done one to kind of take that leap. But I guess the best I can say is when I showed people how to do it. And I you know, I had a friend who I talked through over the phone how to do it. It’s actually not that hard of a flap.

Keri Stephens 27:39
Well, thank you, Dr. Chen. Thank you for joining me today for this great conversation.

Dr. Constance Chen 27:44
Thank you so much for having me.

Keri Stephens 27:47
As always, thank you for joining us and be sure to subscribe the plastic surgery practice podcast to keep up with the latest episodes. And also please check out plastic surgery practice.com for the latest industry news. Until next time, take care