Breast Reconstructions Houston
Breast reconstruction is a delicate balance of reconstructive and cosmetic surgery. Dr. Chevray is a board certified plastic and reconstructive surgeon who specializes in this art and science. Dr. Chevray is passionate about breast reconstruction and has performed over 1,000 breast reconstruction procedures. Dr. Chevray’s experience in breast reconstruction began at the M.D. Anderson Cancer Center here in Houston where he performed more breast reconstruction surgery than any other plastic surgeon during the 8 years he was a faculty member there. He now practices at the Methodist Hospital System and continues to specialize in breast reconstruction using all methods including DIEP, SIEA, TRAM, IGAP and SGAP free flaps.
What sets Dr. Chevray apart from others are his results, which can be seen on the photo pages of this website and in the many peer-reviewed scientific publications that he has authored, some of which are listed below. Dr. Chevray is also known for his warm and gentle bedside manner, and easy going approachable style.
Why Breast Reconstruction with TRAM, DIEP and SIEA Flaps?
Breast reconstruction is commonly accomplished with autologous tissue flaps from the lower abdomen and back, prosthetic breast implants, or a combination of both flaps and implants. It is generally held that autologous tissue flaps from the lower abdomen are capable of reconstructing a breast with the shape, softness, mobility, and warmth of a natural breast that is not possible when using breast implants. However, lower abdominal flap methods involve longer surgical times, longer inpatient hospital stays, longer recovery periods, and some extent of donor site morbidity that is not associated with methods using breast implants alone.
The past 2 decades has seen an evolution of techniques for harvesting the lower abdominal flap of skin and fat for breast reconstruction. The goal has been to minimize the amount of rectus abdominis muscle and fascia that is harvested with the flap in order to decrease abdominal donor site weakness and morbidity. Techniques range from removal of the entire rectus abdominis muscle in pedicled TRAM flaps, to excision of a segment of muscle and fascia in free TRAM flaps, to removal of a plug of muscle and fascia in muscle-sparing free TRAM flaps, to only incision into the muscle and fascia for DIEP flaps. Nevertheless, all of these free flap methods involve removal of the deep inferior epigastric artery which provides the dominant blood supply to the rectus abdominis muscle. Therefore abdominal donor site morbidity, which can include belly muscle weakness, pain, and the risk for bulge or hernia formation cannot be completely prevented with these methods. However, the SIEA flap includes the same flap of lower belly skin and fat as TRAM and DIEP flaps that works so well for breast reconstruction, but involves neither incision nor excision of rectus abdominis muscle, anterior rectus fascia, or the deep inferior epigastric artery. Therefore use of the SIEA flap can virtually eliminate abdominal donor site weakness and the risk of abdominal bulging or hernia formation.
The relative donor site morbidity of free TRAM flaps, muscle-sparing free TRAM flaps, and DIEP flaps has been extensively debated in the literature. It seems that patients who have had DIEP flaps retain more abdominal strength after surgery when compared to patients who have had free TRAM flaps. However, this difference in strength that is measured by dynamometry is probably not clinically significant as patients do not differ in their ability to perform sit-ups after surgery, and patients themselves do not differ when questioned about abdominal donor site morbidity.
Who Can Have Breast Reconstruction with TRAM, DIEP and SIEA Flaps
Prior chemotherapy or chest wall radiation do not preclude breast reconstruction using a TRAM, DIEP or SIEA flap. Dr. Chevray likes to wait at least one month after the completion of chemotherapy to allow the patient’s white blood cell count and immune system to recover. He explains to patients that the average cosmetic result of breast reconstruction after radiation is not as good as results obtained in the absence of radiation. Plastic surgeons in general like to wait 6 to 18 months after radiation before embarking on breast reconstruction. Dr. Chevray tells patients that breast reconstruction can begin 6 months following completion of radiation treatments.
Many surgeons who perform microsurgical free flap breast reconstruction consider a body mass index of greater than 35 kg/m2 to be a contraindication for free TRAM, DIEP or SIEA flap surgery. Dr. Chevray has found that obesity does not increase the risk for free flap loss, but does increase the risk of wound healing complications, and does increase surgical time.
Smoking is a relative contraindication to breast reconstruction with implants or TRAM, DIEP and SIEA flaps. Active smokers are counseled to stop, or at least to abstain for 2 weeks before and after the free flap surgery. Some surgeons will not perform breast reconstruction surgery on patients who are actively smoking, and may test urine nicotine levels to be certain they are not smoking prior to surgery. The reality is that it is very difficult to quit smoking. Dr. Chevray offers smokers breast reconstruction with muscle-sparing free TRAM flaps to maximize the perfusion and reliability of the flap. He does not plan to use DIEP or SIEA flaps on active smokers.
Previous abdominoplasty does prevent breast reconstruction with TRAM, DIEP or SIEA flaps. Previous liposuction of the belly makes breast reconstruction with an SIEA or DIEP flap unreliable, however, Dr. Chevray has used muscle-sparing free TRAM flaps for breast reconstruction in patients who have had previous abdominal liposuction.
Patients with serious medical comorbidities such as heart failure, chronic obstructive pulmonary disease, or previous heart bypass surgery are not usually candidates for breast reconstruction with TRAM, DIEP or SIEA flaps.
What You Should Know about Breast Reconstruction
At your consultation with Dr. Chevray for breast reconstruction he will explain that there are 4 points that are important for patients to understand and realize. First, the realistic goal of breast reconstruction is to have the patient appear normal and symmetric while wearing clothing. Once breast reconstruction is completed and without the cover of clothing, it is usually obvious that the reconstructed breast is not a natural breast. There is often an obvious difference in the color of the skin of the flap and the normal breast skin, and the shape and contour of the reconstructed breast is usually not perfectly symmetric with the opposite natural breast. Only in approximately 10% of cases can a breast be reconstructed that may be mistaken for a natural breast in the absence of clothing. However, while wearing clothing, the expectation is that the patient will appear normal and symmetric, and nobody should suspect that she has had a mastectomy.
Second, Dr. Chevray explains that breast reconstruction by any method typically requires 2 operations to complete. The first operation is the longer surgery of the two, and requires a several day inpatient hospital stay. The typical inpatient stay is 3 or 4 nights for unilateral or bilateral breast reconstruction with TRAM, DIEP or SIEA flaps. The second surgery is an outpatient surgery done to reconstruct a nipple, improve the reconstructed breast shape or position if necessary, and to improve breast symmetry by augmenting, reducing or lifting the contralateral native breast, or the reconstructed breast. This second surgery is usually performed 3 or more months after the initial surgery. Roughly 80% of Dr. Chevray’s breast reconstruction patients have 2 operations to complete breast reconstruction.
The third point is that overall there is a several percent risk that breast reconstruction surgery may fail. This risk is similar whether the breast is reconstructed with an implant or TRAM, DIEP or SIEA flap.
Finally, the fourth point is that breast reconstruction is not required. The patient may elect to forego the additional surgery necessary for breast reconstruction, and live with the results of the mastectomy. The patient may use an external breast prosthesis, or she may choose to have delayed breast reconstruction months or years after her mastectomy.
Breast Reconstruction is Covered by Health Insurance
Some patients express concerns about health insurance coverage for breast reconstruction or the secondary surgery for nipple reconstruction and revision to improve breast symmetry. Dr. Chevray can reassure these patients by explaining that breast reconstruction is considered an integral part of treatment of breast cancer. This belief has been validated by the United States government in the Womens’ Health and Cancer Rights Act of 1998. This federal law states that commercial health insurance companies that cover treatment of breast cancer are required to cover breast reconstruction, and that surgery on the opposite breast to improve breast symmetry is considered part of breast reconstruction.