Patient 3 Gallery

Before and after bilateral prophylactic mastectomies and immediate breast reconstruction with the DIEP flap in a 45 year old BRCA gene positive woman. She was terrified of surgery but even more terrified of getting breast cancer, given her family history and gene positivity.

She had large, pendulous breasts and significant asymmetry of her breasts preoperatively. She was encouraged to think of this surgery as her “Mommy Makeover”, as her body had changed after having children and she hated the current status of her tummy!

Bilateral mastectomies were planned using a breast reduction/lift pattern. Her nipples and areolas were saved during surgery, as they were not involved with any cancer. Skin and fat from her lower abdomen was microsurgically transplanted to her chest as DIEP flaps.

Her abdominal donor site scar was designed very low – just like for an abdominoplasty (tummy tuck) – as is the standard in my practice! DIEP perforator blood vessels can always be found below the belly button, allowing for a low, aesthetic design of the DIEP flap donor site. No imaging of abdominal blood vessels like a CT or MRI scar is required before surgery.

The skin from the DIEP flaps was removed (“deepithelialized”) and the flaps were buried underneath the breast skin, just like a living fat-implant. There is no need to keep a skin paddle showing for monitoring. We routinely anastomose (microsurgically connect under the operating microscope) one artery and two veins to allow for robust blood flowing into the DIEP flap and two routes of venous drainage from the flap.

Her nipples and areolas were reapplied to her breast reconstructions as free nipple-areola grafts. The areola circle was made smaller than her preoperative larger size and moved to a higher and more centralized position, as for a breast lift.

The milk ducts under the nipples were removed out by the breast surgeon and sent to the Pathology lab as a separate specimen. No cancer was found in any area for this patient. The areolas heal just like a skin graft and end up having a slightly paler color than their original hue. Medical tattoo can be done to brighten their color if desired in the future.

After a microsurgical transplant like the DIEP flap or TUG flap breast reconstruction, postoperative monitoring is done clinically by expert microsurgical nurses with decades of experience monitoring microsurgical patients and free flaps, and an implantable venous Doppler probe. This patient took 6 weeks off work and felt “back to normal” by three months postoperatively.

Long term follow up photos are shown at three years after surgery, with improved breast symmetry of size and shape, a nice flat tummy and clear Pathology results! She has continued to work full time and be an active mother, no longer feeling “like a ticking time bomb for breast cancer”. And she LOVES her DIEP flap/Mommy Makeover!