Welcome to the YSC Ask The Expert series, where we ask a leader in the field to respond to YSC constituents' questions on a specific topic during an Ask the Expert residency. To view previous Ask the Expert features, please visit the Ask the Expert Archive Page.

February's Topic: Diet & Nutrition

Carlyn Kappy is a Registered Dietitian, and Certified Clinical Research Professional. She earned her Bachelors of Science in Nutrition and Dietetics from Georgia State University, and completed the Georgia Public Health Dietetic Internship.

Carlyn has experience in developing individually designed nutrition plans to promote healthy body weight, participating in community out-reach wellness programs, educating clients on the appropriate use of nutritional supplements, and treatment of appetite change and meeting nutritional needs when on chemotherapy. Carlyn is currently the Dietitian at Turning Point Women's Healthcare in Alpharetta, Georgia, where she specializes in providing care for women dealing with the challenges of breast cancer.

Carlyn will be answering questions throughout February; please send your question to ask-the-expert@youngsurvival.org.

November's Topic: Breast Reconstruction

Dr. Karen Horton is a Board-Certified Plastic Surgeon and Reconstructive Microsurgeon practicing in the Pacific Heights area of San Francisco. She graduated from Medical School with Honors at the University of Toronto and completed a five-year Plastic Surgery Residency at the University of Manitoba in Winnipeg. Dr. Horton is currently in private practice in San Francisco and operates primarily at California Pacific Medical Center.

Dr. Horton's special training and interest includes reconstruction of the breast after breast cancer. As an invited guest speaker at meetings throughout the United States, Dr. Horton educates, empowers and informs women about options for breast reconstruction after cancer using techniques that do not sacrifice major muscles of the body and enable reconstruction in the least number of stages.

Dr. Horton has published review book chapters on breast reconstruction. She has presented numerous clinical papers at national and international scientific meetings, and has won research awards. She has been featured on television, discussing the latest in plastic surgery techniques. In addition to participating as an active member of many professional associations she also serves as a mentor to young female surgeons and medical students in training.

Question Twelve: I am scheduled to have nipple reconstruction in May and know there are various options available. Can you comment on the differences in cosmetic outcome when utilizing tissue from another part of the body, skin from the flap itself or tattooing alone?

The nipple and areolar complex (NAC) reconstruction involves two components, the nipple prominence and the areolar circle. Sometimes the nipple reconstruction is performed first, with the areola done at a later date; at other times, they are performed together. NAC reconstruction is the finishing touch of a breast reconstruction, and is the "icing on the cake" to complete the breast! See this diagram for details.

Nipple reconstruction usually involves a local flap procedure where wings of tissue (skin and fat) from the breast reconstruction itself are rotated in place to create a nipple prominence. Some surgeons also add some additional tissue inside the local flaps (soft or firm) to try to improve projection of the nipple reconstruction. After surgery, the nipple reconstruction is expected to shrink between 30% and 50%. The ideal nipple prominence matches a natural nipple at rest. It will not have the capacity to become erect with stimulation or cold temperature.

The areolar circle can be made using either a medical tattoo or a skin graft. Natural flesh-colored medical tattoo pigments (ranging from tan, to pink or brownish or black) are available and can be mixed together to very closely match a natural nipple and areola. The nipple prominence is also tattooed to match the other side. Tattooing can be done either in the operating room or in the office of your Surgeon under local anesthesia, and is usually done by the Plastic Surgeon or occasionally a specially-trained surgical Nurse.

Skin grafting for areolar reconstruction involves taking a full-thickness graft (all the layers of the skin, requiring closure of the "donor site" with stitches) from another area of the body. Common sites for harvest of a skin graft for areolar reconstruction include the groin, the other breast's areola (if a balancing breast reduction or a lift is also being done), or rarely, the labia (external genitalia). Skin grafts may heal with either lighter or darker pigmentation than expected, and by definition, require creation of a scar at their donor location. For this reason, I usually use a tattoo for the areolas I create.

Question Eleven: What are the differences between saline and silicone implants, and which type would you recommend?

All breast implants have a silicone shell. Silicone is a biologically inert substance, and is the most extensively studied medical device in the history of medical devices! Many implantable devices ranging from intravenous tubing, to the lining of a pacemaker or joint replacement, are made of silicone. There are also no known allergies or sensitivities to silicone.

The fill of an implant can be either saline or silicone gel. Saline is sterile salt water that can be absorbed by the body if there is ever a leak of the implant. This would result in slow deflation of the implant with gradual flattening of the breast reconstruction.

Saline implants tend to feel slightly less natural, and can have more rippling of their surface than silicone implants. Silicone gel implants have a slightly more viscous nature and can feel and look more natural than saline. Rippling is slightly less noticeable in these implants.

As opposed to saline, silicone is not permeable in the body. If there is a leak of a silicone-filled implant, the silicone cannot be absorbed by the body or travel outside the pocket where the implant has been placed. MRI is the best method to detect leakage of a silicone implant.

For the permanent implant used in breast reconstruction, I usually recommend silicone for the most natural looking and feeling result. The same goes for cosmetic breast augmentation. I advise my patients that implants may not last forever and may need to be replaced during their lifetime. Implant replacement is never an emergency and will require a return trip to the operating room.

A comprehensive and informative website to learn more about the science and safety of all breast implants, saline and silicone, is www.breastimplantanswers.com.

Question Ten: I had a LAT flap procedure a year and a half ago, and since then I can't keep my shoulders back without effort. I have heard that the flap can be detached so that it is "floating" rather than attached via muscle. If this is possible, what are the risks and benefits?

A latissimus dorsi (LAT) muscle flap is a "pedicled flap", which moves all or part of the latissimus muscle from the back around to the front of the chest. Sometimes skin and fat from the back are also attached to the muscle and rotated to the front of the chest to bring in some additional skin and fat for padding. A breast implant is also usually needed for this type of reconstruction.

A pedicled flap implies that a major muscle of the body is used to carry the blood supply to the tissue being moved. Examples of pedicled flaps are the LAT flap and the TRAM flap (transverse rectus abdominis muscle) from the lower abdomen. Sacrifice of a major muscle may cause some permanent weakness, a loss of contour from the "donor site", and or hernia or bulge in the abdominal area (TRAM flap). Following a LAT or TRAM flap, the muscle used to transfer the tissue loses its function and cannot be replaced.

In contrast, a free flap uses Microsurgery to detach blood vessels from the donor site and then to reattach them at the location of the breast reconstruction. Examples of free flaps are the DIEP flap, SIEA flap, TUG flap and free TRAM flap.

Symptoms resulting from a pedicled LAT flap may be somewhat lessened by an attempt to detach as much of the muscular attachment from the humerus (upper arm bone) as possible. This is probably what you are referring to as "floating" - this is not a term that is commonly used in plastic surgery. However, any procedure that involves dissection in the area of the blood vessels to the flap risks injuring the blood supply to the tissue and may result in loss of some or all of the tissue of the flap.

I would recommend seeing a Board-Certified Plastic Surgeon with extensive experience with breast reconstruction and flaps, both pedicled and microsurgical flaps, for their assessment. It is possible that your symptoms are related to another component of your reconstruction (submuscular implants, capsular contracture), and an alternative surgical plan may be of help.

Question Nine: I have heard there is a new type of reconstruction where they use tissue from the thigh as opposed to the stomach or buttocks. Is this true? If so, does it involve any muscle and what are the cosmetic results compared to reconstruction with the stomach or other parts of the body? I am concerned about what my thighs would look like after surgery.

The transverse upper gracilis (TUG) flap, or inner thigh flap, uses skin, fat and a small piece of an expendable muscle from the upper inner thigh flap for reconstruction of the breast.

The TUG flap is a relatively new procedure that compliments other flaps as an option for breast reconstruction. I have recently authored the very first textbook chapter on the TUG flap-read some the text here and view some before and after photos of inner thigh flap breast reconstruction: TUG flap breast reconstruction.

The TUG flap has several advantages for breast reconstruction: it creates a soft, shapely breast reconstruction that uses the body's own tissue, has excellent projection, and can also make a new nipple and areola at the initial procedure. It gives the upper inner thighs a lift, and creates scars that are hidden in all clothing except for underwear or a bathing suit. Most women who have a TUG flap are pleased with their inner thighs, which often no longer touch in the middle and enable them to wear "skinny jeans"!

The inner thigh donor site has absolutely no risk of some of the potential complications of abdominal flaps - such as abdominal weakness, bulge or hernia. The TUG flap is often an option for thin women who do not have enough abdominal tissue for a flap, who do not want the scar created by a DIEP or TRAM flap, and who do not wish to use implants for their reconstruction.

The very small amount of gracilis muscle used in the TUG flap does not create any donor site deformity or functional loss. The gracilis muscle is a small strap muscle that is a minor player in inner thigh adduction. The adductor longus and adductor magnus muscles do most of the work. The entire gracilis muscle is commonly used in reconstruction of the face (to make a new smile in facial paralysis) or for upper or lower extremity injuries; harvest of the entire muscle has no functional loss to the thigh. The TUG flap takes only a small portion of the muscle directly under the flap to ensure the flap has the best possible blood supply.

Question Eight: I am a 42-year-old, four-year stage IIIC breast cancer survivor. After modified radical mastectomy, chemo, radiation and herceptin, I am ready for reconstruction. Two plastic surgeons have recommended the latissimus dorsi flap with implants, but I am obese and diabetic. Free flap surgery is not an option, unless I lose 50-60 pounds. I want to get healthy and lose weight, but I don't want to wait to have my reconstruction as I want to achieve some level of symmetry.

Additionally, three doctors said that I do not need a prophylactic mastectomy on my other side, but, my mother died of breast cancer and my younger sister also has it (I am BRCA1/2 negative). I feel that removing my remaining breast would lessen the chances of developing cancer on that side and help me achieve desired symmetry.

Congratulations on being a four-year breast cancer survivor! Based on your cancer treatment history, a flap is the most appropriate method of reconstruction for you. Implants under radiated tissue carry a high risk of complications.

Have you calculated your BMI (body mass index)? BMI is determined by dividing your weight by your height, squared. This website can be used to calculate your body mass index. Some studies have shown that women with a BMI over 30 (obesity) have an increased risk of complications, regardless of their type of breast reconstruction. In addition, diabetes greatly increases the risk of complications such as infection and wound healing difficulties.

I recommend to all women I see in consultation for reconstruction to achieve their most realistic weight and level of physical fitness and health before taking on breast reconstruction. Surgery is a major injury to the body, and being as fit and healthy as possible will enable you to have smooth healing and to help to avoid complications. Consider seeing a nutritionist and having your physician supervise a gradual and healthy weight loss and fitness program to prepare you for surgery in the safest manner.

A strong family history of breast cancer puts you at higher risk for breast cancer. Having the BRCA gene test is an appropriate first step in determining your personal risk. Seeing a genetic counselor may also be of assistance in making your decision about whether to have a prophylactic (preventative) mastectomy for your other breast.

The function of the breast is for (1) breastfeeding and (2) pleasure! I advise my younger patients to consider delaying a prophylactic mastectomy until they have finished having children and used their breast to feed their babies. You also need to do some soul-searching about what your breast means to you erogenously and sexually. A bilateral reconstruction (doing both sides at once) will achieve the most symmetry, but this is a personal decision that your oncologist and breast surgeon can help you to make.

Question Seven: My surgeon says I can have implants and then do radiation, but I am concerned about the aesthetics of radiated skin and whether it will look and feel normal.

Radiation will cause the skin to become slightly firmer or "woodier" to the touch; it may result in darker pigmentation and may increase the risk of infection or wound healing problems in the future. This is why after radiation and mastectomy, most Plastic Surgeons will recommend a flap over an implant, as the tissue will not stretch around an implant as well as before radiation. However, if you are considering reconstruction before radiation, as long as the major steps of surgery are performed prior to radiation and the skin has been adequately expanded before this therapy, radiation can be performed with minimal additional risk to the reconstruction.

Question Six: I had a bi-lateral mastectomy and want to have DIEP reconstruction. How long do I have to wait after radiation for my reconstruction surgery?

After radiation to the breast, chest wall or axilla (armpit area), it is recommended that you wait at least six months before undergoing reconstruction. During the first six months, the "acute phase" of radiation damage is evident—redness, swelling, tenderness—like a bad sunburn. It takes at least half a year for the tissue to settle and for the acute phase to subside.

Following the acute phase of radiation injury, the body enters the "chronic phase," where the skin can be slightly pigmented darker, it can have a firmer or more "woody" feel to the touch, it will be stiffer and can be prone to slow healing and/or infection. After bilateral mastectomy and radiation, a flap would definitely be advised over an implant reconstruction.

Question Five: I had a bi-lateral mastectomy and tissue expanders placed and have since had ongoing problems with my left side, which was radiated four years prior to my mastectomy. I had skin breakdown; the expander broke through and a skin graft failed. Nine months and seven surgeries later, I've lost the left side completely. My only other option may be a flap procedure. I have been doing some research and would much prefer a muscle sparing procedure. I wonder if you could share your thoughts about what type of outcome I might expect with a flap procedure in light of the complications I've had.

I would definitely recommend a flap for reconstruction given your history! Most Microsurgeons trained in perforator flap reconstruction who perform microsurgical breast reconstruction regularly (at least a few a months) would recommend the DIEP flap over the TRAM flap for most patients. The DIEP flap spares the rectus abdominis muscle from the abdomen and avoids the risks of hernia, lower abdominal bulge and/or weakness i.e., the ability to do sit-ups.

Be sure to do your homework and seek out a Microsurgeon who specializes in breast reconstruction and who has a good success rate (at least 95%). I personally see many patients who travel from their home state to Northern California for their surgery with me. You may also require travel and a stay of at 2–3 weeks in the city where the DIEP surgery will be performed.

Question Four: How safe is the use of cadaver tissue (Alloderm) in breast reconstruction with implants?

Alloderm is one brand name product of human cadaver (donated by dead people) dermis, which is the bottom strength layer of skin. It is sometimes used in reconstructive surgery to potentially add another layer of tissue to thicken the mastectomy skin, to help hold submuscular implants in place or to decrease rippling of implants.

Alloderm is a "graft", which by definition does not have a blood supply. This is in contrast to a "flap", which has a blood supply and may be either attached to a muscle ("pedicled"), or "free", which involves microsurgery to disconnect and then reconnect tiny blood vessels under the microscope.

If the breast skin has been radiated already, the use of Alloderm adds the additional risks of infection, wound healing problems and/or the need for implant or Alloderm removal. This is because the radiation interferes with blood vessels growing into the product and slows the rate of incorporation of the product. I unfortunately have removed much more Alloderm (inserted by other surgeons) in my patients that I have ever put in myself. I personally do not use this product, but understand that many surgeons do.

Question Three: Does a woman need to lose or gain weight for a breast reconstruction if using her own tissue?

I tell my patients that they should be at their body's "set-point" weight. Each of us has a weight at which our bodies are most comfortable, and it is difficult to deviate from this weight.

Yo-yo dieting and restrictive diets do nothing but stress the body, and regular nutrition is needed for wounds to heal properly. This means getting the appropriate amount of protein, fat and carbohydrates, together with the recommended daily amounts of vitamins and minerals. Consider taking a multivitamin if you have major restrictions in your diet or are unable to eat as nutritiously as you should.

If you are eating a healthy, nutritious diet and exercise regularly, you are probably at your normal weight. It is unrealistic to try to gain or lose an excessive amount of weight before surgery, as you will return to your set-point after surgery when you resume your usual eating and activity habits.

Question Two: What is the best way to determine the proper breast size for a reconstruction?

The best reconstructive plan takes into account a woman's breast size (either before children, during breastfeeding or after pregnancy), her aesthetic goals, the details of the cancer and its treatment and her personal situation (home, job, etc.) Plastic surgery can create almost any size, shape or type of breast desired!

I always ask my patients: "How would YOU like your breasts to be? Larger? Smaller? Lifted? Fuller?" Some small-breasted women would love to be larger, other women with very large breasts have always considered a breast reduction, and many women who are mothers would love to have a breast lift!

It is not vain or inappropriate to consider the aesthetic goals of breast reconstruction from our very first meeting, even on the date of being given a breast cancer diagnosis!

I usually give my patients "homework," that may include showing me photos of how they would like their breasts to be (based on a previous time of their life), search the internet for pictures of naked breasts that illustrate what they would love to achieve if possible and to do some soul-searching about their personal goals for reconstruction.

We usually discuss a "balancing" procedure of the other breast to achieve symmetry with the reconstructed one. This is also covered by law by insurance, as is a woman's mastectomy, the reconstructive method of her choice and any needed "touch-up" procedures down the road.

Question One: I have been weighing my reconstruction options between implants and the TRAM flap. I have lymphedema on the right side, where I had a full mastectomy, and plan to have a prophylactic mastectomy on the left. When considering whether implants or natural tissue is better or less risky, which factors should be considered? In your opinion, which one is less risky and has better health benefits?

If you have had radiation already after your mastectomy, then you need a flap! See the other questions on radiation for an explanation of why implants under flat, contracted, radiated tissue are risky and often doomed to failure.

Lymphedema signifies that you have had an aggressive axillary lymph node dissection. As long as the reconstruction does not involve any additional surgery in the armpit area (i.e., microsurgery to the thoracodorsal vessels), then your risk of additional or worsening lymphedema is very low.

The most natural appearing breast reconstruction is always a flap! A flap is warm, soft, living tissue that grows and shrinks with weight changes, ages with you and lasts forever! The tissue that is transferred to the chest area brings with it a new blood supply that helps to counteract radiation damage.

I would recommend the DIEP flap over the TRAM flap for most women. Be sure to see a Reconstructive Microsurgeon who is experienced with the DIEP procedure. Avoiding sacrifice of the muscles of the abdominal wall (which are used in a TRAM flap) will significantly decrease the risks of hernia, bulge or weakness of the abdomen after surgery.

Please email your questions to Ask the Expert.

View previous Ask the Expert features on the Ask the Expert Archive Page.