Ever wonder why your doctor's office calls itself a medical practice? It's because all doctors are still practicing medicine, because in a lot of situations, there is no one right answer.
My most recent example -- although I have many stories now -- is on the topic of reconstruction of the breast. Before I get started with my story, let's get everyone who is uncomfortable with the word "breast" more settled. Breast, breast, breast! I used to fidget when I had to say it out loud too, but I have to say it so many times each day that I don't even blink now.
Ok, so, we were talking about breast reconstruction. There are many ways to accomplish this, but there are reasons why a person might choose a particular method. The simplest and least invasive way of reconstructing a breast is to use something called a tissue expander. Basically, a plastic surgeon creates a pocket in the patient's sub-pectoral muscle and inserts this thing that is alot like a balloon, only it holds sterile saline solution and it can be filled slowly through these little holes in it called ports. The plastic surgeon slowly fills it up to the desired size of the breast cup (A, B, C etc) and then overfills it to create some extra skin. The fill-up process is called "expansion." When expansion is complete, there is a second surgery to swap the expander for an implant. Often during this surgery, the plastic surgeon will also make some alterations to the "good" breast to make it match the newly reconstructed breast which is full and perky. Alterations to the good breast might include adding an implant or giving it a "lift" which is called mammoplasty (or maybe it's mastoplexy, I forget).
Here's where we get into the area of medical practice versus medical science; if a patient is going to have to have radiation to the chest wall after her mastectomy and chemotherapy, then many plastic surgeons and radiation oncologists do not recommend that a patient uses a tissue expander/implant as her reconstructive method. Why not? Well, in some cases, scar tissue will form in an area where radiation has occurred and it can cause complications with an implant. Also, radiation tends to damage skin and makes it lose some of its ability to stretch the way it needs to in order to accomodate the tissue expander.
But...some doctors will tell you that if you get fully expanded and then get radiation, it can alleviate some of the problems. Today, that's what my radiation oncologist suggested when I told her I was hoping to have the simplest method of reconstruction. So now I'm heading back to see the plastic surgeon I liked back in April...we'll see what he has to say. The other thing for me (and the plastic surgeon) to consider is whether or not I have enough sub-pectoral muscle to create the "pocket" for the tissue expander to go in. This is because my oncological surgeon had to remove some of it in order to get clear margins, that is, get all the cancer along with a little bit of healthy tissue.
If the tissue expander method will not work for me, then I have a few other options but they are all fairly involved. The other methods are called "flap" procedures. Sounds gross doesn't it? A "flap" is just that, a flap of skin, fat, tissue and sometimes muscle that is moved from one place on the body -- called a donor site -- and then transplanted to the chest area to form the new breast. Flaps can come from the patient's lower abdomen, her latissimus dorsi (upper lateral back) or the gluteal area. The best donor site varies from patient to patient and mostly that has to do with body type and weight.
A patient like myself who does not much extra flab in the abdomen area can pretty much cross off that area as a donor site. When skin, muscle, tissue and fat is used, this method is called the TRAM flap. When no muscle is taken but skin and tissue are, that method is called DIEP flap. Both also result in a tummy tuck for the patient, which I guess some women love.
The lat flap takes skin, muscle and tissue-- and has its own good and bad points but mostly I don't see it as a good choice for me...I have a one year old baby I want to pick up and hold and it doesn't seem like a good idea to lose muscle strength there. Also, it will create a 6-7" scar across my back. I already have two new scars this year...one from the c-section and one from the mastectomy. I'm not really interested in having a new scar in such a highly visible area. The one good point about the lat flap is that is seems to be pretty reliable as far as its success rate.
The gluteal flap, called a GAP or S-GAP takes skin and fat from the butt and moves it up to the chest to create a breast. That sounds pretty good to me because it also results in liposculpture to the butt. However, the recovery is long and the fail rate is high. That means that in as much as 20% of the time, it results in flap death. This is because the artery that feeds the tissue in the glute area is a much different size than the place it will be transplanted to on the chest area.
The DIEP and the GAP are only done by a handful of doctors, too. The procedures are quite complex and involve delicate microsurgery. It would be important to choose a doctor who did my technique of choice very often and had a good track record for success. In all likelihood, I would have to travel out of town to find a doctor who had that kind of resume. That would mean a big hassle with my insurance company to make them pay for it. I'll do it if I have to but I would much rather do something easier!
There! Now you're a specialist in the techniques of breast reconstruction.