Patients are incredibly concerned as they shold be with natural appearing results.  I have been asked recently about whether not patients would be able to have liposuction.  There are several factors I take into consideration when evaluating whether not a patint is an appropriate candidate or liposuction.  First I address if the patient has had changes in their  weight over the past several months that could unfortunately compromise the result.  I want patient to be at their current weight over the past 6 months and sometimes over the past year in a patient who has had surgical weight loss.  i would like the patient to have a BMI of less than 30 normally.  If these factors are within reason then we will delve into what area or areas they are interested in improving.  Liposuction doesn't remove all the fat in any given area.  I prefer patients to have a greater than 2 to 3cm pinch in any given area they desire liposuction.  Typical areas to have liposuction are the abdomen, flaks, hip roll, inner and outer thighs.  These can be done in conjunction with other procedures but I am not an advocate of large amounts of liposuction on the legs and thighs as well as excision procedures like tummy tucks.  There is an increased risk of DVT with combination procedures of the legs and abdomen.  I typically with confine the liposuction to the lower back, abdomen, flanks with the addition of a tummy tuck.  I feel the extremities can be dealt with in another session.  Also I would prefer that all patients after abdominal rejuvenation whether tummy tuck with or without liposuction feel very comfortable with walking in order to help prevent blood clot development in the veins of their legs.  It would make sense that patients would be less inclined to get up and move around if they have had liposuction of their abdomen, flanks and a tummy tuck as well as liposuction of the thighs and lower legs.  Liposuction is always associated with a certain amount of swelling.  The more swelling that develops the more difficulty the patient will have with pain control after surgery.  As soon as the procedure is finished and the wounds are closed my patient's are placed into the appropriate garments to help decrease swelling.  Swelling typically peaks at 48 to 72 hours after a procedure.  With the compression provided by the garment the patient will help limit their swelling.  This in essence will allow them to move around with less discomfort.  In addition pain medications are more effective when there is less swelling at the operative site.  These are some of the considerations for patients before and after their procedure.  Liposuction is a great technique to both improve those difficult areas of the abdomen, back, flanks, inner and outer thighs as well as a great sculpting tool in thinner patients.

Diep flap surgery in the past was limited by a patient tissues.  I am speaking directly to those patients seeking reconstruction with their own tissues who do not want implants under any circumstances.  In many instances patients who were deemed to thin or those on the other hand who were felt to be to obese were denied the opportunity for this type of breast reconstruction.  Several thoughts have changed regarding DIEP flap surgery and breast reconstruction.  Since the introduction of the bipedicled DIEP flap, double stack DIEP, stacked DIEP flap more women who are relatively thin have been given the opportunity to have breast reconstruction surgery using their own tissue in the form of the DIEP flap.   This is particularly advantageous in situations where patients are having skin sparing mastectomy surgery.  This allows for the most complete breast reconstruction result where the mastectomy or breast skin has been saved by the breast surgeon and the plastic surgeon has the opportunity then to perform breast reconstruction surgery either with the abdominal tissue like a DIEP flap for optimal reconstructive outcomes.

Read an interesting Article in Scientific American, "The Naked Truth", on a flight home recently.  It distills down the pressure the environment posed for the early humans to adapt to the sweltering tropical climates in Africa.  We continue to evolve but the skin seems to be a constant battle.  Bare skin keeps cool but I am constantly asked by patients about laser hair removal.  In breast reconstruction where one breast is in the natural position, slightly drooping, I have to lift it, augment it or both.  If someone is concerned with the appearance of the facial tissues.  Many times unnatural appearances can be created if just the skin envelope is adjusted without any change in the position of the underlying tissues of the cheek and jowls.  It is part of the process of evaluation in  an office consultation to come up with a plan that will fit a given patient in terms of their expectations and the ability to reach expectations with their own tissues.

Several interesting topics were discussed at the Breast Surgery Symposium in Atlanta, GA at the Southeastern Society of Plastic and Reconstructive Surgeons Meeting.  A panel discussing Oncoplastic Breast Conservation Surgery & Nipple Preserving Mastectomy was extremely interesting.   For decades Plastic Surgeons have provided reconstructive options for women undergoing partial and complete mastectomy which are included but not limited to the permanent silicone gel implant, tissue expanders that are later exchanged for implants, expanders and or implant in addition to a latissimus flap, and the now various forms of flap from the lower abdomen and thighs such as the TUG flap, Free TRAM, Pedicled TRAM, and the increasingly popular DIEP flap. Despite all of the options less than 30 percent of women get a reconstruction.  This leads to finger pointing on both sides.  The plastic surgeons think the general or breast surgeons are not referring or discussing breast reconstruction in their initial consultation with the patients and the general surgeon or breast surgeons feel like they cannot get a plastic surgeon to see the patient.  Sometimes because of location there may not be a plastic surgeon nearby.  This is becoming less the case with the aid of the internet.  Finding physicians and surgeons is becoming easier.  There can be hurdles with insurance after that with respect to the providers.  Fortunately it is a Federal Law that women have the ability to under reconstruction after mastectomy and any symmetry procedures on the opposite breast.

One of the take home points from the panel to me was that great reconstruction outcomes can only  happen with great mastectomies.  That means the general or breast surgeon has to do a great job performing the mastectomy in order for the plastic surgeon to then perform the best reconstruction.  In cases of nipple sparing mastectomy the general or breast surgeon performs the mastecomy and sentinel lymph node biopsy and then performs a biopsy of the tissue behind the nipple to confirm there is not cancer.  At this point the plastic surgeon can perform the reconstruction with a comination of expanders and acellular dermal matrix.  The techniques can very among the plastic surgeons who perform the procedure but the outcomes should be great if the mastectomy was done well.  The final product shold look like a breast augmentatin rather than a breast reconstruction.

Fat grafting lips, fat grafting cheeks, fat grafting buttocks, fat grafting breasts have all been described over long periods of time.  Recently I attended the Southeastern Society of Reconstructive Surgeons Meeting in Altanta.  One of the Hot Topics was fat grafting.  In particular autologous fat grafting for breast augmentation.  There are numerous cosiderations with breast augmentation including breast augmentation cost, breast augmentation recovery time, breast augmentation risks, breast augmentation size as well as concerns of the patient on how they will look after breast augmentation.  Concerns over the natural appearance have led many, but most notably, Board Certified Plastic Surgeons, to seek out new avenues to provide durable, natural results with fat.  Liposuction surgery or liposuction plastic surgery allows a Board Certified Plastic Surgeon to harvest fat from the abdomen, flanks, hips and thighs in order to provide fat to augment a breast.  This process can be seen in liposuction surgery video or liposuction surgery pictures on websites and on television.  The majority of patients can be seen and examined to determine whether or not they are good candidate for liposuction surgery and autologous fat grafting breast surgery.  Liposuction procedures and liposuction prices will vary according to the region of the country where you are located.  Many times liposuction can be performed with the use of local anesthesia and sedation.  Liposuction plastic surgery for fat grafting lips, fat grafting cheeks, fat grafting buttocks, and fat grafting breasts can performed safely by Board Certified Plastic Surgeons.

It’s reported that in the United States an estimated 11.7% percent of the population (5.6% male and 17.1% female) is directly affected by chronic migraine headaches.  Chronic migraines are more common than asthma and diabetes combined.  Up until now there have been very few treatment options for patients who suffer from chronic migraines.

Recently it has been shown that the use of Botulinum toxin injected into muscles in the back of the neck, the temple area and the forehead can provide relief from chronic migraines.  In many instances there will be an elimination of the migraine.  If the patient responds to Botulinum Toxin they can be evaluated for the surgical treatment of Chronic Migraines.

Surgical treatment involves the release of the nerves in the back of the neck, the greater occipital, the nerves in the temple area, zygomaticotemporal, and the nerves in the forehead, supraorbital and supratrochlear nerves.  In addition several patients report headaches or symptoms related to the sinuses.  Each patient is evaluated for sinus issues as well as airway issues.  Patients can have problems within their nose that can actually cause a migraine such as a septal spur.  If appropriate patients with septal problems can undergo a procedure to correct this at the same time of at a later date.

I feel fortunate to be able to offer this as another alternative to patients with Chronic Migraines.   It is my hope that I will be able to help as many patients as possible by giving them back the quality of life they’ve lost due to chronic migraines.
 

Immediate or acute nasal fractures management can lead to long term issues.  Proper management techniques  can reduce nasal revision rate. A lower incidence of revision is attributed to complete assessment, use of outpatient controlled general anesthesia, and proper treatment of the septum in cases with severe septal fracture dislocation.

The nose and the eyes are the most prominent facial features. A fracture of the nasal pyramid is the most common facial fracture.  The increasing prevalence of this injury presents the plastic surgeon with challenging treatment options. Although nasal fractures are often discussed as minor injuries.  Traditionally these injuries have been reduced in a less than optimal manner in Emergency Rooms or in the office.  Sometimes this is done after swelling has already created a stiff skin and soft tissue envelope.  Usually the patient is told that this injury will be revised in a year.  Revision rhinoplasty for traumatic nasal deformity is a difficult procedure.a

The numerous factors that contribute to suboptimal aesthetic and functional end results include timing, edema, undetected preexisting nasal deformity, and occult septal deviation/injury. In order to improve results I recommend the immediate or acute treatment of nasal or nose fractures in an effort to correct assess and treat these injuries to improve outcomes.

Recently perforator flaps such as the ALT and DIEP flap have become more and more important in my practice. As I continue to provide patients with the best reconstructive options for reconstruction after removal of tumors whether from the head and neck, breast, or extremities it is always challenging.  The more we are able to perform these procedures and get our patients back to work, become pain free or just have the ability to walk or sit without significant pain each case gets more difficult.  There are special circumstances that arise with large tumors of the pelvic and groin region.  These tumors are difficult to access for the cancer surgeons and often involve blood vessels and nerves.  These types of complicated tumors are best treated with a multidisciplinary approach at a facility where cancer surgeries are routinely performed. Once the tumors have been removed and the blood vessels have been reconstructed by another surgeon, a vascular surgeon, the plastic surgeon then has to design away to provide stabe soft tissue coverage in this area.  This can be carried out using a wide variety of techniques but I have found great success in using pedicled perforator flaps like the DIEP flap and the ALT.  One can come from the opposite side of the abdomen and one can come from the opposite thigh.  I say this because in the cancer surgery the cancer surgeon has to remove many of the branches of the blood vessels on the side where the tumor was removed.  The vascular surgeon has  to reconstruct the large vessels  so there is blood flow to the foot.  The smaller vessels the plastic surgeon would use are not reconstructed.  Therefore I use tissue from places away from the injury and use the natural blood vessel anatomy to help me reconstruct these areas where tumors have been removed.  I consider these operations limb saving procedures because in many instances a patient can avoid a hemipelvectomy and loss of their leg.  If you or one of your friends or family have been told this is the only way to help them I would suggest a second opinion to see if there is any chance that an alternative exists.  I participate in the procedures routinely at Froedtert and the Medical College of Wisconsin where I am a Staff Plastic Surgeon, Assistant Professor of Plastic Surgery and the Microfellowship Director.

Soft tissue sarcoma is a cancer that begins in the muscle, fat, fibrous tissue, blood vessels or other supporting tissue of the body.&nbsp; These are relatively rare cancers but if detected early and treat properly can be controlled.&nbsp; A number of people would ask why would a plastic surgeon be involved with cancer surgery.&nbsp; Plastic surgeons are involved with a number of types of cancer patients.&nbsp; In the last 6 months I have performed reconstructions on patients with squamous cell cancer of the Head and Neck, total breast breast reconstruction after mastectomy for breast cancer, as well as reconstructions of the arms and legs from removal of Sarcomas.&nbsp; In addition to performing the most function reconstruction for these patients I am also very aware of how these reconstructions will look for these patients.I am part of a special multidisciplinary group that cares for patients with Sarcoma at Froedtert and the Medical College of Wisconsin.&nbsp; This group is composed Orthopedic Surgeons who specialize in Musculoskeletal Oncology, Radiation Oncologist, Medical Oncologists, Radiologists, Interventional Radiologists, Thoracic Surgeons, General Surgeons and Plastic Surgeons.&nbsp; This Group meets once a week to discuss new patients and plans for existing patients.&nbsp; As a Plastic Surgeon who performs reconstructions for these patients these are particularly challenging.&nbsp; First of all it is imperative that if you are given the diagnosis of a sarcoma that you seek out the types of doctors I have mentioned to get the most appropriate care.&nbsp;&nbsp; Many times we are performing additional surgery because someone went to their doctor with a lump and had it removed only to find out later that it was cancer and ultimately it was a sarcoma.&nbsp; This creates some issues in terms of how to care for the patient at the next phase.&nbsp; At this point it is especially important that the patient be seen by physicians for comfortable with providing care for those patients with sarcomas that may have been removed without the appropriate surgical margin.&nbsp; Meaning that part of the sarcoma could have been left behind or that it was so close that there may be microscopic disease left that will probably return over time.&nbsp; For my part I try to provide these patients with the most durable and appropriate reconstructions.&nbsp; I prefer to use perforator flaps for these reconstructions.&nbsp; I use the ALT, DIEP and DIEAP, the medial thigh flap as well design of freestyle flaps depending on the defects.&nbsp; The use of these perforator flaps allows the patients to avoid skin graft in nearly all situations.&nbsp; Also it leaves the Plastic Surgeon to create the most functional outcome through flap contouring.&nbsp; </p>

The anterolateral thigh flap (ALT) is an extremely versatile flap.  The lateral thigh can be utilized to bring an island  of tissue that is approximately 8cm X 24cm.  This amount of tissue removal can be closed with one incision.  Depending on the size of the area to be covered by the flap it may be necessary to harvest more tissue from the thigh.  If this is the case a skin graft will be utilized to close the resulting defect on the thigh.  I personally have used ALT flaps up to 35/25cm to cover large wounds of the chest and back.  Normally I utilize the ALT flap for coverage of the arm and leg.  It is very useful for the foot.  There are multiple ways to reestablish the blood supply to the transferred tissue but usually the posterior tibial blood vessels are used.  Microsurgery is used to reestablish blood flow to the tissues.  This is normally done by a plastic surgeon who has had additional training in microsurgery.  Typically these procedure are performed in microsurgery units or facilities where microvascular surgery is performed on a routine basis.  I typically perform, ALT flap, Latissimus flaps, gracilis flaps, DIEP flaps, and freestyle free flaps depending on the needs of the patient after Sarcoma tumor removal, trauma, or infection.  One of the additional points regarding ALT flaps is that they can be easily modified after surgery.  Through thinning of the fat and advancement of the flap a very thin pliable flap can be created which can be then almost indistinguishable in clothing from normal tissue.  Obviously externally there is a scar around the transferred tissue.  I believe this is an ideal flap for multiple reconstructive challenges.

Rhinoplasty ultimately changes the structure of the nose.  Anatomy is the key to understanding and performing rhinoplasty.The skin, nasal bones, upper and lower lateral cartilages externally and the septum internally are the key components in the framework of the nose.  Manipulating these structures will provide significant changes.  Whether it is done with an open or closed rhinoplasty techniques doesn't  matter. Many patients I see initially have septal issues.  The septum has three primary components.  The septal catilage, perpenicular plate of the ethmoid, and the vomer.  There can be a number of reasons for septal problems which nclude but are not limited to nonspecific deviation, deviation to trauma with or without fracture of the boney or cartilaginous septum.  Correction of these deformities can be done using open or closed rhioplasty techniques.  Once access has been gained to the septume and mucoperichondrium has been elevated the defect is evaluated.  The deviation is usually corrected through removal of the septal cartilage and bone.  A certain amount of cartilage is maintained to provide support in the form of an L - Strut.  Cartilage can then be used to provide more structural support in the form of spreader grafts or a columellar strut.  At this point the reconstruction of the septum is relatively complete.  I will contune to blog about nose surgery in the future.

The DIEP flap is an outstanding flap and ideal for large soft issue defects.  It has long been praised for the ability of this flap to provide a natural appearing breast reconstruction.  In addition to its utility in breast reconstruction this tissue flap is useful in a variety of other situations like arm and leg reconstruction after tumor removal like sarcoma.  In fact recently we have used the DIEP flap to care for patients with different sarcoma like angiosarcoma and fibromyoid sarcoma.  These patients have benefited from the quality and amount of skin and fat that can be transferred for their  arm and leg reconstruction just like the DIEP flap when it is used for breast reconstruction.  After multiple types of cancer surgeries the DIEP flap can be used.  Also it is very modifiable after the initial surgery has been performed.  Unlike a muscle flap and skin graft which has been traditionally performed for a number of years the DIEP flap is easily contoured through a combination of techniques involving liposuction of the fat and resection of the excess tissues.  Removal of the fat of the flap in the vertical dimension and the flap can be then stretched as well to flatten it even more.  This makes it ideal for the upper and lower extremity.  Of note this does remove the excess abdominal tissue that would normally be discarded in a tummy tuck procedure.  This procedure can be performed in a number of patients of different heights and weights.  If you are in need of reconstruction of the breast, large are or leg wounds the DIEP flap is a ideal source of healthy tissue.

This is a helpful article on many levels with respect to breast reconstruction.  It discusses the standard methods of your own tissue like the DIEP flap, breast implants, and the combinations of the two as well as future posibilities.  Always keep in mind that until you are seen and examined you should learn as much as possible to engage in a discussion with your breast surgeon and plastic surgeon.

http://www.webmd.com/breast-cancer/news/20080917/new-options-for-breast-reconstruction

This can be used in cases of osteosarcoma, rotationplasty involves a partial amputation of the leg above the knee. The lower leg and foot are rotated 180 degrees, the length is adjusted, and the tibia is then joined to the proximal femur using plates and screws. The foot is positioned where the knee used to be, with the heel portion in front and the toes pointing back. The ankle now functions in place of the knee joint. The primary reason for rotationplasty is to enhance the person's mobility as a prosthesis user. Placing the ankle joint in the position of the knee creates a functional, natural knee, and the toes provide important sensory feedback to the brain.

The appearance of the limb following rotationplasty is very unusual and is a concern for many people from both a cosmetic and a psychological standpoint. Patients and their families who are considering rotationplasty should talk with other people who have had the procedure and are now prosthesis users. For many, the functional advantages quickly outweigh their concerns about appearance. Children and young adults have a lifetime in front of them, and the increased mobility and freedom that may follow rotationplasty can be a significant improvement over the use of a traditional above-knee prosthesis.
 

I am becoming more and more concerned with people being told they are not candidates for the DIEP Flap because of previous abdominal surgery.  These surgeries don't necessarily eliminate you from having a DIEP Flap.  Essentially it depends on your previous surgeries.  If they were done in the middle of your abdomen then it should be relatively straight forward to identify your anatomy and perform the operation.  The typical c-section scar can be fine as well.  It has been my practice sine February 14, 2004 when I ordered the first perforator protocol Cat Scan (CT) of the abdomen at Froedtert&Medcial College of Wisconsin.  I just reviewed the images before writing this blog.  It has been a huge advantage to many of our patients with a history of prior abdominal surgery or who may have a pannus.  I have had many consultation where the patients have seen several surgeons prior to me because they were told that because of their abdominal scar that they would not be candidates.  We look at the blood vessel anatomy to identify to the best of our ability whether or not you can be a candidate.

There are several questions that should have been considered prior to a consult about a procedure that would require a breast implant.

What is your age?

Which implant type of implant are you interested in, Silicone or Saline?

What are your reasons or reason for having breast implant or implants?

Do you need reconstruction?

Is one side significantly different than the other?

If you have surgery are ready to accept the risks and benefits of surgery?

Are you will to accept the change associated with implants and that if there are issues and the need for removal that the appearance may not be desirable?

Can you accept that implants can potentially make it difficult to have mammograms?

Are you able to accept that you will more than likely need additional surgery because of aging, pregancy, significant weight loss or gain, and possibly implant problems?

Will you follow up after to surgery to see your Plastic Surgeon?

Do you have an active infection?

Are you a smoker?

Do you have problems with depression?

Do you have Rheumatoid arthritis, lupus, or other autoimmune disorders or disease?

Do you take medications like steriods, immunosuppressants or other medicines that would delay your ability to heal?

Are you pregnant or nursing?

 I have been pleased with the results of reconstruction of one side of a woman's breast using the entire lower abdomen.  Initially five years ago when I began using the DIEP Flap for breast reconstruction I would only use half of the abdomen for the breast reconstruction and preserve the other portion during the procedure only to remove it and discard it at the end. I began to have more and more women with less abdominal tissue who really desired the DIEP Flap.  I have found this to be an extremely rewarding operation for the patients and for me.  Now I feel like I am utilizing all of the abdominal tissue even when I am reconstructing only one side for the patient.  This added volume allows for a better initial result and less complicated procedures down the road to provide symmetry.  Of course whenever possible and accordance with the patients desires we try improve in symmetry problems by using the patient's own fat.  This fat is harvested and separated into smaller portions then loaded back into smaller syringes and strategically placed to provide symmetry.

I have seen several patients recently after immediate breast reconstruction with a DIEP flap.  i am always impressed at how natural the appearance of the flap is in relationship to the other breast.  Many times I care for patients in other communities such as Greenbay, Sheboygan, Two Rivers, Appleton, and Madison, Wisconsin after mastectomy.  Many patients travel to have these procedures done at Froedtert and the Medical College of Wisconsin.  There is an entire team devoted to women with breast cancer.  Our goal as Plastic Surgeons is provide all available breast reconstruction options to each patient.  Many of our patients choose the DIEP flap because of our experience with the procedure.  We having been performing this procedure routinely over the past five years at Froedtert and the Medical College of Wisconsin.  Whether we need to perform simultaneous reconstruction of bothe sides or perfor a stacked or double diep flap on one side we have the team available.

There is a report today on CNN.com that  Task force opposes routine mammograms for women age 40-49.  The task force states that about 15 % of the time women age 40 will detect breast cancer.  other women will experience false positives, anxiety, and unnecessary biopsies.  This task force differs in its recommendations compared to the American Cancer Society which recommends mammograms stating at age 40.  This will invariably cause problems with insurance plans, their patient's desire for mammography, and the ability of the phsician to recommend what they feel is appropriate.  My personal experience is that the youngest woman I have operated on with the diagnosis with breast cancer is 24.  Fortunately she survived and went on to have reconstruction as well.

For a number of years patients would have difficulty with contour abnormalities of the chest wall, breast reconstruction asymmetry, implant rippling in the lower poles and the most visualized medial area.  It was difficult to inform breast cancer patients about using fat grafting because of the inability to reliably tell the patient how it would work in the short and long term.  Now enough work has been done that fat grafting has firmly taken hold in the practice of plastic surgery for a number of problems.  Just as I suggested in the title of this blog, fat grafting is a major player in breast cancer reconstruction.  Even though a have performed numerous DIEP flaps and I am one of the few Plastic Surgeons who will perform two flaps on one side to provide the most volume at one time.  There are instance particularly on the later aspect of the breast where the addition of fat can be extremely helpful in reconstruction the anterior axillary fold.  I also feel that an poorly treated area by plastic surgeons is what refer to as the patient's view.  When a women looks done if there is not adequate breast volume after all of the effort to get reconstruction it is extremely frustrating.  I start the cases by harvesting the fat and then after it has been separated appropriately I begin to inject the fat.  I start with the patient supine and begin to reconstruct the lateral and inferior portions of the breast reconstruction.  Always adding volume and then comparing side-to-side.I gradually have the anesthesiologist raise the patient up  on the operating table to mimic gravity.  I will walk around and look from above to ensure that I am seeing what the patient will ultimately see.  These are just some of the ways I try to give reproducible results when I use fat graft.

A soft tissue sarcoma is a cancer that begins in the muscle, fat, fibrous tissue, blood vessels or other supporting tissue of the body.  These are relatively rare cancers but if detected early and treat properly can be controlled.  A number of people would ask why would a plastic surgeon be involved with cancer surgery.  Plastic surgeons are involved with a number of types of cancer patients.  In the last 6 months I have performed reconstructions on patients with squamous cell cancer of the Head and Neck, total breast breast reconstruction after mastectomy for breast cancer, as well as reconstructions of the arms and legs from removal of Sarcomas.  In addition to performing the most function reconstruction for these patients I am also very aware of how these reconstructions will look for these patients.I am part of a special multidisciplinary group that cares for patients with Sarcoma at Froedtert and the Medical College of Wisconsin.  This group is composed Orthopedic Surgeons who specialize in Musculoskeletal Oncology, Radiation Oncologist, Medical Oncologists, Radiologists, Interventional Radiologists, Thoracic Surgeons, General Surgeons and Plastic Surgeons.  This Group meets once a week to discuss new patients and plans for existing patients.  As a Plastic Surgeon who performs reconstructions for these patients these are particularly challenging.  First of all it is imperative that if you are given the diagnosis of a sarcoma that you seek out the types of doctors I have mentioned to get the most appropriate care.   Many times we are performing additional surgery because someone went to their doctor with a lump and had it removed only to find out later that it was cancer and ultimately it was a sarcoma.  This creates some issues in terms of how to care for the patient at the next phase.  At this point it is especially important that the patient be seen by physicians for comfortable with providing care for those patients with sarcomas that may have been removed without the appropriate surgical margin.  Meaning that part of the sarcoma could have been left behind or that it was so close that there may be microscopic disease left that will probably return over time.  For my part I try to provide these patients with the most durable and appropriate reconstructions.  I prefer to use perforator flaps for these reconstructions.  I use the ALT, DIEP and DIEAP, the medial thigh flap as well design of freestyle flaps depending on the defects.  The use of these perforator flaps allows the patients to avoid skin graft in nearly all situations.  Also it leaves the Plastic Surgeon to create the most functional outcome through flap contouring. 

The DIEP Flap is a skin and fat flap that Plastic Surgeons use to perfom total breast reconstruction after mastecomy for breast cancer using microsurgery. I like to think of the DIEP Flap as the rifinement of the procedure popularized in the 80's, the TRAM Flap. the main difference is the the DIEP Flap is a muscle and nerve preserving procedure. The results of DIEP, SIEA, TRAM, MS TRAM, are essentially all the same in terms appearance of the breast reconstruction. The differences are found in the effects on the anterior abdominal wall. I believe this is most important in bilateral breast reconstruction where the disturbance or removal of both rectus abdominus muscles can leave a patient with an incredibly weak abdomen. These patients can also have bulges, feelings of pressure, and abdominal discomfort, that occur even without removal of muscle. I firmly believe that the most natural breast reconstruction appearance is dervied from the patient's own tissue. As I was typing this blog when one of my DIEP Flap patient's came in for a post operative visit. She is doing quite well. So well that I have to remind her that she should take it easy since she is less than 2 weeks after her surgery. I had sent a post out on Twitter regarding some thoughts about DIEP flap reconstruction using both DIEP Flaps for unilateral breast reconstruction. That's right I said use both for the one side. Having done DIEP flaps where I use one half of the abdomen or seventy-five percent of the abdomen to create a breast reconstruction I now feel that in a unilateral breast reconstruction that both DIEP flaps should be used. this way the Plastic Surgeon doesn't waste any of the tissue. In a bilateral case the Plastic Surgeon would be unable to perform the reconstruction in this manner because of the need to reconstruct both sides. Of course this is only my opinion and will not necessarily be shared by everyone. I hope this patient and many of my other DIEP flap patient's both with unilateral and bilateral will allow me to show their photos so that other patients can really understand the size, shape and symmetry that can be achieved with the DIEP Flap.

To date I have performed DIEP Flap reconstruction for patients from several states in the Midwest including Michigan, Indiana, Illinois, Missouri, and Wisconsin. I have even had patients travel from Phoenix, Arizona. My practice still provides care mainly for those patients in Milwaukee, Madison, Kenosha, Racine, Green Bay, Sheboygan, Two Rivers, Janesville, and the surrounding areas of Wisconsin, Illinois and Michigan.