DIEP flap breast reconstruction: Sheila’s story

Sheila Flanagan is fearless. She has skied mountains all over the world — including the Swiss Alps and remote peaks of the Canadian Rockies, accessible only by helicopter. She taught school for more than 30 years, including 22 years working with high schoolers. When she learned she had breast cancer in 2003, she was not afraid. “Mostly, my attitude was, ‘You’ve got to be kidding me! Okay, let’s hurry up and get this over with, because I want to be ready for ski season in the coming months,” Sheila recalls.

Is there anything that has really scared Sheila over the years? “As a larger woman who had breast reduction surgery 33 years ago and a mastectomy and implant on one breast 18 years ago, shopping for a bathing suit has always been terrifying,” she laughs. But thanks to DIEP flap surgery — a complex type of breast reconstruction offered at Roswell Park Comprehensive Cancer Center — at age 64, Sheila finally feels comfortable with her body.

Routine screening led to early detection and treatment

Nineteen years ago, a routine annual mammogram revealed a concerning image. A subsequent sonogram and biopsy confirmed the diagnosis: breast cancer.

“I immediately opted to have a mastectomy done to remove the affected breast,” Sheila says. But the decision about having breast reconstruction wasn’t as easy. After researching her options, Sheila considered having a flap reconstruction, in which a flap of complete tissue (including skin, fat, blood vessels and sometimes muscle) is cut from other body areas, such as the patient’s abdomen, back, thighs or buttocks, and transferred to the chest area to create a new breast.

“However, the complete recovery for this procedure is about 12 weeks, and at the time, I didn’t want to take additional time off from work or miss any of my son’s senior year activities,” Sheila says.

Instead, she settled on a breast implant – the most commonly performed type of breast reconstruction in the United States. “At the end of the mastectomy procedure, my surgeon put in a temporary tissue expander to slowly stretch and expand the muscle and skin,” Sheila recalls. She then received chemotherapy under the care of oncologist Saif Soniwala, MD, who had completed a fellowship at Roswell Park. “Dr. Soniwala’s clinic was relatively close to my home and his bedside manner is calm and caring,” Sheila says.

After chemotherapy, Sheila underwent two procedures to complete the reconstruction: first, surgery to remove the expander and place a C cup-size implant in her right breast, and four weeks later, surgery to reduce the size of her left breast to better match the right. “For anyone who might be worried about these types of surgeries, I’m here to say that you can usually go home on the day of the surgery, and I recovered quickly,” Sheila says.

'Time to take care of me'

For the next 18 years, Sheila lived her life: teaching, skiing, retiring from her job, seeing her son get married and caring for her long-term boyfriend as he struggled and eventually died from the devastating effects of COPD.

All the while, she became less satisfied with her breast implant. “The underlying muscles accumulated a great deal of scar tissue, causing contracture, where the position of the implant shifted as the chest muscles moved. Eventually, my once C cup-sized implant contracted to a half an A cup, and due to weight gain, my other breast had grown to about a DD cup. I felt lopsided and self-conscious. So, when the time finally came that I was done taking care of other people, I decided it was time to take care of me!” Sheila says.

Sheila had continued to see Dr. Soniwala for yearly check-ups, and in 2017, his clinic joined forces with Roswell Park, becoming Roswell Park Hematology Oncology Northtowns as part of the Roswell Park Care Network. “When I asked Dr. Soniwala for a recommendation for flap surgery, without hesitation, he recommended Cemile Nurdan Ozturk, MD, of Roswell Park’s Department of Head & Neck and Plastic & Reconstructive Surgery. He told me that Dr. Ozturk was highly skilled, her results were excellent and that patients appreciated her clear explanations and kindness,” Sheila says.

DIEP flap surgery: an improved type of breast reconstruction

Having flap surgery in 2021 means Sheila benefitted from newer techniques. “Flap surgery has improved a great deal since 2003,” explains Dr. Ozturk. “Older types of flap surgeries involve removing a flap of skin, fat, and all or part of the underlying rectus abdominus "six-pack" muscle from the abdomen to reconstruct the breast.”

A relatively newer procedure, DIEP flap surgery does not remove muscle and minimizes damage to the nerves, allowing for quicker recovery and lowered risk of weakened abdominal muscles. The acronym, DIEP, refers to the deep inferior epigastric perforators (blood vessels) which run through the abdomen. Intricate microsurgery techniques reconnect all the blood vessels from the transferred flap to the blood vessels in the chest so that the tissue will survive. While the procedure is not necessarily a “tummy tuck,” removing fat and tissue from the abdomen may yield similar results. However, patients then have two surgical sites to heal.

“It is a long and complex procedure that can only be done by plastic surgeons who have had one to two years of fellowship training in microsurgery in addition to their plastic surgery residency. As such, this type of surgery is usually only performed in larger academic centers that have multiple plastic surgeons and sufficient nursing and operating room support,” Dr. Ozturk says. “In New York, Roswell Park is one of only a few facilities outside of New York City that performs free flaps, and some of our patients travel here from as far away as Albany and Binghamton.”

In early 2020, Sheila made the short trip to Roswell Park to meet with Dr. Ozturk. “Dr. Ozturk is kind and personable. She clearly explained the procedure to me and recommended that I lose some weight before scheduling my reconstruction. Over two seasons of skiing and a summer of swimming, I lost 25 pounds and finally, at the end of March 2021, I was scheduled for surgery,” Sheila recalls.

In a 10-hour procedure, Dr. Ozturk and her team removed Sheila’s implant, transferred abdominal skin and tissue to Sheila’s chest and connected all of the abdominal blood vessels to existing vessels in the breast area. “When I woke up, I was surprised to see that the fat had only been removed from left side of my belly,” Sheila remembers. “Dr. Ozturk explained that the fat on the right side of my belly had been left in place as a reserve to draw from in the event that the transplanted tissue did not survive.”

“Fortunately, flap loss is rare, occurring less than 3% of the time,” says Dr. Ozturk. “We monitor the transplanted tissue for five to seven days, using a tissue oxygen monitor that remains attached to the flap during patient's inpatient stay. Nurses in the special flap unit check on the patient hourly and monitor the flap's temperature, color and other factors.”

A new self-image

After five days of monitoring Sheila’s flap, Dr. Ozturk was confident that the surgery was successful, and she performed an additional shorter surgery to remove Sheila’s remaining abdominal fat. Sheila went home to recover — three weeks of minimal activity, followed by three weeks of light activity. “I was a little uncomfortable, but it was not nearly as painful as recovery from the C-section I’d had years ago,” Sheila says.

After taking a few months to get used to her changed body, Sheila consulted with Dr. Ozturk about revision surgery, to address any additional fixes that the patient and doctor think should occur. In a two-hour follow-up surgery, Dr. Ozturk straightened Sheila’s abdominal scar and adjusted the size of the reconstructed breast to better match the natural breast.

Sheila recently returned to Dr. Ozturk’s office for her six-month check-up. “The visit coincided with my 64th birthday. I told Dr. Ozturk that she had given me one of the best birthday gifts ever: a totally new self-image,” Sheila says. “It’s been a long time since I’ve felt this good about my body.”