This Peg Procedures Questions and Answers are divided into four sections:

Background information
Costs, insurance, pre-existing conditions, health evaluation, etc.

Surgery
What to expect during surgical procedures

Recovery
Length of time and restrictions

Results
What to expect long-term following the Peg Procedures

If you have any further questions, please feel free to email them to us. We will do our best to answer them in this section.

Background Information

Q: Where is the nearest physician to me who can perform this procedure?

A: We have listed a handful of physicians in the Providers section of this website for reference. However, it is not a complete list. Please feel free to discuss these procedures with your physician to see if he/she is familiar with them. The number of surgeons who are trained in the Peg Procedures is growing as the advantages are realized.

Q: How much does the Peg Procedure cost?

A:Professional fees and hospital costs will vary in different geographical areas. In general, the Peg techniques are competitively priced with other procedures and can be less expensive than older kinds of reconstruction because they require fewer surgeries.

Q: Will my insurance pay for this procedure?

A: Most insurance companies will cover breast reconstruction, but very few standards exist as to the level at which patients will receive these benefits. More standardization is required so patients with breast cancer can be assured of adequate coverage.

Q: Are there exercises I can do before the Peg Procedure to help me recover faster?

A: There are no specific exercises that are required. However, the most important preparation for surgery is the cessation of smoking. Obviously, being in good health and physical shape will hasten recovery.

Q: Why are you so concerned about lumpectomies and radiation therapy?

A: There are four areas of concern:
1) Lumpectomy with radiation therapy has not been used for a long enough period of time to accurately assess long term recurrence rates of breast cancer.
2) With lumpectomy and radiation, the woman keeps her residual breast tissue that may be the source of recurrence at a later date.
3) This residual breast tissue can have severe radiation scarring which may complicate follow-up monitoring with mammography.
4) Most patients will require a modified radical mastectomy to treat a local recurrence if they were initially treated with lumpectomy and radiation. The presence of radiation scarring within a mastectomy will severely compromise any method of breast reconstruction.

Q: Do I have to have chemotherapy with the Peg Procedure?

A: In most circumstances, the decision to have chemotherapy is made independent of the type of treatment that is given to the breast itself. Instead, the perceived risk of systemic spread from the breast cancer is the main determinant for chemotherapy. Premenopausal women with larger breast cancers that have positive lymph nodes are more likely to need chemotherapy because they are at a higher risk for systemic spread.

Q: I've already had a mastectomy on my left breast and had it reconstructed. Can you improve the appearance with another operation?

A: Most patients can benefit from a surgical revision when the results of the reconstruction are not optimal.

Q: I had a lumpectomy with radiation with on my breast already, and now it has cancer again. Can I get the Peg Procedure?

A: Patients previously treated with radiation to the breast can have their breast reconstructed even though the results of the reconstruction will be severely compromised by the presence of radiation scarring in the skin and soft tissue.

Q: I had a lumpectomy and radiation on my left breast. Now I have cancer in my right breast. Can I still have the Peg Procedure?

A: Yes. The tissues of the right breast should not be adversely affected by radiation therapy to the left breast.

Q: Can I have both breasts lifted or made bigger at the time of the Peg?

A: Most patients can simultaneously have the size and the shape of their breasts altered during the Peg Procedure.

Q: Can I have a breast reduction at the time of the Peg?

A: Yes, most patients can have the size of their breasts reduced at the same time.

Q: Which Peg Procedure is best, the one where you use my shoulder or stomach muscle, or the one where I come back for an implant? Who decides, and how am I involved in the decision? What are the tradeoffs?

A: Ultimately, it is the patient who chooses the type of procedure that she wants. A Peg Flap reconstruction from the back or abdomen provides equally good results. A Peg Flap is used when the patient does not want a breast implant. Generally these procedures are more extensive than the Pectoralis Peg which uses a breast implant instead of a flap.

Surgery

Q: What types of complications are there during surgery?

A: Any type of surgery can be complicated with bleeding, infection and severe scarring. For the most part, these complications are uncommon and can be treated by the patient's surgeon when they occur.

Complications that are specific to breast reconstruction include skin loss of the remaining breast skin. Breast skin loss occurs because the circulation has been impaired by the mastectomy when the breast tissue is removed. This complication is more likely to occur in patients with larger breasts and in patients who are smokers or diabetics. Skin flap loss is due to an impaired circulation of the flap itself. Contributory factors that can lead to flap loss include obesity, smoking and diabetes. The average patient in good health is unlikely to suffer this effect.

Deflation of a saline breast implant is another possible complication. A deflation will require replacement of the implant.

Finally, patients who have been previously treated with radiation therapy are at a significant risk to suffer these complications due to the extensive scarring and marked reduction in the circulation of the tissues.

Q: Should I donate blood to myself before surgery?

A: Patients that are having an implant method of reconstruction do not need to donate their own blood. Patients who have elected a flap method of reconstruction should donate one to two units of blood to account for the more extensive nature of this operation.

Q: How many hours will I be in surgery?

A: The initial mastectomy and breast reconstruction will take between three and five hours to complete. Implant methods of reconstruction take less time to complete but require the subsequent reconstructive procedure. Peg Flap reconstructions are more extensive and require a longer period of time in the operating room. However, many of these patients can have their mastectomy and reconstruction completed in a single stage.

Q: Will my plastic surgeon and general surgeon assist each other throughout my surgery?

A: With the Peg Procedures that use back or abdominal flaps, the general surgeon and the plastic surgeon must closely coordinate their efforts throughout the surgery. In most circumstances, both surgeons should be present through the entire mastectomy and breast reconstruction procedure.

Q: Will I have a drain in my breast after surgery?

A: Yes. Patients require drains to remove the serum (body fluid) that is produced at a surgery site. If a drain is not used with a mastectomy, then a seroma (accumulation of serum fluid) will occur under the breast skin and underarm area which could lead to infection.

Q: Will I be asleep during the operation?

A: Yes. Patients undergoing a mastectomy with breast reconstruction require a general anesthetic. If a subsequent reconstructive stage is needed, this (less extensive) procedure can typically be performed under a local anesthetic on an outpatient basis.

Recovery

Q: How much pain will I be in after surgery?

A: Following breast reconstruction, patients vary a great deal in their perception of pain. Generally speaking, the more fearful or anxious a patient is, the more she will perceive pain in comparison to patients who are less anxious. Regardless of their pain threshold, patients typically require pain medication for two to three days after surgery. During that period of time, the amount of pain medication is varied depending upon the specific needs of the patient.

Q: Will the movement of my arm be restricted after surgery?

A: For one week after surgery, the patient is asked to keep her arm to her side to protect the incision on the reconstructed breast. Following the first week, the patient is instructed to slowly move her arm and shoulder in a progressive fashion. Patients should have a complete range of motion after their surgery.

Q: When can I resume exercise?

A: Patients can start exercising one month after surgery.

Q: How soon can I fly on a plane or travel or take a vacation?

A: Patients can typically fly on an airplane or travel one month after their surgery.

Q: Will I ever be able to play golf or tennis again?

A: Patients should not be restricted in their ability to play golf or tennis... any more than before their surgery.

Q: Can I drive myself home? If not, when can I drive?

A: As a rule, patients should not drive themselves home after any surgical procedure. Most patients will be able to drive a car two weeks after their surgery.

Q: How long will I need someone at home to help me?

A: It is our recommendation that patients be helped at home for a two-week period of time. For mothers with small children, a one-month period is recommended.

Q: Will I need physical therapy?

A: Most patients will not require physical therapy to improve the movement of their upper arm. Patients are instructed on self exercises during their recuperation period at home.

Q: Can I lift objects? If not, for how long?

A: Patients are restricted from lifting heavy objects for one month after surgery. After that period of time, there is no restriction.

Q: Will I wear a special bra?

A: Patients will be provided with a soft supportive bra after surgery that they will wear for one month. After the first month, patients can wear the bra of their own choosing. The bra can have an underwire support if they desire.

Q: When do the stitches come out or do they dissolve on their own?

A: Patients will have a few skin sutures removed one week after their surgery. The rest of the sutures are under the skin and will dissolve on their own.

Q: How long will I be swollen?

A: Most patients will be swollen for one month after surgery.

Q: Will I bruise a lot?

A: Every patient varies as to the amount of bruising they will have after surgery. Bruising can be reduced significantly by avoiding aspirin and ibuprofen because they act as blood thinners which will result in more bruising with surgery.

Q: When can I return to work?

A: Most patients will return to work within six weeks after surgery.

Q: How long will it take to heal?

A: There is an initial healing period of one month in which the incision and the tissues under the incision are healing. After this initial period, the tissues will soften and the amount of scarring will diminish. This softening or scar maturation period will take between six and twelve months before the permanent result has been reached.

Q: I take vitamins and herbs; can I continue taking them?

A: Patients who take moderate amounts of herbs and vitamins should not be adversely affected. Patients who take excessive amounts of vitamin C and vitamin E may bleed excessively as these vitamins thin the blood in higher concentrations.

Q: Should I apply any special cream (like vitamin E) for better healing?

A: It is doubtful that any crème will significantly alter the surgical scar. It should be mentioned that nearly all scars will improve with time, regardless of any crème that is applied.

Results

Q: If you transplant some tissue from another part of my body, couldn't it get cancer too?

A: Yes and no. Recurrent cancer is certainly a possibility if flap tissue is used to reconstruct a deformity after lumpectomy with radiation. In this circumstance, the remaining breast tissue will be the source of the recurrent breast cancer that grows into the transferred flap tissue. With the Peg Procedures, the remaining breast tissue is removed with a mastectomy. For this reason, it is predicted that long term local recurrence rates will be lower.

Q: How much scarring should I expect?

A: Every patient will vary in the amount of scarring that may occur for a given procedure. Preexisting conditions such as radiation therapy will significantly increase the amount of scarring that a patient will experience. Regardless of the individual variation, the Peg Procedures will camouflage visible scarring by confining the mastectomy and breast reconstruction incisions within the border of the areola.

Q: Will my breast be numb after surgery?

A: Mastectomy essentially involves the removal of all breast tissue. The surgical removal of the breast tissue temporarily interrupts the sensation to the breast. To a lesser degree, the removal of the axillary lymph nodes will temporarily interrupt sensation to the inner parts of the upper arm. The numbness that patients experience will diminish over a six to 12-month period of time. Most sensation of the breast and upper arm will return in the majority of patients.

Q: Will my breast look and feel natural after surgery?

A: The Peg Procedure combines a skin preservation mastectomy with a Peg Flap that further limits scarring on the breast by confining the incisions to the reconstructed nipple. As a result, the appearance and feel of the breast should be more natural than with other surgical methods.

Q: If I exercise too much after I have the Peg Procedure, will the muscle tissue in my breast make it larger or firmer than the other breast?

A: No. Although the tissues in the breast may initially feel firmer, softening of the breast will occur after the surgical swelling is gone. For patients who have had an implant reconstruction, scarring around the implant may lead to a longer-term firmness. Scarring around the implant with breast firmness is much less frequent with the use of saline implants. An exception is patients previously treated with radiation who may experience severe firmness from radiation.

Q: Will I have a nipple?

A: Although the nipple is removed during a mastectomy, a recently developed procedure called the Bowtie Technique can reconstruct the nipple and areola without any additional scarring. For most patients, the natural contours of the breast and the nipple are recreated with this technique.

Q: Will I have any sensation in my new nipple?

A: Although it will not be at the same level as before, most patients will partially regain sensation to their reconstructed nipple.

Q: Will the new nipple have the same color as my own skin or will it be darker?

A: Initially, the reconstructed nipple and areola will have the same color of your skin because the Bowtie Technique uses the breast skin to make the nipple and areola. Six weeks later the new nipple will be pigmented to a color that is similar to the nipple on the opposite breast.

Q: After my surgery, are there any special instructions for when I have a mammogram?

A: There are no special instructions other than informing the radiologist that you have had a mastectomy and a breast reconstruction. For patients who have had an implant reconstruction with the Peg Procedure, you can inform the radiologist that the implant is behind the pectoral muscle.

Q: Do you have before and after pictures that I can look at?

A: Yes. It is important that patients are fully informed about the benefits and potential complications of any procedure. Photographs depicting the very best and the very worst results may be misleading to patients. Instead, patients should view photographs that depict results that are achieved in the majority of patients.

Q: May I speak with a woman like me, who has undergone the operation?