Gail’s Diep Flap and Apex Flap Journey

Diagnosed with Breast Cancer at Age 38

When I was 37 years old, I did a routine self-check and discovered a lump. Although I didn’t have a family history of breast cancer or genetic mutations, I got it checked immediately. Thankfully, it was initially diagnosed as benign.

While unfamiliar with Birad scores at the time, a worker mentioned I should return in 6 months as I was walking out the door.

Nine months later, I went back for a follow-up appointment (as I wasn’t worried about the breast). I was completely surprised when the radiologist came in to chat with me and recommended a biopsy of a suspicious area.

That area turned out to be an aggressive (high grade), early-stage, hormone-negative breast cancer. Due to its characteristics and my young age (38), the tumor board recommended a mastectomy.

Research Into Reconstruction Options

During the diagnosis process, I shared my situation with others. Everyone I spoke to offered the phone number of a woman who had experienced breast cancer. I called each one, learning about their experiences with reconstruction, including implants, using their tissue via TRAM or Latissimus flaps, and foregoing reconstruction altogether. This research solidified my desire to avoid implants and use my tissue.

Once diagnosed, my breast surgeon suggested a DIEP flap reconstruction, but expressed uncertainty about having enough tissue.

Finding the Right Surgeon and the Apex Flap

My local breast surgeon referred me to a plastic surgeon in Bend, Oregon. However, during our first meeting, he spent a significant amount of time pushing implants. When I reiterated my desire for a DIEP flap, he explained the lengthy surgery (14-15 hours), extended ICU stay (3 days) plus a few more days in a hospital room after that, and a difficult recovery period (using a walker for many weeks and feeling like I was hit by a bus). He also dodged my question about success rates, only offering the national average. Furthermore, he expressed concern about my ability to achieve my desired outcome (a solid B cup size) and the possibility of needing an implant if the flap failed (as he didn’t do alternative flaps like SGAP). Needless to say, I left that appointment feeling emotional, scared and discouraged, as he was the only surgeon in Oregon who could perform a DIEP flap within my time-frame.

My local plastic surgeon then ordered a CTA scan to examine my blood vessels for eligibility. After reviewing the results, he informed me that my anatomy necessitated using muscle tissue to harvest the blood vessels for the DIEP flap, a variation he called MS-2 DIEP. Online research yielded zero information about MS-2 DIEP, but I did find references to MS-TRAM flaps, which takes muscle and carries the risk of a permanent bulge and can impact core strength.

Concerned about this possibility, I contacted my local plastic surgeon to clarify if an MS-TRAM flap was planned. He confirmed this would be the procedure and told me it was impossible to not take muscle. Unconvinced that using muscle tissue was unavoidable, I joined online support groups to seek further information.

Through these online support groups, I discovered the APEX Flap, a technique that preserves muscle by severing the blood vessel behind the muscle and rerouting it. Unfortunately, at the time, I couldn’t find any surgeons offering this procedure in the Pacific Northwest (after many phone calls), forcing me to consider surgeons further away. Every surgeon in the PNW wanted to take muscle and use abdominal mesh.

Feeling defeated, I contacted my mentor assigned through Pink Lemonade. While I was lamenting my situation, she urged me to consider the Center for Restorative Breast Surgery in New Orleans, despite being out-of-network. Desperate for a solution, I contacted the Center and sent my imaging overnight. The initial contact, a nurse, made me feel instantly welcome and supported, like a warm hug over the phone. While I was hopeful, I knew I still needed to speak with a surgeon to avoid another disappointing outcome. Thankfully, the Center didn’t charge for a remote consultation, and I was scheduled to speak with Dr. Cabiling.

Dr. Cabiling was kind and understanding. He assured me that his experience and skillset allowed him to perform the Apex Flap based on my unique anatomy, eliminating the need for muscle removal, mesh, and minimizing the risk of a bulge. When I hung up the phone, tears of joy streamed down my face. I finally found the right place for me.

I settled up with billing (shout out to Cappy for holding my hand through the insurance process) and received a quick surgery date as I had active cancer and mastectomy was my treatment instead of radiation.

First Day at the Center for Restorative Breast Surgery

The pre-op appointments scheduled for the day before surgery solidified my choice. Walking into the Center for Restorative Breast Surgery’s waiting room was a transformative experience. Spa music filled the air, beautiful furniture adorned the space, and a sense of calm washed over me.

I met with a physical therapist, the anesthesia team, and my incredible surgical team: Dr. Ordoyne, the breast surgeon I instantly connected with, and Dr. Cabiling, the plastic surgeon, along with his PA, Kati. After a long day of being in surgery, Dr. Cabiling patiently explained the Apex Flap procedure, answered all my questions, and exuded a humble, kind, yet undeniably expert demeanor. Unlike other surgeons who boasted about their credentials, his impressive resume spoke for itself. My husband, who accompanied me, immediately felt confident about our decision to travel for this surgery.

Dr. Cabiling marked the surgical incisions, and with a mix of excitement and nervousness, I knew a life-changing surgery awaited me the next morning.

Diep Flap Surgery Experience at CRBS/St. Charles Surgical Hospital in New Orleans

Early in the morning of September 2023, I arrived at St. Charles Surgical Hospital. Dr. Cabiling stopped by to answer any last-minute questions before surgery. The surgery itself lasted 6.5 hours, significantly shorter than the 14-15 hours estimated by my local surgeon. Dr. Cabiling, along with Dr. Ordoyne and assisting surgeons, worked together seamlessly to perform a double mastectomy, immediate DIEP flap reconstruction, and the Apex Flap technique on my left abdomen.

Remarkably, they even took a picture mid-surgery to show me later that my abdominal rectus muscle remained intact and no mesh was used. Throughout the surgery, text updates were sent to my husband, keeping him informed of my progress. As an added bonus, they even repaired my diastasis recti (a separation of the abdominal muscles that occurred during pregnancy). Thankfully, I experienced no surgical complications and transitioned smoothly to recovery.

I spent my recovery at their amazing 37-bed hospital dedicated to women undergoing mastectomy and/or reconstruction (the only hospital of its kind). The care team was exceptional. Doppler monitors were used to track blood flow to the flap, and I received constant, attentive care in my own private hospital room, complete with a Murphy bed for added comfort of the caregiver.

The next day, the nurses encouraged me to walk three laps around the hospital floor, which I managed with the help of a little (and delicious) pudding bribe! They also provided pain management and taught me how to shower independently. After two nights, I was discharged from the hospital, equipped with all the medical supplies I’d need for recovery, filling an entire empty suitcase!

The First Week After DIEP Flap Surgery

Due to budget limitations, I opted to stay at the Hope Lodge after discharge. This free accommodation, generously funded by the American Cancer Society, provided a supportive environment during my recovery. There was even a room sponsored by the Center for Restorative Breast Surgery, offering comfortable furniture, puzzles, movies, and blankets – a true haven for healing.

While there, I met many other women recovering from various procedures, including DIEP Flap surgery and SGAP Flap (another option for athletic women, women needing a secondary donor site, or those with previous tummy tucks).

About five days post-op, I transitioned from Oxycodone to Advil and Tylenol, allowing for increased mobility and a straighter posture. A week after surgery, I had my first post-op appointment. Dr. Ordoyne reviewed my pathology results, and Dr. Cabiling and his PA, Kati, removed my breast drains and discussed post-operative care.

Flying Home After DIEP Flap and Double Mastectomy

The day after my post-op visit, I flew home with the help of a wheelchair at the airport. To prevent blood clots, I wore compression socks and used an Intermittent Pneumatic Compression Device (IPC) on my calves during the flight.

Thankfully, I experienced minimal discomfort and enjoyed reading and chatting with other passengers. During my layover, I managed to strip my drains (and record output) in a family restroom before continuing my journey home. The trip home went very smoothly.

Diep Flap/Apex Flap Recovery

Back home, I rented a lift chair for a month to aid sleeping on my back. Dr. Cabiling’s PA, Kati, contacted me weekly to address any questions or concerns. The Center assured me they were readily available (which they were), and I could send photos for remote consultations if needed. Thankfully, with the comprehensive supplies provided at discharge, I had everything I needed to manage my recovery at home.

The Center provided everything needed to remove the hip drains at home (about a week after my post-op appointment when the drains produced under 30 mL after 2 days). The removal process itself was painless! Every day, I looked at my incisions and my new flat belly (complete with a cute belly button!), overwhelmed with gratitude for finding a skilled surgeon who performed the Apex Flap and avoided the dreaded bulge (and retained my core muscle).

Unlike my initial surgeon who relied on CTA scans to determine DIEP flap eligibility, the Center uses them as a roadmap for surgery. Their flowchart helps determine the surgical approach based on individual patient anatomy and blood vessel location.

Looking back, I’m amazed at how smooth my recovery was. I was up and walking much sooner than anticipated, without the hunched posture my local surgeon predicted. Yes, there was numbness and tightness, but it was manageable.

Phase 2 DIEP Surgery

Three months after my initial DIEP surgery, I returned for Phase 2 surgery with Dr. Cabiling. While I was already 90% satisfied with my results, I desired some minor cosmetic refinements. During my pre-op appointment, I expected Dr. Cabiling to dictate the surgical plan. However, he surprised me by asking about my specific areas for improvement and actively listened to my desired outcomes before suggesting solutions.

The surgery involved extending my incision to redistribute unwanted upper flank and hip fat to my breasts, along with lowering my front incision for improved aesthetics. The procedure lasted approximately 3.5 hours. I stayed overnight at the hospital, then returned to the Hope Lodge before flying home 3 days post-op.

After taking some additional time off work, I gradually returned to my normal routine.

Now

When I look in the mirror today, I see a beautiful body. I absolutely love my results. It’s hard to believe the initial surgeon told me implants were my only option to preserve my abdominal rectus muscle and achieving a B cup size was unrealistic. Thanks to the Center for Restorative Breast Surgery’s expertise and the Apex Flap technique, I have achieved DD breasts using my own tissue, while preserving my abdominal muscle.

My first surgeon said I would only look “normal with clothes on,” but for me, feeling confident and beautiful without clothes is equally important. I am beyond grateful for my decision to travel for surgery. The Center for Restorative Breast Surgery not only restored my body but preserved my muscular integrity.

Conclusion

If you’re considering DIEP flap reconstruction, I highly recommend the Center for Restorative Breast Surgery. Their expertise, dedication, and commitment to achieving the best possible outcome for their patients are truly remarkable.