Dr. Funk writes about prepparing for the operation and the nipple delay that Angelina Jolie received:
The questions any patient needs to address at this stage include: (1) whether or not to preserve the nipples, (2) if so, whether or not to perform a "nipple delay" procedure, (3) where to place the incision, (4) whether or not to test sentinel nodes, (5) what kind of reconstruction will be done, (6) what supplements might enhance healing and recovery, and finally (7) where should we operate.
NIPPLE DELAY: The delay, performed 1-2 weeks prior to the actual mastectomies, uses the planned mastectomy incision and lifts half of the skin off of the breast surface. A small disc of the tissue directly behind the nipple and areola is also removed and analyzed by a pathologist. This is done to rule out the presence of any disease directly behind the nipples, which would make preserving them a dangerous proposition. Additionally, it recruits extra blood flow to the area, lessening the chances of nipple and skin loss due to insufficient blood supply after the mastectomy. Since starting this technique in 2008, my loss of skin and nipple after mastectomy has decreased to less than 2%. In Angelina's case, she judged it worth taking this extra step of caution.
INCISION: Incision locations must take into consideration a cancer location (if cancer is present), any prior incisions, breast size reduction (if desired), and the technical skill of the surgeon (smaller incisions make for a harder and longer operation). For Angelina, her optimal incision choices were around the areola, or underneath the breast in the inframammary fold – the latter was chosen.
Dr. Funk also details the options for reconstruction, including what type of implants Jolie choose.
RECONSTRUCTION: Reconstruction options vary depending on a number of factors. The two broad categories of reconstruction include implants and flaps. Implants are the most common reconstruction, often requiring two stages, whereby a tissue expander is placed prior to the final implant. A tissue expander is a deflated implant that goes behind the pectoral muscles and gets slowly inflated with saline over a period of 2-3 months, until the chosen volume is reached. A second operation is performed to swap the expander for the final implant (usually silicone). A different implant option can be a "one-step" operation, where the final implant is placed at the time of mastectomy, skipping the expander phase.
Two improvements which I believe can enhance the final outcome for those patients choosing implants include: (1) the newly FDA-approved anatomic implants, which are teardrop shaped, and (2) allograft, or synthetic sheets of material, that create a more natural look.
Autologous flaps use your own skin, fat and sometimes muscle from the abdomen, back (latissimus), thigh (gracilis), or buttock to create a potentially more natural breast reconstruction than implants can achieve. Flaps, however, create scars at the donor site, potential weakness in the donor area, and involve a longer operation than implants, with longer recovery periods and associated hospital stays.
Angelina's body type was best suited to an implant reconstruction with allograft. Although tissue expanders required an additional operation, she preferred to use them. Expanders maximize blood flow to the breast skin and nipple (because they are not fully expanded right after placement, they do not compress the tiny blood vessels in the skin), and they allow us to optimize the final implant size, location and appearance.
Dr. Funk writes that Brad Pitt was there to greet Jolie when she was done with each each of the operations.
On February 2, 2013, Angelina was in the operating room for the first operation, the nipple delay. Her partner was on hand to greet her as soon as she came around from the anesthetic, as he was during each of the operations.