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Breast Reconstruction Surgery: Latissimus Dorsi Flap

Breast cancer unfortunately affects 1 in 8 women in this country. In some families carrying certain genes such as BRCA1 or 2 the risk can be as high as 80% during a woman’s lifetime.

Treatment for breast cancer often involves lumpectomy or mastectomy and adjuvant treatments such as chemotherapy and radiotherapy. While the main breast cancer treatment will be mostly coordinated by your breast surgeon, Dr Aggarwal will work with you and the breast surgeon to offer you the best reconstruction possible.

Breast reconstruction empowers a woman to restore their physical appearance, regain confidence, and remove the stigmata of this illness.

The aim of breast reconstruction is to:

Create a breast mound
Look great in clothes (even tight fitting dresses)
Achieve symmetry with the opposite breast (in cases of one-sided or unilateral reconstruction)
Avoid the use of a prostheses

At Mode we aim to go one step further and will try to make your reconstruction look good even without clothes however this can be difficult to achieve as scars from mastectomy surgery will usually be visible, and perfect symmetry of a reconstructed breast to a native breast can be very difficult to achieve.

Breast reconstruction with latissimus dorsi muscle flap and implants can be:

immediate (at the time of mastectomy) or delayed (after mastectomy and other treatment such as chemo and radiotherapy)
Usually involves the use of breast tissue expanders under the muscle at the first stage
A second stage to swap the tissue expander for permanent implant

Who Is Latissimus Dorsi and Implant Based Reconstruction good for?

The main reasons for having a latissimus dorsi flap in addition to a breast expander or implants (rather than expander or implant alone) include:
- You have had radiation:
  - implants and radiation generally don’t mix well. The rates of complications, requiring revision of reconstruction, are as high as 30-40% in this scenario.
  - This is because radiation causes collateral damage to the tissues increasing risks of
    - Device extrusion, and infection
    - Poor physical shape of the breast due to poor laxity and compliance of the breast soft tissues
    - Higher rate of capsular contracture (breast implants going hard)
  - You have poor quality soft tissues
  - You have previously failed implant only breast reconstruction

The main reasons for having a latissimus dorsi flap in addition to a breast expander or implants (rather than expander or implant alone) include:

You have had radiation:

implants and radiation generally don’t mix well. The rates of complications, requiring revision of reconstruction, are as high as 30-40% in this scenario.
This is because radiation causes collateral damage to the tissues increasing risks of
- Device extrusion, and infection
- Poor physical shape of the breast due to poor laxity and compliance of the breast soft tissues
- Higher rate of capsular contracture (breast implants going hard)
You have poor quality soft tissues
You have previously failed implant only breast reconstruction

Latissimus Dorsi Flap Breast Reconstruction can be an excellent choice for you if:

You desire to restore your physical appearance and regain your confidence and femininity
You wish to look great in your usual clothes
you don’t mind having surgery on the other breast to achieve symmetry (If having one sided breast reconstruction)
Lack donor tissue elsewhere in the body for complete own tissue ‘autologous’ reconstruction.

Who Is Latissimus Dorsi Flap and Implant Based Reconstruction NOT good for?

It may not be necessary to take the latissimus dorsi muscle if you have not had radiation. In this scenario it may be possible to use implants or expanders alone which is a much simpler procedure
It may not give you a good result if you are overweight or have a large, droopy opposite breast in which case a complete autologous (own tissue) reconstruction will be far better.
You have previously had an axillary dissection associated with your mastectomy surgery – it may be necessary to carefully examine you and perform some imaging to see if the blood supply to the latissimus dorsi muscle is still intact.

Dr Aggarwal is fellowship trained in the world’s best plastic surgery centres in both autologous (own tissue) and implant based reconstruction, and performs this surgery at a multitude of private hospitals across Sydney.

At MODE, Dr Aggarwal will guide you through the various breast reconstructive options, and help you select the one that is right for you.

Procedure Snapshot

Anaesthetic: GA by accredited anaesthetist
Time: 3 hours (for delayed reconstruction), 5 hours (for immediate reconstruction). If the opposite breast is also reconstructed additional time will be required.
Duration of stay: Requires inpatient stay with drains that can be for several days up to a week.
Hospital: Offered at all the hospitals where Dr Aggarwal works
Medicare/Health Fund Rebate: Yes, if you have appropriate level of insurance cover.
Recovery: Most people can do most simple things at the end of the first week. It is not unusual for breast and back drains to remain for 1-2 weeks and sometimes longer. Upper body exercise is disallowed for 6 weeks and strenuous exercise for 3 months. Avoid swimming in a pool or beach for 2 weeks, or till when drains are out (whichever is later).
Results: Usually good results can be achieved from latissimus dorsi and implant reconstruction. However a reconstructed breast is different to breast augmentation. The implant can be palpable, and the breast feels different compared to an opposite normal breast. Results also vary from patient to patient largely due to variation in anatomy, breast size and if the reconstruction is unilateral (one sided) or bilateral (both sides).

Latissimus Dorsi Muscle Flap Surgery

This is a large, flat, triangular muscle, covering the lower half of the back.
It rises up just below the shoulder blade to reach the upper arm where it attaches
The blood and nerve supply of the muscle comes from the armpit – these can be injured during a previous axillary dissection.
The action of this muscle is to move the arm back (called extension). While many muscles perform this same action, the latissimus dorsi is a particularly strong muscle for, and therefore well developed in, rock climbers and butterfly swimmers.
For most people loss of the muscle does not cause long term defects in arm function.

This can be performed at the time of mastectomy (Immediate reconstruction; where radiation was used for breast conserving surgery), or after all treatment has been completed (Delayed Reconstruction).

The decision of what type of mastectomy to perform is generally up to the breast surgeon
In Immediate reconstruction your mastectomy will be skin sparing (where the nipple is sacrificed, but the skin is spared) or occasionally nipple sparing (where skin and nipple of the breast is spared)
In delayed reconstruction you will generally have a standard mastectomy where the skin is closed resulting in a flat shape to the chest. Reconstruction is then carried out after treatment for breast cancer has been completed.

You are turned whilst asleep during the operation on to your side
A large incision is made on the back and some of the skin and fat, along with the underlying latissimus dorsi muscle is taken along with its blood supply.
- Smaller amount of skin and fat are needed if you are having immediate reconstruction as majority of the breast skin is likely to have been saved
- A larger amount of skin and fat are needed if you are having delayed reconstruction to replace the skin on the breast lost in the original surgery
The muscle with its overlying skin and fat are then transferred to the front of the chest via a tunnel high up in the armpit
The back is closed over 1-2 drains.
A tissue expander is then placed anteriorly and the muscle stitched over and around the tissue expander to provide complete coverage of the device. Another 1-2 drains may be placed in the breast at the front of the chest.

You will have 1-2 drains inserted in the breast that you have reconstructed, as well as 1-2 drains in the back from where the muscle was taken. These are inserted to collect the fluid that the body places in a site of injury and drains help reduce the chance of a fluid collection (seroma).
You will be kept in hospital for the first few days or week after surgery to help you recover and monitor the drain outputs. The drains will be removed as the output from them reduces.
You will be able to get the area wet when you are down to 1 or 2 drains and the sites have been waterproofed.
You will not be allowed to swim in a pool or beach for at least 2 weeks after surgery or until all drains are removed (whichever is later).
It is possible that you may go home with some drains still in place.
You will be given a script for antibiotics by Dr Aggarwal which you must continue until all drains are removed. You will also be given appropriate pain relief medications.
When you go home it is best to have someone look after you for the first few days as you recover.
While most sedentary activities can be resumed in the first week, you must lay low and not exert yourself. You will also not be allowed to do any heavy lifting or upper body exercises for the first 6 weeks.
Dr Aggarwal will see regularly after your discharge from hospital. Approximately 2 to 3 weeks after surgery he will start to put additional fluid in your expander. This will be continued two weekly until the final expansion is achieved.
We will book you for implant exachange approximately 3 months after your final volume is achieved.

Yes
You will require a day surgery procedure to change the breast tissue expander to the final implant
At the time of implant exchange scar revision, pocket adjustment, and fat grafting can also be performed.

Implants

Dr Aggarwal only use the highest quality implants from the leading manufacturers who back their implants with lifetime guarantees. At Mode Plastic Surgery we will never employ cut price or cheap implants that have not had the most rigorous testing or safety profile

Modern breast reconstruction uses current generation of silicone implants which have advanced significantly since being introduced decades ago. Unlike older generation implants, modern silicone implants are form stable/highly cohesive meaning that:
- They offer greater stability of breast shape
- If they rupture, the silicone retains its shape much like a ‘gummy bear’. It is therefore rare for even the breast to change its shape in the event of a rupture usually being detected on breast imaging.
- Modern silicone implants have a tough outer shell which has very low rupture rates.

There is much lower incidence of gel bleed/ silicone seepage

While implants come in both round and tear drop (anatomical) shapes we only utilise tear drop implants in breast reconstruction. This is because these implants are fuller at the bottom than the top resembling the shape of a native breast
Anatomical implants are always textured though the degree of texturing varies between different implant manufacturers.
- Macrotexturing: is a very coarse texture imparted to the device during manufacturing.
- Microtexturing: this is degree of texturing that is much finer than macrotexturing. We regularly use implants from Mentor which offer microtexturing.
- A disease called ALCL has been associated with textured implants – microtextured implants have a much lower rate of ALCL (see ALCL tab).

These are temporary devices that are textured, and are filled with saline.
They are often inserted in the initial stages of implant based breast reconstruction, slowly filled with saline, and subsequently exchanged to final implants at a second stage.
They have a metal port which can be injected into through the skin, to fill the device with more saline. This injection is not often felt by the patient as the mastectomy skin is often numb following mastectomy surgery. However as the saline fills the device and it expands, a feeling of tightness is felt across the chest.

Mentor is probably the biggest implant manufacturer in the world with the longest safety track record of any manufacturer.
At Mode Plastic surgery we routinely use Mentor implants for our reconstructive surgery patients.
The microtexturing of Mentor implants offers lower risk of ALCL than other manufacturers that employ macrotexturing to their devices.
Mentor implants come with a lifetime warranty.

Modern generation silicone implants are of very high quality but as with all foreign bodies they have a lifespan and must eventually be replaced.
Currently we state that the implants will last 10-15 years. However this does not mean that you will definitely need to sign up for surgery at the 10 year mark.
Dr Aggarwal will examine you every year following breast reconstruction surgery. This is to ensure there are no changes in the breast shape as well as integrity of the implant.
If there is any suspicion of implant integrity or the implants are over a decade it may be worthwhile obtaining imaging at that stage. If imaging detects a problem with the implants or there are other reasons for surgery (e.g. scar revision, etc) you will be offered surgery for exchange of implants.

Risks & Complications

An implant breast reconstruction is very different to having a breast augmentation and the risks of complications are generally higher than for breast augmentation.

Risks of anaesthetic – there are general risks of going under an anaesthetic such as a mild stress on the heart and lungs, risk of reaction to anaesthetic drugs and risk of blotting in the legs. These risks are generally low in patients who are otherwise fit and healthy.
Bleeding (2-3%) – any bleeding is controlled during surgery however unexpected bleeding can occur in the immediate postoperative period. If this occurs it will necessitate a return to theatre to control the bleeding.
Infection (5%) – this is extremely rare given the precautions taken to prevent contamination of implants (read the 14 point plan). However you are given antibiotics during induction (when you are going to sleep), as well as a course of oral antibiotics after your surgery to keep this risk to a minimum. Infection of breast expanders or implants can threaten the reconstruction and the final result.
Seroma (5-10%) – A mastectomy is a reasonable ‘injury’ to the body, to which the body responds by accumulating fluid. Similarly the back from where the muscle has been taken is also notorious for trying to collect fluid. Drains are inserted during surgery to remove the excess fluid that your body does not absorb. Drains are only removed when the fluid reduces. If a fluid collection develops after removal of drains it may need to be removed via a needle through the skin, and/or require a special test called an ultrasound if its hard to feel around the expander or implant. The fluid is removed as if it accumulates there is a risk of it getting infected.

Implant palpability and rippling – it may be possible to see or feel the implant or see/feel rippling. Implant palpability is much more common in breast reconstruction as there is no native breast to hide the implant.
Rupture – rupture rates of modern day silicone gel implants are very rare. If they do occur they are picked up incidentally on imaging as the form stable implants maintain their shape despite the rupture. However given implants are foreign bodies they will lose integrity over time and will eventually need to be replaced.
Rotation – this is an issue for anatomical (or tear drop) implants. To prevent this an exact size of pocket is created to match the size of an implant. Rotation more commonly occurs in the setting of a fluid collection (seroma).
Capsular Contracture – The body reacts to a foreign body such as a silicone implant by forming a layer called the capsule around it. In 5-8% of breast augmentation patients this capsule can become hard over time changing how the implant feels, and sometimes how it looks. It can also become painful in extreme cases. In breast reconstruction the rate of capsular contracture are as high as 20%, and much higher in the setting of radiation.
- Most of these cases occur in the first year after insertion of breast implants
- The treatment for capsular contracture involves removal of the implant, removal of the capsule and insertion of a new implant with care taken to prevent contamination. However in some patients who have had recurrent capsules the only solution is to permanently remove the implants, and perform alternative reconstruction (see autologous or own tissue reconstruction)
ALCL – see tab on ALCL

Mastectomy skin flap necrosis – removal of the breast tissue by the breast surgeon leaves behind the skin of the breast. Most of the blood supply to this skin is removed with the breast tissue, and therefore it is only nourished by blood vessels entering where the skin connects to the chest. If in parts the skin is very thin, it can lose its blood supply altogether and dies. This can cause device exposure and risk infection.
Partial or total flap loss (1-2%) – the latissimus dorsi muscle that is transferred from the back to the front stays alive via its blood supply high in the armpit. The blood supply can be interrupted via previous axillary dissection or during the process of transfer in which case part or all of the flap may not survive. This is very rare but if you have had a full axillary dissection, Dr Aggarwal will examine you carefully and may require you to have some imaging before your procedure to check the blood supply of the muscle.
Absence of skin (and nipple) sensation – this should be expected as normal as the removal of breast tissue takes with it the nerve supply to the overlying skin of the breast.
Animation deformity – this is movement of the implant with muscle activation. This occurs in all patients having implant based reconstruction as the implant is placed below the muscle and the skin of the breast adheres or scars to the pectoralis muscle. In lat dorsi reconstruction, activation of the lat dorsi muscle will be visible through the skin, and secondly the muscle causes movement of the implant.
- It is for this reason for the first 6 weeks upper body exercise will need to be avoided
- Extreme upper body work (such as heavy bench pressing) should probably be avoided to avoid long term implant malposition.
Atrophy of tissues – a foreign object like silicone pushing against the normal breast causes it to thin. In reconstruction this is already in the setting of thin mastectomy skin flaps. The bigger and heavier the implant the greater the degree to which this will occur. As the tissues thin implant visibility, palpability and rippling become more pronounced and the risk of implant malposition become higher.
Unusual breast shape – It takes time for the breast tissues, and the flap to heal, the tissues to relax and for the implant to settle due to gravity. This can take approximately 6 weeks to 3 months. Depending on the initial volume in the breast tissue expander, the breast will look deflated, and lumpy and bruised from the mastectomy skin flaps. This also takes a few weeks to settle.
Asymmetry
- Most women’s breasts are asymmetrical and therefore the mastectomy performed is also asymmetrical in bilateral reconstruction.
- In unilateral reconstruction it is very challenging to match an implant based reconstruction to a normal breast.
- While the aim is to achieve symmetry adjustments of the implant pocket may need to be made at secondary surgery, and a breast lift may need to be performed on the opposite breast
Hypertrophic or poor scars – You will have a long scar on the back in addition to those on the breast, however all scars slowly fade and become less obvious with time, though never disappear. How one’s body behaves to scarring is individual and largely genetic. Some types of skin are more prone to hypertrophic or keloid scarring, and some individuals and families are more prone to this. We will routinely advise you on how to improve the quality of scars over time. You should also discuss any history of abnormal scarring with Dr Aggarwal preoperatively.

ALCL

Breast implant-associated ALCL is a rare type of cancer.
It usually presents as a swelling of one breast due to accumulation of fluid (delayed seroma)
This occurs on average 7.5 years after the insertion of implants. However it can occur much sooner than this (as early as less than a year) and late as 27 years after the operation in Australian and New Zealand data.
Less commonly, breast implant-associated ALCL can take the form of a lump in the breast or a lump in the armpit.
Most cases of breast implant-associated ALCL are cured by removal of the implant and the capsule surrounding the implant.

The risk in the literature varies widely from 1/3,000,000 to 1/50,000.
However a recent study conducted in Australia (Wilkinson et al PRS 2017) documented the risk as
- Biocell or macrotextured implants (Allergan, Inamed, McGhan) = 1/3817. These implants are not used at Mode Plastic Surgery.
- Polyurethane implants (Silimed) = 1/7788. These implants are not used at Mode Plastic Surgery.
- Siltex or microtextured implants (Mentor) = 1/60,631. We commonly use these implants carrying the lowest risk of ALCL of all textured devices.

At this stage this is currently being investigated and new research is ongoing.
It is unlikely that the implants directly create the disease and there is good support for an infective theory – ie that minor contamination of the implant produces a ‘biofilm’ on the implant surface which then causes ongoing inflammation that reaches a critical point to cause the disease.
A study by Adams et al PRS 2017, demonstates that with defined steps to minimise bacterial contamination there were no documented cases of BIA-ALCL in even macrotextured implants.
At Mode Plastic Surgery, Dr Aggarwal employs the 14 point plan to prevent contamination of breast implants.

This is a plan developed in consensus by plastic surgeons across the globe but especially from Australia and USA to reduce bacterial contamination of implants thought to cause not only BIA-ALCL but also capsular contracture
This plan, employed by Dr Aggarwal in all his implant surgeries includes:

Use of antibiotics via a drip at the time of anaesthetic induction (when the patient goes off to sleep)
Avoid peri-areolar incisions (Dr Aggarwal favours the inframammary fold incision for this reason)
Use of nipple shields to prevent spillage of bacteria
Perform meticulous dissection of the breast implant pocket
Performing careful control of any bleeding
Avoiding dissection into the breast tissue (where bacteria live).
Using a dual plane pocket if required (Dr Aggarwal uses this routinely)
Cleaning the breast implant pocket with betadine or antibiotic irrigation solution
Minimising skin-implant contamination
Minimising the time of implant opening, reposition and replacement of implant
Changing surgical gloves prior to handling the implant. We also use clean or new instruments that were not used in the pocket dissection
We avoid using a drainage tube, where possible
Closing the wound in layers
Recommending our patients use antibiotic prophylaxis to cover subsequent dental or surgical procedures that produce bacteremia, and at Mode Plastic Surgery we provide lifelong follow-up

Given the rare occurrence of the disease, we do not recommend removal of breast implants.
Thousands of women have breast implants in Australia each year and have done so for many years without issue.
This disease affects a very small minority – it is therefore important to be aware of it, consider it before committing to surgery and knowing what to look for.

If you develop a late swelling of the breast following breast implant you should inform us immediately.
Dr Aggarwal will refer you for an ultrasound and at the same time a fluid sample will be collected which will be sent off for a special marker of the disease (CD30)
You will not be required to undergo special imaging unless the marker returns positive from the ultrasound guided aspiration.

Given the rarity of the disease, regularl screening is not yet recommended by the TGA
At Mode Plastic Surgery, we offer lifetime yearly checks of your implants and if, as with any procedure, you have any issues or concerns you should notify us to see Dr Aggarwal.

BIA-ALCL has occurred in women who have had breast implants for both cosmetic and reconstructive reasons
However currently there are no reports in Australia of BIA-ALCL occurring in women who have only ever had smooth implants.
At the time of preoperative consultation you should disucss this with Dr Aggarwal.

Most cases are cured by removal of the implant and capsule surrounding the implant.
If a patient was to develop BIA-ALCL on one side we would generally recommend removing the implants and capsules on both sides.
All cases are discussed in a multidisciplinary setting with involvement of a haematologist with experience in lymphoma. Occasionally chemotherapy or radiotherapy is needed – usually when there is a solid lump (not just fluid filled).
Over the last 10 years, three Australian women have died from breast implant-associated ALCL.

Procedure FAQs

It is advisable to obtain a referral for breast reconstruction as it is possible to claim a Medicare rebate of approximately $73 for the consultation if you have a referral
A Medicare/Health Fund rebate may apply to you depending on your level of cover, and having a referral allows you to claim this reducing out of pocket costs substantially.

You can see Dr Aggarwal at the main rooms in Gordon, and he also consults at Hornsby, Hunters Hill and Camperdown.
Please scroll to the bottom of the page to find out more information about these locations

At any of the hospitals where Dr Aggarwal works.

Stop smoking at least 2 weeks before surgery. The risk of mastectomy skin flap necrosis and wound healing problems increases significantly in patients who smoke.
Cease fish oil, and other supplements such as Ginkgo, Ginseng.
Please discuss with Dr Aggarwal if you are on blood thinning medications as to when you should stop and recommence those.

No but you are advised to wear a tight fitting crop top or sports bra for at least 6 weeks after the drains are removed.
You should not wear any bras with an underwire during this period

You should not do any exercise that raises your blood pressure for at least 72 hours after surgery to avoid the risk of an unexpected bleed
Heavy upper body exercise that activates the pectoralis major muscle should be avoided for 6 weeks
Extreme heavy duty upper body exercise such as very heavy bench pressing should perhaps be avoided permanently as this risks displacement of the implant from its ideal pocket location.
You should note that there will be some movement of the implants with exercise as they are commonly placed under the muscle

Dr Aggarwal will provide you with the necessary scripts for antibiotics and pain relief.
For the future you should remember that if you are ever having dental work or other invasive procedures to cover yourself with some oral antibiotics as there is a small risk of bacteria entering the bloodstream with such procedures that can reach the implant cavity.

Yes.
You will need a second stage surgery to exchange the breast tissue expander to permanent implant. At this surgery the opposite breast can also be lifted, and other minor things like scar revision can be undertaken.
Down the track you may elect to have nipple reconstruction on the side of your reconstructed breast.
Longer term, once you have implants, you will require surgery at some stage to exchange them. As they are foreign objects they have a lifespan of roughly 10-15 years.

Dr Aggarwal will offer to see you yearly and once implants are 10 years old it may be wise to image them to inspect whether there are any issues with their integrity.

It is safe to undertake air travel after having implants or expanders.
However we always encourage patients not to be away overseas shortly after having a procedure, so that we can closely follow your recovery and address any concerns that may arise.

You may swim in a pool or beach after 2 weeks or once all drains are out (whichever is longer)

It is best to not drive for the first 1-2 weeks after mastectomy and reconstruction.
If you had day surgery to swap the expanders for implants you should be able to drive after a couple of days of the procedure.

Yes
You should expect that mastectomy surgery will render the breast skin (and nipple if it is kept) insensate, meaning that it will be numb and stay like this forever.
Some parts of the mastectomy skin do recover sensation slowly over 12 months or longer but this is very individual, and unpredictable.

No, Since the breast tissue has been removed during mastectomy.

In bilateral reconstruction, general no.
A mastectomy is more than 95% successful in removing breast tissue.
Because no or minimal breast tissue is left behind there is usually no further imaging required for breast cancer screening.
However you should discuss ongoing surveillance with your breast surgeon who is likely to see you on an ongoing basis for clinical examination and monitoring.
For unilateral (one sided) reconstruction, you should participate in regular screening for the opposite native breast.

There is no association between breast cancer and implants.
Implants more recently have been associated with a rare lymphoma called ALCL. The risk is extremely low and we still consider implants to be very safe way of reconstructing the breast.
For more information read our section on ALCL.

Yes
Reconstruction can be achieved through transfer of your own tissue.
Read our section on autologous breast reconstruction to find out more.

Procedure Pricing

A quote for this procedure will be provided to you after a consultation with Dr. Aggarwal. You can also call or email our office for our current indicative pricing.
A Medicare item number usually applies to breast reconstruction surgery.
- You must confirm with your health fund that you are covered for the appropriate item numbers
- We cannot take responsibility for health funds rejecting claims for coverage of surgeon/anaesthetist or hospital fees.
The above fees include:
- Surgical fees
- Anaesthetist fees (including coverage for mastectomy part of the procedure)
- Hospital fees
- Cost of Mentor breast tissue expander and anatomical Mentor Implant
- Follow up
Please note that the above fees do not include
- Preoperative consultation fees
  - Fees for the breast surgeon for mastectomies
  - Future procedures such as nipple reconstruction, fat grafting, etc
Public patients
- It is possible to have your surgery through the public hospital
- For immediate reconstruction you will first need to see a breast surgeon at RPA or POW if you wish to have Dr Aggarwal participate in your care. We are happy to provide you some suggestions if you are unsure of who to see.
- Breast and plastic surgeons have limited public operating lists and will then coordinate a time for your surgery.
- You should note that under Medicare or as a no gap patient (if insured) there are no out of pocket costs under this system.
- In return for free health care, please note that:
  - You may get limited say as to when your procedure may be scheduled
  - May not have Dr Aggarwal oversee your care (as another plastic surgeon may provide cover if operating time cannot be coordinated)
  - Your reconstruction will be performed by a plastic surgery registrar (under the supervision of Dr Aggarwal)
  - Your follow up will be with the hospital in clinics with the registrars
  - There is waiting list of 12 months for delayed breast reconstruction
  - Your standard of care will still be very good
- Public patients coming to Dr Aggarwal’s private rooms are charged our normal initial and follow-up consult fees.

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