Q&A: Ask the Doctor

Q: How is natural breast reconstruction done and what is the cost? Also, how long is the recovery period? 

A: Thanks for your question, my name is Audrey and I am one of the Physician’s Assistants with the Center for Natural Breast Reconstruction. I will try to give you some basic information and please email or call if you have more.

  • There are three common options for natural reconstruction—DIEP, PAP and GAP:
    DIEP stands for Deep Inferior Epigastric Perforator, and the tissue comes from your abdomen, like a tummy tuck. We never take muscle—only the fat and skin—and then we close up the abdomen similar to the closure for a tummy tuck. The tissue is detached from your body and then placed in the breast pockets. The blood supply to this flap is traced out and dissected, and then the tissue is transplanted into the breast skin envelope. To keep the flap viable, microsurgery is performed to restore its blood supply by attaching its blood vessels to recipient blood vessels in the chest. This flap requires specialized operating room equipment and postoperative personnel. Some skin on the flap is kept as a skin paddle to allow us to monitor the flap’s color, temperature and vessel signals. That skin paddle may be removed at a subsequent stage of surgery in certain patient situations. DIEP is the most commonly performed free flap reconstruction and has the highest success rate.
  • PAP stands for Profunda Artery Perforator. The procedure is the same as above, but it uses tissue from the thighs instead of the abdomen. Often, it is taken from the back and/or inner thighs, and we typically take a small amount from each thigh to make either one or two breasts. The recovery takes a little more time since you would have two donor sites instead of one—but it is very achievable. The risks are the same as with DIEP as is the procedure of connecting the blood vessels through microsurgery.
  • GAP stands for Gluteal Artery Perforator, and the donor site is the buttocks. Depending on whether you need one breast or two, we take only fat and skin from each side of the buttocks to make into breast mounds using the same process as the DIEP. This also has the same risk, can have more than one donor site, and requires repositioning during surgery since we are working on each side of your body.

For each of these procedures, the surgery time is anywhere from 5 to 10 hours with an average of about 7 to 8—it depends primarily on whether you need mastectomies; whether you have had previous reconstruction procedures; and on your personal anatomy in terms of how difficult it is to find and connect your blood vessels. We keep patients in the hospital for three-four nights. Out-of-town patients are asked to stay in the Charleston area for a full week following surgery so we can check in on them, and hopefully remove breast drains, which prevent blood and lymphatic fluid from building up under the skin, before you head home. We provide a list of hotels that offer medical rates to help you control lodging costs. Patients have one drain per breast and then one drain at each donor site. Breast drains are removed within 6-7 days post-op and the donor site drains are in for 2-4 weeks, depending on the site. We require a special MRI called an MRA (magnetic resonance angiography) of the donor area before surgery to look for where your blood vessels are located. We request this be done at Imaging Specialists of Charleston as they have the right equipment and outstanding radiologists who use a specialized protocol to read the MRA and know exactly what to report to our surgeons.

If only a cancer-side mastectomy was completed, the other breast may also require augmentation, lifting, reduction or some combination thereof to establish symmetry.

Breast reconstruction is a staged process with a minimum of two surgeries, with each subsequent surgery getting smaller, and requiring less recovery time. The first stage requires three-four nights in the hospital, and subsequent surgeries typically require a one-night hospital stay. Second stages can be a minimum of three months after the previous surgery (often six months after if you have had radiation), or can be spread out further as needed to fit in with your schedule. The recovery is about six-eight weeks, and requires you to keep your arms close to your sides, no heavy lifting and no high-impact activities. You will, however, be up and walking around and able to do most basic activities with some restrictions. Driving is not allowed for at least the first few weeks. Some patients can go back to work after six to eight weeks—maybe sooner—depending on the job they have.

As follow-up appointments go, within a week to 10 days after the first surgery, you are typically cleared to head home and need not see us again until right before your next surgery stage. If you have a local breast surgeon or plastic surgeon close to home, we recommend following up with them, and we do frequent telephone/email/patient portal outreach to check in. We are always happy to see you in the office if you wish to make the trip.
Our office also does expander/implant reconstruction, but it is harder for patients out-of-state because of the number and frequency of follow-up appointments needed in the first few weeks to months after surgery. If you are interested in hearing more about this option, please let me know.

I hope this information helps to answer your questions and give you a better idea of your natural breast reconstruction options. We are happy to continue answering questions via email or phone calls, and we would love to set up a consult for you to come meet us in the office at a time convenient for you. We often like to gather more health information before you make the trip to make sure that one of these options could work for you. That information includes:

  • Breast cancer details (which breast, when were you diagnosed, what type of cancer is it, do you need radiation?)
  • Mastectomy/reconstruction details (have you had lumpectomy, mastectomy, was it skin/nipple-sparing, did you have any reconstruction done already?)
  • Abdominal surgeries (have you had any major surgeries with large scars across your belly, do you have enough tissue to use?)
  • Medical history (any history of clotting disorders, DVT/PE blood clots, problems with anesthesia, diabetes, obesity, etc?)

Once you have a breast cancer diagnosis, insurance is supposed to cover the cost of breast reconstruction. We have no control over your personal deductibles or out-of-pocket maximums—everything is billed as reconstruction through your insurance. Using your own tissue for reconstruction is not a simple or low-cost procedure; however insurance typically makes it affordable. We are in-network with most major insurers and can usually negotiate a one-time contract with those we are not.

If you want to provide your insurance information, we’re happy to investigate your benefits for you and assure your insurance will cover any procedure you choose. Our office manager, Gail, could give you detailed information about the costs and once we have more information from you.

Please call us or email any questions you have with information/details from above. We look forward to speaking with you soon. Thanks and have a great day!

Audrey Rowen, PA-C
East Cooper Plastic Surgery
The Center for Natural Breast Reconstruction,
Phone: (843) 849-8418
Fax: (843) 849-8419

1300 Hospital Drive, Suite 120
Mount Pleasant, SC 29464

New Technology Can Help Restore Sensation After Mastectomy

According to the most recent statistics from American Cancer Society, 1 in 8 women will develop breast cancer during her lifetime. For many of these women, a mastectomy – which is the removal of most or all of the breast tissue – will be one of their primary, life-saving methods of treatment. A mastectomy, however, comes with various side effects, including loss of sensation to the breasts.

Tingling, numbness and loss of sensation to the breast area, and under the arm from the removal of lymph nodes, is one of the most unwanted side effects. This happens because the procedure severs nerves that provide sensation to the breasts, and the numbness often remains even after breast reconstruction is complete.

Regenerating Nerve Tissue
One Florida-based company dedicated to peripheral nerve repair is changing this life-altering outcome. AxoGen has taken steps to address this numbness, once thought to be a permanent side effect, with a new technology called ReSensation. They use allograft nerve tissue, or donated human peripheral nerve tissue, to regenerate feeling to the breasts.

The Way It Works
ReSensation sounds complex, but it isn’t. The breast surgeon takes donated nerve tissue and attaches it to a patient’s remaining nerve tissue in the affected area. Over time, that donated nerve becomes part of the patient’s body and helps to regenerate nerve-endings in that area. 

“With this new surgical method, we are not only able to provide patients with a more natural-looking breast, but the possibility that the breast will feel more natural to them as well,” says James E. Craigie, M.D., with The Center for Natural Breast Reconstruction. “ReSensation is an exciting development in care that we hope will help bring our patients that much closer to feeling like themselves during and after treatment.” 

Patients interested in ReSensation face few limitations, and the procedure is performed during breast reconstruction. Breast implants pose one limitation in that they are artificial and do not contain nerves, therefore this procedure does not pertain to patients undergoing breast reconstruction via implants. ReSensation is best used for patient’s who choose to reconstruct the breasts using their own tissue.

Once the ReSensation procedure and breast reconstruction is complete, patients can feel confident that they took all steps possible to hopefully restore their breast sensation and therefore achieve an even more natural result. 

What Should You Do Next?
If you are a breast cancer or mastectomy patient, the next step should be to talk to your breast and plastic surgeon about reconstruction options. If you haven’t had a mastectomy yet, your breast surgeon can tell you what you should expect with surgery and recovery from the mastectomy. Your plastic surgeon can also determine if the ReSensation technology is right for you. Keep in mind that the answer is different for everyone. Your current medical conditions and breast cancer treatment plan help determine the final decision.

“We’re excited to offer this cutting-edge procedure to our patients and are committed to offering the women the best care possible,” continued Dr. Craigie. “It is our goal to make sure every patient understands her options for reconstruction and provide access to pioneering surgical treatments that could help improve her quality of life.” 

Is ReSensation right for you? Visit NaturalBreastReconstruction.com to learn more, or call toll-free at (866) 374-2627.

Q&A – Ask the Doctor

Q:  
I have an implant from reconstruction 7 years ago. I do not have breast symmetry as the other breast was a TRAM flap reconstruction. I would, however, like to have symmetry – how can this be achieved?

A:
Great question! You have several options to improve breast symmetry. We could simply “fat graft” the TRAM flap reconstruction to improve the size and enhance the shape of the breast mound. In fat grafting, fatty tissue is removed from other parts of your body – usually your thighs, belly and buttocks – by liposuction. The tissue is then processed into liquid and injected into the breast area to recreate/enhance the breast. This technique is especially helpful when trying to improve the symmetry between an implant reconstruction and autologous reconstruction.

If your implant is currently under the muscle, this can be revised. The implant can be re-placed in front of the muscle with a full ADM (Acellular Dermal Matrix, specially preserved cadaver skin – AlloDerm® is most commonly used brand) wrap. This allows much better control of implant position, and often helps create better projection and shape. The main complication is that you can sometimes see more rippling of the skin than you typically do with an under-the-muscle implant, but not necessarily. It is also possible that simply revising your current implant reconstruction could produce improvement, but we have less control with that method. 

Finally, it may be possible to have the implant replaced with your own tissue. You might consider using another area of the body, such as the buttock or thigh, to replace the implant completely. One option would be the SGAP (Superior Gluteal Artery Perforator). Breast reconstruction with the GAP flap involves moving a segment of skin and fat from the buttock to recreate a breast mound shape after the removal of the breast tissue (i.e., mastectomy defect). This involves the disconnection of the tissues from the gluteal muscles and surrounding gluteal tissue. (We DO NOT take the muscle.) The tissue is then transplanted into the breast skin envelope. To keep the flap alive, its blood supply must be restored by microsurgery, a procedure that attaches its blood vessels to recipient blood vessels in the chest. 

I hope this information helps. Please let me know if you have any further questions. 
 
Lindsey Weaver, FNP-C
East Cooper Plastic Surgery

The Center for Natural Breast Reconstruction

Phone: (843) 849-8418

Fax: (843) 849-8419

In Her Words – CP

natural breast reconstruction
I had a bilateral mastectomy with Superior Gluteal Artery Perforator (SGAP) reconstruction done two and a half years ago. It was all done at the same time. Dr. Kline was my primary and his partner, Dr. Craigie, assisted. They did all the stages [of my reconstruction] and I am very happy with the results. Dr. Kline is an absolute perfectionist as anyone can attest. I had previously had radiation treatment but you would never know it.
FYI, when they do the nipple reconstruction, they will ask you what you want, so in that regard a picture would be helpful for color, amount of projection and so on. Their office staff is incredible – friendly and very helpful. The care is phenomenal. I would be happy to share my experiences and answer any questions; just ask one of the office staff and they will pass your number to me to call at your convenience.
– C.P., Mt. Pleasant, S.C

Flap Procedures for Natural Breast Reconstruction: Understanding Your Options

gap flapWhen a woman is diagnosed with breast cancer, she will be faced with many decisions including “Do I want breast reconstruction?” and if so, “What kind of reconstruction is best for me?” With numerous options available, it is important to evaluate each choice and decide which is best for each woman individually.

Breast reconstruction using the patient’s own tissue, also known as autologous tissue reconstruction, is becoming more and more popular for many reasons. Here, we’ll discuss two options in more detail – the deep inferior epigastric (DIEP) flap and the (gluteal artery perforator) GAP flap.

What is the DIEP Flap?

The DIEP flap procedure reconstructs the breasts using tissue from the patient’s abdomen. The tissue consists of mostly skin and fat and never includes the muscle.

What Is the GAP Flap?

The GAP flap reconstructs the breasts using tissue from the patient’s buttocks. The tissue consists of mostly skin and fat as well and never includes the muscle.

What Are the Benefits of Each One?

Women who are considering natural reconstruction often choose one of these two flap procedures according to what benefits her individual needs. The DIEP flap is popular with many patients because of its potential to provide “tummy tuck” results – a flatter appearance to the lower belly. Meanwhile, patients who elect the GAP flap might prefer the benefit of removing tissue from the buttock area instead. In either case, muscles are spared, reducing recovery time. It is important to note that both procedures can be used for unilateral cases (only one breast needing reconstruction) or bilateral cases (both breasts needing reconstruction).

What Results Should a Patient Expect?

With both the DIEP and GAP flap procedures, the result is a breast reconstructed from the patient’s own bodily tissue. For this reason, patients are often more satisfied with a natural reconstruction than with implant reconstruction. However, the recovery time can be longer than with implant reconstruction and scars on both the breast and donor site are to be expected.

How Should a Patient Choose One Procedure or the Other?

A patient should first decide if natural reconstruction surgery is a viable option for her. Some women are not ideal candidates due to vascular (blood vessel) issues, as healthy blood vessels are necessary for the flap procedure to succeed. Once the patient decides on natural reconstruction, choosing reconstruction via the DIEP or GAP procedure depends on the health of the “donor site” from where the tissue is removed.

No woman should have to choose the best procedure for her alone – it should be an ongoing discussion with her medical professionals. At the Center for Natural Breast Reconstruction, these and other issues are addressed in person within a compassionate and professional environment.

Want to know more? Call toll-free at (866) 374-2627 or visit NaturalBreastReconstruction.com.

Considering Nipple Tattoos? 4 Things Patients Should Know

nipple tattoo

When a woman is diagnosed with breast cancer and begins the journey of considering which reconstruction option is best for her, the hope for a natural looking and feeling breast is normally at the top of her list. A mastectomy may involve removing all of the breast tissue, including the nipples. Thankfully there are now many ways to restore the natural appearance of the breasts following mastectomy and reconstruction. If the original nipples must be removed, many patients with breast cancer opt to have their nipples reconstructed using their own tissue and, as part of the reconstruction, decide to get nipple tattoos.
Curious about how a nipple tattoo works and whether it might be a good option for you? Here are five important things to know.
1. A Nipple Tattoo is the Final Stage of Breast Reconstruction
Nipple tattoos are a beautiful solution to create natural-looking nipples, and most women are candidates for the tattoos. Tattooing is usually done 3-4 months after a woman’s final in-hospital surgery. This is normally when the skin has healed enough from any reconstruction surgeries. If surgical scars aren’t completely healed and mature when the tattoo is created, there is risk of the tattoo becoming distorted over time.
2. The Nipple Tattoo Is Customized to Look Real
The inks used for nipple tattooing are mixed to create the most realistic appearance possible for each patient. The tattoo artist strives to create a shade that resembles the patient’s original nipple and complements her natural skin tone. This is one of the reasons it is important to have a tattoo artist perform the procedure – there is an art to making each nipple unique to each patient.
nipple tattoo3. The Best Tattoos are Done By a Tattoo Artist
Some patients have the option to have their tattoos done within a medical setting by a medical professional; however, there is a fine art to nipple tattooing. This makes finding a tattoo artist who specializes in nipple tattooing key to achieving the best, most realistic results.
Tattoo artist Shannon Purvis Barron, owner of Indigo Rose Tattoo in Columbia, S.C., has been giving breast-cancer survivors tattoos for years, and provides her services once a month in the offices of The Center for Natural Breast Reconstruction.
A lifelong artist, she shifted her focus in college from oil and canvas to ink and skin. She’s seen up close the toll breast cancer can take on women’s bodies and spirits, and believes feeling confident in their bodies is an integral part in the recovery process.
Barron, who will be in The Center for Natural Breast Reconstruction office on September 27, 2018, says she can’t even count the number of scars she has covered with flowers, tree branches and feathers, or botched nipple tattoos she has fixed.
4. The Nipple Will Look Real, Thanks to 3-D Techniques
The 3-D nipple tattoo is a work of art that looks like an authentic nipple. Shading, shadows and other artistic skills make the tattoos look just like real nipples, and helps patients feel confident in their breasts once again.
Women who are interested in learning more about nipple tattoos within a medical environment can contact The Center for Natural Breast Reconstruction at 1-866-374-2627 or online at NaturalBreastReconstruction.com. Call the office to request an appointment for nipple tattooing with Shannon Purvis Barron for our next available date, September 27, 2018.

Ask the Doctor

breast implants

Posted Question:

I had breast reconstruction with under-muscle implant in 2003. The implant was replaced in 2017 but the result has left me very uneven.

I feel that my prior surgeon didn’t take into account the proper shape and size of the breast to match the other breast. He simply measured across the breast, so I have an implant that lays beyond the center of the chest wall and is too flat. It doesn’t fill my bra cup so I have to wear a prosthesis. I trusted him and didn’t look for information about under muscle prosthesis.

Many women have asked my advice about implant procedures. I am extremely unhappy with this result but, at 68 years old, I will have to live with it for the rest of my life. I hate my result and want to be able to help others get more information in order to make sure their doctor is using proper forms/prostheses.

What can be done for a better result? Did I just make a mistake by not seeing multiple surgeons? He was my original surgeon and I was fine with the first implant. It became constricted so we did the replacement. Had I known I would have had this result, I would have just started wearing a prosthesis and skipped the misery of another surgery.

– Pat

 

Hi Pat,

I’m sorry to hear you are disappointed with your newest implant. I’m not sure I understand what was different from the previous implant. If the first was constricted and the second one was to replace the first after releasing the contracture, can you tell me what was done differently? If you liked the first one, I’m sure there is a chance to correct your problem. I think you should find out if the two implants are the same size and type. If the same surgeon did both surgeries, then he/she should have that information. If they don’t match, perhaps you need to replace the new implant with one that is a closer match to your first one.

Thanks for your question let me know if you have more information. 

-Dr. Craigie

Debunking 5 Misconceptions about Breast Reconstruction

“Breast cancer” are two of the scariest words for women. Adding to the pain and fear, options for breast reconstruction after a full or partial mastectomy or lumpectomy are fraught with myths and misinformation.

That’s why it’s important for women to separate the facts about breast reconstruction from the myths and mistruths, and make informed decisions that improve their health and self-image.

Here are five common misconceptions about breast reconstruction that need to be debunked.

  1. Breast Reconstruction Is Only for Complete Mastectomies

Breast reconstruction is not just for women who have had the mastectomy procedure. Because breast reconstruction has come a long way medically in recent years, more and more women are eligible, even if they have only had a lumpectomy. Of course, an individual’s health and history play a part as well, but options are more available than ever.

  1.  Breast Reconstruction Equals Artificial Implants

Good news for women who want to remain all-natural and still have reconstructed breasts: reconstruction methods nowadays offer the opportunity to obtain natural tissues from the woman’s own body, including her thigh, tummy or even rear end. Known as autologous breast reconstruction, these methods are constantly evolving through science and technology and, as a result, are becoming safer and more successful.

  1.  If I Have Chemotherapy or Radiation, I Am Not Eligible for Breast Reconstruction

Many women believe that if they opted to undergo radiation or chemotherapy as a form of breast cancer treatment (or if they plan to undergo such treatments in the future), it will render them ineligible for breast reconstruction. While it is true that certain treatments can mean limitations – again, this depends on the individual woman’s health and history – it does not mean reconstruction is impossible. Many times radiation will force a delay in reconstruction, but not prevent it altogether. This is a subject for each individual patient and her doctors to discuss.

  1.  After a Certain Age, Breast Reconstruction Is Not Possible

Even a woman who is diagnosed with breast cancer in the later years of life can still opt to seek breast reconstruction. While it is true that the body heals differently in our “golden years”, age should not be a factor when considering breast reconstruction, primarily because older women can still benefit from improved self-esteem following reconstruction. Federal law requires most insurance plans to cover breast reconstruction after mastectomy, irrespective of the age of the patient.

  1.  Breast Reconstruction Hinders Diagnosing the Return of Cancer

After successfully battling breast cancer, the idea of a recurrence is scary, but that fear should not deter women from seeking breast reconstruction. While it is true that certain factors can affect the risk of recurring cancer, breast reconstruction neither increases nor decreases the risk, according to the American Cancer Society.

To learn more about natural breast reconstruction and find out if it might be the right choice for you, contact The Center for Natural Breast Reconstruction at NaturalBreastReconstruction.com or toll-free at (866) 374-2627

Q & A

Posted Question:
I had a Latissimus dorsi double mastectomy reconstruction in 2013. I have since lost a lot of weight – about 50 pounds – and I now feel that my breasts are too big. I feel really self-conscious. Is it possible to have a reduction after this type of surgery?

Dr.’s Answer:
Yes, it is usually possible to do a reduction in some fashion. Latissimus flaps are commonly used with implants, and it’s possible your implants could just be downsized. Alternatively, it may be better or necessary to remove some flap tissue as well. It would be difficult to make more specific recommendations without doing an actual exam and getting a few more details, but I’m willing to bet you have some good options.

In Her Words

I had my Stage 1 DIEP in Charleston with Drs. Kline and Craigie on May 25, 2018. On a scale of 1-10, I would rate my experience a 12! Before I go into more detail about my Charleston experience though, let me go back in time a little bit. I had my first unilateral mastectomy in 1998 (right side) with a reduction on the left side and immediate expanders.

A while later, I had the exchange for the permanent implants. This was all done in Atlanta, Georgia. The process was painful and inconvenient, took more than a year and was a complete flop. My right breast was half the size of the left, terribly scarred and deformed. The left breast was oddly shaped and had a very bad, fat scar underneath, and was hard.

The consequences of my low self-esteem led to intimacy problems with my husband, which resulted in divorce. Several attempts by different plastic surgeons only made the appearance of my breasts worse. The emotional consequences became compounded. In short, I felt like a freak. Dating was a concept I couldn’t even fathom – I was so self-conscious about my looks.

One day, 13 years after my first botched surgery, I saw a program on TV that discussed new procedures for reconstruction surgery after mastectomy. I immediately went online to research the DIEP procedure and decided to look into the facilities in Charleston. I was certain that Charleston was the right fit for me. Drs. Kline and Craigie are artists, and their highly trained staff made each and every step of the procedure flawless. Their attention to detail made me feel secure before, during and after. I’m about four months out from Stage 1 now. In those short months, my life has been transformed.

I haven’t had my stage 2 yet – that comes next month – but already I’m walking around with my head up and my shoulders back! My breasts look great. They are soft and warm, and it’s great to have those implants out. I would also like to add, if you are a single woman contemplating a location for reconstructive surgery, I highly recommend Charleston. The entire staff has a special sensitivity for those of us flying solo now.

–B.L., Thomasville, GA