Ask the Doctor: Q&A

Q:
What is a safe cc (cubic centimeters) of fluid to fill breast tissue expanders every two weeks?
Danna

A:
Hi Danna, 
Thank you for reaching out.

The answer to your question depends on multiple factors. Usually there is a certain amount of fluid that needs to be added to an expander after surgery so that the skin is stretched enough to fit around the more permanent implant. Usually the fluid is added gradually until the goal is met. This may take multiple visits to the surgeon until enough is added. The amount added at each visit depends on what size expander was used and how much skin stretching is needed. The healing process is also important. If healing is slow, then less can be added safely. Finally, fluid is usually added until the patient feels tightness, not severe pain. The tightness goes away gradually and in a few days, more can be added and the process is repeated. We can usually expect 50-250ccs added – per visit – depending on the above-mentioned factors. 


I hope this answered your question. Please let me know if you need any additional information.


Thanks again, 

Dr. James Craigie

How to Stay Positive During the Winter Blues

Robert Frost once wrote, “You can’t get too much winter in the winter.” While its shorter days, colder temps and beautiful snow falls put a smile on the faces of some, others would disagree with the famed poet about winter. To them, the season makes them eat more, sleep more and generally feel down in the dumps. They can’t wait for it to be over and for spring to arrive.

If that sounds like you, you might be suffering from more than just cabin fever. Known by its more medical term, Seasonal Affective Disorder (SAD), it is categorized by the National Institutes of Mental Health as a medical condition that really does just last through the winter.

SAD is thought to be caused by the lack of sunlight from shorter days that lowers the serotonin or “feel good” hormones in your body and raises your melatonin levels, which causes you to feel more tired. According to Yale University’s Winter Depression Research Clinic, other symptoms of SAD include carb cravings, difficulty waking up in the morning, reduced work productivity, and withdrawal from social contacts. Those who live in northern and colder climates or who have a family history of depression may also be at a greater risk of suffering from SAD.

The good news is that there are treatments available to help turn the blues around, including daily physical activity, which raises your endorphins and counteracts the signs of depression. So if you can bundle up and get outside, do it, even if it’s just for 15 minutes a day.

Or you can bring the light inside. Sitting in front of a light box with 10,000 lux for 30 to 45 minutes in the morning mimics outside light and can reduce your SAD symptoms. You can also obtain a light box through your medical insurance plan or online, starting at $35. Unfortunately, light boxes might not work for everyone and counseling and anti-depression medications such as sertraline or bupropion might be necessary.

If your idea of dealing with winter blues is pulling the covers over your head and hiding from the world until the snow melts and spring thaws, think again. This is the best time to be more social and make plans with your friends and family, even if it’s just going for a walk together, going shopping or sharing a dinner and a movie.

Most importantly, having a positive outlook can help to reduce your symptoms. You can do this by keeping a gratitude journal or creating a vision board that provides a visual of your dreams and goals for the year. Having something to look forward to can help you to get through the winter blues.

The even better news about seasonal affective disorder is that once spring does start, your symptoms will typically start to wane and SAD patients begin to feel better.
The Center for Natural Breast Reconstruction believes in good health for everyone, regardless of the season. If you or someone you know is in need of breast reconstruction, contact them at NaturalBreastReconstruction.com or toll-free at 866-374-2627.

Ask the Doctor: Q&A

Q:
I had a bilateral mastectomy three years ago because of stage one ER positive breast cancer in the left breast and DCIS in the right. I chose to have a double mastectomy to avoid radiation. I hate my reconstruction! It feels unnatural and bulbous, and the breasts are too far apart. They are uncomfortable when I sleep because they are too big (they are gel inserts). I can’t feel anything on the front of either of my breasts. Can you help me?

Susan

A:

Hi Susan,


You are not alone. Many women have gel implant reconstructions that feel very unnatural. Fortunately, there is an excellent chance we can help you. 
We have reconstructed hundreds of women using only their own tissue (DIEP flaps or sGAP flaps), which leaves the most natural-feeling breast reconstruction currently possible. Fortunately, a prior history of unsatisfactory implant-based reconstructions doesn’t affect our ability to reconstruct your breasts using your own tissue.

In the unlikely event that you do not have adequate donor tissue for a fully natural reconstruction, there are other options available (such as placing the implants in front of the muscle), but we recommend using your own tissue if possible for the most natural, long-lasting result. 
I would be very happy to speak with you by phone, or see you for a consultation, if you would like. Please let us know how we may help.


Richard M. Kline, Jr., MD

Ask the Doctor: Flap Surgeries

natural breast reconstructionQuestion: 

I had a bilateral mastectomy last December after chemotherapy for stage 3 breast cancer in my right breast and lymph node removal. Expanders were inserted, and I had radiation treatment that ended in the spring. I am now ready to get rid of these expanders and have reconstructive surgery. I am confident I want an autologous tissue surgery. I am on my third plastic surgeon and I have concerns about going forward with this doctor since he has not shown me any pictures and does not talk about a “team” approach.

I was interested in the PAP flap surgery since I have large hips and thighs, but he has only talked about doing the DIEP flap surgery or implants. He has other plastic surgeries (not breast reconstruction) he specializes in at his practice. I have never considered going out-of-state for medical treatment, and my work schedule is a concern.

I just want to know your thoughts about my situation and if I should go forward with my current doctor. I have found your website to be a great source of information and encouragement. God bless you for all your doing to help!

Answer: 

Thanks for reaching out to us.

The PAP is our 3rd line flap (after DIEP and SGAP). It is ideal in some situations, and yours may well be one of them, but it does have a few potential downsides:

  1. In MOST people, the flaps are fairly small, typically 200-300 grams (but you may be an exception);
  2. The profunda artery perforator, while usually present, is occasionally absent or very small. The preoperative MRI angiogram will determine this; and
  3. If you have a donor site complication, such as dehiscence (ruptured wound along a surgical incision), it can be difficult to manage due to the location and motion in the area.

One good thing about the PAP in contrast to the TUG (which we do not use) is that it involves few if any lymph nodes, and thus the risk of lower extremity lymphedema is minimal. We usually recommend the DIEP if you have a good donor site, but many people do not. Our DIEP success rate (after around 1350 flaps) is 99.0 percent.

The SGAP, our next choice, is an extremely good flap, although the dissection is difficult, which is why it is not routinely performed in most places. This flap can be quite large, occasionally in excess of 1000 grams in certain individuals. We have completed about 270 of these flaps, most simultaneous bilateral, with a success rate of 94.8 percent. We firmly believe in the team approach, which was taught to us by Dr. Allen, and we would not have the results that we do without it.

At The Center for Natural Breast Reconstruction, we never do flaps without two equally competent microsurgeons present.

Thank you again for your inquiry. Please contact us if you need anything, and we would be happy to speak with you by phone, or see you in-person for a consultation at any time.

Richard M. Kline, Jr., MD, 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, S.C. 29464.

Seeing Friends and Family for the First Time Since Surgery

breast surgery visitorsThere is nothing like a support system to help you get through cancer diagnosis and
treatment. After you have surgery, your family members and friends will probably want
to stop by and visit. They may also want to cook for you, clean your home or just keep
you company as you recuperate.
While seeing friends and family can be a positive part of your recuperation, it can also
be overwhelming. You might not feel up to having company or you might feel self-
conscious about how you look. Here are some tips on how you should handle seeing
friends and family for the first time since surgery:
1. Talk About it Ahead of Time
If friends and family know when you are having surgery and want updates, use that time
to tell them what you expect about having visitors. For example, you—or the person
updating everyone for you—can say, “Mary is out of surgery and recuperating. If you’d
like to stop by and visit, please text or call us ahead of time so Mary can pick a time
when she’ll be up to enjoying your visit.”
2. Limit Time
Once you know when someone is going to stop by, it’s okay to limit how long they
spend with you. Visits can be fun, but they can be tiring. Let your friend or family
member know how much time you have to spend with them before you have to lay
down, change a dressing, etc. This is especially important for those who just drop by
without calling ahead of time. Feel free to say something like, “Thanks so much for
stopping by to see me. We can chat for a bit and then I’m going to lay down for a nap.”
3. Keep the Sick Away
You just had surgery and should be doing what you can to avoid getting sick. Let your
guests know that if they are germy or feeling under the weather in any capacity, they
should change their visit to another time. If they show up sick, it’s okay to tell them
you’re not feeling up to their visit and plan it for another time. For example, you can say,
“I’m excited to see you now that surgery is over, but it sounds like you’re getting a cold.
Can we reschedule your visit until you’re feeling better so I don’t catch it?”
4. Say No When You Need To
It’s okay to say no if you’re not up to having visitors on any particular day or only want
certain family members or friends to visit. This is your surgery recuperation and,
honestly, you have the right to handle it however you want. Simply say, “Thank you so
much for caring enough to visit, but I’m really not feeling up to guests right now. Can we
get together at another time?”
5. Don’t Let Feeling Self-conscious Get in the Way of Enjoying Visitors
Some women are self-conscious about having visitors, especially after surgery. While it
is normal to feel this way for a little while, think about who is visiting you and whether
they are worried more about how you look or how you feel. In most cases, your friend or
relative is there to see you and do what they can to help. They probably don’t care
about how you look, so it’s best to remind yourself why they are really there.
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.

Ask the Doctor: Phase 2 & 3 DIEP Procedure

diep flapQuestion: Hello! I’m currently seeking a surgeon for phase 2 DIEP. My plastic surgeon
here did a great job for phase 1, but doesn’t seem interested in correcting what I think is
a problem for phase 2. My breast size is currently a DD and I do not like the size. They
are heavy and my back hurts by the end of the day. I’m seeking a C cup. Also, my
abdomen is hard and bloated from underneath the breasts to just below my bellybutton.
This hardness makes it difficult to breathe. Is this something you have seen, and
something you could fix?

Answer: For one reason or another, we routinely work with patients who have had
phase 1 DIEP elsewhere, but end up coming to us for the “finishing” work. Of course,
we are delighted to help, no matter who has operated on you, and no matter what
condition you are in. Breast size certainly can be reduced; symmetry often can be
improved; and the donor site usually can be optimized. It is important to remember that
to obtain the optimal result, several procedures are commonly necessary. Typically,
each subsequent procedure decreases in length and complexity as the process
progresses. An average stage 2 scenario would include open revisions of the breast
mounds and donor site, and stage 3 would involve free-fat grafting to further refine the
shape of the breast mounds and lower body. While the initial flap transfer is obviously
the “big procedure,” we believe that the subsequent procedures are absolutely essential
to getting the results most patients to feel confident and pain-free.

Opening up the Conversation on Family Cancer History

natural breast reconstructionAt the doctor’s office, you are given pages upon pages of paperwork to fill out about
insurance information, medications and past illnesses and surgeries. When you get to
the family history page it can be a bit overwhelming or you might even draw a complete
blank. Did your Aunt Mabel have breast cancer? You vaguely remember your father
telling you something about your second cousin’s diagnosis, but you can’t remember,
and now some family members aren’t talking, so the facts are elusive.
It’s important to open up the conversation on family medical history with your family
regardless of how difficult it may be. Why? Whether Aunt Mabel or your second cousin
had breast cancer is important to determining your own risk and your children’s risks.
With this information, you can make decisions about your own health, breast cancer
prevention and potential treatment, if you are diagnosed.

Unfortunately, starting a conversation with family about medical history, and especially
one about cancer, can often be difficult. While some family members may open up,
others may consider this private information, or they might get upset talking about
cancer. Others might not even know their own history.
So how do you find out what you need to know?
1. Make a List
Your medical history should include information from at least three generations of family
members — grandparents, parents, uncles, aunts, siblings, cousins, children, nieces,
nephews and grandchildren. Make a list of who you need to approach.
2. Explain What You’re Doing
Contact each family member – whether in writing, by email or by phone – and explain
that you are trying to obtain family medical history. If they are still reluctant to talk about
everything, try to ask specific questions about breast cancer. Some information is better
than none.
3. Ask Pertinent Questions
You should have a list of questions that you need answered. A complete family medical
history includes the age of the relative and any diagnosis or, if you are asking about a
deceased relative, the age and cause of death.
4. Keep it Confidential
Assure your relatives that the information you are compiling will be kept confidential —
and then keep it confidential.
5. Use Additional Resources
If your relatives are deceased or difficult to talk to, there may be other resources you
can use, such as public records – marriage licenses or death certificates.

Once you have all the information compiled, make sure you give a copy to your doctors
and update it regularly. They are bound by law to keep the information confidential.
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.

Ask the Doctor – Bilateral Mastectomy

bilateral mastectomy

Q: I had a bilateral mastectomy on 12/11/2017 after chemotherapy for stage 3 breast cancer in my right breast with 10 lymph nodes removed. Expanders were inserted, and I had radiation treatment. I am now ready to get rid of these expanders and have reconstructive surgery. I am confident I want an autologous tissue surgery. I am on my 3rd plastic surgeon. I have concerns about going forward with my current surgeon since he has not shown me any pictures and does not talk about a “team” approach. I was interested in the PAP flap surgery since I have large hips and thighs, but he has only talked about doing the DIEP flap surgery or implants. He has other plastic surgeries (not breast reconstruction) that he specializes in his practice. I have never considered going out-of-state for medical treatment, and my work schedule is a concern. I want to know your thoughts about my situation and if I should go forward with my current surgeon. I have found your website to be a great source of information and encouragement. God bless you for all your doing to help!

A: The PAP is our 3rd line flap (after DIEP and SGAP). It is ideal in some situations, and yours may well be one of them, but it has a few potential downsides: 1) In MOST people, the flaps are fairly small, typically 200-300 grams (but you may be an exception); 2) The profunda artery perforator, while usually present, can be absent or very small. The preoperative MRI angiogram will determine this, however; and 3) If you have a donor site complication such as dehiscence, it’s difficult to manage due to the location and motion in area. One good thing about the PAP in contrast to the TUG (which we do not use) is that it involves few if any lymph nodes, and thus the risk of lower extremity lymphedema is minimal. We usually recommend the DIEP if you have a good donor site, but many people do not. Our DIEP success rate (after ~ 1350 flaps) is 99.0 percent. The SGAP—our next choice—is a good flap, although the dissection is difficult, which is why it is not performed in most places. This flap can be large, occasionally over 1000 grams in certain individuals. We have done about 270 of these flaps, most simultaneous bilateral, with a success rate of 94.8 percent. We firmly believe in the team approach, which was taught to us by Dr. Robert Allen— who was the pioneer of the DIEP, SIEA, and GAP flaps—and we would not have the amazing results we do without it. We never do flaps without two competent microsurgeons present. Thank you very much again for your inquiry. Please contact us if you need anything, and I would be happy to speak with you by phone, or see you in consultation.

Richard M. Kline, Jr., MD, East Cooper Plastic Surgery, The Center for Natural Breast Reconstruction, 843-849-8418, Fax: (843) 849-8419, 1300 Hospital Drive, Suite 120, Mount Pleasant, SC 29464.

I Tested BRCA Positive, Now What? 7 Things You Should Know

brca positive

If you have a family history of breast cancer and want to know if you’re at risk of getting it, too, a genetic test might provide the answers. A simple BRCA blood test can determine if there are changes in your genes, known as BRCA1 and BRCA2, which show you are at a higher risk of getting breast cancer. But what happens if your test results come back positive?

  1. A Positive Test Does Not Mean You Have Cancer: First, understand that a positive BRCA test result does not mean you already have breast cancer. Not everyone who is “BRCA positive” will get breast cancer down the road. There are many other factors that determine your ultimate breast cancer risk, including alcohol consumption, body weight, breast density, physical activity levels, age, and reproductive history, and this test result is just one. It is normal to worry about any positive test result, so the best thing to do is to inform yourself about what a positive BRCA test result means and what the next steps are if you test positive.
  2. A Positive Test Indicates You May Be at Risk: Statistics show a BRCA1 or BRCA2 gene mutation diagnosis means you have a 45 to 65 percent chance of getting with breast cancer by the time you turn 70. Remember, this doesn’t mean you will get cancer. It means you have a higher chance than someone else.
  3. A Positive Test May Alter Your Treatment: If you already have breast cancer, knowing you have a BRCA mutation may change your course of treatment as many breast cancers in women that are BRCA positive result in more aggressive tumors. Armed with this information, you should talk to your doctor about your current cancer treatment plan and determine what, if any, changes, should be made.
  4. You May Need Further Screening: If you have not been diagnosed, a BRCA positive test result should prompt you to create a screening plan with your doctor. You will probably have more breast screenings including mammograms, ultrasounds, and MRIs, starting at a younger age.
  5. Better Overall Health Improves Your Odds: Whether your test was positive or negative, taking steps to improve your health will reduce your risk of cancer. Eating right, not smoking, and avoiding the sun and other things that cause cancer help to improve your odds.
  6. You May Opt for Preventative Surgery: Depending on the genetic test results, your own health history and your current health, some women who are BRCA positive have undergone a preventative double mastectomy, which is the surgical removal of both breasts. It’s important to note that this reduces, but does not eliminate, your risk of developing breast cancer.
  7. You Need to Alert Your Family: Getting a positive BRCA test result naturally leads to concern about the breast cancer risk for children and other family members. Notify them of your positive results and talk to the genetic counselor about getting other family members tested.

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.

Ask the Doctor – DIEP Flap

diep flap

Q:  I am weeks out from a unilateral DIEP flap procedure on my right side. Regarding the tightness and cramping in the abdominal area, is there any type of stretching or massage that can be done to speed healing and/or alleviate discomfort? Also, when can I begin to use moisturizers for scar reduction, and what type would you recommend?

A:  Good afternoon, thank you for reaching out to us. Those are great questions! Who was the plastic surgeon who did your DIEP procedure? It might be best to reach out to your surgeon about these questions since every practice has different recommendations. We tell our patients to leave the abdominal incision alone – to let it heal on its own – so we often discourage patients from doing any serious stretching or massage until a few months after surgery. It is OK to try standing up a little straighter each day, but you never want to force it. The tightness and discomfort will resolve on its own over time with little intervention. As far as the scars go, a lot depends on whether your surgeon feels you would benefit from having the abdomen redone at a later stage to remove scar tissue, lower the incision or remove extra skin for an aesthetically pleasing result. If you have the incision reopened, there is no reason to worry about the scars now. If you do not intend to revise the abdominal incision, then we recommend waiting closer to at least 2-3 months post-op before using any scar products.

I hope this was helpful. Please let us know if we can answer additional questions for you and we wish you the best in your recovery. 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, S.C. 29464.