Ask the Doctor – I Was In An Accident And Now Have a Painful Knot On My Reconstructed Right Breast. Should I Be Worried About Long Term Damage?

This week, Richard M. Kline, Jr., MD, of The Center for Natural Breast Reconstruction answers your question about breast reconstruction.

Question: I had reconstruction about 6 years ago after a double mastectomy. I had several surgeries for revisions. I had an SGAP on my right and stacked DIEP on left. Everything was fine until a month and a half ago when I was hit by a driver who ran a stop sign and t-boned me. My car was totalled. I had an impact on my right breast from the steering wheel and the airbags. For the past two months, I have had a large knot on my right breast. This is the SGAP one. It is painful and the knot is the same size. Could there be long-term damage to the reconstructed breast from the accident?

Answer:  If you are still having problems, you should see a plastic surgeon, and likely he or she will order some type of imaging (CT scan or MRI) to assess the situation. It is certainly possible that the flap could be damaged, or even other structures, such as your pectoralis muscle. While it might or might not be possible to do anything to improve any damage, I do recommend that you see someone to have it investigated.

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Ask The Doctor – I Recently Received Concerning Results on a Mammogram. Should I Wait the Recommended 6 Months to Discuss Implant Removal or Begin the Process Now?

pink rose

This week, Richard M. Kline, Jr., MD, of The Center for Natural Breast Reconstruction answers your question about breast reconstruction.

Question: I am a 61-year-old female with breast implants that were placed in 1986. I have been pregnant 6 times, 5 c-sections and one miscarriage. 2 infant deaths and 3 living children. I was able to breastfeed 4 of my children. Approximately 4-5 years ago I had an abnormal mammogram.  (I am in the process of obtaining those records) I underwent an ultrasound to the left breast and was informed that everything was “ok”. Following mammogram was normal. I retired from nursing 2 years ago and moved from Virginia to West Virginia. My most recent mammogram 5/2/2018 stated “There are bilateral breast implants. There is mild to moderate residual parenchyma tissue bilaterally. There is an asymmetric parenchyma nodule in each breast anteriorly, most likely benign. Six month bilateral mammogram advised to confirm stability.” Doctor, I’m not sure I should wait another six months or peruse implant removal and breast tissue removal. You know us nurses “overthink”. I’d like to know if you have another suggestion vs wait for the next mammogram. Thank you so much for you’re valuable time and consideration.

Answer:

Thank you so much for your question. It sounds like you are getting frustrated, and it’s easy to see why.

We don’t actually treat breast cancer per se, we just do reconstruction, so I can’t actually recommend a particular imaging technique or schedule. I can, however, recommend that you see a surgical oncologist who treats breast diseases (if you haven’t already), as they often have a good “feel” from experience for how to manage these type situations. They see many, many images, and, unlike radiologists, later correlate many of those images with what they see in surgery, which gives them a unique perspective. He or she may recommend an MRI or ultrasound, or may just agree with your previous recommendations, but even that might be reassuring.

Thanks again for your question, and have a great weekend!

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Ask the Doctor – What Can Be Done To Fix a Previous Radiated Breast with Implant?

This week, James E. Craigie, MD, of The Center for Natural Breast Reconstruction answers your question.

Question: What can be done for a 2004 radiated breast with implant. As common, it has encapsulated to a high degree and is painful, misshaped and raised, looking very unnatural. Thank you

Answer:  Without question, the course of action most likely to work is to remove the implant and proceed with reconstruction using your own tissue. If you still have breast tissue remaining, it can be removed by a breast surgeon at the same time that your healthy tissue is transferred.

The most common source for the new tissue (the “flap”) is the abdomen, which is usually harvested as a DIEP flap. If the abdomen is not available or not adequate, then the buttocks (“sGAP flap”) can often be used. Our success rates over the last 13 years are 99.07% using the DIEP flap, and 95.7% using the sGAP flap. The initial surgery requires on average 4 nights in the hospital, but subsequent stages are much easier.

If you can’t or don’t want to use your own tissue, there are a couple of other options which may offer some hope, although the chances of success are nowhere near as good as using your own tissue. One is a course of hyperbaric oxygen, which has been shown to bring new blood vessels to the radiated tissue.

Another potential option, which must be regarded as experimental at this point, would be to completely cover the implant with acellular dermal matrix, or “ADM” (Alloderm being the most commonly used variety). This material has some efficacy in preventing contracture, but the effect would be less pronounced in radiated tissue.

Hope this helps. I would be happy to discuss your situation further with you, if you wish.

Have a question about breast reconstruction or post-surgical you’d like answered from our surgical team? Just ask!

Ask the Doctor – Can I Have Large, Under Muscle Implants Replaced With Smaller Ones? Will This Make Them More Comfortable?

This week, Richard M. Kline, Jr., MD, of The Center for Natural Breast Reconstruction answers your question about breast reconstruction.

Question: I’ve had my breast tissues removed and I now have implants. They are under my muscles, too large and very uncomfortable. Is there anything you can do to fix this and make a smaller implant? I am very unhappy with the way my breasts look, This is contributing to already very low self-esteem issues. Can you help me? What are my options?

Answer:  There is an excellent chance that we can help you. The country is currently undergoing a paradigm shift in implant-based breast reconstruction, with more and more surgeons placing the implants in front of the muscle, rather than behind. This allows for numerous potential advantages, and few disadvantages. We have been converting patients with unsatisfactory sub-muscular reconstructions to reconstructions in front of the muscle for a few years, with generally good-to-excellent results.

Another option is to remove your implants and re-build your breasts only with your own natural tissue, usually from tummy or buttocks. This is a larger operation than implant reconstruction but obviously results in an even more natural result.

I would be happy to discuss your situation further with you by phone, if you wish, or see you in my office when convenient.

Thanks for your question.

Have a question about breast reconstruction or post-surgical you’d like answered from our surgical team? Just ask!

Ask the Doctor – How Long Should You Have a Breast Expander In?

Lymphedema after mastectomy

This week, Richard M. Kline, Jr., MD, of The Center for Natural Breast Reconstruction answers your question about breast reconstruction.

Question: How long should you have a breast expander in?

Answer: There is no “one size fits all” answer to your question.

In many cases, expansion can be achieved, and the permanent implant placed, in 2-3 months (more commonly 3).

In other cases, expansion may take longer, or sometimes other factors such as radiation may cause delays in removing the expander and placing the permanent implant. Whenever possible, however, expansion should be completed before the beginning of radiation, because the expansion of radiated skin ranges from difficult to impossible.

I do not think that having expanders in for long periods is likely to cause any lasting problem, although the chance of them deflating goes up. I met a patient recently who, for various reasons, had had an expander placed by another surgeon in place for 15 years. She appeared none the worse for it, we placed a permanent implant, and she is doing well.

Hope this helps, I’d be happy to chat with you if you wish.

Have a question about breast reconstruction or post-surgical you’d like answered by our surgical team? Just ask!

Ask The Doctor – Do You Perform DIEP Free Flap Procedure Without Cutting Or Harvesting Muscle Tissue and Do You Accept BCBS Reimbursement?

White orchidsThis week, Richard M. Kline, Jr., MD, of The Center for Natural Breast Reconstruction answers your question about breast reconstruction.

Question: Do you perform the DIEP free flap procedure without cutting or harvesting any muscle tissue? How many of these are performed by the physicians per year? Do you accept the BCBS reimbursement rates for this procedure?

Answer:

Thanks for your inquiry.

My partner and I are both trained directly by Dr. Robert Allen, the inventor of the DIEP (and sGAP, iGAP, PAP, etc.). He still drops by and operates with us occasionally. We will NEVER take any muscle tissue. However, with rare exceptions (dictated only by individual anatomy), it is impossible to harvest a DIEP without temporarily dividing part of the rectus abdominus muscle (although this almost never results in any functional impairment). If you have read or heard otherwise, that source is simply incorrect. I would be happy to discuss this with anyone who feels otherwise.

We currently perform (150 – 170) perforator flaps for breast reconstruction each year. We have performed a total of about 1700 flaps, of which about 1400 are DIEPs, about 300 are GAPs, and a few are PAPs, tDAPs, etc. Our DIEP survival rate when last calculated was 99.08%, our sGAP survival rate 95.7%. I would not be surprised if these were the best flap survival statistics in the world, but of course I can’t be sure, because we don’t know the details of other groups’ statistics.

We accept insurance as full payment from all carriers doing business in SC, and we are usually “in network by proxy” (or something like that) with all other carriers in the US.

We happily accept patients who have been operated on unsuccessfully by other physicians, no matter how many times, and no matter how bad the situation may seem.

I would be happy to discuss the particulars of your situation with you by phone or in person at any time.

Thanks again for your question, and have a great weekend!

Have a question about breast reconstruction or post-surgical you’d like answered from our surgical team? Just ask!

Ask The Doctor: I Had A Breast Expander Removed and Can’t Re-start Breast Reconstruction For 6 Months. What Are My Best Options?

Daliahs

This week, Richard M. Kline, Jr., MD, of The Center for Natural Breast Reconstruction answers your question about breast reconstruction.

Question: I have started my reconstruction, but had to have one side removed and can’t start on that side for 6 more months. My one side has 80 ml saline in it. What are my best options?

Answer #1: Can you tell me why you had to have one side removed?

Richard M. Kline, Jr., MD

Answer from the patient: It started with a blood clot and just kept getting infecting.  So my surgeon removed it so I could start my chemo and to get the infection cleared up, which it has cleared up completely.  I have started my chemo, which I have 4 to 5 treatments. Then after 6 months from have inflated removed I can start the reconstruction procedure.

Answer #2:  Sorry you’re having trouble. I think your surgeon was wise to remove the expander, you certainly don’t want to delay chemo.

If you weren’t radiated, it may be reasonable to try another expander after finishing chemo. I think the chances of it working may be less than usual since you’ve had trouble before, but nonetheless, it may work next time.

If you would like to forego expanders/implants and have reconstruction with your own tissue, the chance of getting an infection will be much less, and the quality of the reconstructed breasts will be much more natural. The surgery involved is larger, and it’s not for everyone, but once you are done there is essentially nothing to ever go wrong later. Previous unsuccessful reconstruction attempts with implants generally don’t affect our ability to reconstruct you with your own tissue, so if you want to try implants again after chemo, the natural tissue option will still potentially be there if implants don’t work again.

I would be happy to chat with you more about your situation at any time if you wish.

Have a question about breast reconstruction or post-surgical you’d like answered from our surgical team? Just ask!

Ask the Doctor – What Are the Pros & Cons of Reconstructive Breast Surgery?

yellow flowers

This week, James E. Craigie, MD, of The Center for Natural Breast Reconstruction answers your question.

Question:  What are the pros & cons of reconstructive breast surgery?

Answer: Thanks for your question. Ultimately the pros for breast reconstruction include restoration of a woman’s body following surgical removal of part or all of her breast/breasts. Surgery to remove the breast is performed to prevent or treat breast cancer. The ultimate goal of reconstruction is to restore physical well being and quality of life. Breast reconstruction using your own natural tissue provides the opportunity to achieve the most natural results. Even restoring breast sensation is possible (not guaranteed and not necessarily complete) using your own natural tissue. The cons of natural tissue are that the patient must donate the natural tissue from another part of the body. That means scars and healing in more than one area of the body. Surgery always requires down time, recovery and time away from working etc.. Also reconstruction almost always requires more than one surgery.

Breast reconstruction using implants is generally less natural than using natural fatty tissue that contains healthy blood vessels and nerves. The advantage of implant reconstruction is that surgery is not required in another area of the body and there are fewer scars in areas of the body other than the breast. Long-term, reconstructions with implants require more revisions due to implant problems and are generally less permanent than using your own tissue.

There are always individual factors and expectations that may change the pros and cons. Hopefully, this brief synopsis has answered your question. Please let me know if you would like more information.

Have a question about breast reconstruction or post-surgical you’d like answered from our surgical team? Just ask!

Ask the Doctor – How Long Should You Have a Breast Expander In?

pink and white flowers

This week, Richard M. Kline, Jr., MD, of The Center for Natural Breast Reconstruction answers your question about breast reconstruction.

Question: How long should you have a breast expander in?

Answer: There is no “one size fits all” answer to your question.

In many cases, expansion can be achieved, and the permanent implant placed, in 2-3 months (more commonly 3).

In other cases, expansion may take longer, or sometimes other factors such as radiation may cause delays in removing the expander and placing the permanent implant. Whenever possible, however, expansion should be completed before the beginning of radiation, because the expansion of radiated skin ranges from difficult to impossible.

I do not think that having expanders in for long periods is likely to cause any lasting problem, although the chance of them deflating goes up. I met a patient recently who, for various reasons, had had an expander placed by another surgeon in place for 15 years. She appeared none the worse for it, we placed a permanent implant, and she is doing well.

Hope this helps, I’d be happy to chat with you if you wish.

Have a question about breast reconstruction or post-surgical you’d like answered from our surgical team? Just ask!

Ask the Doctor -After Two Different Types Of Reconstruction Over The Years, What Can I Do To Regain Some Symmetry?

Wild RoseThis week, Richard M. Kline, Jr., MD, of The Center for Natural Breast Reconstruction answers your question about breast reconstruction.

Question: I had my first mastectomy in 1991 with a tram flap reconstruction. My second mastectomy was in 2004 with an s-gap reconstruction. In the last few years, my breasts have become increasingly uneven and have shifted on my chest. Is there something I can do to my reconstructed breasts to regain some sort of symmetry?

Answer:  Without knowing any more specifics of your situation, I can state in general terms that asymmetry after reconstruction is very, very common and that there are a host of techniques which we routinely use to minimize asymmetry as much as possible. Some of these techniques are fat grafting, reduction, contour alteration, and position changing. We have currently performed almost 1700 perforator flap reconstructions, and we likely have significant experience dealing with situations very similar to yours. I would be happy to see you in consultation any time or chat on the phone if you wish.

Have a question about breast reconstruction or post-surgical you’d like answered from our surgical team? Just ask!