Q&A: Ask the Doctor

Q: I was wondering if I would be able to schedule a phone consult?

I was recently diagnosed BRCA1 positive in April 2019. I have been working with a breast surgeon and plastic surgeon in the Midwest and I am interested in a double mastectomy with immediate DIEP reconstruction. After the initial consult with our local plastic surgeon, he thought this would be possible. In addition to that he wanted to do a mastopexy in preparation for nipple sparing mastectomy and DIEP.

We did complete the mastopexy almost four weeks ago. At my last appointment, our plastic surgeon told us that he is not comfortable doing the immediate DIEP reconstruction after the mastectomy. This is due to limited resources and being the only microsurgeon capable of doing this near my hometown. He typically will complete these in two steps. We are interested in looking into a second opinion, as we would like to try and complete both surgeries in one step if possible. We are also wondering what a schedule or timeline to get in for this type of procedure would be. In the consult I would also like to discuss my journey so far, including screening results, and my past recommendations.

A: Sorry you are having to go through this, but congratulations on having a great plastic surgeon. I’ve never met him, but I know he’s good because 1) he suggested / did the preliminary mastopexy, and 2) he is obviously putting your welfare first by referring you for bilateral DIEP. We would be honored and delighted to help you through the next stage of your journey. I will be happy to discuss the details with you by phone as soon as it can be arranged.

–Richard M. Kline, Jr., MD

Q&A: Ask the Doctor

Ask the Doctor: Q&A
Q: Three years ago, I had a double mastectomy and am now cancer-free. Unfortunately, my
plastic surgeon did a terrible job with the reconstruction. The left side implant is way off to the
outer side and looks larger than the right. The right side is way too far to the outside. There is
zero cleavage. Is there any way to re-position the implants to the more natural position of the
breast? I do not expect perfect but don’t like looking like a botched job. Please let me know if
your team can help. Thank you.
A: Congratulations on becoming cancer-free. At the Center for Natural Breast Reconstruction it
is part of our mission to help women move on with their lives after breast cancer. We focus our
efforts on helping women get their bodies back together with permanent “natural results.”
I’m sorry you are disappointed with your reconstruction results. If you have had radiation
previously, then it may be more difficult to have your breasts match with implant reconstruction.
If you have not had radiation then perhaps your implants could be revised or adjusted for an
improved appearance.
It is possible that using your own fatty tissue would be a more permanent option without
implants. Sometimes it is hard to start over with another approach but it may be necessary if
you desire a more natural and permanent result. If you would like more information about
natural breast reconstruction with your own tissue let me know.
We are here to help!
James Craigie MD

Q&A: Ask the Doctor

Ask the Doctor: QA’s
Q: I have a history of benign proliferative breast disease with associated atypical ductal
hyperplasia. I have had two needle biopsies and three surgical biopsies in my left breast. I took
Tamoxifen for five years and currently am taking Evista. Last year I completed the Myriad My
Risk Test resulting in a 37.9% remaining lifetime breast cancer risk. My monitoring plan since
2006 has been alternating diagnostic mammogram and breast MRI.
My most recent MRI located an enhancing nodule in my right breast. My oncologist has referred
me to a local surgeon to begin the process for prophylactic double mastectomy. I am interested
in natural breast reconstruction. I would like to schedule an appointment to discuss my options
with your plastic surgeons. I also will need to set up an appointment with the surgeon you use
for the actual mastectomy. I am not sure which appointment should be first.
A: Hi Stacy,
Thank you for contacting us. I am sorry you are having to make very difficult decisions in order
to prevent getting breast cancer. I commend you for being very vigilant with screening. As you
are aware screening alone won’t prevent breast cancer unless you act on the results of the tests
that indicate your risk is high.
Many women would consider preventive mastectomy in your situation. For many women
knowing that they can have immediate natural breast reconstruction for a permanent natural
result makes the decision a little easier to make. If you feel like you have any amount of extra
fatty tissue anywhere on your body then chances are you can use your own natural tissue. I’ll be
glad to answer any other specific questions just let me know.
James Craigie MD

New Breast, Now What: Managing Expectations Following Reconstruction

Let’s face it — no matter what you’re going through your experiences are going to differ from someone else. Others who have had breast cancer, a mastectomy and reconstruction can tell you all about it but your journey will be different than your best friend’s, your neighbor’s or the woman sitting next you in chemo.

However, you are still going to have some expectations of how things may — or may not — happen following your reconstruction. The question is: How do you manage them?

You expect that reconstruction should be easy.

Ann* said that she educated herself immensely throughout her journey, but she was not fully prepared for the magnitude of her reconstruction surgery. She knew it would be a big deal and it would take a few months to recover, but for her, it took multiple surgeries

and her recovery took a lot longer than that. Your body has been through so much and it’s going to take time to heal. Don’t get dejected. Everyone heals at a different pace, but if you’re concerned about how fast your recuperation is going, talk to your doctor.

You expect everything done in one procedure.

Most breast reconstructions require more than one surgery, and, if desired, a nipple tattoo will be added months later to complete the process.

You expect to look the same after reconstruction.

You’re missing your breast and want the new one to look the same. While doctors do what they can to recreate your natural-looking breast, the new one will be a little different. It may end up slightly smaller or higher or rounder or feel different. Expect that there will be changes. It might take time to get used to these changes, but it’s easier to do it if you expect them going in.

You expect that your breast will feel the same.

When Susan had her reconstruction, she expected that the new breast would feel the same as it did before. Instead, it had no feeling at all and made her self-conscious, especially when she was intimate with her spouse. Of course, losing sensation can happen, but fortunately, The Center for Natural Breast Reconstruction offers ReSensation™, where donated nerve tissue attaches to a patient’s remaining new tissue in the affected area. Over time, nerve-endings regenerate and feeling returns.

You expect adjustment to be easy.

Jill said there are many things she misses about not having her natural breast. She didn’t expect to feel so down after a procedure that is supposed to help. To help her cope, Jill reminds herself of her goal to stay healthy for herself and her family, including her beautiful grandchildren and she said that she is grateful for everyday she can do that. Over time, she has learned to accept her new breast and enjoy her life.

You expect limited options.

Your doctors should work with you throughout the process. All breast reconstruction options should be discussed to help you to make a smart, informed decision.

Q&A: Ask the Doctor

Q: I have a history of benign proliferative breast disease with associated atypical ductal hyperplasia. I have had two needle biopsies and three surgical biopsies in my left breast. I took Tamoxifen for five years and currently am taking Evista. Last year I completed the Myriad My Risk Test resulting in a 37.9% remaining lifetime breast cancer risk. My monitoring plan since 2006 has been alternating diagnostic mammogram and breast MRI. My most recent MRI located an enhancing nodule in my right breast. My oncologist has referred me to a local surgeon to begin the process for prophylactic double mastectomy. I am interested in natural breast reconstruction. I would like to schedule an appointment to discuss my options with your plastic surgeons. I also will need to set up an appointment with the surgeon you use for the actual mastectomy. I am not sure which appointment should be first.

A: Hi Stacy, thank you for contacting us. I am sorry you are having to make very difficult decisions in order to prevent getting breast cancer. I commend you for being very vigilant with screening. As you are aware screening alone won’t prevent breast cancer unless you act on the results of the tests that indicate your risk is high. Many women would consider preventive mastectomy in your situation. For many women knowing that

they can have immediate natural breast reconstruction for a permanent natural result makes the decision a little easier to make. If you feel like you have any amount of extra fatty tissue anywhere on your body then chances are you can use your own natural tissue. I’ll be glad to answer any other specific questions just let me know.

Dr. Craigie

Q&A: Ask the Doctor

Q: Hi, I was wondering if I would be able to schedule a phone consultation. I was recently diagnosed BRCA1 positive. I’ve been working with a breast surgeon and plastic surgeon and am interested in a double mastectomy with immediate DIEP reconstruction. After the initial consult with our local plastic surgeon, he thought this would be possible. In addition to that he wanted to do a mastopexy in preparation for nipple sparing mastectomy and DIEP. We did complete the mastopexy almost 4 weeks ago. At my last appointment, our plastic surgeon told us that he is not comfortable doing the immediate DIEP reconstruction after the mastectomy due to limited resources and being the only microsurgeon capable of doing this in my area of the Midwest. We are interested in looking into second opinion, as we would like to try and complete both surgeries in one step if possible. We are also wondering what a schedule or timeline to get in for this type of procedure would be. In the consult I would also like to discuss my journey so far, including screening results, and my past recommendations. Thank you!

A: Hi Laura, sorry you are having to go through this, but congratulations on having a great plastic surgeon. I’ve never met him, but I know he’s good because 1) he suggested /did the preliminary mastopexy, and 2) he is obviously putting your welfare first by referring you for bilateral DIEP.

We would be honored and delighted to help you through the next stage of your journey. I will be happy to discuss the details with you by phone as soon as it can be arranged.

Richard M. Kline, Jr., MD

Cool for Summer: Tips to Feel Confident in Your Summer Wardrobe After a Mastectomy

Baby, it’s hot outside! You want to feel cool and confident in your summer wardrobe, but you’ve been through a lot lately — your breast cancer diagnosis, surgery and now breast reconstruction. You might be feeling a little unsure about stepping out. Here are some tips to help you feel more confident in how you’re dressing post-reconstruction so you can enjoy the summer sun.

Don’t sacrifice your own sense of style and comfort.

You’ve gone through many physical and emotional changes since your diagnosis and having a sense of control is important to feeling more confident. So wear what makes you feel good. Do not think you need a new style or a new wardrobe to bring back your sense of self.

For example, you know that favorite summer t-shirt or sundress that you’ve worn for years because it brings back great memories? If putting either of them on makes you feel good, wear it. When you feel good, you will automatically smile and feel better about yourself.

Dress up another asset.

Feeling insecure? That’s fine. Accentuate a different part of your body for now. Got great legs? Draw attention to them. Or consider getting your hair done to invite conversation about that instead.

Wear the right bra.

It’s already a hot summer, so the last thing you need is to feel sticky and sweaty in your bra. What you wear underneath your clothes is just as important as what you wear on top of your clothes. You should wear a post-reconstruction bra that is soft and provides breathability. Fabrics like cotton make bras more comfortable on sensitive skin and any scar tissue that is still healing. Your current bras might not fit or may be uncomfortable as you heal. Use a company that specializes in post-mastectomy bras, such as Masthead Elizabeth Pink Surgical Bra. They will fit better after reconstruction which, in turn, will provide a much-needed confidence boost.

Find the right swimsuit.

If you have been given the all-clear from your doctor to go into the water, then make sure you’re prepared with a properly-fitted swimsuit. After reconstruction your breasts may not be the same size, so you may need to purchase one with a better fit. If you’re concerned about swimsuits that show scars, don’t be. Many companies offer post-surgical swimsuits that come with a higher neckline and more underarm coverage, so your scars should barely be noticeable.

Keep a positive attitude.

What you see as a breast cancer patient may differ from what others see. Your scars may not be as visible as you think and the change in the look of your new breasts may

not be as extreme as you think they are. It’s important to maintain a positive attitude throughout your entire journey. Then, it won’t matter if you wear a potato sack if you feel good about yourself. You’ll rock any look. Be comfortable and cool and the confidence will show.

Ask the Doctor: Q&A

woman sitting looking out in the distance in front of a lake

Q: I see post bariatric surgery plastic surgery referenced on your site. I didn’t realize you also offered these procedures. Which doctor cares for this? Thank you for any information you can provide.

Thanks,

M

A: Hello, M.

Currently, 90% of our activity is microvascular breast reconstruction. I did a lot of post-bariatric surgery some years ago, which is where the pictures came from. We stopped actively promoting this service (despite leaving the pictures up) because: 1) Unfortunately, insurance doesn’t usually pay for it, and 2) Most patients can’t afford to pay for it themselves. The surgeries are fairly large and serious, and as a rule, complications can be serious and patients usually need to stay in the hospital at least one night. If you can find a surgeon close to you with an express interest in performing this surgery, that would probably be your best bet. If you can’t find one and you determine we are your closest reasonable option, I would be happy to see you to discuss your options.

Thanks for your great question!

Sincerely,

Richard M. Kline, Jr., MD

Sun Safety Tips

 

Close up on woman applying sun cream on her arm with a spray at the beach on a warm, sunny day. Sunscreen protection, skin cancer concept

The warmer, sunnier weather is calling you to the great outdoors, but breast cancer survivors need to take extra special precautions to care for their skin. Why? Both chemotherapy and radiation treatments can make the skin more sensitive to the sun up to two years after treatment is over.

Before you head to the park or to the beach, It’s important for breast cancer patients to follow these tips to stay safe in the sun:

  1. Wait Just a Bit

If you just finished radiation therapy, give your skin a little time to heal before enjoying the sun. It is typically recommended that radiation patients wait a few weeks before venturing out. When exposed to the sun, radiation therapy can cause something called ‘radiation recall’, where the treated area will “remember” that it was exposed to radiation and become red, inflamed, and tender again.

  1. Use Sunscreen

According to the American Cancer Society, sunscreen for breast cancer survivors should have a sun protection factor (SPF) of 30 or higher. The SPF number is the level of protection that the sunscreen provides against UVB rays. Keep in mind that no sunscreen completely protects you, so you should combine other safety tips to increase your chance of protection.

Not sure what you should use? Every breast cancer patient is different, so talk to your oncologist and your radiation oncologist to see what they want you to use. If you have already had a negative reaction to the sun or are sensitive to certain sunscreen ingredients, they may have a different product recommendation.

  1. Cover Up

The area of your breasts that received radiation therapy should be protected from the sun at all times with clothing and sunblock, especially if the area is already red or ‘burned’ because of treatments. It’s also important to keep your surgical scars covered.

  1. Sit in the Shade

Unless your doctor specifically tells you to not go out in the sun at all, you should limit your sun exposure during the times that the ultraviolet or UV rays are the strongest. This is between 10 a.m. and 4 p.m. It’s best to enjoy the early morning or later evening sun.

  1. Protect Your Scalp

Chemotherapy causes hair loss, so if your hair is thinning or if you are completely bald, make sure you wear a hat or apply sunscreen to your scalp – and don’t forget your ears too!

  1. Don’t Get Overheated

Some chemotherapy medications can cause your body to become overheated in the sun, so consider wearing a wide brim hat or a hat that is made from natural fabrics so your scalp can ‘breathe.’

Don’t use tanning beds: They employ the same dangerous ultraviolet rays that the sun emits.

You can certainly enjoy the warm summer outdoors without baking in the sun. Remember, you just finished treatment and need to take it easy and keep your body healthy.

Q&A #2: May 2019

Q:
I had a bilateral mastectomy in October 2016. I finished radiation on the right side in January 2017, and underwent bilateral latissimus flap reconstruction in August 2017. I had capsular contracture (when the scar tissue or capsule that normally forms around the implant tightens and squeezes the implant) on the right side and the implant changed out in March 2018. Once again, I have capsular contracture on the same side. What do I do? They are absolutely not even close to symmetrical. I am only 46. I am kind of thinking that I should just forget reconstruction even though I don’t really want to go flat.

A:
Without knowing all of the details about your situation, I think there is a reasonable chance you have some good options left. Here are a few potential ones:
1. We have reconstructed more than 1,800 breasts with natural tissue alone (no implants) using the abdomen or buttocks. If you have any tissue in those areas, that is our most frequently used option.
2. We have, on several occasions, reconstructed breasts with latissimus flaps alone, with added free-fat grafts, which can sometimes double (or more) the size of the latissimus flap, and make implants unnecessary.
3. For the last 4 1/2 years, we have done all of our implant reconstructions exclusively in front of the muscle, using a full Alloderm (specially preserved donor skin) wrap. This has completely changed our outlook on implant breast reconstruction, and has on occasion produced surprisingly good results – even in radiated breasts. I have converted several “implant-behind-the-muscle” patients (some who already had latissimus flaps) to in-front-of-the-muscle, and they all feel that it is a significant improvement. Free-fat grafting can also be added to implant-based reconstruction to improve shape, size and overall naturalness.
There is absolutely nothing wrong with going flat if you are sure that is what you want to do, but it might be premature for you to decide to do that only because you don’t think you have any other options. I would be delighted to discuss your situation in more detail by phone, if you wish, or see you in person for a consultation.
Thanks for your question! We look forward to hearing from you.

Best,
Dr. Richard M Kline JR MD