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

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.

Ask the Doctor- Why Do Expanders Have To Be Used When a Breast is Removed?

This week, Richard M. Kline Jr. M.D., of The Center for Natural Breast Reconstruction, answers your question.

Question: Why do expanders have to be used when breast are removed and the pocket is empty and ready to be filled with an implant?

Answer:  It is not always necessary to place expanders at the time of mastectomies, but in many situations, it is a safer choice than immediately putting in an implant. Even if the breast surgeon leaves the nipples and removes no skin at all, the skin is not always healthy, as the blood flow is invariably at least somewhat compromised after mastectomy. Placing an implant under very poorly perfused skin would put additional pressure on the skin from within, and quite possibly cause the skin to die that otherwise would have lived. With an expander, we have the option of placing no fill at all at the initial surgery, thus minimizing additional pressure on the skin. In actual practice, sometimes the skin’s blood supply is so poor we don’t even put in an expander right away, but rather return to the operating room several weeks or months later to begin reconstruction.

Having said the above, I do agree it is nice if the final implant can be placed under healthy skin flaps immediately. However, it should only be done under ideal circumstances.

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

 

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.

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

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!

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

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!