Q&A #1: May 2019

 

 

 

 

 

 

 

 

 

 

 

Q:

I had bilateral mastectomy on May 11, 2018, as a result of inflammatory breast cancer. I did have a tumor, but I also had a complete response to chemo and clear margins at surgery, followed by six weeks of radiation. A 5mm metastasis to one lymph node and a total of two lymph nodes were removed. I do have scar tissue and some swelling on the affected side, but I control it with OT and exercise. I am 61 years old, and otherwise healthy. Am I a candidate for reconstruction and, if so, how long should I wait? I currently see my oncologist yearly and my surgeon every six months for a vascular ultrasound.

Thank you!

A:
You are absolutely a candidate for reconstruction with your own tissue, and we would be happy to help you any way we can. I feel it is rarely, if ever, necessary to wait more than six months after radiation for reconstruction, and you are well past that. Also, your history of radiation, fortunately, has no impact on our ability to reconstruct you successfully using your own tissue.
I would be happy to chat with you further by phone, or see you in consultation in our Charleston office. Please let us know what we can do to help.

Best,
Richard M. Kline, Jr., MD

Ask the Doctor: Q&A

 

Q:

What is the success rate for someone with:
• a bilateral mastectomy with immediate reconstruction in 2011;
• encapsulation in 2016 with several fat graft attempts;
• failed implant on radiated left breast site, removed in December 2016; and
• removed right implant in February 2017?
I am now am searching DIEP options.

Thanks,

C

A:

Hi C,
I am sincerely sorry you have had so much trouble. Fortunately, none of your prior problems affect the success rate of DIEP flaps in our practice.
We recently tabulated and presented our 15-year flap experience. After 1,362 DIEP flaps, the overall survival rate was 99 percent. Neither radiation nor previous failed implant reconstructions affects the flap survival rate. Many, many, many patients with a history of radiation and multiple implant failures have gone on to have successful DIEP flap reconstructions.
I would be happy to meet with you and review your options, or chat with you by phone, just let us know how we can help.

Sincerely,

Richard M Kline Jr MD

Ask the Doctor: Q&A

Q:

I had a mastectomy in 2008 with implant reconstruction. I had the implants exchanged during additional procedures to help improve the look of the breast. I am very unhappy with how I look as it is very unnatural. I am not opposed to a procedure with another implant if done correctly. Is this something you do? Otherwise I may need to consider alternatives as I feel so uncomfortable in my own skin.

Thanks,

V

A: Hi V,
Thanks for your inquiry.
We frequently revise implant reconstructions to improve patient satisfaction. For several years, we have done essentially all of our implant-based reconstructions in front of the pectoralis muscle, which confers a number of significant benefits in terms of comfort, appearance and naturalness (compared to behind-the-muscle). I also have converted a number of patients with older behind-the-muscle reconstructions to modern in-front-of-the-muscle reconstructions, and they all feel the result is much nicer.
If implant reconstruction still proved unacceptable to you, using your own tissue is another powerful option. We have completed more than 1,800 natural tissue reconstructions – many in women who previously had unsatisfactory implant reconstruction – with great success.
I would be happy to see you in consultation, or discuss your situation in more detail by phone, if you wish. Please let us know what works for you.
Best,

Richard M. Kline, Jr., MD

Ask the Doctor: Q&A

Q:

I am interested in DIEP and live in N.C., but before I go any further, I have questions. I’m a healthy, 43-year-old female; married with children; I work, and I’m a non-smoker. I was recently diagnosed with multi-centric DCIS in my right breast. MRI enhancing revealed a left breast lesion, and a biopsy will be scheduled soon. Genetic testing came back negative. A local plastic surgery consult indicated sufficient abdominal tissue to create a breast mound. My first question — who are the breast surgeons that your office works with? Would they do a sentinel node biopsy as my surgeon has recommended? Second, could the mastectomy and DIEP occur during a single surgery? Third, do you coordinate care with my current breast surgeon? I anticipate that if the lesion on the left is also DCIS, I would opt for a lumpectomy and radiation on that side since the area is small, and do it locally with my current breast surgeon. Finally, how would I start the process of moving forward with a consult with your office for DIEP?

A:

Hi, Kay,

Thank you for your question, I am sorry you have to go through surgery. It seems you have already gotten a lot of good information about your possible treatment and reconstruction. Our practice has specialized in breast reconstruction using natural fatty tissue and procedures such as the DIEP flap since 2002. My partner and I have performed nearly 2000 breast reconstructions using natural tissue with an overall success rate of 99%. We work with several breast surgeons who we collaborate with on every patient. We are also accustomed to patients having to travel to us from out of state and have had patients come from 48 of the 50 states. We understand the difficulties associated with what you are going through and our mission is to help people in your situation. You have some excellent questions so I will answer them in list format. 

1. Who are the breast surgeons that your office works with?

We work with multiple breast surgeons who we are familiar with and collaborate with to offer our patients the options that are best for each individual situation.  Drs. Megan Baker, Jennifer Fiorinni, and Jennifer Beatty are excellent breast surgeons who we work with. Would they do a sentinel node biopsy as my surgeon has recommended I have done? Yes, they would and frequently do prior to mastectomy to determine if radiation is needed after mastectomy.

2. Could the mastectomy and DIEP Flap occur during a single surgery?

Yes, absolutely! We feel this is very important to get the best result and to minimize the number of surgeries needed.

3.  Do you coordinate care with my current breast surgeon? I anticipate that if the lesion on the left is also DCIS that I would opt for lumpectomy and radiation on that side since it is a small area and would do that locally with my current breast surgeon.

Yes, we coordinate with our patient’s home breast surgeons. For what treatment is best we also rely on the opinion of the breast surgeon here. In your situation it may be best to consider possibly having both breasts removed and then reconstructing both at the same time with the same technique. That approach allows us to achieve better symmetry between the breasts. Sometimes after a lumpectomy and radiation, the breast can develop an abnormal shape that is not desirable and difficult — if not impossible — to match with the opposite breast. The problems might not surface until after radiation and are then nearly impossible to repair. When we use the DIEP flap, it is often available for each breast and therefore makes for a great match. We can discuss this more if you like.

4. How would I start the process of moving forward with a consult with your office for DIEP?

Just let me know if you would like to see me for a consult in person or make an appointment to talk over the phone. Most of the time, we can plan and answer questions before an actual visit in person. My staff can contact you to schedule an appointment and gather additional information.

I hope that I have answered your questions, let me know if you have other questions.

Thank you,

James Craigie, MD

CNBR

Ask the Doctor: Q&A

Q: I had a lumpectomy and radiation for breast cancer. I would like to know if I can get reconstruction surgery.

Sincerely,

Ms. Jones

A: Ms. Jones,
Thank you for your question. You can absolutely get reconstruction after lumpectomy and radiation. Some of your options depend on the extent of deformity/radiation damage and asymmetry between breasts, and whether you want to proceed with a complete mastectomy.
If you are looking to just improve the appearance of your radiated breast, different things that can be done to adjust that breast to achieve a better cosmetic result and symmetry. Often modifying the non-cancer breast with a reduction and/or lift can create better symmetry.

With true breast reconstruction, you need a complete mastectomy for an implant or your own tissue to replace the breast mound. Implants are often not recommended for and do not work the best in a radiated breast, but it is not impossible. Having had a lumpectomy with radiation has no effect on your ability to have the breast reconstructed with your own tissue by using your abdomen, buttocks or thighs as the most likely donor sites.

We work with multiple excellent breast surgeons in our area who could do the mastectomy immediately followed by reconstruction in the same surgery. Depending on your overall risk and preference, you could also have the non-cancer breast removed and reconstructed, but we leave that decision up to you and your oncology team.

Our reconstruction procedures are most commonly a staged process that involves at least two surgeries to achieve something close to a satisfying result. We would be happy to meet you in the office for a consult with one of our surgeons, Dr. James Craigie or Dr. Richard Kline, to discuss your best options and give you more information on the different procedures. If you live out of town, we can often offer a phone consult first to help you better understand the process before you make a long trip here. We also can set up a meeting for you with a local breast surgeon on the same day as your consult with us if you are interested. Please let us know how we can best help you, and we look forward to hearing from you.
Sincerely,

Audrey Rowen, PA-C

Ask the Doctor: Q&A

Q:
Hello,

I had a double mastectomy on June 5, 2018, for breast cancer. I finished chemotherapy on November 28th, 2018. I am interested in having the DIEP done and I read information about the ReSensation™ option and am very interested. I live in Aiken, S.C. and would love to get an appointment scheduled.

Thanks,
Erin

 

A:
Hi Erin,

I’m sorry you have had breast cancer, but we would be delighted to help you. We have done about 1,400 DIEP reconstructions over the last 15 years, with a 99% flap survival rate (plus about 300 other perforator flaps for breast reconstruction, mostly sGAPs and PAPs). We have been using ReSensation™ to improve the chances of restoring sensation since October 2017.

While there is not yet definitive published data proving that the nerve grafts help restore sensation, there are some promising early results. We have had some difficulty with certain insurance companies refusing to pay for the nerve grafts, but we would of course address that with them prior to your surgery. I would be delighted to see you in consultation at a time convenient for you. I typically see new patients on Tuesdays and Fridays, but I can often see patients on other days if it works better for you. Thanks for your inquiry, and have a great day!

Best,
Richard M. Kline Jr., M.D.

Dr. Kline trained in microsurgery with Dr. Robert Allen, who was pioneering the DIEP, SIEA, and GAP flaps.

Ask the Doctor: Q&A

Q:
I recently completed chemo for stage 3 IDC (invasive ductal carcinoma) in my left breast. I have chosen to have a bilateral mastectomy because I’m 44 and my oncologist recommended it. I’m scheduled for radiation after surgery. I was hoping to have immediate DIEP flap reconstruction but the plastic surgeon I spoke to today said he doesn’t recommend it until after radiation. I had originally consulted with an out-of-state plastic surgeon who said they perform the mastectomy and immediate reconstruction with skin flaps but they don’t recommend it with implants. My radiation oncologist even told me that statistically, women are more satisfied with immediate reconstruction. I’m very confused and if I can avoid having two surgeries, I would prefer that. Any advice would be greatly appreciated!

Thanks,
Angie

 

A:
Hi Angie,
I’m sorry you are going through this, but your question is an excellent one, and has been asked by many patients.
We try not to radiate natural tissue (flap) reconstructions, which includes DIEP flaps. As a rule, at best, the radiation will “shrivel up” the flap about 25% and make it firmer; at worst, it will shrivel it up to almost nothing. While some plastic surgeons don’t seem to mind these odds, we feel that in general, we do patients a disservice if we recommend radiating flaps. Additionally, if the flap is delayed until AFTER the radiation, it is usually the IDEAL method of reconstruction, and its success is not at all affected by the fact that the breast area has been radiated.
On the other hand, implant-based reconstructions, while faring more poorly when radiated than when not radiated, at least do not place priceless irreplaceable natural tissue at risk of loss. When we know or strongly suspect that a patient is to need post-operative radiation, we often recommend placing temporary tissue expanders
in front of the muscle at the time of mastectomy(ies). After the radiation is complete, the expander is removed, and reconstruction with natural tissue (such as DIEP flap or sGAP flap) is performed. It is not absolutely necessary that a temporary tissue expander be placed, but it serves the dual purposes of providing a temporary breast mound, and often preventing excessive wrinkling and contraction of the remaining breast skin until reconstruction with your own tissue can be done.
I would be happy to chat with you by phone or see you in person to discuss your situation further, if you wish. We have performed more than 1400 DIEP flaps with a 99% success rate, and we are happy to share what we have learned in the process.

Thanks,
Dr. Richard M. Kline Jr., M.D.

Dr. Kline trained in microsurgery with Dr. Robert Allen, who was pioneering the DIEP, SIEA, and GAP flaps.

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

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.