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!

Ask the Doctor – Would I Be A Candidate For DIEP Flap Surgery After Previous Expanders Are Removed And Will You Accept VA Insurance?

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

Question: I had a bilateral mastectomy with reconstruction and I am terribly dissatisfied with my care so far. 11 Months later, the expanders are still painful. I will be asking to have them removed this week.

I have 2 questions for you. After I  have the expanders removed would I still be a candidate for the DIEP flap? I am still going to chemo (Herceptin) which will run until the end of November, provided there are no more setbacks. My second question is, do you accept VA insurance? One form of payment is through the VA another is Veteran’s Choice. I am not sure which would cover outside care. I look forward to your response.

Answer: I’m sorry you have had so much trouble, but there is a very good chance that we can help you.

Your previous unfortunate experience with expanders does not in any way decrease our ability to successfully reconstruct you with DIEP flaps. The blood vessels which we use to vascularize your flaps are well below the area where tissue expanders are placed, and we have successfully reconstructed literally hundreds of patients in your situation. One potential advantage to having the expanders removed sooner rather than later is that we get an MRI angiogram on all patients who are scheduled for perforator flap breast reconstruction, and most breast tissue expanders are not MRI-compatible. If they use a little magnet to find the port before they fill your expanders, then you can’t get an MRI with those expanders in place.

We have worked with the VA many times in the past, and Gail, our insurance expert, will contact you to investigate your situation further.

Thank you very much for your inquiry, and I look forward to meeting you.

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

Ask the Doctor – Exams Of My Implants Have Shown Nothing Wrong But Increasing Symptoms Have Me Very Worried. Is There Anything I Can Do?

Daisies

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

Question: I have pain on the side of my breast where an implant was attached at reconstruction surgery in 1987. It has always hurt but recently has become much worse. Inflammation increases with sinus and allergy problems.

The implants are still soft so my recent visit to a plastic surgeon was uneventful. As I am 75 years old, they would not remove them. MRIs have shown they are not leaking. The pain keeps me on edge thinking something is very wrong. What are my options?

Answer:  I’m sorry you are having problems so long after your surgery.

I don’t think you necessarily have to just accept your situation. You can have very bad, and painful scarring internally, especially with old implants, even if they are not ruptured. Additionally, if you are otherwise healthy, there is no reason you couldn’t have them removed, even at 75. I’m not saying that this would solve your problems (although it may), but don’t discount the option just because of your age. For what it’s worth, we have actually done DIEP flaps successfully on patients your age, and that is a much larger procedure than removing implants.

I would be happy to speak with you and discuss your situation further 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 – Could Odd Pains In My Body Be The Consequence Of an Old Abdominal Flap Surgery Following A Halstead Radical Mastectomy?

Poppy in a feild

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

Question:  In 1987, I had abdominal flap surgery following a Halstead radical mastectomy. I keep wondering what is NOW going on in my body! When I feel odd pains I wonder if it could be repercussions of that surgery so long ago.

Answer:  Thank you for your question. If you had your surgery in 1987 and you had reconstruction using your abdominal tissue then I will assume that you had a Tram procedure. That surgery relies on partially removing the muscle from the abdominal wall. Not having the muscle in place can cause problems later in life. People can have pain or bulging of the tummy and even hernias. Of course not all patients have those problems. If your problems are in the tummy area then that is a possibility. If your problems are in the area of your breast or mastectomy then you should consider seeing a breast surgeon that specializes in doing mastectomies to make sure all is well with regard to your breast area. You could also see the doctor who follows you regarding your breast cancer history. Scaring from a “Halstead” mastectomy especially after radiation could cause aches and pains later in life. Regardless of what it might be you should definitely be seen by your doctor so they could do a complete evaluation of your symptoms. After an evaluation they could make more specific recommendations. I hope his information helps. Let me know if you have further questions.

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 – What Are My Chances With DIEP Flap Surgery After Several Failed Reconstructions With Tissue Expanders and Implants?

Sunflowers

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

Question: I have had several failed reconstructions with tissue expanders and implant. I have also been put on IV antibiotics due to a staph Infection. I am wondering what my chances are with the DIEP Flap.

Answer:  Great news! Your prior failures with implants does not in any way decrease your ability to get soft, warm breasts with DIEP flaps. Many, many, many of our patients have histories of prior failures with implants, some with (10-20) prior failed surgeries, and we have been able to successfully 99+ % of them with only their own tissue. Once the infection from prior implants is eradicated from your body (if you have been healed for at least 6 months, you can generally assume that all the prior infection is gone), then subsequent reconstruction with your own tissue carries only a minuscule fraction of the infection risk of reconstruction with implants. You didn’t mention if you were radiated, but it makes no difference, breasts reconstructed with your own tissue are still extraordinarily unlikely to have problems with infection.

We would love to chat with you and discuss your options further. Looking forward to speaking with you, and thanks for your inquiry.

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