Ask the Doctor – How Far in Advance Should I Begin Planning and Scheduling Surgery and is Travel Afterward a Problem?

Roses and orchids

This week, Gail Lanter, CPC Practice Manager, of The Center for Natural Breast Reconstruction answers your question.

Question: I had a phone consult with Dr. Kline in December and was very impressed with our conversation.  After researching several microsurgeons, I keep coming back to this center as the perfect fit for me. I had bilateral mastectomy in Jan. 2014 due to DCIS and have saline implants under the muscles. I experience constant inflammation, burning, and the right implant has “shifted” (as my PS said) and feels like it is under my armpit. Due to life situations I am not considering surgery until the end of this year or January, 2019.

How many months ahead should I contact you to schedule the surgery? Also, I’d like to talk to someone about getting insurance approval. I have BCBS of Alabama.

Is it possible to come from Decatur, AL to have this done? I do not feel comfortable using anyone closer at this point. Just worried about the travel afterwards. Thank you.

Answer:  We have many women who travel to have surgery so we know how to help you navigate that hurdle.  As far as your timeline, one thing to consider is that this is a staged procedure – typically the first stage is inpatient for 4 days and then outpatient for Stage 2 a few months later.  Sometimes a 3rd stage (outpatient or in office) if you require nipple reconstruction or further revision to get the result you desire. Taking into account your deductible and out of pocket expenses – you may want to make sure you can get all of those stages done within one plan year.  I’ll be happy to run an eligibility inquiry through your insurance plan and we can find out exactly what your benefits are so you’ll know what to expect. Insurance approval should be no problem at all as we are in the Blue Card Network for BCBS plans. Check your insurance card and see if you have a little suitcase on the front with some letters within it.  That will tell you that your plan is a member of that network. If you’d like to send me some basic demographic information i.e. full name, date of birth, address and a copy of your card, I can get that process started for you. We typically have openings within a 2-3 month time period but to reserve the date you really want, I’d choose it as soon as you know what will work for you.  We operate on Tuesday, Wednesday, and Thursday.

Here is a blog post from September discussing the stages of surgery and how we work with patients out of our area.

http://breastreconstructionnetwork.com/ask-the-doctor-how-many-trips-are-required-to-have-reconstruction-with-your-doctors/

I’ve forwarded your e-mail to Dr. Kline to discuss post- operative travel with you.    Have a great day and I’ll look forward to your reply.

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

Ask the Doctor – Do You Recommend ADM for Support? Are There Other Options?

Tulips

This week, Dr. Kline, of The Center for Natural Breast Reconstruction, answers your question about breast reconstruction.

Question:  I underwent a left skin-sparing mastectomy for DCIS in 2010. I also had immediate free tram reconstruction. My entire lateral mammary and inframammary fold were removed. I have significant pain, rupturing of blood vessels on the skin and I have to wear a bra at all times. I have been told I need an ADM for support to the breast as well as tacking of mastectomy tissue to the chest wall. Is this the procedure you recommend for this or do I have other options? I need surgery ASAP.

Answer:  I’m sorry that you are experiencing these problems.

The options which you have mentioned, placement of ADM and suturing skin to the chest wall, may well be what you need, but it is impossible for me to say so definitively without first evaluating you in person. If you would like to (securely) send pictures for review this may be helpful, but, again, a final recommendation cannot be made without actually in-person assessing factors such as skin laxity (or lack thereof) and flap characteristics (consistency, shape, volume, etc). For what it’s worth, however, I have never personally encountered a patient with completely natural breast reconstruction with contour problems which required the placement of ADM to correct, but that doesn’t mean it can’t happen.

We have certainly had women travel to Charleston with complaints very similar to yours, and have successful surgery here. However, it may be worth your while to consult with other experienced surgeons in your immediate geographic area first, as the techniques we are discussing can ordinarily be competently performed by any capable plastic surgeon with significant breast reconstruction experience. If you decide to come here, however, we will be pleased to help you any way we can.

Thanks for your question, and have a great day!

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

Ask the Doctor – Can My Latissimus Flap Reconstruction Surgery Be Reversed?

This week, Dr. Kline, of The Center for Natural Breast Reconstruction, answers your question about breast reconstruction.

Question: I had that flap reconstruction 4 years after my mastectomy. That was 8 years ago. I’m in constant pain from the pulling in my chest. I hate that I can no longer paddle my canoe or swim.

I’m also having continued back problems that require the use of a chiropractor.

Can this procedure be reversed? I did not have any radiation or chemotherapy.

Answer: What type of flap did you have? It would be very unusual for a free tissue transfer (such as DIEP) to cause pulling, but not so unusual for pedicled flaps like a latissimus (or even a TRAM).

If you did have a latissimus, it could quite possibly be revised to improve your symptoms.

If you had a DIEP, it would require a little more investigation. Please let me know, and I’ll try to give you a more precise answer. I’d also be happy to chat with you by phone, if you wish.

Inquirer’s Response:

I believe it was a latissimus.

They used a portion of muscle from the side of my back, just a few inches lower than the armpit. The breast has also shifted slightly so that it isn’t centered in the chest anymore and is closer to the armpit.

In addition to the pulling pain in the chest, I’m having severe pain in the upper back, shoulders, and neck. I’ve also had recurring numbness and tingling in the hand and sharp pain shooting down my arm.

The chiropractor says that the realignment of the muscle will mean a forever battle of trying to keep the spine aligned and not pinching the nerve.  

Having the latissimus procedure is a huge regret for me. I wish I’d just had an implant.

The other breast just had a lumpectomy, rather than a full mastectomy. I have a small implant on that side that has never caused me any issues.

I want to know if the latissimus can be reversed and have an implant put in.

Answer from Dr. Kline:

I’m sorry you’re having so much trouble. That actually isn’t the norm for latissimus flaps, but it certainly can happen, as you know.

The latissimus can be transferred with or without dividing its motor nerve (thoracodorsal), and with or without dividing its attachment to the humerus (arm bone).

If the breast is shifting away from the center, that’s an indication that it may still be attached to the arm bone. If you have spasms, or intermittent pulling pain, it could be because the nerve isn’t divided, and the muscle is still functioning.

This doesn’t bother most people, but it definitely bothers some.

Sharp pain shooting down your arm (especially the inside of the upper arm) could indicate compression of the intercostobrachial cutaneous nerve, which lies in that area.

Offhand, I can’t think of an obvious anatomical explanation for your hand numbness and tingling, however.

Three muscles, the pectoralis major, the teres major, and the latissimus dorsi all attach to your upper arm bone at about the same place, and all pull the arm towards your body, but they each pull from a slightly different angle.

The latissimus is now rearranged to pull from the same angle as the pectoralis major. Usually, this does not cause a problem, but that’s not to say it never does.

It’s not really practical to actually “reverse” a latissimus flap, in the sense of putting it exactly back where it was. The flap can certainly be removed, however, and it is not at all unreasonable to think that that might help your symptoms.

In addition to perforator flap breast reconstruction, we also do implant reconstruction, but we shifted to placing the implant exclusively in front of the muscle about three years ago.

This can result in some visible rippling, but it has multiple benefits, including lack of animation deformity when the muscle is contracted, less chance of the implant coming out of position, less damage to the pectoralis muscle, and less discomfort.

Successful placement in front of the muscle is made possible by completely or nearly completely wrapping the implant in acellular dermal matrix (preserved skin, such as “Alloderm”), which heals to the tissue around it, and provides support.

While it may often be a very prudent decision to travel to see surgeons with extensive experience for complex procedures such as perforator flaps (DIEP, sGAP, PAP, etc.), simply removing the latissimus and placing an implant (or a tissue expander initially, which can be safer) requires no unusual skill, so I would recommend that you first consult your previous plastic surgeon, or another in your geographic area.

I would still be happy to speak with you about your situation, however, if you wish.

Have a great weekend, and thanks for your inquiry.

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

 

 

Ask the Doctor: I am Ready for My Second Mastectomy. What are my Options and Can I do a Lymph Node Transfer at the Same Time?

purple crocus

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

Question: I am looking at reconstruction options after a right mastectomy in September, ready for other side mastectomy and reconstruction in June. I’m interested in lymph node replacement also.

Answer: We would be more than happy to help you any way we can. We work with several breast oncology surgeons, and routinely do immediate reconstruction with DIEP flaps, GAP flaps, or pre-pectoral implants (usually just local patients for implants, though, as they actually require more postop visits than flaps).

We usually don’t recommend doing lymph node transfer at the same time as flap reconstruction, because 1) doing the nodes at the same time entails compromises in the flap placement, the node placement, or both, and 2) placing a healthy unradiated flap will sometimes improve lymphedema by itself. We do, however, routinely incorporate lymph node transfer in second-stage flap surgeries, and that has worked nicely from a technical standpoint.

I would be happy to chat with you more about your options, or see you any time you would like to make an appointment.

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

Ask the Doctor: Do You Take Medicare Replacement Plans for Breast Reconstruction?

This week, Gail Lanter, CPC Practice Manager, of The Center for Natural Breast Reconstruction answers your question.

Question: The worst part of my battle was with a Medicare Advantage Plan HMO. I’ve switched to a different plan and am thrilled with the way my breast cancer situation has turned out. We are not objects for the medical community. Most women would never initiate what I have had to go through. I am so thankful that I have gone the route I did.

Answer:  Thanks for reaching out. Sounds like things are going well for you, that’s great to hear!

We understand completely the problems many patients are having with Medicare Advantage (Replacement) plans, both the PPO and HMO’s. They are difficult and sometimes impossible to deal with from both the patient and provider perspective. We have decided that our practice will not accept new patients with a Medicare Replacement plan going forward for microsurgical free flap breast reconstruction procedures – only Traditional Medicare.

Maybe one day we’ll reconsider – but not until some significant improvement in both the provider service and claims processing areas within those payers takes place. It’s awful the way two of the top 10 largest insurers in the United States who offer Medicare Replacement Plans treat patients and their providers and it should be stopped.

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

Ask the Doctor – I Was Recently Diagnosed With Cancer. When Is The Optimal Time for Natural Reconstruction If Radiation Treatment Is Planned?

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

Question: I am a newly diagnosed cancer patient in Atlanta.  I am scheduled for a left side mastectomy a week from today.  Mammography and MRI found pretty extensive DCIS on the left side of the left breast extending to and abutting the chest wall.  I am likely to require radiation treatment because of the proximity to the chest wall.  My plan is to have a tissue expander put in at the time of surgery.  I cannot get myself comfortable with the idea of an implant although my plastic surgeon here has said I am too thin for a natural reconstruction procedure.  I am interested in revisiting this and/or maybe getting a second opinion after the mastectomy.  My question is when the optimal time for a natural reconstruction would be when radiation treatment is planned?  Should it be done at the same time as the mastectomy ideally or after radiation treatment?  Thank you.

Answer:  Hi and thanks for your question. Sounds to me like you are on track for doing things the right way. If you need radiation we would not want you to have natural tissue reconstruction until after your radiation treatment. Possibly 3 months after radiation is complete. In the meantime having the expander placed immediately after the mastectomy (same procedure). Then you can remove the expander later at the time of your natural tissue reconstruction. I would be glad to give you my opinion I frequently see patients who other doctors say they don’t have enough tissue. Frequently we can get a nice result with natural tissue. Let me know if you have other questions or would like to talk over the phone.

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

Ask the Doctor – Is It Common To Have Breast Reconstruction Done At The Same Time As A Mastectomy?

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

Question: My dear friend has recently been diagnosed with stage 1 breast cancer – estrogen driven. Cells were found in the ducts but negative in lymph flow.  She has been scheduled for a mastectomy and she has decided to have both removed. She has been informed that she will need to have a hysterectomy soon after. I am an RN having worked in-house bedside with patients for 25 years. She is to be scheduled for surgery later this week and has been told reconstructive surgery for both breasts will be done as the surgery is completed. Is this commonly done? The patients I worked with generally had the reconstruction after chemo and radiation.  What is your professional insight?  She is terribly afraid and she has 11 and 8 yr old sons.

Answer: Yes, it is very common to have reconstruction done at the same time as the mastectomy. While there may be a slight increase in the complication rate doing it this way, most people feel that the advantages of doing them together outweigh any potential disadvantages. The one time that we would NEVER do immediate reconstruction is if the patient wanted natural tissue reconstruction, but we thought there was some chance that she would be radiated, as we NEVER want to radiate the transferred tissue. I do not wish to speak for your friend’s oncologists, but the two most frequent reasons for receiving radiation are 1) one or more positive lymph nodes, or 2) a tumor greater than 5 cm in largest dimension. Even if we know that radiation is to be received postoperatively, however, there is no problem reconstructing with implants or tissue expanders at the same time as mastectomies, and there may, in fact, be some potential advantages, primarily in terms of the quality of the final result.

I certainly understand your concern and your friend’s concern, but there is every reason to think that she will do well. If I can be of any assistance by talking to her or anyone else, please let me know, I would be happy to do so.

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

Ask the Doctor – What Options Do I Have When Removing My Breast Implants?

This week, Audrey Rowen, PA-C, of The Center for Natural Breast Reconstruction answers your question about breast reconstruction.

Question: I had silicone implants in 1988 under skin, which ruptured. In 2012, had bilateral implant exchange with saline implants under muscle. In 2016, the right saline implant ruptured; it was always hard with capsular contraction. I have been trying to find a plastic surgeon who will do a capsulectomy on Rt & Lt… and ideally tissue transfer from my body. (I read the FDA has 356 MDRs of lymphoma including 9 deaths, with saline implants, mostly textured but also smooth.) So, as long as I have a rupture (the right breast is flattened), I may as well have both saline’s removed. Does the fat transfer go under the skin or muscle? Would this be a good option for me at this point? Is the capsulectomy better than the explant-ation? Of course, it also depends on cost! Thank you.

Answer: Thanks for reaching out! I’m sorry to hear that you’ve had quite a lot of trouble with implants over the years. Were your implants placed for reconstruction or for cosmetic purposes? We do a lot with both implant reconstruction and natural tissue, both of which are almost always placed above the muscle. Our office also mostly prefers to use smooth silicone gel implants instead of saline, and we choose not to use textured implants often for a few reasons, one of them being what you researched about the Anaplastic large cell lymphoma.

The biggest question that determines what your best options would be whether you had a breast cancer diagnosis or other factors that would make your case reconstruction vs. cosmetic. Once we get that information from you, I feel we can better give you an idea of what we might be able to do for you.

I look forward to hearing back from you to see how we can help you!

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

Ask the Doctor – Who Do I Ask About My Cancer Treatment, My Plastic Surgeon, Breast Surgeon, Or Oncologist?

This week, Audrey Rowen, PA-C, of The Center for Natural Breast Reconstruction answers your question about breast reconstruction.

Question: Who do I ask about my cancer treatment, my plastic surgeon, breast surgeon, or oncologist?

Answer: Thanks for reaching out to us! That is typically a question we would defer to an oncologist to answer as they can calculate your overall risk for recurrence and how different surgical vs. medical treatments can impact that risk. Technically a lumpectomy is only removing the cancerous area, leaving the rest of your breast tissue intact, so by surface area, a lumpectomy leaves more breast tissue that could potentially develop a new breast cancer, where a mastectomy is an attempt to remove all breast tissue.

The options for reconstruction are much more plentiful with mastectomy vs lumpectomy, but that shouldn’t necessarily sway you either way. If we can answer any reconstruction questions about whichever option for cancer treatment that you may choose, please let us know. But definitely, chat with your oncologist about what they feel is your best option for overall survival.

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

Ask the Doctor – I Have Implants But They Feel Horrible And My Reconstruction Looks Terrible. Is There Any Hope After Reconstruction?

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

Question:  I have implants. Do not like them they feel horrible and my reconstruction looks terrible. Is there any hope after reconstruction. I have appointment 2/23/2018.

Answer:  Fortunately, your previous unfortunate experiences with implants in all probability do not affect our ability to get you a satisfactory reconstruction using only your own tissue.

I look forward to meeting with you!

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