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Are You Comparing Apples to Apples When Weighing Your Breast Reconstruction Options?

January 11, 2013 by

We at The Center for Natural Breast Reconstruction know that the Internet is a great place to read and share information, but it is also a great place to become misinformed. Before making any decisions about your breast health, please make sure to contact a surgeon to discuss all your options and make the most informed decision you can. Keeping with the spirit of the Internet as a research tool, today’s Ask The Doctor Question comes from a discussion forum we participated in on WebMD.com. The answer highlighted below in pink comes from our team and showcases the importance of making sure you really are comparing apples to apples when weighing your breast reconstruction options.

Q: Has anyone had a hard time with breast reconstruction after bilateral mastectomy? I had two infections in my right expander, 2 and 3 months after my surgery. The first we conquered with antibiotics; the 2nd we did not, and I had to have it removed 4 months later. I spent the last 5 months healing from that, and just last week had the expander replaced. Hoping for the best this time! But there is significant skin loss on my right side, and my surgeon wonders if there will be enough stretch to accommodate saline fills to match my other side. And of course we all wonder if THIS expander will behave itself and not get infected. Has anyone had this experience, or one similar? Thanks.

A: Why don’t you go with the DIEP Flap procedure – they use the fat and skin from your abdomen area – I have had no problems from this procedure and I have heard of a couple of people who have had issues with infection with the expanders. Find yourself a Plastic Surgeon who does the DIEP Flap procedure

A: I also had a bilateral mastectomy but had to wait 2 years before reconstruction. I also had the expanders but had no problems, maybe it was too soon after your surgery. I would not recommend a tram flap ,it just sounds like an awful surgery.

A: There is a difference between and DIEP Flap and a trans flap.
The DIEP Flap they only take the fat and skin from your abdomen nothing else – they find a good blood supply at the reconstruction site. The Trans Flap is they take your stomach muscle and pull it up through to the breast cavity and also bring the fat and skin from the abdomen area. I for sure was glad that I did not do the Trans Flap.

A: (The Center For Natural Breast Reconstruction’s Answer) The free TRAM flap sacrifices a portion of the transrectus abdominus muscle (hence the acronym TRAM) but doesn’t tunnel it up through the abdomen. The DIEP flap does not use any of that muscle to transfer the blood supply to the reconstruction site. A skilled micro-surgeon with fellowship training in muscle sparing free flap reconstruction provides a permanent reconstruction option with a successful DIEP without sacrificing needed abdominal musculature. There is A LOT of great information on the web about this and what questions you should ask to make sure you are choosing a microsurgical team who has the experience and at least a 98% success rate. Talk to ladies who have had DIEP, GAP, HIP, SIEA flaps ( but not TRAM, it’s not the same) and see what kind of downtime they have had, you’ll probably find it similar to the amount you have had with the repeated implant/expander problems. Best wishes on your research and recovery.

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What to Know Before Seeking Implants as Your Breast Reconstruction Option

January 4, 2013 by

The below question is answered by Dr. Richard M. Kline of The Center for Natural Breast Reconstruction.

I am weighing my options for breast reconstructions and  considering silicone implants. What should I know before I continue—what questions should I ask a doctor?

Silicone or saline implants, while generally very safe from a medical perspective, are still subject to some complications. The most common problem is that either type implant can develop a hard capsule of scar tissue around it (capsular contracture), which is sometimes painful, and makes the breast mound hard (and often unattractive). Generally speaking, the thicker and more normal the soft tissue covering around them, the better result implants tend to give when used for reconstruction. The presence of radiation injury greatly decreases the chances of success when using either silicone or saline implants for breast reconstruction, and flaps may be a better alternative in that case.

-Dr. Richard M. Kline Jr.

The Center for Natural Breast Reconstruction.

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What Would Disqualify a Patient for Breast Reconstruction?

December 28, 2012 by

The question below is answered by Charleston breast surgeon Dr. James Craigie, of The Center for Natural Breast Reconstruction.

What are some circumstances that may disqualify a patient for breast reconstruction?

Any serious medical conditions which would prevent a patient from tolerating 4-8 hours of general anesthesia would prevent her from having flap reconstruction. Some medical conditions, such as diabetes, increase various risks (in particular, risks of wound healing problems), but do not disqualify the patient from having reconstruction. We do not perform reconstruction on patients who are currently cigarette smokers (or use nicotine in any form) because nicotine’s effects on wound healing after flap surgery is frequently catastrophic. However, most patients will clear all nicotine form their system after a month’s abstinence. Some very slender patients do not have enough donor tissue anywhere on their bodies for flap reconstruction, but this is quite uncommon.

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Natural Breast Reconstruction on Slender Females

December 21, 2012 by

implantsThe below question is answered by Dr. Richard M. Kline, Jr. of The Center for Natural Breast Reconstruction.

I had a 4.6 cm lobular carcinoma treated with neoadjuvant chemo (ac+t). Five treatments to go scheduled to end on 1/17/12. Tumor had been reduced to 2.7cm thus far. Scheduled for bi-lat mast in early Feb. I am slim, 5’4″ and 112 lbs now. Normally about 120 lbs. surgeon here in nj is recommending expander and fills followed by radiation and several months later, an exchange. He says I may have enough abdominal fat for a tram flap for one breast. Could I come to you six months after radiation for a diep flap or some other procedure if I just have mast and do nothing else for six months following rads? Thank you

Hi,

Sorry to hear about your situation, but we would absolutely be happy to see you. If you have decided for sure you want to be reconstructed with your own tissue, I would strongly recommend that you stick to your guns and not have expanders placed, for the following reason. The expanders will create a “divet’ in your bony chest wall, which will not go away, and some of your flap volume will be required to fill the “divet,” and thus not be visible in the breast mound. If you were more “fuller-figured” this would not be an issue, but it is a huge issue for slender patients. We have encountered very few patients who cannot be reconstructed due to inadequate donor sites, although it’s not too uncommon for slim patients to not end up quite as large as they’d wished. If you’d like to send photos of front and back we could give you a preliminary assessment of your donor sites, although of course the absolute assessment is best done in person.

Good luck, and please feel free to call or email with any other questions.

Richard Kline
Center for Natural Breast Reconstruction

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DIEP Flap Procedure: Is this covered by my insurance?

December 14, 2012 by

mental healthThe below question is answered by Charleston breast surgeon, Dr. Richard Kline of The Center for Natural Breast Reconstruction.

I had a double mastectomy last month and am considering the DIEP procedure. My insurance is Aetna PPO and I wanted to know if this is covered. Also, I keep reading about stage 11 follow up to do lipo on the upper abdomen so it is flat like the bottom half ( after surgery) . Is that part of the reconstruction and is it covered by insurance? Thanks

Hi,

I’m almost sure we are in-network for you, but our office will let you know for sure.

We use liposuction to help correct some donor site deformities, such as bulging of the upper abdomen, or fullness of the “muffintop” areas. Often, that fat can be used as graft to enlarge the DIEP flaps, or improve little areas of asymmetry. If we place fat in the breast, we add a code for fat grafting for the insurance company, but we never bill anyone for liposuction per se.

Hope this helps, and thanks for your question.

Richard Kline
Center for Natural Breast Reconstruction

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Implant Procedure Without Expanders?

December 7, 2012 by

breast implantsThe below question is answered by the Charleston breast surgeons at The Center for Natural Breast Reconstruction.

Is it possible to have a simple implant procedure without expanders if you have a lot of skin tissue left?

Yes, absolutely, if you are willing to have Alloderm (acellular dermis) used to help support the implant.  We specialize microsurgical reconstruction using your own tissue so we don’t actually do this procedure in our practice but there are plastic surgeons in every metropolitan area who do.  If you are in or near the Charleston area we can give you names of surgeons who are especially good at this procedure.    We know many out of our area too if you’d like to identify where you are located we can see if we know anyone to suggest you consult.

–The Center for Natural Breast Reconstruction Team

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Wound Healing Post Breast Reconstruction Surgery

November 30, 2012 by

The below question is answered by the Charleston breast surgeon, Dr. James Craigie.

How do you determine when to use a wound vac in place of a traditional drain?

We have discussed the idea of using a wound vac in place of drains.  We have actually determined the use for combining the wound vac and drains under certain circumstances.  Some people have had radiation or have challenging wounds that result from wound healing problems combined with fluid collections caused seromas.  Sometimes drains are needed to evacuate seromas but unfortunately they are not always adequate.  Also, radiated tissues have difficulty healing and wounds developed in radiated tissue sometimes typical wound dressings may not be adequate as well.  We have used the wound vac combined with the drain in order to treat these complex wounds.  We have found that complex wounds are usually a combination of wound separation with fluid collections.  The drain actually passes through the wound vac sponge, the wound vac sponge is then covered with the steel dressing that is connected to a pump and the strong negative pressure generated is greater than the pressure of a normal drain.  This allows a deep pocket of fluid to be dressed with the drain tip and the open skin edge or wound edge to be treated with the sponge.  When the wound vac dressing is changed every 3-5 days, the drain can be backed out slowly and therefore as the wound edge heals, the fluid collection is controlled and the wound eventually heals quicker than other approaches.

-James Craigie, M.D.

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Breast Reconstruction Options To Correct Uneven Breasts

November 23, 2012 by

The below question is answered by the Charleston breast surgeon, Dr. James Craigie.

I had TRAM flap reconstruction in 2006 with revision and a follow up surgery in six months later. Since then some shrinkage has occurred in the reconstructive side and I have a hollow area on the upper portion. Do I have options for more normal looking breast without the hollow area?

You potentially have many options to improve your reconstruction. No one solution is perfect for all situations, but some options include repositioning the flap to a higher location, augmenting the hollow area with your own fat grafts (taken usually from abdomen, thigh, or buttocks), or using any excess skin / fat from under your armpit as an additional flap to lift and augment the TRAM (we call this a 5th intercostal artery perforator flap). Some more aggressive options would include placing a small breast implant under the TRAM flap, or adding a whole new microvascular flap from another area, although this is rarely in practice necessary.

Hope this helps. Please feel free to email or call with any additional questions.

Dr. James Craigie

The Center for Natural Breast Reconstruction

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Could I Be A Candidate for DIEP Reconstruction After Implants?

November 16, 2012 by

The below question is answered by Charleston breast surgeon Dr. James Craigie of The Center for Natural Breast Reconstruction.

I had a bilateral mastectomy and had 850cc silicone implants placed after tissue expansion. I am not happy at all with the result as I had radiation on the right side and that breast is considerably smaller than the left. I am also not happy with the shape and look of the breasts with silicone implants. I currently wear prosthetics in my bra to achieve symmetry and a normal shape. Even with the bra and the prosthetics I am not happy with the result. I am currently a D/DD and would like to maintain that size. Given this situation, could I be a candidate for a DIEP or Stacked DIEP breast reconstruction?

Thank you for your question. I’m sorry you are having some concerns about the shape and evenness of your breast reconstruction. Because you had radiation on the right side it is almost certain that the two sides will be different to some degree regardless of the type of reconstruction. Unfortunately, when this occurs with implant techniques it is usually more noticeable and nearly impossible to fix long-term as long as the implants are in place. The reason for this is the implants will be treated as foreign material by your body and the right side will always react more severely due to previous radiation even if radiation was done before the mastectomy. Also, the process of scar formation continues as long as the implants are in place, making the firmness, shape change, and stiffness more noticeable to you as time goes by. These are the reasons that women who have implant reconstruction have multiple procedures to revise results as time passes.

Fortunately when someone has had problems of this nature with implants we can frequently solve them by removing the implants and replacing them with their own fatty tissue (DIEP, stacked DIEP). We can do this without taking tummy or back muscles. Immediately the fatty tissue takes on a more natural shape compared to implants. Thirty percent of my patients have had failed implants before we start over and use their own tissue. My opinion and answer to your question is that you could have a DIEP to replace your implants and I can usually predict that many of the implant problems are much improved immediately after the surgery. I cannot predict what size you would be without seeing you but the size depends on how much extra tummy tissue you have as well as any previous surgery.

I hope I have answered your questions.

—James Craigie MD

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What Is the Recovery Period for a DIEP Procedure?

November 9, 2012 by

I’m getting ready to have reconstruction surgery in Mount Pleasant and the procedure I’m having consists of the tissue being taken from my abdominal area. How long is the recovery period for this procedure versus having the tissue taken from my back?

If the tissue from the abdomen is being transferred as a DIEP flap, you will probably require 4 – 8 weeks for recovery, of which less than one week will probably be spent in the hospital (usually 4 days in our practice). If the tissue is being transferred as a pedicled TRAM flap (in which your abdominal rectus muscle is sacrificed to carry blood for the flap), the time quoted by your surgeon for recovery may be about the same, but some patients may complain of discomfort for considerably longer periods. With either procedure, some patients will heal faster, and some will heal more slowly, not surprisingly.

When you say tissue is taken from your back, I assume you mean a latissimus muscle flap will be used. This is generally done in conjunction with a prosthetic implant being placed, as the latissimus muscle rarely has enough bulk to make a breast by itself. Generally speaking, a reconstruction using the latissimus is easier to recover from than one using the abdomen, because the latissimus is not used constantly for activities such maintaining posture and breathing. Additionally, at least two other muscles, the teres major and the pectoralis major, have functions which strongly overlap the function of the latissimus, and they are able to “take over for it” to some extent. There are no muscles which duplicate the function of the rectus abdominus quite as closely.

—Richard M. Kline Jr., M.D

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