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Your Questions about DIEP Flap Breast Reconstruction Answered

January 27, 2012 by

The below questions are answered by Charleston breast surgeon, Dr. Richard M. Kline, Jr. of The Center for Natural Breast Reconstruction:

What are the most common reasons a diep flap will fail?

Specifics may vary from case to case and practice to practice, but all failures involve interruption of the blood supply. This can be caused from a clot forming at the arterial or venous anastomosis, or from a conformational change in the blood vessel which produces “kinking” and subsequent interruption of blood supply. Most surgical teams experience dramatically lower failure rates as their experience expands, and it can get very difficult to determine precise reasons for failure (and ways to prevent it) when failure is a very rare event, i.e., success rates of 98-99%, which is typical for experienced surgeons. The best teams will nonetheless strive, whenever they have a failure, to find some “take home message” which they can use to hopefully further minimize their failure rate.

If you had a failure with Diep on one side does that increase your chances of failing again if another flap procedure were done in the future?

In our experience, no, although in a large enough series it may. We have always been able to use the internal mammary vessels, supplied through collaterals, to successfully supply blood to a second flap after an initial flap failed. Generally speaking, the collateral supply to the internal mammary from one intercostal artery is probably sufficient to supply a new flap. I do think that it is advisable, however, to wait at least 3 months following an initial flap failure before attempting a second flap, as this gives time for tissue edema to resolve, and serum protein levels to return to normal.

My Diep Flap failed on one side. I wound up with a silicone implant on the right side, and it is not healing quickly. What should I be watching for ?

That depends on what you mean by “not healing quickly.” If you have an unhealed wound, then something is really wrong, and you should see your surgeon. If it simply hurts or “doesn’t feel right,” then it may improve with time, or you may be developing capsular contracture (a common problem with implants), which may not go away. If you still want a flap, you may well still be able to have one from your buttock or elsewhere.

Do you have a question for the Charleston breast surgeons at The Center for Natural Breast Reconstruction? We’d love to hear from you.



 

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Mastectomy and Breast Reconstruction Questions Answered

January 13, 2012 by

nipple sparing mastectomyThe below questions are answered by Dr. Richard M. Kline, Jr., Charleston breast surgeon for The Center of Natural Breast Reconstruction:

What kind of breast expander do you recommend and employ?

We usually use either Mentor contoured tissue expanders, which have more projection at the bottom than the top, or Mentor round expanders with a remote port. If patients are using tissue expanders only as a “bridge” during post-mastectomy radiation until they can receive a flap reconstruction, then we prefer the remote port model, because it won’t interfere with the MRI we like to get prior to flap surgery to look at the vessels. If the patient is planning on having a permanent implant reconstruction, then the contoured expander (which is not compatible with MRI) may produce a better initial shape.

If I choose immediate breast reconstruction, what happens if it is discovered I need radiation treatment during the mastectomy? What happens then?

It depends on what type of reconstruction you have chosen. If you choose implant reconstruction, radiation doesn’t hurt the tissue expander or implant, although it significantly decreases the chance of achieving an acceptable result. If you have had an immediate flap reconstruction, then learn (unexpectedly) that you need radiation, then the flap may be in serious jeopardy. Experienced oncologic breast surgeons are usually pretty good at anticipating whether a patient will need radiation or not. If significant doubt exists, however, and a flap reconstruction is planned, it is best either place temporary tissue expanders at the time of mastectomy, or delay all reconstruction until after radiation.

What are the disadvantages of postponing breast reconstruction after mastectomy? (scarring, skin sparing options, nipple options)

The only significant disadvantage to postponing reconstruction is potential contraction of skin if a skin-sparing or nipple-sparing mastectomy is used. Depending on the amount of skin present and the ultimate desired breast size, however, this may present a problem for some patients, but not others. The advantages of delaying reconstruction include a decreased incidence of complications, and shorter anesthetics.

For breast reconstruction, what are the options for nipples?

If nipple preservation can be successfully employed, then this may give the best outcome in some cases. Not all attempted nipple-sparing mastectomies are successful, however, and many nipples have failed to survive after this procedure. Nipple reconstruction using local skin flaps has proven to be highly reliable, and tattooing of the areolas can produce very realistic results.

Do you have a question for the Charleston breast surgeons at The Center for Natural Breast Reconstruction? We’d love to hear from you.

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Charleston Breast Surgeon Answers Your Implant and Insurance Questions

January 6, 2012 by

charleston breast surgeonsThe below questions are answered by Dr. James Craigie of The Center for Natural Breast Reconstruction

Should a woman have an MRI follow up every two years after implants to check on things? I’ve been told this.

Let’s go to the source of that information for the best answer . . .

This is from the product insert data sheet included with Mentor Corporation Memory Gel Implants . . .

“Rupture of a silicone gel-filled breast implant is most often silent (i.e., there are no symptoms experienced by the patient and no physical sign of changes with the implant) rather than symptomatic.  Therefore, you should advise your patient that she will need to have regular MRIs over her lifetime to screen for silent rupture even if she is having no problems. The first MRI should be performed at 3 years postoperatively, then every 2 years, thereafter. The importance of these MRI evaluations should be emphasized. If rupture is noted on MRI, then you should advise your patient to have her implant removed. You should provide her with a list of MRI facilities in her area that have at least a 1.5 Tesla magnet, a dedicated breast coil, and a radiologist experienced with breast implant MRI films for signs of rupture.”

You can read the entire product insert data sheet here: http://www.mentorwwllc.com/Documents/gel-PIDS.pdf

Does insurance generally cover redoing of nipples and tattooing?  I’m not completely satisfied with the result of my nipple reconstruction procedure.

Great question . . . Let’s address the insurance portion first. If your health insurance covers mastectomy, it must cover reconstruction throughout all phases. There are some that do not have to abide by this rule, (WHCRA 1998) but they are few and far between. Some may limit the number of times you can undergo a procedure at their expense. The best way to assure they will pay for your procedure is to call the insurance company each time and make sure you have benefits available for the procedure you desire.

Nipple reconstructions can deteriorate over time. Those that seem a little too prominent at first tend to flatten out after a while and may no longer project enough to suit a patient.  Tattoos fade, especially when applied to skin that has a large amount of scar. This being said, repeat nipple reconstructions are a quick procedure routinely performed with local anesthesia and it’s not unusual to require a touch up tattoo.

—James E. Craigie, M.D.

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Does Lymphedema Affect Success of Breast Reconstruction?

December 30, 2011 by

breast reconstructionThe below question is answered by the team at The Center for Natural Breast Reconstruction:

Does having lymphedema (arm and trunk) affect success of breast reconstruction?

We primarily have experience using perforator flaps for breast reconstruction, so I’ll answer from that perspective. Arm lymphedema does not directly affect breast reconstruction, although there are reports of arm lymphedema improving after reconstruction using your own tissue (such as DIEP, GAP, or other perforator flaps). Trunk lymphedema (including breast), while not affecting the survival of the flap, can result in prolonged edema of the breast skin overlying the flap, leaving the reconstructed breast with a heavy, “wooden” character. We have seen this edema gradually resolve in some patients, however, over a period of up to two years, and it is possible that the flap is actually helping with this.

For more answers to your breast reconstruction questions, visit our Ask the Doctor section of this blog.

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Breast Implant Alternatives to Adding Volume, Shape, and Projection to a Breast

December 23, 2011 by

charleston breast surgeonsThe below question is answered by Charleston breast surgeon, Dr. Richard M. Kline, Jr. of The Center for Natural Breast Reconstruction:

In July 2010 I had I-GAP reconstruction. The results are awful. Do you have techniques that can work with a flap and add volume, shape, and projection to a partially recreated breast without the use of implants?

Sorry to hear about your problem, but it’s not terribly unusual to not have quite enough tissue after flap reconstruction. That’s actually good for you, because it means we have some experience dealing with this. The most desirable techniques to try, and in what order, depend on your body type and preferences, but here are some options:

1) Fat grafts: Your fat from anywhere you don’t want it can be harvested with liposuction and injected into the breast mounds in the desired areas. Survival of the fat is not strictly predictable, but often a significant amount remains permanently. Several sessions may be required, however.

2) Vth intercostal artery perforator flap: This is a fancy name we give when we utilize the extra roll of skin and fat that a lot of patients have (& hate) on the side of their chest behind the breast, under the armpit. It is left attached at the front, the skin is removed, and the flap is tunneled under the skin at the side of the breast, then across the top of the breast as far as it will reach. Besides making the breast bigger, this technique has the particular advantages of covering the upper border of the pectoralis muscle (often visible just under the skin after reconstruction), and lifting the breast in what is often a very aesthetically pleasing way. The disadvantage is that it adds a scar under the arm from where the flap was taken.

3) Additional perforator flaps: No one likes to hear this, but sometimes it is the best answer. We have always been able to find suitable blood vessels and add flaps successfully whenever we have had to try this, and the results have been favorable. Definitely not the first choice for most people, but good to know it’s a tried-and-true technique if you absolutely need it.

4) Finally, a small implant under a too small but otherwise healthy flap is often surprisingly well-tolerated, even in radiated patients. Not for everyone, but an option that has been used quite successfully in some instances, nonetheless.

We went through our “iGAP phase” some years ago, and abandoned it not because of the reconstructive results, but because we decided the sGAP donor site resulted in far more favorable buttock aesthetics.

–Dr. Richard M. Kline, Jr.

Share this post with your followers on Twitter. And if you have a question for our breast surgeons, please feel free to send us an email!

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Feel Confident in the Decisions that You Make with the TalkAboutHealth.com Online Community

December 14, 2011 by

talkabouthealthWhenever an individual is diagnosed with cancer or any other type of disease, they often struggle to find the right information, which, in turn, can make them feel alone and frightened. In an effort to provide personalized answers and a greater understanding for health issues, Murray Jones, founder of TalkAboutHealth, decided to create an online community for people seeking support and medical information and advice.

See below for our exclusive interview with Murray, where he discusses what TalkAboutHealth is and how it benefits individuals seeking support and personalized health advice:

1. What inspired you to start TalkAboutHealth.com?

I was inspired to start TalkAboutHealth based on needs that I saw from being a caregiver to my father, who is a two time melanoma survivor. We had so many questions and it felt impossible to find the right information and then understand it in a limited amount of time. We felt alone and lacked confidence in the decisions we had to make. We needed personalized answers to understand our health situation. We needed perspectives from others like us who had been through similar circumstances. We needed guidance to help find relevant information.

As time passed and I met more people in cancer communities, both medical professionals and survivors, I realized that there was so much knowledge that everyone wanted to share that just needed a place to live and someone to organize it. I thought to myself, I can do that. I can build a website where people can share their experiences.

2. How does TalkAboutHealth.com benefit patients? In other words, what does it offer to patients, survivors, and experts?

Our goal is to help patients get the right information at the right time, so they can understand their health needs and make the right decisions for them. We want to help people feel confident in the decisions they are making, know that they are not alone, and have hope after hearing the stories of others.

To accomplish this, we provide personalized answers from leading medical professionals and experienced survivors. When a patient asks a question, we find and notify the right experts, survivors, and organizations to answer. Each question has answers from several perspectives and provides context and narrative to help the patient.

We then curate and provide structure for all of this information so that it is easy to find. In the future, we will test many different formats to educate—from custom web and email tutorials to working with medical experts on video courses.

3. Why did you decide to make TalkAboutHealth.com a community-based structure, as opposed to a website that featured medical information without the opportunity to ask questions and provide feedback?

For two main reasons:

1. Because the combined knowledge and experiences of the community can have an amazing impact in helping others.

2. Community makes it possible to provided personalized and individualized support.

The purpose of TalkAboutHealth is to be a community where all of us share knowledge, stories, and experiences to support each other.

4. Is there anything else you’d like to add?

I encourage everyone, including medical professionals, to tell their story and share their experiences in whatever format is comfortable for them. It is so important for us to share and support each other. None of us are alone, we need each other. If you share your story, you will help others and find the support you need.

Have any questions about TalkAboutHealth or want to learn more? Visit TalkAboutHealth.com or contact Murray directly at murray@talkabouthealth.com.

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Are Overweight Women Better Candidates for DIEP Flap Reconstruction?

December 9, 2011 by

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

I’ve read that women who are overweight are better candidates for DIEP flaps since they have “extra” to use, what is your opinion?

Many women with high BMIs (exceeding 40) have enjoyed successful flap reconstructions; however, they are at significantly higher risk of developing post operative complications.

It is well-demonstrated in the plastic surgery literature, that people with a significantly higher BMI are far more likely to experience complications than those with a lower BMI. There is no magical “line-in-the-sand” cut-off point, though—many factors, such as proportion of fat, which is intra-abdominal (vs. subcutaneous, which is what can be used in a flap), undoubtedly play a role in determining each person’s risk. Besides wound-healing problems, increased BMI also increases the risk for blood clots, which can, of course, be lethal.

Some lay-posters on blogs have stated that you shouldn’t worry about blood clots because injectable blood thinners will prevent them. This is a VERY DANGEROUS misconception—blood thinners only REDUCE the incidence of blood clots, and nothing can completely prevent them in all patients. We feel that it is your surgeon’s duty to you to assess your individual risks, and propose a plan that will get you through the surgery as safely as possible. Other surgeons, and other patients, may feel differently.

Our practice has demonstrated that it IS possible to have an outstanding safety record, while simultaneously maintaining a high reconstruction success rate. My personal flap survival rate over the last 10 years exceeds 99%, and the overwhelming majority of our patients are pleased that they went through the procedure at our facility. Our primary goal, however, is not to try and push limits by seeing what we can “get away with” in higher-risk patients. Instead, we strive to give everyone the best possible Natural Breast Reconstruction with perforator flaps, while at the same time doing everything possible to ensure their safety.

—Richard M. Kline Jr., M.D.

The Center for Natural Breast Reconstruction

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What To Do If Fear Is Keeping You From Undergoing Breast Reconstruction

November 25, 2011 by

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

I am scheduled for reconstruction on the 29th. I feel as though I shouldn’t go through with it because, for one, I am 58 years old and secondly because I am scared that I will not be pleased. Thirdly, I heard that it is very painful and is worse than the bilateral mastectomy I had. I am so confused as to what to do.

Firstly, if you are scared, and feel strongly that you shouldn’t do it, then DON’T—END OF DISCUSSION! We’re talking about a quality-of-life surgery, not life-saving surgery. Attitude about the outcome is far too important to risk going into it feeling like you shouldn’t.

Having said that, unless you have a serious medical condition making the surgery dangerous, diabetes, or inadequate donor sites (I assume we’re talking about DIEP or GAP flaps), statistics suggest it might not be as bad as you fear.

Age is of no consequence—some of our happiest DIEP patients (and best healers) have been in their 70s.

Satisfaction with the final outcome is critically dependent upon realistic expectations, which can only be arrived at through careful preoperative discussion with your surgeon, and ideally, also through discussion with other patients.

Perforator flap surgery IS more painful than mastectomy, but pain is a relative thing. A few patients say it is terrible, most say it was about what they expected, and a few say they had almost no pain, even the day after surgery. I can think of one patient out of hundreds who suggested she might not have gone through it if she knew how bad the recovery would be.

Best of luck to you, and please feel free to ask any more questions.

—Dr. Richard M. Kline, Jr.

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Answering Your Breast Implant Questions

November 18, 2011 by

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

I had cancer in my left breast 15 yrs. ago, had the lump taken out, then developed a rather large cyst in the same breast. I had the cyst removed, which left me with only half a breast. I also had 8 weeks of radiation. I wanted a breast implant but the doctor said I couldn’t get one. Since it has been so long, could I now get one? I am 75 but still don’t feel good about my breast. I wear a breast form, but it’s not the same.

It is sometimes possible to reconstruct a lumpectomy defect with an implant, but your history of radiation makes success less likely. To some extent, the size of the implant you would require, and the amount of radiation injury you have sustained, influence the chances for success. Flap surgery, while significantly more involved, is ideal for use in radiated tissues, as it allows us to use healthy, non-radiated tissue to replace what is missing. Age, in and of itself, does not affect the success of either surgery, as long as you are generally healthy.

—Dr. Richard M. Kline, Jr.

Do you have a question about breast implants or natural breast reconstruction? Ask the doctor by emailing us at blog@naturalbreastreconstruction.com.

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Common Breast Reconstruction Questions Answered

November 11, 2011 by

dr. richard klineThe below questions are answered by Dr. Richard M. Kline, Jr., of The Center for Natural Breast Reconstruction.

1. I had my second part to breast reconstruction and had necrosis removed, but I still have the hardness. How can it be treated? They did liposuction.

If necrosis was removed and there is still hardness, then it is most likely from either 1) additional / remaining fat necrosis, or 2) edema (can feel hard, especially likely in radiated tissue). In either case, resolution is likely without additional surgery, if you wait long enough (may take 1 – 2 years), although breasts will be smaller in either case. If pain is present, and fat necrosis is still present, then surgery to remove the rest of the dead fat may be indicated.

2. I am considering silicone implants for breast reconstruction. What should I know before I proceed—what questions should I ask?

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.

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