Posts Comments

You are here: Home / Archives for Ask the Doctor

Nerve Recovery and Breast Reconstructive Surgery

November 4, 2011 by

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

How long does it take for nerves to recover and for full skin sensation to return after reconstructive surgery?

During any surgery, numerous sensory nerves, generally too small to have names, are invariably cut. Depending on the extent of the surgery, this can result in numbness of the skin or other areas. This is not typically regarded as a complication, but rather an essentially inescapable result of making an incision in the body. Most of the little divided nerves literally “wither away,” and other sensory nerves eventually grow in to take their place, restoring sensation once again. This process can take anywhere from a few months to 1 – 2 years. There is no limit on how late sensation can be regained, but the longer, beyond 1 – 2 years numbness, lasts, the less likely it is that sensation will spontaneously return. Occasionally, numbness can persist indefinitely, although this is uncommon.

In addition to numbness, other symptoms such as discomfort, hypersensitivity, or chronic pain can also result as a consequence of nerve damage following any surgery. Thankfully, these complications are much rarer then numbness. While it can be very difficult to ascertain exactly what mechanism is causing discomfort, some possibilities include traction or tethering of nerves by scar tissue, or formation of a “neuroma,” which is a painful little ball of tissue at the end of a regenerating nerve.

Nerves irritated by adjacent scarring may be helped by massage, injection of local anesthetics, or simply the passage of time. Neuromas, which are thankfully extremely rare following breast surgery, usually result in pain when pressure is applied to a very specific location, and can be much harder to treat. Surprisingly, additional surgery is often not effective in treating these rare cases of chronic pain, and referral to a Pain Therapist for injectable nerve blocks may be the most effective option.

If you want to learn more about breast reconstruction, visit us on Facebook.

Filed Under: Ask the Doctor Tagged With: , , , , , , , ,

What Are My Options for Uneven Breasts?

October 14, 2011 by

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

I had TRAM flap reconstruction in 2002 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.

–The Center for Natural Breast Reconstruction Team

Filed Under: Ask the Doctor Tagged With: , , , , , ,

Handling Breast Implant Infections: What You Need to Know

September 30, 2011 by

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

What is the usual process for handling infections with breast reconstruction when tissue expanders are used?

Infections can occur following any type of surgery. The risk of getting an infection after breast reconstruction is low because the immune system can help defend the body from bacteria if they have invaded and are trying to multiply. Antibiotics can also be used, specifically to fight different types of bacteria, following certain surgical procedures. These antibiotics are sometimes given preventively.

When an infection does occur it is because the defense mechanisms have been compromised and the invading bacteria grow. Specifically with implants the bacteria may enter through a wound healing problem. They attach to the implant shell and hide from the bloodstream that normally delivers the body’s immune response, as well as antibiotics.

The management of this type of infection is difficult and almost always requires removing the implant. When the infection resolves and the area is healthy, then it is possible to restart the process. Usually it is 3 to 6 months before it is safe to try another implant. It is occasionally possible to save the implant when the infection has been caught early and treated with antibiotics and surgery to wash the implant pocket and to put a new one in. This approach usually involves antibiotics for a long time and uncertainty about recurrence of the infection weeks or months later when the powerful antibiotics have been discontinued.

It is important to realize that the antibiotics may resolve the outward signs of infection at first, but it only takes the surviving bacteria hiding on the implant to restart the infection when the antibiotics have been discontinued. With each new infection the bacteria may become more difficult to control because of resistance to the antibiotics. At this point, it is usually my advice to consider a new option for breast reconstruction that does not involve an implant. Usually the skin and fat can be transferred from the tummy, buttock or thighs. This can be done without sacrificing any of the important muscles. In my practice, 30 % of my patients have had problems with implants and we can successfully replace implant problems with healthy tissue and obtain a permanent natural result.

—Dr. James Craigie

Filed Under: Ask the Doctor Tagged With: , , , ,

Mastectomy and Uneven Breast Size: What Are Your Options?

September 23, 2011 by

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

Because of failed implant / expander surgery (3rd degree burn damage) from radiation, I underwent a second reconstruction procedure with DIEP flaps earlier this year and a revision three months later. I have not yet had my nipples created. There is still about a cup size difference in my breasts as well as a hollow part of the cancerous breast at the top. Is this still able to be fixed as part of reconstruction procedure or do I have to live with this? Currently, I wear a prosthetic to try and even them out but it doesn’t take care of the hollow area.

Sorry to hear about your problem. If I understand you correctly, you had a mastectomy for cancer on one side and a prophylactic mastectomy on the other side, then had radiation to the cancerous side, followed by bilateral DIEP flaps.

A size mismatch in that scenario is fairly common, even when the initial flaps weigh the same, for a number of potential reasons. The cancer surgeons are sometimes more aggressive with their mastectomies on the cancerous side, and the radiation sometimes seems to cause loss of additional tissue volume. Additionally, localized fat necrosis can occur within one or both of the flaps, which would decrease their size.

As you might expect, there is no perfect one-size-fits-all solution for this. The easiest solution might be to lift the flap on the cancer side to fill the hollow part, and then reduce the other side to match.  Autologous fat injections to the areas of tissue deficiency are sometimes surprisingly effective and long-lasting, even in the face of radiation, but there is no way to tell if the fat will survive without just going ahead and trying it.

We have significant experience using the excess skin and fat, which many people have beneath their armpit to augment the upper / outer areas of the breast mound, using this tissue as a flap based on the 5th intercostal artery. This technique often carries the added benefit of lifting and rounding the breast mound. While we are not fans of using implants in the face of radiation, the presence of a healthy flap sometimes means a small implant to make up the size difference will be better tolerated. As a last resort, another perforator flap from another donor site could be added to the first flap, but we have rarely found this to be necessary.

I would advise you against having your nipple reconstructions until you are satisfied with the state of the breast mounds, because significant later work on the breast mounds may change the nipple position or orientation.

-Richard M. Kline, Jr. M.D.

Would you like your breast reconstruction question answered? Just ask us!

Filed Under: Ask the Doctor Tagged With: , , , , , , ,

10 Questions to Ask Your Breast Surgeon

September 16, 2011 by

breast surgeryUndergoing any type of surgery is stressful. But the best way to reduce your fears, stresses, and concerns is to do your research and be prepared both before and after surgery. It’s important to understand possible complications during and after surgery, as well as details on the actual procedure.

For patients who are considering breast reconstruction surgery, it’s important to talk with your doctor about your concerns. Some of the most important questions to ask include . . .

1.     Why are you recommending this procedure?

2.     What are the risks? How do they compare with the benefits?

3.     How do I prepare for surgery?

4.     What type of anesthesia will I have?

5.     What happens during and right after surgery?

6.     Who do I talk to about breast reconstruction?

7.     How long will I be in the hospital?

8.     Are there possible complications?

9.     When can I go back to work and resume normal activities?

10.  What are the risks of lymphedema?

Did you find this post helpful? We’d love to hear from you in our comments section.

Filed Under: Ask the Doctor Tagged With: , , , , , ,

Breast Reconstruction Surgeons Answer Your Questions About Reconstructive Surgery

September 9, 2011 by

reconstruction optionsThe question below is answered by Charleston breast surgeons Dr. James Craigie and Dr. Richard M. Kline, Jr., of The Center for Natural Breast Reconstruction.

What is the difference between breast reconstruction and augmentation?

Breast augmentation is when you increase the size of a normal healthy breast, almost always with saline or silicone gel implants.

Breast reconstruction is restoring the form of a breast that has been damaged, partially removed, or completely removed. Breast reconstruction is almost always done after treatment for breast cancer, although there are some birth defects that can result in the need for breast reconstruction. Breast reconstruction can be performed with implants (the same ones used for breast augmentation), or with the body’s own excess tissue (usually from the abdomen or buttocks), thus avoiding the need to place foreign objects in the body.

What are the pros and cons of a DIEP versus a TRAM flap reconstruction?

The primary advantage of DIEP flaps over TRAM flaps is a far greater potential for preservation of rectus abdominus muscle function, since no muscle is removed with a DIEP, yet one or both rectus muscles is obligatorily completely sacrificed with every TRAM flap. Additionally, since the muscle does not need to be tunneled under the skin to reach the breast area with a DIEP, the shape of the inferior region of the breast can be better defined.

The primary advantage of the TRAM flap over the DIEP flap is that it can be done by one surgeon who does not have the skills or equipment (microscope and special instrumentation) to perform a DIEP flap. While TRAM flaps can sometimes be performed more quickly than DIEP flaps, this is not always the case, and is very dependent upon the skills and experience of the surgeon. In our practice, DIEP flaps are always performed with two fully-trained perforator flap surgeons present, which we believe contributes greatly to the success and timely completion of the surgeries.

Why don’t more plastic surgeons offer the DIEP procedure?

When the DIEP flap was originally presented by Dr. Robert Allen in the 1990s, it was frequently criticized as being too difficult for many surgeons to learn to perform easily. While many more surgeons now offer the DIEP flap, it is still more technically demanding for the surgeon than many other procedures, and can be quite difficult to learn without spending significant time with another surgeon who has considerable experience with the operation.

Do you have a question for the breast surgeons of The Center for Natural Breast Reconstruction? If so, we’d love to hear from you. Click here to ask us!

Filed Under: Ask the Doctor Tagged With: , , , , , , ,

How Can I Alleviate Scar Pain and Tightness After Surgery?

September 2, 2011 by

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

I had a Phase 1 SIEA flap reconstruction in February 2010, and a Phase 2 in November 2010. Abdominal and drain scars were revised in November 2010, but I’m still having severe pain, tightness, and discomfort, including bad scarring on part of the big abdominal incision and on both abdominal drain sites. I’m assuming that I need another surgery (I’m seeing my plastic surgeon soon). Is it correct to assume there’s a chance any new revisions might not work? And are there any techniques that could alleviate some of the abdominal tightness?

I’m sorry that you are experiencing a rare, but, unfortunately, persistently recurring, complication – not specifically of breast reconstruction surgery, but of any surgery.

Any time skin or other body structures are cut, myriad nerves, a few named, most unnamed, are unavoidably divided, or at least damaged. Most of the divided or damaged nerves “wither away,” and cause no problem. A very few of the damaged nerves stay “irritated,” and some of the divided nerves form “neuromas,” or very tender balls of nerve tissue. These account for much of the chronic pain, which some people experience following surgery. Why this occurs when it does, and how to predict or prevent it, are questions all surgeons would love to know the answer to. It is not preventable – the best a surgeon can do is warn patients that it could happen.

As a practical matter, re-operating for painful scars may not be very productive. When our patients have chronically painful surgical sites, we refer them to pain management specialists for treatment. Usually this involves injections of local anesthetics, steroids, or other agents. We have generally been pleased with the results we have seen from this.

If there are other reasons to revise your surgical site, it is not completely unreasonable to think that more surgery may favorably affect the pain, and we wish you the best of luck in that scenario.

–Dr. Richard M. Kline, Jr.

Have a question for one of the Charleston breast surgeons at The Center for Natural Breast Reconstruction? Ask us!

Filed Under: Ask the Doctor Tagged With: , , , , , ,

Have a Question About Natural Breast Reconstruction?

August 26, 2011 by

Charleston breast surgeonThe questions below are answered by Charleston breast surgeons, Dr. Richard Kline and Dr. James Craigie of The Center for Natural Breast Reconstruction.

How long does a DIEP flap breast reconstruction last?

Reconstruction of one breast with a DIEP usually takes 4 – 6 hours, and reconstruction of both breasts usually takes 6 – 8 hours. The individual patient’s anatomy accounts for most of the variability. The surgery is usually followed by a 4-day stay in the hospital. Just in case you meant “last” as in will you have to have it redone like with implant reconstruction, the answer is: a successful DIEP breast reconstruction is designed to “last” a lifetime. You may desire aesthetic improvements over time as your reconstructed breasts will behave much like your natural breasts.

Will I have to have another surgery at a future date for maintenance?

Probably not for “maintenance,” but most patients require at least 2 surgeries total (sometimes more) to complete their reconstruction. The second stage of the reconstruction is typically performed 3 months or more after the first stage, taking 2 – 4 hours, and is usually an outpatient procedure. Common things done during the second stage include reshaping the breast mounds, improving the shape of the donor site (tummy or buttocks), and often making new nipples.

For an avid athlete, softball and running, what breast reconstruction do you recommend as the least limiting to continuing sports activities?

All methods have their potential downsides.

Reconstruction with an implant requires elevating the pectoralis major muscle to put the implant under it, as the skin alone is usually not strong enough to hold the implant. While this is usually well-tolerated, it could potentially affect the function of the muscle.

Flap reconstruction using the body’s own tissue usually involves taking extra fat from the abdomen (DIEP flap) or buttocks (GAP flap). No muscle is removed in either case, but it is still possible for muscle function to be affected. While there is room for debate in this area, my feeling is that some disruption of the buttock muscle is probably better tolerated than disruption of the abdominal muscle (rectus abdominus).

Want to learn more about your breast reconstruction options? Visit our Facebook page.

Filed Under: Ask the Doctor

Do You Know Your Breast Reconstruction Options?

August 24, 2011 by

breast reconstruction optionsWe’re thrilled to share some exciting news with you, today! Dr. Richard Kline, Charleston breast surgeon, and the lovely Leslie Haywood, owner of Grill Charms™ and breast cancer survivor, were recently interviewed on one of our local Charleston news channels. During this interview, Leslie shares her inspirational story of breast cancer survival and how she chose to have the breast surgeons of The Center for Natural Breast Reconstruction perform her natural breast reconstruction.

Dr. Richard Kline of The Center for Natural Breast Reconstruction spoke about breast reconstruction options for women who are currently undergoing treatment for breast cancer or who have had a mastectomy.

See below for the interview:

If you want to learn even more about Leslie Haywood’s story (and get a chuckle from her hilarious narrative), click here to view one of our recent blog interviews with her.

For those of you who aren’t aware of The Center for Natural Breast Reconstruction and what we do, here’s a brief description:

Charleston plastic surgeons Dr. James Craigie and Dr. Richard Kline specialize in breast reconstruction for women who have undergone mastectomy and those who are considering risk reducing prophylactic surgery. Some of the procedures performed by these Charleston breast surgeons include DIEP, SIEA, and GAP free flap breast reconstruction, which utilize your own tissue with no implants and no muscle sacrifice.

Our Charleston breast surgeons also perform nipple sparing mastectomy, reconstruction after lumpectomy, microsurgical breast reconstruction, and breast restoration. Visit The Center for Natural Breast Reconstruction website at http://www.naturalbreastreconstruction.com/.

Filed Under: Ask the Doctor, In Her Words Tagged With: , , , , , , ,

Your Questions About Breast Reconstruction Answered

August 19, 2011 by

nipple sparing mastectomyThe questions below are answered by the breast reconstruction surgeons of The Center for Natural Breast Reconstruction, Dr. James Craigie and Dr. Richard Kline:

If a woman has flap reconstruction, are the nipples reconstructed at the same time or at a later date?

While it is sometimes possible to reconstruct the nipples at the same time, usually for various reasons it is preferable to delay the nipple reconstruction until a later time. Nipples must be positioned very carefully to look their best, and that means the final shape of the breast mound must be stable prior to choosing the nipple position. Tissue flaps must be carefully monitored for several days following the initial reconstruction to assure early detection of any problems, and temporarily leaving extra flap skin on the breast mound helps greatly with this. Additionally, FWIW, the skin that the nipples are reconstructed from, whether flap skin or native breast skin, frequently has no sensation, making it even easier to reconstruct the nipples as a small procedure in the office.

If a woman is a candidate for a nipple-sparing mastectomy, can she have flap reconstruction and retain her nipples?

Yes, in many cases. Problems arise when the breasts are very “ptotic” (droopy), especially if the flaps cannot be made as large as the breast tissue that was removed. The nipples can often be saved even in this situation with special techniques (examples include performing a delayed breast lift some months after flap reconstruction with the flap nourishing the nipple, or, in the case of a prophylactic mastectomy, having a breast lift or reduction some months before the mastectomy), but the overall reconstruction is more complicated and prolonged.

Can you explain what you mean by a muscle-sparing free flap breast reconstruction?

“Muscle-sparing” simply means that NO MUSCLE TISSUE at all is removed. This does not necessarily mean that the muscle suffers no injury, as the blood vessels which nourish the flap usually must be removed from the muscle, but the amount of damage is commonly small enough that the muscle ultimately recovers its function.

What are some criteria 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.

For more information on breast reconstruction, visit our website.

Filed Under: Ask the Doctor Tagged With: , , , , , , , ,
« Previous Page
Next Page »