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What Are My Reconstruction Options After a Lumpectomy?

August 12, 2011 by

DIEP flapThe below question is answered by The Center For Natural Breast Reconstruction team:

What are the options for reconstruction surgery after a bilateral lumpectomy?

Great question! Your options would be very similar to those you would have if you had a mastectomy. Keep in mind that if your lumpectomy was followed by radiation, the behavior of the radiated skin and tissue can complicate a reconstruction procedure utilizing implants and your best option may be to use your own tissue to restore your breast size and shape. Nonetheless, it’s your plastic surgeon’s responsibility to tell you all of the options available to you and let you choose how to proceed. Also, discuss with your surgeon any procedure that may need to be done on your unaffected breast to achieve symmetry.

Here’s my short list of options:

1. Tissue expanders and subsequent replacement with permanent implants. Ask about silicone vs. saline implants. How about the use of a skin and tissue replacement like fat or a dermal matrix (like Alloderm)?

2. Autologeous reconstruction with latissimus flap (back). Will implants be needed, as well?

3. TRAM flap (transverse rectus abdominus muscle). Uses the muscle, skin, and fat of the abdomen to rebuild the breast. Make sure you have been told of the risks involved in removing this muscle.

4. DIEP, SIEA (deep inferior epigastric perforator or superficial inferior epigastric artery). Uses the skin and fat of the abdomen to rebuild the breast but leaves the muscle of the abdomen intact.

5. GAP (gluteal artery perforator). Uses the skin and fat from the upper (inferior) or lower (superior) buttocks. Like the DIEP, no muscle is removed for this procedure.

6. TUG (transverse upper gracilis). Inner thigh donor area, utilizes skin, fat, and muscle of the upper inner thigh.

7. Intercostal perforator. Utilizes skin and fat from under the arm.

8. Maybe you’re happy with the size of your post-lumpectomy breast but would like the shape addressed. Procedures such as mastopexy or reduction mammaplasty on the unaffected breast may be the procedures to investigate.

9. If it’s a small defect, a simple fat transfer from another part of your body may remedy the problem.

Best Wishes,

The Center for Natural Breast Reconstruction Team

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Tips for Post Surgical Clothing for Breast Reconstructive Surgery

July 29, 2011 by
breast reconstruction

Chris Murakami RN, CNOR, & Christina Hobgood Naugle, PA-C

The below question is answered by Chris Murakami RN, CNOR, & Christina Hobgood Naugle, PA-C, of The Center for Natural Breast Reconstruction.

I am having a SGAP breast reconstruction in a few weeks. Do I need to buy post op surgical bras? If so, which kind and can I get a prescription for insurance purposes? Also, I heard people use various bras / camisoles with pockets for drains. Have you heard of those or think they are helpful? Do you think button down shirts are something I need to get? Anything else?

No need to buy any special bra, vest, or camisole in advance. Our hospital, East Cooper Regional Medical Center, provides a soft cotton vest with drain pockets as well as a surgical bra that acts as a post operative surgical dressing. Let them know if you feel like you need an extra for when you leave the hospital and they are great about sharing another with you.

Absolutely, I would make sure I had button down shirts and loose clothing that you can easily get in and out of. You’ll have some limitation of lifting your arms above your head so button down shirts are easiest to get on and off without lifting your arms. Some women choose to wear loose sundresses; others track suit pants or cotton shorts. Whatever you are comfortable in is fine, but keep in mind we won’t want you wearing anything right away that could potentially put any pressure on your suture lines.

Here are more helpful hints:

If you are having a DIEP breast reconstruction, abdominal swelling limits clothing choices. Wear loose-fitting garments to the hospital. Women should avoid fitted, zippered pants and skirts because they probably won’t zip when it’s time to leave. Even clothing with snug elastic waistbands may be uncomfortable. A loose chemise or drop waist dress or jumper is a good choice.

Slacks or skirts with elastic in the back and a smooth band in the front may be slightly more comfortable than those with a totally elastic waistband.

Consider clothing that doesn’t wrinkle easily. Resting and naps are necessary while recuperating.

Cotton underwear breathes and is absorbent and comfortable next to the skin. Cotton’s fiber ends help the fabric stand away from the sensitive incision area rather than hug it, as some textured, synthetic fabrics do. If you don’t already have cotton briefs, buy a pair a size larger than your normal size. A little extra room adds comfort during recuperation. For waistline incisions, bikini cut styles may be better, while full cut panties and shorts might be preferred for incisions in the lower abdomen and buttocks.

Loose-fitting nightgowns and nightshirts are comfortable, especially when made from absorbent, breathable cotton or cotton-blends. If you prefer pajamas, select those with drawstrings. Elastic waists may be less comfortable for some people depending on swelling, tenderness, and location of incision. Sweatpants or crew pants are a comfortable change from bed wear, especially those with drawstrings, which allow some flexibility at the waistline.

Flat soled shoes that slip on your feet rather than tie are great to have, too, as you may be limited in your ability to bend over and tie your shoes.

If you do need to have a special bra after your incision lines have healed, we are happy to provide a prescription. We’ve had lots of our patients rave about Nordstrom’s for post mastectomy bras. Not only do the kind folks there provide a professional fitting for mastectomy patients, but they also handle the insurance paperwork for you too!

—Chris Murakami RN, CNOR, & Christina Hobgood Naugle, PA-C

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What is Capsular Contracture?

July 15, 2011 by

breast reconstruction

The below question is answered by The Center For Natural Breast Reconstruction team:

I’m considering implant-based breast reconstruction. My surgeon mentioned a “risk of capsular contracture.” What exactly is that?

Capsular contracture is an abnormal response of the immune system to foreign materials in the human body. Medically, it occurs mostly in context of the complications from breast implants and artificial joint prosthetics.
The occurrence of capsular contraction follows the formation of capsules of tightly-woven collagen fibers, created by the immune response to the presence of foreign objects surgically installed to the human body, e.g. breast implants, artificial pacemakers, orthopedic prostheses; biological protection by isolation and toleration. Capsular contracture occurs when the collagen-fiber capsule tightens and squeezes the breast implant; as such, it is a medical complication that can be very painful and discomforting, and might distort the aesthetics of the breast implant and the breast.

Although the cause of capsular contracture is unknown, factors common to its incidence include bacterial contamination, rupture of the breast-implant shell, leakage of the silicone-gel filling, and hematoma.
Moreover, because capsular contracture is a consequence of the immune system defending the patient’s bodily integrity and health, it might reoccur, even after the requisite corrective surgery for the initial incidence.

The degree of an incidence of capsular contracture is graded using the four-grade Baker scale:

• Grade I — the breast is normally soft and appears natural in size and shape
• Grade II — the breast is a little firm, but appears normal
• Grade III — the breast is firm and appears abnormal
• Grade IV — the breast is hard, painful to the touch, and appears abnormal

–The Center for Natural Breast Reconstruction team

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Is It Normal to Suffer With Abdominal Hernias After Reconstruction Surgery?

July 1, 2011 by

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

Is it routine to suffer with abdominal hernias after reconstruction surgery? Is it possible to correct this so there will be no more hernias or surgeries?

Sorry to hear about your problem.

It’s certainly NOT routine, at least not with experienced surgeons doing muscle sparing reconstruction (such as the DIEP flap). Unfortunately, however, it can occasionally happen under the best of circumstances, and we always warn patients about this risk, although I haven’t had a patient with a hernia in several years. Depending on the particular circumstances, it should almost always be possible to fix it, although in the worst cases it could require the implantation of permanent plastic mesh. A worst-case scenario would be a patient who is significantly overweight, with a large volume of intra-abdominal fat, which would push heavily against the muscular abdominal wall from the inside. However, even this situation should be correctable. If your plastic surgeon isn’t comfortable fixing it, then a general surgeon may be (although general surgeons typically refer the WORST hernias to plastic surgeons).

Good luck, and please feel free to ask more questions if you need more information.

—Dr. Richard M. Kline, Jr.

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What is a BRCA Test and Do I Need One?

June 24, 2011 by

Dear Friends,

Since our physicians and staff members are attending The Joining FORCEs 2011 Conference this weekend, we thought we’d answer a question that pertains to this event.  Hope to see some of you at the conference in Orlando this weekend.

According to the American Association for Clinical Chemistry, “In the general population, the lifetime risk of developing breast cancer is approximately 12% and the lifetime risk of developing ovarian cancer is about 1.4%. The risks increase with age.”

So how can you tell if you are at risk for breast cancer? One way is through a BRCA test.

What is a BRCA test?

There are a variety of BRCA-1 and BRCA-2 mutations present in individuals around the world, and a BRCA-1 and BRCA-2 test is used to detect various mutations in the genes. Some of these mutations are seen in individuals who have a high risk of developing breast and ovarian cancer. If you have a relative who has been diagnosed with breast or ovarian cancer, you would be a good candidate to receive a BRCA test to determine if you carry the same gene mutation. However, a BRCA test is not recommended for the general public. It is only recommended for individuals who have a close relative(s) that has been diagnosed with breast or ovarian cancer, especially before the age of 50.

It’s important to note that there are options for individuals who receive a positive result on their BRCA test and there are ways to help prevent the onset of breast or ovarian cancer. Just because someone receives a positive result on their BRCA test, doesn’t mean they will definitely develop breast or ovarian cancer. The positive result means that they are at higher risk of developing these cancers.

It’s also important to note that if an individual receives a negative result from the BRCA test, this doesn’t completely rule out the development of breast or ovarian cancer in the individual for the future. This is because the BRCA test can only detect if a person has a hereditary breast cancer or ovarian gene mutation.

If you found this post helpful and have more questions about breast cancer and testing for breast cancer, click here to contact us.

 

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Don’t Live in Charleston But Still Want a State-of-the-Art Breast Reconstruction?

June 17, 2011 by

Chris MurakamiThe question below is answered by Chris Murakami, RN, CNOR, and Clinical Supervisor (seen to the left) of The Center for Natural Breast Reconstruction.

I live in Florida and would like to come to Charleston to have a bilateral S-GAP by Dr. Kline and Dr. Craigie. Do I need to come in for a consultation first and then come back at a later date to have the surgery or can it be done all in one trip? Please tell me how this is typically handled.

Great question! There are many ways to approach this situation and do our best to try to minimize the number of trips you need to make to Charleston. You are more than welcome to come and have a face to face consult with your surgeon and then make a second trip for surgery. For some women, that is the scenario they prefer. However, since many of our patients do have to travel to access the state-of-the-art procedures offered by our expert surgeons, we’re prepared to perform your first consultation by telephone.

During this call, we talk about the procedure you are interested in and ask some screening questions to ensure you have no medical contraindication. Once this has been established, we’ll set up a time for you to talk with the surgeon of your choice and you’ll both decide which donor site might be the best to use for your breast reconstruction. Your next step would be to notify us when you would like to proceed with the surgical procedure.

When we’ve settled on a surgical date, we order as much of your pre-operative testing in your hometown as we can. The results of this testing is sent to our office two weeks prior to your surgery day. These tests include blood work, urinalysis, EKG, and Chest X-ray. Go ahead and schedule a full physical with your family doctor or internal medicine doctor and obtain a statement of medical clearance for your estimated length of surgical time.

While all of this medical work is happening, our administrative staff has been diligently working behind the scenes, checking insurance benefits and completing all of the pre-certification processes your insurance company may require.

We’d like you to arrive in Charleston a day or two prior to your surgery date. If a breast surgeon is needed to perform a mastectomy we ask you to come two days prior. You would meet with him / her on the day you arrive, in case any testing needs to be ordered by their office.

The day prior to your surgery date is usually the busiest for you, but we try to coordinate all of your pre-operative activities to be as convenient as possible. You would have various appointments scheduled for you, including a pre-operative interview at the surgical hospital, an MRA to map the blood vessels we plan to use for surgery, and a pre-operative marking appointment and consultation with our surgeon that day before surgery.

Once the surgery day arrives, you would report to the hospital at 6:00 am. Our staff and physicians will obtain contact information for your caregivers and keep them updated on the progress of your surgery throughout your time in the operating room. Once the operation has completed and you have recovered from anesthesia, you would be transferred to the women’s services floor of the hospital for the remainder of your four-day hospitalization. Each room is private and has a twin bed in case you have someone who plans to stay with you throughout your hospital stay.

When you have been discharged from the hospital, we ask that you stay in the Charleston area for a few more days, just to assure all is well and we are easily accessible to you. We ask you to come to your first post operative appointment two days after your discharge and again on the day prior to your planned return home. You may still have donor site drains that need to be removed when you return home and we are happy to help you find a medical professional to do that for you if you don’t have a physician in your hometown who is willing to help.

Once you are home, we’re available to you 24/7 to discuss any concerns you may have, but generally, at this point, you have a viable reconstruction that should heal uneventfully. You can look forward to another visit to Charleston only when or if you require a second stage of surgery after a three-month healing period. This procedure would typically be an outpatient procedure and you might just schedule yourself some “tourist time” to enjoy our beautiful city.

—Chris Murakami, RN, CNOR, Clinical Supervisor

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What is an MRA and What is it For?

June 10, 2011 by

Dr. Richard M. Kline, Jr.

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

Why am I scheduled to have a MRA prior to my DIEP surgery? What is it and what is it for?

Preoperative imaging of perforating vessels by CTA (computerized tomographic angiogram) or MRA (magnetic resonance angiogram) is probably the most significant development in perforator flap breast reconstruction in the last 5 – 10 years.

Some of the potential advantages of preoperative imaging (with CTA or MRA) include:

1. Shortened operating time, due to knowing in advance where the desired perforating vessels are located.

2. Decreased damage to the rectus muscle, due to being able to select perforating vessels with the shortest intramuscular course. This is particularly important because it can decrease the chance of a major motor nerve to the muscle being divided. A few fortunate patients have an unusual anatomic situation in which a large perforating vessel actually goes between the two muscles, which can allow harvest with no damage to the muscle at all; this is instantly recognizable on preoperative imaging.

3. Decreased fat necrosis, due to being able to select the largest perforator.

4. Advanced recognition of those few cases when the SIEA, not the DIEP, might actually be the preferred blood supply for the flap (the same tissue would still be used)

5. Advanced recognition of those very rare instances where the deep inferior epigastric system has been divided form past surgery, or where all usable perforating vessels have been damaged by previous abdominal liposuction.

CTA has the advantage of being most readily available, but also exposes the patient to radiation. MRA does not expose the patient to radiation, but we have found that only a very strong MRI (3 tesla, or 3T) can give us images with enough detail to be really useful for preoperative planning. MRA still requires the administration of intravenous contrast agents, which can rarely have undesirable side effects. On the horizon is MRA without the need for any injection—it’s not quite here yet, but its coming.

We are very fortunate to work with a very skilled group of radiologists with a 3T MRI who are very interested in and skilled at obtaining images for our breast flap patients. We obtain preoperative imaging on all patients preoperatively, whether they are scheduled for a DIEP or GAP flap. If a patient has a contraindication for an MRI / MRA (ferrous metal implanted in the body is the most common), then we obtain a CTA.

—Dr. Richard M. Kline, Jr.

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Does Radiation Affect My Options For Breast Reconstruction?

June 3, 2011 by
Dr. James Craigie

Dr. James Craigie

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

I am not sure if I will need radiation after my mastectomy. What factors should I consider before going ahead with breast reconstruction?

Radiation therapy is part of the treatment for breast cancer for some but not all patients. To determine if it is necessary for any individual, the details of the cancer or the final path results must be known. The most common situation for radiation after mastectomy is based on the size of the cancer and the number of positive lymph nodes.

When a patient would benefit from radiation the treatment may affect the options for breast reconstruction as well as the timing of the reconstruction. There are several advantages to starting the breast reconstruction at the time of the mastectomy. These include: the breast surgeon can save more of the breast skin or even the nipple and this can set the stage for the best possible result, and avoiding an extra step and an extra recovery period.

If radiation will definitely be needed after mastectomy then I do not recommend immediate natural breast reconstruction because the radiation can possibly damage the new breast. In this situation the reconstruction would start approximately 6 months following radiation. These decisions are best made following the advice of your oncologist, breast surgeon, and plastic surgeon all working together. For this reason I am a strong advocate of the multi-specialty breast conference where each patient can be presented to all the specialists at once so they can share their opinions right away. Cooperation between experts can ensure better results and more options for each patient.

It is important to remember that if you need radiation for the treatment of breast cancer it does not mean you cannot have a very good result with natural breast reconstruction. It may however determine the order and timing of when the breast reconstruction should begin.

—James E. Craigie, MD

 

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Can I Have My Current Implant Removed to Receive a Muscle-Sparing Free Flap Breast Reconstruction?

May 20, 2011 by

dr. richard kline

Dr. Richard M. Kline, Jr.

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

I had reconstruction with implants after my breast cancer diagnosis in 2009. How hard is it to go back and do breast reconstruction with a flap? What would the recovery time be?  Also, does insurance give you a hard time about taking out the implants and revising having a flap?

It’s no trouble at all to remove implants and replace them with a muscle sparing free flap breast reconstruction. We’ve done it successfully hundreds of times. Unfortunately, roughly 30% of women who come to us are seeking conversion from a failed or unsatisfactory implant based reconstruction. Recovery time after flaps is usually 6 – 8 weeks, although some ladies recover much faster. I don’t think insurance usually gives you a hard time—once you’ve started the reconstruction process, they seem to follow through until you are finally content with your reconstructed breast.

—Richard M. Kline Jr., M.D

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How Long Should I Wait to Have a DIEP Flap After Radiation?

May 13, 2011 by

Dr. James Craigie

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

How long should I wait to have a DIEP flap after radiation?

Radiation therapy is part of the treatment of breast cancer and will affect the results of breast reconstruction. The treatments can miraculously kill some growing cancer cells but they also change the area of the body left behind after surgery.

All of the elements of the body can be affected: blood vessels, scarring, healing function, and appearance.  The effects of radiation occur in two phases. Short term occurs during and immediately after the treatments. Elective surgery at this time is not possible, for obvious reasons. The long term effects develop after the early “burn-like” injury “settles down.” The long term reaction occurs for approximately the first six months.

The experience can be widely different from one person to the next. We have experienced difficulties with the receiving blood vessels after radiation when we did not wait for the body to recover from both long and short term damage. These types of problems could possibly increase the chance for the new breast to fail. Avoiding these problems may be possible by waiting and that is why the long recovery is needed before reconstruction is started.

—Dr. James Craigie

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