Ask the Doctor -After Two Different Types Of Reconstruction Over The Years, What Can I Do To Regain Some Symmetry?

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

Question: I had my first mastectomy in 1991 with a tram flap reconstruction. My second mastectomy was in 2004 with an s-gap reconstruction. In the last few years, my breasts have become increasingly uneven and have shifted on my chest. Is there something I can do to my reconstructed breasts to regain some sort of symmetry?

Answer:  Without knowing any more specifics of your situation, I can state in general terms that asymmetry after reconstruction is very, very common and that there are a host of techniques which we routinely use to minimize asymmetry as much as possible. Some of these techniques are fat grafting, reduction, contour alteration, and position changing. We have currently performed almost 1700 perforator flap reconstructions, and we likely have significant experience dealing with situations very similar to yours. I would be happy to see you in consultation any time or chat on the phone if you wish.

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

Ask the Doctor – Would I Be A Candidate For DIEP Flap Surgery After Previous Expanders Are Removed And Will You Accept VA Insurance?

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

Question: I had a bilateral mastectomy with reconstruction and I am terribly dissatisfied with my care so far. 11 Months later, the expanders are still painful. I will be asking to have them removed this week.

I have 2 questions for you. After I  have the expanders removed would I still be a candidate for the DIEP flap? I am still going to chemo (Herceptin) which will run until the end of November, provided there are no more setbacks. My second question is, do you accept VA insurance? One form of payment is through the VA another is Veteran’s Choice. I am not sure which would cover outside care. I look forward to your response.

Answer: I’m sorry you have had so much trouble, but there is a very good chance that we can help you.

Your previous unfortunate experience with expanders does not in any way decrease our ability to successfully reconstruct you with DIEP flaps. The blood vessels which we use to vascularize your flaps are well below the area where tissue expanders are placed, and we have successfully reconstructed literally hundreds of patients in your situation. One potential advantage to having the expanders removed sooner rather than later is that we get an MRI angiogram on all patients who are scheduled for perforator flap breast reconstruction, and most breast tissue expanders are not MRI-compatible. If they use a little magnet to find the port before they fill your expanders, then you can’t get an MRI with those expanders in place.

We have worked with the VA many times in the past, and Gail, our insurance expert, will contact you to investigate your situation further.

Thank you very much for your inquiry, and I look forward to meeting you.

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

Ask the Doctor – Exams Of My Implants Have Shown Nothing Wrong But Increasing Symptoms Have Me Very Worried. Is There Anything I Can Do?

Daisies

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

Question: I have pain on the side of my breast where an implant was attached at reconstruction surgery in 1987. It has always hurt but recently has become much worse. Inflammation increases with sinus and allergy problems.

The implants are still soft so my recent visit to a plastic surgeon was uneventful. As I am 75 years old, they would not remove them. MRIs have shown they are not leaking. The pain keeps me on edge thinking something is very wrong. What are my options?

Answer:  I’m sorry you are having problems so long after your surgery.

I don’t think you necessarily have to just accept your situation. You can have very bad, and painful scarring internally, especially with old implants, even if they are not ruptured. Additionally, if you are otherwise healthy, there is no reason you couldn’t have them removed, even at 75. I’m not saying that this would solve your problems (although it may), but don’t discount the option just because of your age. For what it’s worth, we have actually done DIEP flaps successfully on patients your age, and that is a much larger procedure than removing implants.

I would be happy to speak with you and discuss your situation further if you wish.

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

Ask the Doctor – Could Odd Pains In My Body Be The Consequence Of an Old Abdominal Flap Surgery Following A Halstead Radical Mastectomy?

Poppy in a feild

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

Question:  In 1987, I had abdominal flap surgery following a Halstead radical mastectomy. I keep wondering what is NOW going on in my body! When I feel odd pains I wonder if it could be repercussions of that surgery so long ago.

Answer:  Thank you for your question. If you had your surgery in 1987 and you had reconstruction using your abdominal tissue then I will assume that you had a Tram procedure. That surgery relies on partially removing the muscle from the abdominal wall. Not having the muscle in place can cause problems later in life. People can have pain or bulging of the tummy and even hernias. Of course not all patients have those problems. If your problems are in the tummy area then that is a possibility. If your problems are in the area of your breast or mastectomy then you should consider seeing a breast surgeon that specializes in doing mastectomies to make sure all is well with regard to your breast area. You could also see the doctor who follows you regarding your breast cancer history. Scaring from a “Halstead” mastectomy especially after radiation could cause aches and pains later in life. Regardless of what it might be you should definitely be seen by your doctor so they could do a complete evaluation of your symptoms. After an evaluation they could make more specific recommendations. I hope his information helps. Let me know if you have further questions.

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

 

Ask the Doctor – Can I Have Large, Under Muscle Implants Replaced With Smaller Ones? Will This Make Them More Comfortable?

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

Question: I’ve had my breast tissues removed and I now have implants. They are under my muscles, too large and very uncomfortable. Is there anything you can do to fix this and make a smaller implant? I am very unhappy with the way my breasts look, This is contributing to already very low self-esteem issues. Can you help me? What are my options?

Answer:  There is an excellent chance that we can help you. The country is currently undergoing a paradigm shift in implant-based breast reconstruction, with more and more surgeons placing the implants in front of the muscle, rather than behind. This allows for numerous potential advantages, and few disadvantages. We have been converting patients with unsatisfactory sub-muscular reconstructions to reconstructions in front of the muscle for a few years, with generally good-to-excellent results.

Another option is to remove your implants and re-build your breasts only with your own natural tissue, usually from tummy or buttocks. This is a larger operation than implant reconstruction but obviously results in an even more natural result.

I would be happy to discuss your situation further with you by phone, if you wish, or see you in my office when convenient.

Thanks for your question.

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

Ask the Doctor – What Are My Chances With DIEP Flap Surgery After Several Failed Reconstructions With Tissue Expanders and Implants?

Sunflowers

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

Question: I have had several failed reconstructions with tissue expanders and implant. I have also been put on IV antibiotics due to a staph Infection. I am wondering what my chances are with the DIEP Flap.

Answer:  Great news! Your prior failures with implants does not in any way decrease your ability to get soft, warm breasts with DIEP flaps. Many, many, many of our patients have histories of prior failures with implants, some with (10-20) prior failed surgeries, and we have been able to successfully 99+ % of them with only their own tissue. Once the infection from prior implants is eradicated from your body (if you have been healed for at least 6 months, you can generally assume that all the prior infection is gone), then subsequent reconstruction with your own tissue carries only a minuscule fraction of the infection risk of reconstruction with implants. You didn’t mention if you were radiated, but it makes no difference, breasts reconstructed with your own tissue are still extraordinarily unlikely to have problems with infection.

We would love to chat with you and discuss your options further. Looking forward to speaking with you, and thanks for your inquiry.

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

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!

The Center for Natural Breast Reconstruction Gives Answers to Commonly Asked Breast Reconstruction Questions

Having breast reconstruction surgery is a big decision.

It’s only natural that there may be many questions floating around your head about having this procedure. Questions like…

  • How much does the surgery cost?
  • Will my insurance pay for the surgery?
  • How long will it take me to heal and recover?

In order to get these questions answered, we highly encourage you to schedule an appointment with your doctor to get all the details.

In the meantime, however, our expert surgeons give some great insight into some of the most commonly asked questions.

Here’s what they have to say…

How Many Doctor Visits Does Reconstructive Surgery Take for Out of Town Patients?

Poinsetta

Our P.A. Audrey and N.P. Lindsey spend a lot of time on the phone with out-of-town patients (and their local healthcare providers) before we ever see them, making sure that nothing important is overlooked before you make the trip to Charleston.

At some point, our surgeons have a phone consultation with future patients, so that they will have an opportunity to directly ask any questions they wish.

We usually see out of town patients for the first time the day before surgery. On that morning, they get an MR angiogram at Imaging Specialists of Charleston and then bring the disc to our office to help us plan their flap.

We operate the next morning, and our patients usually spend 4 nights in the hospital.  You will typically follow up with your surgeon in our office 2 to 3 days after discharge.

We do our best to minimize the number of follow up visits by remotely managing post-operative care.  Travel is a significant risk factor for blood clots, which is a risk of the surgery (as it is for many other surgeries).

Keep reading…

Why Won’t Insurance Pay for Reconstruction?

Yellow Lily

Original Question: I don’t understand why the insurance company doesn’t pay for reconstruction if you’ve had a lumpectomy. With radiation, your breasts shrink a lot and you are all out of proportion.

Answer: Not getting insurance coverage is not always the case, especially with a lumpectomy.

If the surgery results in a significant defect or radiation negatively impacts the tissue, most times we can submit your case to your insurance company along with photos of the affected area, and they will indeed cover a reconstruction surgery for you.

Keep reading…

Would Reconstruction Be Successful for Me?

two white lilies

Fortunately, a history of radiation (and/or multiple failed attempts at implant reconstruction) does not at all decrease the success rate of subsequent reconstruction using only your own tissue.

We have successfully reconstructed hundreds of women who have had bad experiences in the past.

It is important to realize that natural tissue reconstruction is not just an operation, but a process. The first operation, the microsurgical transfer of the flaps, is by far the largest. It usually takes 6-8 hours, requires a 4-day hospital stay, and a total stay in Charleston of about a week. Recovery takes approximately 6-8 weeks.

After you have healed fully from the first surgery (usually 6 months if you have been radiated), 1-2 additional surgeries are required to achieve optimum results. These are much less involved, ordinarily requiring only one night in the hospital, and you can usually go back home as soon as you are discharged.

While the process can be lengthy, once you are done, you are REALLY done. Most women reconstructed with their own tissue come to regard their reconstructed breasts as their own, and are finally able to put the issue of breast cancer behind them.

Keep reading…

Do you have breast reconstruction questions? Send us your questions here!

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!