“A Learning Experience” In HIS Words

by:  Richard M. Kline Jr., M.D.

learning is a giftI think the biggest thing I learned was how important it is to have providers you trust when you are facing surgery. For me, this was relatively easy, as my wife worked with these people all the time, and I found them immediately likeable when I met them. But how is a lay person to know who to place their trust in? I think the initial step is selecting your surgeon. He or she should immediately look you in the eyes, really listen to everything you say, answer questions honestly, and never be afraid to say “I don’t know.” I think it can help if they have already operated on people you know (as I mentioned, this surgeon had operated on my Dad), but that’s usually not going to be the case. Once you have found a surgeon you trust, the rest should start to fall into place, because they will select the best team they can to help them take care of you. As it turned out, my surgery took longer than expected because it they couldn’t do it laparoscopically, and had to “open me up.” This bothered my surgeon, but it didn’t bother me. I had trust in my team, and felt that however it worked out, it was for the best.

 

I also noticed that, by and large, everyone I came in contact with on the day of my surgery seemed to be “tuned in” to how I was likely feeling at an unusually vulnerable time. I had previously lacked firsthand experience of the importance of that empathy to patients.

 

I think that I also gained some appreciation for how the patient can sometimes contribute to a good outcome. I think my preoperative efforts to lower my blood pressure and improve my overall fitness were helpful.  On the morning of surgery my blood pressure was normal, and I think my postoperative course might have been a little easier because I was in a little bit better shape due to the exercise.

 

And I will still prescribe to my patients those Lovenox shots, because I care about their safety – but I will do it with much more sympathy.

Hey doc how are you

Recovery daze…..

By:  Richard M. Kline Jr., M.D

 

pain scaleI woke up and wasn’t sure where I was. I thought about it a while, and finally asked. A nurse said “the recovery room.” I asked how long I had been there, and she said “30 minutes.” I asked how long the surgery took, and they said “about two hours”. I knew this was longer than was planned, but I didn’t worry about it, as I felt pretty intact. They asked what my pain was on a scale of (0-10), and I said “3.5.” She asked if I wanted some Dilaudid, or if I wanted to go back to the room without it. I said I wanted it, so they gave me 1 mg i.v. While the pain hadn’t been terrible, it was significant, and the Dilaudid did a great job of reducing it. It didn’t get rid of it completely, but it did produce a kind of “warmth” that made me not care too much about the residual pain.

I then went back to the same room I’d been in before surgery, and stayed only briefly before deciding I was ready to go home. When I got up to get dressed, I immediately got nauseous. The bubbly i.v. specialist nurse was there again, and she came over and held an alcohol wipe to my nose until the nausea went away. Then home I went, happy that it was over, and not feeling too badly.

For the first few days it hurt to get out of bed. I would lie there thinking about getting up for several minutes, planning the best way to do it, and only then proceeding. Once I was up, though, moving around wasn’t bad.

About two weeks postop, I noticed that coughing or sneezing didn’t make my incision hurt any more. I started walking on the treadmill at the gym. It hurt a little, but not bad. After that, I started to forget about the surgery.

The final installment of this 4 part series will post April 30.

Surgery Day (and other tidbits)

hospital sign

By:  Richard M. Kline Jr., M.D

My wife took me to the hospital at 6 a.m., and I sat in the preoperative waiting room with the other surgery patients. Eventually my name was called, and I was taken by a female technician to a room to be weighed. I wanted to say “NOT FAIR!” when she weighed me with clothes, shoes, and cell phone, but I realized it didn’t really matter. Next she took me to a private preoperative room, handed me a gown, and told me to take off “everything”, use the bathroom, and put on the gown. This was definitely unsettling, as I’m not used to taking off my clothes in front of strangers, but I realized I was going to have to comply if I was going to get through this. As I put on the gown, I couldn’t help but think about Jack Nicholson with his butt sticking out of his hospital gown in “Something’s Gotta Give.” After I had changed, the young lady returned, and directed me to lie on the stretcher. She then announced she had to “remove my hair,” and mentioned that others would be coming to check her work. I was a little surprised because plastic surgeons have learned that there is really no need to remove hair before surgery, but the last thing I wanted to do at this point was upset the routine. As I lay there trying to be calm while she trimmed my lower abdomen and groin with clippers, she chatted pleasantly, asking at one point if I wanted the “full Brazilian wax.” After she finished, her female supervisor came in, lifted my gown and inspected the job, then told her to trim another inch of hair off the bottom.  After this was done, I got a short reprieve, after which a third woman came in and “checked my prep” again. At this point, I was starting to get over being inspected, and just wanted to move forward.

Another nurse, the self-proclaimed “i.v. specialist,” entered. She was very bubbly and chatty (perhaps even more so after I told her I was terrified of needles). She complained about me grinding my teeth when the local anesthetic went in my hand, but after that I didn’t even feel the i.v. catheter go in, which was a relief. At that point I thought I was safe, but then she pulled out a syringe, smiled, and said “Lovenox!” That needle went into the left side of my freshly prepped abdomen. I didn’t realize until then that Lovenox burns going in. Ouch.

At last I was prepped, and my wife was allowed in. What a relief to see her again! Soon the anesthesiologist came in to see me. I’d never met him, but I knew my wife worked with him frequently and thought highly of him. He was very calm and matter-of-fact, exactly what I wanted. The surgeon then entered for the final preoperative visit, confirmed the procedure, and marked the surgical site. He was calm and reassuring.

Before they wheeled me from the preoperative room to the operating room, they gave me a dose of i.v. Versed, to “take the edge off.” This was a good thing, as the process of being wheeled down to the O.R. in a stretcher was, for me anyway, surreal. I’m usually the one pushing people down these hallways – this was too weird! As the team wheeled me down the hall I said “this is a very different vantage point from down here,” and they all agreed. Once we got in the OR, they had me move myself from the stretcher onto the table. The oxygen mask went over my mouth and nose, and the last thing I remember was the slight burn of the Propofol anesthetic going into my hand and wrist.  —Lights out—

(Part 3 of this series will post April 23)

The Doctor is Out…..

the doctor is outNo worries – he’s back already!  Dr. Kline shares with us his personal experience as a surgical patient and what he has learned from being on the other side of the exam table that will enhance the personal care of his own patients.

“The Doctor is Out” is part 1 of this 4 part series.  Enjoy and have a happy day! – Gail

Three weeks before my surgery, everything was fine. I felt good, a little heavier at 56 than at 26, but still hale and vigorous. Then, while operating late one afternoon, I felt a pain in my groin. “Probably just too much strenuous exercise,” I thought, and dismissed it. It didn’t go away. The next day, it was worse. I felt a bulge. DAMN. I had a hernia.

The whole concept of needing to get treatment, instead of needing to deliver it, was foreign and unsettling. For decades I’d been used to helping other people. Now, whether I liked it or not, I was potentially going to have to sit down and let others help me.

I called the same general surgeon who fixed my 86 year old Dad’s hernia last year (why did mine have to come 30 years sooner?). He told me there was no danger in watching the hernia for a while, and that if I wanted to try and lose some weight it might get better, but it was a long shot.  As it turned out, I didn’t actually have time to try and lose weight, because it started to get worse hurt towards the end of long workdays. I turned over all my long cases to my partner, and I started looking for the soonest, least disruptive time I could find to get it fixed.

I greatly respect the people I work with daily, but I didn’t want to have surgery at the hospital where I usually worked, because I wanted things to be as routine as possible for everyone. I felt that it would be much less stressful on me (and probably everyone else) if I wasn’t in an environment where I was used to giving the orders.

Fortunately for me, my wife is a surgeon, and she regularly works at a hospital I rarely visit. I thought this might be the best place to go – my wife could kind of “watch over” things, but I would not know anyone involved in my care personally.

When I visited the surgeon for my preoperative appointment, he examined me and confirmed that I did in fact have a hernia.  We discussed options, and decided to attempt a laparoscopic repair of the hernia. He advised me that it might turn out that it was too difficult to do the surgery laparoscopically, and that they might have to “open me up.” I assured him that after 20+ years of practicing surgery, I was well aware that things are not strictly predictable, and I asked him to please do whatever he felt he needed to at the time. This was the first time I started to “loosen up” a little bit, and I was actually kind of glad that it would be him, and not me, worrying about the details in surgery that day.

I also found out in his office that I had high blood pressure, for which they put me on medication. I began to limit my salt intake, and cut back on calories. Fortunately, jogging did not aggravate the hernia, so I also increased my aerobic exercise until two days before surgery. Yes, I was “in training” for this.

On the night before surgery, I went to bed early, woke at 2 a.m., and didn’t sleep the rest of the night.

(Part 2 of this series will post April 16)

 

Ask The Doctor: I’m looking for a surgeon that performs DIEP procedures.

<alt="pink roses"/>This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your question.

QUESTION: I was diagnosed with lobular carcinoma in situ breast cancer and am looking for a surgeon that does DIEP, sensory nerve reconstruction, and vascular lymph node transfer. Does your team perform these procedures?

ANSWER: We have been specializing in the procedures you asked about since 2002. If you would like to have me give you my opinion about your specific situation let me know. My partner and I have performed approximately 1,200 muscle sparing breast reconstructions together. We also reconnect sensory nerves and are experienced in vascularized lymph node transfer. We do phone consults if you’re interested in discussing this more. Thank you!

James E. Craigie MD

Center for Natural Breast Reconstruction

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

Ask The Doctor – I am not happy with the results of my DIEP Flap surgery – Should I get an implant?

<alt="orange flowers"/>This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your question.

QUESTION: Hi, in May 2013, I had my transfer done at the same time as my DIEP flap. In that surgery, I also had a reduction on my left breast. The doctor that did my surgery left and moved somewhere else, so I’ve seen another doctor since. My new doctor tried to fix it, but it’s still messed up. He said he really doesn’t know what to do. As far as the transfer is concerned, I’m not sure it worked. I had another procedure done that helped it at first, but my cancer came back again on my pelvis bone and the chemo has made it worse. I am no longer on chemo, but I will take Herceptin for the rest of my life. Is it possible to remove the fat and put an implant in my breast?

ANSWER: Hi, if you had radiation on the reconstructed side, an implant might not be the best option. It is possible to add an implant to a DIEP to increase the size in order to match the other breast. I personally prefer to perform fat grafting to add more volume when possible. It is harder to match a normal opposite breast with an implant breast reconstruction. Removing fat normally is not the answer to revising the shape unless the fat is not living. This is called fat necrosis and feels hard not soft like normal fat. Also, if you went with an implant on that side the results would be more natural if you had more of your own fat to cover the implant. Otherwise the new breast has no natural tissue to cover it and the end result looks less natural.

James E. Craigie MD

Center for Natural Breast Reconstruction

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

Ask The Doctor – Will My Weight Impact My Breast Reconstruction Surgery Goal?

<alt="pink rose"/>This week, Dr. Richard M. Kline of The Center for Natural Breast Reconstruction answers your question.

QUESTION: Hello, I’m a breast cancer survivor. My doctors will not do a reconstruction because they say I have to lose weight. The medicine I’m taking causes me to have body aches and pains, and I’ve gained weight because of it. I’m also afraid that my cancer will return. I’m financially strained and really feel left behind when it comes to improving my body; I want to feel whole again and wanted. I just turned 50 and have been cancer free since June 2011. I’m excited to have another chance to live, but I want to feel like a whole woman again with complete confidence. What are my options? Thank you for your time.

ANSWER: Hi there, I’m sorry you’re having these problems, but we will help if we can. We have learned from hard experiences that it can be dangerous to do reconstruction with your own tissue (we do not do implant reconstruction, as a rule) in patients who are significantly overweight. That being said, the guidelines for using tissue are not strictly rigid, and it depends to some extent on how the extra fat is distributed in your body. If you would like to investigate further, we could have our nurse Chris or PA Kim call and chat with you. Thanks again for your inquiry. Have a great day!

Dr. Richard Kline

Center for Natural Breast Reconstruction

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

Ask The Doctor – Are There Any Tests To See if My Implants Are Causing My Health Problems?

<alt="Pink Flowers in a Field"/>

This week, Dr. Richard M. Kline of The Center for Natural Breast Reconstruction answers your question.

QUESTION: I had a bilateral mastectomy back in 2000 because of numerous precancerous lumps in my breasts. I had Stage 3 melanoma 8 years prior, and they operated numerous times on me. I decided to have latissimus reconstruction surgery, and since then have had numerous problems. I’m allergic to latex, numerous adhesives, sulfa, and penicillin. I’ve been suffering from fibromyalgia, severe edema throughout my body, and itchiness within the area of my chest wall and breasts. After getting this issue checked out, I was told this was not an implant problem and was sent home. Are there any tests that can check to see if the problems relate to my implants? I had a CT scan done at Mayo Clinic, and they said I had an allergic reaction to what they thought was an antibiotic. Have you seen this before in your patients? Any help would be greatly appreciated. Thank you.

ANSWER: I’m not aware of a test to see if your implants are causing any problems. To my knowledge, there has been no firm connection established between implants and symptoms such as yours, but you should check with your rheumatologist to be sure.

Having said that, we do see many patients who have implant reconstructions along with various complaints such as discomfort, tightness, pain, etc. Although it is obviously difficult to objectively quantify, many of them seem to get significant relief from their symptoms if their implants are removed, and their breasts reconstructed with their own tissue. In all fairness, most of these patients have what would be considered unacceptable reconstructions anyway (hardness and asymmetry being common issues), so it is usually pretty easy for them to decide to have their implants removed and replaced with natural tissue. If your reconstruction is presently aesthetically acceptable to you (other symptoms notwithstanding), then the issue of what to do is significantly less clear-cut.

Best of luck, and let me know if we can be of any further assistance.

Dr. Richard M. Kline, Jr.

Center for Natural Breast Reconstruction

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

Ask the Doctor – Will Insurance Cover the Reconstruction of My Breasts?

<alt="pink flower"/>This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your question.

QUESTION: When I had breast cancer in 2010, I didn’t have any insurance. Now, I have great insurance and I want to undergo breast reconstruction. Will insurance cover the reconstruction of my breasts?

ANSWER:  Hi there. Thank you for your question. If you have had a mastectomy for breast cancer reasons and now have insurance, then you should be covered. There is no time limit between having a mastectomy and undergoing breast reconstruction. You should be covered, but make sure you call your insurance company and check what procedures your insurance will take care of.

Dr. James Craigie

Center for Natural Breast Reconstruction

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

Ask the Doctor: Will Scar Tissue Buildup Be A Concern With The Gap Flap?

 

<alt="pink lotus flower"/>This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your questions.

Question: My wife had a double mastectomy 10 years ago. At that time she had latissimus surgery to fill in her breasts. Since then, we’ve had numerous surgeries, about every 2 years, due to scar tissue building up in 1 of the 2 (or both) breasts that causes tightening and even pain. Will scar tissue buildup be a concern with the Gap Flap? 2. Regarding the Gap Flap procedure, what is the rate of failure that you experience with any of the 4 surgery sites (2 buttocks, 2 breasts)? Thanks.

Answer: Hi — I’m assuming your wife has implants under the latissimus flaps, which would explain the buildup of scar tissue. GAP flaps are generally large enough to make a breast by themselves (obviously, sizes differ among different people), so implants are not needed, and internal scar buildup would be a very rare event. We last calculated our statistics in October of last year. Over 10 years, we did 217 GAPs, 49 as unilateral, 168 as simultaneous bilateral. The GAP flap survival rate was 97% overall. All of the failures were in bilateral cases, but no patient lost both flaps, yielding a simultaneous bilateral flap survival rate of 96.4%. We have done quite a few GAPs since then with no failures (most recently a simultaneous bilateral last week), so the current statistics are actually a little better than that. We don’t bury flaps, and therefore can’t miss (or ignore) a failure, so these are ironclad statistics that could survive a GAO audit. To our knowledge, only Dr. Allen (who invented breast perforator flaps and trained the rest of us), his ex-partners in New Orleans, and ourselves actually do simultaneous bilateral GAP flaps on a routine basis. I’d be happy to discuss your situation further if you wish, just call or email.

Dr. James Craigie

Center for Natural Breast Reconstruction

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