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?

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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!

 

 

Ask the Doctor: I am Ready for My Second Mastectomy. What are my Options and Can I do a Lymph Node Transfer at the Same Time?

purple crocus

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

Question: I am looking at reconstruction options after a right mastectomy in September, ready for other side mastectomy and reconstruction in June. I’m interested in lymph node replacement also.

Answer: We would be more than happy to help you any way we can. We work with several breast oncology surgeons, and routinely do immediate reconstruction with DIEP flaps, GAP flaps, or pre-pectoral implants (usually just local patients for implants, though, as they actually require more postop visits than flaps).

We usually don’t recommend doing lymph node transfer at the same time as flap reconstruction, because 1) doing the nodes at the same time entails compromises in the flap placement, the node placement, or both, and 2) placing a healthy unradiated flap will sometimes improve lymphedema by itself. We do, however, routinely incorporate lymph node transfer in second-stage flap surgeries, and that has worked nicely from a technical standpoint.

I would be happy to chat with you more about your options, or see you any time you would like to make an appointment.

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

Ask the Doctor: Do You Take Medicare Replacement Plans for Breast Reconstruction?

This week, Gail Lanter, CPC Practice Manager, of The Center for Natural Breast Reconstruction answers your question.

Question: The worst part of my battle was with a Medicare Advantage Plan HMO. I’ve switched to a different plan and am thrilled with the way my breast cancer situation has turned out. We are not objects for the medical community. Most women would never initiate what I have had to go through. I am so thankful that I have gone the route I did.

Answer:  Thanks for reaching out. Sounds like things are going well for you, that’s great to hear!

We understand completely the problems many patients are having with Medicare Advantage (Replacement) plans, both the PPO and HMO’s. They are difficult and sometimes impossible to deal with from both the patient and provider perspective. We have decided that our practice will not accept new patients with a Medicare Replacement plan going forward for microsurgical free flap breast reconstruction procedures – only Traditional Medicare.

Maybe one day we’ll reconsider – but not until some significant improvement in both the provider service and claims processing areas within those payers takes place. It’s awful the way two of the top 10 largest insurers in the United States who offer Medicare Replacement Plans treat patients and their providers and it should be stopped.

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

Ask the Doctor – Would Reconstruction Be Successful For Me?

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

Question: I had implants put in 33 years ago, got breast cancer, had a lumpectomy, radiation, and got rock hard implants as a result. I just recently decided to have the implants removed and a great deal of scar tissue. They put in expanders that caused me to get an infection. I had to almost beg them to believe me as the pain was horrific. I had a 2nd doctor remove the expanders. I now have a very deformed left breast and a severely drooping right breast. I contacted the doctor who put my implants in years ago. He is no longer in the area but told me about this procedure.

I guess my question is if this procedure would be successful for me? I do not like the way I look, and it is painful as well. I am a teacher and would need to know the time frame this would entail. It has been a horrible summer with this ordeal. I almost wish I left the rock-hard implants in. Please let me know what you think. I am very much interested in hearing your thoughts. 

AnswerThank you very much for your question. I’m sorry you have had so much difficulty. Your situation is unfortunately quite common, but the good news is that natural breast reconstruction with your own tissue can often help dramatically. Fortunately, a history of radiation (&/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 in your situation.

Our first choice for a donor area, if you have some extra tummy tissue, is the DIEP flap. If you do not have adequate tummy tissue, the buttocks (sGAP flap) is also often an excellent donor area.

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.

I would be happy to call and discuss your situation in more detail if you wish, and thanks again 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 Reconstruction Options Using Only My Tissue?

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

Question: I am 39 years old and seeking options regarding a double mastectomy with reconstruction using only my own tissue. I was treated for an aggressive breast cancer in my left breast 3 years ago; went through neoadjuvant chemo, then a lumpectomy followed by radiation. Due to my lifetime high-risk status, I feel a double mastectomy is necessary using my own tissue for reconstruction.

Answer: Thank you for your question, I am glad to hear that you have completed your breast cancer treatment 3 years ago and are doing well. It is very likely that using your own natural tissue is going to be a very good option for you.

Since you have already had radiation on one side the option of removing the remaining breast tissue and having a preventive mastectomy on the other side is the most effective option to minimize your chance of getting breast cancer again.

Although I imagine it is already very low. Have you had any previous surgery on your tummy? Do you feel that you have extra fatty tissue there or any other area of your body? If so then you can probably achieve a proportional natural tissue result without having to sacrifice your important muscles.

If you like I could arrange a convenient time to answer any other questions by phone. Let me know and I’ll have one of my staff contact you to make arrangements.

Thanks again.

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

Ask the Doctor – I Am 3 Years Post Mastectomy With Radiation On My Right Side And I Am Interested In The Diep Flap Surgery.

This week, Audrey Rowen, PA-C, of The Center for Natural Breast Reconstruction answers your question about breast reconstruction.

Question:  I am interested in the DIEP flap surgery. I am 3 years post mastectomy with radiation on my right side. I am 56 years old and live in Columbia and I have spoken with one of your patients who was happy with her breast reconstruction. I would like to make an appointment.

Answer: Thank you for reaching out to us! My name is Audrey and I am the physician assistant here at the practice. We would be happy to make an appointment for you to come and see us! Which days work best for you? Our normal clinic days are Monday, Tuesday, and Friday. If you’d prefer to schedule over the phone vs. email, feel free to call our office at 843-849-8418 anytime over the next few days and we can set that up for you.

Did you have bilateral mastectomies or just the right side? Are you interested in bilateral DIEP reconstruction? Once we get you on the schedule, we like to try getting some of your records in regards to your oncology and surgery history so it is a huge help if you could get us the names of our Oncologist, PCP, and breast surgeon so we can start requesting those records before your appointment. I am also happy to chat with you over the phone if there are any questions you would like answered before you make the trip out to see us.

Please let us know which days and times work best for you to schedule an appointment and let me know what other ways I can help! We look forward to meeting you soon!

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

Ask the Doctor- I’m Having Pain After My Last Latissimus Flap/Implant Reconstruction. What Can I Do Now?

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

Question: I was diagnosed with breast cancer in 2011, and had a mastectomy on my left side followed by chemo. In 2014, my mammogram began showing tumors and I would have an ultrasound every time. This caused panic attacks and I choose to have my right breast removed because the type of cancer I had was Stage 4 Aggressive. In April 2015, I had a bilateral latissimus flat and received implants. Now I am experiencing pain across my back where I was cut and my chest gets uncomfortably tight. The site of the drainage tube is swollen and doesn’t feel good. I stopped seeing my reconstruction doctor because he did things I was not informed of. I am worried because I do not know what is going on anymore. Could you please advise me as to what might be going on or what to do?

Answer: I’m sorry you are continuing to have problems, but you are not alone.

I can’t speak about your situation specifically because I haven’t examined you, but here are some thoughts in general about patients with symptoms like yours.

There is no question that many people with implants describe symptoms such as yours. Often, there is no discernible reason why they should feel discomfort, but they do. Nonetheless, many of them feel relief when the implants are removed. This does not mean that you would or should, it is just an observation.

The latissimus flap can be done with or without dividing the nerve that makes it contract. I have known some patients with latissimus flaps done without dividing the nerve to have discomfort associated with the muscle contracting. Some have experienced relief when the nerve was subsequently divided. Obviously, I don’t know if this is your situation or not.

Sometimes people have complex, persistent pain after surgery or injury which is out of all proportion to what would be expected. This can be difficult to treat but thankfully is rare.

When evaluating a patient with symptoms like yours, we usually start with a careful history and physical evaluation. Sometimes, especially if we have concerns about implant rupture, fluid collections, infection, etc., we then get an MRI and/or CT scan Following the complete evaluation, we then decide together how to proceed.

Hope this helps at least a little. I would be happy to chat with you further by phone about your specific problem or see you in person if you can come for a visit.

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

Ask the Doctor- Can You Do Repair and Nipple Reconstruction Surgery at the Same Time on the Same Breast?

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

Question: I had hybrid DIEP reconstruction at another facility, and I am disappointed with the results. There have been many issues. For example, my breasts are different shapes and sizes, no node involvement and no microinvasion. The surgeon who did the mastectomy said the path report said the margins were not wide enough and he will need to cut additional skin out during the next surgery. The next surgery is supposed to be to reconstruct the nipple. Can you do both procedures on the same breast at the same time? Please Help!!

Answer: I’m sorry you are having to go through this.

Did you have a complete mastectomy on the left breast or a lumpectomy? If your margins were positive (unbeknownst at the time of surgery, obviously), and you had an immediate DIEP flap, that could be a little complicated to resolve, although I’m sure we could work through it. Given that your scenario is a little bit unusual, it would probably be best if we talked by phone. Please let us know what works for you.

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