Ask The Doctor-I am 52 years old and thinking about a bilateral DIEP flap surgery.

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

Question: I am 52 years old and thinking about a bilateral DIEP flap.

Answer: Thank you for your question. Have you already had a bilateral mastectomy? Do you have a specific question regarding the surgery? If you are thinking about a bilateral DIEP you have been considering options for breast reconstruction. This surgery can be done at the time of mastectomy or it can be done any time after. Also it can be appropriate for patients who have had breast cancer or who are at high risk for breast cancer. We would be glad to contact you for more specific information if you like.  

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Ask The Doctor-I have just undergone a nipple sparring bilateral mastectomy, and I’m concerned about the outcome. What are my options?

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

Question: I am a 49 year old woman, and I have just undergone a nipple sparring bilateral mastectomy with a lat flap & expanders put in. My surgery was on 10/30, so I am at 3 weeks and am having necrosis issues on one nipple and in another area near an incision. I am extremely concerned about the outcome of my results and would love to hear your opinions as to what my options might be? We were actually scheduled for a trip to Charleston in Nov for 5 days that I regretfully had to postpone due to my recent breast cancer diagnosis. Any advice you could give me would be GREATLY appreciated!

Answer: Thank you for your question. I’m sorry your having some healing problems.   I know it can be stressful. It can also seem a lot worse than it really is. It is hard to picture the end result when you are going through the healing phase. When my patients have mastectomy skin healing problems we are very conservative and let the healing progess slowly and manage the wounds carefully. Many times the end result is much better than anticipated. I would be glad to see you when your in town to give you my opinion. Just let us know. We can try to make it convenient, it sounds like you could use a nice vacation. My office can contact you to make arrangements if you like.

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

Ask The Doctor- What Can Be Done for Inflammation of Scar Tissue?

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

Question: I have chronic inflammation of scar tissue after having breast cancer surgery and reconstructed surgery. I have been in pain now for over a year. What if anything can been done to for this?

Answer: Thank you for your question. We cannot specifically give you medical advice by email because we would need more information.  You should make sure your surgeons (plastic surgeon and breast) and oncologists know you are having problems right away if you have not already.  They will be familiar with your history and can make sure you have been checked thoroughly.

We specialize in breast reconstruction and frequently help patients having problems with their reconstruction. The effects of radiation and scaring can lead to problems and pain. We help patients with implant problems by replacing their implants with their own fatty tissue. If you would like more information I would need to have my office contact you regarding your specific situation.

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

Just ask!

Ask The Doctor-I had a double mastectomy in 2008 and now wish I had implants…is it too late?

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

Question: I had a double mastectomy in 2008 and now wish I had had implants…is it too late?

Answer: Yes, you can have breast reconstruction 8 years after your mastectomies. I have patients who have waited 22 years. Also its up to you and your plastic surgeon which technique is best for you. That includes implants. Thank you for you question!

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

 

Implant Procedure Without Expanders?

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

Is it possible to have a simple implant procedure without expanders if you have a lot of skin tissue left?

Yes, absolutely, if you are willing to have Alloderm (acellular dermis) used to help support the implant.  We specialize microsurgical reconstruction using your own tissue so we don’t actually do this procedure in our practice but there are plastic surgeons in every metropolitan area who do.  If you are in or near the Charleston area we can give you names of surgeons who are especially good at this procedure.    We know many out of our area too if you’d like to identify where you are located we can see if we know anyone to suggest you consult.

–The Center for Natural Breast Reconstruction Team

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Can I Expect Tissue Problems After Radiation Therapy?

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

What type of tissue problems should I expect after having radiation therapy post mastectomy and chemo? I have implants now, but will be having them removed and have a DIEP procedure. Thank you.

Hello,

If your implants will be removed then you should not expect problems with capsular contracture following radiation. Mainly these problems are related to your body’s rejection of the implant . The radiation will permanently affect the skin and others parts of your body that are treated with radiation. However when you recover from the radiation short term affects (usually 3-6months) you should be able to safely have a DIEP. Using your own tissue will give you the most natural permanent result without a high risk for problems due to radiation. When we know someone will need radiation following mastectomy this is our preferred method.

I hope this helps let me know if you have additional questions.

James Craigie, MD

Center For Natural Breast Reconstruction

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What are the Symptoms of Capsular Contracture from an Implant?

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

What are the symptoms of capsular contracture from an implant?

Capsular contracture is commonly described 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 symptoms can be varying from mild to severe.  Mild capsular contracture may only be detectable by your surgeon.  If the process worsens and becomes severe it may lead to changes in the breast that a person easily could tell themselves.  In other words, the shape may change, the breast may become different in shape, and clothes may begin to fit differently.  The breast may become hard and the skin and tissue over the implant can change in appearance and color.  The most severe problem related to capsular contracture would be pain and discomfort that may eventually limit the range of motion and movement of the shoulder and upper body.  Some patients relate symptoms that they describe as an “iron bra” across the chest when the scar is so thick and tight.  The chest feels like it is wrapped in something as wrapped in an “iron bra” all the way around.  Sometimes the process can worsen and actually press in, move the muscles away from the breast area, and change the shape of the ribs.  This would be the most severe form of capsular contracture and at that point we would recommend removing the implant and replacing the reconstruction with a muscle-sparing procedure.

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What are the Next Steps if Capsular Contracture Occurs from a Breast Implant?

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

What are the next steps if capsular contracture occurs from a breast implant?

The next step would depend on how severe the capsular contracture is.  All implants will develop a capsule and this may slowly lead to changes in the shape or in the most severe cases painful scarring and hardness.  When symptoms develop it may be necessary to surgically intervene.  The next step would depend on whether the patient has had radiation and the available options for reconstruction.  The first step and the least involved regarding surgery would be capsulotomy or release of the scar. Sometimes the healing process, whether there was an infection or a bruise around the breast, could have increased the risk for capsular contracture. Other times it may simply be the body’s reaction to an implant.  If after capsulotomy or capsulectomy the contracture has not resolved, the next step would be to consider moving additional healthy tissue to cover the implant or to remove the implant and replace it with your own tissue.  30% of our patients who choose to undergo autologeous reconstruction have had prior implant reconstruction and their bodies have developed severe capsular contracture.  If someone has had radiation, the capsular contracture will be more severe and most likely once problems develop the problems will continue.  Therefore, when multiple capsular contracture procedures have been necessary; our recommendation would be to consider removing the implant and replacing it with your own tissue using a muscle-sparing procedure.  Your own tissue would not develop capsular contracture and it is the most successful way to solve problems resulting from implant reconstruction.

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How One Breast Cancer Survivor Found Hope by Making Informed and Proactive Decisions

breast reconstructionThe team at The Center for Natural Breast Reconstruction is honored to share with you an In Her Words post written by a recent patient of ours, Linda Burkholder. She is an inspiration to all women who are facing breast cancer or who are at risk for hereditary breast cancer.

See below for Linda’s story:

Breast cancer—you can’t say I didn’t see it coming, but being the eternal optimist, I hoped I would dodge the bullet.  Several members of my family have died from breast cancer, including my grandmother, mother, aunt, and sister. After my sister died in 2006, I began to seriously consider prophylactic surgery. I quickly learned that there is little support in the medical community or among friends for this procedure.

After a benign biopsy two years ago I found F.O.R.C.E. (Facing Our Risk of Cancer Empowered) on the Internet.  F.O.R.C.E. is a support group for those with hereditary breast and ovarian cancer. They posted an application for a scholarship to their annual conference. I applied and much to my surprise I was granted an expense paid trip to the conference in Orlando in 2010. I can’t tell you how that changed my life. I learned so much about everything I wanted to know about breast cancer and I met several plastic surgeons who stood out to me, especially Dr. Kline from The Center for Natural Breast Reconstruction. I made a mental note to keep him in mind and took home a beach towel with his phone number splashed across it.

During the next year I struggled with my decision to have prophylactic surgery. Intellectually, I knew what to do, but emotionally I was really struggling. I joined a local F.O.R.C.E. group and kept learning and thinking and meeting cancer survivors, assuming I would have surgery when I felt more comfortable with the idea. Fast forward to June 2011. It was time for my annual mammogram. I told my family doctor I also wanted an MRI, to which she reluctantly agreed. To make a long story short, the mammogram came back normal, but the MRI showed a 1.2 cm questionable spot—a spot, I was told, because of its location, would never have been seen on any mammogram. It was a Stage 1 cancer.

This was almost 2 years to the date from my previous benign lumpectomy. In July, 2011 I had a second lumpectomy performed by one of the most respected surgeons in my area. Without consulting me she automatically scheduled me for radiation. I refused the radiation because I felt that all treatment was my decision and I wanted to consult with an oncologist first. Also, I had learned at the F.O.R.C.E. convention that radiated tissue is harder to reconstruct and I already knew I ultimately wanted mastectomies with natural breast reconstruction, not implants.

When I told the surgeon I didn’t want implants, she hit the ceiling. Clearly, no one had ever before challenged her standard treatment plan. Thanks to F.O.R.C.E., I was empowered. The next convention was two weeks away and I knew this would be where I would make my final decision, and it was. I talked with EVERY plastic surgeon at the conference. I spoke with Kathy Steligo, author of The Breast Reconstruction Guidebook, for 45 minutes at the round table breakfast. I had read her book for the third time on the plane to Orlando two days before. After the conference I came back to my hometown and started chemotherapy. I also scheduled my surgery for November at The Center for Natural Breast Reconstruction.

After consulting with my oncologist, I elected to have bilateral mastectomies with autologous reconstruction. In September my husband and I made a trip to South Carolina to meet with Dr. Kline and Dr. Baron, the general surgeon. I wanted my husband to meet my doctors. I wanted to make sure I had his full support and I wanted to make sure any lingering questions by either of us were answered.

After that meeting I was sure I wanted to go forward with the DIEP procedure. I felt very confident that everything would be alright. On November 30, 2011 I had the procedure. It was an 8-hour surgery, and everything went very well. I was in East Cooper Medical Center for four days. My nurses were great, especially Angela. I thought of her as my special angel since she was able to anticipate what was needed before being asked and was especially kind. She really took good care of me.

After my discharge from the hospital my husband and I stayed in Charleston another 10 days. I got a handicapped room at a local long-stay hotel. There was a handicapped shower and a recliner in the room. I really appreciated that recliner and I slept in it most nights. It helped to keep my feet elevated.  Every day, at least one time, I took a short, slow walk up and down the hall for exercise. I saw Dr. Kline 3 times during the next 10 days and he assured me everything was fine and my breasts looked “beautiful”—although at that time I didn’t think they looked so beautiful. Now, 5 weeks later, I can see how nicely everything is shaping up and I don’t think I will require a lot of revision at the Stage 2 procedure. I am glad I chose the DIEP procedure. The recovery is long, but it is worth it.

Did I ever seriously consider implants? The answer is yes, because implants represented the path of least resistance. I could have had the surgery done locally and I wouldn’t have had the additional expense of the trip from Indiana to South Carolina. Also, I would have had my entire support system around me. In making my decision I talked to many women who had implants and it seemed to me that they either loved them or hated them. Those that loved them seemed to love them only after 2-3 additional procedures due to complications. Everyone complained about the fills being painful and some found the implants to be cold or uncomfortable. Also there was the risk of capsular contracture and the necessity of replacing the implants every 10-15 years. I also talked with many women I met through F.O.R.C.E. who had flap procedures. I saw their results and they were fabulous. Short of a few fading scars, you could not tell that their breasts were not original. All of them seemed quite pleased with their new breasts.

Yes, recovery is a bit prolonged with DIEP. You definitely need someone very devoted to you to help out those first few weeks. I needed help getting up and down, showering, dressing, and emptying my surgical drains. My husband helped me with everything, dispensed my medications and gave me a blood thinning shot daily. I could do very little without his assistance the first 10 days following surgery, and I slept much of the time. Still, I was able to get around slowly and even went out to local restaurants my two weeks in Charleston. I also had pain medication, which made life bearable.

As the weeks have progressed, I feel my strength slowly returning. I am not yet 100% but I am planning to return to my job part-time on January 9th, with hopes of returning fulltime the following week. For anyone considering a flap procedure but fearful of the recovery, I would advise them that it is doable. It’s not as bad as you think. A certain amount of fear is normal if, like me, you have never had a major surgery. But for me, everything went fine, even though I am 59 years of age, older than any one I have met who had DIEP. So, I think if I can do it, anyone can.

My only regret is that I didn’t come to my decision for prophylactic surgery before I got cancer. Time ran out to make that decision but I am thankful my cancer was found early and I am thankful for my husband of 29 years, Larry, was by my side supporting me every step of the way. I would advise anyone facing cancer to not panic, do your homework, and be very proactive in your treatment. Learn everything about breast cancer that you can so you can understand your options. Choose your doctors carefully. Get second opinions and do what YOU think is best for you. You have many options; don’t let anyone take any of them away from you. Make your own decisions.

Having cancer has changed my view of life. It seems much more precious and much more vulnerable than before. I am thankful for a second chance and thankful that I had so many options that my mother and grandmother did not have. My mother had radical mastectomies, which are very disfiguring. I am glad that I still look much like I did before. I had nipple-sparing surgery and when I look at my breasts I still see me in there. I can’t wait to see the results following my final revisions. I am very grateful for Dr. Kline, Chris Murakami, RN and Clinical Coordinator, and all the staff at The Center for Natural Breast Reconstruction for a very positive reconstructive experience.

About Linda Burkholder

My name is Linda Burkholder and I have lived in Kokomo, Indiana the past 22 years. I am the proud mother of two adult children, a daughter 23 years-old and a son age 21. I have been married to my husband, Larry, for 29 years. I work fulltime at Indiana University as an Administrative Secretary to the Dean of the School of Public and Environmental Affairs. I love animals and have two Pembroke Welsh Corgis and four cats. In my spare time I enjoy reading and knitting.

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Breast Implant Alternatives to Adding Volume, Shape, and Projection to a Breast

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

In July 2010 I had I-GAP reconstruction. The results are awful. Do you have techniques that can work with a flap and add volume, shape, and projection to a partially recreated breast without the use of implants?

Sorry to hear about your problem, but it’s not terribly unusual to not have quite enough tissue after flap reconstruction. That’s actually good for you, because it means we have some experience dealing with this. The most desirable techniques to try, and in what order, depend on your body type and preferences, but here are some options:

1) Fat grafts: Your fat from anywhere you don’t want it can be harvested with liposuction and injected into the breast mounds in the desired areas. Survival of the fat is not strictly predictable, but often a significant amount remains permanently. Several sessions may be required, however.

2) Vth intercostal artery perforator flap: This is a fancy name we give when we utilize the extra roll of skin and fat that a lot of patients have (& hate) on the side of their chest behind the breast, under the armpit. It is left attached at the front, the skin is removed, and the flap is tunneled under the skin at the side of the breast, then across the top of the breast as far as it will reach. Besides making the breast bigger, this technique has the particular advantages of covering the upper border of the pectoralis muscle (often visible just under the skin after reconstruction), and lifting the breast in what is often a very aesthetically pleasing way. The disadvantage is that it adds a scar under the arm from where the flap was taken.

3) Additional perforator flaps: No one likes to hear this, but sometimes it is the best answer. We have always been able to find suitable blood vessels and add flaps successfully whenever we have had to try this, and the results have been favorable. Definitely not the first choice for most people, but good to know it’s a tried-and-true technique if you absolutely need it.

4) Finally, a small implant under a too small but otherwise healthy flap is often surprisingly well-tolerated, even in radiated patients. Not for everyone, but an option that has been used quite successfully in some instances, nonetheless.

We went through our “iGAP phase” some years ago, and abandoned it not because of the reconstructive results, but because we decided the sGAP donor site resulted in far more favorable buttock aesthetics.

–Dr. Richard M. Kline, Jr.

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