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?

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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 – I Was Recently Diagnosed With Cancer. When Is The Optimal Time for Natural Reconstruction If Radiation Treatment Is Planned?

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

Question: I am a newly diagnosed cancer patient in Atlanta.  I am scheduled for a left side mastectomy a week from today.  Mammography and MRI found pretty extensive DCIS on the left side of the left breast extending to and abutting the chest wall.  I am likely to require radiation treatment because of the proximity to the chest wall.  My plan is to have a tissue expander put in at the time of surgery.  I cannot get myself comfortable with the idea of an implant although my plastic surgeon here has said I am too thin for a natural reconstruction procedure.  I am interested in revisiting this and/or maybe getting a second opinion after the mastectomy.  My question is when the optimal time for a natural reconstruction would be when radiation treatment is planned?  Should it be done at the same time as the mastectomy ideally or after radiation treatment?  Thank you.

Answer:  Hi and thanks for your question. Sounds to me like you are on track for doing things the right way. If you need radiation we would not want you to have natural tissue reconstruction until after your radiation treatment. Possibly 3 months after radiation is complete. In the meantime having the expander placed immediately after the mastectomy (same procedure). Then you can remove the expander later at the time of your natural tissue reconstruction. I would be glad to give you my opinion I frequently see patients who other doctors say they don’t have enough tissue. Frequently we can get a nice result with natural tissue. Let me know if you have other questions or would like to talk over the phone.

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

Ask the Doctor – Is It Common To Have Breast Reconstruction Done At The Same Time As A Mastectomy?

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

Question: My dear friend has recently been diagnosed with stage 1 breast cancer – estrogen driven. Cells were found in the ducts but negative in lymph flow.  She has been scheduled for a mastectomy and she has decided to have both removed. She has been informed that she will need to have a hysterectomy soon after. I am an RN having worked in-house bedside with patients for 25 years. She is to be scheduled for surgery later this week and has been told reconstructive surgery for both breasts will be done as the surgery is completed. Is this commonly done? The patients I worked with generally had the reconstruction after chemo and radiation.  What is your professional insight?  She is terribly afraid and she has 11 and 8 yr old sons.

Answer: Yes, it is very common to have reconstruction done at the same time as the mastectomy. While there may be a slight increase in the complication rate doing it this way, most people feel that the advantages of doing them together outweigh any potential disadvantages. The one time that we would NEVER do immediate reconstruction is if the patient wanted natural tissue reconstruction, but we thought there was some chance that she would be radiated, as we NEVER want to radiate the transferred tissue. I do not wish to speak for your friend’s oncologists, but the two most frequent reasons for receiving radiation are 1) one or more positive lymph nodes, or 2) a tumor greater than 5 cm in largest dimension. Even if we know that radiation is to be received postoperatively, however, there is no problem reconstructing with implants or tissue expanders at the same time as mastectomies, and there may, in fact, be some potential advantages, primarily in terms of the quality of the final result.

I certainly understand your concern and your friend’s concern, but there is every reason to think that she will do well. If I can be of any assistance by talking to her or anyone else, please let me know, I would be happy to do so.

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

Ask the Doctor – What Options Do I Have When Removing My Breast Implants?

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

Question: I had silicone implants in 1988 under skin, which ruptured. In 2012, had bilateral implant exchange with saline implants under muscle. In 2016, the right saline implant ruptured; it was always hard with capsular contraction. I have been trying to find a plastic surgeon who will do a capsulectomy on Rt & Lt… and ideally tissue transfer from my body. (I read the FDA has 356 MDRs of lymphoma including 9 deaths, with saline implants, mostly textured but also smooth.) So, as long as I have a rupture (the right breast is flattened), I may as well have both saline’s removed. Does the fat transfer go under the skin or muscle? Would this be a good option for me at this point? Is the capsulectomy better than the explant-ation? Of course, it also depends on cost! Thank you.

Answer: Thanks for reaching out! I’m sorry to hear that you’ve had quite a lot of trouble with implants over the years. Were your implants placed for reconstruction or for cosmetic purposes? We do a lot with both implant reconstruction and natural tissue, both of which are almost always placed above the muscle. Our office also mostly prefers to use smooth silicone gel implants instead of saline, and we choose not to use textured implants often for a few reasons, one of them being what you researched about the Anaplastic large cell lymphoma.

The biggest question that determines what your best options would be whether you had a breast cancer diagnosis or other factors that would make your case reconstruction vs. cosmetic. Once we get that information from you, I feel we can better give you an idea of what we might be able to do for you.

I look forward to hearing back from you to see how we can help you!

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

Ask the Doctor – Who Do I Ask About My Cancer Treatment, My Plastic Surgeon, Breast Surgeon, Or Oncologist?

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

Question: Who do I ask about my cancer treatment, my plastic surgeon, breast surgeon, or oncologist?

Answer: Thanks for reaching out to us! That is typically a question we would defer to an oncologist to answer as they can calculate your overall risk for recurrence and how different surgical vs. medical treatments can impact that risk. Technically a lumpectomy is only removing the cancerous area, leaving the rest of your breast tissue intact, so by surface area, a lumpectomy leaves more breast tissue that could potentially develop a new breast cancer, where a mastectomy is an attempt to remove all breast tissue.

The options for reconstruction are much more plentiful with mastectomy vs lumpectomy, but that shouldn’t necessarily sway you either way. If we can answer any reconstruction questions about whichever option for cancer treatment that you may choose, please let us know. But definitely, chat with your oncologist about what they feel is your best option for overall survival.

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

Ask the Doctor – I Have Implants But They Feel Horrible And My Reconstruction Looks Terrible. Is There Any Hope After Reconstruction?

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

Question:  I have implants. Do not like them they feel horrible and my reconstruction looks terrible. Is there any hope after reconstruction. I have appointment 2/23/2018.

Answer:  Fortunately, your previous unfortunate experiences with implants in all probability do not affect our ability to get you a satisfactory reconstruction using only your own tissue.

I look forward to meeting with you!

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

Ask the Doctor – Do You Have Experience Replacing Silicone Implants When a Patient is Having a Reaction to Them?

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

Question: Do you have experience replacing silicone implants when a patient is having a reaction to them?

Answer:  Thank you for your question.

We have extensive experience replacing implants when patients find them uncomfortable. Most of our experience is with patients who have had mastectomies and reconstruction, but the experience translates to patients who have had cosmetic breast augmentation, as well.

There are many reasons for patients to have problems with implants, some of which we understand, and some of which we probably don’t (yet).

Sometimes the problem can be as simple as the implants have ruptured, and replacing them may solve the problem. While this is very common with older implants (> 25 years old), rupture is much less common with modern gel implants, although it can happen.

Until very recently, breast implants for augmentation were placed exclusively under the pectoralis muscle. We abandoned this approach and started placing implants in front of the muscle (a more anatomically correct location) about three years ago. This is made possible by completely wrapping the implants in Alloderm, which provides strength and padding. Advantages of pre-pectoral (in front of the muscle) placement include less pain, no animation deformity, and a more natural appearance. The primary disadvantage is an increased likelihood of seeing “rippling” in some case. Fat grafting also sometimes necessary to maximize the final appearance. Encouraged by patient acceptance in these cases, we recently starting converting patients with previously placed submuscular implants to pre-pectoral implants. The results thus far, though early, have been very good, with most patients telling us “they feel more like breasts now.”

Of course, not all problems with implants are simply due to submuscular placement. Some people get painful hardening (capsular contracture) regardless of implant position, although the complete Alloderm wrap minimizes the chance of this occurring. Some people just don’t react well to having large foreign objects in them, without being able to narrow down the precise cause further, and these people may not tolerate implants at all. In these situations, if the implants were placed for reconstruction, we have the option of completely removing the implants and replacing them with your own natural tissue taken from your abdomen, buttocks, thighs, etc. This is obviously much more involved than just replacing implants, but the quality of the result is much more natural than an implant reconstruction, and problems after completion of reconstruction are extremely rare..

Any of these techniques could potentially be used for problems after cosmetic breast augmentation, but would involve significant out-of-pocket costs, as insurance will generally not usually cover procedures to correct problems from cosmetic surgery.

I hope this helps some. I would be happy to discuss your situation further with you by phone (1-866-374-2627), or see you in the office whenever convenient.

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

Ask The Doctor – Is it Prudent to Remove the Expanders?

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

Question: I had bilateral nipple sparing mastectomies on 2/9/16 and developed a large necrotic area on the lower pole of my left breast. Air expanders and Alloderm were placed during the surgery and I have also developed redness over the area where the Alloderm is on my right breast. I have been on Keflex 250 mg qid since surgery and Levaquin was added yesterday, 2/26. My surgeon plans to debride the necrosis and perform a skin flap on Friday 3/4. Of course there is no staging of the area under the necrosis at this point. (It turned dusky the day after surgery.)

But I am keen to avoid two surgeries. My questions are these: In your opinion, is it prudent to remove the expanders, allow time for healing and then consider latissimus flap on the left? Under that circumstance, what options are there for healing the wound after debridement? Would closing good skin to good skin be best (I understand distortion is a given) and then flap it later? I will have to be referred for flap surgery and am trying to do diligence on who best to request for this. I am grateful for any advice you might be willing to offer.

Answer:  I’m sorry to hear that you are having a difficult time. From what I can gather from your question it sounds like you have had a difficult time with both breasts. On your left side the healing would be less complicated if you had the expander removed. On the right side if you have an infection then it is possible that the implant may have to be removed.

If the implants are removed then when you have healed you may consider using your own skin and fatty tissue instead of trying another expander. We specialize in breast reconstruction using your own fatty tissue without using implants and without sacrificing your important muscles. That includes the latissimus muscle. I suggest you ask your surgeons if you can consider that route as an option.

I’m sorry I can’t be more specific without more information from you about your situation, previous surgeries and medical history. If you would like more information I could have my office contact you for specifics. Just let me know. Thank you for your question.

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