Ask the Doctor – What Can Be Done To Fix a Previous Radiated Breast with Implant?

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

Question: What can be done for a 2004 radiated breast with implant. As common, it has encapsulated to a high degree and is painful, misshaped and raised, looking very unnatural. Thank you

Answer:  Without question, the course of action most likely to work is to remove the implant and proceed with reconstruction using your own tissue. If you still have breast tissue remaining, it can be removed by a breast surgeon at the same time that your healthy tissue is transferred.

The most common source for the new tissue (the “flap”) is the abdomen, which is usually harvested as a DIEP flap. If the abdomen is not available or not adequate, then the buttocks (“sGAP flap”) can often be used. Our success rates over the last 13 years are 99.07% using the DIEP flap, and 95.7% using the sGAP flap. The initial surgery requires on average 4 nights in the hospital, but subsequent stages are much easier.

If you can’t or don’t want to use your own tissue, there are a couple of other options which may offer some hope, although the chances of success are nowhere near as good as using your own tissue. One is a course of hyperbaric oxygen, which has been shown to bring new blood vessels to the radiated tissue.

Another potential option, which must be regarded as experimental at this point, would be to completely cover the implant with acellular dermal matrix, or “ADM” (Alloderm being the most commonly used variety). This material has some efficacy in preventing contracture, but the effect would be less pronounced in radiated tissue.

Hope this helps. I would be happy to discuss your situation further with you, 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- What Are the Pro’s and Con’s of Over vs. Under the Muscle Breast Reconstruction Using Implants?

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

Question:  I had a Dbl. Mastectomy 6 months ago. The expanders were placed & then removed 2 months later, (necrosis) I’ve lost confidence in the original plastic surgeon & went for 2 consults with new Dr’s. One wants to do above the muscle (as did the original Doctor.).

The other says that it needs to be under the muscle. In my research, I’ve found the pros & cons to both, but I’ve also read that in above the muscle technique there has to be enough breast tissue. So my question is that since I had mastectomy could I have enough tissue for above the muscle? Is there a better choice? One Dr suggested that above the muscle is the lazy way to do it.. is that the case?

Thank you.

Answer:  Thank you for your question. I’m sorry to hear you have had problems with your breast reconstruction. There is no one procedure or technique that is best for every patient or for every plastic surgeon. If you had necrosis after your mastectomy then any technique used for breast reconstruction could be very difficult. Breast reconstruction with implants is always difficult when there is necrosis and putting the expander under the muscle may not help in any way.

Normally the breast is above the chest muscle. When breast reconstruction with implants is performed with the expander or implant below the muscle then there is always distortion or unnatural movement of the breast when the chest muscles contract. For many patients this is a significant problem. The problem is avoidable when the implant is in a more natural position. We call this approach prepectoral breast reconstruction. If someone has a mastectomy they should have no breast tissue to cover an implant/expander. That is one of the downsides to breast reconstruction with implants. It is a problem regardless of whether the implant is above or below the chest muscle.

The best breast reconstruction results with implants are when the implant is not below the muscle, but in the normal pre pectoral position. I strongly disagree with the “lazy” excuse. Breast reconstruction with expanders /implants in front of the muscle is much more work for the plastic surgeon compared to below the chest muscle. It also requires specialized expertise and judgement.

You should also be aware that if you have already had problems with your implant breast reconstruction then your best option for a permanent natural result may not be implants at all. Your own fatty tissue may be your best option. Please let me know if you would like more information about natural muscle sparing breast reconstruction without expander/implants. I hope that I answered your question. Please let me know!

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

Ask the Doctor- Can You Improve the Contour of My Chest Wall Resulting from Mastectomy?

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

Question:  I have had a double mastectomy Dec 2015. I did not rebuild. I went from a full c cup to flat or uneven bumpy. I am mutilated and was looking into perhaps “cleaning” up my chest by removing uneven skin and scars. I am trying to achieve a chest where I can use a prosthetic nipple. I do not want reconstruction. Your thoughts? Thank you.

Answer: I’m sorry you have ended up with what sounds like an unsatisfactory result.

It may well be possible to move closer to the result you seek, with a few caveats. Through a combination of skin and / or fat removal, and possibly fat grafting, it is often possible to achieve a smoother overall contour. While it is not generally possible to completely remove scars, sometimes they can be improved, both in appearance and position.

I can’t really give you more information at this point, because specific recommendations beyond the above generalizations would depend heavily on your precise situation. Ideally, a prospective surgeon would be able see you in person, and then give his best estimate of what would be needed, and what might be the expected outcome.

Hope this helps a little, have a great day!

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

Ask the Doctor- Can I Leave In My Old Silicone and Saline Implants and Just Get A Breast Lift?

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

Question:  I had my breast done once when 25 with silicone implants, once when I was 55 with saline. Now I need a breast lift. My only question is can the same implants stay there and just lift everything? Is that ridiculous. I want to leave the old implants and just lift the breast and move the nipple up some. I think it will be less expensive not to add a new implant.

Answer: It might be possible to leave the implants in place, but it would depend on your particular anatomy, and how much of a lift you needed. Even if you do try to use the same implants, it will be necessary to have “extras” in the operating room in case one is damaged during the surgery and must be replaced.

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

Ask the Doctor- Is the Fat from the Stomach Area Okay to Use for Breast Reconstruction?

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

Question: Is the fat from the stomach area okay to use for breast reconstruction?

Answer: If there is enough stomach fat, it is our preferred donor site to reconstruct the breasts. The exact technique used is the “DIEP flap,” which does not take any muscle at all. If there is not enough stomach fat, our next choice is the buttocks, but we prefer to use stomach if it is adequate.

Thanks for your question, and please let us know if you would like additional information.

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

Ask the Doctor- Is It Possible To Have a Bilateral DIEP after Having a Bilateral Mastectomy?

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

Question: I had bilateral mastectomy in Dec 2009. Is it possible for me to have bilateral DIEP now?

Answer: Thanks for your great question! There is no limit on the time elapsed from your mastectomies for you to have DIEP flaps. In fact, it is not terribly unusual to reconstruct people who, for various reasons, have delayed reconstruction for 10-15 years. Generally speaking, they do at least as well as patients who have immediate reconstruction, and sometimes better. If you have a suitable donor site (which most people do), and you are in reasonably good health, it is very likely that you could have reconstruction with your own tissue.

I would be more than happy to speak with you by phone, or, if you are able, evaluate you in person. If you wish, we could have our NP Lindsey or PA Audrey contact you to get more information.

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

Ask the Doctor- Will My Insurance Cover a Prophylactic Mastectomy If I’ve Had Gene Testing?

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

Question: I did the gene testing in February; tested positive for BRCA 2. I want to go full steam ahead and be proactive with prophylactic mastectomy. I am 31-year-old single mom. However, in regards to insurance, I am in a pickle. I just switched jobs and will be obtaining new/different insurance with new company. Will the new insurance I am obtaining most be okay with the gene testing from prior company and proceed to pay for the mastectomy/reconstruction? I can provide all the results and positive test results as well to them to suffice.

Answer: Most insurances do pay for prophylactic mastectomies when you have a gene conferring increased risk. While I cannot tell you with certainty, the companies that offer the tests are pretty standardized, and there is no logical reason not to accept the results of a prior test. We would be happy to help you further define your options with your present insurance company, 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- Can I have reconstruction at 70 years old?

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

Question: At 70 years and in good health apart from arthritis should I be concerned about an abdominal fat replacement breast reconstruction considering that the operation might be long?

Answer: We have successfully reconstructed a number of ladies aged 70 and older. Generally, they have done well, and age itself is not, strictly speaking, a reason not to have the procedure, if everything else is favorable. Having said that, there do seem to be more “bumps in the road” the older one gets. If you wish, we could call and discuss your particular situation in more detail.

Thanks for your question, and have a great weekend!

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

Ask the Doctor- Can you help me schedule a consultation?

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

Question:  I am 35 years old, my BMI is 29. I have a pathogenic mutation of the ATM gene and strong family history of breast cancer (mom dx in 2016 at age 68 and also has the ATM mutation, two deceased maternal aunts dx in their late 30s). In January 2017 I underwent diagnostic mammogram and ultrasound, then MRI, and then an MRI-guided core needle biopsy of a 4.6×1.4 cm linear nonmass enhancement. Pathology revealed sclerosing adenosis, benign changes, and flat epithelial atypia.

Because of the atypia I am scheduled for an extensional biopsy on February 16, 2017, to remove more tissue and hopefully rule out cancer. I am trying to stay ahead of the curve and I am interested in pursuing what I hope will be a prophylactic mastectomy with immediate flap-type reconstruction, but understand planning and timing will depend on the outcome of the pathology from my next procedure.

I spoke with my doctor about prophylactic mastectomy and reconstruction (my doctor is a surgical oncologist and will be performing my upcoming extensional biopsy) and asked which plastic surgeon she recommended on their team for flap-type reconstruction. She told me that she would perform the mastectomy, that I would be flat for a while, and that the plastic surgeon she recommended would perform reconstruction during a second surgery at a later date because “that’s just how he does it.”

I heard about your center on a DIEP support group on Facebook, and your surgeons are so highly recommended and are in-network with my insurance. I have learned a lot about the procedures in the support group, and I would like a second opinion from your doctors as I know that immediate reconstruction is possible in a lot of situations. I live near Winston-Salem, North Carolina, and I am willing and able to travel to be in the hands of an experienced team. A Monday morning appointment for a consultation would be ideal because of the travel involved, and either location would be fine, but I am flexible. Can you please help me schedule a consultation? I feel uncomfortable asking my doctor/surgeon for a referral at this time.

Answer: Thanks for your question. I’m sorry you are having to go through this, but we will help you any way we can.

The only common reason to NOT do immediate flap reconstruction at the time of mastectomy is if we know or suspect that you will need post-operative radiation, because that can severely damage a new flap. The most common reasons for giving radiation are a cancerous tumor over 5 centimeters in size, or a positive axillary lymph node.

Hopefully, you will end up not having cancer at all, and neither of these situations will apply to you. We do immediate flap reconstruction very routinely, sometimes several times a week, and I suspect there is a very good chance you could have it done that way.

We work with several truly cutting-edge breast surgeons, and we would be happy to arrange for you to see both of us on the same day. If you wish, we will have one of our PA’s (Kim and Audrey) or Nurse Practitioner (Lindsey) contact you to get additional information, and help make arrangements.

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

Ask the Doctor- Is reconstruction possible 14 years after radiation?

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

Question:  In 2003, I was diagnosed with DCIS, had a lumpectomy and radiation on the right breast. Years later I have a large lump and had an MRI today. It probably is nothing but I am considering have that breast removed and having reconstruction done at the same time. Is this possible 14 years after radiation?

Answer: We routinely do successful natural tissue reconstruction on patients who have had previous breast surgery and radiation, and the fact that your radiation was 14 years ago will have no bearing on our chances of success. We would be happy to call and discuss your situation in more detail, if you wish, just let us know.

Have great day!

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