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)

Ask The Doctor-What can be done about infected implants?

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

Question: I had implants, and they got infected. I had six operations I’m in New York right now, but I’m on my way to South Carolina. I would like to come in so I could see what can be done. Thank you.

Answer: I’m sorry your having problems with your implants. We have helped many women who have lost implants due to infection. Let us know when your in town, and I’ll be glad to see you.

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

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-Does lipomodelling make breasts more natural looking?

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

Question: Do doctors do lipomodelling of the affected breast to make it more natural looking? Implant does not help. Thanks.

Answer: Thanks for your question. We perform fat grafting as part of the breast reconstruction process. If you had breast reconstruction with an implant and the results are not natural, fat grafting can help. There are some situations that require removing the implant in order to get a more natural result. Let me know if you need more info.

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

Ask The Doctor-Will my pectoral muscles will return to normal after I have my implants removed?

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

Question: I had a mastectomy with reconstruction using saline implants. I am considering having the implants removed, and am wondering if my pectoral muscles will return to normal.

Answer: Thank you for your question. If you are planning to have your implants removed, then are you planning to have any further reconstruction? Frequently, tissue expanders and breast implants used for breast reconstruction are placed under the chest muscle. If you are having problems with your chest muscles because of the breast implants, it is likely that some of the  problems would improve or possibly go away completely if you have the implants removed. On the other hand, it is very unlikely that your muscles will ever go completely back to normal after they have been lifted up and or divided to cover an implant. In my practice we keep the implants above the muscle. When this is possible the muscle is not disrupted at all. When we have a patient who has had problems with their implants, we can usually help them by removing the implant and capsule and reattaching the muscle. We then perform the breast reconstruction with the new breast on top of the muscle. If you  choose to have breast reconstruction after problems with implants, then replacing them with your own fatty tissue can be a great option. Let me know if you need more information. 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-Is it possible to do a flap reconstruction after first surgeon tried expander on radiated breast on a smoker?

flowerThis week, Richard M. Kline, Jr., MD, of The Center for Natural Breast Reconstruction answers your question.

Question: Is it possible to do a flap reconstruction after first surgeon tried expander on radiated breast on a smoker who had quit 7 weeks before surgery? 4 weeks later I still have open wounds almost the size of a quarter.

Answer: Thanks for your excellent question.

Fortunately, previous breast surgery, no matter how extensive, rarely impacts our ability to do a flap reconstruction using your own tissue. In fact,  a healthy, non-radiated flap is often beneficial in improving the quality of the radiated tissue around it.

As you seem to already be aware, nicotine is an absolute “no-no” when having surgery, and also when trying to heal a chronic wound. Nicotine causes the microscopic blood vessels in your tissue to clamp down, just like shutting off a valve, which deprives the healing tissues of oxygen. Usually, however, nicotine levels are unmeasurable after a full month of exposure cessation.

We have treated several chronic wounds in patients with failed implant reconstructions, and we have always felt that it was best to get the wound healed before proceeding with flap reconstruction. Achieving healing in these situations is often not straightforward,  but we have thus far eventually been successful. Sometimes retained foreign material (such as Alloderm) can play a role in keeping the wound open, and sometimes there is just not enough skin left in the radiated area. Rarely, deep infection of the bone or cartilage can be an issue, although this is unusual.

If you wish, we can set up a phone consultation to discuss your specific circumstances in more detail.

Best of luck, 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-Will you give me your second opinion on insurance coverage?

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

Question: Do you accept BCBS insurance from Ga? I had a double mastectomy a year ago and breast implant reconstruction. I’ve had to have both taken out their weeks apart due to one being infected and one implant exposed. I would like a second opinion on where to go from here.

Answer: I’d have to see your card and check your plan to be completely certain, but we do participate within the Blue Cross Blue Shield Blue Card Nationwide Network.  Does your card have a little suitcase on the bottom corner that looks like the one below?

BlueCross Blue Shield insurance card example

 

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 about hard breasts?

8404745471_aa5de5fd5f_mThis week, James E. Craigie, MD, of The Center for Natural Breast Reconstruction answers your question.

Question: I have had a natural breast reconstruction. I have several places in both breasts that are hard. I also have a hole in the right breast that needs tissue. Will the hard places soften as time goes by? I am considering having tissue taken from my groins to fill the cavity. I also have to have the tummy tuck closed. Please advise. Part of me is thinking to have all the tissue removed. The hard areas feel like armor. Thanks. What do you recommend?

Answer: Thanks for your question, I’m sorry you’re having difficulties. How long ago did you have breast reconstruction? Have you had a second stage yet? If you had reconstruction with your own fatty tissue, sometimes some of the fat may not survive and can cause hard lumps. The lumps will soften with time but usually not completely go away  unless they are small. We usually remove any hard lumps at the second stage procedure about 3 months following the first surgery. If most of the fat is hard then sometimes we might need to add more fat to the breast to give it shape, or start over with tissue from another area. The thigh area is another possible area to get fat if needed depending on your situation. We avoid taking the groin muscles when we use the thigh fat to rebuild the breast. Let me know how long ago you had your surgery. Time may improve your situation and hopefully you won’t feel like you need to go back to having no breasts.

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

Ask The Doctor-What could be causing the cramps in my breast?

5987018633_ca7f1c6f97_mThis week, James E. Craigie, MD, of The Center for Natural Breast Reconstruction answers your question.

Question: I am 70 years old, and 5 years ago had a bilateral with reconstruction. Since then, I have had severe cramps in both breasts and they can even tie a knot in my stomach I can feel knot up when I cough. These are not like stomach pains, they are very painful, hard cramps like one experiences in the calf of their legs….I asked my Plastic Surgeon about them, and he just said he had never heard of cramps in breasts. I can cause my breasts to cramp by simply turning over on. My side, raising my arm or reaching around for something…I’m a tough ole broad, but these cramps make me nauseous they hurt so bad…have you any experience with this? Thank you so much for your time.

Answer: Thanks for your question. I’m sorry you’re having a difficult time. Painful cramping suggests muscles are having spasms. Normally the breast does not have muscle but the chest muscle is underneath the breasts and can have spasms for different reasons. The explanation could possibly be related to the type of breast reconstruction. If you have implant reconstruction the implants are often placed under the muscles. If the body rejects the implants or develops scaring that tightens around the implant the distortion can cause muscle spasm. If you had reconstruction using one of your body muscles to rebuild the breast,  that too could possibly be related to the cramping pain. If the muscles from the tummy wall were used to rebuild your breast or breasts that might explain the “knot in your stomach”. I would need more information to let you know what I would recommend. What type of breast reconstruction did you have? Do you have implants and did you have radiation to the breast? Thanks again.

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

Ask The Doctor- If you choose natural breast reconstruction as opposed to implants is there sensation in the breast?

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

Question: If you choose natural breast reconstruction as opposed to implants is there sensation in the breast? Is there sensation with nipple sparing? What is the rate of success with natural reconstruction? Thank you.

Answer: As a general rule, there is no erogenous sensation after any type of breast reconstruction, although in isolated circumstances some people do seem to get that back, or something like it. Most of the skin is usually completely numb initially, but may regain some feeling after months, or even years. Even after nipple-sparing mastectomy, there is usually no sensation. While it is theoretically possible for the nerves to grow back, it is rare to get normal feeling back, even after a prolonged period. The flap survival rate after natural breast reconstruction is approximately 98%. Completion of reconstruction usually requires 2 or 3 surgeries in all, but they tend to get sequentially shorter and less involved. Once you have competed natural breast reconstruction, however, your breasts will usually continue to improve on their own for many years. This is in sharp contrast to implant-based reconstruction, where the quality of the reconstruction often tends to deteriorate over time. Thank you for your question.

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

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