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

Question: I had a breast augmentation 12 years ago at the age of 21. I am now 33 and after having my son I went up another 1-2 cups sizes. I’m not sure what my options are but I would like the implants removed completely if possible. Do your surgeons only work with cancer patients? The reason I ask is while I’m not a cancer patient I do have health issues including severe osteoporosis and an undiagnosed connective tissue disorder. I really need a doctor that is knowledgeable about the effects of implants over time and how this could be possibly affecting me now or in the future. Thank you.

Answer:  Yes, we do a lot of cosmetic breast surgery, some on its own, and some as an adjunct to breast reconstruction.
There is no demonstrated statistical relationship between breast implants and systemic health issues, but this does not mean it cannot ever be an issue in a given patient (although it may be impossible to prove). If you want the implants out, there is no reason that they cannot come out. Of course, you MAY find the cosmetic appearance of the breasts less favorable without the implants, but some of your concerns could potentially be addressed with additional breast surgery, such as lifting. Sometimes procedures such as lifting the breasts can be performed at the same time the implants are removed, but other times it is safer to let the breasts heal for a few months, then return to do the additional surgery.

I would be happy to see you to discuss further, if you wish, and thanks for your question.

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

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

Question: Why do expanders have to be used when breast are removed and the pocket is empty and ready to be filled with an implant?

Answer:  It is not always necessarily to place expanders at the time of mastectomies, but in many situations it is a safer choice than immediately putting in an implant. Even if the breast surgeon leaves the nipples and removes no skin at all, the skin is not always healthy, as the blood flow is invariably at least somewhat compromised after mastectomy. Placing an implant very poorly perfused skin would put additional pressure on the skin from within, and quite possibly cause skin to die that otherwise would have lived. With an expander, we have the option of placing no fill at all at the initial surgery, thus minimizing additional pressure on the skin. In actual practice, sometimes the skin’s blood supply is so poor we don’t even put in an expander right away, but rather return to the operating room several weeks or months later to begin reconstruction.

Having said the above, I do agree it is nice if the final implant can be placed under healthy skin flaps immediately. However, it should only be done under ideal circumstances.

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

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

Question: I had tram flap surgery 5 years ago for one breast in Sacramento at Kaiser with the Chief of plastic surgery. I am experiencing horrible pain under my breast and around the side of the breast as well. It also feels like 1000 bees are stinging me all the time. It also feels VERY heavy and not a part of my body. I’m in constant discomfort and I HATE it. Is it possible to “just remove this tram flap altogether? I am miserable and wish I had never had the surgery!

Answer:   I’m sorry you are having so much trouble. Discomfort such as yours is very rare, especially when you are reconstructed with your own tissue, but unfortunately it can happen.

Firstly, I would advise you to discuss this with your original plastic surgeon, if at all possible.

It may well be possible to remove the TRAM flap, but there is unfortunately no guarantee that this will help the pain. Has the pain always been there, or is it new? Has the appearance of the reconstruction changed? Is there any drainage, redness, or other symptoms? Imaging studies, such a contrasted MRI, may be useful. While it is not always possible to determine the origin of pain, I think it greatly increases the chances of success if the situation is studied carefully prior to taking action.

I would be happy to discuss your situation further, if you wish.

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

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

Question: I’ve had a mastectomy on right side and am ready for breast reconstruction and enhancement on the left side. I am small framed,thin and a very active mid 60 year old. I am having trouble deciding on saline or silicone implants. My expander feels very hard and I don’t want that for implant.

Answer:   Thanks for your question. It is important for you to know that permanent implants (saline and silicone) are softer than the expander. Expanders are designed with metal ports and thicker shells so they can stand up to the expanding process. Silicone implants are definitely softer than saline filled and are generally preferred for breast reconstruction. My recommendation is that you ask your plastic surgeon to show you each type and let you feel for yourself prior to your surgery.

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

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

Question: I seeking information on reconstruction after radiation. The side that received radiation is very tight and now about 3 inches higher than the non-radiated implant. I have had two stem-cell surgeries and it is suggested to have another. Before going back to surgery for another stem-cell/fat transfer I want to know is there any other options that might help me. Can the radiation side be fixed? Can the non radiation implant be replace to match the radiation side?

Answer: Your problem is very common, unfortunately. Typically, with implant-based breast reconstruction, the radiated side will be harder, higher, less mobile, and often smaller than the non-radiated side.

Fat grafting around the implant is a reasonable and relatively innocuous way to address the problem, but is, at best, only variably successful. It is thought that stem cells within the fat may rejuvenate the radiated tissue in some fashion, and from my experience it seems this may in fact sometimes occur. Other times, however, fat grafting doesn’t seem to have much effect.

The most sure-fire way to address the problem is to remove the implant, and then reconstruct the breast with your own tissue, usually either with a DIEP flap (from the abdomen) or a GAP flap (from the buttocks). We have successfully reconstructed hundreds of patients with failed implant reconstructions by using their own tissue. Neither a history of radiation, or previous failed attempts at reconstruction with implants have any effect on the success of using your own tissue (98-99%).

There are some other recent developments which MAY (notice I said “MAY”) improve the success rate of implants in a radiated field. For the last 2-3 years, we have been performing our implant-based reconstructions by completely wrapping tissue expanders with acellular dermal matrix (Alloderm – processed cadaver skin graft) and placing them in FRONT of the muscle. Please note that if this is done in a patient who needs radiation, it is done BEFORE they receive the radiation.

Most of our patients who receive radiation are planning on having natural tissue reconstruction, and receive tissue expanders only as a temporary measure, as we do not ever want to subject a flap (natural tissue reconstruction) to radiation. However, we have noticed that some patients’ breasts with these Alloderm-wrapped implants remain surprisingly soft after radiation. Theoretically, the implant in a radiated breast could be removed, and an Alloderm-wrapped tissue expander or implant could then be placed (in front of the muscle if possible). I haven’t actually tried this (again, most of our patients in this situation just convert to natural tissue reconstruction), but theoretically it might provide some improvement over your present situation. On the other hand, it could result in a big mess if things didn’t work out well. However, even this would not impact your ability to subsequently have natural tissue reconstruction, if you decided to go that route.

Hope this helps a little bit. I would be happy to chat with you on the phone about your situation in more detail, if you wish.

Have a great weekend!

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

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

Question: Hi. I was wondering if you could answer a couple of questions. My first question is what would deem breast reconstruction medically necessary? My second question is how much would breast reconstruction and nipple reconstruction cost? I am a size B and have collapsed breasts. I used to be a double D. My nipples are also partially inverted.

Answer:  Breast reconstruction is generally regarded as being medically necessary if the breast is removed for cancer, or to prevent cancer in certain high-risk individuals. It sounds like what you are asking about would be considered cosmetic breast surgery. The most common cosmetic breast surgeries are breast augmentation (with saline or silicone filled implants), breast reduction, or breast lifting. What you describe as “collapsed breasts” could potentially be improved with a breast lift, breast augmentation, or a combination of the two.

Inverted nipples are caused by shortened ducts leading to the nipples. They are fixed by making a small incision adjacent to the nipple and dividing the ducts.

Gail in our office can give you prices for these procedures.

Thanks for your question.

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

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!

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!

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!

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!