Ask the Doctor- Can You Do Repair and Nipple Reconstruction Surgery at the Same Time on the Same Breast?

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

Question: I had hybrid DIEP reconstruction at another facility, and I am disappointed with the results. There have been many issues. For example, my breasts are different shapes and sizes, no node involvement and no microinvasion. The surgeon who did the mastectomy said the path report said the margins were not wide enough and he will need to cut additional skin out during the next surgery. The next surgery is supposed to be to reconstruct the nipple. Can you do both procedures on the same breast at the same time? Please Help!!

Answer: I’m sorry you are having to go through this.

Did you have a complete mastectomy on the left breast or a lumpectomy? If your margins were positive (unbeknownst at the time of surgery, obviously), and you had an immediate DIEP flap, that could be a little complicated to resolve, although I’m sure we could work through it. Given that your scenario is a little bit unusual, it would probably be best if we talked by phone. Please let us know what works for you.

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How Long Will Radiation Postpone My DIEP Reconstruction?

This week, Dr. Richard Kline of The Center for Natural Breast Reconstruction answers your questions.

Q: If I am having Mx and immediate DIEP reconstruction surgery that it is determined that radiation will be necessary, is the the DIEP reconstruction continued as planned, or is it postponed until after radiation? If postponed, are tissue expanders temporarily placed until six months later when flap surgery can be performed?

A: We have never, fortunately (as far as I can recall) encountered findings in surgery that caused us to suddenly think that radiation would be needed when we didn’t suspect it previously. The two things that COULD be found intra-operatively and would lead to that would be positive lymph nodes or a very large tumor. The mammogram and MRI are pretty good at seeing these kinds of things preoperatively. Additionally, if there is any suspicion of positive nodes, we routinely have the sentinel node biopsy done as a separate procedure before the mastectomy.

When we DO know that the patient will need radiation, we sometimes offer them placement of a temporary tissue expander if they do not want to go several months without having a breast mound. This has several disadvantages, including 1) doing unnecessary damage to the chest wall and pectoralis muscle, 2) taking up some of the eventual flap’s volume to fill the divet in the ribs left by the tissue expander, and 3) potentially interfering with the delivery of radiation. Some surgeons think the scar pattern can be favorably altered by and expander in this scenario by keeping the skin stretched, but I’ve never been very convinced by this argument, at least not when the expander is ultimately going to be removed and replaced with a flap.

If we did, for whatever reason, unexpectedly determine in surgery that the patient needed radiation, I would probably just do nothing (no tissue expander) and come back after radiation and do the flap(s).

Dr. Richard Kline

Center for Natural Breast Reconstruction

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Chronic Pain After DIEP Flap Surgery–Can You Help?

This week, Dr. Richard Kline of The Center for Natural Breast Reconstruction answers your questions.

Q: After a double mastectomy in April 2010, my left expander was replaced in June 2010 due to leakage and became infected.

I was hospitalized and given vancomycin and oral antibiotics for almost 3 weeks. Infection spread to right breast and both expanders were removed the same month.

I had DIEP flap surgery in December 2010, but I have had severe pain and shocking sensations in chest, ribs and stomach. My surgeon says he does not know what is causing this pain. Is it the result of nerve damage? And is there any way to fix this?

A: So sorry to hear about your experience! Out of 1,011 flaps to date, we have very few patients with chronic pain, but unfortunately it does sometimes occur. We usually examine the areas in question with a CT and/or MRI, but usually this does not show any abnormalities other than normal post-surgical changes.

In this scenario, we then refer the patients to our pain therapists, who almost always are able to provide significant relief. Please let us know if we can provide additional information.

Dr. Richard M. Kline, Jr.

Center for Natural Breast Reconstruction

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DIEP Flap Procedures: Can You Restore My Original Breast Size? Do You Remove Muscle?

This week, Dr. Richard Kline of The Center for Natural Breast Reconstruction answers your questions.

Q: I am having a double mastectomy on August 1st. I want to have a DIEP flap reconstruction, but will have to settle on being half the size I am now because there isn’t an abundance of fatty tissue in my tummy. I am a full C cup now and will probably be a B cup following the reconstruction. Can additional fat be harvested from my buttocks at the time of my initial surgery to make me look like I do now or do I have to wait until Stage 2?

A: There are a few potential ways to look at your situation.

First, it is possible to do DIEPs and GAPs simultaneously (4 separate flaps). We don’t do this, because we have concerns about our ability to monitor the buried flap, but we do know have references to associates who can and we are happy to provide you with this information.

Second, it is possible to inject fat into the DIEP flap, and potentially the mastectomy skin flaps as well (if they are thick enough), as well as in the pectoralis muscle at the time of the DIEP flap. All that together will buy you some extra size, but it’s hard to predict how much.

Finally, you could do fat injections after healing in a subsequent stage(s). I would call this the “tried-and-true” technique, little to lose, much to potentially gain. We are investigating BRAVA as an adjunct to this, but not quite ready to use it yet.

 

Q: What happens if I am getting a DIEP flap done and some muscle has to be removed from my abdominal area?

A: A true DIEP flap never results in the removal of muscle, by definition. Some flap surgeons apparently tell patients they may need to remove a little bit of muscle, and we’re not sure why they say that, because we’ve never found it necessary in many hundreds of flaps.

However, with rare exceptions, the rectus muscle does have to be “disassembled” (and put back together again, of course) to remove the blood vessels, and this can occasionally result in partial loss of muscle function. We work extremely hard in designing each DIEP flap to maximize the blood supply to the flap, while minimizing the potential for loss of muscle function.

We obtain an MR angiogram pre-operation. This  requires an unusually strong 3T MRI for best images, which gives us an excellent “road map” of your individual perforator anatomy. We also frequently use the SPY intraoperative laser fluorescent angiogram to help determine exactly which perforating vessels supply the flap best. Thanks to these technologies, in addition to using the best surgical technique we can, it has been many years since we have encountered any significant functional abdominal wall problems in any of our patients.

Hope this helps!

Dr. Richard M. Kline

Center for Natural Breast Reconstruction

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

Can Small Implants Be Used with Flap Surgery for Added Volume?

This week, Dr. Richard Kline of The Center for Natural Breast Reconstruction answers your questions.

Q: Can small implants be used with flap surgery for added volume?

A: The short answer is “yes, sometimes.”


We have had good success augmenting flaps with reasonable-sized implants in non-radiated patients. In radiated patients, it’s still sometimes possible, but it’s very dependent on how much of the breast mound is covered with flap skin versus radiated breast skin, and what the quality (the technical term is “compliance”) of the radiated breast skin is. Every case is different.

Our nurse or PA can provide you with more information upon request. 

Hope this helps!

Dr. Richard M. Kline

Center for Natural Breast Reconstruction

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

Dr. James Craigie Answers Your Questions About Natural Breast Reconstruction

The below questions are answered by Dr. James Craigie of The Center for Natural Breast Reconstruction.

Do you perform a stacked combination DIEP/SGAP using both to make a breast(s)?

We do on occasion. It may be needed when one area of the body does not have enough tissue to achieve the desired result. This is an unusual situation in our practice we can usually achieve our goals with one area of the body.

There is a lot of discussion about a maximum BMI what about a minimum?

BMI is a guide line that helps the surgeon determine who is at a higher risk for complications. It is not a strict guideline and the final decision is left to the surgeons judgment among other things. Safety is our first priority and studies have definitely linked high BMI to an increased rate of complications without a doubt. Unfortunately  BMI is not a perfect calculation and different doctors may use the information differently. A low BMI is not linked to complications if someone is otherwise fit for surgery. Someone with very little body fat will have a low BMI and possibly not enough tissue to make a very large breast. This does not mean they cannot have a good result. It  may mean they require and combined or stacked flap approach. We have seen many patients who have been told they “don’t have enough tissue” but after consultation can reassure them they can get a very proportional result.

Dr. James Craigie

The Center for Natural Breast Reconstruction

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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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Perseverance: The Valuable Lesson Breast Cancer Taught One Survivor

Today’s In Her Words post comes to us from a past patient of The Center for Natural Breast Reconstruction, Carlette Holmes. Carlette, is a breast cancer survivor who lives in Anderson, SC and traveled to Charleston to receive her reconstructive surgery. Today, Carlette and her childhood best friend partake in a culinary partnership entitled, Buffa’s Cheese Biscuits. The recipe for these delicious biscuits come from Buffa, a cook for Carlette’s grandmother while she was growing up.

See below for out interview with Carlette and to learn more about Buffa’s Cheese Biscuits. All images included are courtesy of Carlette Holmes.

1.  Buffa’s Cheese biscuits, even the name just melts in your mouth. Can you tell me a little bit about these delicious biscuits and where the recipe came from?

I think my grandmother found the recipe in a Jr. League cookbook and gave it to Buffa to try. They were a staple after that. They were always on hand in a covered dish as you came into the kitchen. Everyone who came in knew they were there & grabbed a handful. Buffa’s were always good but often different…. sometimes “short” as she would call them, sometimes crispy, sometimes light and puffy or sometimes dark and crumbly. I know now it could have been due to the humidity on any given day. One challenge I faced was to get them to turn out the same every time. Family and  friends didn’t seem to care, but I felt it was important when I started selling them.

2. It seems you spent a lot of time in the kitchen with Buffa, do you have a favorite memory with her?

My conversations with Buffa are favorite memories. She loved to talk while she cooked and could tell a great story. Often, I would shell peas or snap beans while she “held court”. I loved to “help” her make jams and preserves.

My least favorite memories are those of grease fires and exploding pressure cookers. I am scared for life, and to this day I don’t like to fry in my kitchen. The first time I tried to fry fish for Edmund is was slightly boiled and awful.

3. You have been making these biscuits for your family and friends for years. What was the turning point for you to finally give in and brand Buffa’s Cheese Biscuits to the public?

I think the turning point was surviving breast cancer. My best friend since 7th grade, and partner in BCB, Lide Vandiver, had been after me for years to brand them, but I had a family to take care of and businesses to help my husband, Edmund run. My 2 daughters, Sally Cade and Brelyn, were in college when I was diagnosed. I got through my treatment and I had been thinking of reconstruction options. I had heard horror stories of implants, expanders and that procedure, and I didn’t think that was an option for me. I researched DIEP flap surgery and was so impressed with the procedure. I truly believe that God led me to The Center for Natural Breast Reconstruction. I called another surgeon and was told that they didn’t take my insurance. They directed me to the The Center for Natural Breast Reconstruction. I called and got Gail on the phone. This was on the day that I took my last chemo treatment. Gail talked to me for over an hour that day. It felt right and I am thrilled with my decision. As you can probably tell, I don’t let much grass grow under my feet and DIEP flap seemed to me like the best & fastest way to get through the reconstruction process and move on.

4. How did you decide upon what reconstructive option was right for you?

I was pretty excited about getting rid of my C-Section Pooch. It was just the right size to make C-cups.

5. How has your decision to undergo breast reconstruction impacted your life moving forward?

I saw the picture Dr. Craigie took of me the day I came to him… on the day I got my tattoos. That was start to finish in a flash. It was definitely a process, but one that I wouldn’t trade for anything. I can remember, 6 weeks after my DIEP flap surgery, sitting on the beach in my bathing suit and feeling comfortable and “normal”. I took out my cell phone and called The Center for Natural Breast Reconstruction to leave Dr. Craigie a message of thanks. I don’t have words to describe how good that felt after living with one breast for 6 months. Now they were both gone, but they were there. How amazing! DIEP flap has allowed me to move on. I know myself, and that I would worry if I had not had both breasts removed even though the cancer was only in one. It has been a great decision… nothing to stuff in my bra, no implants to worry about, just my C-Section pooch made into breasts. Dr. Craigie is a real artist (not to mention a gifted surgeon). I am still amazed at how real they look.

6. What advice do you have for women who have a passion, and want to turn that passion into a business?

I think my advice would be to persevere. Lide and I hit obstacles almost every day, but we just have to work through them. I think maybe that fighting cancer taught me a lesson in this. Every day brought it’s obstacles,  but I had no choice but to keep moving forward.

Click here to see where you can pick up Buffa’s Cheese Biscuits near you or place your order online!

 

 

 

What’s Next if My First Attempt at DIEP Flap Breast Reconstruction Fails?

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

If the first DIEP flap breast reconstruction fails what are my options?

This is a rare scenario, but in our practice we generally recommend waiting 3 months for the body to recover, then using another area of tissue, most commonly the buttock to perform the reconstruction.  The failure of the first reconstructive attempt does not seem to adversely affect the success rate of the second reconstructive attempt. We have in the past sometimes attempted to perform the salvage reconstruction at an earlier date, but we have come to feel that the patients do better overall if they are allowed a period of healing before proceeding with the next surgery.

What is DIEP Flap Reconstruction?

Perforator  flaps and natural breast reconstruction represent the state-of-the-art in breast reconstruction. The DIEP flap is the most frequently used type of  perforator surgery for breast reconstruction because of the tummy tuck benefit  that can be part of the process. Doctors  borrow skin and tissue from your abdomen, and use it to create a soft, warm,  living breast.

It starts  with an incision along the bikini line similar to a tummy tuck incision.  Surgeons remove the necessary skin, soft tissue, and tiny feeding blood  vessels. The blood vessels are matched to supplying vessels at the mastectomy  site and reattached under a microscope. Tissue is then transformed into a new  breast mound.

Our refined technique provides all the necessary  tissue to build a breast, without removing the abdominal muscles. In addition  to reconstructing the breast, the contour of the abdomen is often improved –  much like a tummy tuck.

Have questions for our team? Send them on over, we’d love to hear from you!

 

The Benefits of DIEP Flap Breast Reconstruction Over Other Reconstructive Options

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

What are the benefits of the DIEP flap breast reconstruction over other options?

I am going to break this question into two parts.

The first part is what are the benefits of the DIEP flap over reconstructive options using implants?  Let us start with the benefits of implants.  The primary benefit of implant is that the operations are shorter, they are potentially safer, and you do not need to operate on another part of the body. Additionally, implants are readily available, and if you do not have enough extra body tissue somewhere to make a breast, implants may be the preferred choice for this reason.  The advantage of the DIEP flap over implants is that it produces a much more natural feeling, warmer, and trouble free breast (after the reconstruction process is completed).  There is data to suggest that women tend to accept the reconstructed breast as their own more readily if it is made using their own tissue, in comparison to women who have a reconstructed breast using implants.  Additionally, many women feel that they have too much extra tissue in their abdominal area, and they may actually view removing this tissue to make a breast as an added bonus.

The second part of this answer is going to be why is the DIEP flap better than other reconstructive options using the patients own tissue, with the most commonly performed in our practice being the GAP or gluteal artery perforator flap, which is taking the buttock.  The primarily advantage of the DIEP over the GAP is that it is faster, and no position changes are needed during surgery to harvest the flap.  If the patient has adequate abdominal tissue to meet her reconstructive needs, we generally recommend using this as our first line option.  Having said that, however, the buttock serves very well to make breast, although the process is a little more tedious and lengthy.

Would you like your breast reconstruction question answered? Just ask us!