Ask the Doctor – Bilateral Mastectomy

bilateral mastectomy

Q: I had a bilateral mastectomy on 12/11/2017 after chemotherapy for stage 3 breast cancer in my right breast with 10 lymph nodes removed. Expanders were inserted, and I had radiation treatment. I am now ready to get rid of these expanders and have reconstructive surgery. I am confident I want an autologous tissue surgery. I am on my 3rd plastic surgeon. I have concerns about going forward with my current surgeon since he has not shown me any pictures and does not talk about a “team” approach. I was interested in the PAP flap surgery since I have large hips and thighs, but he has only talked about doing the DIEP flap surgery or implants. He has other plastic surgeries (not breast reconstruction) that he specializes in his practice. I have never considered going out-of-state for medical treatment, and my work schedule is a concern. I want to know your thoughts about my situation and if I should go forward with my current surgeon. I have found your website to be a great source of information and encouragement. God bless you for all your doing to help!

A: The PAP is our 3rd line flap (after DIEP and SGAP). It is ideal in some situations, and yours may well be one of them, but it has a few potential downsides: 1) In MOST people, the flaps are fairly small, typically 200-300 grams (but you may be an exception); 2) The profunda artery perforator, while usually present, can be absent or very small. The preoperative MRI angiogram will determine this, however; and 3) If you have a donor site complication such as dehiscence, it’s difficult to manage due to the location and motion in area. One good thing about the PAP in contrast to the TUG (which we do not use) is that it involves few if any lymph nodes, and thus the risk of lower extremity lymphedema is minimal. We usually recommend the DIEP if you have a good donor site, but many people do not. Our DIEP success rate (after ~ 1350 flaps) is 99.0 percent. The SGAP—our next choice—is a good flap, although the dissection is difficult, which is why it is not performed in most places. This flap can be large, occasionally over 1000 grams in certain individuals. We have done about 270 of these flaps, most simultaneous bilateral, with a success rate of 94.8 percent. We firmly believe in the team approach, which was taught to us by Dr. Robert Allen— who was the pioneer of the DIEP, SIEA, and GAP flaps—and we would not have the amazing results we do without it. We never do flaps without two competent microsurgeons present. Thank you very much again for your inquiry. Please contact us if you need anything, and I would be happy to speak with you by phone, or see you in consultation.

Richard M. Kline, Jr., MD, East Cooper Plastic Surgery, The Center for Natural Breast Reconstruction, 843-849-8418, Fax: (843) 849-8419, 1300 Hospital Drive, Suite 120, Mount Pleasant, SC 29464.

Mastectomies and Expanders: Your Questions Answered

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

Q: Both my mother and my aunt have been diagnosed with breast cancer. If I were to get a mastectomy, would it be covered by insurance in the state of Pennsylvania?

A: The situation with “high risk” patients and prophylactic mastectomy seems to be evolving. If you are tested and found to have the BRCA gene, most or all insurers seem to be covering mastectomy and reconstruction. Even if you do not have the BRCA gene, but have a strong family history such that your medical oncologist recommends mastectomy, your insurer may well cover it. There may be other laws specific to this in the state of Pennsylvania of which I am not aware, but possibly Gail, our office manager and insurance specialist, can help you more.

Q: I had breast cancer in my right breast, and received a double mastectomy in November. They placed expanders in both. I didn’t have any trouble on the left side. However, six surgeries later, I opted to have my right-side expander removed. It feels better. However, I am now scared to undergo reconstruction due to this past trouble with my right expander. I still have the expander in my left breast. Any advice for me? Is it common to have trouble with expanders?

A: Sorry you are having trouble.

Unfortunately, trouble with expanders is pretty common. It’s more likely if you were radiated on the “problem” side, but it also happens with some regularity even if you aren’t radiated.

Fortunately, previous trouble with expander or implant-based reconstruction does not adversely affect your ability to have natural breast reconstruction using your own tissue. Many of our patients come with stories very similar to your own, some already having had over 10 surgeries, and almost all have subsequently achieved satisfactory, natural-feeling reconstructions without the use of implants.

I think there is an excellent chance that we can help you. If you wish, we can have our nurse Chris or P.A. Kim call you to discuss the specifics of your situation in more detail.

Dr. Richard Kline

Center for Natural Breast Reconstruction

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

Should I Have a Bilateral Mastectomy Instead of Lumpectomy and Radiation?

This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers a special two-part question.

Q: Do you know of surgeons in northwest Ohio who can do natural breast reconstruction? I was diagnosed with DCIS and had a lumpectomy done and now am considering a bilateral mastectomy instead of radiation. I was a AA cup size and don’t have much breast tissue left, so I feel like I could use the reconstruction, which is why I am considering the mastectomy.

A: Thank you for your question. I’m sorry I don’t know anyone in that area. Based on your situation you are asking a very good question!

If you have little breast tissue remaining after your lumpectomy then if you went through radiation the breast may develop more abnormal shape. When that occurs, it is difficult to fix that breast because of the radiation effects. If you instead remove the remaining breast tissue you could rebuild the breast to the size you wanted based on how much of your own tissue you have to use. Also you would not need radiation. Remember that implants after radiation are more likely to have complications than without radiation. 

Q: If the DCIS is in one breast, would a double mastectomy make sense, so I could even out the “new” size I choose? Also, do you have information on recurrence rates if I try a nipple-sparing or skin sparing mastectomy?  Is that wise at all?

A: Questions regarding recurrence rates are best answered by the surgeon who performs the mastectomy. We work closely with them as a team and perform the reconstruction immediately after the mastectomy. I’ll be glad to forward your question to the expert. In general, recurrence rates should be the same or lower for mastectomy vs.  lumpectomy and radiation. Skin and nipple sparing mastectomy should be the same as well. For your situation we would get the cancer specialists we work with to give us their opinion before we could give you specific recommendations.

We do have patients choose to do what you mentioned frequently, for the same reasons. Preventive mastectomies are done to reduce the chances of getting breast cancer. If someone is high risk, then they  might decide to reduce the risk of DCIS on the other side. When someone has enough donor tissue we try to give them the best result possible based on each person’s expectations. If you had a bilateral mastectomy we would try to make the new breasts fuller and uplifted as long as there was enough donor tissue to work with. I hope this answers your questions. Let me know.

Dr. James Craigie

Center for Natural Breast Reconstruction

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

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!

How One Breast Cancer Survivor Found Hope by Making Informed and Proactive Decisions

breast reconstructionThe team at The Center for Natural Breast Reconstruction is honored to share with you an In Her Words post written by a recent patient of ours, Linda Burkholder. She is an inspiration to all women who are facing breast cancer or who are at risk for hereditary breast cancer.

See below for Linda’s story:

Breast cancer—you can’t say I didn’t see it coming, but being the eternal optimist, I hoped I would dodge the bullet.  Several members of my family have died from breast cancer, including my grandmother, mother, aunt, and sister. After my sister died in 2006, I began to seriously consider prophylactic surgery. I quickly learned that there is little support in the medical community or among friends for this procedure.

After a benign biopsy two years ago I found F.O.R.C.E. (Facing Our Risk of Cancer Empowered) on the Internet.  F.O.R.C.E. is a support group for those with hereditary breast and ovarian cancer. They posted an application for a scholarship to their annual conference. I applied and much to my surprise I was granted an expense paid trip to the conference in Orlando in 2010. I can’t tell you how that changed my life. I learned so much about everything I wanted to know about breast cancer and I met several plastic surgeons who stood out to me, especially Dr. Kline from The Center for Natural Breast Reconstruction. I made a mental note to keep him in mind and took home a beach towel with his phone number splashed across it.

During the next year I struggled with my decision to have prophylactic surgery. Intellectually, I knew what to do, but emotionally I was really struggling. I joined a local F.O.R.C.E. group and kept learning and thinking and meeting cancer survivors, assuming I would have surgery when I felt more comfortable with the idea. Fast forward to June 2011. It was time for my annual mammogram. I told my family doctor I also wanted an MRI, to which she reluctantly agreed. To make a long story short, the mammogram came back normal, but the MRI showed a 1.2 cm questionable spot—a spot, I was told, because of its location, would never have been seen on any mammogram. It was a Stage 1 cancer.

This was almost 2 years to the date from my previous benign lumpectomy. In July, 2011 I had a second lumpectomy performed by one of the most respected surgeons in my area. Without consulting me she automatically scheduled me for radiation. I refused the radiation because I felt that all treatment was my decision and I wanted to consult with an oncologist first. Also, I had learned at the F.O.R.C.E. convention that radiated tissue is harder to reconstruct and I already knew I ultimately wanted mastectomies with natural breast reconstruction, not implants.

When I told the surgeon I didn’t want implants, she hit the ceiling. Clearly, no one had ever before challenged her standard treatment plan. Thanks to F.O.R.C.E., I was empowered. The next convention was two weeks away and I knew this would be where I would make my final decision, and it was. I talked with EVERY plastic surgeon at the conference. I spoke with Kathy Steligo, author of The Breast Reconstruction Guidebook, for 45 minutes at the round table breakfast. I had read her book for the third time on the plane to Orlando two days before. After the conference I came back to my hometown and started chemotherapy. I also scheduled my surgery for November at The Center for Natural Breast Reconstruction.

After consulting with my oncologist, I elected to have bilateral mastectomies with autologous reconstruction. In September my husband and I made a trip to South Carolina to meet with Dr. Kline and Dr. Baron, the general surgeon. I wanted my husband to meet my doctors. I wanted to make sure I had his full support and I wanted to make sure any lingering questions by either of us were answered.

After that meeting I was sure I wanted to go forward with the DIEP procedure. I felt very confident that everything would be alright. On November 30, 2011 I had the procedure. It was an 8-hour surgery, and everything went very well. I was in East Cooper Medical Center for four days. My nurses were great, especially Angela. I thought of her as my special angel since she was able to anticipate what was needed before being asked and was especially kind. She really took good care of me.

After my discharge from the hospital my husband and I stayed in Charleston another 10 days. I got a handicapped room at a local long-stay hotel. There was a handicapped shower and a recliner in the room. I really appreciated that recliner and I slept in it most nights. It helped to keep my feet elevated.  Every day, at least one time, I took a short, slow walk up and down the hall for exercise. I saw Dr. Kline 3 times during the next 10 days and he assured me everything was fine and my breasts looked “beautiful”—although at that time I didn’t think they looked so beautiful. Now, 5 weeks later, I can see how nicely everything is shaping up and I don’t think I will require a lot of revision at the Stage 2 procedure. I am glad I chose the DIEP procedure. The recovery is long, but it is worth it.

Did I ever seriously consider implants? The answer is yes, because implants represented the path of least resistance. I could have had the surgery done locally and I wouldn’t have had the additional expense of the trip from Indiana to South Carolina. Also, I would have had my entire support system around me. In making my decision I talked to many women who had implants and it seemed to me that they either loved them or hated them. Those that loved them seemed to love them only after 2-3 additional procedures due to complications. Everyone complained about the fills being painful and some found the implants to be cold or uncomfortable. Also there was the risk of capsular contracture and the necessity of replacing the implants every 10-15 years. I also talked with many women I met through F.O.R.C.E. who had flap procedures. I saw their results and they were fabulous. Short of a few fading scars, you could not tell that their breasts were not original. All of them seemed quite pleased with their new breasts.

Yes, recovery is a bit prolonged with DIEP. You definitely need someone very devoted to you to help out those first few weeks. I needed help getting up and down, showering, dressing, and emptying my surgical drains. My husband helped me with everything, dispensed my medications and gave me a blood thinning shot daily. I could do very little without his assistance the first 10 days following surgery, and I slept much of the time. Still, I was able to get around slowly and even went out to local restaurants my two weeks in Charleston. I also had pain medication, which made life bearable.

As the weeks have progressed, I feel my strength slowly returning. I am not yet 100% but I am planning to return to my job part-time on January 9th, with hopes of returning fulltime the following week. For anyone considering a flap procedure but fearful of the recovery, I would advise them that it is doable. It’s not as bad as you think. A certain amount of fear is normal if, like me, you have never had a major surgery. But for me, everything went fine, even though I am 59 years of age, older than any one I have met who had DIEP. So, I think if I can do it, anyone can.

My only regret is that I didn’t come to my decision for prophylactic surgery before I got cancer. Time ran out to make that decision but I am thankful my cancer was found early and I am thankful for my husband of 29 years, Larry, was by my side supporting me every step of the way. I would advise anyone facing cancer to not panic, do your homework, and be very proactive in your treatment. Learn everything about breast cancer that you can so you can understand your options. Choose your doctors carefully. Get second opinions and do what YOU think is best for you. You have many options; don’t let anyone take any of them away from you. Make your own decisions.

Having cancer has changed my view of life. It seems much more precious and much more vulnerable than before. I am thankful for a second chance and thankful that I had so many options that my mother and grandmother did not have. My mother had radical mastectomies, which are very disfiguring. I am glad that I still look much like I did before. I had nipple-sparing surgery and when I look at my breasts I still see me in there. I can’t wait to see the results following my final revisions. I am very grateful for Dr. Kline, Chris Murakami, RN and Clinical Coordinator, and all the staff at The Center for Natural Breast Reconstruction for a very positive reconstructive experience.

About Linda Burkholder

My name is Linda Burkholder and I have lived in Kokomo, Indiana the past 22 years. I am the proud mother of two adult children, a daughter 23 years-old and a son age 21. I have been married to my husband, Larry, for 29 years. I work fulltime at Indiana University as an Administrative Secretary to the Dean of the School of Public and Environmental Affairs. I love animals and have two Pembroke Welsh Corgis and four cats. In my spare time I enjoy reading and knitting.

Do you have a question for one of our doctors? Ask us!

Improving Your Self-Esteem after Mastectomy

breast reconstructionA mastectomy affects you not only physically, but also mentally and emotionally. Many women feel like a vital part of them has been taken away, and their self-esteem suffers as a result. If these feelings aren’t resolved, they can lead to depression and other issues. It’s important that if they surface, you recognize them and know you can find help.

Focus on the positive.

While the surgery itself may not be a positive thing, focusing on being optimistic helps your self-esteem. You may decide on breast reconstruction and feel excited about having new breasts, or you may be heartened by the fact that you’re now a breast cancer survivor and can move forward with your life. Often, mastectomy patients find that the smallest things, such as a drive in the mountains or a sunrise, bring them joy.

Allow yourself to grieve.

You’ve had a loss, and it’s likely to provoke the same feelings of grief as losing a loved one. You may feel denial or anger, which is perfectly normal. Allow yourself to experience those feelings instead of minimizing them or holding them inside. If you feel the need for a grief counselor, ask your doctor or religious professional for a referral. A hospice bereavement counselor may also be a good choice.

Talk it out before, during, and after.

Whether you feel relief that the cancer is gone, grief over losing a part of your body, or hesitation in allowing your partner to see you right after your mastectomy, talk it out with someone you trust. Many women confide in their partners first, while others may turn to a family member, fellow breast cancer survivor, or therapist.

Find someone you feel comfortable with, and don’t be afraid to express yourself. The more you bring out in the open, the better you’ll feel.

Consider breast reconstruction as soon as possible.

Many patients look at natural breast reconstruction as their chance to finally have the breasts they’ve always wanted. They become very involved in learning what the surgery entails and what their options are. In fact, reconstruction often improves our patients’ self-esteem because their new breasts signal a new beginning, which is exciting and empowering.

In fact, our happiest patients are those who choose to have reconstruction at the same time as mastectomy, which reduces self-esteem issues.

Treat yourself.

This is the time to celebrate the amazing, unique woman you are. Be kind to yourself, and treat yourself to what you desire as often as you can. Travel, go shopping, and pursue those dreams.

If you’re a survivor, what advice can you give?

Breast Cancer Survivor Shares Reconstruction Success Story

according to shirleyWe are so happy to share with you another In Her Words post, this time with Shirley Trainor-Thomas, a breast cancer survivor, Hodgkin’s lymphoma survivor, and reconstruction success story!

Shirley was a patient of ours at The Center for Natural Breast Reconstruction and we are delighted to share her story with you.

See below for the interview (*Don’t forget to download a copy of According to Shirley, a short story / information booklet written by Shirley about her breast reconstruction experience):

When you were diagnosed with breast cancer in your left breast, you chose to have a double mastectomy. What influenced this decision? In other words, what factors did you consider when deciding whether or not to have a double mastectomy?

“It’s not good, princess.” Those were the exact words Dr. Bob Flowers used when he called to tell me the results of my biopsy. I promptly informed him that it was not the right answer! And after I caught my breath, I asked what we were going to do about it. He said he would get me to a surgeon that very day. True to his word, my husband and I were in Dr. Stan Wilson’s office that afternoon and we started discussing options. I was a bit of a difficult case because many years ago I had Hodgkin’s lymphoma and radiation to my entire torso—which is what likely caused my breast cancer. There was a lot of discussion among physicians and tests that were taken to make sure we had all of the information we needed to make the best decision.

The waiting to get answers and opinions that would lead to a plan was excruciating. All I could think about was breast cancer and I spent endless hours on the Internet trying to learn everything I could about my diagnosis and choices. My husband and I were in a fog.

Long story short, it appeared that chemo and mastectomy was my option. But, Dr. Wilson wasn’t totally convinced chemo was the really indicated and sent my tissue to have the Oncotype test.   As we waited on those results, we were moving forward with the chemo option. On a Thursday evening, I was preparing for surgery to take place the next morning to have a port put in—and at 8:00 pm, Dr. Wilson called with the Oncotype results—they were great. We opted to not have chemo.

Because other cells in my breasts were described as “busy” by the pathologist, I knew there was a chance of cancer striking my other breast. Given the painful waiting and emotional impact we went through, my husband and I said that we need to eliminate the chance of having to go through this again. Playing into that decision was that I was aware of the DIEP reconstruction option. I’m lucky, not everyone knows about that option and most people have to do a lot of research to find it or the right surgeon. I knew right out of the gate that the only person I would allow to do this procedure was Dr. Richard M. Kline, Jr. of The Center for Natural Breast Reconstruction.

2. What type of reconstruction surgery did you have and how do you feel about the results? Would you make the same decision again if you could go back?

I had DIEP. The great thing for me is that I went into surgery with bosoms and came out with bosoms—and a flat tummy. Bi-lateral mastectomy and reconstruction were done in one surgery.

Recovery was frustrating. As Dr. Kline kept telling me, “It’s a process.” No matter what he told me, I was convinced I would be back to normal in just a few weeks. Okay, so it took longer.  I got tired easily and couldn’t stand up straight for a while because of the stomach incision. But, my job requires travel and I was able to get on an airplane six weeks after surgery and get back to work.

My energy level took some time to return—it’s a big surgery. But, if faced with the same decision today, knowing what I know, I absolutely would do it again.

My bosoms are perfect.

Unfortunately, I didn’t have enough tummy fat to make them bigger than they were (my one chance—had I known, I would have eaten a lot more over the years!). Even my oncologist has marveled at how real they look and feel. But I would only allow Dr. Kline and Dr. Craigie to do it. I’ve read some horror stories online about women who went to surgeons who either weren’t trained properly or didn’t have the skill level needed for microsurgery. I actually communicate with women around the country to share my experience and to alert them that they really need to investigate their surgeon’s success record.

3. You decided to write a short story / information booklet about your breast reconstruction experience titled According to Shirley. Why did you choose to write this book and what do you hope readers will get from reading it?

I love Dr. Kline and his entire staff. But, when planning for surgery they gave me a booklet of what to do and expect. After going through the experience, I let them know they left A LOT of information out! It was written by medical professionals who never actually experienced the procedure. When I told them that the information was technically good, but needed to include more practical information, they said fine—write one. So I did. It’s really meant to give women a better idea of what to expect throughout the process and to keep positive about the experience.

4. What advice would you give to women who have undergone a mastectomy or double mastectomy and are unsure about natural breast reconstruction?

Research, research , research. Unfortunately, not all plastic surgeons will present options that they are not capable of providing, such as DIEP. Talk to several surgeons and get a feel for the success rate of the surgeon. Talk to their patients. It’s a major procedure. Women need to know how many procedures the surgeon has done and what his or her success rates are.

Have you downloaded your copy of According to Shirley? If not, click here.