Ask the Doctor – Could Odd Pains In My Body Be The Consequence Of an Old Abdominal Flap Surgery Following A Halstead Radical Mastectomy?

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

Question:  In 1987, I had abdominal flap surgery following a Halstead radical mastectomy. I keep wondering what is NOW going on in my body! When I feel odd pains I wonder if it could be repercussions of that surgery so long ago.

Answer:  Thank you for your question. If you had your surgery in 1987 and you had reconstruction using your abdominal tissue then I will assume that you had a Tram procedure. That surgery relies on partially removing the muscle from the abdominal wall. Not having the muscle in place can cause problems later in life. People can have pain or bulging of the tummy and even hernias. Of course not all patients have those problems. If your problems are in the tummy area then that is a possibility. If your problems are in the area of your breast or mastectomy then you should consider seeing a breast surgeon that specializes in doing mastectomies to make sure all is well with regard to your breast area. You could also see the doctor who follows you regarding your breast cancer history. Scaring from a “Halstead” mastectomy especially after radiation could cause aches and pains later in life. Regardless of what it might be you should definitely be seen by your doctor so they could do a complete evaluation of your symptoms. After an evaluation they could make more specific recommendations. I hope his information helps. Let me know if you have further questions.

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

 

10 Important Breast Cancer Facts

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Because October is Breast Cancer Awareness Month, we want to highlight the significance of this serious illness. Below you’ll find a list of 10 facts about breast cancer.

This post pairs well with our 10 Breast Cancer Fundraising Ideas post. If you want to raise money for awareness, the ideas we shared in that post will help get you started.

Now let’s go over these very important facts:

1. About 1 in 8 women born today in the United States will get breast cancer at some point. The bright side of this is women can survive breast cancer if it’s found and treated early. How? With a mammogram — the best screening test to detect signs of breast cancer.

2. Breast cancer is the most commonly diagnosed cancer in women. Each year it is estimated that over 220,000 women in the United States will be diagnosed with breast cancer.

3. Breast cancer is the second leading cause of death among women. It is estimated that over 40,000 women will die from breast cancer every year.

4. Men get breast cancer, too. Although breast cancer in men is rare, an estimated 2,150 men will be diagnosed with breast cancer and approximately 410 will die each year.

5. Breast cancer rates vary by ethnicity. Rates are highest in non-Hispanic white women, followed by African American women. They’re lowest among Asian/Pacific Islander women.

6. Genetics have a role in breast cancer. Breast cancer risk is approximately doubled among women who have one first-degree relative (mother, sister, or daughter) with the disease. On the other hand,more than 85 percent of women with breast cancer have no family history.

7. Breast cancer risk increases as you get older. Even though breast cancer can develop at any age, you’re at greater risk the older you get. For women 20 years of age, the rate is 1 in 1,760. At 30, it significantly jumps to 1 in 229. At 50, it’s 1 in 29.

8. It’s the most feared disease by women. Yet, breast cancer is not as harmful as heart disease, which kills 4 to 6 times the amount of woman than breast cancer.

9. The majority of breast lumps women discover are not cancer. But you should still visit your doctor anyway, even though 80% are benign.

10. There is so much HOPE! There are currently more than 2.5 million breast cancer survivors in the United States alone — and this number continues to climb each year.

It’s important to understand the facts about breast cancer, and learn how you can support loved ones and friends who are suffering from this illness, or have been affected by it. To learn more about breast cancer, you can download a PDF about the last 2013-2014 breast cancer facts from cancer.org.

To learn more about our mission, our practice, and our team, start here and meet our doctors.

Ask the Doctor: Lymphedema and Lymph Node Transfer

<alt="3 pink roses"/>This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your question.

QUESTION: I’ve had breast cancer and developed lymphedema after my mastectomy.  I recently heard about Lymph Node Transfer surgery.  Does it work?  I’m scheduled for a DIEP breast reconstruction, can it be done at the same time?

ANSWER: Lymphedema is a very difficult problem that results when a patient has had breast cancer and has to undergo surgical removal of the lymph nodes under the arm as part of their surgical treatment for breast cancer. There are other causes of lymphedema but our specific interest has been in patients who have had breast cancer.

Lymphedema can be a very debilitating process; it remains a terrible problem worldwide, for all types of reasons. There is still much to be learned about why some people develop lymphedema and others do not. It appears that lymphedema is directly related to several factors in our breast cancer patients. It is directly related to having the lymph nodes removed from under the arm and seems to develop from the scarring that occurs under the arm following mastectomy and / or axillary dissection.

Undergoing radiation of the arm or axilla increases this risk. However, there are many people who undergo removal of the lymph nodes and radiation that do not develop lymphedema. There are also people who have mastectomy, have lymph nodes removed followed by radiation, and don’t develop lymphedema until many years after their surgery. That is the main reason that patients are warned to pay particular attention to their arm if they have had removal of any lymph nodes.

It is also possible that someone could get lymphedema even after simply having a sentinel node removed. A sentinel node procedure (lymphadenectomy) is a way to examine the lymph node without having to remove more than one or two. The whole idea of examining only the sentinel node is to lower the risk for lymphedema, but even with the sentinel node procedure, there is still a chance of developing lymphedema. Our practice became interested in options to help breast cancer patients with lymphedema as we see many who are suffering from the symptoms of this process while undergoing breast reconstruction.

Our practice specializes in microsurgical free flap breast reconstruction utilizing skin, underlying tissue, and microscopic blood vessels that transport life-giving blood to the reconstructed breast. This procedure is commonly referred to as the DIEP if using the abdomen or a GAP if using the buttock tissue. The muscles of the abdominal wall are left intact as it is the removal of the muscles of the abdominal wall that can lead to problems in the donor area, like hernias and bulging, as well as a more involved extended recovery. The lower tummy wall is the most common area that we transfer and it’s also an area where lymph nodes are present. Therefore, over the first decade this surgery was being done, we would encounter lymph nodes in the area of the blood vessels, as well as fatty tissue.

It became obvious that we could transfer lymph nodes on the blood vessels as we refine our technique for microsurgery. Due to the lack of effective treatment for lymphedema, for years surgeons doing perforator flaps have taken on this challenge and are trying to come up with ideas and techniques to treat it. We began doing an extensive amount of research, spanning the globe, looking for information on procedures that may help these patients. In 2005, we formed a group known as the Group for the Advancement of Breast Reconstruction, known as GABRs, and we included members throughout the world who had had a unique experience with our type of breast reconstruction.

We encountered one individual who had 15-years of experience with what is now known as “vascularized lymph node transfer” for the treatment of lymphedema. Initially, Dr. Robert Allen had attempted lymph node transfer during breast reconstruction and the biggest concern was how to transfer lymph nodes from one area of the body to treat lymphedema but not to create lymphedema in the donor area. In 2006, the GABRs met in Beijing, China and invited Corrine Becker, a surgeon from France who had a long history of experience with vascularized lymph node transfer.

She presented her work and through communication and travel to Paris to work with her, members of the GABRs group began to gain experience and learn more of her technique. The biggest hurdle that we were able to overcome was learning how to select the lymph nodes that could be removed as the donor lymph nodes and use those for breast reconstruction without causing lymphedema of the leg. We spent an extensive amount of time discussing her techniques and reviewing her results, as well as her publications.

We then made arrangements for her to travel to South Carolina and actually performed surgery on our own patients with her as an assistant surgeon. Since that time we have been very encouraged by the results with vascularized lymph node transfer as an effective treatment for reduction of the symptoms of lymphedema. We feel very excited but yet are very cautious about all results. It is important that patients realize that this procedure is still evolving and that there are risks involved, but to date we have had very good results and no serious complications.

Improvement of symptoms with vascularized lymph node transfer can occur immediately; however, they also may take up to 2 years to be appreciated. In most of our patients, the indicators of success are different. For the majority, the goal was to improve the edema, lessen the need to wear compression garments on a regular basis, and to eliminate the risk for frequent infections, which are the typical problems that those affected by lymphedema experience.

In order to lower the risk for complications and to closely study our results in conjunction with other colleagues who perform this procedure, we prefer to perform vascularized lymph node transfer as an isolated procedure. It can be done at the time of breast reconstruction; however, there is a chance that some people with mild lymphedema who undergo breast reconstruction may have improvement without lymph node transfer. Therefore, in order to closely study our results, we perform the breast reconstruction first followed by vascularized lymph node transfer as the second step. When the results are complete, we can determine whether it was the reconstruction or the transferred lymph nodes that gave the end result. It is important again to reemphasize that the main risk for of the surgery is that the transfer may not work. It is possible that if the transfer did not work resulting in more scar, the lymphedema could worsen.

Thankfully, to date, we have not experienced this complication. Other complications are damage to the blood vessels under the arm or the nerves under the arm. Therefore, our preference is to have an oncologic surgeon, who performs axillary dissection, release the scar under arm.  At the same surgical setting, after the scar is released, we perform the transfer by removing very specialized lymph nodes from the outer and lower abdominal wall or outer upper leg. We preserve the lymph nodes of the inside leg. These are the ones that drain the lower extremity and therefore, we feel that the risk for lymphedema of the donor area is reduced.

At this point, we have received some very exciting results along with some mixed results and continue to follow our patients very closely. We have had no patients with any serious complications and no patients at this point with lymphedema of the donor site. We are hopeful that the future holds vascularized lymph node transfer as an effective option for people with lymphedema following breast cancer surgery.

We plan to continue to devote and focus our energies on a surgical solution while simultaneously not exposing people to excess risk of additional problems. Once again, we do have to admit that the surgery, although giving some promising results, is  still evolving at this point and we choose to proceed with caution in the best interest of our patients.

— James Craigie, M.D.

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

Why Microsurgical Breast Reconstruction?

<alt="pink flower"/>The access to GAP and DIEP procedures is not widespread, only a handful of surgeons have invested the time to learn this intensely specialized microsurgical procedure, and have access to another equally qualified micro-surgeon to provide the required surgical assistance.

To give you an idea of how few of these surgical teams exist, in late 2007 we were one of only three practices in the country that offered simultaneous bilateral GAP reconstruction.  As a result, we see patients from all over the United States seeking this highly successful option, with 30 to 40% of our patients referred to us as a result of repeatedly failed implant reconstructions.

In a critical analysis of 142 GAP procedures published by six physicians at LSU, the GAP procedure is reported as “not easy to learn; however, it does provide a reliable flap and an excellent aesthetic reconstruction.”  The report further states “overall flap survival was 98%”and perhaps most importantly “patient satisfaction with the reconstructed breast and donor site has been excellent.”

A little bit about us:

Co-directors Dr. Richard M. Kline and Dr. James E. Craigie are certified by The American Board of Plastic Surgery. Both surgeons have trained under Dr. Robert J. Allen, a pioneer in breast reconstruction using the DIEP, SIEA, and GAP flaps. Dr. Craigie completed a microsurgical breast reconstruction fellowship dedicated to muscle sparing techniques (directed by Robert J. Allen, M.D.). Dr. Kline completed his residency at LSU while Dr. Allen was developing these techniques.

Our entire surgical team is dedicated to remaining at the forefront of breast reconstruction surgery to provide excellent care and results for each individual patient. Because of this commitment, the practice consistently earns referrals from our patients, as well as from other surgeons throughout the United States.

Knowing the right questions to ask:

When searching for a surgeon to perform your microsurgical breast reconstruction, it’s important to ask him or her the right questions. Below are a few questions to ask:

  • Are you a microsurgeon? Where and by whom were you trained in this specialty?
  • How many microsurgeries have you performed? And how often do you perform them?
  • What is your success rate?
  • Can you arrange for me to speak with some of your patients who have had the procedure I am seeking? (Candidates should speak with people of similar ages and lifestyles).
  • How long do you anticipate I will be under anesthesia for the procedure?
  • How many board certified physicians will be assisting with the first stage of the procedure? Will there be physicians in training (residents) involved with my surgery
  • Will I have to sign a consent that if a physician is unable to complete the procedure, I will have to consent to a TRAM/Free TRAM?

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

Ask The Doctor: I’m looking for a surgeon that performs DIEP procedures.

<alt="pink roses"/>This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your question.

QUESTION: I was diagnosed with lobular carcinoma in situ breast cancer and am looking for a surgeon that does DIEP, sensory nerve reconstruction, and vascular lymph node transfer. Does your team perform these procedures?

ANSWER: We have been specializing in the procedures you asked about since 2002. If you would like to have me give you my opinion about your specific situation let me know. My partner and I have performed approximately 1,200 muscle sparing breast reconstructions together. We also reconnect sensory nerves and are experienced in vascularized lymph node transfer. We do phone consults if you’re interested in discussing this more. Thank you!

James E. Craigie MD

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!

Ask The Doctor – I am not happy with the results of my DIEP Flap surgery – Should I get an implant?

<alt="orange flowers"/>This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your question.

QUESTION: Hi, in May 2013, I had my transfer done at the same time as my DIEP flap. In that surgery, I also had a reduction on my left breast. The doctor that did my surgery left and moved somewhere else, so I’ve seen another doctor since. My new doctor tried to fix it, but it’s still messed up. He said he really doesn’t know what to do. As far as the transfer is concerned, I’m not sure it worked. I had another procedure done that helped it at first, but my cancer came back again on my pelvis bone and the chemo has made it worse. I am no longer on chemo, but I will take Herceptin for the rest of my life. Is it possible to remove the fat and put an implant in my breast?

ANSWER: Hi, if you had radiation on the reconstructed side, an implant might not be the best option. It is possible to add an implant to a DIEP to increase the size in order to match the other breast. I personally prefer to perform fat grafting to add more volume when possible. It is harder to match a normal opposite breast with an implant breast reconstruction. Removing fat normally is not the answer to revising the shape unless the fat is not living. This is called fat necrosis and feels hard not soft like normal fat. Also, if you went with an implant on that side the results would be more natural if you had more of your own fat to cover the implant. Otherwise the new breast has no natural tissue to cover it and the end result looks less natural.

James E. Craigie MD

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!

Ask the Doctor – Will Insurance Cover the Reconstruction of My Breasts?

<alt="pink flower"/>This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your question.

QUESTION: When I had breast cancer in 2010, I didn’t have any insurance. Now, I have great insurance and I want to undergo breast reconstruction. Will insurance cover the reconstruction of my breasts?

ANSWER:  Hi there. Thank you for your question. If you have had a mastectomy for breast cancer reasons and now have insurance, then you should be covered. There is no time limit between having a mastectomy and undergoing breast reconstruction. You should be covered, but make sure you call your insurance company and check what procedures your insurance will take care of.

Dr. James Craigie

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!

Ask The Doctor – Can A Saline Implant Leak Long After Surgery?

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

QUESTION: Can a saline implant slowly leak approximately 16 months after surgery? Also, can a bacterial or fungal infection occur during this time? I am hearing and feeling a gurgling sound in my right breast which I believe is fluid. I am concerned because I read that an implant can leak out and cause fungal and bacteria infections.

ANSWER: Thank you for your question! A saline implant can leak at any time after surgery. The leak can be slow or sudden. Eventually, you would notice the size go down. Implants are normally filled with sterile saline that would not cause an infection. If you have an infection it most likely would not be from the fluid that was in the implant. Usually that fluid is absorbed by the body after a leak and causes no medical problems. The best way to get an accurate answer would be to report what you are experiencing to your surgeon who performed the implant surgery.

Dr. James Craigie

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!

Ask the Doctor: Will Scar Tissue Buildup Be A Concern With The Gap Flap?

 

<alt="pink lotus flower"/>This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your questions.

Question: My wife had a double mastectomy 10 years ago. At that time she had latissimus surgery to fill in her breasts. Since then, we’ve had numerous surgeries, about every 2 years, due to scar tissue building up in 1 of the 2 (or both) breasts that causes tightening and even pain. Will scar tissue buildup be a concern with the Gap Flap? 2. Regarding the Gap Flap procedure, what is the rate of failure that you experience with any of the 4 surgery sites (2 buttocks, 2 breasts)? Thanks.

Answer: Hi — I’m assuming your wife has implants under the latissimus flaps, which would explain the buildup of scar tissue. GAP flaps are generally large enough to make a breast by themselves (obviously, sizes differ among different people), so implants are not needed, and internal scar buildup would be a very rare event. We last calculated our statistics in October of last year. Over 10 years, we did 217 GAPs, 49 as unilateral, 168 as simultaneous bilateral. The GAP flap survival rate was 97% overall. All of the failures were in bilateral cases, but no patient lost both flaps, yielding a simultaneous bilateral flap survival rate of 96.4%. We have done quite a few GAPs since then with no failures (most recently a simultaneous bilateral last week), so the current statistics are actually a little better than that. We don’t bury flaps, and therefore can’t miss (or ignore) a failure, so these are ironclad statistics that could survive a GAO audit. To our knowledge, only Dr. Allen (who invented breast perforator flaps and trained the rest of us), his ex-partners in New Orleans, and ourselves actually do simultaneous bilateral GAP flaps on a routine basis. I’d be happy to discuss your situation further if you wish, just call or email.

Dr. James Craigie

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!

Ask the Doctor: What Are My Options for Natural Breast Reconstruction?

 

<alt="pink peony"/>This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your question.

Question: I had right breast ductal carcinoma, Stage 2. Two out of 22 lymph nodes had cells. I did a gene test, and had both chemo and radiation. The expanded radiation destroyed it. I had a mastectomy in Charleston, and now I’m ready to have my breasts fixed. I don’t want to have implants. I’d rather have a reconstruction using my own body fat and tissue. What are my options?

Answer: Hi — I’m sorry you’ve had so much trouble, and hopefully things will continue to improve for you. Your history of radiation fortunately has no bearing on our ability to do a reconstruction using only your own tissue. Many of our patients initially had failed implant reconstructions elsewhere, only to be later successfully reconstructed with their own tissue. Please feel free to come by for a consultation if you live locally, or, if you’d rather, we can arrange a phone consultation. Thanks for your inquiry, have a great day!

Dr. James Craigie

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!