“A Learning Experience” In HIS Words

by:  Richard M. Kline Jr., M.D.

learning is a giftI think the biggest thing I learned was how important it is to have providers you trust when you are facing surgery. For me, this was relatively easy, as my wife worked with these people all the time, and I found them immediately likeable when I met them. But how is a lay person to know who to place their trust in? I think the initial step is selecting your surgeon. He or she should immediately look you in the eyes, really listen to everything you say, answer questions honestly, and never be afraid to say “I don’t know.” I think it can help if they have already operated on people you know (as I mentioned, this surgeon had operated on my Dad), but that’s usually not going to be the case. Once you have found a surgeon you trust, the rest should start to fall into place, because they will select the best team they can to help them take care of you. As it turned out, my surgery took longer than expected because it they couldn’t do it laparoscopically, and had to “open me up.” This bothered my surgeon, but it didn’t bother me. I had trust in my team, and felt that however it worked out, it was for the best.

 

I also noticed that, by and large, everyone I came in contact with on the day of my surgery seemed to be “tuned in” to how I was likely feeling at an unusually vulnerable time. I had previously lacked firsthand experience of the importance of that empathy to patients.

 

I think that I also gained some appreciation for how the patient can sometimes contribute to a good outcome. I think my preoperative efforts to lower my blood pressure and improve my overall fitness were helpful.  On the morning of surgery my blood pressure was normal, and I think my postoperative course might have been a little easier because I was in a little bit better shape due to the exercise.

 

And I will still prescribe to my patients those Lovenox shots, because I care about their safety – but I will do it with much more sympathy.

Hey doc how are you

Recovery daze…..

By:  Richard M. Kline Jr., M.D

 

pain scaleI woke up and wasn’t sure where I was. I thought about it a while, and finally asked. A nurse said “the recovery room.” I asked how long I had been there, and she said “30 minutes.” I asked how long the surgery took, and they said “about two hours”. I knew this was longer than was planned, but I didn’t worry about it, as I felt pretty intact. They asked what my pain was on a scale of (0-10), and I said “3.5.” She asked if I wanted some Dilaudid, or if I wanted to go back to the room without it. I said I wanted it, so they gave me 1 mg i.v. While the pain hadn’t been terrible, it was significant, and the Dilaudid did a great job of reducing it. It didn’t get rid of it completely, but it did produce a kind of “warmth” that made me not care too much about the residual pain.

I then went back to the same room I’d been in before surgery, and stayed only briefly before deciding I was ready to go home. When I got up to get dressed, I immediately got nauseous. The bubbly i.v. specialist nurse was there again, and she came over and held an alcohol wipe to my nose until the nausea went away. Then home I went, happy that it was over, and not feeling too badly.

For the first few days it hurt to get out of bed. I would lie there thinking about getting up for several minutes, planning the best way to do it, and only then proceeding. Once I was up, though, moving around wasn’t bad.

About two weeks postop, I noticed that coughing or sneezing didn’t make my incision hurt any more. I started walking on the treadmill at the gym. It hurt a little, but not bad. After that, I started to forget about the surgery.

The final installment of this 4 part series will post April 30.

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)

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)

 

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: Questions About Reconstruction Surgery Years After A Mastectomy

<img src="image.gif" alt=A pink rose" />This week, Dr. Richard Kline of The Center for Natural Breast Reconstruction answers your questions.

Q: I have been cancer free for 4 years, and have been very undecided about reconstruction. My surgery removed the underside of my right breast. I am very lumpy and the scar is very hard. Would I need to have a reduction in the other side or can the surgery site be repaired? I am “usually” a D in size currently. Also, is this surgery considered a “tummy tuck” type operation?

A:  You have several potential options, depending on your present physical situation, and your wishes.

I’m assuming you are radiated (please correct me if I’m wrong). With this in mind, an implant to increase the size of the right breast is not likely to work. Increasing the size of the right breast with a DIEP flap (I assume this is what you meant by “tummy tuck”) is potentially a large operation for a lumpectomy defect, but sometimes it is actually the best option.

If you don’t mind being smaller than you were, reducing the size of the left breast may well be your best (and simplest) option to get better symmetry. That’s probably all I should try to say without knowing more details about your particular situation. We’d be happy to have our nurse Chris or PA Kim call you to discuss your situation further, if you wish. Thanks for your question, and have a great day!

Q: I had bilateral mastectomy in 2011, but didn’t have insurance. Now that I do have insurance, can I get reconstructive surgery? And how do I go about it?

A:  Thanks for your question. There is no time limit to when you can have reconstruction surgery. Your next step would be to start researching what kind of procedure would achieve your goals. If you’d like a permanent reconstructive procedure, the ones we offer might be what you are looking for. We use excess tissue of your abdomen, buttock or upper thigh and transfer that along with it’s blood supply to build a new warm natural breast.

Richard M. Kline, Jr., MD
The Center for Natural Breast Reconstruction

Ask the Doctors: Listen In, Again!

Yesterday’s live call was amazing—did you miss it?

Here’s a shot of Dr. James Craigie in action, as he listened and answered questions.

If you missed the call, don’t worry!

Here’s a link to the replay:

==> http://InstantTeleseminar.com/?eventID=43480677

Drs. Craigie and Kline answered your questions on a wide range of topics related to natural breast reconstruction, including:

    • Recovery issues–how long do certain procedures take
    • Aesthetic concerns—scar tissue, nipple sparing, etc.
    • More about preventive mastectomies…
  • And much more you’ll want to hear!

We are here for you. Feel free to scroll back through our comprehensive Ask the Doctor archive here on the blog, too, for more information! Or contact us anytime.

Can a Mammogram Hurt My TRAM Flap?

Can a mammogram hurt my tram flap?

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

 

Q: I have an 18-year TRAM (Transverse Rectus Abdominis Myocutaneous) flap. Recently I have found a perpendicular ridge about an inch from my sternum. It feels like a lump. I have had an ultrasound and now they want to do an MRI and an mammogram. They found nothing on the ultrasound. My concern is the mammogram. Could this cut off blood supply to my TRAM flap? I would like to ask my original doctor but he is strictly doing plastics. Thank you for your help!

 

A: While it’s not impossible, a mammogram is highly unlikely to hurt your TRAM flap, especially after this length of time. Certainly it is important to find out what the lump is, anyway.

Good luck, let us know if we can be of any help.

 

 Richard M. Kline, Jr., MD

Center for Natural Breast Reconstruction

 

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

Natural Breast Reconstruction: What Are My Options If I Have Scarring?

The below question is answered by Dr. Richard M. Kline of The Center for Natural Breast Reconstruction.

I lost my implants in 07 due to an infection from my lymphedema. I had both removed and didn’t have reconstruction since the prior surgery was a failure. I have scaring from radiation in 2001. I’d like to think about reconstruction again BUT afraid of failure due to the scaring. Do I have options? Really would rather not have implants, I’ve both types, didn’t like either but would accept silicon over saline.

Hello,

Natural Breast Reconstruction almost certainly represents your best chance for a successful reconstruction, even with your past unfortunate experiences. If you have adequate donor tissue in your abdomen, buttocks, or thighs, there is an excellent chance that it can be used for your reconstruction. Your past surgeries and history of radiation may affect the final appearance of your breasts due to effects on your skin, but they usually have no impact on our ability to successfully transfer your donor tissue using microvascular techniques. If you’d like more info, we could have our nurse Chris call you. If you wanted to send pictures, that would also be very helpful.

Thanks for your inquiry.

Richard Kline
Center for Natural Breast Reconstruction

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

 

Are You Comparing Apples to Apples When Weighing Your Breast Reconstruction Options?

We at The Center for Natural Breast Reconstruction know that the Internet is a great place to read and share information, but it is also a great place to become misinformed. Before making any decisions about your breast health, please make sure to contact a surgeon to discuss all your options and make the most informed decision you can. Keeping with the spirit of the Internet as a research tool, today’s Ask The Doctor Question comes from a discussion forum we participated in on WebMD.com. The answer highlighted below in pink comes from our team and showcases the importance of making sure you really are comparing apples to apples when weighing your breast reconstruction options.

Q: Has anyone had a hard time with breast reconstruction after bilateral mastectomy? I had two infections in my right expander, 2 and 3 months after my surgery. The first we conquered with antibiotics; the 2nd we did not, and I had to have it removed 4 months later. I spent the last 5 months healing from that, and just last week had the expander replaced. Hoping for the best this time! But there is significant skin loss on my right side, and my surgeon wonders if there will be enough stretch to accommodate saline fills to match my other side. And of course we all wonder if THIS expander will behave itself and not get infected. Has anyone had this experience, or one similar? Thanks.

A: Why don’t you go with the DIEP Flap procedure – they use the fat and skin from your abdomen area – I have had no problems from this procedure and I have heard of a couple of people who have had issues with infection with the expanders. Find yourself a Plastic Surgeon who does the DIEP Flap procedure

A: I also had a bilateral mastectomy but had to wait 2 years before reconstruction. I also had the expanders but had no problems, maybe it was too soon after your surgery. I would not recommend a tram flap ,it just sounds like an awful surgery.

A: There is a difference between and DIEP Flap and a trans flap.
The DIEP Flap they only take the fat and skin from your abdomen nothing else – they find a good blood supply at the reconstruction site. The Trans Flap is they take your stomach muscle and pull it up through to the breast cavity and also bring the fat and skin from the abdomen area. I for sure was glad that I did not do the Trans Flap.

A: (The Center For Natural Breast Reconstruction’s Answer) The free TRAM flap sacrifices a portion of the transrectus abdominus muscle (hence the acronym TRAM) but doesn’t tunnel it up through the abdomen. The DIEP flap does not use any of that muscle to transfer the blood supply to the reconstruction site. A skilled micro-surgeon with fellowship training in muscle sparing free flap reconstruction provides a permanent reconstruction option with a successful DIEP without sacrificing needed abdominal musculature. There is A LOT of great information on the web about this and what questions you should ask to make sure you are choosing a microsurgical team who has the experience and at least a 98% success rate. Talk to ladies who have had DIEP, GAP, HIP, SIEA flaps ( but not TRAM, it’s not the same) and see what kind of downtime they have had, you’ll probably find it similar to the amount you have had with the repeated implant/expander problems. Best wishes on your research and recovery.

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