Ask the Doctor – Can My Latissimus Flap Reconstruction Surgery Be Reversed?

This week, Dr. Kline, of The Center for Natural Breast Reconstruction, answers your question about breast reconstruction.

Question: I had that flap reconstruction 4 years after my mastectomy. That was 8 years ago. I’m in constant pain from the pulling in my chest. I hate that I can no longer paddle my canoe or swim.

I’m also having continued back problems that require the use of a chiropractor.

Can this procedure be reversed? I did not have any radiation or chemotherapy.

Answer: What type of flap did you have? It would be very unusual for a free tissue transfer (such as DIEP) to cause pulling, but not so unusual for pedicled flaps like a latissimus (or even a TRAM).

If you did have a latissimus, it could quite possibly be revised to improve your symptoms.

If you had a DIEP, it would require a little more investigation. Please let me know, and I’ll try to give you a more precise answer. I’d also be happy to chat with you by phone, if you wish.

Inquirer’s Response:

I believe it was a latissimus.

They used a portion of muscle from the side of my back, just a few inches lower than the armpit. The breast has also shifted slightly so that it isn’t centered in the chest anymore and is closer to the armpit.

In addition to the pulling pain in the chest, I’m having severe pain in the upper back, shoulders, and neck. I’ve also had recurring numbness and tingling in the hand and sharp pain shooting down my arm.

The chiropractor says that the realignment of the muscle will mean a forever battle of trying to keep the spine aligned and not pinching the nerve.  

Having the latissimus procedure is a huge regret for me. I wish I’d just had an implant.

The other breast just had a lumpectomy, rather than a full mastectomy. I have a small implant on that side that has never caused me any issues.

I want to know if the latissimus can be reversed and have an implant put in.

Answer from Dr. Kline:

I’m sorry you’re having so much trouble. That actually isn’t the norm for latissimus flaps, but it certainly can happen, as you know.

The latissimus can be transferred with or without dividing its motor nerve (thoracodorsal), and with or without dividing its attachment to the humerus (arm bone).

If the breast is shifting away from the center, that’s an indication that it may still be attached to the arm bone. If you have spasms, or intermittent pulling pain, it could be because the nerve isn’t divided, and the muscle is still functioning.

This doesn’t bother most people, but it definitely bothers some.

Sharp pain shooting down your arm (especially the inside of the upper arm) could indicate compression of the intercostobrachial cutaneous nerve, which lies in that area.

Offhand, I can’t think of an obvious anatomical explanation for your hand numbness and tingling, however.

Three muscles, the pectoralis major, the teres major, and the latissimus dorsi all attach to your upper arm bone at about the same place, and all pull the arm towards your body, but they each pull from a slightly different angle.

The latissimus is now rearranged to pull from the same angle as the pectoralis major. Usually, this does not cause a problem, but that’s not to say it never does.

It’s not really practical to actually “reverse” a latissimus flap, in the sense of putting it exactly back where it was. The flap can certainly be removed, however, and it is not at all unreasonable to think that that might help your symptoms.

In addition to perforator flap breast reconstruction, we also do implant reconstruction, but we shifted to placing the implant exclusively in front of the muscle about three years ago.

This can result in some visible rippling, but it has multiple benefits, including lack of animation deformity when the muscle is contracted, less chance of the implant coming out of position, less damage to the pectoralis muscle, and less discomfort.

Successful placement in front of the muscle is made possible by completely or nearly completely wrapping the implant in acellular dermal matrix (preserved skin, such as “Alloderm”), which heals to the tissue around it, and provides support.

While it may often be a very prudent decision to travel to see surgeons with extensive experience for complex procedures such as perforator flaps (DIEP, sGAP, PAP, etc.), simply removing the latissimus and placing an implant (or a tissue expander initially, which can be safer) requires no unusual skill, so I would recommend that you first consult your previous plastic surgeon, or another in your geographic area.

I would still be happy to speak with you about your situation, however, if you wish.

Have a great weekend, and thanks for your inquiry.

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

 

 

Ask the Doctor- I’m Having Pain After My Last Latissimus Flap/Implant Reconstruction. What Can I Do Now?

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

Question: I was diagnosed with breast cancer in 2011, and had a mastectomy on my left side followed by chemo. In 2014, my mammogram began showing tumors and I would have an ultrasound every time. This caused panic attacks and I choose to have my right breast removed because the type of cancer I had was Stage 4 Aggressive. In April 2015, I had a bilateral latissimus flat and received implants. Now I am experiencing pain across my back where I was cut and my chest gets uncomfortably tight. The site of the drainage tube is swollen and doesn’t feel good. I stopped seeing my reconstruction doctor because he did things I was not informed of. I am worried because I do not know what is going on anymore. Could you please advise me as to what might be going on or what to do?

Answer: I’m sorry you are continuing to have problems, but you are not alone.

I can’t speak about your situation specifically because I haven’t examined you, but here are some thoughts in general about patients with symptoms like yours.

There is no question that many people with implants describe symptoms such as yours. Often, there is no discernible reason why they should feel discomfort, but they do. Nonetheless, many of them feel relief when the implants are removed. This does not mean that you would or should, it is just an observation.

The latissimus flap can be done with or without dividing the nerve that makes it contract. I have known some patients with latissimus flaps done without dividing the nerve to have discomfort associated with the muscle contracting. Some have experienced relief when the nerve was subsequently divided. Obviously, I don’t know if this is your situation or not.

Sometimes people have complex, persistent pain after surgery or injury which is out of all proportion to what would be expected. This can be difficult to treat but thankfully is rare.

When evaluating a patient with symptoms like yours, we usually start with a careful history and physical evaluation. Sometimes, especially if we have concerns about implant rupture, fluid collections, infection, etc., we then get an MRI and/or CT scan Following the complete evaluation, we then decide together how to proceed.

Hope this helps at least a little. I would be happy to chat with you further by phone about your specific problem or see you in person if you can come for a visit.

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

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.

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

What is a Compression Garment?

Ask the Doctor

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

Q: I’ve been told I might need to wear a “compression garment” after Stage 2 of my DIEP.  What exactly is that, where do I purchase it, and how long do I have to wear it.  Does everyone need to have one?

A: A compression garment is worn after body contouring to support the swollen area of the body. It is a tight fitting elastic type of under garment. Not everyone will need one. It depends on whether liposuction or fat grafting is performed. Usually it is placed on in the operating room after surgery when needed. DIEP and GAP patients may need them and they are typically provided by the hospital.  They are worn after surgery until the swelling is gone, usually around 3 weeks or more. They should be worn all the time at first and less later.

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!

Can I Have Natural Breast Reconstruction if I Had Radiation on my Right Side?

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

Q: Can I get natural breast reconstruction if I have had radiation on my right side? I have had both breasts removed, but the first time the cancer was found I had a lumpectomy and radiation. The next time I had it removed.

A: Natural breast reconstruction with your own tissue is usually the best option for patients who have had radiation. Sometimes (but not always) it can be difficult to get the radiated side to match the non-radiated side as closely as desired because the radiated skin can be much tighter, but the chances of success are still usually much better using your own tissue than using implants.

We’d be happy to have our nurse Chris or PA Kim call to chat with you more about the specifics of your situation, if you wish.

Dr. Richard Kline

Center for Natural Breast Reconstruction

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

Can I Have Breast Reconstruction After A Lumpectomy? Will Insurance Cover My Reconstruction?

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

Q: I had a lumpectomy 10 years ago. Can I have reconstruction to fix my breast? The scar is under my left arm and the lump was taken out of the left side of my breast.

A: Thank you for the question! Some women who have had lumpectomy and radiation to treat breast cancer  develop problems with the shape of their breast or problems with one side being smaller than the other. When this happens we recommend breast reconstruction. It is possible to remove the breast tissue and save the nipple and skin. Then at the same procedure  reconstruction with your own fatty tissue is performed. This has the advantage of removing the radiated scar and breast tissue and reduces the theoretical chance of breast cancer coming back in that breast. It should already be very low.

Dr. James Craigie

Q: I had breast cancer in 2002 in my left breast. A lumpectomy was performed and I only had radiation. I had a breast reduction on the right side to match the approxmate size of the left breast, but since then I have gained so much scar tissue around the left breast and it is now much smaller than the right breast. I am 69 years old, but still consider myself to be middle aged and attractive and this bothers me. Will insurance cover these procedures even though it has been over 11 years since the cancer and 10 years since the reduction? I have a Medicare PPO.

A: Insurance will cover almost any reconstruction-related procedures, if you have had the diagnosis of breast cancer.

There are several potential options available to you, depending on your goals. We would be happy to have our nurse Chris or PA Kim call to discuss your situation further,  if you wish.

Dr. Richard Kline

Thanks for your inquiry!

Center for Natural Breast Reconstruction

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

Should I Get Permanent Sutures to Help My Implant After Lumpectomy?

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

Q: I had a lumpectomy followed by chemo and radiation treatment. The tumor was on the inner edge of my left breast — basically skin and bone. My plastic surgeon (whom I respect and appreciate) used an implant and Neulasta. He formed a sling and sewed in to my sternum and ribs. I’ve had this procedure done twice. Each time the sutures were absorbed, the skin lifted and resulted in symmastia. I am wondering if non-dissolvable stitches along with sewing the neulasta to the area behind my breast which wasn’t super blasted  — forming a sort of “sail” would be an option. I would be interested in what you think and what solution you might have.

Thank you for your time!

A: We primarily do flap, not implant reconstruction, but I can still offer some insight.

Permanent sutures could possibly help, but if there is long-term significant force on them (which it sounds like there may be), they can work their way through soft tissue and still come loose (just like an orthodontist can move teeth through bone over long time periods). Nonetheless, it’s probably worth a try, especially if you liked the way your breast looked before the sutures dissolved.

There are also some potential options using your own tissue. Unfortunately, replacing the defect with free fat grafts, while technically straightforward, is a little controversial, as there is some concern that this could increase the risk of local recurrence (but this is far from definitively established). There are centers (one in Boston comes to mind) who are doing this as part of a controlled study. Also, depending on the size of the defect and the location of your scars, reconstruction with a small microsurgical flap might be a reasonable (although significantly more complicated) option.

It sounds like you have a good relationship with your surgeon, which is great. Please continue to share your thoughts with him, and I’m confident things will work out for you one way or another.

Dr. Richard Kline

Center for Natural Breast Reconstruction

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

How Long Do I Need to Wait To Have a DIEP Flap Procedure After Radiation?

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

Q: How long should I wait to have a DIEP flap after radiation?

A: Radiation therapy is part of the treatment of breast cancer and will affect the results of breast reconstruction. The treatments can miraculously kill some growing cancer cells but they also change the area of the body left behind after surgery.

All of the elements of the body can be affected: blood vessels, scarring, healing function, and appearance.  The effects of radiation occur in two phases. Short term occurs during and immediately after the treatments. Elective surgery at this time is not possible, for obvious reasons. The long term effects develop after the early “burn-like” injury “settles down.” The long term reaction occurs for approximately the first six months.

The experience can be widely different from one person to the next. We have experienced difficulties with the receiving blood vessels after radiation when we did not wait for the body to recover from both long and short term damage. These types of problems could possibly increase the chance for the new breast to fail. Avoiding these problems may be possible by waiting and that is why the long recovery is needed before reconstruction is started.

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!

Replacing an Implant With a Flap: Will My Muscles Recover and Function Normally?

The following question is answered by  Richard Kline of The Center for Natural Breast Reconstruction.

 

Q: My reconstruction consisted of chest muscle to create a pocket for a silicone implant. I have had it since 2004. They used an expander. It was the best choice for me at the time. If the implant is removed and the muscles are fixed, will they recover and function normally? For example, will I be able to do pushups and bench presses again?

 

A:  Thank your for your question. Although the muscle is replaced against the chest wall when an implant is replaced with a flap, it is impossible to duplicate the strength of the original muscle attachment.

Having said that, most patients function quite well with an implant under the muscle, and I’m hesitant to tell you you’ll see dramatic functional improvement if you convert your implant to a flap.

I hope this helps.

 

Richard Kline
Center for Natural Breast Reconstruction

 

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

What to Know Before Seeking Implants as Your Breast Reconstruction Option

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

I am weighing my options for breast reconstructions and  considering silicone implants. What should I know before I continue—what questions should I ask a doctor?

Silicone or saline implants, while generally very safe from a medical perspective, are still subject to some complications. The most common problem is that either type implant can develop a hard capsule of scar tissue around it (capsular contracture), which is sometimes painful, and makes the breast mound hard (and often unattractive). Generally speaking, the thicker and more normal the soft tissue covering around them, the better result implants tend to give when used for reconstruction. The presence of radiation injury greatly decreases the chances of success when using either silicone or saline implants for breast reconstruction, and flaps may be a better alternative in that case.

-Dr. Richard M. Kline Jr.

The Center for Natural Breast Reconstruction.

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