Q&A #2: May 2019

I had a bilateral mastectomy in October 2016. I finished radiation on the right side in January 2017, and underwent bilateral latissimus flap reconstruction in August 2017. I had capsular contracture (when the scar tissue or capsule that normally forms around the implant tightens and squeezes the implant) on the right side and the implant changed out in March 2018. Once again, I have capsular contracture on the same side. What do I do? They are absolutely not even close to symmetrical. I am only 46. I am kind of thinking that I should just forget reconstruction even though I don’t really want to go flat.

Without knowing all of the details about your situation, I think there is a reasonable chance you have some good options left. Here are a few potential ones:
1. We have reconstructed more than 1,800 breasts with natural tissue alone (no implants) using the abdomen or buttocks. If you have any tissue in those areas, that is our most frequently used option.
2. We have, on several occasions, reconstructed breasts with latissimus flaps alone, with added free-fat grafts, which can sometimes double (or more) the size of the latissimus flap, and make implants unnecessary.
3. For the last 4 1/2 years, we have done all of our implant reconstructions exclusively in front of the muscle, using a full Alloderm (specially preserved donor skin) wrap. This has completely changed our outlook on implant breast reconstruction, and has on occasion produced surprisingly good results – even in radiated breasts. I have converted several “implant-behind-the-muscle” patients (some who already had latissimus flaps) to in-front-of-the-muscle, and they all feel that it is a significant improvement. Free-fat grafting can also be added to implant-based reconstruction to improve shape, size and overall naturalness.
There is absolutely nothing wrong with going flat if you are sure that is what you want to do, but it might be premature for you to decide to do that only because you don’t think you have any other options. I would be delighted to discuss your situation in more detail by phone, if you wish, or see you in person for a consultation.
Thanks for your question! We look forward to hearing from you.

Dr. Richard M Kline JR MD

The Affordable Care Act’s Day(s) in Court

The Supreme Court heard arguments about the Obama Administration’s Affordable Care Act earlier this spring, and is expected to hand down a decision regarding the healthcare law any day now. Here’s a look at how various possible decisions could affect the state of healthcare in the United States.

Option 1: The Supreme Court Rules the Affordable Care Act Is Good to Go

The main argument against the Affordable Care Act challenges its so-called individual mandate, which, if enacted, would require all Americans to have health insurance (through the government, employers, or an individually purchased plan). If the individual mandate is given the green light, then…

  • Uninsured Americans will have to purchase health insurance by a certain deadline or face a penalty charged at tax time.
  • Health insurance companies will be required to make insurance coverage available to everyone, including those with preexisting conditions.
  • Low-income Americans (those with household incomes up to 138% of the poverty line) will qualify for government assistance for medical insurance (possibly in the form of Medicaid).

The individual mandate could be good news for women with breast cancer who have been denied coverage or reimbursement for treatment, because it will require insurers to cover them regardless of their current or former health.

But most health professionals, regardless of their political affiliation, agree that the individual mandate is far from an ideal system.

Option 2: The Supreme Court Strikes Down the Individual Mandate

If the Supreme Court rules that the individual mandate is unconstitutional, the Affordable Care Act may be doomed. Without the guarantee that all Americans buy health coverage, there is no incentive for health insurance providers to make coverage available to those with breast cancer and other potentially costly conditions.

Without the individual mandate, the health insurance landscape in the U.S. may remain as it is for the immediately foreseeable future.

More Reasonable Healthcare Down the Road?

Some commentators on the health care hearings have suggested that there might be greener pastures ahead for health insurance in the States. It seems that a dismissal of the individual mandate could, by some analyses, pave the way to a single-payer insurance system, under which all Americans would be covered by the federal government, regardless of job or health status.

While most Americans agree that the current state of health insurance in this country is far from ideal, few understand how important comprehensive coverage is better than those who have had life altering illnesses like breast cancer and major procedures such as breast reconstruction.



Tricks to Enjoy Yummy Beers and Wine without Packing on the Pounds

light alcoholWhen you’re watching your weight, one of the first things you normally reduce or eliminate is alcohol. While drinking too much can cause weight gain and other issues, moderate consumption of alcohol is good for your heart. You don’t need to deprive yourself to keep your weight down and stay healthy—you just need to do a little planning.

Often, small changes are all you need to make your favorite drinks healthier. For example, if you enjoy beer, you might like the new low-calorie and low-carb light beers. Most of the domestic beer makers have low-calorie options, such as Budweiser Select, Michelob Ultra, Miller Genuine Draft 64, and Aspen Edge. These beers vary in alcohol content.

If you prefer wine, lighter whites such as Chardonnay, Pinot Noir, and Chablis tend to be lower in calories than reds. White Zinfandel is also a good choice. Sweet dessert wines such as Port and Madeira contain high levels of sugar and alcohol and are high in calories.

The calories in mixed drinks and cocktails often come from the mixers you choose. While sweet liqueurs such as crème de menthe are high in calories by themselves, if you add high-calorie juices or cream, you can go from 100 calories to over 500 in no time. If you choose a drink that combines several types of alcohol, the calories will also climb.

The simpler the drink, the better. An average shot of 80-proof alcohol is around 100 calories before you add anything. Asking for diet soda pop, water, or diet tonic will help keep your calorie count down. Gin and tonic, rum and diet coke, and whiskey and water may not be very exciting, but their calorie counts are low. You could opt for shots of liqueur or flavored vodka, or order them on the rocks.

Some drinks have spawned their own low-calorie versions. For example, a skinny margarita leaves out the syrupy mix of the regular margarita. Ordering the regular-sized margarita instead of the fishbowl-sized margarita will help your weight stay where you want it. Some super-sized drinks can have 1,000 calories or more.

To reduce your consumption of alcohol and related calories, consider drinking a glass of water or simple mocktail between drinks, and skip the munchies at the bar. After a few drinks, your inhibitions are low, which also affects your resolve to watch yourself. If you know you’re going out one night, skip snacks or eat light during the day to save up calories for later. Eat before you go out so you aren’t tempted to eat high-calorie bar snacks.

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5 Ways to Avoid Diabetes

diabetesType 2 Diabetes is one of the most prevalent serious diseases in the United States. Diabetes is responsible for a range of complications, such as blindness, amputation, kidney failure, stroke, and heart disease. The American Diabetes Association estimated that diabetes contributed to over 230,000 deaths in 2007.

Type 2 Diabetes is a chronic metabolic disease caused by insulin resistance. When we digest food, glucose (sugar) enters the bloodstream to be carried to the cells of the body. The pancreas secretes an appropriate level of insulin to help the glucose enter the cells, much like a key fits a lock. High levels of glucose require the pancreas to secrete high levels of insulin.

If there are prolonged levels of high glucose, sometimes the cells become resistant to insulin and the glucose cannot leave the bloodstream, which in turn prompts the pancreas to secrete even more insulin. These elevated blood glucose levels are the cause of Type 2 diabetes.

While being overweight or having a family history of diabetes may raise your risk of developing diabetes, it is preventable with knowledge and just a few lifestyle changes.

Check your glucose and your family history.

Insulin resistance can progress to full-blown diabetes with no warning, so if you’re over age 45, it’s a good idea to go to the doctor at least once a year and have your glucose levels checked. If you have a family history of diabetes, glucose checks should start no later than age 40.

Watch your diet.

Healthy eating is one of the best ways to ward off insulin resistance and diabetes. Eat more fresh fruits and vegetables, and minimize your intake of junk and snack foods. Avoid high-fructose corn syrup and partially hydrogenated oils, and minimize sugary drinks and soda. Choose whole grains such as oats, barley, and wild rice, and buy leaner meat, such as turkey, bison, and fish.

Become a label reader and study the ingredients in the foods you eat. The more real food you can eat, the better. Buy less processed food, and if the label shows ingredients you can’t pronounce, reconsider buying that food.

Do some kind of physical activity every day.

Exercise helps keep your blood glucose low, reduces your risk for diabetes, and keeps your heart and lungs healthy. You don’t have to run 20 miles a day to reap the benefits of daily physical activity, but you do need to move. The key is to do something you enjoy every day, whether it’s playing tennis, walking the dog, or dancing.

Maintain a healthy weight.

Being overweight increases your Type 2 diabetes risk, as well as the risks of heart disease and stroke. Even a small weight loss of 10 or 15 pounds can reduce your risk. Follow the dietary and exercise recommendations above, and set realistic goals for weight loss. Every small step takes you closer to your goal, so keep going even if you get frustrated. Find a support system to help you stay on track.

Stop smoking.

Smoking raises your blood glucose levels and contributes to insulin resistance. This is why people who smoke often aren’t hungry. To stop smoking, call your state’s tobacco quit line. In addition to valuable coaching help to quit, many states offer free or low-cost aids such as nicotine patches and gum. Keep in mind that once you stop smoking, not only does your risk for diabetes go down, but your risks of heart disease, stroke, and cancer are also reduced.

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The First Step in Quitting Smoking: Why Do You Want to Quit?

quit smokingAre you ready to quit smoking?

The first step in quitting is to determine why you want to quit. You know you should, and maybe your doctor has told you that you need to quit. However, you won’t be successful long-term unless the desire to quit comes from you, and the reasons you quit have to be your reasons. You can’t quit to please others or because they’re pressuring you. If you do, you’ll use that person as your excuse to go back to smoking.

You know what we’re talking about. At least once, you’ve tried to quit because someone was bugging you. When you did, you lasted for a few weeks or even a few months, but it was a tough quit to maintain because you weren’t doing it for yourself. In the end, you went back to it because deep down, you didn’t want to quit then—and you were even a little resentful of the person who was pressuring you.

So if you’re thinking about quitting for your kids, your spouse, or the dog, stop right there. What are your reasons for quitting? What do you want out of it? Your reasons will keep you going when you have that irresistible craving for a smoke. Your reasons will help your quit go more smoothly. Yes, quitting can be difficult at times—but quitting for other people’s reasons is even harder.

Here are ten common reasons for quitting we’ve heard from successful smokers:

  • I was tired of spending all my money and having nothing to show for it.
  • I woke up one day and decided I was done. I’d had enough of the smell, the expense, and the coughing.
  • I knew I could do so much more with the money and time I spent on smoking.
  • I wanted to feel better and not be dependent on cigarettes to get me through the day.
  • I didn’t like being addicted to nicotine because I was missing a lot of life.
  • I was sick of smelling and feeling bad all the time.
  • I wanted to run and play with my kids (or grandkids).
  • Being a smoker wasn’t for me—I’m worth a lot more than that, and I want to live to be an old lady.
  • The thought of having lung cancer or COPD scared me, and I knew it was time to quit.
  • I just got tired of the habits: waking up and smoking, driving and smoking, eating and then smoking . . . it was ridiculous.

Do any of these reasons resonate with you? What benefits of quitting are you looking forward to? When you have your own, clear reasons to quit, it’s time to move forward and do it—but quitting without a reason that is meaningful to you is a setup for failure.


How to Make Sure You and Your Doctor Communicate Effectively

breast reconstructionYour relationship with your doctor is a partnership, and one of the best ways you can help each other is to communicate effectively. You’ll avoid misunderstandings and hurt feelings, and the two of you can quickly move forward in your treatment. When it’s time for your next appointment, using the following tips can make a positive difference in your relationship.

Always be as honest and as specific as possible.

Even if you’re uncomfortable, tell the truth—your doctor can’t successfully treat you otherwise. If you’re not sure how to answer a question, say so instead of guessing. Your answers should be as specific as possible, even if you need to add more information or ask questions before replying.

Don’t be afraid to ask or tell your doctor anything—he or she has literally heard it all.

Listen, and then ask questions.

Sometimes while the doctor is talking, patients have an emotional reaction that prevents them from hearing the rest of what the doctor has to say. Listen to everything the doctor says, try not to react right away and let it process for a moment, and then ask questions.

Note anything unusual, and write down your questions before you go.

Keep a calendar or day planner with you, and jot down any symptom that is unusual for you. The night before you go to the doctor, make a note of these symptoms as well as questions you have. Often we go to the doctor with a list of questions in our head, and then forget what we wanted to ask. This step will save time for both of you during the appointment.

Never ignore unusual pain, discharge, or bleeding. Contact your doctor immediately.

Tell your doctor about everything you take.

Make a list of your medications and any dietary supplements you take, including vitamins and aspirin. Be sure to note dosage size and frequency. Give the list to your doctor for your file, and send a copy to your pharmacist. Update these lists at least once or twice a year.

Don’t be offended by non-medical questions.

Your doctor might ask about your job or what you do on weekends, and this is not to pry, but to evaluate how your lifestyle might be affecting your health. Stress, eating habits, and alcohol consumption may be factors in your condition.

Let your doctor know if he or she doesn’t communicate well with you.

Your doctor needs to know if his or her communication style isn’t effective. Think back on your last few appointments. Did he or she say anything that upset you, and was everything explained in a way you could understand? Were you comfortable talking with him or her?

Give your doctor specific suggestions to improve your partnership. If you’re not comfortable doing that in person, send an email or leave a voice mail after hours on the doctor’s private line.

Your doctor is there to help you—and he or she can do a much better job when you have built a relationship based on trust and good communication. This process can take a little time but is well worth the effort.

What do you and your doctor do to create effective communication?