Ask The Doctor-Is it possible to do a flap reconstruction after first surgeon tried expander on radiated breast on a smoker?

flowerThis week, Richard M. Kline, Jr., MD, of The Center for Natural Breast Reconstruction answers your question.

Question: Is it possible to do a flap reconstruction after first surgeon tried expander on radiated breast on a smoker who had quit 7 weeks before surgery? 4 weeks later I still have open wounds almost the size of a quarter.

Answer: Thanks for your excellent question.

Fortunately, previous breast surgery, no matter how extensive, rarely impacts our ability to do a flap reconstruction using your own tissue. In fact,  a healthy, non-radiated flap is often beneficial in improving the quality of the radiated tissue around it.

As you seem to already be aware, nicotine is an absolute “no-no” when having surgery, and also when trying to heal a chronic wound. Nicotine causes the microscopic blood vessels in your tissue to clamp down, just like shutting off a valve, which deprives the healing tissues of oxygen. Usually, however, nicotine levels are unmeasurable after a full month of exposure cessation.

We have treated several chronic wounds in patients with failed implant reconstructions, and we have always felt that it was best to get the wound healed before proceeding with flap reconstruction. Achieving healing in these situations is often not straightforward,  but we have thus far eventually been successful. Sometimes retained foreign material (such as Alloderm) can play a role in keeping the wound open, and sometimes there is just not enough skin left in the radiated area. Rarely, deep infection of the bone or cartilage can be an issue, although this is unusual.

If you wish, we can set up a phone consultation to discuss your specific circumstances in more detail.

Best of luck, and thanks again for your question.

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

Stop Smoking: Make It More Than a New Year’s Resolution

breaking a cigaretteUnfortunately, we can’t live in our parent’s blissful ignorance anymore. And it’s  not news that smoking is bad for your health.

If you are a smoker, quitting isn’t as easy as cutting out sugar or making a commitment to walk three times a week.

That’s why we’ve compiled a list of realistic ways to stop smoking. We aren’t talking quitting as a New Year’s resolution. We mean making an actual lifestyle change. So if you wake up on February 2and decide that is the day to quit, don’t let the fact that the New Year has passed stop you from making this change in your life.

Nicotine Replacement Therapy

Quitting smoking can be overwhelming because nicotine is incredibly addictive. Being able to wean yourself off nicotine, without the harmful effects from carcinogens, can help raise your chances of not giving up on day one. Using patches or gum helps you fight cravings by getting a measured amount of nicotine. Both nicotine replacements have different dosages, so you can slowly cut back the amount of nicotine intake.

Prescription Drugs

There are many prescription drugs that can help you quit smoking. Some of the prescriptions are used along with nicotine replacement therapy, while others you need to start taking before “Quit Day.” These drugs help counteract certain chemicals in the brain to help ease cravings. As with all prescription medications, make sure you consult your doctor and are aware of any potential side effects.

Write It Down

Write down all of the reasons you want to quit smoking on notecards or on your phone. Is it for your children or to stop having to hide your habit? Anytime you’re feeling particularly weak, bring that list out. Remind yourself there is a good reason why you’re doing this, and that in time it will get easier.


You may know that acupuncture is often used to relieve medical ailments, but did you know it also might help you kick the habit? Treatments focus on jitters, cravings, irritability, and restlessness—all symptoms that commonly plague people who are trying to cease smoking.

Make a Plan

Do you know when you’re most likely to smoke? Make a plan to do something else during the times you would usually light up. Is it after dinner? Try making a hot cup of green tea instead. Is it after work? Go for a walk. Is it with a cup of coffee? Take a cup of coffee with you on a walk. Other methods that may help are to keep your mouth busy: chew gum, snack on sunflower seeds, always have a drink like flavored water or tea.

Read more about how smoking may increase breast cancer risk.


Ask the Doctor: Smoking, Risks During Reconstruction, Researching Your Options

Ask the Doctor July 18This week, Dr. Richard Kline of The Center for Natural Breast Reconstruction answers your questions.

Q: I need to have breast reconstruction due to breast cancer occurring twice since 1999. I’m scared because I can’t quit smoking. The surgeon will not perform the procedure unless I quit. Are there any surgeons who will perform reconstruction even though I am a smoker?

A: Surely there are some physicians who will do reconstruction while you’re smoking, but we are not among them. This policy is only because we have personal experience dealing with the many months of wound healing problems (and tears) that commonly follow this type of surgery performed on smokers.

Smoking  isn’t just bad, it’s absolutely terrible. If you want all of your wounds to fall apart, leaving you miserable for months, there may be no better way to accomplish it than to smoke during your reconstruction. The good news is, if you stop for one month before and 3 months after your surgery (with absolutely no cheating), you can often have successful surgery.


Q: I am, after total mastectomy performed 12 months ago, scheduled for reconstruction. My age is 59 and I do not have any emotional concerns about being without a breast. However, I would like to stop wearing epiteze, and would like to not worry that it will show in summer. My concern is whether the long-lasting and repeated reconstruction (several operations, including making the healthy breast smaller) represents too big of a risk to my health. After anesthesia last year, I experienced problems with forgetting and lack of focus for about 3 months. Also, what about the operation and healing stress to the overall body? I would hate to start a new health problem because of reconstruction. What is the general risk apart from risks mentioned here?

A: The risks you are worried about are probably not so much from the surgery, but more from the anesthesia. I would suggest you discuss your concerns with your primary care provider. We can advise you about risks such as bleeding, blood clots, infection, etc., but these do not usually result in the problems you describe.


Q: Am I putting my health at risk in order to research the best reconstruction method before surgery?

A: No, I think you are looking out for your health by doing careful research in advance. Please let us know if we can help you


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!

Stop Smoking Series: All about Tobacco Quitlines

Tobacco QuitlinesEvery state has a tobacco quitline, typically paid for with funds from the Tobacco Master Settlement Agreement. In 1998, the states settled Medicaid lawsuits against the tobacco companies to recover their costs for treating tobacco-related illness, and the tobacco companies agreed to pay the state over $200 billion over 25 years.

Hundreds of thousands of smokers and chewers call quitlines every year, and the North American Quitline Consortium reports that depending on whether nicotine replacement therapy is part of the program, 30-day success rate ranges from 14–36%

The quitlines are telephonic tobacco cessation services that help smokers and chewers quit through phone coaching or counseling, medications, and education. Each quitline coach or counselor has had extensive training in tobacco addiction and best practices in quitting. The staff of each quitline stays up-to-date on the latest research in tobacco cessation and relapse prevention, and is trained to coach in the use of the various medications such as nicotine replacement therapy (NRT), antidepressants, and Chantix.

Each state determines how its quitline will provide services, including the hours of operation, whether medication will be offered, whether there will be a charge for participants, and the duration of the program. To find out more about your state’s quitline, call 1-800-QUIT NOW.

The coaching that you receive from a quitline is instrumental in helping you quit. The coach will discuss your smoking history with you, including your previous quit attempts. He or she will give you tips on quitting and strategies to deal with cravings. Many of these coaches are former smokers themselves and know what you’re going through; however, even if they have never smoked, the coaches are highly trained in helping you quit.

You will be encouraged to set a quit date either on the initial call or during a follow-up call. Setting a quit date is an important first step in your quit plan and signals your commitment to stop tobacco. The coaches will call you on a regular schedule throughout the program, and you are encouraged to call in any time you have issues or uncontrollable cravings.

All you have to lose is your tobacco addiction. Call your state’s quitline at 1-800-QUIT NOW and get started creating a healthier you today.


Step 3 in Quitting Smoking: Taking Effective Actions to Stop

quit smokingThe one thing that many people don’t understand when it comes to quitting smoking is that addressing the physical addiction to nicotine is not enough. They must also learn to manage the ingrained habits that led them to smoke. People smoke after meals, while driving, and while under stress, to name just three examples. Those urges do not go away simply because the cigarettes are gone.

Quitters need to have a plan for when the habitual part of smoking raises its ugly head. We discussed that a little in our previous post about the 4Ds, but here are a few more tips to master the mental piece of quitting.

Look at your habits.

When did you have your first cigarette of the day? Was it right when you got up, after your shower, or after breakfast? Breaking that habitual urge can be as simple as changing your routine. If you smoked first thing, try going outside for a quick walk instead, or hop into the shower right away.

If your habits don’t change, your chances of staying quit are dramatically lower than if you consciously alter the path of your day.

Have substitutes handy.

If you can’t stop doing something that triggers you to smoke, keep something handy that you can put in your hand or in your mouth. Driving is a strong smoking trigger for many, and most cannot avoid it. Try putting a straw in your hand or a cinnamon toothpick in your mouth. If you find yourself lighting up at a certain intersection on your way to work, find a new route until you’re more secure in your quit.

Enlist help.

If you live with smokers, see what they are willing to do to help you maintain your quit. Having them smoke outside is ideal, since you were likely to smoke with them as part of your habitual conditioning and it’s easier to have them out of sight, out of mind. If they will not go outside, perhaps they would confine their smoking to one room of the house and keep the door closed.

If those you live with don’t smoke, perhaps they can help you identify your smoking habits and ways to break those habits.

You may need to alter your routine for only a few weeks while you master the initial difficulty of quitting, or you may need to change a few things more or less permanently. The main thing to remember is to never take one drag. This is no different from being addicted to any other drug. You would not suggest that an alcoholic or heroin addict has “just one” . . . and you can’t either.

What are your tips to quitting smoking?

Stop Smoking Series: the 4Ds

stop smokingQuitting smoking can be challenging, but if you know what to do when a craving hits, you’ll be ready to conquer any urge. The 4Ds are a good guideline to follow when you desperately want a cigarette. The order we show them is a general guideline, so modify it to work for you.


The moment the craving hits, tell yourself you can have a cigarette in 10 minutes. Then when the 10 minutes are up, tell yourself what a good job you did and challenge yourself to go 20 minutes. Any craving will go away in a few moments as long as you don’t keep thinking about it. After you delay, the next thing to do is . . .

Drink water.

In fact, get up and get a glass of water as you’re telling yourself to wait 10 minutes. And you want to drink water, not pop, coffee, or alcoholic beverages. First, while you’re quitting, your body is trying to get rid of the toxic materials you’ve inhaled all these years, and it needs water remove the junk from your system. Second, for many women, other drinks are triggers to smoke, especially coffee and alcohol. Third, the water will change the taste in your mouth and help to break the craving.

Please don’t make the excuse that you don’t like water. You can filter it or flavor it with fruit or small amounts of fruit juice. Find what works for you, and do it.

Do something else.

Your success in quitting may be determined by how well you shift your focus when you have an urge to smoke. The more you think about a craving, the worse it will become. After you’ve had your glass of water, find something else to do. If you were watching TV, move to another room and read a book. Take the dog for a walk. You need to break the association with whatever you were doing when you felt the craving.

Try keeping a bag of entertaining distractions with you, which could include puzzle books, books, art projects, or needlepoint. The main thing to remember is that you need to abruptly and quickly change what you’re doing and thinking to survive the craving.

Deep breathing.

This step can be done at any point in time, as many times as necessary. Deep breathing will release endorphins, which will help you feel better. It will also show you how well your respiratory system is healing during your quit. Take at least 10 deep breaths in through your nose—your stomach will move if you’re truly taking deep breaths. Exhale through your mouth with pursed lips, as if you’re kissing someone. Blow out hard, and imagine you are forcing out all the air in your lungs.

The 4Ds will feel awkward at first, but as you get used to them, you’ll find they are very helpful during cravings.


Step Two in Quitting Smoking: Pick a Time to Stop

quit smokingIf you’ve read the First Step in Quitting Smoking post, (link to first smoking post) you know why you want to quit. Now it’s time to take that step and do it.

Have you decided how you want to quit? You have several options, including pharmaceutical aids such as nicotine replacement therapy or Chantix, hypnotherapy, laser therapy, a telephone quitline, and cold turkey. Any of these methods can work, but only you know what is likely to work for you, based on your previous quit attempts. If you’re not sure which way you want to go, call your state’s quitline, or talk to your doctor.

Once you’ve decided how and why you want to do it, when are you going to do it? If you wait for the perfect time, it may never come. On the other hand, most smokers can remember a time when their minds or bodies were screaming it was time to quit, and they ignored those signals. If a signal comes to you in the middle of the night or while you’re driving home, get rid of those cigarettes immediately, and let that signal be the first moment of your quit.

There’s a reason your mind and body are telling you to quit at that moment—don’t ignore it.

Should you set a quit date?

If you call a quitline, they will ask you to set a quit date so you’ll commit to quitting. Some people question whether that is a good idea. The answer to that is, “it depends.” For some people, having a date is the first goal of their quit plan. They have time to prepare themselves and others for their quit. They can rid the house and car of all smoking paraphernalia, buy any pharmaceutical aids they need, and decide beforehand how to avoid and deal with cravings.

Some ex-smokers swear that picking a quit date wouldn’t have worked for them because it would have added even more stress to the process of quitting. Some people feel a sense of failure if they miss the quit date. Others use the quit date as an excuse to avoid quitting. They’ll set a quit date two weeks away, then as the date approaches, they move it back another two weeks. They tell themselves they need more time to plan, when they need to take action instead.

In the end, you have to decide what will work for you. In the end, it doesn’t matter if you quit on the first or the fifth of the month—you need to quit, and the time is now. If planning your life typically makes you more successful, pick a quit date, but don’t stretch it out more than two weeks. If setting a quit date will make you put off quitting, or if you feel motivated to do it now, seize the moment and get rid of the cigarettes.

Has setting a quit date ever worked for you? Why or why not?