Ask the Doctor- Why Do Expanders Have To Be Used When a Breast is Removed?

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

Question: Why do expanders have to be used when breast are removed and the pocket is empty and ready to be filled with an implant?

Answer:  It is not always necessary to place expanders at the time of mastectomies, but in many situations, it is a safer choice than immediately putting in an implant. Even if the breast surgeon leaves the nipples and removes no skin at all, the skin is not always healthy, as the blood flow is invariably at least somewhat compromised after mastectomy. Placing an implant under very poorly perfused skin would put additional pressure on the skin from within, and quite possibly cause the skin to die that otherwise would have lived. With an expander, we have the option of placing no fill at all at the initial surgery, thus minimizing additional pressure on the skin. In actual practice, sometimes the skin’s blood supply is so poor we don’t even put in an expander right away, but rather return to the operating room several weeks or months later to begin reconstruction.

Having said the above, I do agree it is nice if the final implant can be placed under healthy skin flaps immediately. However, it should only be done under ideal circumstances.

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

 

Ask the Doctor – I Was In An Accident And Now Have a Painful Knot On My Reconstructed Right Breast. Should I Be Worried About Long Term Damage?

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

Question: I had reconstruction about 6 years ago after a double mastectomy. I had several surgeries for revisions. I had an SGAP on my right and stacked DIEP on left. Everything was fine until a month and a half ago when I was hit by a driver who ran a stop sign and t-boned me. My car was totalled. I had an impact on my right breast from the steering wheel and the airbags. For the past two months, I have had a large knot on my right breast. This is the SGAP one. It is painful and the knot is the same size. Could there be long-term damage to the reconstructed breast from the accident?

Answer:  If you are still having problems, you should see a plastic surgeon, and likely he or she will order some type of imaging (CT scan or MRI) to assess the situation. It is certainly possible that the flap could be damaged, or even other structures, such as your pectoralis muscle. While it might or might not be possible to do anything to improve any damage, I do recommend that you see someone to have it investigated.

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

Ask the Doctor – How Long Should You Have a Breast Expander In?

Lymphedema after mastectomy

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

Question: How long should you have a breast expander in?

Answer: There is no “one size fits all” answer to your question.

In many cases, expansion can be achieved, and the permanent implant placed, in 2-3 months (more commonly 3).

In other cases, expansion may take longer, or sometimes other factors such as radiation may cause delays in removing the expander and placing the permanent implant. Whenever possible, however, expansion should be completed before the beginning of radiation, because the expansion of radiated skin ranges from difficult to impossible.

I do not think that having expanders in for long periods is likely to cause any lasting problem, although the chance of them deflating goes up. I met a patient recently who, for various reasons, had had an expander placed by another surgeon in place for 15 years. She appeared none the worse for it, we placed a permanent implant, and she is doing well.

Hope this helps, I’d be happy to chat with you if you wish.

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

Ask the Doctor -After Two Different Types Of Reconstruction Over The Years, What Can I Do To Regain Some Symmetry?

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

Question: I had my first mastectomy in 1991 with a tram flap reconstruction. My second mastectomy was in 2004 with an s-gap reconstruction. In the last few years, my breasts have become increasingly uneven and have shifted on my chest. Is there something I can do to my reconstructed breasts to regain some sort of symmetry?

Answer:  Without knowing any more specifics of your situation, I can state in general terms that asymmetry after reconstruction is very, very common and that there are a host of techniques which we routinely use to minimize asymmetry as much as possible. Some of these techniques are fat grafting, reduction, contour alteration, and position changing. We have currently performed almost 1700 perforator flap reconstructions, and we likely have significant experience dealing with situations very similar to yours. I would be happy to see you in consultation any time or chat on the phone if you wish.

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

Ask the Doctor – Would I Be A Candidate For DIEP Flap Surgery After Previous Expanders Are Removed And Will You Accept VA Insurance?

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

Question: I had a bilateral mastectomy with reconstruction and I am terribly dissatisfied with my care so far. 11 Months later, the expanders are still painful. I will be asking to have them removed this week.

I have 2 questions for you. After I  have the expanders removed would I still be a candidate for the DIEP flap? I am still going to chemo (Herceptin) which will run until the end of November, provided there are no more setbacks. My second question is, do you accept VA insurance? One form of payment is through the VA another is Veteran’s Choice. I am not sure which would cover outside care. I look forward to your response.

Answer: I’m sorry you have had so much trouble, but there is a very good chance that we can help you.

Your previous unfortunate experience with expanders does not in any way decrease our ability to successfully reconstruct you with DIEP flaps. The blood vessels which we use to vascularize your flaps are well below the area where tissue expanders are placed, and we have successfully reconstructed literally hundreds of patients in your situation. One potential advantage to having the expanders removed sooner rather than later is that we get an MRI angiogram on all patients who are scheduled for perforator flap breast reconstruction, and most breast tissue expanders are not MRI-compatible. If they use a little magnet to find the port before they fill your expanders, then you can’t get an MRI with those expanders in place.

We have worked with the VA many times in the past, and Gail, our insurance expert, will contact you to investigate your situation further.

Thank you very much for your inquiry, and I look forward to meeting you.

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

Ask the Doctor – What Are My Chances With DIEP Flap Surgery After Several Failed Reconstructions With Tissue Expanders and Implants?

Sunflowers

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

Question: I have had several failed reconstructions with tissue expanders and implant. I have also been put on IV antibiotics due to a staph Infection. I am wondering what my chances are with the DIEP Flap.

Answer:  Great news! Your prior failures with implants does not in any way decrease your ability to get soft, warm breasts with DIEP flaps. Many, many, many of our patients have histories of prior failures with implants, some with (10-20) prior failed surgeries, and we have been able to successfully 99+ % of them with only their own tissue. Once the infection from prior implants is eradicated from your body (if you have been healed for at least 6 months, you can generally assume that all the prior infection is gone), then subsequent reconstruction with your own tissue carries only a minuscule fraction of the infection risk of reconstruction with implants. You didn’t mention if you were radiated, but it makes no difference, breasts reconstructed with your own tissue are still extraordinarily unlikely to have problems with infection.

We would love to chat with you and discuss your options further. Looking forward to speaking with you, and thanks for your inquiry.

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

Ask the Doctor – How Far in Advance Should I Begin Planning and Scheduling Surgery and is Travel Afterward a Problem?

Roses and orchids

This week, Gail Lanter, CPC Practice Manager, of The Center for Natural Breast Reconstruction answers your question.

Question: I had a phone consult with Dr. Kline in December and was very impressed with our conversation.  After researching several microsurgeons, I keep coming back to this center as the perfect fit for me. I had bilateral mastectomy in Jan. 2014 due to DCIS and have saline implants under the muscles. I experience constant inflammation, burning, and the right implant has “shifted” (as my PS said) and feels like it is under my armpit. Due to life situations I am not considering surgery until the end of this year or January, 2019.

How many months ahead should I contact you to schedule the surgery? Also, I’d like to talk to someone about getting insurance approval. I have BCBS of Alabama.

Is it possible to come from Decatur, AL to have this done? I do not feel comfortable using anyone closer at this point. Just worried about the travel afterwards. Thank you.

Answer:  We have many women who travel to have surgery so we know how to help you navigate that hurdle.  As far as your timeline, one thing to consider is that this is a staged procedure – typically the first stage is inpatient for 4 days and then outpatient for Stage 2 a few months later.  Sometimes a 3rd stage (outpatient or in office) if you require nipple reconstruction or further revision to get the result you desire. Taking into account your deductible and out of pocket expenses – you may want to make sure you can get all of those stages done within one plan year.  I’ll be happy to run an eligibility inquiry through your insurance plan and we can find out exactly what your benefits are so you’ll know what to expect. Insurance approval should be no problem at all as we are in the Blue Card Network for BCBS plans. Check your insurance card and see if you have a little suitcase on the front with some letters within it.  That will tell you that your plan is a member of that network. If you’d like to send me some basic demographic information i.e. full name, date of birth, address and a copy of your card, I can get that process started for you. We typically have openings within a 2-3 month time period but to reserve the date you really want, I’d choose it as soon as you know what will work for you.  We operate on Tuesday, Wednesday, and Thursday.

Here is a blog post from September discussing the stages of surgery and how we work with patients out of our area.

http://breastreconstructionnetwork.com/ask-the-doctor-how-many-trips-are-required-to-have-reconstruction-with-your-doctors/

I’ve forwarded your e-mail to Dr. Kline to discuss post- operative travel with you.    Have a great day and I’ll look forward to your reply.

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

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 am Ready for My Second Mastectomy. What are my Options and Can I do a Lymph Node Transfer at the Same Time?

purple crocus

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

Question: I am looking at reconstruction options after a right mastectomy in September, ready for other side mastectomy and reconstruction in June. I’m interested in lymph node replacement also.

Answer: We would be more than happy to help you any way we can. We work with several breast oncology surgeons, and routinely do immediate reconstruction with DIEP flaps, GAP flaps, or pre-pectoral implants (usually just local patients for implants, though, as they actually require more postop visits than flaps).

We usually don’t recommend doing lymph node transfer at the same time as flap reconstruction, because 1) doing the nodes at the same time entails compromises in the flap placement, the node placement, or both, and 2) placing a healthy unradiated flap will sometimes improve lymphedema by itself. We do, however, routinely incorporate lymph node transfer in second-stage flap surgeries, and that has worked nicely from a technical standpoint.

I would be happy to chat with you more about your options, or see you any time you would like to make an appointment.

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

Ask the Doctor – Who Do I Ask About My Cancer Treatment, My Plastic Surgeon, Breast Surgeon, Or Oncologist?

This week, Audrey Rowen, PA-C, of The Center for Natural Breast Reconstruction answers your question about breast reconstruction.

Question: Who do I ask about my cancer treatment, my plastic surgeon, breast surgeon, or oncologist?

Answer: Thanks for reaching out to us! That is typically a question we would defer to an oncologist to answer as they can calculate your overall risk for recurrence and how different surgical vs. medical treatments can impact that risk. Technically a lumpectomy is only removing the cancerous area, leaving the rest of your breast tissue intact, so by surface area, a lumpectomy leaves more breast tissue that could potentially develop a new breast cancer, where a mastectomy is an attempt to remove all breast tissue.

The options for reconstruction are much more plentiful with mastectomy vs lumpectomy, but that shouldn’t necessarily sway you either way. If we can answer any reconstruction questions about whichever option for cancer treatment that you may choose, please let us know. But definitely, chat with your oncologist about what they feel is your best option for overall survival.

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