Can You Obtain Perfect Symmetry in Breast Reconstruction?

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

Q: I looked at your gallery  and I’m concerned about what I see as a mismatch in the photo examples. Is this not something you try to achieve?

A: Thank you for your wonderful question!

By “mismatch,” I’m assuming you mean the two breasts do not look the same when reconstruction is completed.

Firstly, we have many patients with very symmetrical breasts following reconstruction, and we could easily put only their pictures on our website, if we wished.

Thus far,  we have chosen to put less-perfect results on our website as well, believing it serves our potential patient population better, for the following several reasons.

In the real world, many patients will not be able to achieve a highly symmetrical result due to prior conditions, or will choose to not go through the multiple surgeries that will be required to get them as close to perfect symmetry as possible. If all patients came to us before their cancer was removed, we would coordinate their surgery with one of our highly experienced breast surgeons, they would nearly all receive nipple-sparing or at least skin-sparing mastectomies, and they would then have the greatest potential for good symmetry in the end.

In actuality, we see many patients from out of town who have already had non-skin-sparing mastectomies (often when nipple-sparing or skin-sparing mastectomies would have treated the cancer just as effectively). In this scenario, they have little potential to have their scar pattern converted to a more favorable one, and commonly need a lot of extra flap skin left in place in the breast. Occasionally a temporary tissue expander can be used to reduce the size of the skin paddle, but this does not always work, especially in radiated patients. If they chose to have a contralateral prophylactic mastectomy, they could then of course choose to have the same type of mastectomy on the other side (which would help symmetry), but many patients understandably do not want to do any more damage to their healthy breast than they have to.

Additionally, many patients are left with permanent changes in their skin from radiation, which can cause permanent color mismatches, as well as excessive tightness in the skin. This can make it very hard to match a radiated side to a non-radiated side, more so in some patients than others. The more times we can operate in this situation, the closer we get, but sometimes ideal symmetry remains elusive.

We want ladies who have already had aggressive mastectomies, who are left with significant radiation damage, or who don’t want to go through many, many surgeries in pursuit of ideal symmetry to know that there is still help for them, without implying to them that they will get a result that is probably not realistic. All busy reconstructive practices have these patients, but not all choose to put them on their websites. It may not be a good marketing decision for us, but we feel it is the most honest way to deal with our prospective patients.

We’d enjoy any feedback you’d care to give us on this topic, as we argue about it a good bit amongst ourselves.


Dr. Richard M. Kline, Jr.

Center for Natural Breast Reconstruction

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

How One Breast Cancer Survivor Found Hope by Making Informed and Proactive Decisions

breast reconstructionThe team at The Center for Natural Breast Reconstruction is honored to share with you an In Her Words post written by a recent patient of ours, Linda Burkholder. She is an inspiration to all women who are facing breast cancer or who are at risk for hereditary breast cancer.

See below for Linda’s story:

Breast cancer—you can’t say I didn’t see it coming, but being the eternal optimist, I hoped I would dodge the bullet.  Several members of my family have died from breast cancer, including my grandmother, mother, aunt, and sister. After my sister died in 2006, I began to seriously consider prophylactic surgery. I quickly learned that there is little support in the medical community or among friends for this procedure.

After a benign biopsy two years ago I found F.O.R.C.E. (Facing Our Risk of Cancer Empowered) on the Internet.  F.O.R.C.E. is a support group for those with hereditary breast and ovarian cancer. They posted an application for a scholarship to their annual conference. I applied and much to my surprise I was granted an expense paid trip to the conference in Orlando in 2010. I can’t tell you how that changed my life. I learned so much about everything I wanted to know about breast cancer and I met several plastic surgeons who stood out to me, especially Dr. Kline from The Center for Natural Breast Reconstruction. I made a mental note to keep him in mind and took home a beach towel with his phone number splashed across it.

During the next year I struggled with my decision to have prophylactic surgery. Intellectually, I knew what to do, but emotionally I was really struggling. I joined a local F.O.R.C.E. group and kept learning and thinking and meeting cancer survivors, assuming I would have surgery when I felt more comfortable with the idea. Fast forward to June 2011. It was time for my annual mammogram. I told my family doctor I also wanted an MRI, to which she reluctantly agreed. To make a long story short, the mammogram came back normal, but the MRI showed a 1.2 cm questionable spot—a spot, I was told, because of its location, would never have been seen on any mammogram. It was a Stage 1 cancer.

This was almost 2 years to the date from my previous benign lumpectomy. In July, 2011 I had a second lumpectomy performed by one of the most respected surgeons in my area. Without consulting me she automatically scheduled me for radiation. I refused the radiation because I felt that all treatment was my decision and I wanted to consult with an oncologist first. Also, I had learned at the F.O.R.C.E. convention that radiated tissue is harder to reconstruct and I already knew I ultimately wanted mastectomies with natural breast reconstruction, not implants.

When I told the surgeon I didn’t want implants, she hit the ceiling. Clearly, no one had ever before challenged her standard treatment plan. Thanks to F.O.R.C.E., I was empowered. The next convention was two weeks away and I knew this would be where I would make my final decision, and it was. I talked with EVERY plastic surgeon at the conference. I spoke with Kathy Steligo, author of The Breast Reconstruction Guidebook, for 45 minutes at the round table breakfast. I had read her book for the third time on the plane to Orlando two days before. After the conference I came back to my hometown and started chemotherapy. I also scheduled my surgery for November at The Center for Natural Breast Reconstruction.

After consulting with my oncologist, I elected to have bilateral mastectomies with autologous reconstruction. In September my husband and I made a trip to South Carolina to meet with Dr. Kline and Dr. Baron, the general surgeon. I wanted my husband to meet my doctors. I wanted to make sure I had his full support and I wanted to make sure any lingering questions by either of us were answered.

After that meeting I was sure I wanted to go forward with the DIEP procedure. I felt very confident that everything would be alright. On November 30, 2011 I had the procedure. It was an 8-hour surgery, and everything went very well. I was in East Cooper Medical Center for four days. My nurses were great, especially Angela. I thought of her as my special angel since she was able to anticipate what was needed before being asked and was especially kind. She really took good care of me.

After my discharge from the hospital my husband and I stayed in Charleston another 10 days. I got a handicapped room at a local long-stay hotel. There was a handicapped shower and a recliner in the room. I really appreciated that recliner and I slept in it most nights. It helped to keep my feet elevated.  Every day, at least one time, I took a short, slow walk up and down the hall for exercise. I saw Dr. Kline 3 times during the next 10 days and he assured me everything was fine and my breasts looked “beautiful”—although at that time I didn’t think they looked so beautiful. Now, 5 weeks later, I can see how nicely everything is shaping up and I don’t think I will require a lot of revision at the Stage 2 procedure. I am glad I chose the DIEP procedure. The recovery is long, but it is worth it.

Did I ever seriously consider implants? The answer is yes, because implants represented the path of least resistance. I could have had the surgery done locally and I wouldn’t have had the additional expense of the trip from Indiana to South Carolina. Also, I would have had my entire support system around me. In making my decision I talked to many women who had implants and it seemed to me that they either loved them or hated them. Those that loved them seemed to love them only after 2-3 additional procedures due to complications. Everyone complained about the fills being painful and some found the implants to be cold or uncomfortable. Also there was the risk of capsular contracture and the necessity of replacing the implants every 10-15 years. I also talked with many women I met through F.O.R.C.E. who had flap procedures. I saw their results and they were fabulous. Short of a few fading scars, you could not tell that their breasts were not original. All of them seemed quite pleased with their new breasts.

Yes, recovery is a bit prolonged with DIEP. You definitely need someone very devoted to you to help out those first few weeks. I needed help getting up and down, showering, dressing, and emptying my surgical drains. My husband helped me with everything, dispensed my medications and gave me a blood thinning shot daily. I could do very little without his assistance the first 10 days following surgery, and I slept much of the time. Still, I was able to get around slowly and even went out to local restaurants my two weeks in Charleston. I also had pain medication, which made life bearable.

As the weeks have progressed, I feel my strength slowly returning. I am not yet 100% but I am planning to return to my job part-time on January 9th, with hopes of returning fulltime the following week. For anyone considering a flap procedure but fearful of the recovery, I would advise them that it is doable. It’s not as bad as you think. A certain amount of fear is normal if, like me, you have never had a major surgery. But for me, everything went fine, even though I am 59 years of age, older than any one I have met who had DIEP. So, I think if I can do it, anyone can.

My only regret is that I didn’t come to my decision for prophylactic surgery before I got cancer. Time ran out to make that decision but I am thankful my cancer was found early and I am thankful for my husband of 29 years, Larry, was by my side supporting me every step of the way. I would advise anyone facing cancer to not panic, do your homework, and be very proactive in your treatment. Learn everything about breast cancer that you can so you can understand your options. Choose your doctors carefully. Get second opinions and do what YOU think is best for you. You have many options; don’t let anyone take any of them away from you. Make your own decisions.

Having cancer has changed my view of life. It seems much more precious and much more vulnerable than before. I am thankful for a second chance and thankful that I had so many options that my mother and grandmother did not have. My mother had radical mastectomies, which are very disfiguring. I am glad that I still look much like I did before. I had nipple-sparing surgery and when I look at my breasts I still see me in there. I can’t wait to see the results following my final revisions. I am very grateful for Dr. Kline, Chris Murakami, RN and Clinical Coordinator, and all the staff at The Center for Natural Breast Reconstruction for a very positive reconstructive experience.

About Linda Burkholder

My name is Linda Burkholder and I have lived in Kokomo, Indiana the past 22 years. I am the proud mother of two adult children, a daughter 23 years-old and a son age 21. I have been married to my husband, Larry, for 29 years. I work fulltime at Indiana University as an Administrative Secretary to the Dean of the School of Public and Environmental Affairs. I love animals and have two Pembroke Welsh Corgis and four cats. In my spare time I enjoy reading and knitting.

Do you have a question for one of our doctors? Ask us!

Your Questions About Breast Reconstruction Answered

nipple sparing mastectomyThe questions below are answered by the breast reconstruction surgeons of The Center for Natural Breast Reconstruction, Dr. James Craigie and Dr. Richard Kline:

If a woman has flap reconstruction, are the nipples reconstructed at the same time or at a later date?

While it is sometimes possible to reconstruct the nipples at the same time, usually for various reasons it is preferable to delay the nipple reconstruction until a later time. Nipples must be positioned very carefully to look their best, and that means the final shape of the breast mound must be stable prior to choosing the nipple position. Tissue flaps must be carefully monitored for several days following the initial reconstruction to assure early detection of any problems, and temporarily leaving extra flap skin on the breast mound helps greatly with this. Additionally, FWIW, the skin that the nipples are reconstructed from, whether flap skin or native breast skin, frequently has no sensation, making it even easier to reconstruct the nipples as a small procedure in the office.

If a woman is a candidate for a nipple-sparing mastectomy, can she have flap reconstruction and retain her nipples?

Yes, in many cases. Problems arise when the breasts are very “ptotic” (droopy), especially if the flaps cannot be made as large as the breast tissue that was removed. The nipples can often be saved even in this situation with special techniques (examples include performing a delayed breast lift some months after flap reconstruction with the flap nourishing the nipple, or, in the case of a prophylactic mastectomy, having a breast lift or reduction some months before the mastectomy), but the overall reconstruction is more complicated and prolonged.

Can you explain what you mean by a muscle-sparing free flap breast reconstruction?

“Muscle-sparing” simply means that NO MUSCLE TISSUE at all is removed. This does not necessarily mean that the muscle suffers no injury, as the blood vessels which nourish the flap usually must be removed from the muscle, but the amount of damage is commonly small enough that the muscle ultimately recovers its function.

What are some criteria that may disqualify a patient for breast reconstruction?

Any serious medical conditions which would prevent a patient from tolerating 4-8 hours of general anesthesia would prevent her from having flap reconstruction. Some medical conditions, such as diabetes, increase various risks (in particular, risks of wound healing problems), but do not disqualify the patient from having reconstruction. We do not perform reconstruction on patients who are currently cigarette smokers (or use nicotine in any form) because nicotine’s effects on wound healing after flap surgery is frequently catastrophic. However, most patients will clear all nicotine form their system after a month’s abstinence. Some very slender patients do not have enough donor tissue anywhere on their bodies for flap reconstruction, but this is quite uncommon.

For more information on breast reconstruction, visit our website.

What Are My Reconstruction Options After a Lumpectomy?

DIEP flapThe below question is answered by The Center For Natural Breast Reconstruction team:

What are the options for reconstruction surgery after a bilateral lumpectomy?

Great question! Your options would be very similar to those you would have if you had a mastectomy. Keep in mind that if your lumpectomy was followed by radiation, the behavior of the radiated skin and tissue can complicate a reconstruction procedure utilizing implants and your best option may be to use your own tissue to restore your breast size and shape. Nonetheless, it’s your plastic surgeon’s responsibility to tell you all of the options available to you and let you choose how to proceed. Also, discuss with your surgeon any procedure that may need to be done on your unaffected breast to achieve symmetry.

Here’s my short list of options:

1. Tissue expanders and subsequent replacement with permanent implants. Ask about silicone vs. saline implants. How about the use of a skin and tissue replacement like fat or a dermal matrix (like Alloderm)?

2. Autologeous reconstruction with latissimus flap (back). Will implants be needed, as well?

3. TRAM flap (transverse rectus abdominus muscle). Uses the muscle, skin, and fat of the abdomen to rebuild the breast. Make sure you have been told of the risks involved in removing this muscle.

4. DIEP, SIEA (deep inferior epigastric perforator or superficial inferior epigastric artery). Uses the skin and fat of the abdomen to rebuild the breast but leaves the muscle of the abdomen intact.

5. GAP (gluteal artery perforator). Uses the skin and fat from the upper (inferior) or lower (superior) buttocks. Like the DIEP, no muscle is removed for this procedure.

6. TUG (transverse upper gracilis). Inner thigh donor area, utilizes skin, fat, and muscle of the upper inner thigh.

7. Intercostal perforator. Utilizes skin and fat from under the arm.

8. Maybe you’re happy with the size of your post-lumpectomy breast but would like the shape addressed. Procedures such as mastopexy or reduction mammaplasty on the unaffected breast may be the procedures to investigate.

9. If it’s a small defect, a simple fat transfer from another part of your body may remedy the problem.

Best Wishes,

The Center for Natural Breast Reconstruction Team

7 Ways to Beat Stress

stress reliefStress adversely affects every aspect of your life, from your health to your relationships. Many people don’t realize how stressful their lives are, and they don’t know how to deal with or reduce their stress. Let’s explore seven ways to improve your life by beating stress.

Determine your stressors.

We all have different areas of our lives that cause stress. While you may not be able to change stressful situations, by identifying your stressors, you can develop a plan to deal with them as effectively as possible. For example, if work causes stress, you can go to the gym after work to release tension with a workout, or leave the building for lunch to get away from your desk for a few minutes.

You might be able to change your response to stressors by altering the situation to make it easier to bear. For example, if visiting the doctor during the day is stressful because you need to go to work afterward, perhaps you can meet the doctor in the evening or on a weekend day. If you become agitated during rush hour traffic, try a new route or travel at a different time.

Avoid people, places, and things that upset you.

We all have people who make us uncomfortable or tasks we dislike doing. When those aggravations become stressful, it’s time to take matters into your own hands. Rethink whether it’s necessary to have dinner with the neighbor who criticizes your cooking. Perhaps it makes sense to find an accountant to do your taxes or a detailer to wash your car. Delegating tasks and avoiding stressful people not only reduce your stress, but they also give you a marvelous feeling of freedom.

Know your limits.

Be realistic about your time and what you can do, and say no when you need to. When you’re at your limit, additional items on your to-do list become stressors. Stand your ground and be assertive when you need or want to say no.

Give yourself a treat.

Integrative therapies such as massage, reflexology, and aromatherapy help to reduce stress, lower blood pressure, and relax you. They’re also fun and rejuvenating. Find a certified practitioner or visit a spa, keep an open mind, and give it a try.

Turn off the noise.

Unplug and spend at least 30 minutes alone and quiet every day. We’re all bombarded by technology and advertising, and it’s overwhelming. When you get away from the constant noise, you’ll feel your stress melt away. Spend that time doing what you enjoy, whether it’s a walk or a hot bubble bath. Unwind and enjoy.

Tune out negativity.

Do you really need to watch the 10 pm newscast each night or read the paper every day?  The news is mostly negative, which raises your stress levels. Your mind doesn’t need any more input on weather disasters or the latest political upheavals around the world. Don’t take on the world’s problems as your own. Rather than watch the news, find a comedy or cartoon to watch. Better yet, turn off the TV and read a book.

Experiment to find your best release.

Some women relieve stress by laughing or crying, and others find exercise or art to be their release valve. You may need to try a few different outlets to relieve stress, such as watching classic TV comedies, renting a movie that makes you cry, painting, or going to the gym. You may find one perfect stress reliever, or you may decide a combination of activities helps.

As you work through your stress, stay positive. Negativity is an unhealthy stressor and can creep into areas of your life that aren’t stressful. An upbeat attitude will do wonders to combat stress and help you feel healthy and at your best.

What do you do to combat stress?

Who Can Have a Skin-Sparing and Nipple-Sparing Mastectomy and Why?

**We are delighted to introduce our guest blogger, Dr. Paul Baron, MD F.A.C.S of Cancer Specialists of Charleston. Dr. Baron shares with us his insight on who can have a skin-sparing and nipple-sparing mastectomy and why.

See below for Dr. Baron’s guest post:

The best cosmetic results from breast reconstruction are clearly in patients who still keep much of the original skin of the breast. It leads to a more normal shape, appearance, and texture. In the past, the fear was that the cancer overlying a breast tumor needed to be removed; even if the cancer was far away from the skin in the back of the breast. All mastectomies were done with a large horizontal elliptical incision that removed a large segment of skin extending from the sternum to the lateral chest. The nipple and areola were removed at the same time as there was concern that the cancer could march up the ducts and be left behind if the nipple is left behind.  As a result, there was not enough pliable tissue to allow placement of an implant or tissue flap under the skin. The reconstruction could only be done by stretching the skin first with a tissue expander or leaving a large island of skin with the attached underlying flap of tissue (TRAM, latissimus, DIEP, or GAP). The result was a very unnatural breast reconstruction.

We now know that in most mastectomies, virtually all the skin overlying the breast can be left behind as long as the cancer is not immediately underneath it. In this case, we still remove a small patch of overlying skin. The most common incision for a skin-sparing mastectomy goes just around the areola with an extension inferiorly (kind of like a tennis racket shape), or a horizontal ellipse that is half the distance of the more traditional mastectomy incision. The resulting reconstruction is more natural in appearance as there is a very small scar and often no visible island of skin.

Another approach gaining in popularity is a nipple-sparing mastectomy. In this case, the entire breast is removed through an incision that completely leaves the nipple and areola intact. There are many ways to make this incision. Clearly these patients have the most normal appearing breast reconstruction. Also, to relieve the concern of cancer cells being left in the ducts, we actually core out the ducts as they enter the nipple. The shell of the nipple is left behind and as a result, often looks better than the nipple reconstruction.

We will not perform a nipple-sparing mastectomy if the cancer is close to the nipple. Also, if a patient had a prior mastectomy in which the nipple and areola were removed with one breast, we will usually remove the contra lateral nipple at the time of prophylactic mastectomy so the reconstruction result is symmetrical. It should also be pointed out that in most cases in which the nipple is left behind, it does not have normal sensation. It can have sensation to touch and temperature, but lose erotic sensation.

We have made huge strides in breast cancer surgery. For patients requiring or choosing mastectomy, the final reconstructed version can have a natural reconstruction as a result of usually leaving the skin behind as part of a skin-sparing mastectomy. We have improved this even more by performing nipple-sparing mastectomies. The optimum result is when the breast surgeon works as a team with the plastic surgeon in planning the type of mastectomy from a cancer point of view, and the orientation of the incision from a cosmetic point of view.

About Dr. Paul Baron:

Dr. Baron is Board Certified in General Surgery and completed a Surgical Oncology Fellowship at Memorial Sloan-Kettering Cancer Center in New York City. He is a graduate from the Boston University Six-Year Medical Program. Dr. Baron subsequently completed a residency in General Surgery at the Medical College of Virginia.

Cancer Specialists of Charleston –