April 2005: Reconstruction and Safe, Sexy Cosmetics

Timeframe for reconstruction?

Question from Amy: My sister may be facing a double mastectomy. She wants to wait until after chemo and radiation to have reconstructive surgery. Do surgeons have a preferred timeframe for reconstruction after a mastectomy?

Answer —Carolyn Chang, M.D.: Actually, it depends a little bit on the area in which the woman lives on what's available. Ideally, if the cancer is at a relatively earlier stage, then we, as plastic surgeons, would recommend trying to do the reconstruction at the same time as the mastectomy. If the patient is otherwise healthy, that's often the best choice. If that's not available, or if the general surgeon does not think that this is advisable, then she can have the surgery done in a delayed fashion. However, she needs to be aware that once somebody has radiation, it's extremely difficult to use an implant for reconstruction on the radiated side. In other words, the chance of failure of that implant due to infection or hardening of the breast or capsular contracture is very high.

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Allergic reaction to k-flex?

Question from Karissa: I just had a mastectomy with expanders three weeks ago today. I am having an allergic reaction to the k-flex, I believe. Is this common? Or are there cases of reactions to the silicone casing of an expander? I was just wondering.

Answer —Carolyn Chang, M.D.: It is very unlikely that you are having a reaction to the implant itself or the shell of the implant. It's not impossible, but it is much more likely that you're having a reaction to your antibiotic. Please check with your plastic surgeon.

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Options for tight implants?

Question from Twin: I feel like my implants are stuck to my rib cage; they are very tight. It's difficult at times to expand my lungs, especially when running. They are Mentor 350cc. What are my options to feel somewhat normal again?

Answer —Carolyn Chang, M.D.: One of the most common problems after breast implant reconstruction is what is known as hardening of the implants or capsular constructure. What this means is that scar tissue forms around the implant and makes that implant feel very tight and very hard. If it gets so tight, sometimes one can feel as if they can't expand their lungs, as well. I would certainly check with your plastic surgeon or someone qualified to do breast reconstruction and see if this is the case for you. And if it is, you can always have the scar tissue removed and the implants replaced, and it should be much more comfortable.

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Best and safest implants?

Question from Debbie: I am having a prophylactic bilateral mastectomy in June and am confused as to which is the best and safest implant.

Answer —Carolyn Chang, M.D.: If you're having the mastectomy done at the same time as the reconstruction, then you have to use an implant that can be inflated, thereby expanding the skin. In our practice, we like to use what we call an adjustable implant, which is made of saline with a silicone shell. The alternative is that you can use a half-and-half saline and silicone implant where the silicone is on the outside and the saline is on the inside. There are two chambers so you can fill the inner chamber with saline but the outside is silicone. Both of these implants are safe to use, and it really depends upon your anatomy and your personal preference as to which one would be better for you. The bottom line is that you need some type of implant, initially, that can be filled in order to have the best reconstruction possible. Please ask your plastic surgeon as to what they would recommend for you and why.

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Options for lumpy scar?

Question from Dorothea: I had a lumpectomy in February, but the scar is very noticeable and lumpy-feeling. I'm wondering if I should have something done to try and remove it or at least smooth it out.

Answers —Carolyn Chang, M.D.: The scar has not had a chance to fully mature. At this time, it is most likely still raised and purple. If that's the case, one of the best treatments is manual massage and silicone sheeting, which can be obtained at your doctor's office. You can still use the topical application if you're in radiation treatments. Once the scar fully matures, if the massage and the silicone did not take care of the appearance to your satisfaction, you can speak to your physician about a scar revision or consult with the OB as to what might be available for more camouflage.

Lillie Shockney, R.N., B.S., M.A.S.: If you're still undergoing radiation, your breast will go through changes for as long as a year after radiation has been completed. It takes a minimum of at least six months to a year for scars to fully mature, and with the radiation in the mix, each person will react slightly differently.

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Permanent cosmetics interfere with MRI?

Question from GnuMonia: I have been told that permanent cosmetics, i.e. eyeliner and eyebrows, will interfere with a future MRI. Is this true?

Answer —Anna-Dee Rinehart, S.C.S.: There are iron oxide-based products or pigmentations that are more likely to have a reaction or reactivity to MRI. The response comes from the mercury or the chemicals in the iron, and it can leave a rather strong stain in the eyeliner and brow area. So this is a consideration. If your doctor approves this procedure, the nurse will provide this service, and they will try to find you the pigment that has less of these iron oxide-based products. There are some doctors that will agree and say it's all right; it's a minimal response in comparison to what they are looking for in an MRI. There are others who will say to avoid it completely. It's really between the patient and the physician. In my experience, plastic surgeons have said, "Okay, we will do it."

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Protecting skin during radiation?

Question from Ipivovar: How do I protect skin during radiation treatment?

Answer —Carolyn Chang, M.D.: In general, you want to keep the skin moist. Moisturize and keep it clean. Don't use perfumed soap—if you can, find an anti-allergenic soap—and avoid the sun at all costs. For more details, I would really defer to a radiation therapist.

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Options for capsular contracture?

Question from Susan: I had immediate reconstruction done using the muscle in my back and an implant. I now have capsular contracture, and I wanted to know what I can do about this. This is the second time having a new implant inserted.

Answer —Carolyn Chang, M.D.: There are several reasons why someone gets capsular contracture. There can be a low grade infection in the capsule. There can be fluid or blood in the area around the implant which will stimulate the tight scar tissue formation. And finally, there's also bad luck. There are a few people where capsular contracture occurs no matter what one does. Some of the best results that we get combating capsular contracture are to use smooth round saline implants, which are slippery on the surface. Therefore, we can really massage that implant and move it around in the pocket, as opposed to a textured implant which tends to stay in place. Also, if an implant exchange surgery is done where the scar tissue is removed, you need to be sure the pocket is fully cleaned and adequately drained so there is no infection.

Finally, speak to your plastic surgeon about why he/she thinks this is recurring. There's also a medicine that is sometimes used to combat capsular contracture: Pavabid. This is a smooth muscle relaxant, but should only be dispensed by a qualified surgeon.

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Nurse-aesthetician for nipple tattoo?

Question from Carlotta: How do I find a nurse-aesthetician for my nipple tattooing? Will my plastic surgeon have one on their team?

Answer —Anna-Dee Rinehart, S.C.S.: If your team has a medical aesthetician that would be the first. You can find one through the Aesthetics' International Association. Their fee is usually incorporated into the general surgical fee when they work with a plastic surgeon. Some private aestheticians provide the service at no charge. It's important to have a nurse-aesthetician with a lot of experience, and preferably, they'd be referred by their plastic surgeon or oncologist. The individual usually has specialized training in this type of procedure.

Nipple tattooing is not painful, and it adds a sense of completeness to nipple reconstruction. Sometimes, if the pigment doesn't take the first time, it might require two or even three sessions for a fuller presentation.

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Unsuccessful nipple reconstruction?

Question from Susan: I had nipple reconstruction done with the skin on my inner thigh. I have a pronounced areola, and it wasn't very successful. I had it done the second time with skin from the other leg and cartilage from my ear. Again, it wasn't successful. What can I do?

Answer —Carolyn Chang, M.D.: Nipple/areola reconstruction can be done two ways. One is using a graft from a separate location to either reconstruct the areola or the nipple and the areola. It would depend upon what it is that was not successful about your nipple as to what the options are. However, you can always talk to your surgeon about the possibility of using your own native skin to create the nipple and doing tattooing for the areola color. Or you might perhaps graft part of the normal nipple onto the reconstructed breast, if you still have the other breast.

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Noncarcinogenic cosmetics and dyes?

Question from Paula C: Many cosmetics and hair dyes have carcinogens. It is my understanding that Europe is way ahead of us in this. Cosmetic companies cannot sell products that contain carcinogens, and even if an ingredient is suspect to being a carcinogen, it cannot be used. How can we get these products? Can you recommend USA products, especially hair dyes?

Answer —Anna-Dee Rinehart, S.C.S.: I'm not prepared to offer a recommendation. If we could choose a product, we would choose a natural product with as few parabens as possible and recommend dermatologist-accepted products. However, we won't give any specific name of a product.

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Differences in surgical recommendations?

Question from Bev Nurse: I'm confused. My HMO recommends a modified radical mastectomy with radiation followed by delayed reconstruction (six months to a year). An outside breast surgeon at the nearest breast cancer center recommends a simple mastectomy and axillary dissection with immediate reconstruction (my choice is DIEP) followed by radiation. Why the disparity in recommendations?

Answer —Carolyn Chang, M.D.: There are often multiple ways to treat breast cancer. If someone is unsure about the recommendations that they're getting, and if they have the luxury of a little bit of time, a third opinion would not be unheard of. Because whatever treatment they decide to do, they need to be comfortable that they're making the right decision.

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Latissimus dorsi flap limitations?

Question from LM Smith: I had a bilateral mastectomy two years ago. I had a consultation with a plastic surgeon who recommended the latissimus dorsi flap. I am a pianist and am concerned about back weakness or changes in my ability to play. Are you aware of any limitations with this type of surgery?

Answer —Carolyn Chang, M.D.: With any tissue, you are taking muscle from another site, so you will have some weakness in that area with a bilateral mastectomy. If your surgeon has recommended bilateral reconstruction with back flap, then for everyday activity I would not expect a huge limitation. However, when it's people who are very specialized or who do very competitive sports, I would anticipate that their strength would change. With bilateral mastectomies, however, if there has not been any radiation, oftentimes implants are really the best choice. I would definitely speak to your plastic surgeon about your concerns.

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Implants after radiation?

Question from P Kott: A plastic surgeon told me that I was no longer a candidate for having an implant alone because I had had radiation. I have an active lifestyle and do not wish to give up any muscle, whether abdominal or latissimus. Are there documented successful outcomes for reconstruction with an implant alone in women who have finished a full course of radiation treatments?

Answer —Carolyn Chang, M.D.: Very good question. Yes, you can try to do it; however, the failure rate is very, very high. It is really much more standard of care to have an autologous flap-a flap taken from your own body. That's why you were recommended that. There is a DIEP flap, which spares the majority of the muscle in the abdomen, and might be an option if it's available in your area. But you have to be aware that radiation makes this micro-surgical procedure much more difficult to do, yet not impossible.

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Reconstruction after prophylactic mastectomy?

Question from DG: Two years ago, I had lumpectomy, rads and chemo. I just had the BRCA1 testing done and I do have the BRCA1 gene. With my young age and family background, everyone is recommending I do a prophylactic bilateral mastectomy. I wanted to know if there is no evidence of disease, can the reconstruction be done immediately?

Answer —Carolyn Chang, M.D.: Absolutely, yes, but you would need to discuss the particulars with your surgeon to make sure that is something he or she agrees with. With the radiation on one side, your options for a simple implant might be limited. You should be followed by a general surgeon very closely, and that would include screening mammograms.

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Implants behind muscle?

Question from Penelope Pit Stop: I had a lumpectomy 2 years ago, and prior to that was considering breast implants because I am very small-chested. Could you give me your thoughts on gel implants placed behind the muscle at this stage?

Answer —Carolyn Chang, M.D.: If you had a lumpectomy, you probably had radiation. Once again, in the field of radiation, implants become very unreliable because of the high rate of capsular contracture or scar tissue formation on the side of the radiation. You can put implants in to augment the breast, but you do take a chance that it might not work, in which case the implants have to come out. I would definitely discuss the particulars of your case with a qualified plastic surgeon.

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Fixing GAP flap reconstruction?

Question from Mebert: I had GAP reconstruction five and one-half months ago and was devastated to discover that the graft was much higher up than my real breast. I feel like I have a baseball hanging off of my clavicle. Does this happen commonly, and can it be brought down? My real breast is exactly where I want it to be, I don't want it lifted, I want the graft brought down to match it.

Answer —Carolyn Chang, M.D.: It's difficult to know what the options are. You should speak to your surgeon and consider a second opinion from someone else.

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Research on safety of implants?

Question from MJ: I am concerned about the confusion and safety of silicone and saline implants. Some say it is an ongoing problem years down the road. I want to know if there is research to support how safe the implants are over time. Thanks.

Answer —Carolyn Chang, M.D.: This is a very complex topic. There has never been any definitive evidence that has concluded that silicone implants are harmful to individuals. Obviously, there may be some outlying cases, but as a whole they have remained safe. Thus, contrary to popular belief, they have always been on the market and have never been off for very specialized cases-breast reconstruction being one of them.

Currently, the implant companies and the FDA are in investigational phases. It is my feeling that because of the emotional nature of breast implants in general, the proceedings are happening at a very slow rate, and the FDA is being extremely cautious. But if you have breast cancer, the silicone implants are available to you. You have to be enrolled in a study, and in my experience, in a very large practice of a tremendous amount of silicone implant patients, I do not have any hesitation putting them in. All that being said, however, implants as a whole-be they saline or silicone-have a life expectancy to them. In other words, they're not forever. One has to understand that when embarking on an implant, albeit cosmetic or reconstructive, that it is an investment in time, energy, and, most probably, more procedures in the future should the implants fail.

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Success rate of DIEP flap reconstruction?

Question from DCannis: Due to failed implant and radiation, I am not a candidate for another implant. I am being told by plastic surgeons that I should have the TRAM, as the DIEP would fail due to the vessel that they would need to attach it to having been radiated. The plastic surgeons in my area do not do the DIEP. I am willing to travel, but really need to know what the true success rate would be.

Answers —Carolyn Chang, M.D.: The DIEP flap is something that has come into vogue lately. With a DIEP flap, the issue is micro-surgery. In the radiated area, the vessels that one would need to use to hook the flap to would be in the radiated chest area. Therefore, the flap success rate becomes harder because the micro-surgical technique becomes more difficult. If you want a more reliable reconstruction, the pedicle TRAM is a safer alternative with almost 100% success rate, even in radiated patients.

Lillie Shockney, R.N., B.S., M.A.S.: Surgeons who specialize in DIEP flap will assess that vessel before cutting it to see how viable it is. If it looks pretty good, they'll go ahead and harvest it and do DIEP. That judgment call isn't able to be made until you're on the operating room table.

Carolyn Chang, M.D.: You need a center such as our micro-surgical center in San Francisco that is very specialized, or you need a university setting. It's a matter of what you want to invest in, whether you want to travel or stay local. I feel very strongly that, for the vast majority of patients, a pedicle TRAM is an outstanding reconstruction with a very low rate of abdominal complications. I have marathon runners, competitive athletes, and iron man people who have had them and have no problems with anything they do. It depends on how well the belly is closed, and that takes a certain amount of expertise.

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Differences between reconstruction flaps?

Question from Ramona: Can you distinguish each flap? TRAM, DIEP, GAP, free, and pedicle?

Answer —Carolyn Chang, M.D.: All flaps are known as autologous tissue flaps, meaning they come from your own body. Within that heading, one should really think about flaps in terms of what structure they're taken from. A gluteal or GAP flap is taken from the buttocks, a TRAM flap is taken from the abdomen, and a latissimus is taken from the back. Within each of these categories, the flap can either be done with micro-surgical techniques, thereby calling them free flaps, or they can be done as a pedicle flap, meaning the flap is never detached completely from the body. The exception to this is the gluteal flap, which because of its location must be done as a free flap.

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Preparation for DIEP, fat transfers?

Question from Allison M: What is the best way to prepare physically for the DIEP operation? Also, is it possible to use fat removed by liposuction from other areas of the body, (e.g. upper thighs) to increase a reconstructed breast, or is the only option a synthetic implant?

Answer —Carolyn Chang, M.D.: Fat transfers can be done; however, it's very difficult to achieve any amount of bulk. So generally speaking, we use fat grafting for fine, specialized areas such as wrinkles in the face or maybe in the hands. It would be very difficult to transfer enough fat to make an impact on the breast mound. That's simply because a very large percent of any fat graft does not take as a graft with any transfer. To prepare for the DIEP operation, just as you would need to prepare for any operation, be a healthy non-smoker, stay away from herbs or aspirin products before surgery, and make sure your nutrition levels and blood counts are good.

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Remove acrylic nails before surgery?

Question from S Farber: Regarding safe cosmetics, I have acrylic nails. I will be having a level 1 and 2 lymph node resection. Should I remove my acrylic nails before surgery?

Answers —Anna-Dee Rinehart, S.C.S.: Yes, I would say absolutely to remove the acrylic nails, as they can harbor infection. It's not a good idea to have them, because it might be hiding a fungus. It's not a good idea to have anything like that on your hands or your body.

Lillie Shockney, R.N., B.S., M.A.S.: And they'll need to stay off. Post-operatively, you can't put them back on. Just let your nails grow out naturally and don't use artificial nails in the future due to increased risk of infection. You want to reduce the possibility of infection in your arm because it can trigger lymphedema.

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Beauty procedures during treatment?

Question from Aphrodite: Is it okay to use Botox, Restylane, StriVectin, and other beauty treatments during or after breast cancer treatments?

Answers —Anna-Dee Rinehart, S.C.S.: I would say no. Only if Botox was approved by the plastic surgeon, oncologist, and radiologist should you consider it. It's a nice procedure and does improve aesthetics, but the risks must be weighed against the benefits. I would say that it's something that should not be done in the first year, although perhaps it might be approved down the line-maybe the second year. StriVectin, no. There's no reason for you to use this for stretch marks, or any other popular brand. Mild soaps and detergents and non-chemically oriented products should be used. Again, everything you put on your skin has to be approved by the plastic surgeon and the oncologist.

Lillie Shockney, R.N., B.S., M.A.S.: In general, any injectable or deep-cleaning blood draws, anything where you have the potential of creating an infection, should be really looked at carefully while somebody is on chemo, especially because of the much reduced blood cell count that the chemo causes. It makes patients very susceptible to infections. However, once somebody's white counts normalize, I don't know of any real contraindications to doing the Botox or the Restylane. I'm not aware of any interactions to more ongoing chronic treatments, but I would not do it during the acute injectable chemotherapy. It is vital that you discuss this with your oncologist.

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Are cohesive gel implants available?

Question from Luke: My plastic surgeon told me about cohesive gel implants which may come before the FDA panel for review in June. Could these be available within the next nine months?

Answer —Carolyn Chang, M.D.: I doubt it. Silicone implants have not been available for the last 10 years. It would be hard for me to believe that the FDA would approve a cohesive gel so easily. If you desire a cohesive gel, there are many investigators around the country that you can consult as a potential subject in the investigation trial. I would probably contact the American Society of Plastic Surgeons for more information.

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Options if DIEP not available?

Question from Mitla: What would you suggest for the patient who wants a DIEP, but doesn't find it readily available in her area?

Answer —Carolyn Chang, M.D.: If you really want a DIEP flap and it's not readily available in your area, your only option is to travel. You can always have it done after the mastectomy in a delayed fashion. The other alternative, of course, is a regular pedicle TRAM flap, which, once again, I feel is an outstanding reconstruction. I don't know your particular concerns. There really aren't any other options if the DIEP isn't available to you other than going to where the DIEP is available.

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Options for failed implants?

Question from Ali: One of my implants failed as you described. Now I am lopsided. What are my options?

Answer —Carolyn Chang, M.D.: You want to have the implant removed and replaced most likely. You can leave it out, I suppose, or take the other one out. You really should see whoever put them in. If they're saline, you can leave the bag in for a short period of time, but it's generally recommended to get them out as soon as possible for you. If they're silicone and they've ruptured, I would recommend taking care of that immediately.

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Options after lumpectomy?

Question from Stella Bella: I had a lumpectomy and a re-excision lumpectomy that left me with a pulled-in, nasty scar and a nipple that faces to the side. What can be done to get me back to a somewhat normal look?

Answer —Carolyn Chang, M.D.: The options for lumpectomy radiation patients where the aesthetic result is not optimal are somewhat limited. You would need to be evaluated by someone qualified to use breast implants. One option potentially could be an augmentation; however, that has a very high failure right in the face of radiation. Another option, if the breast is extremely deformed, is to actually complete the mastectomy and do a formal reconstruction with autologous tissue--a flap, in other words.

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Starting reconstruction after rupture?

Question from Holly: I had a tissue expander placed in November 2004, but after only one "fill-up," my incision ruptured and the expander had to be removed. Is it safe to start reconstruction again?

Answer —Carolyn Chang, M.D.: When the reconstruction fails and the implant is exposed, it's safe to replace the tissue expander approximately six months after the implant was removed and the skin was closed. In other words, it takes six months for the skin wound area to clear itself of infection and to get strong enough to accept another implant.

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Reconstruction after inflammatory breast cancer?

Question from Amelia: I have been diagnosed with inflammatory breast cancer. I have finished chemo and I am just starting radiation followed by a mastectomy. What is the current thought on reconstruction for this type of cancer?

Answers —Carolyn Chang, M.D.: The inflammatory cancer is very aggressive. That would really depend on the opinion of your general surgeon and your oncologist as to whether or not this would be safe for you. In my practice, I have personally done reconstruction for patients with your type of cancer, but only on the recommendation of the general surgeon and the oncologist.

Lillie Shockney, R.N., B.S., M.A.S.: Most oncologists recommend waiting at least two years after completion of treatment before considering it, and that's because the risk of local recurrence of inflammatory breast cancer in the skin of the chest wall is highest during those two years. So it's a goal for you to achieve later, and I hope you do.

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Dying hair after chemotherapy?

Question from Abellntn: How long after chemo do you need to wait to color your hair? Should it be a certain length of time?

Answers —Anna-Dee Rinehart, S.C.S.: This needs to be approved by the plastic surgeon and oncologist.

Lillie Shockney, R.N., B.S., M.A.S.: Most of the time they'll say to wait at least six months, because the new hair won't actually hold the color. So whatever color you'd like it to be, it won't come out that way if you're premature in having it done.

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TRAM flap if implant unsuccessful?

Question from Debbie4: There was a statement on the side of this conference that states women that either will have or had radiation should not have an implant. My surgeon is recommending an implant, preferably silicone. If there is any problem with the implant than he felt that we could always do a TRAM. Does this sound like the right plan of action?

Answers —Carolyn Chang, M.D.: It depends upon how much we as plastic surgeons are willing to try riskier procedures as long as the patient is fully informed that there is a high possibility, or not a small possibility that the reconstruction would fail. The patient would have to be willing to have an autologous transfer in this case, in the high likelihood that the implants were to fail. So I don't think this approach is entirely unreasonable; however, you as the patient have to be very realistic about the chance that you're taking that the implant won't work. You can't be disappointed if it doesn't work. These are decisions that need to be made between you and your surgeon very frankly from both sides with full understanding.

Lillie Shockney, R.N., B.S., M.A.S.: Women who are having mastectomy with chest wall radiation have a higher risk of an implant failing than a woman who had lumpectomy with radiation in the past and is now embarking on a mastectomy with reconstruction. It depends on the doses of radiation and the quality of skin remaining and the size of the breast. The basic thing you need to know about radiation is that it makes things more unreliable. It doesn't mean things are impossible, but it makes things much more unreliable.

Depending on your anatomy, the particulars of your cancer, and the amount of radiation that you had, you may or may not be a successful candidate for implant reconstruction. As a whole, it's much more preferable, if possible, to do autologous tissue. In medicine, it's rarely all or nothing, but I think the overwhelming problem with the lumpectomy patients is that they don't understand the effects of radiation on their skin, and if they come back with a recurrence and need to have a mastectomy they need to be aware that it makes an implant reconstruction more difficult.

Radiation affects the elasticity of your skin. It makes it difficult to expand the skin and even get the skin healed in certain patients. I have done many patients with Hodgkin's disease, and they have done just fine with mantel radiation. So it's not necessarily all types of radiation.

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Did guest have reconstruction?

Question from Cecilia: Lillie Shockney, I saw in the bio information that you're a survivor too. Did you do reconstruction? Would you do the same now?

Answer —Lillie Shockney, R.N., B.S., M.A.S.: The answer is yes. I've had bilateral DIEP flap reconstruction done, and I'd do it again in a heartbeat.

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Reconstruction increases lymphedema risk?

Question from Kerri: I have had a lumpectomy with some node removal. I am now going to have a double mastectomy with reconstruction using stomach tissue. Will this increase my risk of lymphedema in my arm? And what are the risks of the stomach tissue not working out for new breasts?

Answer —Carolyn Chang, M.D.: That's something you would need to talk to your operating surgeon about. It varies from person to person, and it's not always entirely predictable. Having reconstruction should not directly impact your lymphedema. A pedicle TRAM flap in a healthy non-smoker who's close to her ideal weight is virtually 100%. I will say that, in my opinion, one of the better indications for undergoing a micro-vascular DIEP flap would be a bilateral stomach flap, because when you take rectus muscles you do weaken the abdominal wall.

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Liposuction on non-affected breast?

Question from Chat: Do you have an opinion about liposuction on the non-affected breast to make it more the size of the breast that has had the lumpectomy?

Answer —Carolyn Chang, M.D.: In general, I think that if you have a diagnosis of breast cancer, you want to be able to biopsy all of the tissue that comes out of the other breast, because you cannot do that with liposuction. I think that a traditional breast reduction on that side would be a safer alternative. You can't look at the tissue that's removed from the liposuction.

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Scleroderma interferes with implants?

Question from Wendy: Does having the CREST variety of scleroderma interfere with the success of a saline/silicone breast implant, post-breast cancer and chemotherapy?

Answer —Carolyn Chang, M.D.: Anybody who has any collagen vascular disease, be it scleroderma or more commonly lupus, is at higher risk for circulatory problems because the disease usually interferes with the fine blood vessels in the body. If the patient had the mastectomy before and wants to do the implants in a delayed fashion, then she will have a higher success rate because the skin will have had time to get a lot stronger.

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Too overweight for reconstruction?

Question from Darlbel: Can you be too overweight for reconstructive surgery?

Answer —Carolyn Chang, M.D.: Absolutely. You can be too overweight to have surgery safely done, period. For instance, a belly flap would have a much higher rate of complications in an obese patient.

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Smoke-free before TRAM surgery?

Question from Di: How long should one be smoke-free before TRAM surgery can be considered?

Answer —Carolyn Chang, M.D.: That is something that's controversial among surgeons. I like for my patients to be off smoking for at least two weeks; however, I prefer six weeks. It may be that due to the amount of smoking that someone does that they are eliminated from being a candidate for TRAM surgery at that time. It depends on the overall health and other co-morbidity factors that that patient has and the amount that they smoke.

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Expertise for TRAM surgery?

Question from Darlbel: How do you find someone with the expertise to do the TRAM surgery? How do you know which doctor that can do it and has done it?

Answer —Carolyn Chang, M.D.: I think, in general, when choosing any doctor, the same principles can be used. You want to see before and after photographs, and you want to be sure the doctor is board certified or at least board eligible. You want to see that they've been trained properly as a plastic surgeon and not in a different specialty. It's always helpful to talk to former patients, as well. Also, the recommendation of your general surgeon can be extremely helpful.

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Treating skin to improve results?

Question from Elli: Are there any long term applications (Aquaphor, etc.) that will help to maintain the integrity of radiation-exposed skin that would help improve the results of future reconstruction?

Answer —Carolyn Chang, M.D.: I don't know exactly what it is topically that one would recommend. I think time is probably the best thing. One thing we have investigated in our practice is the use of hyperbaric oxygen. It has been shown to increase blood vessel growth in damaged radiated skin. These are things to talk about with your radiologist/oncologist.

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