Ask the Doctor: Q&A


I had a double mastectomy on June 5, 2018, for breast cancer. I finished chemotherapy on November 28th, 2018. I am interested in having the DIEP done and I read information about the ReSensation™ option and am very interested. I live in Aiken, S.C. and would love to get an appointment scheduled.



Hi Erin,

I’m sorry you have had breast cancer, but we would be delighted to help you. We have done about 1,400 DIEP reconstructions over the last 15 years, with a 99% flap survival rate (plus about 300 other perforator flaps for breast reconstruction, mostly sGAPs and PAPs). We have been using ReSensation™ to improve the chances of restoring sensation since October 2017.

While there is not yet definitive published data proving that the nerve grafts help restore sensation, there are some promising early results. We have had some difficulty with certain insurance companies refusing to pay for the nerve grafts, but we would of course address that with them prior to your surgery. I would be delighted to see you in consultation at a time convenient for you. I typically see new patients on Tuesdays and Fridays, but I can often see patients on other days if it works better for you. Thanks for your inquiry, and have a great day!

Richard M. Kline Jr., M.D.

Dr. Kline trained in microsurgery with Dr. Robert Allen, who was pioneering the DIEP, SIEA, and GAP flaps.

Breast Cancer and Younger Women

Most breast cancer is found in women who are over 50 years old, but lately it is becoming more common for younger women to be diagnosed with the disease. As a matter of fact, the Centers for Disease Control and Prevention (CDC) states that about 11 percent of all new cases of breast cancer in the United States are found in women who are younger than 45 years of age.

Young women who have been diagnosed are often confused and angry. Here are some stories from younger women (their last names have been withheld to protect their anonymity).

Jamie always felt like she had a higher risk of breast cancer, but never thought she’d be diagnosed at 38. “I thought if I ever got cancer it would be much later in life – when I was in my 60s or 70s,” she says.

Sarah was diagnosed two weeks shy of her 37th birthday. An otherwise healthy young woman, she was angry when the doctor told her she had breast cancer at such a young age.

Anna was diagnosed when she was only 34-years-old and, as a young mom to a 17-month-old daughter, she felt like her future family plans were quickly fading away.

Kristen has a three-year-old daughter, but her breast cancer diagnosis and chemo treatment wiped away her dreams of having another child. “This is the time when all my friends who had babies at the same time as me are having their second child,” she says.

According to the CDC, younger women are at a higher risk for breast cancer if they have close relatives who have also been diagnosed at a younger age, if they have the BRCA1 and BRCA2 gene, are of Ashkenazi Jewish heritage or have been treated with radiation therapy to the breast or chest in childhood or early adulthood. If they are diagnosed, the breast cancer is often found to be at a later stage and more aggressive.

Once diagnosed, younger women must make a variety of decisions concerning their treatment and their future. That includes decisions to have a mastectomy and reconstruction surgery, as well as deciding about childbirth. That is because some breast cancer chemo treatments might damage the ovaries, which can sometimes cause immediate or delayed infertility.

Dana says the hardest part of being a young breast cancer patient was going into the chemo room where the average age of the patients was about 60. “They look at me with such pity and said, ‘At least I’ve had a long life, saw my kids and grandkids grow up,’” she says. “But I will survive and will also see my kids grow up.”

The Center for Natural Breast Reconstruction believes in good health for everyone, regardless of their age. If you or someone you know is in need of breast reconstruction, contact them at or toll-free at (866) 374-2627.

Ask the Doctor: Q&A

I recently completed chemo for stage 3 IDC (invasive ductal carcinoma) in my left breast. I have chosen to have a bilateral mastectomy because I’m 44 and my oncologist recommended it. I’m scheduled for radiation after surgery. I was hoping to have immediate DIEP flap reconstruction but the plastic surgeon I spoke to today said he doesn’t recommend it until after radiation. I had originally consulted with an out-of-state plastic surgeon who said they perform the mastectomy and immediate reconstruction with skin flaps but they don’t recommend it with implants. My radiation oncologist even told me that statistically, women are more satisfied with immediate reconstruction. I’m very confused and if I can avoid having two surgeries, I would prefer that. Any advice would be greatly appreciated!



Hi Angie,
I’m sorry you are going through this, but your question is an excellent one, and has been asked by many patients.
We try not to radiate natural tissue (flap) reconstructions, which includes DIEP flaps. As a rule, at best, the radiation will “shrivel up” the flap about 25% and make it firmer; at worst, it will shrivel it up to almost nothing. While some plastic surgeons don’t seem to mind these odds, we feel that in general, we do patients a disservice if we recommend radiating flaps. Additionally, if the flap is delayed until AFTER the radiation, it is usually the IDEAL method of reconstruction, and its success is not at all affected by the fact that the breast area has been radiated.
On the other hand, implant-based reconstructions, while faring more poorly when radiated than when not radiated, at least do not place priceless irreplaceable natural tissue at risk of loss. When we know or strongly suspect that a patient is to need post-operative radiation, we often recommend placing temporary tissue expanders
in front of the muscle at the time of mastectomy(ies). After the radiation is complete, the expander is removed, and reconstruction with natural tissue (such as DIEP flap or sGAP flap) is performed. It is not absolutely necessary that a temporary tissue expander be placed, but it serves the dual purposes of providing a temporary breast mound, and often preventing excessive wrinkling and contraction of the remaining breast skin until reconstruction with your own tissue can be done.
I would be happy to chat with you by phone or see you in person to discuss your situation further, if you wish. We have performed more than 1400 DIEP flaps with a 99% success rate, and we are happy to share what we have learned in the process.

Dr. Richard M. Kline Jr., M.D.

Dr. Kline trained in microsurgery with Dr. Robert Allen, who was pioneering the DIEP, SIEA, and GAP flaps.

Love Yourself

February is the month of love! As we celebrate Valentine’s Day and show those who are special to us how much we love them, why not do the same for yourself? As a breast cancer patient, you’ve been through diagnosis, surgery, treatment and possibly reconstruction and, of course, all the emotional ups and downs that have gone with it. This month, make sure you take some time to love and pamper yourself because you deserve it!

Love Your Bod

With breast cancer comes scars, hair loss, weight fluctuations and other changes to your body. Sometimes they are hard to accept, so the best way to start off a month about loving yourself is by loving your body and how it looks now. Yes, it’s changed, but it is hard at work fighting a disease, so be more confident about how beautiful you look. Maintain your beauty routine if it makes you feel good, accept compliments and wear clothes and hats that make you look and feel better.


This month, millions of Americans will buy heart-shaped boxes of chocolates and indulge on rich desserts. It’s OK for you to indulge, too. If that occasional decadent dessert, piece of chocolate or dinner out makes you feel better, enjoy it!

Go Outside

In some parts of the country, it’s too chilly to take a walk, but if you can get outside for a bit, go for a walk. Many cancer patients stay inside during treatment and recovery and can suffer from winter blues. Going outside for some fresh hair and daylight can help your body to fight depression, sleep better and feel better. Even 15 minutes can make a difference.


Sometimes loving yourself means shutting out the world and enjoying your version of relaxation. Maybe it’s putting on your favorite music or romantic comedy movie. Perhaps it’s a long hot soak in a tub, reading a New York Times best-selling novel or filling in their crossword puzzle. Whatever it is, take time to do it. Your body and mind will appreciate it.

Pamper Yourself

Loving your bod, indulging and relaxation are all ways of pampering yourself, but if you need a few more ideas, how about a day at the spa? Buy that dress you always wanted or, depending on how you feel, take a quick weekend getaway from the hustle and bustle of tests and doctor appointments.

Breast reconstruction after mastectomy has been proven to help women feel better emotionally and physically. If you’ve recently gone through breast reconstructive surgery, loving yourself will help you to feel better about your breast cancer journey and how you look and feel. Also, talking to others who have gone through the process before you will also help.

Buddha once said, “You yourself, as much as anybody in the entire universe, deserve your love and affection.”

The Center for Natural Breast Reconstruction believes in good health for everyone, regardless of the season. If you or someone you know is in need of breast reconstruction, contact them at or toll-free at (866) 374-2627.

Ask the Doctor: Q&A

What is a safe cc (cubic centimeters) of fluid to fill breast tissue expanders every two weeks?

Hi Danna, 
Thank you for reaching out.

The answer to your question depends on multiple factors. Usually there is a certain amount of fluid that needs to be added to an expander after surgery so that the skin is stretched enough to fit around the more permanent implant. Usually the fluid is added gradually until the goal is met. This may take multiple visits to the surgeon until enough is added. The amount added at each visit depends on what size expander was used and how much skin stretching is needed. The healing process is also important. If healing is slow, then less can be added safely. Finally, fluid is usually added until the patient feels tightness, not severe pain. The tightness goes away gradually and in a few days, more can be added and the process is repeated. We can usually expect 50-250ccs added – per visit – depending on the above-mentioned factors. 

I hope this answered your question. Please let me know if you need any additional information.

Thanks again, 

Dr. James Craigie

How to Stay Positive During the Winter Blues

Robert Frost once wrote, “You can’t get too much winter in the winter.” While its shorter days, colder temps and beautiful snow falls put a smile on the faces of some, others would disagree with the famed poet about winter. To them, the season makes them eat more, sleep more and generally feel down in the dumps. They can’t wait for it to be over and for spring to arrive.

If that sounds like you, you might be suffering from more than just cabin fever. Known by its more medical term, Seasonal Affective Disorder (SAD), it is categorized by the National Institutes of Mental Health as a medical condition that really does just last through the winter.

SAD is thought to be caused by the lack of sunlight from shorter days that lowers the serotonin or “feel good” hormones in your body and raises your melatonin levels, which causes you to feel more tired. According to Yale University’s Winter Depression Research Clinic, other symptoms of SAD include carb cravings, difficulty waking up in the morning, reduced work productivity, and withdrawal from social contacts. Those who live in northern and colder climates or who have a family history of depression may also be at a greater risk of suffering from SAD.

The good news is that there are treatments available to help turn the blues around, including daily physical activity, which raises your endorphins and counteracts the signs of depression. So if you can bundle up and get outside, do it, even if it’s just for 15 minutes a day.

Or you can bring the light inside. Sitting in front of a light box with 10,000 lux for 30 to 45 minutes in the morning mimics outside light and can reduce your SAD symptoms. You can also obtain a light box through your medical insurance plan or online, starting at $35. Unfortunately, light boxes might not work for everyone and counseling and anti-depression medications such as sertraline or bupropion might be necessary.

If your idea of dealing with winter blues is pulling the covers over your head and hiding from the world until the snow melts and spring thaws, think again. This is the best time to be more social and make plans with your friends and family, even if it’s just going for a walk together, going shopping or sharing a dinner and a movie.

Most importantly, having a positive outlook can help to reduce your symptoms. You can do this by keeping a gratitude journal or creating a vision board that provides a visual of your dreams and goals for the year. Having something to look forward to can help you to get through the winter blues.

The even better news about seasonal affective disorder is that once spring does start, your symptoms will typically start to wane and SAD patients begin to feel better.
The Center for Natural Breast Reconstruction believes in good health for everyone, regardless of the season. If you or someone you know is in need of breast reconstruction, contact them at or toll-free at 866-374-2627.

Ask the Doctor: Q&A

I had a bilateral mastectomy three years ago because of stage one ER positive breast cancer in the left breast and DCIS in the right. I chose to have a double mastectomy to avoid radiation. I hate my reconstruction! It feels unnatural and bulbous, and the breasts are too far apart. They are uncomfortable when I sleep because they are too big (they are gel inserts). I can’t feel anything on the front of either of my breasts. Can you help me?



Hi Susan,

You are not alone. Many women have gel implant reconstructions that feel very unnatural. Fortunately, there is an excellent chance we can help you. 
We have reconstructed hundreds of women using only their own tissue (DIEP flaps or sGAP flaps), which leaves the most natural-feeling breast reconstruction currently possible. Fortunately, a prior history of unsatisfactory implant-based reconstructions doesn’t affect our ability to reconstruct your breasts using your own tissue.

In the unlikely event that you do not have adequate donor tissue for a fully natural reconstruction, there are other options available (such as placing the implants in front of the muscle), but we recommend using your own tissue if possible for the most natural, long-lasting result. 
I would be very happy to speak with you by phone, or see you for a consultation, if you would like. Please let us know how we may help.

Richard M. Kline, Jr., MD

Ask the Doctor: Flap Surgeries

natural breast reconstructionQuestion: 

I had a bilateral mastectomy last December after chemotherapy for stage 3 breast cancer in my right breast and lymph node removal. Expanders were inserted, and I had radiation treatment that ended in the spring. I am now ready to get rid of these expanders and have reconstructive surgery. I am confident I want an autologous tissue surgery. I am on my third plastic surgeon and I have concerns about going forward with this doctor since he has not shown me any pictures and does not talk about a “team” approach.

I was interested in the PAP flap surgery since I have large hips and thighs, but he has only talked about doing the DIEP flap surgery or implants. He has other plastic surgeries (not breast reconstruction) he specializes in at his practice. I have never considered going out-of-state for medical treatment, and my work schedule is a concern.

I just want to know your thoughts about my situation and if I should go forward with my current doctor. I have found your website to be a great source of information and encouragement. God bless you for all your doing to help!


Thanks for reaching out to us.

The PAP is our 3rd line flap (after DIEP and SGAP). It is ideal in some situations, and yours may well be one of them, but it does have a few potential downsides:

  1. In MOST people, the flaps are fairly small, typically 200-300 grams (but you may be an exception);
  2. The profunda artery perforator, while usually present, is occasionally absent or very small. The preoperative MRI angiogram will determine this; and
  3. If you have a donor site complication, such as dehiscence (ruptured wound along a surgical incision), it can be difficult to manage due to the location and motion in the area.

One good thing about the PAP in contrast to the TUG (which we do not use) is that it involves few if any lymph nodes, and thus the risk of lower extremity lymphedema is minimal. We usually recommend the DIEP if you have a good donor site, but many people do not. Our DIEP success rate (after around 1350 flaps) is 99.0 percent.

The SGAP, our next choice, is an extremely good flap, although the dissection is difficult, which is why it is not routinely performed in most places. This flap can be quite large, occasionally in excess of 1000 grams in certain individuals. We have completed about 270 of these flaps, most simultaneous bilateral, with a success rate of 94.8 percent. We firmly believe in the team approach, which was taught to us by Dr. Allen, and we would not have the results that we do without it.

At The Center for Natural Breast Reconstruction, we never do flaps without two equally competent microsurgeons present.

Thank you again for your inquiry. Please contact us if you need anything, and we would be happy to speak with you by phone, or see you in-person for a consultation at any time.

Richard M. Kline, Jr., MD, East Cooper Plastic Surgery, The Center for Natural Breast Reconstruction, Phone: (843) 849-8418, Fax: (843) 849-8419, 1300 Hospital Drive, Suite 120, Mount Pleasant, S.C. 29464.

Seeing Friends and Family for the First Time Since Surgery

breast surgery visitorsThere is nothing like a support system to help you get through cancer diagnosis and
treatment. After you have surgery, your family members and friends will probably want
to stop by and visit. They may also want to cook for you, clean your home or just keep
you company as you recuperate.
While seeing friends and family can be a positive part of your recuperation, it can also
be overwhelming. You might not feel up to having company or you might feel self-
conscious about how you look. Here are some tips on how you should handle seeing
friends and family for the first time since surgery:
1. Talk About it Ahead of Time
If friends and family know when you are having surgery and want updates, use that time
to tell them what you expect about having visitors. For example, you—or the person
updating everyone for you—can say, “Mary is out of surgery and recuperating. If you’d
like to stop by and visit, please text or call us ahead of time so Mary can pick a time
when she’ll be up to enjoying your visit.”
2. Limit Time
Once you know when someone is going to stop by, it’s okay to limit how long they
spend with you. Visits can be fun, but they can be tiring. Let your friend or family
member know how much time you have to spend with them before you have to lay
down, change a dressing, etc. This is especially important for those who just drop by
without calling ahead of time. Feel free to say something like, “Thanks so much for
stopping by to see me. We can chat for a bit and then I’m going to lay down for a nap.”
3. Keep the Sick Away
You just had surgery and should be doing what you can to avoid getting sick. Let your
guests know that if they are germy or feeling under the weather in any capacity, they
should change their visit to another time. If they show up sick, it’s okay to tell them
you’re not feeling up to their visit and plan it for another time. For example, you can say,
“I’m excited to see you now that surgery is over, but it sounds like you’re getting a cold.
Can we reschedule your visit until you’re feeling better so I don’t catch it?”
4. Say No When You Need To
It’s okay to say no if you’re not up to having visitors on any particular day or only want
certain family members or friends to visit. This is your surgery recuperation and,
honestly, you have the right to handle it however you want. Simply say, “Thank you so
much for caring enough to visit, but I’m really not feeling up to guests right now. Can we
get together at another time?”
5. Don’t Let Feeling Self-conscious Get in the Way of Enjoying Visitors
Some women are self-conscious about having visitors, especially after surgery. While it
is normal to feel this way for a little while, think about who is visiting you and whether
they are worried more about how you look or how you feel. In most cases, your friend or
relative is there to see you and do what they can to help. They probably don’t care
about how you look, so it’s best to remind yourself why they are really there.
To learn more about natural breast reconstruction and find out if it might be the right
choice for you, contact The Center for Natural Breast Reconstruction at or toll-free at 866-374-2627.

Ask the Doctor: Phase 2 & 3 DIEP Procedure

diep flapQuestion: Hello! I’m currently seeking a surgeon for phase 2 DIEP. My plastic surgeon
here did a great job for phase 1, but doesn’t seem interested in correcting what I think is
a problem for phase 2. My breast size is currently a DD and I do not like the size. They
are heavy and my back hurts by the end of the day. I’m seeking a C cup. Also, my
abdomen is hard and bloated from underneath the breasts to just below my bellybutton.
This hardness makes it difficult to breathe. Is this something you have seen, and
something you could fix?

Answer: For one reason or another, we routinely work with patients who have had
phase 1 DIEP elsewhere, but end up coming to us for the “finishing” work. Of course,
we are delighted to help, no matter who has operated on you, and no matter what
condition you are in. Breast size certainly can be reduced; symmetry often can be
improved; and the donor site usually can be optimized. It is important to remember that
to obtain the optimal result, several procedures are commonly necessary. Typically,
each subsequent procedure decreases in length and complexity as the process
progresses. An average stage 2 scenario would include open revisions of the breast
mounds and donor site, and stage 3 would involve free-fat grafting to further refine the
shape of the breast mounds and lower body. While the initial flap transfer is obviously
the “big procedure,” we believe that the subsequent procedures are absolutely essential
to getting the results most patients to feel confident and pain-free.