Ask the Doctor – DIEP Flap

diep flap

Q:  I am weeks out from a unilateral DIEP flap procedure on my right side. Regarding the tightness and cramping in the abdominal area, is there any type of stretching or massage that can be done to speed healing and/or alleviate discomfort? Also, when can I begin to use moisturizers for scar reduction, and what type would you recommend?

A:  Good afternoon, thank you for reaching out to us. Those are great questions! Who was the plastic surgeon who did your DIEP procedure? It might be best to reach out to your surgeon about these questions since every practice has different recommendations. We tell our patients to leave the abdominal incision alone – to let it heal on its own – so we often discourage patients from doing any serious stretching or massage until a few months after surgery. It is OK to try standing up a little straighter each day, but you never want to force it. The tightness and discomfort will resolve on its own over time with little intervention. As far as the scars go, a lot depends on whether your surgeon feels you would benefit from having the abdomen redone at a later stage to remove scar tissue, lower the incision or remove extra skin for an aesthetically pleasing result. If you have the incision reopened, there is no reason to worry about the scars now. If you do not intend to revise the abdominal incision, then we recommend waiting closer to at least 2-3 months post-op before using any scar products.

I hope this was helpful. Please let us know if we can answer additional questions for you and we wish you the best in your recovery. Have a great day!

Audrey Rowen, PA-C, 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.

Q&A: Ask the Doctor

Q: How is natural breast reconstruction done and what is the cost? Also, how long is the recovery period? 

A: Thanks for your question, my name is Audrey and I am one of the Physician’s Assistants with the Center for Natural Breast Reconstruction. I will try to give you some basic information and please email or call if you have more.

There are three common options for natural reconstruction—DIEP, PAP and GAP:

  • DIEP stands for Deep Inferior Epigastric Perforator, and the tissue comes from your abdomen, like a tummy tuck. We never take muscle—only the fat and skin—and then we close up the abdomen similar to the closure for a tummy tuck. The tissue is detached from your body and then placed in the breast pockets. The blood supply to this flap is traced out and dissected, and then the tissue is transplanted into the breast skin envelope. To keep the flap viable, microsurgery is performed to restore its blood supply by attaching its blood vessels to recipient blood vessels in the chest. This flap requires specialized operating room equipment and postoperative personnel. Some skin on the flap is kept as a skin paddle to allow us to monitor the flap’s color, temperature and vessel signals. That skin paddle may be removed at a subsequent stage of surgery in certain patient situations. DIEP is the most commonly performed free flap reconstruction and has the highest success rate.
  • PAP stands for Profunda Artery Perforator. The procedure is the same as above, but it uses tissue from the thighs instead of the abdomen. Often, it is taken from the back and/or inner thighs, and we typically take a small amount from each thigh to make either one or two breasts. The recovery takes a little more time since you would have two donor sites instead of one—but it is very achievable. The risks are the same as with DIEP as is the procedure of connecting the blood vessels through microsurgery.
  • GAP stands for Gluteal Artery Perforator, and the donor site is the buttocks. Depending on whether you need one breast or two, we take only fat and skin from each side of the buttocks to make into breast mounds using the same process as the DIEP. This also has the same risk, can have more than one donor site, and requires repositioning during surgery since we are working on each side of your body.

For each of these procedures, the surgery time is anywhere from 5 to 10 hours with an average of about 7 to 8—it depends primarily on whether you need mastectomies; whether you have had previous reconstruction procedures; and on your personal anatomy in terms of how difficult it is to find and connect your blood vessels. We keep patients in the hospital for three-four nights. Out-of-town patients are asked to stay in the Charleston area for a full week following surgery so we can check in on them, and hopefully remove breast drains, which prevent blood and lymphatic fluid from building up under the skin, before you head home. We provide a list of hotels that offer medical rates to help you control lodging costs. Patients have one drain per breast and then one drain at each donor site. Breast drains are removed within 6-7 days post-op and the donor site drains are in for 2-4 weeks, depending on the site. We require a special MRI called an MRA (magnetic resonance angiography) of the donor area before surgery to look for where your blood vessels are located. We request this be done at Imaging Specialists of Charleston as they have the right equipment and outstanding radiologists who use a specialized protocol to read the MRA and know exactly what to report to our surgeons.

If only a cancer-side mastectomy was completed, the other breast may also require augmentation, lifting, reduction or some combination thereof to establish symmetry.

Breast reconstruction is a staged process with a minimum of two surgeries, with each subsequent surgery getting smaller, and requiring less recovery time. The first stage requires three-four nights in the hospital, and subsequent surgeries typically require a one-night hospital stay. Second stages can be a minimum of three months after the previous surgery (often six months after if you have had radiation), or can be spread out further as needed to fit in with your schedule. The recovery is about six-eight weeks, and requires you to keep your arms close to your sides, no heavy lifting and no high-impact activities. You will, however, be up and walking around and able to do most basic activities with some restrictions. Driving is not allowed for at least the first few weeks. Some patients can go back to work after six to eight weeks—maybe sooner—depending on the job they have.

As follow-up appointments go, within a week to 10 days after the first surgery, you are typically cleared to head home and need not see us again until right before your next surgery stage. If you have a local breast surgeon or plastic surgeon close to home, we recommend following up with them, and we do frequent telephone/email/patient portal outreach to check in. We are always happy to see you in the office if you wish to make the trip.
Our office also does expander/implant reconstruction, but it is harder for patients out-of-state because of the number and frequency of follow-up appointments needed in the first few weeks to months after surgery. If you are interested in hearing more about this option, please let me know.

I hope this information helps to answer your questions and give you a better idea of your natural breast reconstruction options. We are happy to continue answering questions via email or phone calls, and we would love to set up a consult for you to come meet us in the office at a time convenient for you. We often like to gather more health information before you make the trip to make sure that one of these options could work for you. That information includes:

  • Breast cancer details (which breast, when were you diagnosed, what type of cancer is it, do you need radiation?)
  • Mastectomy/reconstruction details (have you had lumpectomy, mastectomy, was it skin/nipple-sparing, did you have any reconstruction done already?)
  • Abdominal surgeries (have you had any major surgeries with large scars across your belly, do you have enough tissue to use?)
  • Medical history (any history of clotting disorders, DVT/PE blood clots, problems with anesthesia, diabetes, obesity, etc?)

Once you have a breast cancer diagnosis, insurance is supposed to cover the cost of breast reconstruction. We have no control over your personal deductibles or out-of-pocket maximums—everything is billed as reconstruction through your insurance. Using your own tissue for reconstruction is not a simple or low-cost procedure; however insurance typically makes it affordable. We are in-network with most major insurers and can usually negotiate a one-time contract with those we are not.

If you want to provide your insurance information, we’re happy to investigate your benefits for you and assure your insurance will cover any procedure you choose. Our office manager, Gail, could give you detailed information about the costs and once we have more information from you.

Please call us or email any questions you have with information/details from above. We look forward to speaking with you soon. Thanks and have a great day!

Audrey Rowen, PA-C
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, SC 29464

Q&A – Ask the Doctor

I have an implant from reconstruction 7 years ago. I do not have breast symmetry as the other breast was a TRAM flap reconstruction. I would, however, like to have symmetry – how can this be achieved?

Great question! You have several options to improve breast symmetry. We could simply “fat graft” the TRAM flap reconstruction to improve the size and enhance the shape of the breast mound. In fat grafting, fatty tissue is removed from other parts of your body – usually your thighs, belly and buttocks – by liposuction. The tissue is then processed into liquid and injected into the breast area to recreate/enhance the breast. This technique is especially helpful when trying to improve the symmetry between an implant reconstruction and autologous reconstruction.

If your implant is currently under the muscle, this can be revised. The implant can be re-placed in front of the muscle with a full ADM (Acellular Dermal Matrix, specially preserved cadaver skin – AlloDerm® is most commonly used brand) wrap. This allows much better control of implant position, and often helps create better projection and shape. The main complication is that you can sometimes see more rippling of the skin than you typically do with an under-the-muscle implant, but not necessarily. It is also possible that simply revising your current implant reconstruction could produce improvement, but we have less control with that method. 

Finally, it may be possible to have the implant replaced with your own tissue. You might consider using another area of the body, such as the buttock or thigh, to replace the implant completely. One option would be the SGAP (Superior Gluteal Artery Perforator). Breast reconstruction with the GAP flap involves moving a segment of skin and fat from the buttock to recreate a breast mound shape after the removal of the breast tissue (i.e., mastectomy defect). This involves the disconnection of the tissues from the gluteal muscles and surrounding gluteal tissue. (We DO NOT take the muscle.) The tissue is then transplanted into the breast skin envelope. To keep the flap alive, its blood supply must be restored by microsurgery, a procedure that attaches its blood vessels to recipient blood vessels in the chest. 

I hope this information helps. Please let me know if you have any further questions. 
Lindsey Weaver, FNP-C
East Cooper Plastic Surgery

The Center for Natural Breast Reconstruction

Phone: (843) 849-8418

Fax: (843) 849-8419

Ask the Doctor

breast implants

Posted Question:

I had breast reconstruction with under-muscle implant in 2003. The implant was replaced in 2017 but the result has left me very uneven.

I feel that my prior surgeon didn’t take into account the proper shape and size of the breast to match the other breast. He simply measured across the breast, so I have an implant that lays beyond the center of the chest wall and is too flat. It doesn’t fill my bra cup so I have to wear a prosthesis. I trusted him and didn’t look for information about under muscle prosthesis.

Many women have asked my advice about implant procedures. I am extremely unhappy with this result but, at 68 years old, I will have to live with it for the rest of my life. I hate my result and want to be able to help others get more information in order to make sure their doctor is using proper forms/prostheses.

What can be done for a better result? Did I just make a mistake by not seeing multiple surgeons? He was my original surgeon and I was fine with the first implant. It became constricted so we did the replacement. Had I known I would have had this result, I would have just started wearing a prosthesis and skipped the misery of another surgery.

– Pat


Hi Pat,

I’m sorry to hear you are disappointed with your newest implant. I’m not sure I understand what was different from the previous implant. If the first was constricted and the second one was to replace the first after releasing the contracture, can you tell me what was done differently? If you liked the first one, I’m sure there is a chance to correct your problem. I think you should find out if the two implants are the same size and type. If the same surgeon did both surgeries, then he/she should have that information. If they don’t match, perhaps you need to replace the new implant with one that is a closer match to your first one.

Thanks for your question let me know if you have more information. 

-Dr. Craigie

Q & A

Posted Question:
I had a Latissimus dorsi double mastectomy reconstruction in 2013. I have since lost a lot of weight – about 50 pounds – and I now feel that my breasts are too big. I feel really self-conscious. Is it possible to have a reduction after this type of surgery?

Dr.’s Answer:
Yes, it is usually possible to do a reduction in some fashion. Latissimus flaps are commonly used with implants, and it’s possible your implants could just be downsized. Alternatively, it may be better or necessary to remove some flap tissue as well. It would be difficult to make more specific recommendations without doing an actual exam and getting a few more details, but I’m willing to bet you have some good options.

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 – I Recently Received Concerning Results on a Mammogram. Should I Wait the Recommended 6 Months to Discuss Implant Removal or Begin the Process Now?

pink rose

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

Question: I am a 61-year-old female with breast implants that were placed in 1986. I have been pregnant 6 times, 5 c-sections and one miscarriage. 2 infant deaths and 3 living children. I was able to breastfeed 4 of my children. Approximately 4-5 years ago I had an abnormal mammogram.  (I am in the process of obtaining those records) I underwent an ultrasound to the left breast and was informed that everything was “ok”. Following mammogram was normal. I retired from nursing 2 years ago and moved from Virginia to West Virginia. My most recent mammogram 5/2/2018 stated “There are bilateral breast implants. There is mild to moderate residual parenchyma tissue bilaterally. There is an asymmetric parenchyma nodule in each breast anteriorly, most likely benign. Six month bilateral mammogram advised to confirm stability.” Doctor, I’m not sure I should wait another six months or peruse implant removal and breast tissue removal. You know us nurses “overthink”. I’d like to know if you have another suggestion vs wait for the next mammogram. Thank you so much for you’re valuable time and consideration.


Thank you so much for your question. It sounds like you are getting frustrated, and it’s easy to see why.

We don’t actually treat breast cancer per se, we just do reconstruction, so I can’t actually recommend a particular imaging technique or schedule. I can, however, recommend that you see a surgical oncologist who treats breast diseases (if you haven’t already), as they often have a good “feel” from experience for how to manage these type situations. They see many, many images, and, unlike radiologists, later correlate many of those images with what they see in surgery, which gives them a unique perspective. He or she may recommend an MRI or ultrasound, or may just agree with your previous recommendations, but even that might be reassuring.

Thanks again for your question, and have a great weekend!

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

Ask the Doctor – What Can Be Done To Fix a Previous Radiated Breast with Implant?

This week, James E. Craigie, MD, of The Center for Natural Breast Reconstruction answers your question.

Question: What can be done for a 2004 radiated breast with implant. As common, it has encapsulated to a high degree and is painful, misshaped and raised, looking very unnatural. Thank you

Answer:  Without question, the course of action most likely to work is to remove the implant and proceed with reconstruction using your own tissue. If you still have breast tissue remaining, it can be removed by a breast surgeon at the same time that your healthy tissue is transferred.

The most common source for the new tissue (the “flap”) is the abdomen, which is usually harvested as a DIEP flap. If the abdomen is not available or not adequate, then the buttocks (“sGAP flap”) can often be used. Our success rates over the last 13 years are 99.07% using the DIEP flap, and 95.7% using the sGAP flap. The initial surgery requires on average 4 nights in the hospital, but subsequent stages are much easier.

If you can’t or don’t want to use your own tissue, there are a couple of other options which may offer some hope, although the chances of success are nowhere near as good as using your own tissue. One is a course of hyperbaric oxygen, which has been shown to bring new blood vessels to the radiated tissue.

Another potential option, which must be regarded as experimental at this point, would be to completely cover the implant with acellular dermal matrix, or “ADM” (Alloderm being the most commonly used variety). This material has some efficacy in preventing contracture, but the effect would be less pronounced in radiated tissue.

Hope this helps. I would be happy to discuss your situation further with you, 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 – Can I Have Large, Under Muscle Implants Replaced With Smaller Ones? Will This Make Them More Comfortable?

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

Question: I’ve had my breast tissues removed and I now have implants. They are under my muscles, too large and very uncomfortable. Is there anything you can do to fix this and make a smaller implant? I am very unhappy with the way my breasts look, This is contributing to already very low self-esteem issues. Can you help me? What are my options?

Answer:  There is an excellent chance that we can help you. The country is currently undergoing a paradigm shift in implant-based breast reconstruction, with more and more surgeons placing the implants in front of the muscle, rather than behind. This allows for numerous potential advantages, and few disadvantages. We have been converting patients with unsatisfactory sub-muscular reconstructions to reconstructions in front of the muscle for a few years, with generally good-to-excellent results.

Another option is to remove your implants and re-build your breasts only with your own natural tissue, usually from tummy or buttocks. This is a larger operation than implant reconstruction but obviously results in an even more natural result.

I would be happy to discuss your situation further with you by phone, if you wish, or see you in my office when convenient.

Thanks for your question.

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