Breast Reconstruction After Lumpectomy and Radiation

The below questions are answered by Dr. Richard M. Kline, Jr. of The Center for Natural Breast Reconstruction.

Can I have a breast reconstruction two years after the lumpectomy and radiation?

Absolutely! While reconstruction with implants after radiation (even if lumpectomy and not a whole mastectomy were performed) can often be problematic (if not impossible), the chance of getting a successful reconstruction using your own tissue is very high. In the simplest scenario, it is usually possible to use tissue from the abdomen or buttocks to simply “replace” the breast tissue lost from lumpectomy and radiation.

Alternatively, sometimes a better result can be obtained if the lumpectomy is converted to a mastectomy prior to reconstruction. Finally, if the survivor is in a high-risk group for developing another breast cancer, she may wish to consider whether bilateral mastectomy is advisable prior to reconstruction. Usually reconstructing a lumpectomy defect will require only one side of the abdomen, so if the other side is not needed for reconstruction, it will be removed for symmetry and discarded.

What tips do you share with your patients for them to achieve the very best results from breast reconstruction?

1. Have a positive attitude! Patients who are excited about their reconstruction frequently do very well and tolerate any “bumps in the road” much better.

2. Education. Try to become very familiar with your desired type of reconstruction, both through reading and discussing it with patients who have been through it already. Knowing what to expect allays fears and makes everything easier.

3. If time permits, maximize your body’s fitness through diet and exercise, to the extent that you are comfortable doing so.

—Richard M. Kline Jr., M.D.

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The Benefits of DIEP Flap Breast Reconstruction Over Other Reconstructive Options

diep reconstructionThe below question is answered by Charleston breast surgeon, Dr. Richard M. Kline, Jr. of The Center for Natural Breast Reconstruction:

What are the benefits of the DIEP flap breast reconstruction over other options?

I am going to break this question into two parts.

The first part is what are the benefits of the DIEP flap over reconstructive options using implants?  Let us start with the benefits of implants.  The primary benefit of implant is that the operations are shorter, they are potentially safer, and you do not need to operate on another part of the body. Additionally, implants are readily available, and if you do not have enough extra body tissue somewhere to make a breast, implants may be the preferred choice for this reason.  The advantage of the DIEP flap over implants is that it produces a much more natural feeling, warmer, and trouble free breast (after the reconstruction process is completed).  There is data to suggest that women tend to accept the reconstructed breast as their own more readily if it is made using their own tissue, in comparison to women who have a reconstructed breast using implants.  Additionally, many women feel that they have too much extra tissue in their abdominal area, and they may actually view removing this tissue to make a breast as an added bonus.

The second part of this answer is going to be why is the DIEP flap better than other reconstructive options using the patients own tissue, with the most commonly performed in our practice being the GAP or gluteal artery perforator flap, which is taking the buttock.  The primarily advantage of the DIEP over the GAP is that it is faster, and no position changes are needed during surgery to harvest the flap.  If the patient has adequate abdominal tissue to meet her reconstructive needs, we generally recommend using this as our first line option.  Having said that, however, the buttock serves very well to make breast, although the process is a little more tedious and lengthy.

Would you like your breast reconstruction question answered? Just ask us!



If I Have Had Natural Breast Reconstruction Do I Need To Have A Yearly Mammogram?

diep and mammogramThe below question is answered by Charleston breast surgeonDr. James E. Craigie. of The Center for Natural Breast Reconstruction:

After having breast reconstruction using the DIEP method do I need to have yearly mammogram?  If so, can the pressure from the procedure cause any damage to the tissue or blood vessels used in the reconstruction?

First of all, following mastectomy and reconstruction with your own tissues, a mammogram is routinely not needed on a regular screening basis.  Screening mammograms are only helpful for normal breast tissue; therefore, in our patients we do not recommend that they have regular screening mammograms.  From time to time, people will be seen in follow up for examination and have areas of the breast feel firm or hard and sometimes the oncologist or other physicians will order mammograms to investigate a specific finding.  This would normally be performed after the first and second stages of the reconstruction process were completed and therefore should pose no risk of injury to the blood vessels that were connected to the breast.

-James E. Craigie, M.D.

Do you have a question about breast implants or natural breast reconstruction? Ask the doctor by submitting your questions here.


Your Questions about DIEP Flap Breast Reconstruction Answered

The below questions are answered by Charleston breast surgeon, Dr. Richard M. Kline, Jr. of The Center for Natural Breast Reconstruction:

What are the most common reasons a diep flap will fail?

Specifics may vary from case to case and practice to practice, but all failures involve interruption of the blood supply. This can be caused from a clot forming at the arterial or venous anastomosis, or from a conformational change in the blood vessel which produces “kinking” and subsequent interruption of blood supply. Most surgical teams experience dramatically lower failure rates as their experience expands, and it can get very difficult to determine precise reasons for failure (and ways to prevent it) when failure is a very rare event, i.e., success rates of 98-99%, which is typical for experienced surgeons. The best teams will nonetheless strive, whenever they have a failure, to find some “take home message” which they can use to hopefully further minimize their failure rate.

If you had a failure with Diep on one side does that increase your chances of failing again if another flap procedure were done in the future?

In our experience, no, although in a large enough series it may. We have always been able to use the internal mammary vessels, supplied through collaterals, to successfully supply blood to a second flap after an initial flap failed. Generally speaking, the collateral supply to the internal mammary from one intercostal artery is probably sufficient to supply a new flap. I do think that it is advisable, however, to wait at least 3 months following an initial flap failure before attempting a second flap, as this gives time for tissue edema to resolve, and serum protein levels to return to normal.

My Diep Flap failed on one side. I wound up with a silicone implant on the right side, and it is not healing quickly. What should I be watching for ?

That depends on what you mean by “not healing quickly.” If you have an unhealed wound, then something is really wrong, and you should see your surgeon. If it simply hurts or “doesn’t feel right,” then it may improve with time, or you may be developing capsular contracture (a common problem with implants), which may not go away. If you still want a flap, you may well still be able to have one from your buttock or elsewhere.

Do you have a question for the Charleston breast surgeons at The Center for Natural Breast Reconstruction? We’d love to hear from you.


Low-Fat Ways to Spice up Any Dish

low-fat dishesOne criticism of low-fat diets is boredom and blandness, because fat adds flavor to meals. Spices and condiments can add all the flavor you want without adding extra calories or contributing to health issues.

When using spices, don’t be afraid to experiment. One way to know if a spice is right for your dish is to do the sniff test. Smell the spice, and you’ll be able to tell right away if it’s right for the meal you’re planning. We’ve searched our spice rack to bring you some fresh ideas to create new flavors without fat.

Meat and poultry

Even low-fat cuts of meat benefit from thoughtful use of spices. Try tenderizing and then marinating your meat overnight before cooking. You can find plenty of commercial marinades in a variety of flavors, but some have high fructose corn syrup or excess sodium, so be sure to read all labels. Try using steak sauce, beer, wine, soy sauce, or fruit juice. Marinade recipes abound online and provide variety.

Spice and seasoning blends such as Mrs. Dash, Nature’s Seasons, and seasoned salt and pepper take a simple cut of meat or poultry and make it taste like a gourmet masterpiece. Instead of simply sprinkling the spice, try rubbing it into the meat directly. Single spices that pack a flavor punch include garlic, dill, sage, rosemary, and cinnamon. You can also add vegetables during cooking, such as mushrooms and onions.


Lemon pepper and fresh-squeezed citrus fruit enhance seafood, as do low-sugar, low-fat tartar sauce and cocktail sauce. Most spice companies produce spice blends specifically for seafood, and for a real treat, add a little parmesan before baking.


Veggies are an important staple of a low-fat diet because of their fiber and low calorie count. Spice blends are delicious on vegetables, and some spices that add a unique flavor include marjoram, nutmeg, onion, and cinnamon. Think outside the box when using spices. Perhaps an apple pie or pumpkin pie spice would work with squash. Instead of butter and sour cream for baked potatoes, try some low-fat plain yogurt with chives, salt, and fresh-ground pepper.

Be sure to keep an eye on sodium, high-fructose corn syrup, and hydrogenated fat when you’re spicing up your food. The main rule in using spices is that there is no right or wrong. Use the spices you like in combinations that make sense to you. You never know what delicious spice blends you’ll create.

Do you have any low-fat ways to spice up a dish? We’d love to hear about them in our comments section!

A Journey You Don’t Have to Take Alone

breast cancer survivor

Shirley's book cover

Dear Sister in this Journey,

My name is Shirley. I have just undergone a double mastectomy and breast reconstructive surgery as a result of having breast cancer. I am one of the fortunate ones who did not have to endure chemotherapy, as well.

My cancer was in my left breast, but I chose to have a double mastectomy to mitigate future risk of recurrence.  Based on the reputation and firsthand knowledge I had of Dr. Kline and Dr. Craigie, I chose the Center for Natural Breast Reconstruction to take care of my small, but precious bosoms.

Once the decision was made to move forward with bilateral DIEP reconstruction surgery, I was given a patient handbook that provided information about what to do pre and post surgery. No offense to the medical team that put together a technically comprehensive document, but boy did they leave out a lot of information that would have been helpful! The kinds of things that, really, only a patient would know.

So, I thought I’d write about my personal experiences to share with others—maybe it will help those who are about to undergo a DIEP reconstruction procedure to be more prepared and know more about what to expect. If you would like a copy of my booklet, get in touch with the center at, they’ll be happy to give you one.

It’s all from my perspective and I hope it helps in understanding what will happen. And I hope it helps keep others positive as they face the surgery.

Good luck on your Journey!

Most sincerely,

Shirley Trainor-Thomas

Breast Cancer Survivor

Hodgkin’s Lymphoma Survivor

Reconstruction Success Story

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What Are My Options If I Develop Lymphedema?

I’ve had breast cancer and developed lymphedema after my mastectomy.  I recently heard about Lymph Node Transfer surgery.  Does it work?  I’m scheduled for a DIEP breast reconstruction, can it be done at the same time?

Question answered by Dr. James Craigie:

Lymphedema is a very difficult problem that results when a patient has had breast cancer and has to undergo surgical removal of the lymph nodes under the arm as part of their surgical treatment for breast cancer. There are other causes of lymphedema but our specific interest has been in patients who have had breast cancer.

Lymphedema can be a very debilitating process; it remains a terrible problem worldwide, for all types of reasons. There is still much to be learned about why some people develop lymphedema and others do not. It appears that lymphedema is directly related to several factors in our breast cancer patients. It is directly related to having the lymph nodes removed from under the arm and seems to develop from the scarring that occurs under the arm following mastectomy and / or axillary dissection.

Undergoing radiation of the arm or axilla increases this risk. However, there are many people who undergo removal of the lymph nodes and radiation that do not develop lymphedema. There are also people who have mastectomy, have lymph nodes removed followed by radiation, and don’t develop lymphedema until many years after their surgery. That is the main reason that patients are warned to pay particular attention to their arm if they have had removal of any lymph nodes.

It is also possible that someone could get lymphedema even after simply having a sentinel node removed. A sentinel node procedure (lymphadenectomy) is a way to examine the lymph node without having to remove more than one or two. The whole idea of examining only the sentinel node is to lower the risk for lymphedema, but even with the sentinel node procedure, there is still a chance of developing lymphedema. Our practice became interested in options to help breast cancer patients with lymphedema as we see many who are suffering from the symptoms of this process while undergoing breast reconstruction.

Our practice specializes in microsurgical free flap breast reconstruction utilizing skin, underlying tissue, and microscopic blood vessels that transport life-giving blood to the reconstructed breast. This procedure is commonly referred to as the DIEP if using the abdomen or a GAP if using the buttock tissue. The muscles of the abdominal wall are left intact as it is the removal of the muscles of the abdominal wall that can lead to problems in the donor area, like hernias and bulging, as well as a more involved extended recovery. The lower tummy wall is the most common area that we transfer and it’s also an area where lymph nodes are present. Therefore, over the first decade this surgery was being done, we would encounter lymph nodes in the area of the blood vessels, as well as fatty tissue.

It became obvious that we could transfer lymph nodes on the blood vessels as we refine our technique for microsurgery. Due to the lack of effective treatment for lymphedema, for years surgeons doing perforator flaps have taken on this challenge and are trying to come up with ideas and techniques to treat it. We began doing an extensive amount of research, spanning the globe, looking for information on procedures that may help these patients. In 2005, we formed a group known as the Group for the Advancement of Breast Reconstruction, known as GABRs, and we included members throughout the world who had had a unique experience with our type of breast reconstruction.

We encountered one individual who had 15-years of experience with what is now known as “vascularized lymph node transfer” for the treatment of lymphedema. Initially, Dr. Robert Allen had attempted lymph node transfer during breast reconstruction and the biggest concern was how to transfer lymph nodes from one area of the body to treat lymphedema but not to create lymphedema in the donor area. In 2006, the GABRs met in Beijing, China and invited Corrine Becker, a surgeon from France who had a long history of experience with vascularized lymph node transfer.

She presented her work and through communication and travel to Paris to work with her, members of the GABRs group began to gain experience and learn more of her technique. The biggest hurdle that we were able to overcome was learning how to select the lymph nodes that could be removed as the donor lymph nodes and use those for breast reconstruction without causing lymphedema of the leg. We spent an extensive amount of time discussing her techniques and reviewing her results, as well as her publications.

We then made arrangements for her to travel to South Carolina and actually performed surgery on our own patients with her as an assistant surgeon. Since that time we have been very encouraged by the results with vascularized lymph node transfer as an effective treatment for reduction of the symptoms of lymphedema. We feel very excited but yet are very cautious about all results. It is important that patients realize that this procedure is still evolving and that there are risks involved, but to date we have had very good results and no serious complications.

Improvement of symptoms with vascularized lymph node transfer can occur immediately; however, they also may take up to 2 years to be appreciated. In most of our patients, the indicators of success are different. For the majority, the goal was to improve the edema, lessen the need to wear compression garments on a regular basis, and to eliminate the risk for frequent infections, which are the typical problems that those affected by lymphedema experience.

In order to lower the risk for complications and to closely study our results in conjunction with other colleagues who perform this procedure, we prefer to perform vascularized lymph node transfer as an isolated procedure. It can be done at the time of breast reconstruction; however, there is a chance that some people with mild lymphedema who undergo breast reconstruction may have improvement without lymph node transfer. Therefore, in order to closely study our results, we perform the breast reconstruction first followed by vascularized lymph node transfer as the second step. When the results are complete, we can determine whether it was the reconstruction or the transferred lymph nodes that gave the end result. It is important again to reemphasize that the main risk for of the surgery is that the transfer may not work. It is possible that if the transfer did not work resulting in more scar, the lymphedema could worsen.

Thankfully, to date, we have not experienced this complication. Other complications are damage to the blood vessels under the arm or the nerves under the arm. Therefore, our preference is to have an oncologic surgeon, who performs axillary dissection, release the scar under arm.  At the same surgical setting, after the scar is released, we perform the transfer by removing very specialized lymph nodes from the outer and lower abdominal wall or outer upper leg. We preserve the lymph nodes of the inside leg. These are the ones that drain the lower extremity and therefore, we feel that the risk for lymphedema of the donor area is reduced.

At this point, we have received some very exciting results along with some mixed results and continue to follow our patients very closely. We have had no patients with any serious complications and no patients at this point with lymphedema of the donor site. We are hopeful that the future holds vascularized lymph node transfer as an effective option for people with lymphedema following breast cancer surgery.

We plan to continue to devote and focus our energies on a surgical solution while simultaneously not exposing people to excess risk of additional problems. Once again, we do have to admit that the surgery, although giving some promising results, is  still evolving at this point and we choose to proceed with caution in the best interest of our patients.

—James Craigie, M.D.

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