Ask the Doctor- I Am Not Eligible For Diep Surgery. Can I Have Gap Surgery At The Same Time As I Have Both Breasts Removed?

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

Question:  I learned from my doctor at MUSC yesterday that I do not have enough fat and am therefore not a candidate for DIEP surgery. He suggested I make an appointment with you before my surgery for mastectomy.  I do not have clean margins in my right breast after lumpectomy and I have chosen to have both breasts removed. If I am eligible for GAP, is there any difference with having it done at the same time or later? I am 70 years old, healthy, an avid tennis player, with no chemo or radiation needed.

Answer: We have done about 300 GAP flaps with a 95.7% success rate. There are actually advantages to having the GAP surgery done at a later date, as it is a much more involved and lengthy surgery than the DIEP.
I would be delighted to see you at any time, evaluate your donor sites, and discuss options in more detail.

Thanks for contacting us, and I look forward to hearing from you.

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

Ask the Doctor: Will Scar Tissue Buildup Be A Concern With The Gap Flap?


<alt="pink lotus flower"/>This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your questions.

Question: My wife had a double mastectomy 10 years ago. At that time she had latissimus surgery to fill in her breasts. Since then, we’ve had numerous surgeries, about every 2 years, due to scar tissue building up in 1 of the 2 (or both) breasts that causes tightening and even pain. Will scar tissue buildup be a concern with the Gap Flap? 2. Regarding the Gap Flap procedure, what is the rate of failure that you experience with any of the 4 surgery sites (2 buttocks, 2 breasts)? Thanks.

Answer: Hi — I’m assuming your wife has implants under the latissimus flaps, which would explain the buildup of scar tissue. GAP flaps are generally large enough to make a breast by themselves (obviously, sizes differ among different people), so implants are not needed, and internal scar buildup would be a very rare event. We last calculated our statistics in October of last year. Over 10 years, we did 217 GAPs, 49 as unilateral, 168 as simultaneous bilateral. The GAP flap survival rate was 97% overall. All of the failures were in bilateral cases, but no patient lost both flaps, yielding a simultaneous bilateral flap survival rate of 96.4%. We have done quite a few GAPs since then with no failures (most recently a simultaneous bilateral last week), so the current statistics are actually a little better than that. We don’t bury flaps, and therefore can’t miss (or ignore) a failure, so these are ironclad statistics that could survive a GAO audit. To our knowledge, only Dr. Allen (who invented breast perforator flaps and trained the rest of us), his ex-partners in New Orleans, and ourselves actually do simultaneous bilateral GAP flaps on a routine basis. I’d be happy to discuss your situation further if you wish, just call or email.

Dr. James Craigie

Center for Natural Breast Reconstruction

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

What can I expect during a DIEP / GAP free flap breast reconstruction?

This frequently-asked question comes center stage again for 2014, and we At the Center for Natural Breast Reconstruction, we are here for you and your questions. Feel free to Contact Us anytime!

What are the stages involved in DIEP / GAP free flap breast reconstruction?

The stages of breast free flap reconstruction at our facility can vary depending upon what time in the treatment process we initially meet the patient. The best scenario occurs when the treatment is mastectomy, alone. In those patients, we are able to discuss a skin and possible nipple-sparring mastectomy. This approach means that there is a possibility that the patient would only require one step, although most women are not opposed to a second stage when liposuction, “body contouring,” is involved. Many patients do not have this opportunity, so for them, this process usually involves three stages.

The first stage, being the most involved, is the “technical” stage—the microsurgery element.  After meeting with one of our physicians and discussing the best donor site tissue (tummy, buttocks or inner thigh) the process begins and we relocate the tissue to form a new breast mound. Only the donor site fatty tissue and the blood vessels that nourish that tissue are removed. NO muscle is sacrificed. This blood supply is separated from the body and reconnected to the vessel in the chest wall that once nourished the native breast.

Since the new breast mound is solely relying on the tiny vessels we reconnected initially, we keep you in the hospital for four days to monitor the blood flow into the relocated tissue. This stage of the procedure can require about a six to eight week recovery period, depending upon healing. It varies greatly when women are feeling well enough to return to work or resume the activities they enjoyed prior to surgery.

About three months after Stage One, we may begin discussing each specific patient’s Stage Two.  Three months is the minimum amount of time that we allow. In some cases, we recommend waiting slightly longer than three months (example: radiated tissue, healing issues, or unilateral reconstruction).

Stage Two could be described as the “plastic surgery” side of the breast reconstruction. This is the stage where we fine tune everything that was accomplished in the first procedure, and attempt to improve upon your concerns and how clothes fit. During the first stage, we try our best to achieve symmetry between the two breasts, but sometimes the doctors are limited on the shaping that they are able to accomplish because of the microsurgery portion. Stage Two is about improving symmetry between the two breasts, re-building a nipple if needed, and improving the donor site. This is usually an outpatient hospital procedure but, on the rare occasion, the patient may need to stay overnight.

The procedures performed during this stage vary from person to person, according to their needs. Recovery time varies, too. It could be as little as a day or two weeks, according to the procedures that need to be performed to achieve your desired result.

Three months after your second stage, it is time for your areola tattoo, Stage Three. Women who were able to save their nipple / areola complex at Stage One do not require this stage and are complete at Stage Two. The tattoo is performed in the office under local anesthesia. There is really nothing to this phase. You may drive yourself to the office and expect to be out in one to two hours. It’s really a lot like a social visit and other than exposing your newly tattooed area to public bodies of water like swimming pools, lakes or beaches, there is not much aftercare to speak of. Simple local wound care is all that is required. The risks are minimal and infection and complications are rare.

Many women think of the tattooing as the final hurdle. The best comment I’ve heard was from a woman who stated that after the tattoo healed, she got out of the shower one day and upon looking in the mirror, felt like everything was behind her.

A few other things to keep in mind:

  • Scars look their worse at about three to six months, from that point they should steadily lighten and become less noticeable. It’s hard, but be patient. It takes a while for scars to fully mature and everyone is different.
  • You’ll meet with your surgeon and discuss the best case scenario for you and how to get your breast reconstruction accomplished in as few steps as possible. It is important, even though you are plagued with so many other physicians and concerns, to meet with your surgeon before you have your mastectomy to keep the surgical stages to a minimum. At this point, we’re able to discuss with you your breast surgeon incision site techniques and helpful concepts to improve you final outcome. We also ask your surgeon to weigh the amount of breast tissue removed. It helps for our reconstructive surgeons to know how much breast tissue was removed with your mastectomy and use that number to work toward  rebuilding your new breast, hopefully achieving a symmetrical result earlier in the process to minimize the number of surgical stages.
  • Most patients after the first stage have breast mounds and feel comfortable in clothing. If they must delay State Two of their procedure to undergo chemotherapy, build up time off from work, or just desire time with their family, they are not on a time restriction. (Do keep in mind your deductable.)
  • Vanity is not even a consideration in the breast reconstruction process and these surgeries are not cosmetic plastic surgical procedures. It all comes down to trying to get your body back together and make you as happy as possible, so you can move forward with your life and not have the reminder of everything that you have been through and overcome.
  • Procedures in the breast not affected by breast cancer are insurance covered reconstructive procedures, too. When patients have unilateral reconstruction, achieving symmetry is a little bit more complicated. We have to let the newly relocated tissue settle and heal. The second stage surgical procedures in this case can include, breast lift, reduction, and / or minor procedures to fine tune and attempt to achieve symmetry between the native and reconstructed breast.

We like our patients to discuss with us the things that bother them about their reconstructive result. There are usually things we can improve upon, whether it’s a local procedure in our office or an additional stage. The three stages described in this piece are an outline to the overall process.

Breast reconstruction cases vary and affect each individual differently based upon a number of factors. Some people require one stage and others two or three outpatient or minor procedures to return their bodies back to where they are comfortable and confident.  After you overcome the first stage, the rest are just fine tuning by standard outpatient procedures and local procedures. It is all about making you as comfortable and confident as possible.

How Long Do I Need to Wait To Have a DIEP Flap Procedure After Radiation?

This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your questions.

Q: How long should I wait to have a DIEP flap after radiation?

A: Radiation therapy is part of the treatment of breast cancer and will affect the results of breast reconstruction. The treatments can miraculously kill some growing cancer cells but they also change the area of the body left behind after surgery.

All of the elements of the body can be affected: blood vessels, scarring, healing function, and appearance.  The effects of radiation occur in two phases. Short term occurs during and immediately after the treatments. Elective surgery at this time is not possible, for obvious reasons. The long term effects develop after the early “burn-like” injury “settles down.” The long term reaction occurs for approximately the first six months.

The experience can be widely different from one person to the next. We have experienced difficulties with the receiving blood vessels after radiation when we did not wait for the body to recover from both long and short term damage. These types of problems could possibly increase the chance for the new breast to fail. Avoiding these problems may be possible by waiting and that is why the long recovery is needed before reconstruction is started.

Dr. James Craigie

Center for Natural Breast Reconstruction

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

At What Point During Your Journey Is It Time To See Our Surgical Team?

time to see a doctorThe below question is answered by Richard M. Kline Jr., M.D., of The Center for Natural Breast Reconstruction.

At what point in the process should a breast cancer patient see a breast reconstruction surgeon?

Opinions on this vary, but I think the prevailing opinion is the sooner the better.  Ideally, the patient would see the reconstructive surgeon even before plans were finalized for treating her cancer.  This is because many times several options are available to the patient, and she may not fully understand the implications of the various options available to her unless she understands what reconstructive options are available in each setting.

A Little Bit About Our Surgical Team :

Co-directors Dr. Richard M. Kline and Dr. James E. Craigie are certified by The American Board of Plastic Surgery. Both surgeons have trained under Dr. Robert J. Allen, a pioneer in breast reconstruction using the DIEP, SIEA, and GAP flaps. Dr. Craigie completed a microsurgical breast reconstruction fellowship dedicated to muscle sparing techniques (directed by Robert J. Allen, M.D.). Dr. Kline completed his residency at LSU while Dr. Allen was developing these techniques.

Our entire surgical team is dedicated to remaining at the forefront of breast reconstruction surgery to provide excellent care and results for each individual patient. Because of this commitment, the practice consistently earns referrals from our patients, as well as from other surgeons throughout the United States.

Knowing the RIGHT Questions to Ask:

When searching for a surgeon to perform your microsurgical breast reconstruction, it’s important to ask him or her the right questions.

Below are a few questions to ask:

  • Are you a microsurgeon? Where and by whom were you trained in this specialty?
  • How many microsurgeries have you performed? And how often do you perform them?
  • What is your success rate?
  • Can you arrange for me to speak with some of your patients who have had the procedure I am seeking? (Candidates should speak with people of similar ages and lifestyles).
  • How long do you anticipate I will be under anesthesia for the procedure?
  • How many board certified physicians will be assisting with the first stage of the procedure? Will there be physicians in training (residents) involved with my surgery
  • Will I have to sign a consent that if a physician is unable to complete the procedure, I will have to consent to a TRAM/Free TRAM?

Do you have a question about breast implants or natural breast reconstruction? Ask our surgical team by clicking HERE.

Your Question about Reconstruction Surgery and Lymph Node Transfers Answered

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

Can a one-sided microsurgical reconstruction be done in conjunction (same surgery) with lymph node transfer?

Lymph nodes can be “piggy-backed” on a DIEP flap, but our impression is that that precludes the ideal positioning of eitherthe nodes or the flap. Additionally, we have concerns that the nodes may not be as well vascularized (have as good a blood supply) that way (rather than doing them as their own separate flap), although extra small blood vessels can sometimes be hooked up to the nodes themselves.

Our preference is to just do the autogenous (your own tissue, no implant) reconstruction first, as some patients with lymphedema will improve with this alone. If they don’t improve, we’ve found that a vascularized lymph node transfer fits in very well with the second stage of the breast reconstruction. Of course, it is possible to do a DIEP or GAP with a separate vascularized lymph node transfer in one setting, but that makes a long procedure about 2 hours longer, so we haven’t pursued it.

-Dr. Richard M. Kline, Jr., MD
Center for Natural  Breast Reconstruction

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Dining Out in Downtown Charleston

downtown charlestonDowntown Charleston is a dining nirvana. You can find everything from Southern comfort food to the finest French and Japanese cuisine. Following are some of our favorite restaurants.

Cru Café
Quaint Lowcountry Dining $$$$
18 Pinckney Street, Charleston, SC 29401-2006, (843) 534-2434
Lunch and Dinner

Known for its motto, “Comfort Served Daily,” Cru Café features amazing entrees such as Thai Seafood Risotto, Poblano and Mozzarella Fried Chicken, and barbecued beef brisket. Run by famed Le Cordon Bleu Chef John Zucker, Cru Café has been one of Charleston’s top restaurants since its opening in 2002.

Fine Italian Dining $$$
102 North Market Street, Charleston, SC  29401, (843) 722-6393

Voted Charleston’s Best New Restaurant by the City Paper, Mercato is noted for its incredible Italian dishes, such as Veal Picatta, Housemade Potato Gnocchi, and Prosciutto and Arugula Pizza. Mercato’s atmosphere transports you to Italy with its Venetian plaster walls, fine Italian leather seats, and 60-year-old Italian chandelier.

39 Rue de Jean
French $$$
39 John Street, Charleston, SC 29403, (843) 722-8881
Lunch, dinner

According to its website, 39 Rue de Jean is “a refined French café and bar offering the best in classic Brasserie cuisine.” Enjoy delicious wine from France’s finest vineyards as you dine on Trout Beurre Blanc with almond rice pilaf, Lamb Shank with brandied figs, and Duck Confit with goat-cheese potato croquette.

Wasabi of Charleston
Wasabi Sushi and Japanese Fusion Bar $$$
61 State Street, Charleston, SC  29401, (843) 577-5222
Lunch, dinner

With professional chefs trained in Japan, Wasabi of Charleston is quickly becoming the place to go for sushi and fine Japanese cuisine. You’ll have a difficult time deciding what to order with entrees such as Nabe Yaki Udon and Hibachi Steak and Shrimp and over 45 varieties of sushi and sashimi, including tamago (egg custard) and saba (Japanese king mackerel).

Hominy Grill
Southern (excellent for brunch and breakfast) $$ – $$$
207 Rutledge Ave, Charleston, SC 29403-5864, (843) 937-0930
Brunch, Breakfast, Lunch, dinner

For some good old Southern comfort food, go to the nationally acclaimed Hominy Grill. Everything is prepared with locally sourced, fresh ingredients, and you’ll love the hearty breakfast with housemade sausage and hominy grits for breakfast. For brunch, try the salmon potato cakes with poached eggs, and for lunch or dinner, indulge in the Low Country Purloo, rice casserole with ham, sausage, chicken wings, and shrimp.

Which amazing downtown Charleston restaurants have you tried?

Does Lymphedema Affect Success of Breast Reconstruction?

breast reconstructionThe below question is answered by the team at The Center for Natural Breast Reconstruction:

Does having lymphedema (arm and trunk) affect success of breast reconstruction?

We primarily have experience using perforator flaps for breast reconstruction, so I’ll answer from that perspective. Arm lymphedema does not directly affect breast reconstruction, although there are reports of arm lymphedema improving after reconstruction using your own tissue (such as DIEP, GAP, or other perforator flaps). Trunk lymphedema (including breast), while not affecting the survival of the flap, can result in prolonged edema of the breast skin overlying the flap, leaving the reconstructed breast with a heavy, “wooden” character. We have seen this edema gradually resolve in some patients, however, over a period of up to two years, and it is possible that the flap is actually helping with this.

For more answers to your breast reconstruction questions, visit our Ask the Doctor section of this blog.

Breast Implant Alternatives to Adding Volume, Shape, and Projection to a Breast

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

In July 2010 I had I-GAP reconstruction. The results are awful. Do you have techniques that can work with a flap and add volume, shape, and projection to a partially recreated breast without the use of implants?

Sorry to hear about your problem, but it’s not terribly unusual to not have quite enough tissue after flap reconstruction. That’s actually good for you, because it means we have some experience dealing with this. The most desirable techniques to try, and in what order, depend on your body type and preferences, but here are some options:

1) Fat grafts: Your fat from anywhere you don’t want it can be harvested with liposuction and injected into the breast mounds in the desired areas. Survival of the fat is not strictly predictable, but often a significant amount remains permanently. Several sessions may be required, however.

2) Vth intercostal artery perforator flap: This is a fancy name we give when we utilize the extra roll of skin and fat that a lot of patients have (& hate) on the side of their chest behind the breast, under the armpit. It is left attached at the front, the skin is removed, and the flap is tunneled under the skin at the side of the breast, then across the top of the breast as far as it will reach. Besides making the breast bigger, this technique has the particular advantages of covering the upper border of the pectoralis muscle (often visible just under the skin after reconstruction), and lifting the breast in what is often a very aesthetically pleasing way. The disadvantage is that it adds a scar under the arm from where the flap was taken.

3) Additional perforator flaps: No one likes to hear this, but sometimes it is the best answer. We have always been able to find suitable blood vessels and add flaps successfully whenever we have had to try this, and the results have been favorable. Definitely not the first choice for most people, but good to know it’s a tried-and-true technique if you absolutely need it.

4) Finally, a small implant under a too small but otherwise healthy flap is often surprisingly well-tolerated, even in radiated patients. Not for everyone, but an option that has been used quite successfully in some instances, nonetheless.

We went through our “iGAP phase” some years ago, and abandoned it not because of the reconstructive results, but because we decided the sGAP donor site resulted in far more favorable buttock aesthetics.

–Dr. Richard M. Kline, Jr.

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What Are My Reconstruction Options After a Lumpectomy?

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

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

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

Here’s my short list of options:

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

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

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

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

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

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

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

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

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

Best Wishes,

The Center for Natural Breast Reconstruction Team