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 – Bilateral Mastectomy

bilateral mastectomy

Q: I had a bilateral mastectomy on 12/11/2017 after chemotherapy for stage 3 breast cancer in my right breast with 10 lymph nodes removed. Expanders were inserted, and I had radiation treatment. 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 3rd plastic surgeon. I have concerns about going forward with my current surgeon 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) that he specializes in his practice. I have never considered going out-of-state for medical treatment, and my work schedule is a concern. I want to know your thoughts about my situation and if I should go forward with my current surgeon. I have found your website to be a great source of information and encouragement. God bless you for all your doing to help!

A: 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 has 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, can be absent or very small. The preoperative MRI angiogram will determine this, however; and 3) If you have a donor site complication such as dehiscence, it’s difficult to manage due to the location and motion in 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 ~ 1350 flaps) is 99.0 percent. The SGAP—our next choice—is a good flap, although the dissection is difficult, which is why it is not performed in most places. This flap can be large, occasionally over 1000 grams in certain individuals. We have done 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. Robert Allen— who was the pioneer of the DIEP, SIEA, and GAP flaps—and we would not have the amazing results we do without it. We never do flaps without two competent microsurgeons present. Thank you very much again for your inquiry. Please contact us if you need anything, and I would be happy to speak with you by phone, or see you in consultation.

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

3 Common Breast Reconstruction Questions

Undergoing breast reconstruction surgery is a life-changing event.

It’s a decision that often requires multiple doctor’s consultations and lots of personal reflection after a battle with breast cancer.

And even after all that time spent planning, researching the best doctors, and doing your homework, it’s possible that you might walk out of a reconstructive surgery and be unhappy with the results.

It’s heartbreaking, and we hate to see women suffer through this.

That being said, there’s a lot that can be done to help repair reconstructive surgeries that didn’t go as planned.

And thanks to innovative technology and our amazing surgeons at The Center for Natural Breast Reconstruction, our team can often help women achieve their reconstructive goals in order to feel beautiful and confident once again.

Are you feeling disappointed after a reconstructive surgery?

If so, we encourage you to take a look at some of the most common questions we get from women who are looking for reconstructive help to see how we’ve been able to help them in the past.

Chances are, if you have similar issues, we’ll be able to help you, too!

Check it out…

QUESTION 1: Is It Possible to Do Repair and Nipple Reconstruction Surgery at the Same Time on the Same Breast?

Not long ago, we received the following question from a prospective patient…

Question: I had hybrid DIEP reconstruction at another facility, and I am disappointed with the results. There have been many issues.

For example, my breasts are different shapes and sizes, no node involvement and no microinvasion. The surgeon who did the mastectomy said the path report said the margins were not wide enough and he will need to cut additional skin out during the next surgery.

The next surgery is supposed to be to reconstruct the nipple. Can you do both procedures on the same breast at the same time? Please Help!”

Here’s our response…

Answer: “I’m sorry you are having to go through this.If your margins were positive and you had an immediate DIEP flap, that could be a little complicated to resolve, although I’m sure we could work through it.

Reconstructive surgery can be different for every patient that we encounter. However, many times it is possible to do both at the same time. The best way to determine what method will work best for you is to come in for an evaluation.”

QUESTION 2: I’m Unhappy with My Reconstructive Result from Another Surgeon – Are You Able to Make It Look More Natural?

The question we received was…

Question: “Three years ago, I had a double mastectomy and am now cancer free. My plastic surgeon did a terrible job with the reconstruction. The left side implant is way off to the outer side and looks larger than the right side.

The right side is way too far to the outside. There is zero cleavage.

Is there any way to reposition the implants more to the natural position of the breast? I do not expect perfect but don’t like looking like a botched job. Thank you.”

Our response is as follows…

Answer:  “I’m glad to hear you have been cancer free and have your treatment for breast cancer behind you. At The Center for Natural Breast Reconstruction, it is part of our mission to help women move on with their lives after breast cancer. We focus our efforts on helping women get their bodies back together with permanent, natural results.

I’m sorry you are disappointed with your reconstruction. If you have had radiation, then it may be very hard to have your breasts match with implant reconstruction. If you have not had radiation, then perhaps your implants could be revised or adjusted for an improvement.

Unfortunately, these corrections are all too often temporary. It is possible that using your own fatty tissue would be a more permanent option without implants.

Sometimes it is hard to start over with another approach, but it may be necessary if you desire a more natural and permanent result. So, the answer is yes–it’s likely that we CAN help you achieve a more natural look.

If you would like more information about natural breast reconstruction with your own tissue, let me know.”

QUESTION 3: I Am Unhappy with My Previous Bilateral Mastectomy with Reconstruction Using Implants. Are You Able to Fix It?

Question: “I’m not happy with the results of my bilateral mastectomy with reconstruction using implants. Reaching out to see if it can be fixed.”

Answer:  “It is very likely that we could help you with your unsatisfactory reconstruction. This problem can often be fixed either by using your own tissue, or by revising your implant reconstruction.

I will be happy to discuss your situation and provide you with some options.”

Looking for options to improve your breast reconstruction results? Give us a call at 1-866-374-2627 or contact us online to find out more!

In Her Words- I am back to “me”


At the time I came to your office, I was unsure that I would ever feel normal again.  I had undergone a bilateral mastectomy in 2013 and had expanders put in at the same time to plan for my implants.  After waiting for about a year and a half, the surgery for the implants was performed.  Within three months, one of my breast implants had to be removed since the skin would not hold due to the radiation I had received.  My plastic surgeon told me it was possible that I might have to live with only one breast.  He told me I was not handling things right and sent me for counseling.  My counselor said my feelings were normal.

I decided to do some research and found you on the internet.  I liked the fact that in your website you said you used my own tissue and muscle.  I think what was most important was that your website said that you understood and saw my situation as a unique individual.  You actually cared about my feelings and that was something I did not feel my plastic surgeon cared about.  

You accepted my insurance and an appointment was set.  From our first meeting I felt very comfortable with you and your staff.  I felt I had been guided to your hands. 

Now after two surgeries I am back to “me”.  I have my body and my life back thanks to Dr. Craigie and The Center for Natural Breast Reconstruction.  If I had known about you and your procedure in the first place I would have been there sooner and saved myself several surgeries and disappointments.  My husband and I would both like to thank you so much for being there for me.  

D.S. – Myrtle Beach, S.C.

Ask The Doctor-Should I have a preventative mastectomy?

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

Question: I am 60. I have had a core bio in right breast, and my maternal aunt had breast cancer. My left breast is became two sizes bigger than right, and I have fibefib. Cystic diseases. Last year my mamo showed no cancer, but I am about a 36 c in right breast and 38c in left. It’s painful. Should I be proactive and have both removed since already in right? I have had a core bio for two lumps showed benign. Thanks

Answer: Thanks for your question. Women who are at an increased risk for breast cancer and/or who have difficult breasts to screen for breast cancer do sometimes consider preventive mastectomies. Certainly not every woman in your situation would do that. In order for you to make a decision you should discuss your specific situation with a breast surgical oncologist. They could give you more specifics about your risks. Other considerations are quality of life issues. Having to undergo frequent biopsies or repeat imaging are all reasons some of our patients tell us they have preventive mastectomies. Finally, the options for breast reconstruction available to you can make a difference to you in your decision. We can give you more specifics about those options if you like. We have all our patients discuss their risks with one of the breast oncologist and geneticists we work with. Let me know if I can help in any way.

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

Should I Have a Bilateral Mastectomy Instead of Lumpectomy and Radiation?

This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers a special two-part question.

Q: Do you know of surgeons in northwest Ohio who can do natural breast reconstruction? I was diagnosed with DCIS and had a lumpectomy done and now am considering a bilateral mastectomy instead of radiation. I was a AA cup size and don’t have much breast tissue left, so I feel like I could use the reconstruction, which is why I am considering the mastectomy.

A: Thank you for your question. I’m sorry I don’t know anyone in that area. Based on your situation you are asking a very good question!

If you have little breast tissue remaining after your lumpectomy then if you went through radiation the breast may develop more abnormal shape. When that occurs, it is difficult to fix that breast because of the radiation effects. If you instead remove the remaining breast tissue you could rebuild the breast to the size you wanted based on how much of your own tissue you have to use. Also you would not need radiation. Remember that implants after radiation are more likely to have complications than without radiation. 

Q: If the DCIS is in one breast, would a double mastectomy make sense, so I could even out the “new” size I choose? Also, do you have information on recurrence rates if I try a nipple-sparing or skin sparing mastectomy?  Is that wise at all?

A: Questions regarding recurrence rates are best answered by the surgeon who performs the mastectomy. We work closely with them as a team and perform the reconstruction immediately after the mastectomy. I’ll be glad to forward your question to the expert. In general, recurrence rates should be the same or lower for mastectomy vs.  lumpectomy and radiation. Skin and nipple sparing mastectomy should be the same as well. For your situation we would get the cancer specialists we work with to give us their opinion before we could give you specific recommendations.

We do have patients choose to do what you mentioned frequently, for the same reasons. Preventive mastectomies are done to reduce the chances of getting breast cancer. If someone is high risk, then they  might decide to reduce the risk of DCIS on the other side. When someone has enough donor tissue we try to give them the best result possible based on each person’s expectations. If you had a bilateral mastectomy we would try to make the new breasts fuller and uplifted as long as there was enough donor tissue to work with. I hope this answers your questions. Let me know.

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!

Could I Be A Candidate for DIEP Reconstruction After Implants?

The below question is answered by Charleston breast surgeon Dr. James Craigie of The Center for Natural Breast Reconstruction.

I had a bilateral mastectomy and had 850cc silicone implants placed after tissue expansion. I am not happy at all with the result as I had radiation on the right side and that breast is considerably smaller than the left. I am also not happy with the shape and look of the breasts with silicone implants. I currently wear prosthetics in my bra to achieve symmetry and a normal shape. Even with the bra and the prosthetics I am not happy with the result. I am currently a D/DD and would like to maintain that size. Given this situation, could I be a candidate for a DIEP or Stacked DIEP breast reconstruction?

Thank you for your question. I’m sorry you are having some concerns about the shape and evenness of your breast reconstruction. Because you had radiation on the right side it is almost certain that the two sides will be different to some degree regardless of the type of reconstruction. Unfortunately, when this occurs with implant techniques it is usually more noticeable and nearly impossible to fix long-term as long as the implants are in place. The reason for this is the implants will be treated as foreign material by your body and the right side will always react more severely due to previous radiation even if radiation was done before the mastectomy. Also, the process of scar formation continues as long as the implants are in place, making the firmness, shape change, and stiffness more noticeable to you as time goes by. These are the reasons that women who have implant reconstruction have multiple procedures to revise results as time passes.

Fortunately when someone has had problems of this nature with implants we can frequently solve them by removing the implants and replacing them with their own fatty tissue (DIEP, stacked DIEP). We can do this without taking tummy or back muscles. Immediately the fatty tissue takes on a more natural shape compared to implants. Thirty percent of my patients have had failed implants before we start over and use their own tissue. My opinion and answer to your question is that you could have a DIEP to replace your implants and I can usually predict that many of the implant problems are much improved immediately after the surgery. I cannot predict what size you would be without seeing you but the size depends on how much extra tummy tissue you have as well as any previous surgery.

I hope I have answered your questions.

—James Craigie MD

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

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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What To Do If Fear Is Keeping You From Undergoing Breast Reconstruction

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

I am scheduled for reconstruction on the 29th. I feel as though I shouldn’t go through with it because, for one, I am 58 years old and secondly because I am scared that I will not be pleased. Thirdly, I heard that it is very painful and is worse than the bilateral mastectomy I had. I am so confused as to what to do.

Firstly, if you are scared, and feel strongly that you shouldn’t do it, then DON’T—END OF DISCUSSION! We’re talking about a quality-of-life surgery, not life-saving surgery. Attitude about the outcome is far too important to risk going into it feeling like you shouldn’t.

Having said that, unless you have a serious medical condition making the surgery dangerous, diabetes, or inadequate donor sites (I assume we’re talking about DIEP or GAP flaps), statistics suggest it might not be as bad as you fear.

Age is of no consequence—some of our happiest DIEP patients (and best healers) have been in their 70s.

Satisfaction with the final outcome is critically dependent upon realistic expectations, which can only be arrived at through careful preoperative discussion with your surgeon, and ideally, also through discussion with other patients.

Perforator flap surgery IS more painful than mastectomy, but pain is a relative thing. A few patients say it is terrible, most say it was about what they expected, and a few say they had almost no pain, even the day after surgery. I can think of one patient out of hundreds who suggested she might not have gone through it if she knew how bad the recovery would be.

Best of luck to you, and please feel free to ask any more questions.

—Dr. Richard M. Kline, Jr.

Will My Insurance Company Pay for a Mastectomy to Reduce My Risk of Breast Cancer?

health insuranceWe’re putting a little twist on our Ask the Doctor post today. We receive lots of great questions from patients; some are medical while others pertain to insurance, billing, and other-office related information. Today, I will be answering a popular question we receive regarding insurance.

I’d like to have a mastectomy to reduce my risk of breast cancer.  Will my insurance company pay for it?

Most insurance companies do have criteria under which they will consider a prophylactic mastectomy medically necessary—as a reminder, if they pay for your mastectomy they must also cover a reconstructive procedure of your choice. There are always exceptions to this rule, as outlined in WHCRA 1998, but this law does protect the majority of women insured in the United States.

I’ll highlight some of the actual criteria obtained from medical policy documents from some of the nation’s largest insurers. This is a pretty comprehensive list but it’s always a good idea to consult your plan’s medical policy documents to determine their specific coverage criteria prior to undergoing any medical / surgical procedure.

“BIG INSURANCE CO #1” covers prophylactic mastectomy as medically necessary for the treatment of individuals at high risk of developing breast cancer when any ONE of the following criteria is met:

Individuals with a personal history of cancer as noted below:

Individuals with a personal history of breast cancer when any ONE of the following criteria is met:

  • Diagnosed at age 45 or younger, regardless of family history.
  • Diagnosed at age 50 or younger and EITHER of the following:
    • At least one close blood relative with breast cancer at age 50 or younger.
    • At least one close blood relative with epithelial ovarian, fallopian tube, or primary peritoneal cancer.
  • Diagnosed with two breast primaries (includes bilateral disease or cases where there are two or more clearly separate ipsilateral primary tumors) when the first breast cancer diagnosis occurred prior to age 50.
  • Diagnosed at any age and there are at least two close blood relatives* with breast cancer or epithelial ovarian, fallopian tube, or primary peritoneal cancer diagnosed at any age.
  • Personal history of epithelial ovarian, fallopian tube, or primary peritoneal cancer.
  • Close male blood relative with breast cancer.
  • An individual of ethnicity associated with higher mutation frequency (e.g., founder populations of Ashkenazi Jewish, Icelandic, Swedish, Hungarian, or Dutch).
  • Development of invasive lobular or ductal carcinoma in the contralateral breast after electing surveillance for lobular carcinoma in situ of the ipsilateral breast.
  • Lobular carcinoma in situ confirmed on biopsy.
  • Lobular carcinoma in situ in the contralateral breast.
  • Diffuse indeterminate microcalcifications or dense tissue in the contralateral breast that is difficult to evaluate mammographically and clinically.
  • A large and / or ptotic, dense, disproportionately-sized contralateral breast that is difficult to reasonably match the ipsilateral cancerous breast treated with mastectomy and reconstruction.
  • Personal history of epithelial ovarian, fallopian tube, or primary peritoneal cancer.
  • Personal history of male breast cancer.

Individuals with no personal history of breast or epithelial ovarian cancer when any ONE of the following is met:

  • Known breast risk cancer antigen (BRCA1 or BRCA2), p53, or PTEN mutation confirmed by genetic testing.
  • Close blood relative with a known BRCA1, BRCA2, p53, or PTEN mutation.
  • First- or second-degree blood relative meeting any of the above criteria for individuals with a personal history of cancer.
  • Third-degree blood relative with two or more close blood relatives with breast and / or ovarian cancer (with at least one close blood relative with breast cancer prior to age 50).
  • History of treatment with thoracic radiation.
  • Atypical ductal or lobular hyperplasia, especially if combined with a family history of breast cancer.
  • Dense, fibronodular breasts that are mammographically or clinically difficult to evaluate, several prior breast biopsies for clinical and / or mammographic abnormalities, and strong concern about breast cancer risk.

Who is a close blood  relative? A close blood relative / close family member includes first- , second-, and third-degree relatives.

A first-degree relative is defined as a blood relative with whom an individual shares approximately 50% of his / her genes, including the individual’s parents, full siblings, and children.

A second-degree relative is defined as a blood relative with whom an individual shares approximately 25% of his / her genes, including the individual’s grandparents, grandchildren, aunts, uncles, nephews, nieces, and half-siblings.

A third-degree relative is defined as a blood relative with whom an individual shares approximately 12.5% of his / her genes, including the individual’s great-grandparents and first-cousins.

GET IT IN WRITING: Some of the above criteria may sound like Greek to most of us.  Ultimately the key to finding out if your insurance will consider prophylactic mastectomy in your individual case lies in the hands of your physician and you. A comprehensive set of medical records clearly outlining your particular risk along with a request made to your insurance company for written pre-authorization or pre-determination of benefits is the best thing to do to assure if your insurance company will consider your procedure medically necessary.

–Gail Lanter, CPC, Office Manager