Ask the Doctor- What Are My Reconstruction Options Using Only My Tissue?

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

Question: I am 39 years old and seeking options regarding a double mastectomy with reconstruction using only my own tissue. I was treated for an aggressive breast cancer in my left breast 3 years ago; went through neoadjuvant chemo, then a lumpectomy followed by radiation. Due to my lifetime high-risk status, I feel a double mastectomy is necessary using my own tissue for reconstruction.

Answer: Thank you for your question, I am glad to hear that you have completed your breast cancer treatment 3 years ago and are doing well. It is very likely that using your own natural tissue is going to be a very good option for you.

Since you have already had radiation on one side the option of removing the remaining breast tissue and having a preventive mastectomy on the other side is the most effective option to minimize your chance of getting breast cancer again.

Although I imagine it is already very low. Have you had any previous surgery on your tummy? Do you feel that you have extra fatty tissue there or any other area of your body? If so then you can probably achieve a proportional natural tissue result without having to sacrifice your important muscles.

If you like I could arrange a convenient time to answer any other questions by phone. Let me know and I’ll have one of my staff contact you to make arrangements.

Thanks again.

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

Implant Procedure Without Expanders?

breast implantsThe below question is answered by the Charleston breast surgeons at The Center for Natural Breast Reconstruction.

Is it possible to have a simple implant procedure without expanders if you have a lot of skin tissue left?

Yes, absolutely, if you are willing to have Alloderm (acellular dermis) used to help support the implant.  We specialize microsurgical reconstruction using your own tissue so we don’t actually do this procedure in our practice but there are plastic surgeons in every metropolitan area who do.  If you are in or near the Charleston area we can give you names of surgeons who are especially good at this procedure.    We know many out of our area too if you’d like to identify where you are located we can see if we know anyone to suggest you consult.

–The Center for Natural Breast Reconstruction Team

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


Wound Healing Post Breast Reconstruction Surgery

The below question is answered by the Charleston breast surgeon, Dr. James Craigie.

How do you determine when to use a wound vac in place of a traditional drain?

We have discussed the idea of using a wound vac in place of drains.  We have actually determined the use for combining the wound vac and drains under certain circumstances.  Some people have had radiation or have challenging wounds that result from wound healing problems combined with fluid collections caused seromas.  Sometimes drains are needed to evacuate seromas but unfortunately they are not always adequate.  Also, radiated tissues have difficulty healing and wounds developed in radiated tissue sometimes typical wound dressings may not be adequate as well.  We have used the wound vac combined with the drain in order to treat these complex wounds.  We have found that complex wounds are usually a combination of wound separation with fluid collections.  The drain actually passes through the wound vac sponge, the wound vac sponge is then covered with the steel dressing that is connected to a pump and the strong negative pressure generated is greater than the pressure of a normal drain.  This allows a deep pocket of fluid to be dressed with the drain tip and the open skin edge or wound edge to be treated with the sponge.  When the wound vac dressing is changed every 3-5 days, the drain can be backed out slowly and therefore as the wound edge heals, the fluid collection is controlled and the wound eventually heals quicker than other approaches.

-James Craigie, M.D.

Get answers to your questions about breast reconstruction and breast health straight from our surgical team! Submit your questions here today.


Increase Breast Size Through DIEP Flap Natural Breast Reconstruction Surgery?

The below question was answered by Charleston breast surgeon, Dr. James E. Craigie  of The Center for Natural Breast Reconstruction:

Can I increase the previous size of my breast during a DIEP breast reconstruction?

Breast reconstruction requires detailed planning before surgery.  One of the most important considerations is the desire of the patient to either be the same as she was before mastectomy or to change some aspect of the breast.  When there is adequate donor tissue (in the case of a DIEP excess tummy tissue) we may have the opportunity to increase the patient’s bra cup size given adequate planning and adequate donor tissue.  The desire of the outcome is always to be proportional and if someone has more tissue on the tummy we can usually achieve this.  In ideal circumstances, we plan to make the reconstructed breast approximately 20% larger at the first stage than the end goal after the reconstruction process is complete.   During the first stage of surgery, the tissue from the tummy is transferred and the primary goal is to have adequate blood supply and healthy nourished tissue.  The shaping of the breast is secondary to the functioning of the blood vessels during this stage. At the second stage of surgery, in order to create a more natural shape, some tissue may need to be removed or any tissue that did not survive the initial transfer (fat necrosis) removed.

Therefore, when planning the first stage procedure, we try to end up with slightly more than desired.  That gives us the ability to shape the breast and we can always make it slightly smaller at the second procedure; which is a much easier adjustment than making it larger.  So, it is possible to increase the current breast size with the DIEP, but it would depend on the size of the breast prior to the mastectomy and  how much donor tissue is available for reconstruction.

Are you thinking of having reconstructive surgery and have questions or just want more information? Then click here to ask our team, we’d love to hear from you!



What’s Next if My First Attempt at DIEP Flap Breast Reconstruction Fails?

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

If the first DIEP flap breast reconstruction fails what are my options?

This is a rare scenario, but in our practice we generally recommend waiting 3 months for the body to recover, then using another area of tissue, most commonly the buttock to perform the reconstruction.  The failure of the first reconstructive attempt does not seem to adversely affect the success rate of the second reconstructive attempt. We have in the past sometimes attempted to perform the salvage reconstruction at an earlier date, but we have come to feel that the patients do better overall if they are allowed a period of healing before proceeding with the next surgery.

What is DIEP Flap Reconstruction?

Perforator  flaps and natural breast reconstruction represent the state-of-the-art in breast reconstruction. The DIEP flap is the most frequently used type of  perforator surgery for breast reconstruction because of the tummy tuck benefit  that can be part of the process. Doctors  borrow skin and tissue from your abdomen, and use it to create a soft, warm,  living breast.

It starts  with an incision along the bikini line similar to a tummy tuck incision.  Surgeons remove the necessary skin, soft tissue, and tiny feeding blood  vessels. The blood vessels are matched to supplying vessels at the mastectomy  site and reattached under a microscope. Tissue is then transformed into a new  breast mound.

Our refined technique provides all the necessary  tissue to build a breast, without removing the abdominal muscles. In addition  to reconstructing the breast, the contour of the abdomen is often improved –  much like a tummy tuck.

Have questions for our team? Send them on over, we’d love to hear from you!


Potential Issues to Watch for After DIEP Flap Breast Reconstruction

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

What potential issues should I be watching for right after having DIEP flap breast reconstruction?

I am going to split the answer for this into two parts.  First, what you should watch for while you are in the hospital (at which time you will, of course, have lots of help watching for things). Second, what should you watch for when you go home?

When you are in the hospital, we primarily look for changes in the vascular status of the flap.  There are monitors attached to the flap which will within seconds pick up any change in the blood flow to the flap.  If on further evaluation by the nurses, it shows that there is a problem, we will take you back to surgery immediately and attempt to correct the problem.  Fortunately, incidents such as these are rare, but if they do occur.  We have learned that the most important factor is to get to the operating room quickly, in which case we can almost always fix whatever might be wrong.

Thankfully, it is unbelievably rare to have a problem with the blood flow to the flap after going home, although it is not impossible.  Your primary concern should be to follow the specific directions which we have given in terms of positioning and brassiere support.  Most patients still have temperature monitoring strips attach to the flap, and this can serve as useful reassurance to let you know that your flap is fine.  Infections are extremely rare after DIEP flap surgery, but they can occur either at the reconstruction site or at the abdominal donor site.  Wound healing problems are not as rare as infections but may occur.  If you are not radiated, the most likely place to have a wound healing problem is your abdomen.  If you are radiated, it is very common to have a little bit of a wound healing problem where the healthy flap tissue meets the radiated breast skin.  Essentially all wound healing problems can be managed very effectively, so it is not something you need to worry about.

Share this post with friends and family on twitter or facebook. Do you have a question for our surgical team? Submit them here!

The Latest Technology in Preventative Mastectomy Procedures

Today we are putting a twist on our usual Ask the Doctor series and sharing a video interview with our very own Dr. James Craigie. If a picture is worth a thousand words a video must be worth at least a million, right? With the discovery of the correlation between breast cancer and family history, more and more women and opting for preventative mastectomy procures. Watch as Dr. James Craigie highlights the latest advanced reconstruction techniques offered at The Center for Natural Breast Reconstruction to restore a woman’s natural look.

As part of our weekly ask the doctor series we encourage you to submit your questions to our team or leave a comment below and we will get back to you! For more information on The Center for Natural Breast Reconstruction visit our website. We’d love to hear from you!

Charleston Breast Surgeon Answers Your Implant and Insurance Questions

charleston breast surgeonsThe below questions are answered by Dr. James Craigie of The Center for Natural Breast Reconstruction

Should a woman have an MRI follow up every two years after implants to check on things? I’ve been told this.

Let’s go to the source of that information for the best answer . . .

This is from the product insert data sheet included with Mentor Corporation Memory Gel Implants . . .

“Rupture of a silicone gel-filled breast implant is most often silent (i.e., there are no symptoms experienced by the patient and no physical sign of changes with the implant) rather than symptomatic.  Therefore, you should advise your patient that she will need to have regular MRIs over her lifetime to screen for silent rupture even if she is having no problems. The first MRI should be performed at 3 years postoperatively, then every 2 years, thereafter. The importance of these MRI evaluations should be emphasized. If rupture is noted on MRI, then you should advise your patient to have her implant removed. You should provide her with a list of MRI facilities in her area that have at least a 1.5 Tesla magnet, a dedicated breast coil, and a radiologist experienced with breast implant MRI films for signs of rupture.”

You can read the entire product insert data sheet here:

Does insurance generally cover redoing of nipples and tattooing?  I’m not completely satisfied with the result of my nipple reconstruction procedure.

Great question . . . Let’s address the insurance portion first. If your health insurance covers mastectomy, it must cover reconstruction throughout all phases. There are some that do not have to abide by this rule, (WHCRA 1998) but they are few and far between. Some may limit the number of times you can undergo a procedure at their expense. The best way to assure they will pay for your procedure is to call the insurance company each time and make sure you have benefits available for the procedure you desire.

Nipple reconstructions can deteriorate over time. Those that seem a little too prominent at first tend to flatten out after a while and may no longer project enough to suit a patient.  Tattoos fade, especially when applied to skin that has a large amount of scar. This being said, repeat nipple reconstructions are a quick procedure routinely performed with local anesthesia and it’s not unusual to require a touch up tattoo.

—James E. Craigie, M.D.

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.

Share this post with your followers on Twitter. And if you have a question for our breast surgeons, please feel free to send us an email!

Mastectomy and Uneven Breast Size: What Are Your Options?

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

Because of failed implant / expander surgery (3rd degree burn damage) from radiation, I underwent a second reconstruction procedure with DIEP flaps earlier this year and a revision three months later. I have not yet had my nipples created. There is still about a cup size difference in my breasts as well as a hollow part of the cancerous breast at the top. Is this still able to be fixed as part of reconstruction procedure or do I have to live with this? Currently, I wear a prosthetic to try and even them out but it doesn’t take care of the hollow area.

Sorry to hear about your problem. If I understand you correctly, you had a mastectomy for cancer on one side and a prophylactic mastectomy on the other side, then had radiation to the cancerous side, followed by bilateral DIEP flaps.

A size mismatch in that scenario is fairly common, even when the initial flaps weigh the same, for a number of potential reasons. The cancer surgeons are sometimes more aggressive with their mastectomies on the cancerous side, and the radiation sometimes seems to cause loss of additional tissue volume. Additionally, localized fat necrosis can occur within one or both of the flaps, which would decrease their size.

As you might expect, there is no perfect one-size-fits-all solution for this. The easiest solution might be to lift the flap on the cancer side to fill the hollow part, and then reduce the other side to match.  Autologous fat injections to the areas of tissue deficiency are sometimes surprisingly effective and long-lasting, even in the face of radiation, but there is no way to tell if the fat will survive without just going ahead and trying it.

We have significant experience using the excess skin and fat, which many people have beneath their armpit to augment the upper / outer areas of the breast mound, using this tissue as a flap based on the 5th intercostal artery. This technique often carries the added benefit of lifting and rounding the breast mound. While we are not fans of using implants in the face of radiation, the presence of a healthy flap sometimes means a small implant to make up the size difference will be better tolerated. As a last resort, another perforator flap from another donor site could be added to the first flap, but we have rarely found this to be necessary.

I would advise you against having your nipple reconstructions until you are satisfied with the state of the breast mounds, because significant later work on the breast mounds may change the nipple position or orientation.

-Richard M. Kline, Jr. M.D.

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