Ask The Doctor-Which is the best procedure for a natural looking breast?

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

Question:  A week ago I was diagnosed with invasive Mammary Carcinoma with Ductal & Lobular features, Intermediate and stage1. Since I have had a Lumpectomy and radiation 10yrs ago on same breast they said I would have to have a mastectomy. They have suggested I have the TRAM flap done.

I have been reading on your site about TRAM versus DIEP flap. I would really like I think to have the DIEP flap but not sure if the Plastic Surgeon that my Dr. uses does this. I’m really concerned and want the best results for a natural looking breast. He will have to later when recovered put a nipple on. Tell me your suggestions. Thank you.

Answer:  Thank you for your question. I’m sorry to hear that you need to have a mastectomy. I’m glad to hear it was detected early and is Stage 1.  Have they talked to you about needing chemotherapy? You have done some good research regarding breast reconstruction. Since you have had previous radiation then breast reconstruction using your own fatty tissue would give you the chance for the most natural result following your mastectomy.

The TRAM procedure uses your own fatty tissue from the tummy but unfortunately it sacrifices your tummy wall muscle in the process. The DIEP is another way to use your own natural tummy fatty tissue and does not sacrifice your tummy muscle. You don’t need muscle to rebuild your breast.  You do need your tummy wall muscle located where it naturally is.  After a TRAM, patients can have problems related to removing the muscle. Therefore you should request a plastic surgeon who has experience with the DIEP procedure to see you in advance of your mastectomy. If there are none in your area then you may have the option to travel to a practice that does specialize in the DIEP procedure.

In our practice we have had patients from almost every state in the U.S travel to us because of our expertise in breast reconstruction using natural fatty tissue. It is not easy to travel for surgery but unfortunately for this specialized type of procedure it is sometimes necessary. If you need more information about how that works or the things we can do to help our traveling patients just let me know.

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DIEP Flap Reconstruction Surgery After Capsular Contracture

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

Does anybody have any idea what the difference is “surgically” when DIEP surgery involves removing an implant that has developed a capsular contracture? That is what my situation is. I’m wondering if the skin that has been stretched over the implant will be removed, or become part of the new flap?

Thirty percent of our patients have previous implant surgery that has failed. During the reconstruction we remove the implant, implant capsule and any Alloderm that may have been used.   We also must return the chest muscle to its natural position because the implant always goes under the muscle. Unfortunately the muscle may be permanently changed from implant surgery. The stretched skin over the implant is allowed to recover and usually not removed.  If the skin initially needed to be stretched by the implant/expander then that indicates breast skin has been removed during the mastectomies. Usually skin from the DIEP will be needed depending on previous radiation and size of the DIEP breast. If the remaining breast skin is thin, tight, too scarred or damaged by radiation we may need to remove more of it at another surgical stage.

-James Craigie

Center for Natural Breast Reconstruction

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DIEP Flap Procedure: Is this covered by my insurance?

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

I had a double mastectomy last month and am considering the DIEP procedure. My insurance is Aetna PPO and I wanted to know if this is covered. Also, I keep reading about stage 11 follow up to do lipo on the upper abdomen so it is flat like the bottom half ( after surgery) . Is that part of the reconstruction and is it covered by insurance? Thanks


I’m almost sure we are in-network for you, but our office will let you know for sure.

We use liposuction to help correct some donor site deformities, such as bulging of the upper abdomen, or fullness of the “muffintop” areas. Often, that fat can be used as graft to enlarge the DIEP flaps, or improve little areas of asymmetry. If we place fat in the breast, we add a code for fat grafting for the insurance company, but we never bill anyone for liposuction per se.

Hope this helps, and thanks for your question.

Richard Kline
Center for Natural Breast Reconstruction

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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!



Exploring the Recovery Process after DIEP Breast Reconstruction

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

What is the recovery process like for DIEP flap breast reconstruction?

Generally speaking, patients can sit in a chair the day after surgery, they are walking by 2 days after surgery, and they leave the hospital on the fourth day after surgery.   We ask you to sleep on your back for a minimum of a month, sometimes longer (depending on the size of the flaps), and to avoid vigorous physical activity for at least 6-8 weeks.  Most people seem to feel like they are well on their way to recovery within 2 months, although obviously healing goes on for a significantly longer.  However, everyone is different, and some patients recover more rapidly, other seems to take a little more time.  We feel that the optimal approach is to let you speak to other patients who have been through the process, so that they may share their experiences directly with you.

Below are some additional tips for optimal post surgical experience.

Family and Friends: Support from loved ones is very helpful. But understand that comments they may make during your recovery can cause you concern. Remember this: We will tell you honestly how you are doing and what we expect your result will be.  Please trust in our knowledge and experience when we discuss your progress with you.

Healing: You will heal! How quickly depends on factors your genetic background, your overall health and your lifestyle (exercise, smoking, drinking, etc.). Many people believe the surgeon “heals” the patient.  No person can make another heal. Dr Craigie and Dr Kline can facilitate, but not accelerate, the healing process.  But you play the starring role, so your cooperation is key.

Swelling: You may find swelling of your new breast and abdomen (DIEP) or buttock (GAP) to be troublesome and your clothes may not fit.  Be patient, this swelling will gradually subside and you will feel better in a few weeks.  There will be a certain amount of tightness in the area where the flap was taken from.  This will slowly relax in a few months.

Following Instructions: Another way to improve healing is by following the instructions given by Dr. Craigie and Dr. Kline’s staff.  We believe “the difference is in the details” and strive to achieve the best possible results for you.  It is imperative that you act as a partner in this process — not a passive participant.  The instructions are designed to give you the best opportunity for healing without delay or surprise.

Click here for a complete list of post surgery healing and recovery tips and instructions.


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