Ask the Doctor – Would I Be A Candidate For DIEP Flap Surgery After Previous Expanders Are Removed And Will You Accept VA Insurance?

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

Question: I had a bilateral mastectomy with reconstruction and I am terribly dissatisfied with my care so far. 11 Months later, the expanders are still painful. I will be asking to have them removed this week.

I have 2 questions for you. After I  have the expanders removed would I still be a candidate for the DIEP flap? I am still going to chemo (Herceptin) which will run until the end of November, provided there are no more setbacks. My second question is, do you accept VA insurance? One form of payment is through the VA another is Veteran’s Choice. I am not sure which would cover outside care. I look forward to your response.

Answer: I’m sorry you have had so much trouble, but there is a very good chance that we can help you.

Your previous unfortunate experience with expanders does not in any way decrease our ability to successfully reconstruct you with DIEP flaps. The blood vessels which we use to vascularize your flaps are well below the area where tissue expanders are placed, and we have successfully reconstructed literally hundreds of patients in your situation. One potential advantage to having the expanders removed sooner rather than later is that we get an MRI angiogram on all patients who are scheduled for perforator flap breast reconstruction, and most breast tissue expanders are not MRI-compatible. If they use a little magnet to find the port before they fill your expanders, then you can’t get an MRI with those expanders in place.

We have worked with the VA many times in the past, and Gail, our insurance expert, will contact you to investigate your situation further.

Thank you very much for your inquiry, and I look forward to meeting you.

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

Ask the Doctor – I Am 3 Years Post Mastectomy With Radiation On My Right Side And I Am Interested In The Diep Flap Surgery.

This week, Audrey Rowen, PA-C, of The Center for Natural Breast Reconstruction answers your question about breast reconstruction.

Question:  I am interested in the DIEP flap surgery. I am 3 years post mastectomy with radiation on my right side. I am 56 years old and live in Columbia and I have spoken with one of your patients who was happy with her breast reconstruction. I would like to make an appointment.

Answer: Thank you for reaching out to us! My name is Audrey and I am the physician assistant here at the practice. We would be happy to make an appointment for you to come and see us! Which days work best for you? Our normal clinic days are Monday, Tuesday, and Friday. If you’d prefer to schedule over the phone vs. email, feel free to call our office at 843-849-8418 anytime over the next few days and we can set that up for you.

Did you have bilateral mastectomies or just the right side? Are you interested in bilateral DIEP reconstruction? Once we get you on the schedule, we like to try getting some of your records in regards to your oncology and surgery history so it is a huge help if you could get us the names of our Oncologist, PCP, and breast surgeon so we can start requesting those records before your appointment. I am also happy to chat with you over the phone if there are any questions you would like answered before you make the trip out to see us.

Please let us know which days and times work best for you to schedule an appointment and let me know what other ways I can help! We look forward to meeting you soon!

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

Ask the Doctor- Can You Do Repair and Nipple Reconstruction Surgery at the Same Time on the Same Breast?

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

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!!

Answer: I’m sorry you are having to go through this.

Did you have a complete mastectomy on the left breast or a lumpectomy? If your margins were positive (unbeknownst at the time of surgery, obviously), and you had an immediate DIEP flap, that could be a little complicated to resolve, although I’m sure we could work through it. Given that your scenario is a little bit unusual, it would probably be best if we talked by phone. Please let us know what works for you.

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

How Long Will Radiation Postpone My DIEP Reconstruction?

This week, Dr. Richard Kline of The Center for Natural Breast Reconstruction answers your questions.

Q: If I am having Mx and immediate DIEP reconstruction surgery that it is determined that radiation will be necessary, is the the DIEP reconstruction continued as planned, or is it postponed until after radiation? If postponed, are tissue expanders temporarily placed until six months later when flap surgery can be performed?

A: We have never, fortunately (as far as I can recall) encountered findings in surgery that caused us to suddenly think that radiation would be needed when we didn’t suspect it previously. The two things that COULD be found intra-operatively and would lead to that would be positive lymph nodes or a very large tumor. The mammogram and MRI are pretty good at seeing these kinds of things preoperatively. Additionally, if there is any suspicion of positive nodes, we routinely have the sentinel node biopsy done as a separate procedure before the mastectomy.

When we DO know that the patient will need radiation, we sometimes offer them placement of a temporary tissue expander if they do not want to go several months without having a breast mound. This has several disadvantages, including 1) doing unnecessary damage to the chest wall and pectoralis muscle, 2) taking up some of the eventual flap’s volume to fill the divet in the ribs left by the tissue expander, and 3) potentially interfering with the delivery of radiation. Some surgeons think the scar pattern can be favorably altered by and expander in this scenario by keeping the skin stretched, but I’ve never been very convinced by this argument, at least not when the expander is ultimately going to be removed and replaced with a flap.

If we did, for whatever reason, unexpectedly determine in surgery that the patient needed radiation, I would probably just do nothing (no tissue expander) and come back after radiation and do the flap(s).

Dr. Richard Kline

Center for Natural Breast Reconstruction

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

Chronic Pain After DIEP Flap Surgery–Can You Help?

This week, Dr. Richard Kline of The Center for Natural Breast Reconstruction answers your questions.

Q: After a double mastectomy in April 2010, my left expander was replaced in June 2010 due to leakage and became infected.

I was hospitalized and given vancomycin and oral antibiotics for almost 3 weeks. Infection spread to right breast and both expanders were removed the same month.

I had DIEP flap surgery in December 2010, but I have had severe pain and shocking sensations in chest, ribs and stomach. My surgeon says he does not know what is causing this pain. Is it the result of nerve damage? And is there any way to fix this?

A: So sorry to hear about your experience! Out of 1,011 flaps to date, we have very few patients with chronic pain, but unfortunately it does sometimes occur. We usually examine the areas in question with a CT and/or MRI, but usually this does not show any abnormalities other than normal post-surgical changes.

In this scenario, we then refer the patients to our pain therapists, who almost always are able to provide significant relief. Please let us know if we can provide additional information.

Dr. Richard M. Kline, Jr.

Center for Natural Breast Reconstruction

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

DIEP Flap Procedures: Can You Restore My Original Breast Size? Do You Remove Muscle?

This week, Dr. Richard Kline of The Center for Natural Breast Reconstruction answers your questions.

Q: I am having a double mastectomy on August 1st. I want to have a DIEP flap reconstruction, but will have to settle on being half the size I am now because there isn’t an abundance of fatty tissue in my tummy. I am a full C cup now and will probably be a B cup following the reconstruction. Can additional fat be harvested from my buttocks at the time of my initial surgery to make me look like I do now or do I have to wait until Stage 2?

A: There are a few potential ways to look at your situation.

First, it is possible to do DIEPs and GAPs simultaneously (4 separate flaps). We don’t do this, because we have concerns about our ability to monitor the buried flap, but we do know have references to associates who can and we are happy to provide you with this information.

Second, it is possible to inject fat into the DIEP flap, and potentially the mastectomy skin flaps as well (if they are thick enough), as well as in the pectoralis muscle at the time of the DIEP flap. All that together will buy you some extra size, but it’s hard to predict how much.

Finally, you could do fat injections after healing in a subsequent stage(s). I would call this the “tried-and-true” technique, little to lose, much to potentially gain. We are investigating BRAVA as an adjunct to this, but not quite ready to use it yet.


Q: What happens if I am getting a DIEP flap done and some muscle has to be removed from my abdominal area?

A: A true DIEP flap never results in the removal of muscle, by definition. Some flap surgeons apparently tell patients they may need to remove a little bit of muscle, and we’re not sure why they say that, because we’ve never found it necessary in many hundreds of flaps.

However, with rare exceptions, the rectus muscle does have to be “disassembled” (and put back together again, of course) to remove the blood vessels, and this can occasionally result in partial loss of muscle function. We work extremely hard in designing each DIEP flap to maximize the blood supply to the flap, while minimizing the potential for loss of muscle function.

We obtain an MR angiogram pre-operation. This  requires an unusually strong 3T MRI for best images, which gives us an excellent “road map” of your individual perforator anatomy. We also frequently use the SPY intraoperative laser fluorescent angiogram to help determine exactly which perforating vessels supply the flap best. Thanks to these technologies, in addition to using the best surgical technique we can, it has been many years since we have encountered any significant functional abdominal wall problems in any of our patients.

Hope this helps!

Dr. Richard M. Kline

Center for Natural Breast Reconstruction

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

Can Small Implants Be Used with Flap Surgery for Added Volume?

This week, Dr. Richard Kline of The Center for Natural Breast Reconstruction answers your questions.

Q: Can small implants be used with flap surgery for added volume?

A: The short answer is “yes, sometimes.”

We have had good success augmenting flaps with reasonable-sized implants in non-radiated patients. In radiated patients, it’s still sometimes possible, but it’s very dependent on how much of the breast mound is covered with flap skin versus radiated breast skin, and what the quality (the technical term is “compliance”) of the radiated breast skin is. Every case is different.

Our nurse or PA can provide you with more information upon request. 

Hope this helps!

Dr. Richard M. Kline

Center for Natural Breast Reconstruction

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

Dr. James Craigie Answers Your Questions About Natural Breast Reconstruction

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

Do you perform a stacked combination DIEP/SGAP using both to make a breast(s)?

We do on occasion. It may be needed when one area of the body does not have enough tissue to achieve the desired result. This is an unusual situation in our practice we can usually achieve our goals with one area of the body.

There is a lot of discussion about a maximum BMI what about a minimum?

BMI is a guide line that helps the surgeon determine who is at a higher risk for complications. It is not a strict guideline and the final decision is left to the surgeons judgment among other things. Safety is our first priority and studies have definitely linked high BMI to an increased rate of complications without a doubt. Unfortunately  BMI is not a perfect calculation and different doctors may use the information differently. A low BMI is not linked to complications if someone is otherwise fit for surgery. Someone with very little body fat will have a low BMI and possibly not enough tissue to make a very large breast. This does not mean they cannot have a good result. It  may mean they require and combined or stacked flap approach. We have seen many patients who have been told they “don’t have enough tissue” but after consultation can reassure them they can get a very proportional result.

Dr. James Craigie

The Center for Natural Breast Reconstruction

Do you have a question about breast implants or natural breast reconstruction? Submit them here for an answer straight for our surgical team!

Can I Expect Tissue Problems After Radiation Therapy?

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

What type of tissue problems should I expect after having radiation therapy post mastectomy and chemo? I have implants now, but will be having them removed and have a DIEP procedure. Thank you.


If your implants will be removed then you should not expect problems with capsular contracture following radiation. Mainly these problems are related to your body’s rejection of the implant . The radiation will permanently affect the skin and others parts of your body that are treated with radiation. However when you recover from the radiation short term affects (usually 3-6months) you should be able to safely have a DIEP. Using your own tissue will give you the most natural permanent result without a high risk for problems due to radiation. When we know someone will need radiation following mastectomy this is our preferred method.

I hope this helps let me know if you have additional questions.

James Craigie, MD

Center For Natural Breast Reconstruction

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

Perseverance: The Valuable Lesson Breast Cancer Taught One Survivor

Today’s In Her Words post comes to us from a past patient of The Center for Natural Breast Reconstruction, Carlette Holmes. Carlette, is a breast cancer survivor who lives in Anderson, SC and traveled to Charleston to receive her reconstructive surgery. Today, Carlette and her childhood best friend partake in a culinary partnership entitled, Buffa’s Cheese Biscuits. The recipe for these delicious biscuits come from Buffa, a cook for Carlette’s grandmother while she was growing up.

See below for out interview with Carlette and to learn more about Buffa’s Cheese Biscuits. All images included are courtesy of Carlette Holmes.

1.  Buffa’s Cheese biscuits, even the name just melts in your mouth. Can you tell me a little bit about these delicious biscuits and where the recipe came from?

I think my grandmother found the recipe in a Jr. League cookbook and gave it to Buffa to try. They were a staple after that. They were always on hand in a covered dish as you came into the kitchen. Everyone who came in knew they were there & grabbed a handful. Buffa’s were always good but often different…. sometimes “short” as she would call them, sometimes crispy, sometimes light and puffy or sometimes dark and crumbly. I know now it could have been due to the humidity on any given day. One challenge I faced was to get them to turn out the same every time. Family and  friends didn’t seem to care, but I felt it was important when I started selling them.

2. It seems you spent a lot of time in the kitchen with Buffa, do you have a favorite memory with her?

My conversations with Buffa are favorite memories. She loved to talk while she cooked and could tell a great story. Often, I would shell peas or snap beans while she “held court”. I loved to “help” her make jams and preserves.

My least favorite memories are those of grease fires and exploding pressure cookers. I am scared for life, and to this day I don’t like to fry in my kitchen. The first time I tried to fry fish for Edmund is was slightly boiled and awful.

3. You have been making these biscuits for your family and friends for years. What was the turning point for you to finally give in and brand Buffa’s Cheese Biscuits to the public?

I think the turning point was surviving breast cancer. My best friend since 7th grade, and partner in BCB, Lide Vandiver, had been after me for years to brand them, but I had a family to take care of and businesses to help my husband, Edmund run. My 2 daughters, Sally Cade and Brelyn, were in college when I was diagnosed. I got through my treatment and I had been thinking of reconstruction options. I had heard horror stories of implants, expanders and that procedure, and I didn’t think that was an option for me. I researched DIEP flap surgery and was so impressed with the procedure. I truly believe that God led me to The Center for Natural Breast Reconstruction. I called another surgeon and was told that they didn’t take my insurance. They directed me to the The Center for Natural Breast Reconstruction. I called and got Gail on the phone. This was on the day that I took my last chemo treatment. Gail talked to me for over an hour that day. It felt right and I am thrilled with my decision. As you can probably tell, I don’t let much grass grow under my feet and DIEP flap seemed to me like the best & fastest way to get through the reconstruction process and move on.

4. How did you decide upon what reconstructive option was right for you?

I was pretty excited about getting rid of my C-Section Pooch. It was just the right size to make C-cups.

5. How has your decision to undergo breast reconstruction impacted your life moving forward?

I saw the picture Dr. Craigie took of me the day I came to him… on the day I got my tattoos. That was start to finish in a flash. It was definitely a process, but one that I wouldn’t trade for anything. I can remember, 6 weeks after my DIEP flap surgery, sitting on the beach in my bathing suit and feeling comfortable and “normal”. I took out my cell phone and called The Center for Natural Breast Reconstruction to leave Dr. Craigie a message of thanks. I don’t have words to describe how good that felt after living with one breast for 6 months. Now they were both gone, but they were there. How amazing! DIEP flap has allowed me to move on. I know myself, and that I would worry if I had not had both breasts removed even though the cancer was only in one. It has been a great decision… nothing to stuff in my bra, no implants to worry about, just my C-Section pooch made into breasts. Dr. Craigie is a real artist (not to mention a gifted surgeon). I am still amazed at how real they look.

6. What advice do you have for women who have a passion, and want to turn that passion into a business?

I think my advice would be to persevere. Lide and I hit obstacles almost every day, but we just have to work through them. I think maybe that fighting cancer taught me a lesson in this. Every day brought it’s obstacles,  but I had no choice but to keep moving forward.

Click here to see where you can pick up Buffa’s Cheese Biscuits near you or place your order online!