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.

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Ask The Doctor-Are the lymph nodes disturbed during DIEP flap reconstruction?

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

Question: After a DIEP flap reconstruction, the top part of my tummy above the incision protrudes over the scar-especially in the evening. Is this a lymph issue or edema? Are the lymph glands disturbed in the abdomen with this kind of surgery?

Answer: Thanks for your question. During a typical DIEP procedure the lymph nodes that serve the tummy area are not removed and the lymphatic fluid can move in the normal direction. It is possible to have lymphedema of the tummy area after a DIEP but it certainly is not very common. It would be more likely if someone had multiple tummy surgeries and scars before the DIEP procedure. In my patients I see that their tummy wall and tummy incision may be swollen for 3-4 months after the surgery. If someone has healing problems, infections or a seroma (pocket of fluid underneath the incision), then swelling can be more prolonged. If someone has persistent swelling and none of the above issues for 6 months then I would consider having a therapist who has experience treating lymphedema see them for possible lymphatic massage treatments. Let me know if you need more information, thanks again.

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

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Ask The Doctor- Do you do 3T MRI of both the abdomen and the chest before a DIEP flap?

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

orange flowerQuestion: Hello, I was wondering if you do a 3T MRI of both the abdomen and the chest before a DIEP flap? I would rather not have more radiation, because I had mantle radiation when I had Hodgkin’s 20 years ago and developed breast cancer as a result. Also have you heard of an APEX flap? Thank you for your time.

Answer: Thanks for your great question! We perform preoperative MR Angiograms with an open 3T MRI protocol on all possible patients we have who are undergoing breast reconstruction with a DIEP procedure. We do the same for any of the multiple muscle sparing natural tissue reconstruction procedures we regularly perform. We do not perform MR angiogram of the chest. That would not provide us with any useful preoperative planning information. There are quite a few people who cannot have a MRI. People who have metal knee replacements or breast expanders with metal parts are examples of reasons some of our patients cannot have an MRI. In our practice we have found CT angiograms are not as useful and avoid them if we can because of the increased radiation. As you may be aware, your history of previous mantle radiation may also increase your chances for problems with implant breast reconstruction. I agree that a DIEP may be a very good option for you. I hope I answered your question. If you would like more information please let me know.

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

Can I Have Reconstruction After Recurrence of Cancer? Should I Go to My Local Surgeon or Elsewhere?

This week, Dr. Richard Kline and Dr. James Craigie of The Center for Natural Breast Reconstruction answer your questions.

Q: I have been diagnosed with a second primary breast cancer in the right breast. 13 years ago it was IDC now DCIS. What are my reconstruction options? 

A: I’m sorry you are having to deal with a recurrence. Glad to hear it is DCIS. I imagine you had radiation before and could have mastectomy with immediate reconstruction. If you like I will have my office contact you for a few more details.  I would be glad to set up a phone consult so you could get my opinion right away.

Dr. James Craigie


Q: I was referred by a coworker who was a patient. I’ve had a bilateral mastectomy, expanders and two sets of implants (taken out due to capsular contracture). My plastic surgeon said my body just isn’t taking to the implants and suggests I try DIEP flap reconstruction. My plastic surgeon does them, but my coworker said she recommends more experience. At this point I am torn. She suggested I contact you. I live in Florida and I am very comfortable with my surgeon, but understand the more you do, the better you are. I’ve also had a gastric bypass 10 years ago and I am scheduled for a hysterectomy (via DaVinci robot) Oct 2nd.

A: Thanks for your inquiry, and sorry for the trouble you’ve had.

Having said that, more surgeon experience, having two microsurgeons involved, and using a hospital with a dedicated flap team does potentially provide benefits, probably most so in terms of shorter operating times and increased flap survival rates. We have presently done about 1030 DIEP and GAP flaps, with a 98.4% survival rate, and we would be happy to see you at any time.

However, I would suggest that you consider discussing your concerns with your plastic surgeon, and if he still feels confident he can do it, I think I would give him the benefit of the doubt. Even if you ultimately decide to have your surgery elsewhere, it would be very helpful to have him on board with your decision.

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!

I’m Having Trouble Healing After My DIEP Flap Surgery. Is This Normal?

 This week, we continue with Dr. James Craigie of The Center for Natural Breast Reconstruction answering your questions about DIEP flap surgery. 

Q: I had the DIEP flap surgery for both breasts in February this year. The incision in my stomach area has split and I am being told that this happens to 50% of patients. Is this true? I am told to use wet to dry dressing twice a day. I just don’t know if this is accurate because at the same time I’m told to exercise more? Can you please advise? Thank you for your time.

A: I am sorry you are having problems healing. It is not uncommon after a DIEP procedure to have some healing problems. These range from minor (usually little treatment needed) to more involved (may require a longer time to heal, special wound care or surgery). Because the tummy is pulled together, sometimes tight, an opening in the incision is pulled open even more by tension.

One of the benefits of the DIEP is that your muscles are spared and no artificial mesh over your tummy wall is needed. Therefore infection is usually not a serious problem. Healing may take a while. Take special care but it should not permanently affect the end result. I hope this answers your question and you have a speedy recovery.

James E Craigie, MD

Center for Natural Breast Reconstruction

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What Is the Recovery Period for a DIEP Procedure?

I’m getting ready to have reconstruction surgery in Mount Pleasant and the procedure I’m having consists of the tissue being taken from my abdominal area. How long is the recovery period for this procedure versus having the tissue taken from my back?

If the tissue from the abdomen is being transferred as a DIEP flap, you will probably require 4 – 8 weeks for recovery, of which less than one week will probably be spent in the hospital (usually 4 days in our practice). If the tissue is being transferred as a pedicled TRAM flap (in which your abdominal rectus muscle is sacrificed to carry blood for the flap), the time quoted by your surgeon for recovery may be about the same, but some patients may complain of discomfort for considerably longer periods. With either procedure, some patients will heal faster, and some will heal more slowly, not surprisingly.

When you say tissue is taken from your back, I assume you mean a latissimus muscle flap will be used. This is generally done in conjunction with a prosthetic implant being placed, as the latissimus muscle rarely has enough bulk to make a breast by itself. Generally speaking, a reconstruction using the latissimus is easier to recover from than one using the abdomen, because the latissimus is not used constantly for activities such maintaining posture and breathing. Additionally, at least two other muscles, the teres major and the pectoralis major, have functions which strongly overlap the function of the latissimus, and they are able to “take over for it” to some extent. There are no muscles which duplicate the function of the rectus abdominus quite as closely.

—Richard M. Kline Jr., M.D

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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!



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!




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.

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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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