Ask the Doctor- I’ve Completed Radiation. When Is The Right Time To Make A Consultation Appointment To See If I Can Have DIEP Flap Reconstruction?

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

Question: I had a right mastectomy December 8, 2016, and radiation ended March 2017. Currently, I’m having problems with fluid buildup because the skin cells haven’t healed enough to absorb bodily fluids. When should I set an appointment to see if I can have the DIEP flap reconstruction?

Answer: Thank you for your question. No need to wait for a consult. I could see you anytime. Usually, we wait 3 months after completion of radiation before start DIEP breast reconstruction. Every situation is different. If it is convenient to come for a consult I could evaluate your progress and readiness to proceed. Just let me know if you would like my office to contact you about an appointment.
Thanks again!

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!

What can I expect during a DIEP / GAP free flap breast reconstruction?

This frequently-asked question comes center stage again for 2014, and we At the Center for Natural Breast Reconstruction, we are here for you and your questions. Feel free to Contact Us anytime!

What are the stages involved in DIEP / GAP free flap breast reconstruction?

The stages of breast free flap reconstruction at our facility can vary depending upon what time in the treatment process we initially meet the patient. The best scenario occurs when the treatment is mastectomy, alone. In those patients, we are able to discuss a skin and possible nipple-sparring mastectomy. This approach means that there is a possibility that the patient would only require one step, although most women are not opposed to a second stage when liposuction, “body contouring,” is involved. Many patients do not have this opportunity, so for them, this process usually involves three stages.

The first stage, being the most involved, is the “technical” stage—the microsurgery element.  After meeting with one of our physicians and discussing the best donor site tissue (tummy, buttocks or inner thigh) the process begins and we relocate the tissue to form a new breast mound. Only the donor site fatty tissue and the blood vessels that nourish that tissue are removed. NO muscle is sacrificed. This blood supply is separated from the body and reconnected to the vessel in the chest wall that once nourished the native breast.

Since the new breast mound is solely relying on the tiny vessels we reconnected initially, we keep you in the hospital for four days to monitor the blood flow into the relocated tissue. This stage of the procedure can require about a six to eight week recovery period, depending upon healing. It varies greatly when women are feeling well enough to return to work or resume the activities they enjoyed prior to surgery.

About three months after Stage One, we may begin discussing each specific patient’s Stage Two.  Three months is the minimum amount of time that we allow. In some cases, we recommend waiting slightly longer than three months (example: radiated tissue, healing issues, or unilateral reconstruction).

Stage Two could be described as the “plastic surgery” side of the breast reconstruction. This is the stage where we fine tune everything that was accomplished in the first procedure, and attempt to improve upon your concerns and how clothes fit. During the first stage, we try our best to achieve symmetry between the two breasts, but sometimes the doctors are limited on the shaping that they are able to accomplish because of the microsurgery portion. Stage Two is about improving symmetry between the two breasts, re-building a nipple if needed, and improving the donor site. This is usually an outpatient hospital procedure but, on the rare occasion, the patient may need to stay overnight.

The procedures performed during this stage vary from person to person, according to their needs. Recovery time varies, too. It could be as little as a day or two weeks, according to the procedures that need to be performed to achieve your desired result.

Three months after your second stage, it is time for your areola tattoo, Stage Three. Women who were able to save their nipple / areola complex at Stage One do not require this stage and are complete at Stage Two. The tattoo is performed in the office under local anesthesia. There is really nothing to this phase. You may drive yourself to the office and expect to be out in one to two hours. It’s really a lot like a social visit and other than exposing your newly tattooed area to public bodies of water like swimming pools, lakes or beaches, there is not much aftercare to speak of. Simple local wound care is all that is required. The risks are minimal and infection and complications are rare.

Many women think of the tattooing as the final hurdle. The best comment I’ve heard was from a woman who stated that after the tattoo healed, she got out of the shower one day and upon looking in the mirror, felt like everything was behind her.

A few other things to keep in mind:

  • Scars look their worse at about three to six months, from that point they should steadily lighten and become less noticeable. It’s hard, but be patient. It takes a while for scars to fully mature and everyone is different.
  • You’ll meet with your surgeon and discuss the best case scenario for you and how to get your breast reconstruction accomplished in as few steps as possible. It is important, even though you are plagued with so many other physicians and concerns, to meet with your surgeon before you have your mastectomy to keep the surgical stages to a minimum. At this point, we’re able to discuss with you your breast surgeon incision site techniques and helpful concepts to improve you final outcome. We also ask your surgeon to weigh the amount of breast tissue removed. It helps for our reconstructive surgeons to know how much breast tissue was removed with your mastectomy and use that number to work toward  rebuilding your new breast, hopefully achieving a symmetrical result earlier in the process to minimize the number of surgical stages.
  • Most patients after the first stage have breast mounds and feel comfortable in clothing. If they must delay State Two of their procedure to undergo chemotherapy, build up time off from work, or just desire time with their family, they are not on a time restriction. (Do keep in mind your deductable.)
  • Vanity is not even a consideration in the breast reconstruction process and these surgeries are not cosmetic plastic surgical procedures. It all comes down to trying to get your body back together and make you as happy as possible, so you can move forward with your life and not have the reminder of everything that you have been through and overcome.
  • Procedures in the breast not affected by breast cancer are insurance covered reconstructive procedures, too. When patients have unilateral reconstruction, achieving symmetry is a little bit more complicated. We have to let the newly relocated tissue settle and heal. The second stage surgical procedures in this case can include, breast lift, reduction, and / or minor procedures to fine tune and attempt to achieve symmetry between the native and reconstructed breast.

We like our patients to discuss with us the things that bother them about their reconstructive result. There are usually things we can improve upon, whether it’s a local procedure in our office or an additional stage. The three stages described in this piece are an outline to the overall process.

Breast reconstruction cases vary and affect each individual differently based upon a number of factors. Some people require one stage and others two or three outpatient or minor procedures to return their bodies back to where they are comfortable and confident.  After you overcome the first stage, the rest are just fine tuning by standard outpatient procedures and local procedures. It is all about making you as comfortable and confident as possible.

How Long Do I Need to Wait To Have a DIEP Flap Procedure After Radiation?

This week, Dr. James Craigie of The Center for Natural Breast Reconstruction answers your questions.

Q: How long should I wait to have a DIEP flap after radiation?

A: Radiation therapy is part of the treatment of breast cancer and will affect the results of breast reconstruction. The treatments can miraculously kill some growing cancer cells but they also change the area of the body left behind after surgery.

All of the elements of the body can be affected: blood vessels, scarring, healing function, and appearance.  The effects of radiation occur in two phases. Short term occurs during and immediately after the treatments. Elective surgery at this time is not possible, for obvious reasons. The long term effects develop after the early “burn-like” injury “settles down.” The long term reaction occurs for approximately the first six months.

The experience can be widely different from one person to the next. We have experienced difficulties with the receiving blood vessels after radiation when we did not wait for the body to recover from both long and short term damage. These types of problems could possibly increase the chance for the new breast to fail. Avoiding these problems may be possible by waiting and that is why the long recovery is needed before reconstruction is started.

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!

Do You Provide the BRAVA and AFT Procedure?

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

Q: I am a breast cancer patient who has recently finished chemotherapy. I am looking now into reconstruction, but I was wondering if you performed the BRAVA+AFT procedure?

A: We are actively looking into BRAVA and AFT, but not doing it yet. I would suggest you contact Dr. Khouri, he’s certainly the expert at this point. If you should need GAPs, PAPs, or DIEPs, we would be happy to help you.


Q: I recently finished 8 weeks of chemotherapy. I did not have radiation. I still have Herceptin until next May. I understand you do not currently offer BRAVA, but I’m interested in a fat transfer. Do you use expanders or something? I really want to have something done sooner than later but am willing to wait if it’s necessary. Could you explain to me the procedures you recommend?

A: I would not recommend fat transfer alone as a breast reconstruction technique without BRAVA. Even with BRAVA, it will probably take several sessions to get to the size you want, and there is still no guarantee that it will ultimately be successful, as fat survival is not strictly predictable.

We primarily offer microsurgical breast reconstruction (DIEP, sGAP, PAP), we do it on an almost daily basis, and our flap survival rate over the last 10 years (98.4 %) is realistically probably as high as anyone’s. However, we realize that this is not for everyone. If you have not had radiation, implants may well be a good option for you, and there is likely no need for you to travel a long distance for this, as most communities of any size have plastic surgeons skilled in this area.

Any type of reconstruction can usually be done in between Herceptin treatments, although we ultimately defer to your oncologist’s advice on this.  If you live near us and want an opinion, we’ll be happy to see you in consultation at any time.

Hope this helps!

Dr. Richard M. Kline

Center for Natural Breast Reconstruction

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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

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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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At What Point During Your Journey Is It Time To See Our Surgical Team?

time to see a doctorThe below question is answered by Richard M. Kline Jr., M.D., of The Center for Natural Breast Reconstruction.

At what point in the process should a breast cancer patient see a breast reconstruction surgeon?

Opinions on this vary, but I think the prevailing opinion is the sooner the better.  Ideally, the patient would see the reconstructive surgeon even before plans were finalized for treating her cancer.  This is because many times several options are available to the patient, and she may not fully understand the implications of the various options available to her unless she understands what reconstructive options are available in each setting.

A Little Bit About Our Surgical Team :

Co-directors Dr. Richard M. Kline and Dr. James E. Craigie are certified by The American Board of Plastic Surgery. Both surgeons have trained under Dr. Robert J. Allen, a pioneer in breast reconstruction using the DIEP, SIEA, and GAP flaps. Dr. Craigie completed a microsurgical breast reconstruction fellowship dedicated to muscle sparing techniques (directed by Robert J. Allen, M.D.). Dr. Kline completed his residency at LSU while Dr. Allen was developing these techniques.

Our entire surgical team is dedicated to remaining at the forefront of breast reconstruction surgery to provide excellent care and results for each individual patient. Because of this commitment, the practice consistently earns referrals from our patients, as well as from other surgeons throughout the United States.

Knowing the RIGHT Questions to Ask:

When searching for a surgeon to perform your microsurgical breast reconstruction, it’s important to ask him or her the right questions.

Below are a few questions to ask:

  • Are you a microsurgeon? Where and by whom were you trained in this specialty?
  • How many microsurgeries have you performed? And how often do you perform them?
  • What is your success rate?
  • Can you arrange for me to speak with some of your patients who have had the procedure I am seeking? (Candidates should speak with people of similar ages and lifestyles).
  • How long do you anticipate I will be under anesthesia for the procedure?
  • How many board certified physicians will be assisting with the first stage of the procedure? Will there be physicians in training (residents) involved with my surgery
  • Will I have to sign a consent that if a physician is unable to complete the procedure, I will have to consent to a TRAM/Free TRAM?

Do you have a question about breast implants or natural breast reconstruction? Ask our surgical team by clicking HERE.

Ask The Expert Series Spotlights The Center for Natural Breast Reconstruction

We’re thrilled to share some exciting news with you, today! Our very own Dr. Richard Kline and Dr. James Craigie, Charleston breast surgeons, were recently on ABC News 4 Ask the Experts Series. During this interview the doctors answer questions on air about natural breast reconstruction submitted by viewers .

See below for the interview:


For those of you who aren’t aware of The Center for Natural Breast Reconstruction and what we do, here’s a brief description:

Charleston plastic surgeons Dr. James Craigie and Dr. Richard Kline specialize in breast reconstruction for women who have undergone mastectomy and those who are considering risk reducing prophylactic surgery. Some of the procedures performed by these Charleston breast surgeons include DIEP, SIEA, and GAP free flap breast reconstruction, which utilize your own tissue with no implants and no muscle sacrifice.

Our Charleston breast surgeons also perform nipple sparing mastectomy, reconstruction after lumpectomy, microsurgical breast reconstruction, and breast restoration. Visit our website today for more information.

Do you have a question for the Charleston breast surgeons at The Center for Natural Breast Reconstruction? We’d love to hear from you.


Our Recommendations for Post Surgical Clothing After Breast Reconstructive Surgery

post operativeThe below question is answered by the team at the The Center for Natural Breast Reconstruction.

I am having a SGAP breast reconstruction in a few weeks. Do I need to buy post op surgical bras? If so, which kind and can I get a prescription for insurance purposes? Also, I heard people use various bras / camisoles with pockets for drains. Have you heard of those or think they are helpful? Do you think button down shirts are something I need to get? Anything else?

No need to buy any special bra, vest, or camisole in advance. Our hospital, East Cooper Regional Medical Center, provides a soft cotton vest with drain pockets as well as a surgical bra that acts as a post operative surgical dressing. Let them know if you feel like you need an extra for when you leave the hospital and they are great about sharing another with you.

Absolutely, I would make sure I had button down shirts and loose clothing that you can easily get in and out of. You’ll have some limitation of lifting your arms above your head so button down shirts are easiest to get on and off without lifting your arms. Some women choose to wear loose sundresses; others track suit pants or cotton shorts. Whatever you are comfortable in is fine, but keep in mind we won’t want you wearing anything right away that could potentially put any pressure on your suture lines.

Here are more helpful hints:

If you are having a DIEP breast reconstruction, abdominal swelling limits clothing choices. Wear loose-fitting garments to the hospital. Women should avoid fitted, zippered pants and skirts because they probably won’t zip when it’s time to leave. Even clothing with snug elastic waistbands may be uncomfortable. A loose chemise or drop waist dress or jumper is a good choice.

Slacks or skirts with elastic in the back and a smooth band in the front may be slightly more comfortable than those with a totally elastic waistband.

Consider clothing that doesn’t wrinkle easily. Resting and naps are necessary while recuperating.

Cotton underwear breathes and is absorbent and comfortable next to the skin. Cotton’s fiber ends help the fabric stand away from the sensitive incision area rather than hug it, as some textured, synthetic fabrics do. If you don’t already have cotton briefs, buy a pair a size larger than your normal size. A little extra room adds comfort during recuperation. For waistline incisions, bikini cut styles may be better, while full cut panties and shorts might be preferred for incisions in the lower abdomen and buttocks.

Loose-fitting nightgowns and nightshirts are comfortable, especially when made from absorbent, breathable cotton or cotton-blends. If you prefer pajamas, select those with drawstrings. Elastic waists may be less comfortable for some people depending on swelling, tenderness, and location of incision. Sweatpants or crew pants are a comfortable change from bed wear, especially those with drawstrings, which allow some flexibility at the waistline.

Flat soled shoes that slip on your feet rather than tie are great to have, too, as you may be limited in your ability to bend over and tie your shoes.

If you do need to have a special bra after your incision lines have healed, we are happy to provide a prescription. We’ve had lots of our patients rave about Nordstrom’s for post mastectomy bras. Not only do the kind folks there provide a professional fitting for mastectomy patients, but they also handle the insurance paperwork for you too!

Thank you,

The team at The Center for Natural Breast 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!