Q: How long after chemo, surgery and radiation does one have to wait to get DIEP flap reconstruction?   A: We would ask for clearance from your oncologist regarding chemotherapy, but typically, we ask that patients wait at least 4-6 weeks following completion of chemo.  Following radiation, you would need to wait at least three months before proceeding with DIEP.  This allows the radiation to treat the cancer properly but spares the reconstructed tissue of the treatment's harmful effects.   A: Our first priority is to do everything possible to avoid radiation to a Diep flap. In other words, if radiation is needed then we would wait 3 months after radiation is complete before doing the flap. The wait after chemo is not as long and varies depending on recovery from chemo. 6 - 8 weeks average.   Q: Also, is it necessary to put an expander in place at the time of surgery if doing a DIEP flap at a later date after radiation?   A: To answer simply, no, a tissue expander is not necessary.  That said, “delayed immediate” breast reconstruction, which involves placement of a tissue expander at the time of your mastectomy, can have added benefits as opposed to doing nothing.  Assuming you are having a nipple or skin-sparing mastectomy, the expander will fill the overlying breast skin and prevent it from collapsing and scarring together during the radiation.  Once the radiation is completed, and the tissue has been given time to heal (3-6 months), the tissue expander and its capsule will be removed and replaced with your own healthy tissue.  Should you decide an expander is not the right option for you, this will have no impact on the ability to reconstruct your breast using a DIEP flap after radiation. However, this option may require a small piece of abdominal skin "skin paddle" to be left in place to help with the overall shape of the breast. A: It is not always necessary to have an expander in place during radiation. Sometimes the expander helps sometimes it doesn’t. It can be a problem later if a DIEP is planned. We need an MRI and that cannot be done with the expander in place. We have our patients get the MRI before mastectomy if an expander may be placed.   Q: Does the reconstructed breast match the remaining breast in shape, size, etc.?   A: Ultimately, our goal is to create a breast mound of good shape, volume and position, ideally with aesthetic features of a nipple and areola reconstruction if needed. Reconstructive surgery aims to establish symmetry between the breasts; however, exact symmetry is rare in nature and difficult to achieve surgically. A flap reconstruction will yield a more natural result in terms of shape and feel.   A: After radiation the radiated breast side will always be different. But symmetry and comfort in clothes can be achieved. The best symmetry is usually when natural tissue reconstruction is performed on the radiated side. Things may look different without clothes on but overall the breasts should feel warm natural and comfortable   Q: If a lumpectomy is possible, how can you reconstruct the breast if it is misshapen?   A: Given the need for radiation with a lumpectomy, the best option to repair the defect is with a local tissue rearrangement and possible lift of the contralateral breast for symmetry.   Radiation increases the risk for capsular contracture, wound healing complications and the possibility of infection when used in combination with an implant.   I hope this helps answer some of your questions.  Please let me know if I can be of more assistance; I am happy to call you or set up an in-office visit at your convenience. Lindsey Weaver, FNP-C Dr. James Craigie East Cooper Plastic Surgery The Center for Natural Breast Reconstruction