What is the SGAP breast reconstruction procedure?

The Superior Gluteal Artery Perforator Flap, or SGAP, is an alternative breast reconstruction procedure where we can use the upper, outer butt, sometimes referred to as the muffin top. The benefit is that it’s a great source of fat. The complementary result is a behind lift and a thigh lift. So now we have more than adequate volume to reconstruct them. These are often patients who are either too lean on their abdomen or have had prior surgery, or, in many cases, those who have had failures of DIEP flaps from another surgeon. 

This surgery is specialized. And that’s what we do here. We’re world-renowned for our expertise in perforator flap reconstruction, specifically autologous breast reconstruction, where we can reconstruct your breasts, preserving all of the underlying muscle. There’s no muscle taken, and you maintain the integrity of the muscle unit.

You preserve their ability so they have no disability. The pain and recovery are much less. Many of our patients, unfortunately, have suffered some complications from reconstruction, most implant-based, but also a large volume of them are failures of other flaps. And it’s very rare for surgeons to perform GAP flaps. GAP flaps are the hardest flaps to do by far, so that’s why most people don’t do them.

At least they stay within the bounds of their skill set. Many will choose to go to a PAP or a TUG. Those are inner-thigh flaps with poor quality and are very painful. They break down and have contour deformities of the inner thighs. They often, unfortunately, result in women peeing forward from having their inner thigh skin taken.

Commonly, there’s inadequate volume to reconstruct one breast; you need two of them to make one breast. Despite that, it is still done as the second choice for someone who can’t have a DIEP flap. So, of the approximately 6,000 or 7,000 perforator flaps I’ve done, about a third, or 2,500 to 3,000, have been GAP flaps.

More recently in my career, more than half of the flaps I perform are GAP flaps. I’ve innovated the new style. The new style is upper-outer. It’s in the position of a string bikini on the behind, so very nicely hidden. It gives a really nice lift to the behind and the thigh. What I do is take the flank fat, that is, the fat that hangs over the waist that you want to eliminate in everyone. That’s either removed to contour the donor site, or it’s shifted down to add volume and projection to the behind. This flap is only found at the Center for Restorative Breast Surgery. There is no one else who does it–only my colleagues and me–because this is a technique that I originated. There are many others that we originated here–the stack flap, stack GAP flap, stack DIEP flap, stack TDAP flap, extended DIEP flap, the bilateral SGAP flap, and the APEX flap. So we have these innovations, but the SGAP is my particular specialty; what I’m known for. 

How does SGAP differ from DIEP and other flap techniques?

If you compare S-GAP to a DIEP flap, the technique is the same. The technique is a perforator flap: you identify a small perforator that serves that area and dissect it through the muscle, preserving the muscle. DIEP flap is on the abdomen, GAP flap is on the behind. For the GAP flap, the vascular anatomy is entirely different. It’s highly variable from one individual to another and from one side to the other, whereas the DIEP flap is relatively consistent across individuals. So it’s a much easier operation to do. The depth of the dissection is much shallower. Gluteal flaps are considered the most difficult perforator flap technique.

Who is a good candidate for SGAP breast reconstruction?

The best SGAP candidates are often patients who are either too lean on their abdomen or have had prior surgery, or, in many cases, those who have had failures of DIEP flaps from another surgeon. This surgery is specialized. And that’s what we do here. We’re world-renowned for our expertise in perforator flap reconstruction, specifically autologous breast reconstruction, where we can reconstruct your breasts, preserving all of the underlying muscle. There’s no muscle taken, and you preserve the integrity of the muscle unit.

Who is a good candidate for SGAP breast reconstruction?

Commonly, the patient is very thin and has inadequate volume, or they want a buttock lift or a thigh lift. Some people who have adequate abdominal volume choose this surgery, preferring to get the aesthetic benefit of the contoured behind. The other complementary patients are those who’ve had prior abdominal surgery, such as abdominal explorations for diverticulitis, or prior abdominal plastic surgery, liposuction, or even CoolSculpting. For those patients or patients whose tissue has been traumatized, we look to an a-traumatic area, and that is typically the behind. It’s a great location and a great resource. 

Everyone says, “I wish I could take this big butt of mine and make a breast with it.” Well, now you can, and it works very well. It’s very reliable in a technically skilled surgeon’s hands. Those skilled hands are within the Center for Restorative Breast Surgery. The SGAP is not widely available and requires an additional level of skill. To put it into perspective, there are black belts that go up to 8th or 10th degree. This is a 10th-degree black belt operation. An operation where you need someone who does this all the time; it’s the focus of their profession. You have one opportunity to do it. If it’s done wrong, you can’t fix it because you’ve lost the donor site.

Go to the experts at the Center for Restorative Breast Surgery, where we deliver the best results. The GAP flap is the hardest; it’s the most difficult surgery to do. It takes the most time and skill.

Who is a good candidate for SGAP breast reconstruction?

The best candidate is someone who is too skinny and doesn’t have enough belly fat to reconstruct and get the volume of the breast they want. Other candidates are those who have had prior operations on their abdomen or prior explorations where they may have a variety of incisional scars, including liposuction or CoolSculpting. And you have those who just want their behind a little bit smaller and thighs a little bit tighter. It’s a great resource to give ample volume to the behind. The other nice thing about a GAP flap is that it’s much thicker. The thicker it is, the more projection you get, the more cleavage you get, the better shape you get. The patients almost look like they have implants with the amount of projection that they get.

Example Patient: A 5’ 3”, 104 lbs. female. We got 320g of tissue on her behind from each side. That provided enough tissue to make her a small C. Whereas on her abdomen, she had 60g of tissue. So, you can get substantial amounts relative to the abdomen and still get a pretty good-sized breast. 

Why is the recovery for the GAP flap substantially easier, with much less pain, compared to a DIEP flap or a TUG or PAP flap? 

Abdominal flap reconstruction often results in plication of the muscle. Patients commonly have an erectus diastasis, so we tighten the muscles and do a rectus plication, which gives them a better aesthetic result in the abdomen, but it can make it a bit more sore. Also, tightening the skin makes them walk hunched over, so their back bothers them more, whereas lifting the butt just makes them feel the butt is tight, without creating a postural problem. That also makes recovery easier.

What are the advantages of SGAP reconstruction using your own tissue?

The advantage of an SGAP using your own tissue gives patients another alternative as a source of donor site tissue to reconstruct their breast. You can’t beat your own tissue; it doesn’t expire, doesn’t extrude, doesn’t rupture, doesn’t have a malposition to it, doesn’t require replacement, it can’t be rejected, and it can’t have a capsular contracture. As we get a little bit older, a little bit heavier, and our skin gets saggier, the SGAP offers a complementary perkiness to the backside. 

The success rate at the Center for Restorative Breast Surgery is well over 99%. Our failure rate is about 1 in 300. It’s very rare, but it’s not zero. Failures tend to occur a little later in recovery. Why is that? It may be related to the patient’s activity level. However, it’s still very, very safe to do. It gives an excellent aesthetic result to the donor site and the breast, and it lasts your whole life. It functions like your own tissue. 

The other significant benefit is that they get a better return of sensation. One of the problems we have when we do the mastectomy is that some of the sensory nerves that run through the breast tissue are removed, and there is diminished sensation to the central part of the breast.

Sensory nerves try to grow back. They obviously can’t grow back through an implant, but through their own tissue, they can, and so you commonly find, and the studies prove this, that return of sensation to the central portion of the breast is significantly greater in those who use their own tissue. Those who have an autologous reconstruction at the time of the mastectomy have the best return of sensation.

What is the recovery process like after SGAP surgery?

The recovery process after SGAP surgery is the easiest among all flap reconstructions, including implant-based reconstructions. The recovery pain is minimal. Patients report only tightness in the behind. The breasts have very little pain at all. The drains are a nuisance because they stay a little longer with a GAP flap than with the other flaps, but that helps it heal better. In comparison to implant reconstruction, where drains remain in place for significantly longer, there is a much higher risk of complications, failures, extrusions, and infections, and, particularly in a radiated setting, the implant failure rate is frankly unacceptable. 

How does the move toward using more radiation instead of removing lymph nodes affect breast cancer treatment, and what does that mean for patients considering GAP flap reconstruction?

Your own tissue handles radiation very well. What we’re seeing now is a transition to incorporating more radiation in the treatment of breast cancer. For example, some recent articles are promoting not doing axillary dissections and simply radiating it. The benefit is that you still treat the axillary lymph nodes, but by not removing or violating the lymphatics, you have a much lower risk of lymphedema than with going in and taking a couple of lymph nodes. It’s been standard practice to take a couple of lymph nodes; if they’re positive, they go in and take more. Then they get radiated. So there’s a significant risk of lymphedema, which we don’t have the perfect treatment for. We can do lymph node transfers, Lymphovenous Anastomosis, which have limited improvement, but it’s really a terrible disease. It would be nice to avoid, if not eliminate it, altogether. So the incorporation of your own tissue dovetails with this new mode of therapy, where they’re using more radiation. 

What makes the Center for Restorative Breast Surgery uniquely qualified to perform SGAP surgery? 

The Center for Restorative Breast Surgery is the most qualified for all autologous reconstruction, specifically, complex autologous perforator flap reconstruction, such as the SGAP. Our offices in New Orleans and Dallas collectively perform about 14%-15% of the total perforator flaps in the United States, totaling about 1,500 a year. Of that, about 600 are GAP flaps. We’re the one-stop shop if you want an innovative, complex microsurgical perforator flap reconstruction. That’s all we do. 

What also makes us unique is that we include an aesthetic eye to the surgery. We’re not just technically advanced microsurgeons; we combine tried-and-true cosmetic techniques with our reconstructive efforts. We do that not only in the first stage, as we position the tissue and shape the body with it, but also in the second stage to further refine the outcomes of the breast and the donor site. 

Why is the St. Charles Surgical Hospital the only hospital dedicated solely to breast reconstruction?

At the Center for Restorative Breast Surgery in New Orleans, we have the great fortune to operate at St. Charles Surgical Hospital. St. Charles Surgical Hospital is the only hospital in the world solely dedicated to the care and treatment of women going through breast reconstruction as related to breast cancer or congenital reconstruction.

That’s all we do here. It’s specialized just for that. You know right when you walk in the door that the aesthetic was fashioned and designed to appeal to female tastes. Also, the security you’ll feel and the warmth of all our staff are very important to us. We have the best and latest equipment, not only microscopes but also all the instruments, follow-up, and post-surgical surveillance equipment we need. We have nurses who have been with us for decades, and that’s how they like it. 

Breast cancer touches everyone, so it’s not hard to be empathetic. At the Center,  staff from across all roles–from nurses and scrub techs to receptionists, cooks, and those who clean the rooms–have been affected in some way. We have survivors here who have been patients. We have previvors who have the genetic predisposition and have had treatment. And we have those who’ve had a family member who has had to deal with the challenges of breast cancer or breast cancer-related things. 

I think the best care, outcomes, and experience can only be provided here at the Center because it’s multifaceted. It starts when we receive your inquiry—walking you through educational options, helping with insurance, and connecting you with the doctor, both virtually and in person, even sharing their cell phone number so you feel supported. From there, you’ll come in for your consultation and surgery day, with nurses who’ve guided countless patients through this process. During recovery, those same nurses make sure you’re on track, meeting your goals, and progressing well, while also closely monitoring the vascularity of your reconstruction. That careful attention matters because if any issues arise, catching them early makes them simple to fix.

Since this is all we do, our seven O.R.s are available 24/7. Lights don’t go out. If I have to take someone back to surgery, I’m back in the O.R. in an hour and sometimes less. There is no way that could happen in any other hospital. There, they are dealing with things such as a level one trauma, an appendectomy, someone taking out infected hardware, or someone doing a C-section. We, fortunately, don’t have any of that here. It is specifically for the care and treatment of women who are undergoing reconstruction. So the accessibility to care preoperatively and post-surgically, as well as the availability and the expedited response for anything post-op, is unparalleled.

How has SGAP evolved since you developed the technique? 

SGAP has evolved quite a bit. Much of it has been my evolution of it because I became very dissatisfied with the donor site result. I found just providing someone a good-looking breast and giving them the “shark bite” on their behind was unappealing to me. I did not like it. I thought it did them a disservice, to be quite honest. And so, as my colleagues and I became better microsurgeons, we challenged ourselves. The challenge was not only to enhance our microsurgical skills but also to achieve better donor-site outcomes. Initially, the fat for GAP flaps was taken from the center part of the butt. Most of these women are skinny, so they don’t have much of a behind to begin with, and then we would take the little behind they have, and the result was just awful. So, as we do here, we’re very critical of our work; I think you have to be critical of your work in order to improve upon it.

We continued to improve the surgery. The second iteration was moved close to the waist, which took it off the behind. Now you’re taking less fat from the behind and getting more of a lift. I do more contouring to the behind and address the flank fat to achieve the ultimate result.

A few iterations over 25 years, and it has turned out looking really nice. Women appreciate the appearance of the donor site. In fact, with the last iteration, I was writing an article to describe it, and I asked my younger colleagues what I should call it because it’s not really a GAP, it’s a new way, a new result. One woman said, “You need to call it snatched gap.” I said, “Snatched? What is that? It doesn’t sound very good. And what does snatched mean?” The young kids were laughing, so I had to ask my daughters. They told me it’s when you have a real narrow waist, a great behind, and great hips. I agree, that is a good description of it.

So when I titled my article, I called it “snatched gap flap,” and it was sent in for publication. Two of the reviewers said they were offended by that name. So I revised it to SGAP flap. I still like “snatched,” it makes sense to me.

What advice do you have for someone newly diagnosed with breast cancer, considering reconstruction? 

Someone newly diagnosed with breast cancer obviously faces a very, very difficult thing. Often, they are overwhelmed. It’s great if they have a family unit, friends, or a support group to turn to. 

Empower yourself. Make sure you trust your doctor who made the diagnosis or discussed it with you. You may feel an urgency in getting something done now. You have this time bomb, and you want it out. That’s a common thought, but it’s probably not the best thought. The best plan is to take a pause. Get yourself and your support group together and understand what you have. There are a variety of breast cancers, some more significant than others, and many different treatments. Don’t be ashamed or embarrassed, and don’t talk yourself out of getting other opinions. You have nothing more valuable than your health. Make sure you understand with the help of your doctor what type of cancer you have, what it means, what the course of treatment is, and when it comes to reconstruction, what your reconstructive options are and what that obligates you to. 

For example, an implant reconstruction is straightforward and has an easy recovery. While an implant is tolerated well, it’s still a foreign body. There’s still a life expectancy for it. There’s uncertainty about whether the body will accept it. There’s a reasonable level of infection or capsular contracture. If you’re getting radiated, then it’s a bad idea. You need to understand that there are risks that go along with it. 

Using your own tissue has its pros and cons, as well. There is donor site pain, donor site scar, and donor site recovery. Breast area recovery is very easy; its results are permanent, and you don’t need any implant maintenance. 

So it’s up to you. Empower yourself. You’re the protector of your health and well-being. Understand what is available, understand who’s taking care of you and their skills, and be a smart shopper. Don’t worry about offending someone. If you decide to go somewhere else, you need to do what’s best for you.

What inspired you to build a surgical hospital that goes beyond medical excellence to embrace the subtleties of healing, such as curing art on the walls and crafting a nurturing environment? How do these details contribute to the emotional recovery of your breast reconstruction patients?

When Dr. DellaCroce and I started, we were running around different hospitals doing what we do now, perforator flaps. But our patients were vulnerable; they felt broken. They were in a difficult spot, and we saw how much extra stress they faced. Even something as simple as checking in could take two hours. For us, it was stressful, too: sometimes we didn’t have the equipment we needed, or a patient would return to a room without sheets, or worse, find ants. There was nothing warm or reassuring about that experience. Breast reconstruction after breast cancer is deeply personal, and it deserves to be treated that way. These women need to feel safe, secure, and comfortable. We know that reducing anxiety lowers cortisol levels, supports healing, and helps patients rest. That’s why we set out to create a different environment. From the very beginning, we wanted to control every detail. Patients arriving at the airport were greeted by a limo service that took them on a special route through New Orleans, sharing the city’s history along the way—and they loved it. When they arrived at the hospital, there was no real check-in; they went straight to their room. And in the O.R., everything was exactly as it should be—perfect. 

Dr. DellaCroce and I don’t have this type of taste, so we had to rely on someone who did.  

We asked Ms. Emory Clark, world-renowned for art and healing, to work with us. She did an incredible job, pointing out things that were obvious to us, and some that were not. Like, you will see no red artwork in here. Everything is something that calms you. It’s often a scene that takes you to a special, secure place or to a vacation, from the moment you’re in the holding area through the entire experience. The scenery that is placed on the lights above–it looks like you’re looking out of a window, a sunroof, just to relax you. The aromatherapy is the same way. The colors in here, the furnishings, it’s like a high-end hotel, which was the intent. When you walk into a hospital, the smell of alcohol or whatever other stench may be there creates an additional level of anxiety. These women are already stressed out, so we’ve found that a calming environment helps them recover substantially better. We also used Crestia’s Interior Design. They just do high-end hotels. Together, Emory Clark and John Crestia did a fantastic job. 

What is the SGAP breast reconstruction procedure?

The SGAP breast reconstructive procedure is one where you take fat from the upper outer part of the behind and give a nice butt lift and thigh lift. Breast reconstruction and butt lift–you can’t beat that! 

How does SGAP differ from DIEP and other flap techniques? 

For SGAP, everyone is a candidate; for DIEP flap, not everyone is. The techniques are the same: you’re preserving the muscle. However, for some, the DIEP flap is not available, whereas SGAP is always available. SGAP recovery is much easier as well. The only drawback about SGAP is that it’s very technically difficult to perform, so you want to go to the place that specializes in that, like the Center for Restorative Breast Surgery. 

Who is a good candidate for SGAP breast reconstruction? 

The most common candidates for SGAP reconstruction are very lean women. Both old and young—you don’t have to be old to have laxity in your behind. So it works out very well with all patients. 

Patient example: The patient had bilateral implant reconstructions from Montana. She is very fit, runs marathons, and is very lean. She developed complications related to a capsular contracture. She had 330 cc implants, and wanted to keep that size or a little bit bigger, but she didn’t have enough abdominal tissue– only 80 to 100 cc’s on either side. On her behind, we got 420g, so we were able to give her the volume she desired and preserved her muscle, so she can still do her half and full marathons. She had a really nice lift and contour to the butt. She probably will not even need a second stage; it came out very nicely. 

How is the SGAP flap procedure performed at the Center for Restorative Breast Surgery?

The SGAP, like all our procedures, is performed as a team. Two microsurgeons are operating on you at the same time. And we have the most highly skilled physician assistants. These women also help improve the operation’s efficiency. Our surgeries take far fewer hours than at other facilities thanks to our efficient team approach. That’s the value you get here at the Center for Restorative Breast Surgery.

Of course, if there needs to be oncologic breast surgery, we have the best oncological breast surgeons on the planet. That is a critical ingredient in getting a good result. Not only a good aesthetic result, but also a good, healthy result because you need oncologically sound resection of the tissue. Too aggressive and you kill the skin. Not aggressive enough, you leave tissue. So you need the perfect specialists that you’ll find here–Dr. Ordoyne, Dr. Colfry, Dr. Corsetti—all of them outstanding. 

What makes the Center for Restorative Breast Surgery uniquely qualified to perform the SGAP surgery?

The surgeons at the Center for Restorative Breast Surgery are the experts in perforator flap breast reconstruction. We do more than anywhere else in the world. We perform approximately 14-15% of the perforator flaps performed in the United States. All of our surgeons have many years of training, and this is all we do. So when this is all you do, you do it more efficiently. The failure rates are extraordinarily low. 

What makes the Center for Restorative Breast Surgery uniquely qualified to perform the SGAP surgery?

At the Center for Restorative Breast Surgery, perforator flaps are all we do. We are the experts in superior gluteal artery perforator flaps and apex flaps.

What is the recovery process like after SGAP?

SGAP recovery is relatively easy. Patients are up and about in no time. 

Are there any risks or complications with SGAP breast reconstruction? 

SGAP is a very safe surgery in capable hands. There just aren’t many capable hands. You can find the best surgeons at the Center for Restorative Breast Surgery. 

The most significant complication in incapable hands is failure, which is quite devastating. Then there’s the failure of botching your behind by putting it in a traditional location. So, be a smart shopper. Investigate who will take care of you. It’s a big responsibility. In our hands, failures for gap flaps are only one in 200 to 250. Not zero, but very low. The main complication is seromas. Most seromas, if they occur, will be absorbed naturally. Sometimes they have to be aspirated, but the chances are very low. 

At the Center for Restorative Breast Surgery, you are in very safe hands. Our success rate is well over 99%. The aesthetic outcomes are phenomenal. 

Can SGAP reconstruction be done at the same time as mastectomy?

At the Center for Restorative Breast Surgery, we most commonly do them at the time of mastectomy. There are multiple benefits to this. First, there is only one operation for the patient. Second, there is the benefit of improved return of sensation. At the time of mastectomy, if you incorporate your own tissue and not an appliance, you return a sensation significantly better. 

Nationally, it is less common for patients to have a flap done at the time of mastectomy. They’ll have a mastectomy with an expander as a temporary placement. It’s just a lack of coordination between the breast surgeon and the plastic surgeon. 

What separates the Center for Restorative Breast Surgery from other facilities out there?

What separates us from what’s out there is that we do these complex perforator flap reconstructions at the time of mastectomy–GAP flap, Body Lift, DIEP flap, APEX, all of them. 

More commonly across the US, patients have staged procedures–they’ll have a mastectomy and have an expander put in, even though the patient wants her own tissue. One reason may be that the breast surgeon and the plastic surgeon cannot coordinate their schedules. So they’ll put in an expander, which can take several hours, until a second surgery can be scheduled. It takes the surgeons at CRBS less time, or as much time, to do a DIEP flap with mastectomy as it does to put implants in after mastectomy. 

The other common and probable reason is that they don’t trust the breast surgeon with their mastectomy. Having a bad mastectomy and killing the skin or distorting the parameters of the breast makes it unrecoverable. So more commonly, you see the situation where they’re putting in an expander and underfilling the expander so that they’re saving the space and they’re allowing the breast skin to recover. Then the surgeon can electively take the appliance out and use the patient’s own tissue. 

In my opinion, I would be suspicious of a setup like that: number one, it’s not coordinated, so the parties aren’t talking to one another; number two, it’s not in the patient’s best interest to have multiple operations that could be done at the same time. And then it’s the commitment of the physicians: if they can’t take the time to take care of you, and they’re too busy doing their own business, that might be a sign: “I need to go to New Orleans and the Center for Restorative Breast Surgery.” 

Why is the Center for Restorative Breast Surgery the only hospital in the world dedicated solely to breast reconstruction? 

The Center for Restorative Breast Surgery made a decision a long time ago that we were going to do microsurgical breast reconstruction exclusively. The reason was multifactorial: not only because it’s a better environment for surgeons to deliver their best work, but also because it’s the best way to control the patient’s experience. From the moment they walk in the door to the moment they exit, everything is tailored to them—from the aesthetics and artwork to the aromatherapy to the institution’s location on St. Charles Avenue. There are 20 restaurants within three blocks. You have the streetcar to hop on and off, and go up and down the avenue. We have our own chef who helps patients with their nutritional recovery, and it’s all personalized to each patient. So, if you’re the smart shopper, if you care for quality, if you care for exceptional results, the Center for Restorative Breast Surgery is where you need to go.

What should patients expect when coming to the Center for Restorative Breast Surgery for care? 

For an individual seeking care at the Center for Restorative Breast Surgery, the experience should be profound. It is tailored for them–a very personalized experience with a warm and secure feeling. We’re confident we can deliver the results you want at a very, very low complication rate. It’s a multifaceted approach, from our care and thoughtfulness, and protecting you from lymphedema with our lymphedema therapist, to our nutritional staff, to our nursing staff, that this is all they do.

It’s unparalleled care, and it’s what you deserve. We designed it specifically for that, to stand out as the best. 

How do you approach complex breast reconstruction cases referred from other centers? 

Unfortunately, revisional reconstruction is a large part of our business. These patients are being mismanaged or experiencing failures that may not be related to their actions. The failures may be related to the treatment that they’re getting, specifically radiation, for the treatment of their disease, which can create significant complications to any reconstruction. That’s a large part of our business, and I think that you’ll find in any community of professionals that when you’re at the top, and you do the best work, you also will get the most complicated cases. And that, in fact, was one of the reasons we created all these varieties of other flaps. It was for special cases that came in, where there was no other alternative. So we had to be creative and say, “Okay, how are we going to modularly reconstruct this with a TDAP here, a GAP there?”

What role does microsurgery play in modern breast reconstruction? 

Microsurgery is modern breast reconstruction. Implants are the old school stuff. They’re still done, still the most popular type because they’re easy to do. The implants these days are pretty safe. It’s nice to have a highly cohesive gel, but there is implant illness. We say the implants are inert, but they’re not inert; the body just tolerates them. They create a wall of scar tissue, a capsule around it, but that’s an inflammatory process. So if you have a chronic, deliberate inflammatory process, it’s not healthy. Then you add some of the vaccinations that have overhyped and overaugmented our immune system, as well, that’s why you see now much more prevalence of breast implant illness. It is actually a reasonable amount of our practice. An interesting correlation is that we find removing the implants significantly improves, if not resolves, the symptoms. 

How do you ensure natural-looking results in your reconstruction?

To get the best natural-looking results in reconstructions, more of your own tissue needs to be incorporated. It is key to have a great mastectomy. Some women look great after just the first stage surgery. But some women, like those who have had children, their breasts may be a little deflated, so they would benefit at the second stage for further enhancement and rejuvenation. 

What inspired you to specialize in restorative breast surgery? 

Reflecting on my professional path, I thought I wanted to be a facial plastic surgeon. But what drew me to breast surgery was that it was a new field. When I finished medical school in 1999, perforator flaps were very new, and I was exposed to that procedure. What intrigued me was that I liked doing things that were considered hard and that not many people did. And looking back at the aesthetic results, they were poor. It certainly was an improvement to a TRAM, where you’re taking all the muscle, putting mesh in their abdomen, and the result is the patient can’t do sit-ups. Functionally, flaps were much better. Technically, they were much more difficult. And we were doing a single perforator flap that would take 8 to 10 hours on one side, or doing bilaterals for 16 hours or so. Those take only 3 or 4 hours now that we’ve become more efficient. That was the intrigue, and on top of that, knowing that I could innovate in the field because I thought the results were inferior was a huge draw for me. The cherry on top of that was that the patients were so lovely. They were inspiring. They come to you because they need real help. Seeing what was out there that was really bad, and knowing that I can do a lot better, that was a significant driver. And that was why we did all of this. 

Why do I do it? 

I love my mom, and I wanted my mom to be proud of me. She wanted me to be either a priest or a doctor, and I definitely wasn’t going to be a priest. That’s a true story. 

How does your engineering background influence your surgical approach? 

I still consider myself an engineer more than a doctor. I’m a problem solver. I think that’s why I embrace engineering more. In engineering, all we did was problem-solve. And that’s what it is for reconstruction. Assess the situation. What am I missing here? What do I have structurally? What is vulnerable, or what is caustic and needs to be removed? What do I have to work with? What parts do I have to work with? How can I retain the function? What will give the best aesthetic outcome? It’s a series of internal questions you have to answer, and then you choose the outcome or option. I think I have an advantage as an engineer. I think I see the world a little bit differently. So that helps me do what I do.

I went through engineering college, and I still consider myself an engineer, a gearhead. I’m not an artist. I’m a surgeon, but I think of myself more as an engineer. 

How do you support emotional healing alongside physical recovery?

You have to put yourself in their shoes. Think about how I would want to be treated, or more specifically, how my wife, mom, or my daughter should be treated. That thought process is missing at some places. And unfortunately, many of those places are big institutions where people go for specialty stuff, but it’s not personalized. That’s what we emphasize here. It’s personalized care. That’s why patients get our phone numbers. That’s why when people come for the first time, they say things like, “Where is Liz?” She is one of the educators they encounter before arriving here. It becomes like you’re a family, and it’s what they deserve. The personalized care goes hand in hand with the emotional support they receive here.

What advice do you have for someone newly diagnosed with breast cancer and considering reconstruction?

My recommendation for someone newly diagnosed with breast cancer, if they’re considering reconstruction, is to call the Center for Restorative Breast Surgery. We are happy to talk to anyone and help them understand things, whether you come here or not. I think it’s vital that you know all your options. You may decide that you’re just going to do a lumpectomy and radiation, which is great; it’s an excellent choice of treatment. You may choose to stay locally in your community for treatment, but you have some questions about your options. I encourage you to call us and discuss that with us. We’re always available. That’s one reason we go out and give conferences and lectures and write articles. It’s to get the word out and educate people. But I encourage them to take a moment and call to chat with us at any time. And then, second, confirm your caregiver’s skill and expertise. Be confident in them and comfortable with them.

How is the SGAP flap procedure performed at the Center for Restorative Breast Surgery? 

At the Center for Restorative Breast Surgery, both in New Orleans and Dallas, we specialize in autologous reconstruction, specifically SGAP reconstruction. We are the experts. We’re probably the only people who do it, and indeed the only people in the world who do it regularly at the volume we do it presently. Personally, I average about 300 to 350 perforator flaps a year. More than half are GAP flaps.

I’ve been doing GAP flaps since 1997, and I continue to refine the technique, mainly focusing on the aesthetics of the donor site. It is certainly one of those buyer-beware situations. You need to research who you’re going to. DIEP flaps are more widely available, but you still need to check the surgeons’ skill set and make sure they’re dedicated to their practice. But for a GAP flap, if you value quality, it’s worth checking out the Center for Restorative Breast Surgery.