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*Since 1985, October has served as Breast Cancer Awareness (BCA) Month — a period devoted to educating the public on the disease that, [according to the Centers for Disease Control and Prevention (CDC)](https://www.cdc.gov/cancer/breast/statistics/index.htm), is the second most common form of cancer in women, regardless of race or ethnicity. Men can also be diagnosed with breast cancer (albeit at a much lower rate), and The AEDITION is devoting much of its coverage this month to [BCA](https://aedit.com/aedition/category/breast-cancer-awareness), from expert guides to mastectomies and reconstructive breast surgery to powerful patient perspectives and roundups of products that give back.*

For women affected by breast cancer or those with the BRCA gene mutation who are proactive, post-mastectomy life used to be either an implant or no-breast kind of existence. There is, however, a promising new reconstructive procedure offering [mastectomy patients](https://aedit.com/aedition/what-to-expect-before-during-after-mastectomy-breast-cancer) a third option. It’s called SWIM Breast Reconstruction, and we spoke to the woman who is pioneering the technique, Beverly Hills-based board certified plastic and reconstructive surgeon [Lisa Cassileth, MD](https://www.drcassileth.com/surgeons/dr-lisa-cassileth.html), to learn more about the method.

## **History of SWIM Breast Reconstruction** 
First and foremost, you may be wondering what ‘SWIM’ means. SWIM stands for skin-sparing wise-pattern internal mammary perforator. The procedure, which Dr. Cassileth says “spares the skin you need and spares the mastectomy appearance,” combines a nipple-sparing mastectomy with a breast reduction. Blood flow to the nipple is preserved, all breast mammary tissue is removed, and the leftover skin and fat from the original breast and surrounding area is folded to create a new breast.

The idea for this procedure was born when Dr. Cassileth and mastectomy surgeon [Heather Richardson, MD](https://www.bedfordbreastcenter.com/mastectomy-surgeon-heather-richardson-md/), of the Bedford Breast Center in Beverly Hills, were talking about the limited options patients are offered. The fact of the matter is, all too often, the [plastic surgeon isn’t in the room](https://aedit.com/aedition/post-mastectomy-breast-reconstruction-process-breast-cancer) for reconstruction conversations before or during a mastectomy procedure. Getting rid of the cancer is, understandably, the only goal. As a result, many patients simply leave with a scar. 

When the two surgeons finally worked on the same patient, it wasn’t an ideal situation. There was a radiated breast on one side and new cancer on the other. The patient — Dr. Cassileth’s coordinator’s mother in law — needed a bilateral mastectomy, and the doctors wanted to do the best thing they could for her. The duo created the idea of the SWIM reconstruction procedure, performed it together, and were pleased with the results. 

Within weeks, they had a similar patient. “We developed this procedure over time for these needy patients with nowhere to go and no options for them,” she explains. Previously, many women who had total mastectomies end up wearing a bra with a ‘chicken cutlet’ insert or a padded bra to match the other breast. But, when they raise their arms, the bra can “stick” in their mastectomy divot, Dr. Cassileth says. This is a common experience for thousands of women. As time went on, another segment of the population also embraced the SWIM technique — a younger demographic who wanted to avoid implants.

## **How SWIM Breast Reconstruction Works**
Before this procedure, Dr. Cassileth says her practice encountered women who simply didn’t want implants or aren’t a good candidate for them. The way the SWIM procedure works is that, after a mastectomy, the skin and fat surrounding the breast are meticulously folded and reshaped to create a new breast, while preserving the existing nipple. The breast reconstruction takes place during a one-stage surgery and adds a couple hours to the mastectomy.

First, the mammary tissue is removed during the mastectomy portion of the procedure, while the skin and subcutaneous fat are preserved. During the reconstruction portion of the surgery, the extra fat is folded and placed to create the breast shape. Unlike traditional flap surgeries, no muscle is sacrificed and no abdominal, back, or buttocks tissue is transferred. This provides an alternative for women who want to avoid the extensive surgery, incisions, and long recovery period involved with a [TRAM and DIEP flap procedures](https://aedit.com/aedition/comprehensive-guide-to-breast-reconstruction-nipple-reconstruction-after-breast-cancer). 

There are no long-term negatives or additional surgeries with the SWIM breast reconstruction, Dr. Cassileth says. But there are some finer details to understand. Below, she answers some common questions about the procedure:

### **1. Who Is A Good Candidate for SWIM Breast Reconstruction?** 
Women with breasts that are a B cup or larger are good candidates for this procedure. “Any configuration of a female bigger than a B, you’ve definitely got extra skin,” she explains. You take the breast tissue out of the breast, and you still have all the skin. “You use the extra and fold it up to make this cute breast ... and there’s no maintenance on it,” she says.

Proactive patients, such as those with the BRCA gene mutation, have been opting for the SWIM procedure because they often have a bit more time to consider their options. “The more time people have to research, the more likely they are to find this surgery,” Dr. Cassileth says. These women represent about 50 percent of Dr. Cassileth’s patients for this procedure. “Many women don’t want implants because the implant is foreign body,” she explains. “Plus, they don’t want surgery every 15 years to redo it.”

### **2. Who Isn’t A Candidate For SWIM Breast Reconstruction?** 
If someone is an A cup or smaller, they’re not a good candidate. “They need leftover skin to make a breast out of,” Dr. Cassileth explains. 

### **3. Is there more risk of cancer returning with SWIM reconstruction?**
No, the mammary tissue is completely removed with the SWIM flap procedure, Dr. Cassileth says. “It follows a complete, total, skin-sparing mastectomy — the same mastectomy as is done with a typical reconstruction,” she adds. It’s important to note, however, that no mastectomy has zero recurrence risk. Recurrence is one to three percent for every mastectomy, regardless of the reconstruction technique. 

### **4. Can the new breast(s) be customized?**
“The hard thing to counsel on is gauging how big people will be, and they do ask,” Dr. Cassileth says. It’s a guess, as she must see what’s left over from the skin and subcutaneous fat after the mastectomy. “You could have very heavy breasts but a small amount of subcutaneous fat,” she explains. You can also have little breasts with a lot of subcutaneous fat. Dr. Cassileth can estimate from there and use whatever her patients “give her.” “I’ll keep whatever I can,” she says. 

While a patient typically won’t go from a D cup to an A, sometimes people say they want to be at least a C. In this case, patients can return for an additional procedure, like [fat grafting](https://aedit.com/aedition/why-everyone-is-talking-about-fat-grafting), down the line. “That is an additional procedure and is all natural, all you,” Dr. Cassileth explains. “But you have to build the foundation and go from there.”

### **5. What Is SWIM Breast Reconstruction Recovery Like?** 
Dr. Cassileth says it’s similar to mastectomy reconstruction and takes about a month. You have a week of being sore and a second week of being functional, but you can’t jog or lift anything heavy. “I won’t let someone do super heavy weights until the fourth week,” she says, but, by the third week, you’re pretty much back to your regular routine. This recovery is two weeks shorter than direct-to-implant reconstruction, which is a procedure she still performs regularly. 

## **The Takeaway**
Earlier this year, Dr. Cassileth and Dr. Richardson had an [article published](https://www.journalacs.org/article/S1072-75152030076-4/fulltext) in the *Journal of the American College of Surgeons* about the procedure, and the pair have been training fellow surgeons in the technique. The hope is that, long term, SWIM breast reconstruction will catch on and become a safe, effective, and common breast reconstruction option for women around the world. 

Now Trending

For women diagnosed with breast cancer or those with the BRCA gene mutation who are proactive, post-mastectomy life used to be either an implant or no-breast kind of existence — until now.

SWIM Breast Reconstruction: A No-Implant Technique For Breast Cancer Mastectomy Patients

SWIM Breast Reconstruction: A New No-Implant Technique For Mastectomy Patients

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*Since 1985, October has served as Breast Cancer Awareness (BCA) Month — a period devoted to educating the public on the disease that, [according to the Centers for Disease Control and Prevention (CDC)](https://www.cdc.gov/cancer/breast/statistics/index.htm), is the second most common form of cancer in women, regardless of race or ethnicity. Men can also be diagnosed with breast cancer (albeit at a much lower rate), and The AEDITION is devoting much of its coverage this month to [BCA](https://aedit.com/aedition/category/breast-cancer-awareness), from expert guides to mastectomies and reconstructive breast surgery to powerful patient perspectives and roundups of products that give back.*

It is estimated that some 250,000 women in the U.S. will be diagnosed with breast cancer each year. More than half of these cases will require invasive treatment like mastectomy procedures. 

For many, surgical breast reconstruction is an important part of the treatment and recovery process (read our comprehensive guide to breast reconstruction [HERE](https://aedit.com/aedition/comprehensive-guide-to-breast-reconstruction-nipple-reconstruction-after-breast-cancer)). Just as advancements have been made to mastectomy techniques, similar progress has occurred in reconstruction. Life-like, three-dimensional tattoos now offer patients a non-surgical alternative to traditional areola and nipple restoration. These medical tattoo techniques allow patients to achieve natural-looking breasts after surgery, as well as treatment for conditions like burn disfigurement, scarring, and skin discoloration. 

## __What Are Medical Tattoos?__

Medical tattooing, also known as medical [micropigmentation](https://aedit.com/procedure/scalp-micropigmentation), is a technique that is used as part of restorative and reconstructive medicine to help patients regain the natural appearance of their post-surgical and post-trauma skin with tattoos. The method, which involves sterile pigments being injected into the top layers of the skin using a medical tattoo machine, can be used to treat a wide variety of cosmetic concerns that have resulted from injury or illness.

One of the most life-changing applications of the method is for areola and nipple reconstruction in patients who have had a mastectomy. The procedure, when carried out by an experienced practitioner, allows patients to have natural-looking breasts once again — without additional surgery. 

## __What Options Are Available for Nipple and Areola Reconstruction?__

The main decisions patients face when it comes to nipple and areola reconstruction is whether they wish to undergo an additional surgery, opt for a non-surgical approach, or settle on a combination of the two. 

In terms of surgical options, patients can have a nipple created using a flap of skin on the breast that is reshaped to mimic the natural protrusion of the area. A skin graft, meanwhile, is employed to recreate the areola. These procedures are typically classified as outpatient and performed under local or general anesthesia after the initial reconstructive surgery scars have healed. Patients can also have the skin flap nipple reconstruction without the areola restoration. In this case, the areola is tattooed when the wound has healed.

For patients who do not wish to have further surgery, they may choose to commission a personalized silicone prosthesis or opt for reconstructive tattoos. Not your average ink, the tattoos must be carried out by a highly skilled and specialized practitioner, who understands the anatomy of the area, in addition to having a deep understanding of the emotional impact of the process.

## __Ask the Expert__

[Dominique Bossavy](https://www.dominiquebossavy.com/) is a pioneer of the reconstructive tattoo field. Born and raised in France, she trained in Paris before establishing her practice in the U.S. Using her proprietary NanoColor Infusion technique, she works with clients in both New York and L.A., offering both medical and cosmetic tattoo services — including scar treatment, eyebrow microblading, and French lip blushing to name a few.

She works clients following surgery or trauma to help them feel like themselves again by improving the appearance of scars and other skin concerns, and her areola restoration has become an important part of the breast reconstruction process for post-mastectomy patients. Here, she tells The AEDITION about her technique and the life-changing impact her work has on cancer survivors.

__The AEDITION:__ *How did you start your career in semi-permanent cosmetics? How did that journey result in you honing the NanoColor technique you use today?*

__Dominique Bossavy:__ At first, I was a client who was interested in the services of semi-permanent cosmetics. Unfortunately, I ended up with a botched job on my lips, which looked like I had a dark, unsightly line outlining my lips. It was upsetting and disfiguring. I was looking to find something to enhance my lips and thought that the product and process were possible, but the execution was just not there. I knew that needed to be a way to use this process and this technology, so it was really my search to find someone to help me fix the unsightly black line around my lips that I found my mentor and my calling. I was in France and found someone who was, at the time, a leader in the field and she offered me an internship to learn the art of her trade and techniques. 

Although I loved the concept and was fascinated by it, I still hated the results, which were still too obvious and unnatural. Even training with the best in the field at that time, I felt the industry was unsuccessful at truly enhancing the real essence of a woman’s beauty. So, I was faced with the challenge to either find a different way or to quit the industry.

I took on the challenge and began to dissect the entire process — from the application process to the molecular breakdown of colors — and figure out why it looked so flat or why the colors always looked unnatural or eventually faded to unnatural colors. I wanted to find the best solution to enhance features — with undetectable definition, dimension, and dynamic — to highlight natural beauty. I researched every aspect of the procedure in-depth and collected valuable facts before creating my specific NanoColor Infusion techniques.

__The AEDITION:__ *What concerns are you able to address for patients using your NanoColor Infusion technology and tattooing technique?*

__DB:__ I have worked on solutions to several problems women face, including burn disfigurements, post-trauma and post-surgery scars, stretch marks, hypo- and hyper-pigmentation, vitiligo, and alopecia. I even recreated a trompe l'oeil version of a missing toe and toenail and have tattooed the cornea of a blind eye. When people come to me with a problem, I always do my best to be the solution — even if it has never been done before.

__The AEDITION:__ *How does the nipple and areola restoration work?* 

__DB:__ I use non-allergenic microparticles of custom-blended colors that are skillfully infused into the dermal layer of skin to simulate natural-looking or well-defined makeup. 

In cases of reconstructive breast surgery after mastectomy, the medical micropigmentation process is used to improve the aesthetic appearance of the nipple-areola complex. The application of flesh-colored pigments to the restored areas of the areola may be utilized either as a supplement to or as a less invasive alternative to the skin-grafting procedure that, for many years, was the only available method of restoring balanced coloration to the area. 

Scar removal or camouflage is key, as is the realistic appearance of the areola pigmentation with its nuances. No one has only one color or texture in their breast tissue, and there are veins, hair follicles, and other details that make each client unique too. 

<CaptionImg url={https://images.ctfassets.net/zw35sfestf1t/1x1Cvi2ILWXeH4VIjUA6CW/00397e001b465fd5e2337edbf2a3276e/Screen_Shot_2019-10-17_at_11.53.45_AM.png}>
  A before-and-after of Bossavy's trompe l'oeil 3D areola for a breast reconstruction patient.
</CaptionImg>

__The AEDITION:__ *What does the consultation and tattooing process entail?*

__DB:__ Usually, the process takes several visits to obtain the desired final result. First, I take measurements, assess the asymmetries, and draw the areola onto the woman's breast. Then, I pick the three colors necessary to create a three-dimensional effect. A topical anesthetic is then applied to the client's breast and, within 45 minutes to an hour, the work is complete. It takes about nine days to heal. A second session is scheduled at six weeks to perfect the work and sometimes a third appointment is needed for some additional layering of color or texture. 

__The AEDITION:__ *How realistic are the results?*

__DB:__ Areola pigmentation has come a long way. It is no longer a bullseye tattoo over the breast mound. I actually create a 3D nipple which gives the illusion of protrusion that makes the tattooed areola very realistic with some depth and details of color and texture. I also recreate the illusion of the Montgomery glands and texture of a natural areola. When I reveal the results to a client, the first reaction is stupefaction — they can't believe how real they look. In some cases, clients have said that they look better than the real one they had. 

__The AEDITION:__ *How do the tattoos impact clients’ confidence?*

__DB:__ When a person is diagnosed with breast cancer, it is one of the scariest times of their lives. It can change them completely, particularly physically. Once a person has beaten cancer, they can focus on rebuilding themselves emotionally and physically, so restoring their physical femininity definitely has a positive effect. This is the final step of breast reconstruction, post-mastectomy. The emotional toll of not having nipples is important. Often, at the time of the reveal, they are so overwhelmed by happiness, they start crying. They are elated and say they feel complete and like a woman again. 

Clients have told me that they are no longer reminded of what happened to them, and they are able to move on with their lives. In many cases, they are ready to live a normal life again — being able to undress at the gym, to go to the beach, or start a new romance. They all have one thing in common: They want to leave the past behind.

In this society of filters and social media perfection, the impact of losing vibrancy, beauty, femininity, and the original or natural beauty of features like breasts is even more painful. My work gives them back a sense of normalcy by giving them back what was taken away by a truly traumatic and life-changing situation. They feel like they can face mainstream society again with confidence.

The impact that this 3D nipple-tattooing has on body image, self-esteem, emotional wellbeing, intimacy, and relationships is undeniable. It's a very emotional experience for my clients, and I am proud to contribute in some way to helping erase the constant reminders of a bad chapter in their life. As an artist on a live canvas, my mission is always to recreate the look of normalcy as artistically and scientifically possible.

__The AEDITION:__ *Do you often hear from your clients after you finish working with them?* 

__DB:__ I do! "I never thought I would feel whole again" are not words to a song, but a common phrase I hear from the many women I have helped after breast cancer. It's a very emotional experience for my clients, being able to erase the constant reminder of a bad chapter in their lives. A client recently shared: "The 3D areola gave me my confidence back, which I needed after everything that happened. It made me feel more comfortable looking at myself in the mirror. Now I feel confident enough to date again and get on with my life."

__The AEDITION:__ *Do you foresee restorative tattoos becoming a more common part of the reconstructive and recovery process?*

__DB:__ Surgeons and doctors see valuable benefits with this procedure. It's also now a legal requirement to provide reconstructive procedures — medical insurance companies must cover the cost of the procedure. I am in touch with top cosmetic surgeons locally and globally who want to work in tandem to provide this service to their clients. Oncologists and cosmetic surgeons, nurse practitioners, physician assistants, and counselors all realize there is more to healing than just removing cancer. The emotional and physical scars are painful and are all part of the recovery process to be addressed.

Expert Opinion

Breast reconstruction is an important part of the breast cancer treatment and recovery process. Life-like, three-dimensional medical tattoos now offer patients a non-surgical alternative to traditional areola and nipple restoration.

Interview With Dominique Bossavy About Reconstructive Nipple Tattoos For Breast Cancer Survivors 

Inside The Life-Changing Industry Of Reconstructive Tattoos

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*Since 1985, October has served as Breast Cancer Awareness (BCA) Month — a period devoted to educating the public on the disease that, [according to the Centers for Disease Control and Prevention (CDC)](https://www.cdc.gov/cancer/breast/statistics/index.htm), is the second most common form of cancer in women, regardless of race or ethnicity. Men can also be diagnosed with breast cancer (albeit at a much lower rate), and The AEDITION is devoting much of its coverage this month to [BCA](https://aedit.com/aedition/category/breast-cancer-awareness), from expert guides to mastectomies and reconstructive breast surgery to powerful patient perspectives and roundups of products that give back. *

Now that you have a better understanding of the physical and emotional toll of breast reconstruction and the importance of finding the right surgical team (read our overview of how to approach the breast and nipple reconstruction process [HERE](https://aedit.com/aedition/post-mastectomy-breast-reconstruction-process-breast-cancer)), it is time to dive deeper into the surgical options that exist for post-mastectomy patients to reconstruct their breasts and nipples.

Generally speaking, there are two categories of breast reconstruction: implant-based and autologous tissue (a.k.a. “flap”) based. In some cases, a combination is used to achieve the most natural and symmetrical results. Similarly, there are two main types of nipple reconstruction. One involves tattooing alone, while the other is a hybrid of reconstruction and tattooing.

“I want all of my patients to understand their options so that they can make the best choice for them,” says Nashville-based board certified plastic surgeon [Jacob Unger, MD](https://aedit.com/provider/jacob-unger-md-2649), who performs hundreds of breast reconstructions a year. “And then my job is to give the best result I can under those constraints.”

Here, a comprehensive guide to the most common types of breast and nipple reconstruction.

## __Reconstruction With Breast Implants__

The most popular form of breast reconstruction, breast implants offer a shorter surgery and recovery time than other reconstructive procedures. Implant reconstruction can either be delayed (performed in the months following mastectomy) or direct (performed in conjunction with the mastectomy surgery), and medical advances — like skin-sparing mastectomies, cohesive gel silicone implants, and internal support technologies like [AlloDerm](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4184054/) and [GalaFLEX mesh](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070449/) — have allowed surgeons to create increasingly natural-looking results.

Despite the popularity, the technique is not without fault. “The challenge with implant-based reconstruction is that there is no natural soft tissue of the breast to help camouflage and contour an implant or to help rearrange tissue and nipple position in the same way that you can when there’s native breast tissue,” says Dr. Unger.

With that in mind, it is important to understand the different facets of implant-based reconstruction.

### __Pre-Pectoral Implant Placement__

While [breast implants](https://aedit.com/procedure/breast-augmentation-with-implants) (both reconstructive and cosmetic) have historically been placed under the pectoral muscle to help achieve a more natural look, the trend is now toward pre-pectoral (read: over-the-muscle) placement. 

“Pre-pectoral implants allow for an easier recovery with less pain and discomfort,” says UCLA board certified plastic surgeon [Jason Roostaeian, MD](https://aedit.com/provider/jason-roostaeian-md-449). Another perk? The lack of animation deformity. “When you have an implant under the pec muscle and you flex it, and it makes things look a little off,” he shares.

<CaptionImg url={https://images.ctfassets.net/zw35sfestf1t/4kGyMFWGZDViCo4RyAozgb/7b738a9b9c468daccac9743810d02f07/JacobUnger__1_.jpg}>
A before-and-after of Dr. Unger's pre-pectoral breast reconstruction following a nipple-sparing mastectomy.
</CaptionImg>

Ideal candidates for [pre-pectoral placement](https://aedit.com/procedure/pectoral-implants) are those with younger, thicker skin, which better camouflages the implant directly below. Technique is also important. “Wrapping the implant in a dermal matrix (sterilized cadaver skin) allows you to contain the implant well and gives it an extra layer of coverage,” Dr. Roostaeian notes. “But the most important technique we use to disguise the implant is fat grafting.”

Rather than using an implant alone, plastic surgeons will often recommend a hybrid procedure that involves harvesting fat from a donor site (think: the belly, flanks, or inner thighs) to be injected around the breast implant. The result? Smoother and more natural-looking breasts.

“Fat grafting has changed the way I do breast reconstruction,” says Beverly Hills-based board certified plastic surgeon [Leif Rogers, MD](https://aedit.com/provider/leif-rogers-md-578). “It can improve the outcome of any breast reconstruction, creating a more natural appearance and giving me the ability to fine-tune my results in a way not previously possible.”

Additionally, Dr. Rogers has been having success with a new liposuction-alternative called [Renuva](https://www.mtfbiologics.org/our-products/detail/renuva). “Renuva is a biological allograft product that stimulates your body to grow its own fat cells,” he says. “This would be an ideal product for small contour irregularities after breast reconstruction as opposed to using a patient’s own fat.” 

### __Delayed Reconstruction Using Implants__

Depending upon a patient’s individual anatomy and treatment plan, he or she may choose not to combine their mastectomy and reconstruction procedures. Similarly, surgeons may recommend delaying the placement of permanent breast implants until a later date for better results. 

In such cases, tissue expanders are sutured into the breast pocket immediately following the mastectomy. In the weeks and months following the surgery, the expanders are gradually inflated in a plastic surgeon’s office using air or saline. “A tissue expander preserves the space where the breast needs to be,” says Dr. Unger. And, since placing a heavy silicone implant into an empty breast pocket would compress the fragile blood supply that remains post-mastectomy and lead to tissue death, he notes that the tissue expander “allows the mastectomy flaps to rest without putting undue weight there.”

<CaptionImg url={https://images.ctfassets.net/zw35sfestf1t/QWzB5aIWpQK0olqHTiNQD/617149c0afa434bc6b455775044c2c95/dr_jason_plastic_surgery_breast_reconstruction_subpec_implant_f__2_.jpg}>
  A before-and-after of Dr. Roostaeian's unilateral subpectoral breast and nipple reconstruction.
</CaptionImg>

Although the expansion process can be uncomfortable, tissue expanders have the additional benefit of giving both plastic surgeons and their patients time to home in on an aesthetic goal. Once the expanders reach the appropriate size, they are exchanged for permanent breast implants. Dr. Roostaeian’s patient Caroline* (diagnosed at 39) admits that the expanders proved to be a necessary evil. “My expanders didn’t look natural, and were sometimes very painful after they were filled,” she recalls. “But they helped me get a really good idea of what size implants would ultimately be best for me.”

After years of monitoring benign tumors and then a cancer diagnosis at age 31, Dr. Unger’s patient Laura says she chose a nipple-sparing double mastectomy because of the quality of reconstruction available today. “I was tired of the breasts I had, but I wasn’t ready to give them up completely,” she confides. “I was really lucky because he was able to place the expanders on top of the muscle, which was a lot easier recovery for me.” 

Laura chronicled her journey on Instagram [@laura_birdwell](https://www.instagram.com/laura_birdwell/?hl=en) and her blog, [tatatocancer](https://tatatocancer.blog/), and, once her expanders were filled, Dr. Unger exchanged them for permanent implants and performed simultaneous fat grafting. Like many reconstruction patients, Laura then had an additional surgery to further refine her results. “I think they look better now than they did before,” she says of her breasts.

### __Direct-to-Implant Reconstruction__

In some cases, women can skip the expander step by having their permanent breast implants placed immediately after their mastectomy. With its promise of only one surgery (which means less anesthesia and recovery time), the direct-to-implant option is understandably appealing — though it’s not for everyone. 

According to Dr. Unger, good candidates are usually women with “smaller, ideally shaped breasts,” who “want to be close to the same size, are very healthy, and have very robust mastectomy flaps” (read: ample blood supply). 

Hayley, diagnosed at age 30, initially had a lumpectomy. “That gave me time,” she says of the procedure. “They got the tumor out, and found out it hadn’t spread.” In her search for a highly skilled surgeon with experience performing pre-pectoral, direct-to-implant reconstruction, Hayley found Dr. Roostaeian after interviewing five or six surgical teams.

During this kind of reconstruction, Dr. Roostaeian uses a new fluorescence imaging technology called SPY to evaluate blood flow right in the OR. “It’s another tool in our arsenal to help ensure the long-term success of the reconstruction,” he says.

Kelly, diagnosed at 45, opted for a unilateral mastectomy and immediate reconstruction with Dr. Rogers. “I had cosmetic implants, and I really liked how I looked before,” she shares. “Whether or not to have reconstruction was never a question in my mind.” 

She was able to undergo a sub-pectoral, direct-to-implant reconstruction, in part because she already had breast implants placed under the muscle. Dr. Rogers also replaced the implant in the non-cancer breast to ensure symmetry, and Kelly ended up having a couple of subsequent surgeries — including fat grafting and nipple reconstruction — for further refinement. Eight years later, she is still very happy with the results. “You can’t even tell the difference,” she says.

While there are plenty of direct to implant success stories, there is also risk. Because of the fragile nature of post-mastectomy skin flaps, many surgeons prefer the two-stage (expander followed by implant) process. “Everybody wants less surgery. Everybody wants to be done and have it behind them,” says [Michael Newman, MD](https://aedit.com/provider/michael-newman-md-795), a board certified plastic surgeon at South Bay Plastic Surgeons in Torrance, CA. “But it’s more important for me to give them a more durable, long-term result.” He prefers using a tissue expander because “it’s very light” and “doesn’t put any pressure on the skin or the mesh,” which “allows the sutures to heal.”

Additionally, the procedure is seldom as ‘one and done’ as it sounds. Patients almost always require additional surgeries to achieve their aesthetic goals. “Direct to implant is a nice concept,” says Dr. Unger, “But the vast majority of the time, you’re going to need to go back to the operating room to touch things up or round things out or add some fat.” 

## __Flap Reconstruction__ 

Autologous tissue reconstruction — more commonly known as “flap surgery” — involves the transfer of tissue from one area of the body (i.e. a donor site) to the chest to create a breast mound. Surgeons can either shift the tissue from one area to another, leaving the primary blood supply of the donor site intact (a.k.a. a pedicle flap), or completely remove the tissue from its original spot and reattach it to the chest in a free flap procedure. 

Free flaps require intricate microsurgery, during which plastic surgeons suture blood vessels together under a microscope to re-establish the blood supply between the donor tissue and the chest. It’s meticulous and time-consuming work (bilateral free flap surgeries can take up to 12 hours to complete), and patients are closely monitored in the hospital for up to five days post-op to ensure the flap is viable. 

The recovery process can be more complex than implant surgery because patients have multiple surgical sites to contend with (the chest and the donor area), though patients report similar pain and discomfort levels with each type of procedure.

### __Types of Flap Reconstruction__

Because of the donor site component, there are a variety of flap procedures for a patient to choose from based on their anatomy and aesthetic goals. The names are based upon the donor sites, including those from the abdomen (TRAM and DIEP), back or shoulder (LAT), inner thigh (TUG), and buttocks (GAP).

<CaptionImg url={https://images.ctfassets.net/zw35sfestf1t/6tVaTrX0SELcdJYzGiEfbF/430d029fe1f2c807e002d916c354e783/10-16-2019_Editorial_Before-After_BreastReconstruction.jpg}>
  A before-and-after of Dr. Newman's bilateral DIEP flap breast and nipple reconstruction.
</CaptionImg>

Among the plastic surgeons we interviewed, the most popular flap surgeries are the latissimus dorsi (LAT) flap and the deep inferior epigastric perforator artery (DIEP) flap. While a LAT flap is often used in conjunction with a breast implant reconstruction for better results, the DIEP is a free flap procedure that removes abdominal skin and fat only (similar to a tummy tuck) to create a breast mound. 

#### __LAT Flap__
- __Donor Site__: Composed of muscle, skin, and fat from the back
- Type of Flap: A pedicle flap (it remains attached to its primary blood supply)
- __Scarring__: Creates a donor site scar along the back that can usually be concealed in the bra line and an oblong scar around the new breast mound
- __Surgery Time__: 5 to 7 hours, on average 

#### __DIEP Flap__
- __Donor Site__: Composed of skin and fat (no muscle) from the abdomen
- __Type of Flap__: A free flap (it is completely detached from its original blood supply)
- __Scarring__: Creates a donor site scar between the hip bones (similar to a cosmetic tummy tuck) and an oblong scar around the new breast mound
- __Surgery Time__: 8 to 12 hours, on average

### __Advantages of Flap Reconstruction__

While flap procedures are more complicated to perform and require longer surgery times, Dr. Roostaeian says they remain the “gold standard” for breast reconstruction because they create a result that most closely resembles and behaves like a natural breast.

Unlike an implant, the new breast mound feels more like a natural breast because it is created with the patient’s own fat and skin. In the case of unilateral reconstruction, the plastic surgeon will be better able to match the new breast to the unaffected breast. Additionally, breasts created from flap procedures can fluctuate in size and shape as a patient gains or loses weight. 

“Flap surgery is ideal for patients who’ve opted for unilateral reconstruction because that flap changes with your body,” says Dr. Roostaeian, who adds that the results are, long term, much more permanent than implants. “When you choose the implant route, you’re basically signing up for more surgeries in your life because implants tend to have some issues down the road.”

<CaptionImg url={https://images.ctfassets.net/zw35sfestf1t/35Yvu4Q4Y1iyJmiDjQDUHU/9a54e787069024a30d7755bb2ce90c84/Flap_Reconstruction__1_.jpg}>
  A before-and-after of Dr. Rogers' unilateral flap breast and nipple reconstruction.
</CaptionImg>

That lack of future revisions led Marjan, one of Dr. Roostaeian’s DIEP flap patients who was 47 at the time of her surgery, to choose the procedure. “I told him that because I was young, I didn’t want to have to go under the knife in my seventies,” she recalls. 

Dr. Rogers’ patient Meredith* didn’t want breast implants because she thought they’d look unnatural and possibly interfere with her active lifestyle. “When Dr. Rogers explained that the DIEP procedure would be a tummy tuck — replacing my breasts with my own tissue — and I wouldn't have implants, I was all in,” she shares. “I knew it would be a long 12- to 13-hour surgery the day of, but I was ready to go for it.”

Though she was initially concerned about scarring and the longer recovery time, Meredith is “beyond satisfied” with her reconstruction. And, with her nipple reconstruction also complete, she says her breasts appear so natural that it looks like she had a [breast lift](https://aedit.com/procedure/breast-lift) and [abdominoplasty](https://aedit.com/procedure/abdominoplasty) (i.e. tummy tuck) — not a double mastectomy.

Flap surgery is also an option for women whose implant reconstruction failed due to radiation or persistent capsular contracture issues. Dr. Roostaeian’s patient Caroline originally had bilateral, implant-based reconstruction, but radiation damaged her tissue and caused healing problems. “Dr. Roostaeian told me that the only way to permanently address the situation was to have a DIEP flap,” she says. “It was daunting, and I didn’t think I had enough fat, but he was able to create a small breast and augment it with an implant. It’s so natural that I wish I’d had enough fat to do the other side too.”

## __Nipple Reconstruction__

While skin- and nipple-sparing mastectomies have become commonplace, the patient’s diagnosis may not always allow surgeons to keep the nipples intact. This leaves patients with two reconstruction options: tattooing alone or a combination of surgical reconstruction and tattooing. 

In the former, a medical tattoo artist matches the new nipple and areola to the existing one (after unilateral mastectomy) or creates two new nipple/areolar complexes based on the patient’s aesthetic preferences (after bilateral mastectomy). Shading and color variations help create the illusion of depth and projection.

Surgical nipple reconstruction, meanwhile, takes about 45 minutes and can be done either in conjunction with a follow-up reconstructive surgery or alone under local anesthesia. Surgeons use skin from the center of the breast to create a nipple, leaving a small horizontal scar. Patients can then have the areola and nipple tattooed for a more natural-looking color and to conceal any visible scarring.

## __The Takeaway__

Just as no two breast cancer diagnoses are the same, the reconstruction process is a deeply personal experience that patients may choose to undergo when it is most comfortable for them. With that said, understanding the options available prior to having a lumpectomy or mastectomy can ensure the patient ends up with the best results for their anatomy and aesthetic goals. Finding the right surgical team and seeking the support of women and men who have been through the experience can help to make sense of the process.  

*Patient names have been changed

Aesthetics

From immediate and delayed implant reconstruction to the numerous types of flap surgeries, The AEDITION has compiled an in-depth guide to post-mastectomy breast and nipple reconstruction.

A Comprehensive Guide To Breast Reconstruction And Nipple Reconstruction

A Comprehensive Guide To Breast And Nipple Reconstruction

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*Since 1985, October has served as Breast Cancer Awareness (BCA) Month — a period devoted to educating the public on the disease that, [according to the Centers for Disease Control and Prevention (CDC)](https://www.cdc.gov/cancer/breast/statistics/index.htm), is the second most common form of cancer in women, regardless of race or ethnicity. Men can also be diagnosed with breast cancer (albeit at a much lower rate), and The AEDITION is devoting much of its coverage this month to [BCA](https://aedit.com/aedition/category/breast-cancer-awareness), from expert guides to mastectomies and reconstructive breast surgery to powerful patient perspectives and roundups of products that give back.* 

From the emotional toll to a whirlwind of appointments, testing, and treatment options, a breast cancer diagnosis can bring a flurry of confusion and fear. Each aspect comes with its own impact — not only on a woman’s health, but on her sense of self. Fortunately, early detection and advances in both technology and surgical techniques have created better breast reconstruction options that help patients to feel like themselves again. 

To better understand the intricacies of the mastectomy and breast reconstruction process, The AEDITION spoke to leading plastic and reconstructive surgeons and their patients about the logistical, physical, and emotional aspects of breast reconstruction — whether it’s finding the right surgical team, understanding what the results will look like, or learning how to heal (physically and emotionally) after surgery. 

## **Finding the Best Surgical Team**

Although it can be hard for a woman recently diagnosed with breast cancer to focus on the long term, the success of her breast reconstruction may ultimately depend on it. “Some patients are so focused initially on getting the cancer out that they don’t really explore the options for reconstruction,” cautions plastic surgeon [Michael Newman, MD](https://aedit.com/provider/michael-newman-md-795), of South Bay Plastic Surgeons in Torrance, CA. “But then they get to that stage when the cancer is out, they’re feeling better, and they really want a better result.” 

When that happens, they often try to find another surgeon, and Dr. Newman says he treats a fair number of patients seeking a revision after surgery elsewhere. While he is able to help the majority of such patients, it is not the most optimal way to do things. 

“There are a lot of breast surgeons who don’t leave the best tissue behind for the plastic surgeon to work with. When there’s a limited amount of tissue to work with, even the best plastic surgeon can’t do a great job,” he says. “It’s better to optimize their reconstruction from the beginning because they end up with a better final result.”

In order to do so, Dr. Newman recommends women take the time to find the best breast surgeon, so they can “set the stage for an ideal reconstruction.” In a perfect world, he says patients should visit a plastic surgeon at the outset to get a referral for a breast surgeon (though it generally happens the other way around). But, if a patient has already chosen a breast surgeon, Dr. Newman suggests asking her plastic surgeon if that doctor is someone they’ve worked with in the past.

The key, according to Dr. Newman, is to find a breast surgeon capable of achieving a balance between removing all of the breast tissue and leaving an adequate amount of skin, fat, and blood vessels behind to support the reconstruction. And he says you shouldn’t be shy about asking your breast surgeon about their experience level and their philosophy regarding tissue removal. 

Another piece of advice? Find support.

Dr. Newman advises women to seek out breast cancer support groups (often offered at hospitals) for advice on which doctors to choose. “When you talk to other people who have been through it, they’ve not only had their own experiences, but they’ve heard from other people too,” he shares. 

Once you’ve found your team, the next step is determining the best course of action for your diagnosis. 

## **Removing the Cancer: Lumpectomy vs. Mastectomy**

Deciding on a breast cancer treatment plan often depends on the type and stage of the cancer, the philosophy of the doctors, and the patient’s own goals and preferences. 

During a lumpectomy procedure, a breast surgeon removes only the tumor, leaving the rest of the breast tissue intact. Less invasive than a mastectomy, a lumpectomy may not have a noticeable impact on the size and shape of the breast — though a growing number of patients are opting to combine the procedure with aesthetic surgery.

“Women with very large breasts who are getting lumpectomy surgery sometimes are getting [breast lifts](https://aedit.com/procedure/breast-lift) or [breast reductions](https://aedit.com/procedure/breast-reduction) as part of that surgery,” says Dr. Newman. “It’s either to make them feel more comfortable, more symmetric, or to facilitate their secondary treatment such as radiation.”

Additionally, Dr. Newman has noticed that younger women are increasingly choosing to undergo a mastectomy — either unilateral (one breast) and bilateral (both) — during which the surgeon removes all of the breast tissue (read our comprehensive guide to the surgery [HERE](https://aedit.com/aedition/what-to-expect-before-during-after-mastectomy-breast-cancer)). “As breast reconstruction results have improved, patients are more likely to move towards a mastectomy or even a double mastectomy than they had in the past,” he says. 

Historically, surgeons removed the breast tissue, nipple, and much of the skin, but the rise of nipple- and skin-sparing procedures have been game-changers for breast reconstruction results. During a nipple-sparing mastectomy, the breast tissue is essentially scooped out, leaving the outside of the breast (nipple and skin) virtually intact. “You don’t have to sacrifice the most difficult aspect of the breast to reconstruct,” says Nashville-based plastic surgeon [Jacob Unger, MD](https://aedit.com/provider/jacob-unger-md-2649), of the technique. “To create a nipple, you either need to get a tattoo, which leaves no projection, or reconstruct one, which leaves scarring in the center of the breast.” 

According to Dr. Unger, who performs several hundred breast reconstructions per year, data shows that, in most cases, leaving the nipple and skin intact does not adversely impact a patient’s long-term prognosis — but it can do wonders for the post-surgery outcome. Sparing the nipple and concealing the surgical scar in the breast fold allows surgeons to create the most natural-looking results. 

## **Types of Breast Reconstruction**

Generally speaking, there are two categories of breast reconstruction: implant-based and autologous tissue (a.k.a. flap)-based.

- __Implant__: Most commonly used thanks to its shorter surgical and recovery time, implant-based reconstruction can be performed in conjunction with a mastectomy or at a later time and involves using an implant to recreate the breast. 

- __Autologous Tissue__ (a.k.a. Flap): In this procedure, the surgeon utilizes the body’s own tissue to construct a breast mound by transferring tissue from one area of the body (known as the donor site) to the chest.

Sometimes, a combination of the two is used to achieve the most natural, symmetrical results. “I want all of my patients to understand their options so that they can make the best choice for them,” says Dr. Unger. “And then my job is to give the best result I can under those constraints.”

Creating a natural *and* symmetrical result can be challenging — regardless of the type of mastectomy or breast construction technique performed. In patients who opt for a unilateral mastectomy with an implant, for example, it is difficult to match real breast tissue to the standard shape of an implant. 

A patient’s unique anatomy, meanwhile, can pose challenges for reconstruction after a bilateral mastectomy, too. “People aren’t always even between their two sides,” UCLA plastic surgeon [Jason Roostaeian, MD](https://aedit.com/provider/jason-roostaeian-md-449), points out. “We want the best aesthetic results, but there are a lot of variables out of our control: how the mastectomy was performed, whether they are planning to have radiation, the structure of their ribcage — all of these things that nobody really ever thinks about.”

While surgeons take all of these nuances into account, there’s no such thing as perfection. In fact, relying solely on measurements — particularly for things like nipple placement — can leave a patient with an unnatural result. “The good news is that since nobody is perfectly symmetric, it’s more about making each breast look good on its own,” says Dr. Roostaeian. “They are sisters, not twins.” 

Ultimately, the surgeon’s well-trained eye is paramount because the reconstruction process is equal parts art and science, and managing a patient’s expectations is key. “Women who are undergoing breast cancer care today are expecting and hoping for results similar to aesthetic breast surgery,” says Dr. Unger. “It’s about having appropriate expectations and having good lines of communication.”

## **The Emotional Impact of Breast Reconstruction**

While a successful breast reconstruction can have a tremendous impact on helping women start to feel whole again after a cancer experience, the path isn’t always smooth or linear. It is not uncommon for reconstruction patients to experience some degree of post-surgery depression and seeking help through support groups or therapy can make a big difference. 

Dr. Roostaeian’s patient Marjan was ultimately very happy with her flap surgery, but it was emotionally challenging at first. “I started getting really emotional,” she says of her experience, which included a flap procedure, refining surgery, and nipple reconstruction. “I was regretting not getting the double mastectomy because I was afraid I’d have to go through all of this again.”

Initially, she says that every time she saw herself in the mirror, her unaffected breast reminded her of what she’d lost, but Marjan sought therapy and eventually came to terms with her new appearance. “I changed my perspective, my outlook on body image,” she shares. “When I see people now who look different, it doesn’t phase me. It’s just normal.”

Hayley, meanwhile, chose a pre-pectoral, direct-to-implant reconstruction in part because she wanted to be done with the process sooner. “I wanted to move on with my life, to feel like my old self again,” she says. But months after her treatments, Hayley experienced symptoms that her oncologist said were long-lasting side effects of everything her body’s been through. “Even though I know that I’ll never truly be my old self after going through something really scary, I grew a lot from it,” she says of her experience.

Caroline* also went through a period of conflicting emotions after her reconstruction. “It hit me at the end,” she says. “You’re so focused on getting through all of the terrible parts — mastectomy, chemo, radiation — to reach this goal of reconstruction, and, when you get there, you have to come to terms with the fact that no matter how well they put you back together, it’s not the old you. You have to learn to embrace the new you.”

One thing that can help give patients peace of mind is knowing that they had the best care. Dr. Unger’s implant reconstruction patient Laura, who chronicled her breast cancer journey on [Instagram](https://www.instagram.com/laura_birdwell/?hl=en) and her [blog](https://tatatocancer.blog/), says that finding the right plastic surgeon helped her get through an otherwise incredibly challenging time. “When you’re going through everything, and you’re losing your hair, it’s just such a comfort,” she says. “I call him ‘the good doctor.’”

Kelly feels the same way about the rapport she built with her own plastic surgeon, [Leif Rogers, MD](https://aedit.com/provider/leif-rogers-md-578). “It’s really important to educate yourself and to find someone you trust,” she says. “It’s a relationship, not a ‘one and done.’” 

*Patient names have been changed

The AEDITION speaks to leading plastic and reconstructive surgeons and patients about the logistical, physical, and emotional aspects of breast reconstruction — from finding the right surgical team to learning how to heal after surgery. 