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

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), 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, 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 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, 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, 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 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.

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, 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 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.