KR, Age 41
Breast Reconstruction

Patient-specific goals
A 41-year-old woman with newly diagnosed right breast cancer who decided upon a plan for a double mastectomy with removal of the nipple and areolas. Surgery was all that was necessary, she did not require chemotherapy or radiation.  Her goals were to maintain a natural shape to the breast and have a similar, but slightly fuller volume.

Our Solution
We planned and performed a two-stage implant-based breast reconstruction with initial temporary expander implants placed partially below the muscle.  Round silicone implants were subsequently used to create the final breast mound.  At 3 months, nipple and areola reconstruction was performed to complete the creation of a natural breast shape, sized to her desire.

DO, Age 45
Breast Reconstruction, BRCA carrier

The Challenge
This 45-year-old woman carried the BRCA gene mutation making her a high risk for developing a future breast cancer.  She decided on prophylactic removal of both breast glands to minimize any future risk.  She ideally wanted to maintain a near similar shape after mastectomy, with some additional volume if safely achievable.

Our Solution
We worked closely with our surgical oncologist to offer a double mastectomy with nipple preservation, entirely performed through the under fold of the breast.  We planned and performed a two-stage implant-based breast reconstruction with initial temporary expander implants placed partially below the muscle.  At 3 months an outpatient procedure to position round silicone implants was done to give the final natural result she was hoping for.

NS, Age 41
Breast Reconstruction, BRCA carrier

The Challenge
This 41-year-old woman carried the BRCA1 gene mutation making her a high risk for developing a future breast cancer.  She previously dealt with ovarian cancer, another malignancy associated with the BRCA1 mutation, for which she had previously undergone hysterectomy and ovary removal. She decided on prophylactic removal of both breast glands to minimize any future risk.  She ideally wanted to maintain a near similar shape after mastectomy, with some additional volume if safely achievable.

Our Solution
We worked closely with our surgical oncologist to offer a double mastectomy with nipple preservation, entirely performed through the under fold of the breast.  We planned and performed a two-stage implant-based breast reconstruction with initial temporary expander implants placed partially below the muscle.  At 3 months an outpatient procedure to position round silicone implants were done to give the final natural result she was hoping for.

DU, Age 42
Breast Reconstruction

The Challenge
This lovely 42-year-old woman was newly diagnosed with biopsy-proven breast cancer and decided on bilateral mastectomies for treatment.  When discussing her ideal result, she expressed feeling burdened her whole life by a breast size that she felt was bigger than her frame.  She ideally wanted to maintain a similar or smaller final breast appearance and hoped that the pre-existing asymmetry (larger left breast) could be improved upon.

Our Solution
This patient was a good candidate oncologically for a nipple preserving mastectomy that could be safely performed through the breast fold.  Knowing she desired a more symmetrical appearance and an avoidance of a final size any larger than before mastectomy, we planned a two-staged implant reconstruction.  These are results with high profile round silicone implants.  The implants are positioned in a partial submuscular position with the creation of an allograft sling, a technique that is performed in many implant reconstructions to support the breast implant internally.

BN, Age 58
Breast Reconstruction, Implant Reconstruction

The Challenge
This 58-year-old woman was newly diagnosed with right breast cancer at the time she came in for a consultation for post-mastectomy breast reconstruction. She preferred using an implant technique and hoped for a slightly fuller breast mound, but one that was still natural in appearance.

Our Solution
This patient’s cancer location was far enough from the nipple location that after discussion with her breast surgeon, we agreed her surgery could be done with nipple preservation. In this fashion, she would be completed in two surgeries, beginning with a temporary expander that at 3 months was replaced with a permanent round silicone implant. Given that she had room within her skin envelope to accomodate an implant larger than her native breast, we could safely end with a fuller result with natural sloping to the breast. Most women we see want to avoid a result that mimics a breast augmentation with excessive upper breast fullness and are so pleasantly surprised how it can be done!

DN, Age 45
DIEP Flap Breast Reconstruction

This 45-year-old woman had left breast cancer treated upfront with chemotherapy and followed with mastectomy surgery to remove both breast glands including the skin of the nipple and areola.  She preferred a similar cup size breast, but with some shape lifting if feasible.  Ideally, she wanted to avoid an implant and use her own tissue from the lower abdomen hoping it would also improve the abdominal appearance.

Our Solution
Our plan was to perform some additional skin lifting with the mastectomy so that we can envelope the tissue flap reconstruction higher on the chest.  The lower abdominal tissue was divided in half, with each DIEP flap transferred to the breast to replace the removed glandular volume.  The final step involved reconstructing the nipple and areola appearance and some final liposuctioning of the abdominal area to achieve the nice abdominal improvement and nicely shaped breast reconstruction made without any implants, just her own tissue.

HM, Age 49
DIEP Flap Breast Reconstruction

This 49-year-old woman was diagnosed with breast cancer and came to decide on having a double mastectomy with removal of the nipple and areolas with the breast tissue.  Her preference was to use her own tissue but was unsure if being otherwise trim would be prohibitive to doing a tissue flap reconstruction.

Our Solution
Despite being seemingly thin, often times I find during the examination that there is enough laxity to the lower abdominal tissue to safely be able to still perform a DIEP, or tissue flap, breast reconstruction.  Each case is unique, and experience guides my judgment as to whether there is an adequate volume from the tummy area to replace the planned tissue volume being removed during mastectomy.  The result shown is after double DIEP flap reconstruction and after a nipple reconstruction surgery was performed.  The photo shows the intermediate result before the final nipple coloring tattoo is completed.  Color selection and areola sizing are done with the patient’s preferences considered.  The procedure itself is done in the office and is a wonderful tool for achieving a realistic result.

MZ, Age 33
Bilateral Mastectomy + DIEP

The Challenge
This 33-year-old extremely active young woman was newly diagnosed with a left breast cancer. Given her young age and desire for a permanent, maintenance-free reconstruction, she opted for a tissue-based reconstruction. She knew at the time of diagnosis that surgery would follow with chemotherapy and radiation treatment.

Our Solution
During our initial consultation, she reiterated the active lifestyle she lives and her love for the outdoors, biking, hiking and distance swimming. Given the plan for radiation and her adequate candidacy for a tissue flap reconstruction, we pursued immediate DIEP flap reconstruction bilaterally. After mastectomy and DIEP flap surgery, she went on for chemotherapy and radiation. The minor changes that occurred after radiation was easily mitigated at the time of nipple reconstruction where the balance between radiated and non-radiated tissues was performed. She had a beautiful result and is thrilled to not have to deal with any implant. Her result was so natural in appearance she said her internist couldn’t believe they weren’t her original breasts!

DD, Age 58
BRCA+ Prophylactic Mastectomy + DIEP

The Challenge
This case illustrates the available option for a BRCA+ patient who is electing to undergo prophylactic, risk-reducing mastectomy and reconstruction. She strongly was looking to be reconstructed using her own abdominal based tissue and obtain a slimmer abdominal contour in the process.

Our Solution
During our initial consultation, she mentioned having recently undergone a breast reduction at another institution to create a smaller breast mound with a raised nipple position. This was done in hopes of a future nipple-sparing mastectomy procedure with flap reconstruction. A DIEP flap reconstruction was performed in conjunction with a nipple-sparing mastectomy done through the vertical scar from the breast reduction. No new scars on the breast! A really nice staged approach and result for a patient that may have the luxury to have a breast reduction prior to mastectomy. This process was doable because the mastectomy was prophylactic in nature, but for cancer patients, a similar lumpectomy and reduction procedure followed with completion nipple-sparing mastectomy with reconstruction can be done.

TD, Age 54
Bilateral Mastectomy + DIEP

The Challenge
This 54-year-old woman with newly diagnosed cancer presented with a strong desire to use her own stomach tissue for reconstruction. She was an active smoker and her history was also notable for prior cesarean section. At 5’10” she was accustomed to a large DD cup breast and wanted to maintain her current proportions.

Our Solution
During our initial consultation, we emphasized the immediate need to stop smoking before any reconstruction could be offered. After confirming her abdominal anatomy using CT imaging, we proceeded with DIEP flap surgery. She is a wonderful candidate for a nice result because of the combination of improved abdominal appearance and ability to create a naturally shaped, full cup breast reconstruction with her own tissue. This result is after nipple-areola construction which truly adds to the final result.

DD, Age 69
Delayed breast reconstruction with DIEP

The Challenge
This case illustrates the available option for a woman who desires breast reconstruction at a period of time after the initial mastectomy.  This healthy and active woman had a prior left breast mastectomy and an attempt at an implant reconstruction with another surgical team.  That procedure was complicated by skin loss and infection, ultimately needing further surgery to remove the implant.  She was left with the deformity shown.  She was referred to our practice for our expertise in tissue flap, DIEP flap, reconstruction.

Our Solution
During our initial consultation, she expressed a hope to achieve improved balance and symmetry as well as a reduction in breast size compared to her native breast.  To achieve the result shown, a right breast reduction and left breast reconstruction using her extra tissue from the abdomen was used as a DIEP flap.  At a second stage, we performed a left nipple reconstruction.  This photo is before a final office procedure wherein tattooed coloring is added to the reconstructed nipple to match the opposite appearance.  A nice result can still be achieved even in patients in whom an initial surgery may have not been successful.

DN, Age 61
Referral after unsuccessful implant surgery

The Challenge
This case illustrates one of the numerous challenging types of secondary breast reconstruction that are referred to my practice. This lovely woman, who had a history of a prior breast reduction, was newly diagnosed with a left breast cancer.
Her original surgeons pursued bilateral nipple-sparing mastectomies with tissue expander reconstruction, performed by opening the original breast reduction scars. Unfortunately, she developed nipple-areola and mastectomy skin necrosis which led to an implant infection. The right tissue expander needed removal with skin debridement leaving her with the appearance seen on the left. She expectedly felt anxious about another attempt at surgery but was encouraged to seek a second opinion to discuss options.

Our Solution
During our initial consultation, we discussed that despite being on the thinner side, there was a variation of the DIEP flap procedure that could adequately allow for enough tissue to recreate a matching breast mound. The technique involves ‘supercharging’ or connecting two separate vascular channels to nourish the entire lower abdominal tissue. She did well after surgery and is extremely happy with the improved balance to her chest appearance. The left breast is reconstructed with an implant. At a second stage, nipple-areola creation or three-dimensional nipple-areola tattooing will be performed to maximize the restoration of the breast form.

BB, Age 49
Radiated Implant Reconstruction

The Challenge
At 49, this patient was diagnosed with right breast cancer.  It was known at the time of diagnosis, that she would benefit from radiation therapy after mastectomy to reduce her risk of a future breast cancer.  A patient with a tumor size over a threshold amount, or clear lymph node involvement, are usually given this recommendation in addition to the use of chemotherapy.  Living a very active lifestyle and having a busy professional career, she opted for a shorter downtime implant reconstruction as opposed to one using her own tissue.  The tissue option often times fair better for patients who require radiation.

Our Solution
Despite the larger tumor size, the tumor location was a distance away from the nipple and so oncologically she was a candidate for nipple preserving mastectomy.  The tumor was along the side of the breast and so the procedure was not performed through the breast fold, our preferred approach, but along the side of the breast so that some skin could be removed over the tumor.  You’ll appreciate the mild darkening of the right breast skin after radiation.  In real life, the right breast is somewhat firmer and tighter when compared to the non-radiated left breast.   Nonetheless, she is pleased with overall size, shape and symmetry and values the reduction in cancer recurrence achieved through radiation.

MZ, Age 33
Bilateral Mastectomy + DIEP

The Challenge
This 33-year-old extremely active young woman was newly diagnosed with a left breast cancer. Given her young age and desire for a permanent, maintenance-free reconstruction, she opted for a tissue-based reconstruction. She knew at the time of diagnosis that surgery would follow with chemotherapy and radiation treatment.

Our Solution
During our initial consultation, she reiterated the active lifestyle she lives and her love for the outdoors, biking, hiking and distance swimming. Given the plan for radiation and her adequate candidacy for a tissue flap reconstruction, we pursued immediate DIEP flap reconstruction bilaterally. After mastectomy and DIEP flap surgery, she went on for chemotherapy and radiation. The minor changes that occurred after radiation was easily mitigated at the time of nipple reconstruction where the balance between radiated and non-radiated tissues was performed. She had a beautiful result and is thrilled to not have to deal with any implant. Her result was so natural in appearance she said her internist couldn’t believe they weren’t her original breasts!

CC, Age 53
Complication Management of  Implants + Radiation

The Challenge
This case illustrates the challenges of radiation on implant reconstruction.  This lovely woman was previously diagnosed with right breast cancer and treated elsewhere with right breast skin-sparing mastectomy (removing the nipple) and tissue expander placement.  Radiation was delivered to the right breast.  After the second stage procedure where the expander was exchanged for a permanent implant, she suffered from delayed wound healing with the implant becoming exposed through an opening in the skin.  She urgently required surgery to remove the implant and re-insert a limited inflated tissue expander.  At this point she was referred to our practice for our expertise in tissue flap, DIEP flap, reconstruction.

Our Solution
To achieve a size in balance with the oppose breast, we needed to utilize a tissue flap reconstruction to replace and supplement the skin on the right breast to achieve a similar cup size.  DIEP flap reconstruction, wherein the lower abdominal skin and fat is transplanted to the chest is a perfect solution for this case.  The procedure involves transplanting the appropriate combination of fatty tissue and skin and tailoring it to match the existing left breast.  At a second stage, a nipple reconstruction surgery was performed to improve the realism of the reconstruction.  DIEP flap, also known as an autologous free tissue flap from the abdomen, is the primary reconstructive solution in these complicated revision/salvage of threatened implant cases.

TN, Age 58
Bilateral Mastectomy, Staged Expander then DIEP

The Challenge
This 58-year-old woman was diagnosed with inflammatory left breast cancer. Her breast surgeon recommended a modified radical left mastectomy and quickly wanted to get the patient to chemotherapy and radiation. Oncology was concerned about a possible skin recurrence and asked that we delay any definitive reconstruction for a period of at least one year.

Our Solution
Inflammatory breast cancer is often approached more aggressively with surgery and adjuvant chemotherapy and radiation because of the higher likelihood of local recurrence. In this case, we focused initially on simply preserving the skin after the left mastectomy by placing a temporary tissue expander in place. She went on with adjuvant therapies including radiation to the left breast (middle). After one year, she underwent prophylactic right mastectomy, removal of left expander and bilateral DIEP flap reconstruction. She ultimately went on for nipple reconstruction and has been recurrence-free and happy with a soft breast reconstruction using her own tissues. It was an ideal pathway for a complicated case involving radiation therapy.

DM, Age 54
Pre-Pectoral Breast Reconstruction

The Challenge
This case was a good case for using an above the muscle breast reconstruction technique.  She was content with her overall current breast size and her tumor was remote enough from the nipple that a nipple-sparing mastectomy through the breast fold could be performed. We work closely with some amazing breast surgeons who carefully remove the breast tissue without disturbing the skin and undersurface fatty tissue of the breast.  This is paramount to our success with pre-pectoral breast reconstruction.  She lives an active lifestyle and wanted to minimize muscle violation if possible.    This final result is 3 months after mastectomy at the conclusion of a surgery where the temporary implant is replaced for a final round silicone implant.

Our Solution
To achieve a size in balance with her current breast, we decided on a bilateral reconstruction performed through the breast fold using a two-stage expander-implant technique.  At the mastectomy surgery we fashioned an internal sling using human-derived tissue grafts to provide a supportive pocket for the future implant to reside in.  The temporary implant allowed us to hone in and adjust the final desired volume.  Three months after the mastectomy we were able to exchange the temporary implant for a round silicone implant.  Often times a touch of fat grafting is performed at this second procedure to feather out any inconsistencies appreciated after the initial procedure has healed.

DD, Age 61
Pre-Pectoral Reconstruction

The Challenge
This 61-year-old patient was found to have a stage 1A left breast cancer and had decided upon bilateral mastectomies when she came for consultation. She was hopeful for a nipple-sparing reconstruction and was excited about the prospect of having more fullness to the breast if she had to have a mastectomy reconstruction.

Our Solution
This patient was advised that she is a great candidate for a nipple-sparing mastectomy, with above the muscle (pre-pectoral) reconstruction. Many women have some involution of the breast volume after pregnancy and with time. A common request is to return to a pre-pregnancy breast contour or the fullness they recall around that childbearing time. These oblique angle photos truly show the change in breast contours achievable. The pre-pectoral approach has the nice value of not violating the pectoral muscle anatomy and avoids what can be a troubling distortion to the breast appearance when the implant is behind the muscle and the patient engages their pectoral muscles. As someone now living in Florida, she’s thrilled with the ability to upgrade her summer wardrobe!

DM, Age 50
Pre-Pectoral Reconstruction

The Challenge
This 50-year-old patient was noted to have multiple areas of the left breast with DCIS, ductal carcinoma in-situ. Her opposite breast also had atypical findings on biopsy and after a guided discussion with her breast surgeon, she decided on a bilateral mastectomy. She was hopeful for a nipple-sparing reconstruction and expressed a strong preference for wanting some additional volume to the breast in comparison to the original size.

Our Solution
This patient was advised that she could, in fact, pursue nipple-sparing reconstruction with an implant. The procedure was performed as a standard two-staged technique with placement of an adjustable expander implant at the time of mastectomy. Surgical incisions tucked in the breast fold for the initial and subsequent procedure. Three months after mastectomy, a smooth round silicone implant was placed giving an overall nice result.

JM, Age 50
Direct-to-Implant Reconstruction

The Challenge
This 50-year-old patient was identified as carrying the BRCA mutation after her sister was diagnosed with both breast and fallopian tube cancers. Given her higher risk for developing breast cancer, she had decided on risk-reducing prophylactic mastectomies. Her medical history was notable for a prior saline implant breast augmentation and she preferred to ideally have a similar breast size and appearance. Additionally, she lives overseas and if feasible was hoping for a single-stage procedure to minimize both the downtime and need for follow-up procedures in the States.

Our Solution
During the consultation we discussed that she is an excellent candidate for a nipple-sparing mastectomy with implant reconstruction. Despite traditionally being done in a two-stage fashion, I explained that it could be feasible to perform a direct-to-implant, single-stage operation in hopes of streamlining the process. I explained my general sentiment that maximal precision of the result is always more likely in a two-stage process. She understood the pro’s and con’s and still preferred a single-stage reconstruction if safely achievable. In this case, the mastectomy and reconstruction were performed via the breast fold approach. Despite the original saline implant augmentation being placed behind the muscle, I opted for an above the muscle reconstruction to avoid a muscle animation deformity. At her two month post-operative visit, she is very happy with her choice of procedure and the early results.

Medical tattooist extraordinaire, Kris has been a part of our in-house services for patient undergoing post-mastectomy breast reconstruction since 2019.  She comes from an art background and found a passion in using her artistry to helping women with photo-realistic level nipple areola tattooing.  Restoring a near identical appearing nipple areola is paramount in the complete restoration of the breast after undergoing a mastectomy.  Living between Florida and New Jersey, she is spreading her gift to patients far and wide!

Kris’ genuine artistry can be appreciated in this video of her digitally creating and coloring a nipple and areola on her tablet.  The layering of details is an incredible process to watch.  Our patients are so fortunate to have her help in the reconstructive process.

This is a great example of the powerful impact of ‘3D’ nipple areola tattooing.  This young woman had a double mastectomy that required nipple removal.  She was reconstructed with tissue expanders followed with silicone implants.  Use the slider to appreciate the difference pre-mastectomy and then before/after nipple areola tattooing.  This final touch brings an unbelievable realism to the reconstruction result!