Mastectomy and Flap Reconstruction

Who is a good candidate?

The best candidates for this approach are patients whose excess soft tissue along their sides and back is similar to the size of their breasts.  In this way, the breast tissue can be removed and tissues from the sides and back can be used to reconstruct the breast without a significant decrease in breast size.  This approach is most appropriate for obese patients and can be used in smokers as well.  It is also safe in patients that have undergone or will require radiotherapy.  These factors make it an attractive alternative to implant-based reconstructions where these factors make using an implant unsafe.

Most patients are good candidates for nipple-sparing mastectomy and flap reconstruction and have hidden incisions placed in the crease of their breast with no obvious scars seen when standing up.  For those patients who are not good candidates for a nipple-sparing approach secondary to oncological concerns or because the nipple is located very far from its ideal location, Dr. Schwartz can immediately reconstruct them a nipple or transplant their own nipples as skin grafts into a more ideal position at the time of mastectomy.  Most patients who have significant excess skin and “ptosis” where the nipple is located well below the breast crease will require a “Wise-pattern mastectomy” where the skin is reduced and the nipple repositioned use breast reduction incisions.  These patients are often able to still preserve their nipple and appear as if they have had breast reduction surgery.  This is performed using a technique that Dr. Schwartz has innovated and published as well.  Patients have breast reduction scars- around the areola and then from the areola straight down to the breast crease and then in the breast crease as well (see breast reduction surgery).  These are very discreet and aesthetic scars.  The tissue that is removed from the sides and back results in a long scar in the bra line that travels from the front all the way to the spine, in the back.  This scar is well hidden when wearing a bra.

Dr. Schwartz has significant experience performing just one-sided mastectomy surgery and reconstructions and getting good symmetry with the opposite healthy breast, sometimes without operating on it.  Some patients who prefer to have just a mastectomy on one side require a breast reduction or lift on the other side to get good symmetry with their reconstructed breast that has undergone mastectomy and flap reconstruction. Dr. Schwartz performs all of this surgery in one operation and uses his expertise to get the best result possible with just one surgical procedure.  He will inform you at your consultation whether it is necessary to operate on the healthy breast to obtain good symmetry.

Consultation and Procedure

During your consultation, Dr. Schwartz will evaluate your individual case and formulate a treatment plan that is right for you. Thanks to Dr. Schwartz’s access to a private Outpatient Surgery Center, patients who undergo unilateral (one-sided) mastectomy and flap reconstruction are scheduled without a delay.  Mastectomy and flap reconstruction is always covered by health insurance companies and this coverage is guaranteed under federal law.  Patients who undergo bilateral mastectomy (both sides) and flap reconstruction have their surgeries performed in the hospital as this surgery is longer and typically requires overnight observation.

Dr. Schwartz typically completes a unilateral mastectomy and flap reconstruction in about three hours, while bilateral cases take seven to eight hours under general anesthesia.  Typically, one drain is placed into each breast unless a significant lymph node dissection is performed (for more advanced cancers) when 2 drains will be placed.  A single drain is also placed into the back donor site where the tissue is obtained to reconstruction the breast.  For unilateral mastectomy and reconstruction, patients are discharged home on the day of surgery. Dr. Schwartz is just one of a few surgeons in the country who can offer patients a mastectomy and tissue reconstruction without hospital admission.  Bilateral mastectomy and are reconstructions are performed in the hospital with overnight admission for observation. Dressings are placed in the operating room which stay on until the following week when they are removed and a sports bra is put on.

Recovery and Results

Recovery times after mastectomy and flap reconstruction vary depending on the individual and breast size and whether unilateral or bilateral surgery is performed.  Typically, patients can return to normal activities within three weeks and exercise without restrictions within 4-6 weeks. Drains are left in place for 10-14 days in the breast and 14-21 days in the back.  Patients are placed in a sports bra at their first post-operative visit and should wear this for two to three months.   Most patients never need additional surgery, but some choose to improve their aesthetic result with fat transfer and or repositioning the flap 3-6 months after their initial surgery.  Results from mastectomy and flap reconstruction are typically very good, with most patients maintaining or even improving their breast appearance.

Your surgical or sports bra will need to be worn for 8-12 weeks following your mastectomy and reconstruction.  You should plan to be off work for at least 3-4 weeks, depending on the type of work you perform.   You also may feel pulling or stretching in your breast area. Although you may need pain medicine for a week or two, you can expect to feel better and stronger each day. For several weeks, you may get tired easily or have less energy than usual. You also may have the feeling that fluid is moving in your breasts. This feeling is normal and will go away over time.  You may also feel a tight sensation in your back where the tissues were taken to reconstruct your breast.  This will loosen up and return to normal over time.

Mastectomy and reconstruction results in significant changes in sensation, with most losing significant nipple sensation permanently.  Over time, much of the breast skin will regain normal sensation.    Keep in mind that it may take time to get used to your new breasts. You will have swelling at first. But the breasts will soften and appear more natural over time. You are likely to feel well enough to return to work after 2 to 4 weeks, based on your progress. You can usually resume normal physical activities in this time frame as well.   You should expect some scarring following mastectomy and flap reconstruction; however, these scars will gradually fade over time.