Unlike implants, which are artificial objects, a breast created with your own living tissue depends upon a consistent, healthy flow of blood to survive—blood vessels in the tissue flap are reconnected to existing blood vessels in the chest, which bring oxygen and nutrients to the new breast. Without actually viewing the blood vessels involved in a tissue flap reconstruction, however, plastic surgeons can’t be sure which vessels are strongest and provide the best chance of success.

The SPY Elite Imaging System® takes the guesswork out of the equation. It’s one example of a technological innovation that helps plastic surgeons work with greater precision, shortens operating intervals, and streamlines procedures.

Using SPY, a plastic surgeon can observe a patient’s blood flow in real-time. First, a laser lights up harmless dye that is injected into the patient’s bloodstream. Then, using a special SPY scanner, the surgeon can see which blood vessels are more robust: vessels with a strong blood flow are illuminated, while weakened vessels remain dark. The SPY equipment is small and mobile. It can be quickly set up, and does not expose the patient to radiation.

SPY can be used before, during or after breast reconstruction surgery:
  • Pre-operatively, it eliminates guesswork as to which blood supply to the new breast is the most robust, and therefore has the best chance of thriving.
  • During surgery, it provides a way to assess blood circulation after blood vessels in the flap are connected to blood vessels in the chest. The plastic surgeon can watch the dye as it flows into the flap in the artery, lights up the tissue, and returns back to the vein.
  • After surgery, it is a valuable tool for monitoring blood circulation in the new breast. (It is also a good way to monitor circulation to the skin flaps left after mastectomy.) If necrosis (tissue death) develops in a portion of a flap, SPY can pinpoint the precise problematic blood vessel.

Combined data from 12 different studies of SPY showed that among tissue flap breast reconstruction patients, rates of necrosis (tissue death) were 4% or less among surgeons who used SPY, compared to 10-25% among surgeons who did not.

SPY is also FDA-approved for use in other cosmetic and reconstructive surgeries, as well as other microsurgeries, including heart bypass procedures, gastrointestinal operations, and organ transplants.

Silicone gel “gummi bear” breast implants are said to be more reliable than older models of silicone implants, but how true is that?

Three manufacturers—Allergan, Mentor, and Sientra—provide all breast implants used in the U.S. for augmentation and breast reconstruction. All three companies now offer contoured (anatomically shaped) cohesive silicone gel breast implants—is any one of them better than the others?

A new study shows that contoured gummi bear breast implants used for breast reconstruction have similar rates of complications and patient satisfaction, regardless of who makes them.

This study followed 695 breast augmentation and breast reconstruction patients ranging in age from 18 to 82 (mean age 42.7 years) over 10 years. All participants were patients of a single plastic surgeon; however, they were also included in an FDA clinical trial from 2001 to 2013. (Cohesive silicone gel breast implants were approved by the FDA in 2012, but they were available for pre-market approval studies during the previous 10 years.)

Of the patients, 384 (55%) had primary augmentation, 198 (29%) had secondary augmentation, and 113 (16%) had breast reconstruction. Contoured cohesive silicone gel implants from all three manufacturers were used:

        Manufacturer                        Patients
        Allergan                                 164 (24%)
        Mentor                                   245 (35%)
        Sientra                                   286 (41%)

Patients with Mentor breast implants for primary augmentation experienced significantly lower rates of complications, while women who had breast implants for secondary augmentation or breast reconstruction were found to have similar rates of complications regardless of the implant manufacturer; no statistically significant differences with regard to capsular contracture, rupture, rotation, or rippling were observed.

Rates of reoperation (additional surgical procedure related to the implant) or explantation (implant removal without replacement) were also about the same. This study didn’t compare the reasons for reoperation or explantation, but more women in the secondary augmentation and breast reconstruction groups had explantation than those in the primary augmentation group.

Both patient and surgeon satisfaction with the implants was initially high after 1 year, as previous studies have found, but declined at 5 years. Study authors noted that this dissatisfaction was likely related to issues such as capsular contracture, implant rupture, or other implant-related complications.

If you'd like to see a precise breakdown of the types of complications that occurred, take a look at the source study below.

Source: Doren EL, Pierpont Y N, Shivers SC, et al. “Comparison of Allergan, Mentor, and Sientra Contoured Cohesive Gel Breast Implants: A Single Surgeon’s 10-Year Experience.” Plastic & Reconstructive Surgery (2015): vol. 136, No. 5, pp. 957-66.

PictureImage: AirXpanders.com

A newer, quicker method of breast reconstruction with implants moved one step closer to reality last week, as AirExpanders released its interim results of the XPAND trial using AeroForm patient-controlled tissue expanders at the 2015 American Society of Plastic Surgeons (ASPS) Meeting.

Traditional implant reconstruction uses temporary expanders to gradually form a pocket behind the pectoralis muscle to eventually hold the breast implant. The entire tissue expansion process typically takes several weeks, depending on how much and how often more saline is added to the tissue expander.

AeroForm devices appear to represent a greatly improved tissue expansion process, allowing patients to self-inflate the expander at home. Like traditional tissue expansion, using AeroForm still requires a tissue expander be placed behind the muscle, but offers three significant differences:

Traditional breast expanders      
-filled with saline                  
-requires period saline injections             
 by plastic surgeon
-filled with carbon dioxide
The XPAND trial showed that compared to traditional tissue expansion, this new do-it-yourself concept produces similar results in a shorter timeframe, with less discomfort, and allows the patient to control when, where and how much she is expanded, without injections or office visits. Patients use a wireless remote control to release up to 30 cc per day (three doses of 10 cc each) from a small reservoir within the expander, in their own home and at their own pace.

Both traditional saline expanders and AeroForm were found to be safe and effective during the trial, culminating in exchange surgery to remove the expander and position the breast implant in the behind-the-muscle pocket. The 138 women who used AeroForm, however, reached their targeted expander volume in an average of 18.2 days, compared to an average of 57.4 days for women who randomly received traditional saline expanders. Ninety-eight percent of the AeroForm patients said the device was convenient and easy to use.

 AeroForm expanders are already available in Europe and Australia. 
FDA approval for use in the U.S. is expected in 2015.

Read earlier blogs about the AeroForm trial (scroll down the page).
Mastectomy isn’t easy.

No matter how strong your willpower, no matter how prepared you might think you are, looking down and seeing the landscape of your chest without your natural breasts takes some serious self-talk and time to wrap your brain around this "new normal."

Not all women choose to have immediate breast reconstruction (or any type of reconstruction) after mastectomy. For some, reconstruction is delayed for treatment or other health reasons. And although lots of women are comfortable being flat-chested after mastectomy, many are disappointed to learn that they cannot wear a prosthesis until their mastectomy scars sufficiently heal, usually about five to six weeks after surgery.

If you have a single or double mastectomy in your future and you don’t want to have (or can’t have) immediate breast reconstruction but you want to regain your previous silhouette when you’re clothed, you may be interested in Knitted Knockers, soft contoured prostheses that you pop right into the cups of your regular bra.

Knitted Knockers are the product of an expanding network of generous, caring volunteers who knit or crochet the prostheses and provide them free of charge to women after mastectomy. They are firm enough to provide a natural, contoured shape under clothing, yet they’re soft and light, so they don’t irritate sensitive chest incisions and skin after surgery. The Knockers come in a variety of colors and sizes, and are made with acrylic or cotton yarn (wool is avoided because it is too itchy against sensitive skin). The knitted forms are overstuffed with hypoallergenic polyester fiberfill to accommodate women who end up with a concave chest following mastectomy. Any recipient of a Knitted Knocker, however, can simply remove stuffing and then knot the prostheses closed to customize it to her own size and shape.  

Based in Washington, the non-profit organization has about 1,000 volunteers in 30 other states and distributes the soft prostheses throughout the country; other affiliates do the same in the United Kingdom, Canada, South Africa and other countries.


If you’re facing mastectomy and you would like to be the recipient of a Knitted Knocker, visit the organization’s website to request a single or pair.

If you’re someone who enjoys knitting or crocheting, and you would like to do something special for breast cancer survivors, you can view a tutorial, read about preferred yarn and knitting style, and download patterns from the website; patterns are free, but donations are welcome.  You can donate your handmade Knocker to a friend, family member or neighbor who is facing mastectomy, provide them to your community cancer clinic or hospital, or send them to Knitted Knockers (see the address and instructions for shipping on the website) for distribution to those who need them (the organization will even reimburse you for postage). Kits that include the pattern and yarn are also available from Apple Yarns, who donate a portion of the sale of each kit back to Knitted Knockers.
Celebrity chef Sandra Lee made news earlier this year when she announced that she had been diagnosed with breast cancer and would have a double mastectomy.

Lee was diagnosed with ductal carcinoma in situ (DCIS), a non-invasive type of cancer that begins in the milk ducts of the breast. (DCIS is the most common type of non-invasive breast cancer and accounts for about 25% of all cancers detected by mammogram.)

Lee’s treatment began with lumpectomy, however her surgeon was unable to obtain clean margins (the remaining breast tissue still showed signs of cancer). Although radiation was a treatment option, Lee didn’t want to undergo six to eight weeks of that treatment, and worried that she might later have to relive the entire experience in the opposite breast. So on the advice of her physicians, Lee, who tested negative for a BRCA gene mutation, decided to have both breasts removed.

As Lee herself has said, “Breast cancer beats you up in two ways, both physically and emotionally.” Most women who have been told they have breast cancer would probably agree. It is difficult to hear the diagnosis, and it is incredibly tough to wrap your mind around having your breasts taken away. To make matters worse, Lee developed a massive infection after her bilateral mastectomy that caused painful swelling around the scar tissue, and didn’t initially respond to treatment. Last week she was back in OR for surgery to treat the infection. Now she’s back home with IV antibiotics and home nursing until the infection has been completely eradicated.

If you’re facing mastectomy, Lee’s story is undoubtedly troubling and you’re probably wondering whether you’ll face the same difficult outcome. All surgery has risk, but in fact, most women do not develop post-mastectomy infections. Skin is the body’s natural barrier to infection; anytime it’s opened, infection has an opportunity to sneak in. Precautionary procedures, including a sterile operating environment and washing incision sites with antibacterial wash protect you during surgery. After surgery, drains are placed at the surgical site to prevent fluid build-up that could lead to infection. Additionally, most mastectomy (and breast reconstruction) patients are given antibiotics during and after their operations.

Despite these precautions, infection does happen sometimes, and that is why it is so very important to know the early warning signs—redness or warmth in the skin, fever, chills or unusual fatigue—and have them treated as soon as possible. Caught early on, most infections respond well to oral antibiotics. Allowed to progress, infections that do not respond to oral antibiotics may require hospitalization, intravenous antibiotics, and possibly additional surgery to drain off excess fluids, as was the case for Lee.

If you are diabetic, a smoker, obese or you have certain other health conditions, you are more likely to develop a post-operative infection. In Lee’s case, she was diagnosed with lupus anticoagulant, an autoimmune condition that creates a greater-than-average likelihood of developing blood clots.  Health insurance that covers the cost of mastectomy must also pay for infections or other complications that are directly related to the surgery.

Nipple-sparing mastectomy preserves all of a woman’s breast skin, including the nipple and areola. Essentially, it allows women to keep the part of the breast that we actually see—the skin, nipple and areola—while the breast tissue is removed and replaced with either a breast implant or a flap of her own tissue.

Whether women have mastectomy to prevent or treat breast cancer, most are candidates for nipple-sparing mastectomy. Individuals with very large tumors or tumors in or close to the nipple are not candidates for nipple-sparing procedures. Women with moderate to severe breast ptosis (sagging) are also routinely advised against nipple-sparing mastectomy. Ptosis develops when aging or gravity causes the breasts to sag (breast tissue contains no supportive muscle). Ptosis can also occur after pregnancy, breastfeeding or significant weight loss. Smoking also accelerates ptosis because it erodes skin elasticity.

In round, non-sagging (or minimally sagging) breasts, the retained nipple is more likely to end up where it should be after reconstruction: in the center of the new breast. Large, pendulous breasts tend to be low-hanging and oblong rather than round, with nipples that are positioned far south of center. They make nipple-sparing mastectomy difficult, because of the likelihood that the nipples cannot be appropriately positioned on the new breast.

It’s mostly a problem of excess skin.
Ptotic breasts hang low on the chest, with nipples that point downward.

Patients and surgeons don’t face the same issue when a traditional mastectomy is performed, because much of the excess breast skin that encloses the droopy breast can be removed along with the nipple and areola. But what do you do with all that excess skin when a nipple-sparing mastectomy leaves the nipple, areola and breast skin intact, and how do you elevate the nipple so that it is centered on the new breast?

It’s a problem that presents technical and aesthetic surgical challenges.

A recently-published study in the journal Plastic and Reconstructive Surgery introduces a new procedure that is specifically designed to provide nipple-sparing mastectomy as an option for women with ptotic breasts, as long as an oncologic reason doesn’t preclude them from having nipple-sparing mastectomy.

NSM + tissue flap + breast lift = NSM for low-hanging breasts

The new technique combines nipple-sparing mastectomy, perforator flap reconstruction and breast lift procedures. First, a breast surgeon who is experienced with nipple-sparing mastectomy removes the breast tissue through a periareolar (around the areola) incision. Then the reconstructive surgeon performs a perforator flap reconstruction, restoring volume from missing breast tissue with fatty tissue from a patient’s hip or abdomen. Finally, a full breast lift is performed on the reconstructed breast: the transferred flap of tissue is tightened and reshaped, excess skin is removed, and the incision is closed. The result is a newly-recreated breast with a correctly positioned natural nipple and areola.

Like all reconstructive surgeries, the new procedure requires appropriate surgical skill and experience to preserve adequate blood flow to the nipple. It’s a new concept and a new technique that will probably take a while to catch on.

DellaCroce J, Blum CA, Sullivan S K, et al. "Nipple Sparing Mastectomy and Ptosis: Perforator Flap Breast Reconstruction Allows Full Secondary Mastopexy with Complete Nipple Areolar Repositioning." Journal of Plastic and Reconstructive Surgery, July 2015; Vol. 136, Issue 1: p. 1e–9e.
Surgeons routinely caution women who smoke or carry extra weight about the increased possibility of post-op complications from breast reconstruction. Any major surgery—not only breast reconstruction—has the potential for problems, but smoking and extra weight complicate matters even more, increasing the likelihood that problems may develop.

If you smoke, most surgeons will require you to quit for several weeks before and after your breast reconstruction procedure. It’s for your own good: smoking  compromises your respiratory capability and overall health; inhaled carbon monoxide and nicotine from tobacco smoke restrict blood flow and increases the chances of infection, excessive scarring, and poor wound healing. Smokers are also more likely to experience necrosis, or tissue death, in the reconstructed breast. This is particularly problematic with tissue flap reconstruction when a portion or all of the new breast dies because it doesn’t get adequate blood and oxygen.

The good news: Women who stop smoking at least three weeks prior to surgery have no greater complications than non-smokers who have the same surgery.

Overweight or obese
Being obese doesn’t automatically limit your ability to have immediate or delayed breast reconstruction. In fact, obese women are just as likely to be satisfied with their reconstructive results as women who are thinner. If you are obese, however, particularly if you have a BMI of 35 or higher, you are more likely to develop infection, delayed wound healing, clotting complications and other problems, regardless of the type of reconstruction. The odds of developing problems are even greater if your BMI is 40 or more.

Three recent studies confirm what we already knew
While many studies (and surgeon’s experience with patient outcomes) have shown that smokers and heavier women generally can expect more problems after breast reconstruction, research published this year shows that both groups also more frequently need revision surgery (a separate surgery to correct cosmetic issues or healing problems). Researchers concluded that:
  • Among women who had bilateral immediate, delayed or immediate-delayed breast reconstruction, those who had a BMI greater than 30 were twice as likely to experience a complication as those with a normal BMI. A higher Body Mass Index was also significantly related to infection, seroma, hematoma and delayed wound healing.

  • Among 2,899 women who had breast reconstruction with any type of tissue flap, 18.2% of smokers developed wound complications compared to 8.4% non-smokers.

  • Considering all free autologous (tissue flap) reconstructions at a single institution between 2005-2011, women who smoked or were obese suffered more delayed wound healing (operative wounds requiring dressing changes for longer than 3 weeks) compared to other non-smokers and thinner women who had similar reconstructive surgeries.

The bottom line: It makes good sense to do your very best to lose weight and stop smoking before your surgery. Under the very best conditions, recovery from mastectomy and breast reconstruction is physically and emotionally taxing. You'll reap the benefits of preparing yourself for the ordeal--being in the best possible shape (that includes a body that isn't compromised by the effects of nicotine or excess weight)--so that you can minimize the effects of your surgery and bounce back to your "normal" as soon as possible.

Chung CU, Wink JD, Nelson JA, et al. “Surgical Site Infections after Free Flap Breast Reconstruction: An Analysis of 2,899 Patients from the ACS-NSQIP Datasets.” Journal of Reconstructive Microsurgery Apr 24, 2015. [Epub ahead of print]

Nelson JA, Chung CU, Fischer JP, et al. “Wound healing complications after autologous breast reconstruction: a model to predict risk.” Journal of Plastic, Reconstructive & Aesthetic Surgery (2015); 68(4): pp. 531-9.

Mirzabeigi MN, Wilson AJ, et al. “Predicting and managing donor-site wound complications in abdominally based free flap breast reconstruction: improved outcomes with early reoperative closure.” Plastic & Reconstructive Surgery (2015); 135(1): pp. 14-23.


Most people know that Botox®—the most popular minimally invasive cosmetic procedure—is most commonly used to erase facial wrinkles. Derived from the bacterium Clostridium botulinum, Botox is a neurotoxin; it works by impeding nerve impulses that cause muscle contractions. Injections into the forehead or the “crows feet” area beyond the eye eliminates wrinkles for a few months, while Botox injected into the underarm temporarily eliminates excessive perspiration. It is also used to curtail overactive bladders.

What most people do not know is that Botox is also a very effective painkiller that some physicians now use to relieve the pain of migraine headaches and other types of chronically painful conditions. New research shows that it may also ease the discomfort many women experience with tissue expanders, and shorten the overall expansion timeline. 

For many women, the pressure exerted by tissue expanders on the pectoralis chest muscle can be quite uncomfortable, and even painful. Botox relaxes the muscle, reducing discomfort and generally creating a more tolerable experience as a woman proceeds through the stages of expanding the pocket behind the muscle to make room for a breast implant.

A small study at Loma Linda University involved 30 patients who had mastectomies with immediate reconstruction with tissue expanders or acellular dermal matrix. Half of the patients received 40 units of Botox serially injected directly into their pectoralis muscles; the remaining participants—the control group—received four serial injections of sodium chloride (saline).

Compared to women who received the placebo (the saline), women who received the neurotoxin benefited in three ways:

·      They reported less pain and muscle spasms.

·      They completed the expansion process sooner because they were able to tolerate more saline during office “fill” visits: a mean of 98 cc per fill compared to 54 cc in the placebo group.

·      They required fewer opioids and valium after the first post-op week (subsequent use of oral NSAIDs was about the same in both groups).

The two groups were of similar age, with no significiant differences between initial fills and expander sizes. No complications or side effects from the neurotoxin were reported, and complication rates for seroma, infection, skin necrosis, expander loss and hematoma did not vary.

This study echoes the results of various other small studies over the past few years, but the use of Botox is by no means standard with tissue expansion for breast reconstruction. Although Botox is FDA-approved for various applications, its use in breast reconstruction is  “off label,” meaning it might be helpful but that is not specifically its approved use. (That’s why its use in breast reconstruction may not be covered by insurance.)

A larger-scale clinical study is currently underway at the Mayo Clinic; its results may have a more profound influence on whether Botox becomes more common during tissue expansion, and whether or not insurance will cover it.

Source: Gabriel A, et al. “The efficacy of botulinum toxin a in post-mastectomy breast reconstruction: a pilot study.” Aesthetic Surgery Journal (2015) 35(4): p. 402-9.

For women who plan to have immediate breast reconstruction, traditional skin-sparing mastectomy removes the breast tissue, nipple and areola. In an optional procedure, new nipples can then be recreated on the reconstructed breasts.

Nipple-sparing mastectomy is a newer, more conservative option for women who have immediate breast reconstruction; it preserves all of the breast skin, including the nipple and areola. Many women feel that this allows them to keep a small part—and from an emotional perspective, perhaps the most important part—of their natural breasts.

Here's what you should know about nipple-sparing mastectomy:
  1. It’s safe. Numerous studies over the past decade have shown that nipple-sparing mastectomy is a safe option for the right candidates. A Stanford University School of Medicine analysis of 19 previous studies involving more than 5,000 mastectomy patients concluded that nipple-sparing procedures result in similar rates of recurrence and survival compared to skin-sparing mastectomy procedures that remove the nipple.

  2. Not all women are candidates. Women with a small early-stage tumor that is not in the skin or close to the nipple may be eligible for nipple-sparing mastectomy. It is also viable for women who choose prophylactic mastectomy to reduce their unusually high risk of developing breast cancer due to a strong family history or inherited genetic mutation (like Angelina Jolie Pitt). Nipple-sparing procedures are not recommended for women who have multiple breast tumors close to the skin or nipple (although some experts consider this is acceptable if the tumors are not in close proximity to the nipple). The entire nipple and areola are removed if the tissue beneath the nipple is found to contain cancerous cells. Positioning nipples on the reconstructed breast can also be an issue; they may not be centered ideally if the reconstructed breasts are smaller or larger than the natural breasts.

  3. It facilitates cosmetically superior breast reconstruction. Because the breast skin, areola and nipple are retained, and the mastectomy scar is usually hidden under the breast or in the areola, your reconstructed breasts will likely appear as natural and as good or better than your own breasts before mastectomy. Although what is under the skin is different—breast tissue is replaced with breast implants or your own natural tissue—outwardly, the exterior of the breast appears intact and virtually unchanged.

  4. Incision placement is critical. Traditional skin-sparing mastectomy is performed through an elliptical incision around the nipple and areola. In a nipple-sparing mastectomy, a shorter incision is made just below the nipple—requiring the breast surgeon to remove the same amount of tissue through this smaller incision. Some women, particularly those with very large or sagging breasts, may need an additional horizontal incision from the nipple towards the arm, or an additional vertical incision from the nipple towards the bottom of the breast.

  5. The retained nipple may be different. Nipple sensation after nipple-sparing mastectomy varies, but it is usually considerably reduced because the fine nerves and small muscle fibers that trigger sensation and response are cut when breast tissue is removed. After nipple-sparing mastectomy, nipples may also flatten or look differently.

  6. Not all surgeons are qualified. Nipple-sparing mastectomy is now more common, but it is by no means standard. Many breast surgeons do not have the training or experience to perform the procedure, which is technically more demanding than other mastectomy procedures. Surgeons must be able to carefully remove the underlying tissue without compromising the blood supply the nipple needs to survive; leaving behind too much breast tissue increases the risk of another diagnosis.

Ideally, breast reconstruction is performed at the same time as mastectomy, but sometimes that isn’t always possible. Some women are undecided about reconstruction at the time of their mastectomy, while others prefer to forego any further surgery, but change their minds months or years later, and then decide to pursue delayed reconstruction. In some cases, oncologists may recommend that certain individuals, especially those with underlying health conditions that may delay healing, postpone reconstruction. 

Immediate planning for delayed breast reconstruction
If your oncologist recommends a mastectomy to treat invasive breast cancer, you may or may not also need radiation therapy after the surgery, depending on the stage of your tumor and lymph node involvement. Unfortunately, it isn't always clear if radiation therapy will be needed until post-mastectomy pathology results are available. Under these circumstances, many surgeons advise against immediate breast reconstruction if there is a possibility you may need radiation treatments.

If you have your heart set on immediate reconstruction with a breast implant or a flap of your own tissue, delaying your reconstruction can be a hard pill to swallow, because you will wake up with a flat chest and miss out on the advantages of immediate breast reconstruction. Delayed-immediate reconstruction is a unique approach to this issue. It recognizes the potential need for radiation therapy and also provides the aesthetic advantages of immediate reconstruction. As soon as the breast tissue is removed, a tissue expander is positioned under the chest muscle, and fully inflated to preserve your breast shape and skin for later reconstruction. After your mastectomy, if it turns out that you don’t need radiation after all, you can proceed with reconstruction, exchanging the expander for an implant or swapping it for an autologous tissue flap of your own skin, fat and/or muscle.

If you do need radiation therapy, the tissue expander can be deflated and left in place, and then later reinflated when your radiation is completed. (Deflating the expanders also addresses the concern that immediate reconstruction may interfere with the delivery of radiation.) Several months later, you can proceed with tissue flap reconstruction—implants aren’t generally advised after radiation because of the high potential for complications.