Your Personal Guide to Breast Reconstruction Scroll to Begin Your Journey

Start Your Journey With Me

As a breast reconstruction surgeon, I have dedicated my career to helping patients along their personal journey to reclaiming a sense of femininity and well being. Over the years, I have had the privilege to answer many questions and concerns that patients have expressed during their treatment process. The following guide was created to provide additional information and support as you embark on this new stage in your life. I hope that this guide will help ease your fears and inspire you with the confidence to know that you will not only get through this, but also will emerge feeling beautiful and whole again.

Navigating Your Guide

This guide was made with you in mind and keeping true to Dr. Spiegel's philosophy this is not a cookie-cutter experience. The guide can be viewed simply by scrolling from page to page or you can access the content that is most important to you by clicking on a jump link from the Table of Contents. At the bottom of each section you will see a small arrow, click the "" to find your way back to the Table of Contents or just keep scrolling to see what's next.

You are unique! Feel free to scroll along from start to finish or jump from page to page, the choice is yours.

All the lovely ladies featured in this guide are Dr. Spiegel's actual patients

Breast Cancer Information

When faced with surgery for the treatment or prevention of breast cancer, it is important for you to educate yourself. This will allow you to make informed decisions along your breast reconstruction journey.

Breast Cancer Diagnosis

I've been diagnosed with breast cancer, now what?

Receiving a breast cancer diagnosis can be an overwhelming and frightening experience. Many emotions and issues can arise at this time. Thoughts about mortality, femininity, family dynamics, support and work concerns all play a role. In many cases, the diagnosis comes out of the blue and coping with it often resembles the common stages experienced with loss - denial, anger, bargaining, depression, and finally acceptance. Amidst this roller coaster of emotions, major decisions about the treatment plan and the type of reconstruction procedure have to be made. Keep in mind that making these decisions and getting prepared for surgery takes some time. We are here to help guide you through this process, so that when surgery time arrives, you will have reached acceptance and will be ready to start the reconstructive phase with positive energy.

What are the types of breast cancer?

The breast is made of three major components: the mammary glands known as lobules (where milk is produced), the ducts (channels where the milk travels to the nipple) and fatty tissue. Breast cancer can arise both in the lobules and in the ducts. Ductal Cancer is more common, and can be present at various stages. “Ductal Carcinoma in situ” means that the tumor is confined to the duct and has not spread into the rest of the breast tissue. Once the tumor is more advanced, it can spread to the lymph nodes under the arm. The tumor is classified according to a staging system depending on the extent of involvement. The stage of cancer is important when determining the type of treatment program that will be most effective.

Preventive Mastectomy

Should I consider a preventive mastectomy?

When the diagnosis of breast cancer is made on one breast, most patients have to make a decision about the management of the other healthy breast. Some patients prefer to keep the unaffected breast, knowing that they will continue to have mammograms and close radiological follow up. Other patients have anxiety related to having to get periodic screening and prefer to undergo a preventive mastectomy. This decision is individual and there is no “right answer.” Talking to your general surgeon and oncologist can help you with this decision. We usually recommend having a thorough screening, possibility with an MRI, to evaluate the other breast. This is particularly important when performing an abdominal flap reconstruction since this can only be performed once.

What about BRCA and other genetic risk factors?

Women with a genetic predisposition to breast cancer, or women with a strong family history of breast cancer, may elect to undergo prophylactic mastectomies (removal of breast tissue prior to a cancer diagnosis). Working closely with our general surgeons, we can offer nipple sparing mastectomies with immediate reconstruction utilizing natural tissue or implant based reconstruction. A nipple sparing mastectomy in combination with immediate breast reconstruction minimizes the scarring around the breast to provide the most natural restoration.

Types of Breast Surgery

What are the types of breast surgery?
  • Total (modified radical) Mastectomy - the entire breast including skin is removed
  • Skin-Sparing Mastectomy - the nipple and areola are removed with the breast tissue
  • Areolar-Sparing Mastectomy - the nipple is removed with the breast tissue
  • Nipple-Sparing Mastectomy - the breast tissue is removed, the outer skin and nipple-areolar complex are preserved
  • Lumpectomy - the cancerous area is removed along with some of the surrounding normal tissue. Surgery is typically followed by breast radiation therapy
What is removed with a mastectomy?

The goal of a mastectomy is to remove all the breast tissue as well as any tissue affected by the tumor. The skin of the breast can usually be preserved unless the cancer is more advanced. In some cases the areola (the pigmented area around the nipple) can be preserved which allows the retention of the natural color. Nipple sparing mastectomies can also be performed in certain patients. This is an option for patients seeking a preventive or prophylactic mastectomy. A nipple sparing mastectomy may also be an option for a patient whose tumor is located more than 2 cm away from the nipple. Both your oncologist and general surgeon can help you determine the mastectomy that is best for you.

After a nipple sparing mastectomy, the breast tissue is removed but the skin, areola, and nipple remain intact.
What parts of the breast need to be restored?

The parts of the breast that need to be restored depend on the type of mastectomy that is performed. With a nipple sparing mastectomy, only the internal volume of the breast needs replacement since the outer skin envelope is maintained. With a skin sparing mastectomy, the breast tissue, as well as the nipple and areola, are removed. Therefore, the internal volume and the area where the areola/nipple were removed need to be restored. After a total mastectomy, all the parts of the breast need to be reconstructed, which includes the entire breast skin and breast volume, as well as the nipple and areola.

Breast Reconstruction Information

There are many breast reconstruction options available. Below you will find valuable information so that you may decide which option is best for you.

Breast Reconstruction Overview

What is a successful breast reconstruction?

There are many opinions on this subject, but we feel that the patient is the ultimate judge of her breast reconstruction, not her surgeon or even significant other. After all, you are the one that sees yourself in the mirror everyday and it is important that you feel confident and like what you see in your reflection. When we talk during your consultation, we will consider various types of reconstructions to determine which one is best for you.

What breast size should I be?

Most women have an image in their mind of their dream breast size. Sometimes patients are very aware of this and know this size immediately. Other times, this answer takes some thinking and consideration. As we help patients arrive at this answer, we take into consideration their breast size history, width of the shoulders and the hips, body proportions, and personal wishes. Going through your breast reconstruction journey can be difficult but having the breast size you have always dreamed of can serve as a silver lining.

Will the reconstructed breast(s) be made symmetrical?

Yes, a symmetry procedure is performed approximately four to six months after the initial breast reconstruction procedure. The symmetry procedure that is performed is based upon your specific situation, including the breast surgery and breast reconstruction procedure performed, as well as if the reconstruction was bilateral (performed on both breasts) or unilateral (performed on just the affected breast).

For bilateral reconstruction, the symmetry procedure, if needed, allows for refinement of the shape and size of the reconstructed breasts. For unilateral breast reconstruction, the symmetry procedure, allows for the reconstructed breast to be refined and at the same time a procedure is also performed on the other breast (breast lift, breast reduction, etc) to achieve optimal balance between the breasts.

What are the main types of breast reconstruction?
  • Natural Tissue Reconstruction - Tissue (skin, fat) is donated from one area of your body to be used to reconstruct the breast
  • Implant Based Reconstruction - An FDA-approved implantable device is used to reconstruct the breast
  • Combination of Both Natural Tissue and Implant Reconstruction - An implant may be placed in combination with your own tissue to achieve your desired breast volume
  • Oncoplastic Reconstruction -  Breast tissue rearrangement performed in combination with a lumpectomy
What type of breast reconstruction is best for me?

There are several types of breast reconstruction procedures ranging from flaps to implant reconstruction. We specialize in all types of advanced breast reconstruction procedures. We hope to educate you about the pros and cons of each to make sure that you choose the option best suited for you. Using your own tissue is considered the gold standard because you are replacing “like with like”. However, this requires a longer recovery than implant reconstruction. The type of reconstruction possible also depends on what tissue is missing. A patient after a nipple-sparing mastectomy has many more options, since only the volume of the breast tissue needs to be replaced. Other patients who had to undergo removal of some of their breast skin and/or had radiation may be better candidates for flaps, as skin must be replaced.

Steps Through Reconstruction

How long does the reconstruction process take?

At this point, you have gone through a lot, both emotionally and physically. It is understandable to want to hurry up and cross that finish line. The length of the entire reconstruction process varies depending on the type of procedure you choose. Generally, it takes between six to eight months to complete the process but may take longer if you must undergo chemotherapy or radiation therapy.

Although reconstruction is an upfront time investment, it is an important part of the healing process that helps a woman normalize her life in the long term after breast cancer treatment. It is the light at the end of the tunnel that restores your sense of confidence and well-being.

Will I need to have more than one surgery?

Breast reconstruction is typically performed in two stages. The first stage is the technical stage. The priority is for the breast general surgeon to remove the breast tissue and any cancer, while the plastic surgeon focuses on maintaining your natural breast shape and contour. The second stage of breast reconstruction focuses on enhancing the breast and addresses any breast asymmetry present. A second stage procedure is not always necessary and depends on the type of breast reconstruction performed. This will be discussed in detail during your consultation.

What if I need radiation treatment?

Depending on the stage of the breast cancer, radiation therapy sometimes needs to be added to maximize the outcome of breast cancer treatment. Radiation tends to have a significant effect on the skin of the breast, decreasing its elasticity and wound healing, increasing fibrosis, and making the breast more susceptible to infection. If you require radiation, reconstruction can be performed with an implant or tissue expander prior to your therapy.

If your preference is natural tissue reconstruction, we tend not to perform immediate flap reconstruction at the time of mastectomy if we know that there is a medium to high risk of radiation therapy. In these cases, we may elect to place a temporary tissue expander or implant, allow for radiation to be completed, and perform flap reconstruction at about six to eight months after radiation. This prevents the transplanted tissue from being radiated and allows time for the breast tissue to heal prior to flap reconstruction.

Natural Tissue Reconstruction

Breast reconstruction using your own tissue results in a natural reconstruction that behaves and feels most like your native breast. Using your own tissue for reconstruction has the added benefit of replacing not only the breast volume, but also any tissue (skin, areola, nipple) that was removed during your breast surgery.

Flap Reconstruction Overview

Can I use my own tissue for reconstruction?

When making a recommendation regarding breast reconstruction your overall health, the tissue deficit present from your breast surgery, as well as your personal desires are considered. A physical examination is also necessary to determine if there is any excess tissue available to donate to your breast.

Most often, the abdomen is chosen as the donor site and the tissue removed is similar to that of a “tummy tuck.” However, women who are thin or had previous abdominal surgery may not be candidates for this option, so areas such as the buttock or the back may be considered. Fortunately, significant advancements in plastic surgery allowing us to tailor the breast reconstructive process to the individual woman.

What is a "flap"?

Flap reconstruction is when the patient’s own tissue (skin, fat, muscle) from one area of the body is used to reconstruct the breast. We call the area where the tissue is taken from the “donor site” and the tissue that is donated the "flap".

What are the stages of flap reconstruction?

Most flap reconstructions are performed in three stages

This result requires more than one surgical procedure. This patient had a left skin sparing mastectomy with DIEP flap reconstruction, nipple reconstruction, and nipple/areola tattooing.

Stage I: Flap Reconstruction

This is the technical stage of your reconstruction. Donor tissue (flap) is transferred to restore the breast. In many cases, this is performed immediately at the time of the mastectomy. However, if you already had a mastectomy or required radiation, reconstruction can still be performed at a later date in a “delayed” fashion. This stage in flap reconstruction is more involved and can be a longer procedure because it is intricate, frequently requiring microsurgery to reconnect the small blood vessels of the transplanted tissue. The hospital stay is between two to four days, recovery period is around 4 weeks to return to a desk job, and 6 weeks to gradually start resuming sports activities. The main focus of the first stage is to replace the breast with like tissue and allow time for the reconstructed breast to heal and settle.

Stage II: Symmetry Procedure

Three months after your surgery you will have a follow-up consultation to discuss the second stage - symmetry procedure. This is the "touch up" or symmetry stage where the breast flap is shaped and adjustments are done to the native breast to gain symmetry. This is a short outpatient procedure where we concentrate more on the cosmetic aspects of reconstruction including shape, symmetry, and volume. We may decide that a lift, reduction, fat grafting, or augmentation with an implant is necessary to obtain the best result. Abdominal scar revision may be performed at this time and some patients elect to proceed with other cosmetic procedures such as liposuction during this stage.

Stage III: Nipple Reconstruction

Nipple Reconstruction (if necessary) may be performed as an in-office procedure or may be combined with the symmetry procedure. Nipple and areola tattooing is the final stage to complete the reconstruction

What if I am not a flap candidate?

When considering your options, if using your own tissue is not possible, we can perform implant based reconstruction. Implant reconstruction is best when very little or no skin is removed with the mastectomy, such as in a nipple sparing mastectomy or skin sparing mastectomy. In these patients only the breast volume needs to be replaced to reconstruct the breast, which can be achieved with an implant.

Flap Donor Sites

Types of Flap Surgery

What is a DIEP or SIEA flap?

Both the DIEP (Deep Inferior Epigastric Perforator) and SIEA (Superficial Inferior Epigastric Artery) flaps utilize excess abdominal skin and fat from the lower part of the abdomen, leaving the underlying abdominal muscles intact. The difference between the two is the choice of blood vessels that nourish the flap tissue and this decision is made in the operating room.

The skill of the surgeon in DIEP and SIEA flap procedures is important, as they are considerably more demanding than earlier methods of breast reconstruction. The operation can be lengthy due to the precise nature of this microsurgical procedure. However, the surgical effort is rewarded by excellent cosmetic results. In the case of DIEP and SIEA flaps, the operation leaves a horizontal scar on the lower abdomen, similar to that created in a cosmetic tummy tuck, and a slimmer more contoured abdomen. Additionally, for both the DIEP and SIEA, we can now offer routine re-innervation where nerves are connected to facilitate gradual return of sensation in the reconstructed breast.

This patient underwent immediate left breast reconstruction with a DIEP flap. The final result is shown after nipple reconstruction and a breast lift on the right side.
What is a SGAP flap?

The SGAP flap, or Superior Gluteal Artery flap (buttock flap), is ideal for those who do not have an adequate amount of excess tummy tissue. The breast may be reconstructed with the skin, fat, and the tiny blood vessels taken from the buttock area to achieve a B or C cup breast size. The SGAP flap uses tissue from the top part of the buttock without injury or sacrifice of the underlying gluteal muscles. A slight buttock lift results in the donor area with a fine line incision easily hidden within the panty line.

This patient had a modified radical mastectomy and subsequent chemotherapy. At the time of her mastectomy, she elected not to have reconstruction but changed her mind a year or so later. A delayed right-sided breast reconstruction with the SGAP flap was performed for this patient. The SGAP flap was chosen because the patient did not have adequate abdominal tissue
What is a Latissimus Dorsi flap?

The latissimus dorsi myocutaneous flap is an option that may be used for reconstruction, with or without an implant. In this flap the tissue is rotated from the back to the breast, keeping its original attachment to the back. This flap includes a small ellipse of skin from the back and the underlying back muscle. The latissimus muscle is a fan-shaped muscle that starts at the shoulder and extends to the back area. The muscle does not have any function related to the back , but does act on the shoulder. Fortunately, other muscles in the rotator cuff (shoulder) take over the function of the latissimus muscle for normal activities. When this muscle is used there is a slight limitation in specific activities, such as climbing or pushing off with the arm, but daily living activities are not affected.

This patient presented with left infiltrating ductal carcinoma, which required a mastectomy. She wanted immediate reconstruction but did not wish to have a flap from the abdominal area and chose the latissimus flap. She underwent this procedure in two stages. The first was a left breast mastectomy with immediate reconstruction utilizing a latissimus flap with tissue expander. The second stage was an exchange of the tissue expander for an implant and nipple reconstruction.
What is a TAP flap?

The Thoracodorsal Artery Perforator flap (TAP flap) is a small flap that utilizes the tissue from the area on the side of the breast and the back. This flap is an option for small defects, such as in breast conservation or lumpectomy patients. Unlike the latissimus dorsi flap, this flap preserves the back muscle. The resulting scar is well hidden in the bra strap line.

Following two lumpectomies, this patient was left with only two-thirds of her left breast remaining. She was an excellent candidate for a partial breast reconstruction utilizing the TAP flap. The final result shows improvement in nipple position, breast shape, and scar release.

DIEP Flap Reconstruction

Am I a candidate for DIEP Flap Reconstruction?

Most women who have had a full-term pregnancy have enough abdominal laxity to use their tummy tissue for breast reconstruction. The amount of volume that can be achieved in the reconstructed breast(s) depends on the thickness of the fat layer in this area. In many women, a proportional reconstruction of one or both breasts can be performed. If there is enough laxity but not enough volume to reach the desired breast size, an implant can be placed under the flap during a second stage symmetry surgery to achieve the desired breast volume.

Patient underwent bilateral nipple sparing mastectomy with immediate DIEP flap reconstruction.
What are the advantages to DIEP flap reconstruction?

There are multiple benefits of the DIEP and SIEA procedures including:

  • Natural feel and appearance of the breast
  • Flatter contoured abdomen
  • Ability to correct deformity present from prior procedures through skin and tissue transfer
  • Improved breast sensation
  • Improved lymphedema

Combination Flap + Implant Surgery

What types of combination surgery do you perform?
  • Flap Reconstruction Combined with Implant Placement - This may be an option for a patient that needs a significant amount of skin transferred to reconstruct the breast after a mastectomy, but has minimal excess fat at the donor site to achieve their desired breast size
  • Implant Reconstruction Combined with a Mini-Flap - This may be an option for a patient who has had a skin sparing mastectomy and prefers the look of implant reconstruction or has minimal excess fatty tissue present. This reconstruction allows for the aesthetic of an implant and the benefit of replacing the tissue that was lost during the mastectomy
  • Flap or Implant Reconstruction Combined with Fat Grafting - Fat grafting can be used to supplement other forms of breast reconstruction. Fat grafting improves breast contour and symmetry and also has the added benefit of improving skin quality
What are the stages of flap reconstruction combined with implant placement surgery?

Stage I: Flap Reconstruction

The first step is the same as in the “flap only” reconstruction, where the donor tissue is transferred to restore the breast.

Stage II: Implant Placement

After adequate time is given for the flap tissue to settle and heal, the second surgery is performed where the implant is placed to achieve the desired breast cup size and improve breast projection. Fat grafting may also be performed during this surgery to improve breast contour.
This patient underwent bilateral nipple sparing mastectomy and DIEP flap reconstruction. She had excess skin and laxity present to her abdomen but minimal fatty tissue to achieve her desired breast size. After the patient healed from her flap surgery, an implant was placed under the flap to achieve a fuller breast shape.

Implant Based Reconstruction

Dr. Spiegel has been on the forefront of implant based reconstruction and has advanced techniques to improve the patient experience. In some patients, it is possible to reconstruct the breast in one stage, without the need for any additional procedures, allowing the patient to go home the same day with minimal pain.

Direct to Implant Reconstruction

What is Direct to Implant Reconstruction?

Direct to Implant is a one-stage reconstruction technique where a permanent breast implant is placed immediately following the mastectomy, without the need to use a tissue expander. Placing an implant directly depends on multiple factors, but we can now routinely reconstruct the breast with the direct to implant technique.

During the mastectomy, the breast tissue is removed and immediately following an implant is placed to the breast pocket using the prepectoral direct to implant technique. The implant is placed above the chest muscle and a dermal matrix is used to support the implant
What is Prepectoral Breast Reconstruction?

During a mastectomy, the breast tissue and the support structures within the breast tissue are removed. Historically, the breast was reconstructed by placing the implant underneath the pectoralis, or chest muscle (subpectoral reconstruction).

In prepectoral breast reconstruction, the implant is placed above the chest muscle and is supported by an acellular dermal matrix. This advancement in breast reconstruction allows the implant to be placed where the breast tissue naturally was located prior to the mastectomy, above the muscle. This innovative technique results in a softer, more natural, reconstructed breast. It is also a less invasive procedure with an easier recovery for the patient.

This patient underwent bilateral nipple sparing mastectomy with immediate direct to implant reconstruction. Her incision is hidden in her breast crease for a natural result.
What is an acellular dermal matrix?

The dermis is the strength layer of our natural body tissue. Acellular dermal matrix (ADM) is made from the dermis of cadaver tissue and is used as an internal brassiere to support the breast implant and provide additional tissue coverage between the breast implant and the mastectomy skin. ADM technology has paved the way for prepectoral implant reconstruction by allowing the implant to be placed above the chest muscle without sacrificing implant coverage or support.

Dr. Spiegel is a pioneer in prepectoral implant reconstruction and developed a patented acellular dermal matrix design specifically for prepectoral breast reconstruction. This matrix is used during all her prepectoral breast reconstructions, which has reduced operation time and allows for an implant reconstruction that is tailored to you.

The ADM is designed to be sewn above the muscle around the breast pocket to support the implant, acting as an internal brassiere. The matrix is sewn into place with absorbable sutures, which will dissolve, and the matrix will completely incorporate into your own tissue.

Tissue Expander Staged Reconstruction

Why would I need a tissue expander?

A tissue expander may be placed for safety following a mastectomy if there is a question regarding the perfusion, or blood supply, to the breast skin and/or nipple areola. If there is decreased blood flow to the skin or nipple, stretching the skin by placing an implant increases the risk of complications. A tissue expander is beneficial in this case because it allows for the breast pocket to be maintained, without putting unwanted tension on the skin. As the skin heals, the tissue expander can slowly be expanded in the office until the desired breast volume is achieved. The tissue expander is then exchanged for an implant.

What are the stages of tissue expander reconstruction?

Stage I: Tissue Expander Placement

The tissue expander is placed above the pectoralis muscle and is supported by the dermal matrix (collagen). It is left underfilled to allow the mastectomy skin time to heal without tension.

Stage II: Tissue Expansion

The tissue expander has a metal port, which allows saline to be injected into the expander. Expansions are performed through interval saline injections in the clinic until the desired breast size is achieved. The breast skin has decreased sensation after a mastectomy and with the additional placement of numbing cream this is a comfortable procedure.

Stage III: Implant Placement

The tissue expander is removed and replaced with an implant approximately 6-8 weeks after your final expansion. In addition, fat grafting or “liposculpting” may be performed to even out irregularities and provide more “padding” over the implant. A nipple maybe reconstructed at this time, or at a later date as a simple in office procedure.

Types of Implants

What are my implant options?

Our office uses smooth, round, silicone implants to reconstruct the breast. Saline implants are not typically used because they feel less natural, as they are filled with liquid. Also, saline implants have a higher risk of implant ripple deformity and rupture compared to silicone implants.

When choosing the optimal silicone implant we consider implant projection (combination of the implant height and width), silicone gel cohesion (viscosity), and implant size. We also consider breast symmetry to determine the implant that will work best for each patient.

During your consultation, we will discuss implants and determine what implant style is most appropriate. A range of sizes will then be ordered and in the operating room implant sizers are placed in the breast pocket. This allows for the size to be "tried on" and symmetry to be assessed, before choosing the final implant size.

Interval increase in implant projection is illustrated from left to right. The lowest "profile" corresponds with the lowest projection, or greatest width compared to height.
What are cohesive gel implants?

Cohesive gel implants have been widely used for many years and all silicone implants currently approved in the US are filled with cohesive silicone gel. The silicone implants of the past were quite problematic due to their thin shells and liquid silicone filling. These implants would frequently break or leak causing pain, hardness, or capsular contracture. In the early 90s, the cohesive gel implant was developed to address these issues. The shell was made thicker and the silicone gel was altered to make it more cohesive, meaning the gel particles are closer together. When these implants are cut, there is no oozing of the gel and the implant maintains its shape, preventing the silicone from spreading outside the implant shell and into other areas of the body.

Cohesive gel implants come in different grades of cohesivity. Cohesive gel implants of lower levels are softer and have the benefit of a more natural feeling and looking breast. High level cohesive implants hold their shape better than lower level implants, but results in a firmer less mobile feel. High level cohesive implants may be chosen if the patient prefers a more augmented look or if they have minimal fatty tissue present to hide any implant rippling.

As the cohesivity level increases from 1 to 3 implant rippling is less noticeable and implant shape is maintained for a more rounded look on the chest. Level 1 cohesive implants are softer and will look and feel more natural, dynamically changing to a tear-drop shape when seated or standing. Cohesive gel will not leave the implant if a rupture occurs.
Are implants safe?

Yes, breast implants are FDA-approved devices and are an important option for breast reconstruction. Breast implants have been studied and placed worldwide for decades and hundreds of thousands of patients have breast implants placed every year and report no adverse effects

Oncoplastic Reconstruction

Lumpectomy & Reconstruction

What is oncoplastic reconstruction?

Oncoplastic reconstruction combines breast reconstruction with a lumpectomy. This type of reconstruction involves rearranging the breast tissue to hide the defect created from the lumpectomy. Oncoplastic reconstruction is typically performed at the time of the lumpectomy or shortly after the lumpectomy and includes a breast reduction or breast lift.

This type of reconstruction is typically performed on patients with larger breasts. In smaller busted patients, the lumpectomy defect may be too significant with minimal tissue available for rearrangement. Like other forms of breast reconstruction, Dr. Spiegel works closely with your general surgeon to determine if this procedure is best for you.

I've already had a lumpectomy, what are my options?

Many options are available and after your consultation with Dr. Spiegel she will determine a plan to address your specific needs. Fat grafting is often used to improve breast contour and camouflage the lumpectomy defect. Fat grafting has the added benefit of improving skin quality after radiation therapy. If a large defect is present, you may be a candidate for flap reconstruction to bring skin and tissue to the area.

This photo was taken in Puerto Varas, Chile where Dr. Spiegel was honored to be invited to teach and perform live surgery on topics of Neurotization in Breast Reconstruction and Lymph Node Transfer

Additional Procedures

Resensation Surgery

Will I still have sensation to my breast?

Breast sensation is important to many women. After a mastectomy there will be a loss of some sensation. The extent of sensation loss varies from patient to patient. If you are having flap reconstruction, it may be possible to reconnect a sensory nerve from the donor tissue to the chest to improve the chances for regaining sensation. Dr. Spiegel is also pioneering a nerve graft procedure that can be performed in select patients during implant based reconstruction. This may reestablish temperature and pain sensation. In some patients, sexual sensitivity to the nipple may be restored, however this sensation is less likely to be regained.

Lymphedema Surgery

Is there anything that can be done for post-mastectomy lymphedema?

Although there is still no cure for lymphedema, vascularized lymph node transfer is proving to be successful in the treatment of lymphedema and can also be performed to reduce the risk of developing lymphedema in high risk patients. This procedure is performed routinely by Dr. Spiegel but requires a high degree of technical skill and surgical precision

The lymph node transfer procedure involves harvesting one or two lymph nodes from the groin area, along with their supporting artery and vein. These lymph nodes are then microsurgically transplanted to the under arm. The lymph node transfer can be performed as a stand-alone procedure or in conjunction with a DIEP flap.

Nipple Reconstruction

Do I really need nipple reconstruction?

Many patients who had to have their nipple removed with their mastectomy wonder if they really need nipple reconstruction. Sometimes, if the nipple reconstruction requires an additional procedure, going through another step seems laborious and feelings of doubt may creep in. Do I really need to do this? The nipple reconstruction is performed using the local breast tissue, so no other donor site is required. It is a simple procedure that can be performed in the office and results in a nipple with a moderate amount of projection in minutes. This step really does make the breast reconstruction look more natural and complete, like placing a bow atop a present.

What about nipple and areola tattooing?

If nipple reconstruction is necessary, tattooing is done six months later to complete the color of the areola. It is performed in the office by a licensed medical aesthetician. The color is matched to preoperative areola color but is made slightly darker initially because the pigment tends to fade with time. The tattooing is typically not painful but if necessary a numbing cream or numbing injection can be done to keep you comfortable.

Life After Breast Reconstruction

Common Questions

When can I wear a pretty bra?

After surgery we provide a surgical bra that is comfortable, non-constrictive, opens in the front, and is made of breathable cotton. This provides the best environment for your incisions to heal. Depending on the type of procedure, we recommend wearing this bra for two to four weeks.

Once you are cleared by the office, you will receive information to transition to a bra with medium support. Approximately three months after your final surgery, you will be ready to get that pretty bra you have been wanting. It is important to remember that you may have decreased breast sensation after your mastectomy. Due to this, we recommend avoiding bras with underwire as your everyday bra, as these might rub or pinch the skin. Underwire bras can be worn but it is important to check your skin regularly to ensure the bra is not causing irritation.

How will my scars look?

Scarless surgery is not yet within our reach, so most procedures will involve a scar to some extent. We use plastic surgery techniques when suturing the incisions, including absorbable sutures, to minimize the scar. Initially, the scar will appear red as the site is healing. Fortunately, scars are like wine, they get better with age. One to two years after surgery the redness disappears and the scars become less visible. Some women are prone to making thick raised scars. This also occurs in areas where there is a lot of tension and pulling on the skin, which tends to make scars wider or thicker. To decrease the tension we may recommend that you tape your scar to protect it from pulling.

Most scars are strategically designed to be hidden under a bikini. This will allow you to enjoy the pool without any visible scars. Of course it is important to use a high SPF sunblock (even under your swim suit!) to protect the scar and prevent hyper-pigmentation. Many patients ask about scar creams. We recommend scar therapy for all of our patients so please ask us for information when in the office.

Do I still need to do a self breast exam?

Self breast exams continue to be an important part of your ongoing breast care. Although the risk is low, breast cancer can return after a mastectomy. It is important to note that breast reconstruction does not increase or decrease the risk of recurrence, but understandably, many women wonder how the self-examination process changes after breast reconstruction surgery.

The answer is that while the reconstructed breast is different, the approach to self-exams remains the same. Check both your native breast and the reconstructed breast(s) to learn what feels normal. This will help you more easily discern any changes in the future. If you notice a change, always contact your doctor to ensure what you are feeling is normal or if you would benefit from breast imaging. Your doctor or nurse will also help you understand what is normal after reconstruction and can advise you on the best ways to perform breast self-examination following your mastectomy and reconstruction.

Click image to enlarge
Will I need future mammograms?

Many women experience anxiety around having to get a mammogram, which is only natural, but it is important to consider how this issue will be managed after breast reconstruction.

If you have had a lumpectomy, you still have native breast tissue and it is important to follow your oncologists recommendation for regular breast imaging.

Regular mammograms are not necessary after a skin sparing mastectomy, but if there were to be any area of concern noticed on your self breast exam then breast imaging would be ordered. If you elect to have a nipple sparing mastectomy it is important to discuss with your general surgeon whether a mammogram will be necessary in the future to examine the area under the nipple. Some surgeons and oncologists may want to have their patients continue to get mammograms to examine the area under the nipple.

Mammograms will still be required on your native breast if a preventive mastectomy is not performed.

Pink Sisters Support Group

What is the Pink Sisters Support Group?

Pink Sisters is a support group made up of women just like you who have already gone through the same fear, uncertainty, isolation, and resentment that can often pervade throughout the breast cancer treatment journey. This group is made up of Dr. Spiegel's previous patients that are dedicated to helping women get through this experience step-by-step with a sense of clarity and empowerment. Pink Sisters members are there for you to answer questions, provide guidance, or just be a friend who can relate to your experiences.

Can I be matched with a Pink Sister?

Yes! A Pink Sister can be invaluable support during your breast reconstruction journey. After you have your consultation with Dr. Spiegel and a procedure path is chosen, our team will "match" you with a Pink Sister whose life situation and procedure type best resemble your journey.

I completed my journey, can I help others?

Yes! Pay it forward and join our Pink Sisters Support Group!

Congratulations on completing your journey through breast reconstruction. Some of you battled breast cancer, while others have chosen to prevent it. Either way, each of you have experienced personal growth, empowerment, and a sense of community.

As you know, having a strong support network to rely on during this process can provide a great deal of relief and comfort. The emotional support of friends and family is essential during this time, but it can also be tremendously beneficial to connect with other women who have already been through the experience and who can offer clear information and knowledgeable advice.

The journey through the rest of your life awaits and we encourage you to join our Pink Sisters Support Group and continue to empower others with your story.

Thank you

We hope that this information has been helpful and look forward to continuing to support you along your breast reconstruction journey.