SWIM Flap:Natural Breast Reconstruction Without Implants

How SWIM developed from the Goldilocks technique

I developed the SWIM flap with Dr. Heather Richardson, who created the original Goldilocks mastectomy technique with Dr. Grace Ma. Both techniques use skin and fatty tissue remaining after mastectomy to create a breast reconstruction. The original Goldilocks technique did not preserve the nipple; SWIM preserves the nipple on a specialized blood supply when cancer treatment and circulation allow. We published the SWIM technique in the Journal of the American College of Surgeons in 2020.

SWIM stands for Skin-Sparing, Wise-Pattern, Internal Mammary Perforator. The Wise pattern is a skin-reshaping pattern commonly used in breast reduction surgery, generally producing scars around the areola, vertically down the lower breast, and along the breast fold along lines used for aesthetic results. The remaining skin and fatty subcutaneous tissue are folded and shaped into the reconstruction while preserving the internal mammary perforator blood supply to the nipple and surrounding tissue.

Why women choose SWIM reconstruction

Women interested in SWIM often want natural-tissue reconstruction without the monitoring and potential future surgery associated with breast implants. Some have concerns about silicone or prefer not to have a foreign device in their body. Others want to use their own tissue but do not want a more extensive operation involving tissue transfer from another part of the body. SWIM offers an option without an initial implant, microsurgical tissue transfer, or a separate flap donor site.

How SWIM differs from free-flap reconstruction

A free flap transfers tissue from another part of the body to the chest, reconnecting its blood vessels using microsurgery. The second surgical site and microsurgical portion generally mean a longer operation and more extensive recovery. In my experience, SWIM generally takes about half as long as free-flap reconstruction, although surgical time varies.

Final breast size after free-flap reconstruction depends on the amount of tissue harvested from the donor site. With SWIM, I must work with the healthy skin and subcutaneous fat remaining after mastectomy, so there is less control over the final breast size. The distinction is not that free flaps always create larger breasts. When someone says, “My friend had a flap,” she is often describing a microsurgical free flap, which is different from SWIM reconstruction using tissue already present at the mastectomy site. Many surgeons do not perform the SWIM flap and may not be able to tell you whether you are a candidate.

Candidacy and expected breast size

The best candidates are women who want reconstruction without implants or a distant flap donor site, have sufficient usable skin and subcutaneous fat, and are comfortable with uncertainty about their final breast size. Women with larger or more drooping breasts often have more tissue available, but starting breast size alone does not determine the result. A woman with very large breasts may have thin subcutaneous fat and relatively little usable volume after mastectomy, while someone with moderately sized breasts may have a thicker fatty layer and a fuller reconstruction.

Other clues that may suggest more available tissue include fatty rather than dense breasts and a tendency to carry subcutaneous fat around the upper torso and midsection. These features may indicate a thicker mastectomy flap, which is the fat used for SWIM. I have also performed SWIM reconstruction for women with smaller breasts who were happy with a small, proportionate result. The key is how much healthy tissue remains after mastectomy and whether the patient’s expectations match what it can create.

Patients should expect to be smaller than before surgery, sometimes smaller than they consider proportionate to their frame. SWIM may not suit someone who wants to remain large, requires a particular cup size, or expects to achieve that size in one operation. Previous surgery, radiation, nicotine use, medical conditions, and tissue circulation also influence candidacy.

SWIM reconstruction before and after

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After

Before

After

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After

Nipple preservation and healing

SWIM preserves the nipple’s blood supply when it is safe to keep the nipple during the mastectomy. In my practice, nipple necrosis, or tissue loss from inadequate blood flow, has been uncommon, although slightly more frequent than with my direct-to-implant reconstructions. I use SPY-PHI fluorescence imaging during surgery to assess circulation and guide decisions about preserving the nipple and mastectomy skin. Nipple preservation still depends on both the cancer treatment and the blood supply.

The reconstruction requires careful postoperative monitoring. Healing problems, infection, bleeding, fat necrosis, asymmetry, or partial tissue loss can occur, and I review individual risks during consultation. Additional wound care or surgery may be needed if tissue does not heal as expected.

A complete mastectomy

The breast surgeon or surgical oncologist performs a complete mastectomy. SWIM uses the preserved skin and subcutaneous fat, not the breast gland, to reconstruct the breast; glandular breast tissue is not intentionally retained to provide volume. Although the result may resemble a breast reduction in shape and scar pattern, the underlying operation is a mastectomy followed by reconstruction.

Breast contour without implants

Even a small breast reconstruction can make a meaningful difference in body contour and clothing fit. Some patients feel that a flat chest makes their abdomen appear more prominent; others have difficulty keeping a padded bra or external prosthesis in position when raising their arms. A reconstructed breast can provide contour and a base for padding if desired. Flat closure remains a valid choice, while SWIM offers another option for women who want breast shape without implants or a free-flap procedure.

Adding volume with fat grafting or implants

Some women choose no further surgery because their priority is the simplest reconstructive course possible. Others choose outpatient fat grafting to improve volume, contour, fullness, or symmetry. In my practice, approximately half or more of the SWIM patients who are particularly concerned about breast appearance elect to have later fat grafting. This transfers fat from another area of the body into the reconstructed breast, and more than one session may be needed.

I do not combine fat grafting with the initial SWIM reconstruction. My concern is that adding fat at that time could compromise the blood supply to the mastectomy skin and increase the risk of tissue loss. I prefer to let the reconstruction heal before adding volume.

Patients who later decide they want implants may have them placed after healing, typically six months after SWIM or later. Recovery may be similar to breast augmentation, although suitability depends on skin quality, soft-tissue coverage, anatomy, and the patient’s goals.

Sensation and nerve reconstruction

Preserving the nipple’s appearance does not necessarily preserve its sensation because sensory nerves are divided during mastectomy. In selected SWIM procedures, I perform nerve preservation or reconstruction to support sensory recovery. Because there is no implant for the nerve to travel around, the patient’s own nerve tissue can often be used without a cadaveric donor nerve graft. The technique depends on which nerves remain available and the distance they need to reach.

Recovery after SWIM reconstruction

In my practice, recovery typically includes a special Prevena VAC dressing that applies gentle negative pressure to help reduce tension and protect the incisions. The dressing stays in place for five days. Surgical drains are usually removed at approximately one week. Patients may shower as soon as the dressing is removed. Patients traveling for surgery generally stay in town for two weeks for postoperative care and monitoring. Oral antibiotics are not routinely required after this procedure.

When possible, patients receive postoperative hyperbaric oxygen therapy to support oxygen delivery and healing in the reconstructed tissue. There are no restrictions on arm range of motion, but heavy lifting and high-impact aerobic activity are restricted for one month. Patients are generally cleared for swimming, including in the ocean, at one month, provided the incisions are fully healed. These timelines may be adjusted according to individual healing.

Considering SWIM reconstruction?

During a consultation at my Beverly Hills practice, we review your mastectomy plan, the tissue likely to remain, and your goals for breast shape and size to determine whether SWIM is a good option for you.

Request a SWIM reconstruction consultation