Direct-to-Implant Reconstruction

Surgical techniques have continued to improve, and experienced surgeons can now create a breast that often looks as good as or better than the original. However, mastectomy typically leaves the breast and nipple numb. I am now happy to offer patients a nerve graft at the time of the mastectomy surgery and finally give patients an option to restore some sensation. During the surgery, before the breast tissue removal, the large nerves exiting the chest wall are dissected before they enter the breast tissue. These are safely preserved so they are not removed with the mastectomy sensation. During the same surgery, and once the mastectomy is completed, these nerves are meticulously and carefully reconnected to severed nerve endings in the back of the skin, essentially providing a “jumper cable” around the breast implant. Patients typically start to notice sensation returning as early as three months after the mastectomy.

Sensation-preserving mastectomies are good options for women who want to preserve as much sensation as possible and are undergoing mastectomy. The nerves used are typically the lateral intercostal nerves, which enter the breast just behind the nipple and slightly to the side. The nerve that is used must be away from any area that may contain DCIS or breast cancer. Breast implant size may need to be limited depending on the individual patient’s anatomy.

Traditional mastectomy usually causes the loss of sensation to some of the breast and nipple, and more importantly, light touch, which is protective, as well as pleasure sensation. That is because traditional mastectomy may cut the nerves that supply sensation to the majority of the breast skin and nipple. The cut nerves can even cause painful sensations or, rarely, neuromas. With sensation-preserving mastectomy, a few months after surgery, sensation will start to improve. The sensation will spread over the top of the breast until the area above the graft has reinnervated, which may take up to one year. Breast sensation is not normal but is better than without the nerve graft.

Sensation-preserving mastectomy is best performed by a team of surgeons specializing in their unique skills, in which the mastectomy surgeon and the plastic surgeon work together to dissect the nerve at the beginning of the case and before the mastectomy, and that nerve remains undamaged during the mastectomy. The operation is a microsurgical procedure and involves advanced training with nerve grafting. Following the reconstruction, the nerve is reconnected at the skin and chest wall using microsurgical techniques that involve advanced training. I am proud to be part of the first team to offer this operation in Southern California.

We often hear from patients that other surgeons have told them they “are not a candidate for direct-to-implant reconstruction.” They are told that it is too dangerous and it only works for non-droopy, A- and B-sized breasts. Having performed hundreds of direct-to-implant reconstructions over more than 15 years, I can tell you that it’s not true. First, consider that it’s the first part of the surgery, the mastectomy, that is typically higher risk. For most breast cancer surgeons, the complication rate due to mastectomy flap necrosis is 30% or more.

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That means that most plastic surgeons are very wary of trying direct-to-implant reconstruction because they fear that the skin or nipple may die after the surgery. This would mean that the skin would need removal and closure. So they advise their patients to have a three-phase surgical process, with mastectomy and placement of tissue expanders, followed by three months of painful expansion, followed by surgery to replace the expanders with permanent implants. With our mastectomy surgeons, the risk of mastectomy flap necrosis is very low, around 1%. This means we can trust the breast skin, nipple, and areola to survive. I believe tissue expanders are outdated, and I hope other centers can improve their techniques to make this a safe, commonly performed procedure someday. With a pre-pectoral implant that easily fits in place of the breast tissue, a tissue expander is not needed. Direct-to-implant can be used in combination with other techniques where appropriate. For women with large or droopy breasts, I may use an "autoderm flap," which lifts and protects the implant and breast appearance at the same time; this is where extra skin is used to reinforce the implant position, and a breast lift is done concomitantly to the mastectomy. For patients who have undergone radiation therapy of the breasts, it is much safer to perform the reconstruction over the muscle and also use the direct-to-implant techniques to minimize the increased risk of infection that comes with multiple implant surgeries. For patients with existing breast augmentation, the implants are usually placed under the muscle since the muscle is already partially detached from the chest wall.

Many women would like to avoid breast implants for reconstruction and don’t want free flaps that take many hours and have extended recovery. There are a few options that allow implants and long surgeries to be avoided. First, we can choose to “go flat,” meaning that the breast is closed in a long line with a smooth contour. This is also called “Aesthetic Flat Closure”. Here, avoiding the dreaded “dog ear” or other unsightly skin bulges that ruin the result is critical. Many, though, don’t want the long scar and don’t want to be completely flat. For this group, we have the SWIM flap, a modification for smaller breasts that I am fondly calling the “K. Lo” after my patient who was too small for the SWIM techniques but avidly refused an implant. In these techniques, extra skin and subcutaneous fat are preserved and used to make a new, albeit much smaller, breast. My

SWIM breast reconstruction

is an enhanced and refined version of the Goldilocks technique but with preservation of the nipple and recruitment of any bra roll fat. Like direct-to-implant reconstruction, the SWIM breast reconstruction is carried out at the same time as a mastectomy but involves creating a breast from the patient's own tissue and fat instead of using an implant. My article, published in the Journal of the American College of Surgeons, details the procedure and proves the many benefits of this approach.

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The SWIM is ideal for larger-breasted women who want natural-looking, smaller breasts, as well as those who have undergone radiation treatments for cancer or who have multiple risk factors and health issues. I perform more than 500 reconstruction cases each year. This includes Direct-to-Implant breast reconstruction, nipple reconstruction,

reconstruction revisions

, SWIM flaps, and fat grafting. Most of those cases are one-stage procedures—primary breast reconstructions done at the same time as the patient's mastectomy—in our Beverly Hills surgery center. I am dedicated to helping women live with confidence and comfort. During your consultation appointment, we will discuss your medical history and aesthetic goals, and I will answer any questions you may have. If you are not an ideal candidate for single-stage reconstruction with saline or silicone implants, I will guide you to a procedure that is right for your needs and goals.

If you're seeking breast reconstruction in Beverly Hills or the Los Angeles, CA area,

Dr. Lisa Cassileth

is a board-certified plastic and reconstructive surgeon specializing in complex breast procedures. Dr. Cassileth is renowned for offering cutting-edge options, including direct-to-implant reconstruction, designed to provide natural, beautiful results in fewer steps.

Contact us

today to learn more about the personalized solutions available for your breast reconstruction journey.