Breast Reconstruction
A breast cancer diagnosis changes everything in an instant, and the decisions that follow can feel overwhelming. Among the most personal of those decisions is how to approach breast reconstruction. At Golden State Plastic Surgery, we believe every patient deserves a reconstruction plan shaped around their body, goals, and treatment path.
Staged Reconstruction with Tissue Expander
When the skin and tissue of the chest are too tight after mastectomy to accommodate an implant right away, a staged approach using a tissue expander is the standard solution. A tissue expander is a deflated silicone shell with a small built-in valve. It is placed beneath the skin or chest muscle during the mastectomy or in a separate procedure.
Over the following weeks, your provider gradually fills the expander with saline through the valve using a small needle. This is performed during regular office visits and is typically well tolerated. The process stretches the skin and soft tissue until it can comfortably support a permanent breast implant that matches your desired size.
Once the skin has expanded enough, a second surgery is performed to remove the expander and place the final implant. This exchange typically happens several months after the initial placement. Fat grafting may be performed simultaneously to smooth contour irregularities and help camouflage the implant, resulting in a more natural appearance.
Tissue expander reconstruction is an outpatient procedure with relatively little downtime. Most patients return to light daily activity within about four weeks. The staged approach is particularly helpful for patients who need their nipple or areola removed, who require radiation therapy, or whose skin blood supply needs time to heal safely before a permanent implant is placed.
Direct-to-Implant Reconstruction
For patients whose skin quality and tissue coverage allow it, direct-to-implant reconstruction eliminates the need for a tissue expander entirely. The breast implant is placed at the time of mastectomy in a single surgery, and patients can go home the same day.
This technique has become more widely available thanks to advances in acellular dermal matrix (ADM) technology. ADM is a graft derived from donated human skin tissue, with cells removed to prevent rejection. Your surgeon stitches the ADM to the chest wall to create a supportive pocket for the implant, functioning like an internal sling. Over the following months, your own blood vessels grow into the matrix, and your body naturally incorporates it.
Golden State Plastic Surgery routinely performs prepectoral direct-to-implant reconstruction, meaning the implant sits above the chest muscle rather than beneath it. This approach avoids the discomfort and animation distortion that can occur when implants are placed under the pectoralis muscle. When combined with a nipple-sparing mastectomy, the result can closely resemble the appearance of a natural, unoperated breast.
Direct-to-implant is not right for every patient. Factors such as cancer location, mastectomy type, and desired breast size all influence whether this approach is safe and appropriate.
Oncoplastic Breast Reduction
Oncoplastic breast reduction combines a standard lumpectomy with the techniques of a breast reduction, allowing patients with larger breasts to have their cancer removed and their breast reshaped in a single operation. This approach is part of the growing field of oncoplastic breast surgery, which brings together cancer surgery and reconstructive plastic surgery to achieve both optimal oncologic outcomes and improved cosmetic results.
During the procedure, the breast surgeon removes the tumor along with a generous margin of healthy tissue. The plastic surgeon then reshapes the remaining breast tissue into a smaller, higher, and more naturally rounded form. The nipple-areolar complex is typically preserved on its blood supply and repositioned higher on the chest wall. If only one breast has cancer, the opposite breast is usually reduced at the same time to achieve symmetry.
Large studies comparing oncoplastic reduction to standard lumpectomy have found equivalent cancer outcomes, with the added benefit of higher patient satisfaction regarding breast appearance and symmetry. Candidates are generally patients with moderate to large breasts who need a significant volume of tissue removed and may already experience symptoms like back pain, neck pain, or shoulder grooving from heavy breasts. Patients with small breasts or those who smoke are generally not good candidates.
Because radiation may cause the treated breast to shrink somewhat over time, your surgeon may leave the treated side slightly larger to anticipate this change. A preoperative MRI is often performed to fully map the extent of disease and minimize the need for additional surgery.
Partial Breast Reconstruction with LICAP and TDAP Flaps
When a lumpectomy removes a large portion of breast tissue, the resulting change in shape can be noticeable, particularly after radiation therapy. Partial breast reconstruction addresses this by restoring the lost volume and contour using nearby tissue. Two flap techniques that Golden State Plastic Surgery uses for this purpose are the LICAP flap and the TDAP flap.
The TDAP (thoracodorsal artery perforator) flap uses skin and fat from the upper back, near the armpit area, to fill the lumpectomy defect. The LICAP (lateral intercostal artery perforator) flap uses skin and fat from the side of the chest, also near the armpit. Both are perforator flaps, meaning that the tissue is removed with its blood supply while sparing the underlying muscle. This preserves arm and shoulder strength and speeds recovery compared to techniques that sacrifice muscle.
These flaps are particularly effective for reconstruction of the outer breast. The incision can typically be concealed in the armpit area or along the bra line. Because the tissue remains connected to its blood supply and is simply rotated into position, microsurgery is not required. Most patients can return to work within 2 to 4 weeks and resume vigorous activity within 4 to 6 weeks.
Latissimus Flap Breast Reconstruction
The latissimus dorsi flap, commonly called the lat flap, uses skin, fat, and the latissimus dorsi muscle from the back to reconstruct the breast. The tissue is rotated from the back to the chest on its original blood supply, which avoids the need for microsurgery and makes this a shorter, less complex operation compared to procedures like the DIEP flap.
The latissimus dorsi muscle sits on the back below the shoulder and behind the armpit. While it contributes to shoulder function, other muscles in the rotator cuff compensate once it is transferred. After surgery, most patients retain a full range of motion and notice little difference in daily activities, though specific movements like climbing or twisting may feel slightly limited.
Because the back typically does not contain much fat, a tissue expander or implant is usually placed alongside the transferred tissue to achieve the desired breast volume. The lat muscle covers and protects the implant, while the skin and fat fill any deficit left by mastectomy or radiation. The donor site scar on the back is positioned to be concealed beneath the bra line.
This reconstruction is performed in two stages. The first focuses on safely transferring tissue to the breast. The second, performed no earlier than three to four months later, refines breast shape and symmetry. Patients typically spend 2 to 3 days in the hospital and can return to normal daily activities at about 4 weeks, with full unrestricted activity by 2 to 3 months.
The latissimus flap is a reliable option for patients who are not candidates for other types of flap reconstruction due to limited abdominal or buttock tissue, previous surgeries, or medical history. It is also a valuable tool for breast reconstruction revision and for repairing breast deformity caused by prior surgery or radiation.
Goldilocks Procedure
The Goldilocks procedure is a reconstruction technique for patients with larger or ptotic (drooping) breasts who want to avoid both implants and donor site surgery. During a Goldilocks mastectomy, the breast surgeon removes the breast tissue while preserving the breast skin and underlying fatty tissue. The plastic surgeon then reshapes this preserved tissue into a new breast mound during a single operation.
Because the Goldilocks approach does not use implants, it avoids the associated risks of capsular contracture, implant rupture, and future implant maintenance. And because it does not take tissue from another part of the body, there are no wounds or scarring at a separate donor site. For patients who have wanted a breast reduction, this procedure can achieve that while simultaneously treating their cancer.
Candidates for the Goldilocks procedure generally have enough breast skin and fatty tissue to create a satisfactory mound. Non-smokers tend to have better outcomes because smoking can impair blood flow to the reconstructed breast. Nipple preservation may be possible if the blood supply remains sufficient after breast tissue is removed.
Aesthetic Flat Closure
Not every patient wants breast reconstruction, and aesthetic flat closure is a recognized reconstructive option for those who choose to go flat after mastectomy. This procedure involves smoothing the chest wall, removing excess skin and tissue, and creating a clean, symmetric incision closure. The goal is to produce a smooth, flat contour rather than leaving irregular tissue or “dog ears” that can result from mastectomy alone.
Aesthetic flat closure is classified as reconstructive surgery, not cosmetic. The National Cancer Institute defines it as surgery that rebuilds the shape of the chest wall after one or both breasts are removed. The procedure may be performed at the time of mastectomy or as a later revision, including after removal of breast implants.
Several incision patterns are available, and the right approach depends on factors like breast size, skin quality, tumor location, and patient preference. Your surgeon will guide you in choosing the approach that best matches your anatomy and goals.
Revision Breast Reconstruction
Breast reconstruction does not always go as planned, and some patients may experience complications or cosmetic concerns after their initial surgery. Revision breast reconstruction, also called corrective surgery, addresses problems such as breast pain, increasing tightness or firmness, changes in breast shape or position, implant displacement, capsular contracture, or asymmetry between the breasts.
The corrective approach is always customized to the specific situation. In some cases, your surgeon may recommend waiting several months after your initial reconstruction to allow swelling and minor distortions to resolve on their own. If you are still undergoing radiation or chemotherapy, those treatments typically need to be completed before revision surgery can proceed.
At Golden State Plastic Surgery, our team evaluates each patient individually and develops a tailored plan to achieve improved symmetry, comfort, and confidence.
Choosing the Right Path Forward with Golden State Plastic Surgery
Breast reconstruction is not a one-size-fits-all decision. Your cancer treatment, body type, personal preferences, and lifestyle all play a role in determining which approach is best for you. Golden State Plastic Surgery offers a full range of reconstructive options, so each patient can receive a truly individualized plan. Get started on your reconstruction journey by scheduling a consultation with our experienced team today.
