Every surgery has risks. What should patients know before reconstructive surgery, and what should they know post-surgery? Our guest speaker is Jamie Levine, MD, a plastic surgeon in New York City and affiliated with multiple hospitals in the area, including NYU Langone Hospitals and NYC Health and Hospitals-Bellevue. He will detail the different reconstruction options, suggested healing times, potential risks, and side effects that can occur either during surgery or afterward.

1. Breast Reconstruction
Jamie Levine, M.D.
Associate Professor of Plastic Surgery
New York University School of Medicine

2. Mastectomy Reconstruction
• First major decision after deciding on a
mastectomy is about whether or not to
proceed with breast reconstruction.
• When deciding for breast reconstruction
the patient has multiple options.
• No matter what process the main
objective is to achieve an appropriate
and aesthetic breast reconstruction for
the patient.

3. Breast Reconstruction
• When I started, about 8% of eligible patients
were getting reconstruction
– Rates of breast reconstruction after mastectomy
rose 62% from 2009 to 2014
– 2016 40% of patients had reconstruction
• Performed when all or part of the breast is
removed
• Will produce a new breast mound and a new
nipple-areola complex
• Three major options exist

4. Surgical Options
• Three main types of breast reconstructive
options
• 1. Autologous
• 2. Implant based
– One or two staged
• 3. Combination reconstruction with own
tissue and an implant (latissimus (or other)
and Implant)

5. Postmastectomy Reconstruction-
Patient Selection
• Individualized to meet patient psychological,
emotional and physical requirement.
• Tissue expander / Implant most commonly
used
– Individuals in need of additional skin can
benefit from tissue expansion.
• TRAM/DIEP flap is commonly performed
– Individuals who have moderate amount of fat
without a midline scar.

6. Techniques to Create a Mound
Using artificial materials, also
called expander-implant
technique
Using own tissue, also
called the auto-logous
technique

7. Autologous Breast Reconstruction
• Uses the Patients own tissue, usually fat
and skin
• Most commonly used are the Stomach
(TRAM), Back (Latissimus), Thigh
(multiple locations) or Buttock (Gluteus).
• No artificial materials are needed

8. TRAM (Transverse Rectus Abdominus
Myocutaneous) Flap
• A flap is typically a combination of muscle, fat,
and skin and can be taken from the patient's
abdomen, back, or other parts of the body.
– In the case of a TRAM flap, the tissue is taken from
the abdomen.
• There are three main forms of TRAM flap
operations that are used for mastectomy
reconstruction.
– The Pedicled TRAM Flap
– The Free TRAM Flap
– The DIEP Flap (Muscle-Sparing Free Tram Flap)

9. TRAM (Transverse
Rectus Abdominus
Myocutaneous) Flap

10. Pedicled TRAM Flap
• Uses the rectus abdominal muscle for the breast
reconstruction. Surgery begins with an incision from
hip to hip, than a flap of skin, fat, and one of the
patient’s abdominal muscles is tunneled under the
skin to the chest to create a new breast.
• Small Incidence of minor complications:
– Wound dehiscence
– Fat necrosis (tissue become hard due to lack of blood
supply)
– Abdominal complications such as bulging /hernia

11. Pedicled TRAM Flap

12. Pedicled TRAM Flap After Tattoo

13. Free TRAM Flap
• Remove Same tissue as the TRAM but use blood
vessels without taking all of the muscle
• Specifically this procedure involves disconnecting
the flap from the patient’s body, transplanting it
to the chest, and reconnecting the flap to the
patient’s body using microsurgery.
• This procedure decreases abdominal wall
morbidity, improved blood supply, decreases
partial necrosis, decreases wound complications.
• More shaping with improved aesthetics, more
resistant to adjuvant therapies (chemotherapy,
radiation).

14. Free TRAM
Flap

15. Free TRAM Flap – Post Op

16. Perforator Flaps
• Microcirculatory bed and skin / adipose
tissue transferred only
• No muscle resection – decreased
postoperative pain and morbidity
• Variable perforator anatomy
• Types of Perforator Muscle Flaps:
–DIEP , PAP, LTAP, SIEA , S-GAP etc.

17. DIEP (Deep Inferior Epigastric
Perforator) Flap
• Uses the patient’s own abdominal tissue to
reconstruct natural breast after mastectomy. There
is no sacrificing of abdominal muscle in this
procedure (all abdominal muscle preserved).
• The blood vessels (perforators) are required to keep
the skin and fat alive without the use of the
abdominal muscle.
• After the skin, tissue, and perforators are collected
they are disconnected from abdomen and
transplanted and connected to the patient’s chest.
• Patients receive a tummy tuck along with the
procedure.

18. DIEP Flap

19. BILATERAL SKIN SPARING MASTECTOMIES
WITH DIEP MVFF
(DEEP INFERIOR EPIGASTRIC PERFORATOR MICROVASCULAR FREE FLAP RECONSTRUCTION)
Breast Reconstruction

20. Pre-op Breast Reconstruction

21. Pre-op Breast Reconstruction

22. Post-op DIEP Flap

23. Post-op DIEP Flap

24. Post-op DIEP Flap

25. BILATERAL SKIN SPARING MASTECTOMIES
WITH DIEP MVFF RECONSTRUCTION
(DEEP INFERIOR EPIGASTRIC PERFORATOR MICROVASCULAR FREE FLAP RECONSTRUCTION)
Breast Reconstruction

26. Pre-op Breast Reconstruction

27. Pre-op Breast Reconstruction

28. Post-op DIEP Flap

29. Post-op DIEP Flap

30. Post-op DIEP Flap

31. BILATERAL SKIN SPARING MASTECTOMIES
WITH DIEP MVFF
(DEEP INFERIOR EPIGASTRIC PERFORATOR MICROVASCULAR FREE FLAP RECONSTRUCTION)
Breast Reconstruction

32. Pre-op Breast Reconstruction

33. Post-op DIEP Flap

34. Post-op DIEP Flap

35. RIGHT BREAST SKIN SPARING MASTECTOMY
WITH DIEP MVFF RECONSTRUCTION
(DEEP INFERIOR EPIGASTRIC PERFORATOR MICROVASCULAR FREE FLAP RECONSTRUCTION)
Breast Reconstruction

36. PRE-OP RIGHT BREAST MASTECTOMY

37. PRE-OP RIGHT BREAST MASTECTOMY

39. PHASE I
Post Op Right Breast Mastectomy with DIEP MVFF Reconstruction

40. PHASE I
Post Op Right Breast Mastectomy with DIEP MVFF Reconstruction

41. BEFORE & AFTER
Right Breast Mastectomy with DIEP MVFF Reconstruction
(Deep Inferior epigastric perforator microvascular free flap reconstruction)

42. BILATERAL SKIN SPARING MASTECTOMIES
WITH DIEP MVFF RECONSTRUCTION AND
LATISSIMUS FLAPS
(DEEP INFERIOR EPIGASTRIC PERFORATOR MICROVASCULAR FREE FLAP RECONSTRUCTION)
Breast Reconstruction

43. Pre-op Breast Reconstruction

44. Pre-op Breast Reconstruction

45. Post-op DIEP Flap

46. Post-op DIEP Flap

47. Post-op DIEP Flap

48. BILATERAL SKIN SPARING MASTECTOMIES
WITH DIEP MVFF RECONSTRUCTION AND
PAP FLAPS
(DEEP INFERIOR EPIGASTRIC PERFORATOR MICROVASCULAR FREE FLAP RECONSTRUCTION)
Breast Reconstruction

53. BILATERAL NIPPLE SPARING MASTECTOMIES
WITH DIEP MVFF RECONSTRUCTION
(DEEP INFERIOR EPIGASTRIC PERFORATOR MICROVASCULAR FREE FLAP RECONSTRUCTION)
Breast Reconstruction

54. PRE-OP BILATERAL MASTECTOMIES

55. POST-OP
Bilateral Nipple Sparing Mastectomies with DIEP MVFF Reconstruction

56. POST-OP
Bilateral Nipple Sparing Mastectomies with DIEP MVFF Reconstruction

57. POST-OP
Bilateral Nipple Sparing Mastectomies with DIEP MVFF Reconstruction

58. BEFORE & AFTER
Bilateral Nipple Sparing Mastectomies with DIEP MVFF Reconstruction

59. BILATERAL NIPPLE SPARING MASTECTOMIES
WITH DIEP MVFF RECONSTRUCTION
(DEEP INFERIOR EPIGASTRIC PERFORATOR MICROVASCULAR FREE FLAP RECONSTRUCTION)
Breast Reconstruction

60. PRE-OP BILATERAL MASTECTOMIES

61. POST-OP
Bilateral Nipple Sparing Mastectomies with DIEP MVFF Reconstruction

62. BEFORE & AFTER
Bilateral Nipple Sparing Mastectomies with DIEP MVFF Reconstruction

63. GAP (Superior Gluteal Artery
Perforator) Flap (S-GAP / A-GAP)
• Patient who do not have adequate amount of
abdominal tissue – no abdominal pannus
• This procedure uses excess skin and fat from
the gluteal (buttock region) and leaves the
gluteal muscle behind.
• The patient will gently be turned over onto
stomach after performing mastectomy, the
GAP flap will be harvested and disconnected,
the new breast will be transferred to the chest
using microsurgery and reshaping.

64. GAP (Superior
Gluteal Artery
Perforator)
Flap (S-GAP /
A-GAP)

65. Breast Reconstruction
RIGHT BREAST SKIN SPARING MASTECTOMY
WITH PRIOR LEFT GLUTEAL MVFF
RECONSTRUCTION

66. PRE-OP RIGHT BREAST MASTECTOMY

67. *This patient has a history of left breast nipple sparing mastectomy with SGAP reconstruction.
PRE-OP RIGHT BREAST MASTECTOMY

68. PRE-OP RIGHT BREAST MASTECTOMY

69. PHASE I
Post Op Right Breast Skin Sparing Mastectomy with SGAP MVFF

70. PHASE I
Post Op Right Breast Skin Sparing Mastectomy with SGAP MVFF

71. BEFORE & AFTER
Post Op Right Breast Skin Sparing Mastectomy with SGAP MVFF

72. PAP (Profunda Artery Perforator Flap)

73. BILATERAL NIPPLE SPARING MASTECTOMIES
WITH PAP MVFF RECONSTRUCTION
(PROFUNDA ARTERY PERFORATOR MICROVASCULAR FREE FLAP RECONSTRUCTION)
Breast Reconstruction

74. PRE-OP BILATERAL MASTECTOMIES

75. PRE-OP BILATERAL MASTECTOMIES

76. PHASE I
Post Op Bilateral Mastectomies with PAP MVFF Reconstruction

77. PHASE I
Post Op Bilateral Mastectomies with PAP MVFF Reconstruction

78. PHASE I
Post Op Bilateral Mastectomies with PAP MVFF Reconstruction
PHASE II WILL INCLUDE:
Upper thigh scar revision

79. BILATERAL NIPPLE SPARING MASTECTOMIES
WITH PAP MVFF RECONSTRUCTION
(PROFUNDA ARTERY PERFORATOR MICROVASCULAR FREE FLAP RECONSTRUCTION)
Breast Reconstruction

80. PRE-OP BILATERAL MASTECTOMIES

81. PRE-OP BILATERAL MASTECTOMIES

82. PHASE III POST-OP
Bilateral Mastectomies with PAP MVFF Reconstruction,
right nipple reconstruction, fat grafting, and nipple/areola tattoo
PHASE III POST-OP
Bilateral Mastectomies with PAP MVFF Reconstruction,
right nipple reconstruction, fat grafting, and nipple/areola tattoo

83. PHASE III POST OP
Bilateral Mastectomies with PAP MVFF Reconstruction,
right nipple reconstruction, fat grafting, and nipple/areola tattoo

85. BEFORE & AFTER
Bilateral Mastectomies with PAP MVFF Reconstruction,
right nipple reconstruction, fat grafting, and nipple/areola tattoo

86. LTAP (Lateral Thigh Artery Perforator
Flap) Flap Pictures

87. BILATERAL NIPPLE SPARING MASTECTOMIES
WITH LTAP MVFF RECONSTRUCTION
(LATERAL THIGH ARTERY PERFORATOR MICROVASCULAR FREE FLAP RECONSTRUCTION)
Breast Reconstruction

88. PRE-OP BILATERAL MASTECTOMIES

89. PRE-OP BILATERAL MASTECTOMIES

90. PHASE I
Post Op Bilateral Mastectomies with PAP MVFF Reconstruction

91. PHASE I
Post Op Bilateral Mastectomies with PAP MVFF Reconstruction

92. PHASE II
Post Op Bilateral Mastectomies with PAP MVFF Reconstruction & skin paddle excision

93. PHASE II
Post Op Bilateral Mastectomies with PAP MVFF Reconstruction & skin paddle excision

94. PHASE II
Post Op Bilateral Mastectomies with PAP MVFF Reconstruction & skin paddle excision

95. PHASE II
Post Op Bilateral Mastectomies with PAP MVFF Reconstruction & skin paddle excision

96. BEFORE & AFTER
Post Op Bilateral Mastectomies with PAP MVFF Reconstruction

97. Advantages of Autologous Breast
Reconstruction
• Better aesthetics. The Patients own
tissue is used; it looks and feels more
natural, and will age and hang with the
patient.
• Lower risk of long term complications.
• More resistant to adjuvant therapy.
• One stage type reconstruction.

98. Disadvantages of Autologous Breast
Reconstruction
• More complex surgery
• Longer post operative, hospital and
recovery time
• Abdominal wall morbidity for the free
TRAM

99. Expander / Implant Breast
Reconstruction
• Most popular form of breast
reconstruction
• Can be performed in a one-step or a
multiple-step procedure (mostly
multiple-step)
• Expeditious and safe

100. Expander Breast Reconstruction

101. Implant Breast Reconstruction

102. Expander / Implant Breast
Reconstruction
Stage One – (Operation # 1)
• Placement of the tissue expanders. Can
be done at the time of the mastectomy
(immediate reconstruction) or after the
mastectomy is healed (delayed
reconstruction)
• Expanders are temporary implants that
act as spacers.

103. Expander /Implant Breast
Reconstruction
Stage Two
• Expand weekly for 6-10 weeks
• The expanders are filled as much as
possible at the time of initial surgery
• Further expansion is performed in the
office as required after incision is healed

104. Expander /Implant Breast
Reconstruction
Stage Three (Operation # 2)
• Once that the tissue expanders are
adequately filled they are exchanged for
permanent breast implants. Two types
of breast implant are available to
patients:
–Saline
–Silicone

105. Implant / Expander Advantages
• Simple and safe, adds about 30 minutes
to initial surgery
• Rapid recovery and return to work
• Produces an aesthetic breast mound,
especially in patients with small breast
• No new scars other than from
mastectomy

106. Implant / Expander Disadvantages
• Lifelong risk of implant complications
– Mechanical failure
– Capsular contracture
• Aesthetics and appearance worsen with time
• Less able to tolerate adjuvant chemo or
radiation therapy
• Multiple office visits and ops required

107. Saline Verses Silicone
• All considered safe – FDA approved
• Shaped versus round
• Advantages of each kind
• Individual decision to be made with
physician

108. RIGHT BREAST SKIN SPARING MASTECTOMY
WITH NIPPLE RECONSTRUCTION & LEFT
BREAST IMPLANT AUGMENTATION
She desires larger breasts
Breast Reconstruction

109. PRE-OP RIGHT BREAST MASTECTOMY

110. PRE-OP RIGHT BREAST MASTECTOMY

111. PRE-OP RIGHT BREAST MASTECTOMY

112. PHASE I POST OP
Right Breast Skin Sparing Mastectomy with Tissue Expander (TE) Reconstruction
*Patient desired larger breasts therefore the right breast TE was filled to desired size

113. PHASE I POST OP
Right Breast Skin Sparing Mastectomy with Tissue Expander (TE) Reconstruction
*Patient desired larger breasts therefore the right breast TE was filled to desired size

114. PHASE I POST OP
Right Breast Skin Sparing Mastectomy with Tissue Expander (TE) Reconstruction
*Patient desired larger breasts therefore the right breast TE was filled to desired size

115. PHASE II POST OP
Right Breast sp Mastectomy with Second Stage Implant Reconstruction and Left Breast Augmentation

116. PHASE II POST OP
Right Breast sp Mastectomy with Second Stage Implant Reconstruction and Left Breast Augmentation

117. PHASE II POST OP
Right Breast sp Mastectomy with Second Stage Implant Reconstruction and Left Breast Augmentation

118. PHASE III POST OP
Right Breast Nipple Reconstruction

119. PHASE III POST OP
Right Breast Nipple Reconstruction

120. PHASE III POST OP
Right Breast Nipple Reconstruction

121. BEFORE & AFTER
Right Breast sp Mastectomy with Implant & Nipple Reconstruction
Left Breast Augmentation
*Right breast nipple/areola tattoo to be completed

122. BILATERAL SKIN SPARING MASTECTOMIES
STAGED IMPLANT RECONSTRUCTION
Breast Reconstruction
Patient desires larger breasts

123. PRE-OP BILATERAL MASTECTOMIES

124. PRE-OP BILATERAL MASTECTOMIES

125. PRE-OP BILATERAL MASTECTOMIES

126. PHASE III POST OP
Silicone Implant Reconstruction, Nipple Reconstruction, Areola Tattoo

127. PHASE III POST OP
Silicone Implant Reconstruction, Nipple Reconstruction, Areola Tattoo

128. BEFORE & AFTER
Bilateral Skin Sparing Mastectomies
Staged Implant Reconstruction with Nipple Reconstruction and Areola Tattoo

129. BILATERAL NIPPLE SPARING MASTECTOMIES
STAGED IMPLANT RECONSTRUCTION
Patient with BRCA, prophylactic treatment.
She desires larger breasts
Without pre-op photos
Breast Reconstruction

139. Pre-op Breast Reconstruction

140. Pre-op Breast Reconstruction

141. Post-op Implant Exchange

142. Post-op Implant Exchange

143. BILATERAL NIPPLE SPARING MASTECTOMIES
STAGED IMPLANT RECONSTRUCTION
Breast Reconstruction

144. Pre-op Breast Reconstruction

145. Pre-op Breast Reconstruction

146. Post-op Implant Exchange

147. Post-op Implant Exchange

148. BILATERAL NIPPLE SPARING MASTECTOMIES
SINGLE STAGE IMPLANT RECONSTRUCTION
Breast Reconstruction

149. PRE-OP BILATERAL MASTECTOMIES

150. PRE-OP BILATERAL MASTECTOMIES

151. PRE-OP BILATERAL MASTECTOMIES

152. POST OP
Bilateral Mastectomies with Single Stage Implant Placement

153. POST OP
Bilateral Mastectomies with Single Stage Implant Placement

154. POST OP
Bilateral Mastectomies with Single Stage Implant Placement

155. BEFORE & AFTER
Bilateral Mastectomies with Single Stage Implant Placement
*This procedure is best for a woman who has an already well lifted breast,
does not anticipate radiation and wishes to maintain pre-op breast size.

156. PRE-OP BILATERAL MASTECTOMIES

157. PRE-OP BILATERAL MASTECTOMIES

158. PRE-OP BILATERAL MASTECTOMIES

159. PRE-OP BILATERAL MASTECTOMIES

160. POST OP
Bilateral Mastectomies with Single Stage Implant Placement

161. POST OP
Bilateral Mastectomies with Single Stage Implant Placement

162. POST OP
Bilateral Mastectomies with Single Stage Implant Placement

163. BEFORE & AFTER
Bilateral Mastectomies with Single Stage Implant Placement

164. Surgical Options-Lat/Implant
• Limited by previous incisions thoracotomy etc.
• Requires Drains in donor site and recipient site
– One to three weeks
• Avoid lifting etc.
• Out of work depending on job 4-6 weeks
• Excellent intermediate technique for one stage
reconstruction with less recovery than TRAM
• Downside is that requires donor site and implant
• Rare complaint of incision (transverse or oblique) or
muscle loss

165. Latissimus Flap
• Skin, fat, and muscle is detached from
the back of the shoulder bland and
brought to the breast area.
• The muscle, skin, and fat creates the
breast envelope and mound is shaped.
• Fill volume with implant below this
muscle.

166. Latissimus Flap

167. Latissimus Flap –Post Op

169. Lat/Implant

170. LATISSIMUS MYOCUTANEOUS
FLAP AND PRIMARY IMPLANT
PLACEMENT
170
Latissimus Dorsi Flaps: What is the
Role?
38 y/o DCIS

171. 171
Latissimus Dorsi Flaps: What is the
Role?

172. 172
Latissimus Dorsi Flaps: What is the
Role?

173. 173
Latissimus Dorsi Flaps: What is the
Role?
2 Months

174. 174
Latissimus Dorsi Flaps: What is the
Role?

175. Lat/Implant
175
Latissimus Dorsi Flaps: What is the Role?
41 y/o Invasive Ductal ~4 months postop

176. 176
Latissimus Dorsi Flaps: What is the Role?
2.5 years postop and
post XRT

177. 177
Latissimus Dorsi Flaps: What is the
Role?
52 y/o with Invasive Ductal 3
months post-op

178. Conclusion
• Breast Reconstruction can create a
normal appearing and feeling breast.
• Nearly all women are candidates for
breast reconstruction.
• The choice of technique is highly
complex and personal. It should only be
made after consultation with the plastic
surgeons who is able to explore all
options with you.