![]() What if there was a “middle way”? What if patients could choose reconstruction of a flat/convex structure or very small breast mound, with a moderately longer anesthesia burden, but without comprising any other part of their body – and without the need for multiple surgeries? The New Middle Way? Using Local Tissues to Contour But even with a dedicated and highly skilled oncoplastic surgeon, and/or plastic surgeon using traditional techniques, patients can be left with significant concavity – the appearance of being “scooped out.” Concavity is currently addressed with fat grafting, which means additional surgeries, pain and bruising at the donor site, uncertain cosmetic results, and sometimes produces hard lumps (fat necrosis) which can be distressing to patients. Traditional surgical techniques to remove all redundant (excess) tissue and create a smooth contour go a long way to producing results patients can live with. It seems that until very recently, no one has thought to ask the patients making this choice the simple question, “what DO you want your chest to look like post-mastectomy?” Unfortunately, many patients going flat are left with results that are nowhere near smooth or flat – concavity (which is largely unavoidable with traditional techniques), lumps, sagging excess skin (“in case you change your mind” about implant reconstruction ( Figure 6 )), redundant fatty tissue, dog ears, wrinkled/puckered incisions, and asymmetry ( Figure 4). The ideal resulting contour would approximate that of the prepubescent female chest – a reconstruction of a normal anatomical structure that falls squarely into “reconstructive surgery” territory… not cosmetic.įigure 4 Mastectomy patients who asked for a flat result In terms of cosmesis, patients going flat report desiring a smooth, flat (not concave) result with the original breast contour removed to the greatest extent possible. So, they proceed with the default reconstructive option: no reconstruction, or going flat. ![]() They have weighed their options and are simply not willing to shoulder the risk burden presented by traditional breast reconstruction in order to achieve an artificial breast mound. The truth is that these patients have made an affirmative, informed decision. A common misconception about these patients is that they “don’t care about how their body looks.” This notion is rooted in historical sexism and sexual objectification of the female body. But cosmesis for patients going flat has historically been devalued or outright ignored. These patients are also motivated by minimizing their exposure to additional surgeries beyond the original mastectomy, and traditional reconstruction almost always involves multiple surgeries.ĪLL patients care about their cosmetic result. Rejection of submuscular implant reconstruction avoids damage to the pectoral muscle that can impair function (this muscle is partially detached from the ribs to accommodate the device) ( Figure 3). Rejection of autologous flap reconstruction, for example, avoids a second surgical wound that may compromise recovery time and/or function – especially in the case of muscle tissue transfer, i.e., LD ( Figure 1) and TRAM flaps ( Figure 2). Patients who reject traditional breast reconstruction are often motivated by wanting to preserve form and function for the rest of their bodies. ![]() Traditional breast reconstruction involves additional risk beyond simple mastectomy and can impair function. Why Not Use Traditional Breast Reconstruction? ![]() ![]() The surgeons who offer it say that its risks are similar to that of a skin-sparing mastectomy. It’s important to note that because this is a new procedure, there is no long term data on its safety from an oncology perspective. This option, while not currently available to most patients, focuses specifically on maximizing cosmesis for patients having mastectomies without traditional reconstruction. Today we discuss a new technique called the “Goldilocks mastectomy,” or SWIM. Goldilocks/SWIM Page Reconstructing a normal anatomic chest contour post-mastectomy using a new plastic surgery technique without implants or distant tissue donor sitesĪs patient demand grows for high quality, aesthetically pleasing flat mastectomy closures, cutting edge surgical techniques will be part of the conversation. ![]()
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