Q: You’re often asked to participate in the management of patients about to undergo mastectomy for breast cancer diagnosis. Does a particular case come to mind?

A: A patient was sent to me by her breast surgeon with very large, sagging breasts and a plan for non-nipple sparing mastectomy of one breast.

Q: How did you handle this patient’s condition?

A: The traditional non-nipple sparing mastectomy relies on linear, transverse excision of the nipple and areola along with a small local amount of skin along with all breast tissue. In large, sagging breasts however, this approach will never allow for nice aesthetics because there is no accounting for the sag without leaving the breast too wide. I approach it differently and use a breast reduction type pattern for the mastectomy, considering the 3D nature of the breast. To protect the very fragile remaining blood supply remaining from mastectomy, I de-epithelialize bridging tissue and bury it to shape the remaining envelope. Coupling this with tissue expanders and alloderm creates the initial foundation. I also air fill my expanders initially instead of using saline, keeping things lighter for the patient with less discomfort. That also allows me to expand much more quickly. Subsequently, I can better establish proper preliminary shaping. I then switch from air to saline at the end of expansion.

Q: What was the end result?

A: After replacing the expander with an implant, refining the shape and doing opposite side breast reduction there is real symmetry because after I make new nipples on the reconstruction side, the shapes are more closely matched and the scar pattern matches. This approach is truly light years ahead of what is considered the standard and acceptable procedure for women with large, sagging breasts.