Considering Breast Reconstruction?

Breast reconstruction is done to restore the breast lost to cancer. It is one of the most rewarding breast enhancement surgical procedures available today. With modern refinements, we can create breasts that come close in form and appearance to matching a natural breast. Sometimes the shock and the number of necessary decisions are overwhelming when a woman is diagnosed with breast cancer. Reconstruction can be done immediately, at the time of mastectomy, or it can be delayed. Reconstruction can be done with a breast implant/expander or with your body’s own tissue.

Some women choose to have breast reconstruction, others do not. The choice is a personal one. When you meet with a plastic surgeon, we can help you identify what decision is best for you. I have assisted many patients in determining whether undergoing breast augmentation is the right choice for them. We can meet in the comfort of my office and discuss all the options available to you.

When you are first diagnosed, the world turns on its ear. Make the decisions you need to, and don’t think about the rest yet. You will need to figure out:

"Dr. Greenberg was very thorough in explaining the results to me and I gave her my full trust and rightly so – she did a beautiful job with both breasts – one that was 35% missing tissue due to breast cancer. I could not be more happy about the results." - M.M., Saratoga
*Individual results may vary
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types of breast reconstruction

autologous reconstruction

The most common procedure done in this group is the TRAM flap. A TRAM flap uses your body’s own fat and skin from the abdomen to reconstruct the breast. It has the additional benefit of giving an abdominoplasty. The surgery and recovery time are longer than the expander/implant reconstruction. In an appropriate patient, it is a great breast enlargement surgery. There is definitely a benefit in feel and softness to use natural tissue. I find many of my patients don’t have enough fat on their abdomen to do this surgery.

implant reconstruction +/- tissue expander

Implant reconstruction is using a silicone gel or saline implant to replace the breast volume. There are many options for the surgery, which you need to discuss with your plastic surgeon. Many depend on your tumor, the thickness of your skin flaps, and other issues.

nipple and areola reconstruction

This occurs months after your initial reconstruction if you did not have a nipple sparing mastectomy. The nipple is reconstructed by using a local skin flap. The areola is reconstructed using a skin graft or tattoo. Examples of both can be reviewed. Depending on your surgery, you can have surgery at Stanford, the Menlo Park surgery center, or an outpatient center in Palo Alto.

symmetry procedure

This procedure is done to the contralateral (the other) breast to help the breasts look alike. This may involve a breast lift, breast enlargement, breast reduction or a combination of these breast enhancement procedures during surgery. This is covered by insurance.

nipple sparing mastectomy

Nipple sparing mastectomies are gaining traction. Why? In a nipple sparing mastectomy you preserve your original nipple. We love to do this when we can because nothing makes your breast look like your original breast like keeping your nipple and areola. There are times where this is not possible due to tumor size or location, but when you can do it, it tends to give superior results to your reconstruction.

When doing a nipple sparing mastectomy, the incision to remove the breast tissue will likely be under the breast in the inframammary fold (where your underwire goes), as this is better hidden and gives better blood supply to the nipple.

The breast cancer reconstruction during a nipple sparing mastectomy is usually with an implant. This can be placed in a

  • single stage – straight to the final implant, or
  • two stage procedure where you have a tissue expander first, followed by a second surgery for the implant.

It can be with an implant in front of the muscle using ADM or behind the muscle, depending on the thickness and vascularity of the skin flaps raised by the general surgeon during the mastectomy breast removal portion of the procedure. There are technologies which can try to confirm the blood supply in the skin flaps prior to reconstruction.

Studies indicate a 8% risk of nipple loss during this procedure.

types of mastectomy


Your original nipple is preserved.  Your incision to remove the breast tissue can be “radial,” where it is in a line going to the outside of your breast or “Inframammary” if it is where your underwire goes for a bra.

Ideal candidate:

  • Negative margins
  • Minimal drooping of the breast
  • Small breast size
  • BMI <30
  • Small tumor
  • Tumor located peripherally in breast


This involves removal of the nipple areola complex and some breast skin if the skin envelope is too loose.  Why would one do this surgery?

  • Big tumor
  • Aggressive tumor
  • Tumor near the nipple/areola complex
  • Women who may have a hard time healing: diabetes, smokers, prior radiation
  • Large breasts (**see my notes on doing a two stage breast reduction followed by nipple sparing mastectomy)

Doing a breast reduction or lift before the mastectomy

If you are doing a prophylactic mastectomy (think BRCA positive / high risk for breast cancer), we love to do a nipple sparing mastectomy because they just look so good. But what do you do if you are droopy or too big? In a nipple sparing mastectomy, it is risky to lift the nipple at the same time. So if you need to move the nipple higher what can you do?

The answer is a two stage surgery.

STAGE ONE: Do a breast lift or breast reduction 3 – 6 months before the mastectomy. WHY? Because we need to get your nipple into the right position, let it heal in its new position and get a blood supply there, and then do the mastectomy.  The choice between a lift and reduction is based on your goal after your mastectomy.  Both a breast lift and breast reduction will lift and reposition  your nipple.  The difference is what size do you want to be? If you want to be smaller, then do a breast reduction to get your breasts to the right size before mastectomy.

STAGE TWO: The nipple sparing mastectomy.  Now with your nipple in the right place and your skin envelope tightened, and having given time so the nipple has a good blood supply from its new position in the skin, you can more safely do a mastectomy. There is always risk of nipple loss, but doing it in two stages has been shown to reduce that risk.


BRCA & prophylactic mastectomy

For those with a high risk of breast cancer you may choose to remove your breast prior to getting cancer.  A woman’s lifetime risk of getting breast cancer is 1 in 8 (12.5%) over her lifetime.

The most common breast cancer gene is BRCA, a tumor suppressor gene.  There are two variants of the BRCA gene

  • BRCA1  Lifetime risk of breast cancer is 60-90%
  • BRCA2  Lifetime risk of breast cancer is 30-85%

The BRCA gene tends to run in women of Eastern European Jewish descent, found in 8-10% of Ashkenazi Jews. It can be passed down through the mother or father’s genes. Norweigan, Dutch, and Icelandic peoples also have higher incidence.

Women with BRCA are at higher risk for a second breast cancer and for ovarian cancer.

Treatment varies, but many women will decide in their 40s or early 50s to electively remove their breast tissue (and ovaries) to avoid getting breast cancer. The benefit of this is to remove the tissue before a cancer can occur. You choose the timing. A bilateral surgery tends to give good cosmetic outcomes. You can do a nipple sparing mastectomy. And you avoid the anguish of cancer, chemotherapy, and the radiation it brings.

See blogs on the subject HERE

breast cancer information and support groups

There are a multitude of Internet sites, community groups, and supports. I have information in my office on everything from support groups to where to buy a good wig. Much of my information comes from my patients. When a new patient comes in, I try to match them with a similar age/diagnosis patient. I find this is a difficult time, as many women try to be strong for their family, husbands, colleagues, and children. I strongly urge you to find a doctor whom you like. Breast cancer is about far more than the surgery.

I am a regular speaker at the Thursday night open house at Breast Cancer Connections in Palo Alto. They are a great, free resource, and I would strongly urge anyone in the Bay Area who has been diagnosed to go in. In addition to information, they have open houses, buddy systems, and therapists to help you.