breast procedures

Breast Reconstruction Bergen County

Breast reconstruction is more than just cosmetic surgery. A woman who has lost a breast is missing a body part and is no longer symmetric. Despite the use of an external prosthesis, the absence of a breast can interfere with wearing clothing and with some physical activities. It can also cause psychological and emotional harm. Dr. Tzvi Small believes that breast reconstruction is an integral part of cancer treatment and should be available to all women who must undergo mastectomy and who desire breast reconstruction. Dr. Small is an active member of the breast cancer teams at the Cancer Centers at Hackensack University Medical Center and The Valley Hospital in Bergen County. Contact our Paramus, New Jersey practice to schedule a breast reconstruction consultation with Dr. Tzvi Small.

Timing of Breast Reconstruction

Breast reconstruction can be performed at the same time as the mastectomy (immediate reconstruction) or months or years later if the patient chooses to undergo reconstruction at a later time (delayed reconstruction). Dr. Small generally prefers immediate reconstruction when possible because it is more convenient for the patient and can provide better aesthetic results.

Types of Breast Reconstruction

Missing breast skin can only be replaced with the patient’s own skin, either by expanding (stretching) remaining skin already present on the chest wall or by transferring it from somewhere else using a flap. The missing breast tissue volume, however, can be replaced either by a prosthetic implant or by the patient’s own tissues (autologous tissues). Each of these two types of breast reconstruction has certain advantages and disadvantages. No one approach is ideal for all patients. Which method of reconstruction is chosen for any individual patient will depend on many factors, including the patient’s preference and physical condition.

Implant-Based Reconstruction

The initial stages of the implant-based breast reconstruction are much quicker and require less surgery than reconstruction with autologous tissues (the patient’s own tissues). For this reason, implant-based reconstruction is usually the best choice for patients who cannot afford the down-time associated with autologous tissue reconstruction. Implant-based reconstruction may also be the best choice for patients without sufficient autologous tissue to make an adequate breast.

Sometimes, there is enough skin remaining on the chest wall that breast reconstruction can be achieved simply by inserting an implant. In most cases, however, extra skin needs to be generated by stretching the available, remaining skin. The most common method for doing this is with tissue expansion. In this technique, a balloon-like device (the tissue expander) is placed beneath whatever skin remains on the breast immediately following the mastectomy. Over the next 2 months, salt water (saline) is gradually injected into the expander at weekly intervals to fill it and stretch the overlying skin. When the skin has been sufficiently stretched (usually within 4 to 6 months), the expander is removed and replaced by a more permanent device containing silicone gel or saline.

Another commonly used method of breast reconstruction based on implants is the latissimus dorsi myocutaneous flap. In this technique, a flap of skin and muscle is taken from the back and transferred to the front of the chest where it is used to cover an implant. In most cases, tissue expansion is not necessary and the reconstruction can be completed in one stage. There is a scar on the back and the use of one latissimus dorsi muscle is lost. Nevertheless, most women are not significantly bothered by the donor site scar, and excellent results can be obtained. Please contact our practice in Paramus, New Jersey, in Bergen County to learn more about breast reconstruction with implants.

Reconstruction with Autologous Tissues – Using Your Own Tissues to Reconstruct Breasts

Breast reconstruction with autologous tissues involves using the patient’s own skin and fat to create the breast instead of implants. This form of breast reconstruction creates soft, natural-looking results that can even improve over time. A successful breast reconstruction with autologous tissue often looks, moves, and feels much like a real breast.

Although the initial surgical procedure required to reconstruct a breast with autologous tissue is much longer and more complicated than that required for implant-based reconstruction, subsequent surgical procedures are simpler, shorter, and less frequent. In the long run, autologous tissue reconstruction usually requires no more (and sometimes less) time in the operating room and hospital than does reconstruction based on an implant. Because of this, and because the quality of the reconstruction is much better over the long term, Dr. Small generally prefers autologous tissue breast reconstruction when that option is available.

Pedicled TRAM Flaps

The first successful method of breast reconstruction was the pedicled transverse rectus abdominis myocutaneous (TRAM) flap. In this operation, a wide ellipse of skin and fatty tissue is removed from the patient’s lower abdomen, but left attached to one of the two rectus abdominis muscles. A tunnel is created between the abdominal dissection and the defect left by removal of the breast, and the flap is passed up onto the chest wall. The flap gets its blood supply from the superior epigastric artery and vein, which remain attached to it and keep it alive. Because a woman’s abdomen is designed to stretch to accommodate pregnancy, the donor site can be closed with sutures. The flap is then shaped to form a facsimile of a breast.

The pedicled TRAM flap is capable of achieving very good results and was a tremendous advance in the art of breast reconstruction. For certain patients, it still remains the technique of choice. For some patients, however, (especially those who are obese or who smoke) the blood supply of the pedicled TRAM flap can be insufficient, leading to partial flap loss and poor aesthetic results. For more information on the pedicled TRAM flap, please contact our Paramus, Bergen County practice and schedule a breast reconstruction consultation.

Free TRAM Flaps

One way to improve the blood supply to the TRAM flap is to get its supply from the deep inferior epigastric vessels. In this procedure, called the free TRAM flap, these blood vessels are divided and then reattached (using fine sutures and a microscope) to recipient vessels in the chest wall or in the axilla. The free TRAM flap has two advantages over the conventional, pedicled TRAM flap. First, the blood supply is more direct so that it is stronger and less likely to cause partial flap loss or fat necrosis. Secondly, only a small part of the rectus abdominis muscle need be sacrificed so there is less postoperative pain and abdominal wall weakness. Patients recover from breast reconstruction surgery more quickly and the aesthetic results tend to be better.

The main disadvantage of the free TRAM flap is its total dependence on the successful connection (anastomosis) of the blood vessels to maintain survival of the flap. If the anastomosis becomes obstructed and blood does not reach the flap, the tissue will die and the breast reconstruction will fail. In experienced hands, the failure rate is less than 2 percent. Failure is even less common in patients who are not obese.

Free TRAM flaps tend to have especially good aesthetic results because the excellent blood supply allows more aggressive shaping of the flap. They have a lower incidence of fat necrosis (areas of scar tissue caused by dead fat cells) than pedicled TRAM flaps. Free TRAM flap patients are also more likely to be able to do situps postoperatively than patients who have had pedicled TRAM flaps. For these reasons, Dr. Small prefers to use this type of TRAM flap when the blood vessels are suitable. Please contact our practice in Paramus, New Jersey, in Bergen County to schedule a breast reconstruction consultation to learn more about the free TRAM flap procedure.

DIEP (Perforator) Flaps

A DIEP Flap is a variation of the free TRAM flap. In this flap, the skin and fat island are identical to that of the TRAM flap but one, two, or three perforating blood vessels are dissected through the rectus abdominis muscle so that the muscle can be left in the abdomen rather than harvested with the flap. The DIEP flap therefore consists only of skin, fat, and blood vessels. No muscle is sacrificed (although some may be damaged), so the patient has less postoperative pain and a stronger abdominal wall. In appropriate patients, the results can be excellent.

The main disadvantage of this technique is that the blood supply to the flap is reduced somewhat and fat necrosis and partial flap loss are more common than after standard free TRAM flaps. For this reason, Dr. Small prefers to limit the use of the DIEP flap to patients in whom only 65% or less of the TRAM flap skin island will be needed to make the breast. Using this approach, there is less chance of fat necrosis and partial flap loss.


Despite Dr. Small’s best efforts to achieve symmetry in the first operation, almost all patients will need at least one revision of their breast mound reconstruction to achieve reasonable breast symmetry. These revisions should be considered an integral part of the reconstruction process, and both patients and their insurance companies should expect them. Most revisions can be performed as an out-patient procedure under local anesthesia, and the surgery is minor compared to the magnitude of a TRAM flap. With revisions, breast symmetry and the aesthetic result of the reconstruction can be significantly improved. Even after revision, the result will rarely be perfect but in most cases the symmetry is good enough that the patient will look normal in her clothing (or even a bathing suit) and will be satisfied. Please schedule a consultation at our Paramus, Bergen County practice to learn more about breast reconstruction and revisions.

Nipple Reconstruction

Nipple reconstruction is usually performed only after the breast shaping has been completed. The most important part of nipple reconstruction is its location. Even the best nipple will not look right if it is in the wrong place. Although there are many techniques for nipple reconstruction, most modern techniques use local flaps of skin and fat to create a projecting nub, and do not require any type of grafting. Tattooing is used to pigment the nipple and create the areola. Nipple reconstruction can be performed in the office under local anesthesia. In this way it can be kept simple, inexpensive, convenient, and relatively painless. Although the results of nipple reconstruction are not perfect, the presence of a reconstructed nipple does contribute significantly to the illusion of having re-created a normal breast. Patients are therefore encouraged to undergo nipple reconstruction and complete the process of breast reconstruction whenever possible.

Balancing Procedures

To ensure that the reconstructed breast looks as natural and beautiful as possible, a balancing procedure might be necessary for the opposite breast.  Depending on the patient’s needs, breast augmentation, breast reduction, or breast lift may be performed on the non-reconstructed breast in order to create symmetry.

Please Contact Our Paramus Practice to Schedule a Breast Reconstruction Consultation

Our practice is located in central Bergen County in Paramus and provides breast reconstruction surgery to patients from throughout New Jersey. Please contact us today to schedule a consultation with Dr. Tzvi Small.