Tom McClellan, MD and Jenna Enoch, PA-C

Breast reconstruction is not just about restoring shape; it's about protecting your health, minimizing risk, and achieving the best possible long-term results. Over the past three years, I have developed and refined a reconstruction approach designed specifically to reduce complications while improving aesthetic outcomes. This method is called Tissue Optimized Delayed Direct-to-Implant Reconstruction. I created this technique out of necessity. The complications from traditional immediate reconstruction approaches were just too high, particularly when implants or tissue expanders were placed into tissue that was underperfused following mastectomy. I chose to take a different path, one that allows your body to heal first and then reconstruct under optimal conditions. I perform reconstruction this way because I believe it is better for you. It is not the fastest path, but it consistently produces safer outcomes, more predictable results, and better aesthetic results.

Why This Approach Is Different

Traditional immediate breast reconstruction often places an implant or tissue expander

immediately at the time of mastectomy, frequently using a mesh or allograft for support. While this is common, it introduces a foreign body into tissue that has just been surgically traumatized and has a reduced blood supply. This creates an environment that increases the risk of infection, skin necrosis, fluid collections, and implant loss. In many studies, complication rates for immediate breast reconstruction approach 20 to 40%. My goal is to minimize these risks whenever possible, especially in patients who do not require radiation therapy. This approach is based on a straightforward concept. Let your body heal first, then reconstruct your breast under more ideal conditions.

The Five-Step Approach

Step 1: Precision Mastectomy and Surgical Planning

I am present and scrubbed in for your mastectomy alongside your breast surgeon. This allows me to design the incision, perform the initial incision, and ensure that your skin and tissue are arranged in a way that supports the best possible reconstruction later. For smaller breasts, I use a technique I developed called the Lazy Lateral Incision, which avoids the traditional straight-line scar and produces a more natural, aesthetically pleasing result. For patients with larger or more ptotic (lower) breasts, I use a Wise Pattern design, similar to what's used in a breast lift. The Wise Pattern allows me to control the breast envelope, remove excess skin, narrow the breast width, raise the height, improve symmetry, and place scars in more favorable and less visible locations. During your mastectomy, I prepare the future reconstruction pocket, place a drain, and personally close the incision.

In most cases, I do not preserve the native nipple areola complex (NAC) during the mastectomy. If the NAC is spared during mastectomy, it tends to scar and displace laterally, making it difficult to reposition in the future, which leads to a less aesthetic result. For NAC reconstruction after breast reconstruction, I prefer 3D

nipple areola tattooing, which typically produces a more natural and symmetric appearance.

I also follow enhanced recovery (ERAS) protocols, including a Pectoralis I and II nerve block, which significantly reduces postoperative pain and greatly improves comfort after surgery. After the mastectomy, you will stay in the hospital overnight for observation and are typically discharged the following morning.

Figure 3: The Wise Pattern mastectomy incision, similar to a breast lift, allows me to reshape and elevate the breast skin at the time of mastectomy. This approach gives me better control of the breast envelope, including the lateral breast and excess skin, while improving overall shape and symmetry. By reducing and tightening the tissue envelope, it creates a more controlled and aesthetically favorable foundation for the second stage of reconstruction, leading to a more natural and balanced final result.

Figure 4: The blue line represents the traditional transverse mastectomy incision, which often results in a flatter, more unnatural breast contour after reconstruction. In contrast, the black line represents the Lazy Lateral Incision. Although slightly longer, its curvilinear design follows the natural contours of the breast, allowing the scar to blend more discreetly into the surrounding shape. By avoiding the central portion of the breast, this approach also makes it easier to wear lower-cut clothing without visible scarring. Importantly, this incision pattern helps preserve a more natural, rounded breast shape and contributes to a more aesthetically pleasing final result.

Step 2: Healing Without an Implant

After the mastectomy, your breast skin is closed without placing an implant, tissue expander, mesh, or allograft. A drain is left in place for about one week and then removed in the office. This is a critical part of the process. By avoiding foreign materials during this early healing phase, the risk of infection and other complications is significantly reduced. Your skin, blood supply, and lymphatic system are able to recover naturally, without added pressure/stress from a Tissue Expander or Implant pushing on the skin envelope.

If issues such as infection, hematoma, or skin healing problems do occur immediately post-op, they are much easier to manage because there is no foreign body present. Just as importantly, this approach helps improve the long-term outcome of your reconstruction. By allowing the tissue to heal fully before placing an implant, there is a lower risk of infection and better preservation of skin quality. This can lead to a longer-lasting implant and reduce the likelihood of needing additional procedures, such as early implant exchange or skin envelope loosening, in the first few years after surgery.

Step 3: Skin Conditioning and Recovery

Once the drain is removed, I have you begin a guided skin massage protocol for approximately two to three months. This helps maintain soft, flexible tissue and prepares your skin to accept an implant in the future. This step is often overlooked in traditional reconstruction, but it plays an important role in improving both safety and final aesthetic outcomes by allowing the tissue to become more pliable and better suited for reconstruction.

I typically recommend using Aquaphor or a body lotion to gently but firmly massage the breast skin. This helps improve lymphatic drainage, keeps the tissue mobile, and reduces the risk of scar tissue forming beneath the skin.

During this phase, I also allow you to return to exercise and normal activities sooner than with traditional reconstruction. In many cases, I incorporate physical therapy to help accelerate recovery and restore strength and mobility more quickly.

Step 4: Final Reconstruction in an Outpatient Setting

After two to three months, once your tissue is fully healed and ready, you return for a short outpatient procedure. At this stage, I place a properly sized silicone implant without the need for a tissue expander. The implant is positioned in a new, untouched submuscular plane, creating a clean surgical environment and avoiding scar tissue from the initial mastectomy.

The procedure is performed through a small incision under the breast, which helps keep scars discreet. I do not use mesh, allograft, or additional support materials. This allows for a more controlled and predictable operation with a lower risk of complications.

Placing the implant in the submuscular plane also provides important long-term benefits. It improves implant support and upper pole fullness and is associated with a lower risk of capsular contracture over time. Together, these advantages contribute to a more durable, natural-looking result that is less likely to require additional surgery in the future.

At this stage, I also perform a matching procedure on the opposite breast when needed. This may include a lift, reduction, or implant to improve symmetry and achieve the best overall aesthetic result.

Step 5: Return to Activity, Nipple Areolar Tatoo, Long-Term Outcomes 

This approach is designed to create a safer, more reliable reconstruction with better long-term results. By separating the mastectomy from the reconstruction and allowing your body time to heal between stages, complication rates are significantly reduced compared to traditional immediate reconstruction. In my experience, this leads to more predictable outcomes, improved implant longevity, and a more natural overall aesthetic. 

Recovery is also more streamlined. Most patients are able to return to normal daily activities and exercise within about three weeks, since this technique avoids the added stress and restrictions associated with mesh or allograft-based reconstruction. 

Approximately 2-3 months after reconstruction is complete, 3D nipple-areolar tattooing can be performed in an outpatient setting. This is a simple, painless procedure that is customized to match your skin tone and desired appearance, helping restore symmetry and a natural look. There is minimal downtime, and for many patients, this final step is an important part of feeling complete and confident in their reconstruction.

Example Results on our patients:

Figure 5: Pre-op, Midstage, and Post-op photographs of a Lazy Lateral Mastectomy with delayed submuscular implants. 

Figure 6: Pre-op, Midstage, and Post-op photographs of a Wise Pattern Mastectomy with delayed submuscular implants.

About Our Team

I have spent much of my career focused on improving breast reconstruction and developing new

surgical techniques and technologies. My interest in this field is personal. My mother had breast cancer and underwent a bilateral mastectomy, and that experience shaped how I approach this work. Since then, I have been driven to make reconstruction safer, more predictable, and aesthetically better for patients.

I developed the Lazy Lateral Incision to improve the appearance of mastectomy scars, and I have invented multiple FDA-cleared tissue expander technologies that are now used across the United States. Most recently, I co-founded Available Health, a platform designed to help women better understand breast cancer and breast reconstruction, as well as navigate their care.

An essential part of our team is Jenna Enoch, PA-C. Jenna is compassionate, thoughtful, and

deeply committed to patient care. She spends a great deal of time with each patient, helping explain the process, answering questions, and providing support throughout recovery. She is also actively involved in research alongside me and plays an important role in delivering the high-quality outcomes we strive for.

Our focus has always been the same. To create solutions that improve patient safety and lead to better outcomes.

Summary

Tissue Optimized Delayed Direct-to-Implant Reconstruction is designed to reduce complications, improve aesthetic results, and provide a safer, more controlled path to reconstruction. By allowing your body to heal first and reconstructing under optimal conditions, we can achieve better outcomes with significantly lower risk. If you have questions, I will walk through each step with you so you feel informed, comfortable, and confident in your care.

Selected References

1. Chun YS, Verma K, Rosen H, Lipsitz S, Morris D, Kenney P, Eriksson E. Implant based breast reconstruction using acellular dermal matrix and the risk of postoperative complications. Plastic and Reconstructive Surgery.

2. Ho G, Nguyen TJ, Shahabi A, Hwang BH, Chan LS, Wong AK. Complications following immediate compared to delayed breast reconstruction. Annals of Surgical Oncology.

3. Zenn MR, Garofalo JA. Delayed immediate breast reconstruction: surgical technique and outcomes. Plastic and Reconstructive Surgery.

4. Nahabedian MY. Overview of implant based breast reconstruction and outcomes. Clinics in Plastic Surgery.

5. Sbitany H, Piper M, Lentz R. Prepectoral versus submuscular implant based breast reconstruction: outcomes and considerations. Plastic and Reconstructive Surgery.

Learn More with Available Health

If you would like to better understand your diagnosis, your reconstruction options, or what to

expect throughout this process, I encourage you to download Available Health on the App Store. I co-founded this platform to help women navigate their care with more clarity and confidence.

Available Health is designed to give you personalized, easy-to-understand information based on your own medical history. You can securely upload your health information and receive guided explanations about breast cancer, reconstruction options, recovery, and what questions to ask at each stage of your journey. Rather than searching the internet and getting overwhelming or conflicting information, this allows you to access information that is tailored specifically to you.

Many patients find that using Available Health helps them feel more informed, more prepared for appointments, and more confident in their decisions. It is meant to complement your care, not replace it, and to serve as a trusted resource you can use anytime throughout your treatment and recovery.