Breast reconstruction is a surgical procedure to restore the appearance of a breast for women who have had a breast removed to treat breast cancer. The surgery rebuilds the size and shape of the breast and, if you desire, the nipple and areola (the darker area surrounding the nipple). Most women who have had a mastectomy can have reconstruction. Women who have had a lumpectomy usually do not need reconstruction. Breast reconstruction is done by a plastic surgeon.
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Subscribe in a reader This information is designed to give you the facts you need to make an informed decision about breast reconstruction. The decision to have breast reconstruction is a matter of personal choice. No single source of information can provide every fact or give you all the answers. You and those close to you should discuss any questions and concerns about reconstructive surgery with your doctor.
New Choices in Breast Reconstruction
Each year more than 200,000 American women face the reality of breast cancer. Today, the emotional and physical results are very different from what they were in the past. Great strides have been made in our understanding of the disease and its treatment. New approaches in treatment, as well as advances in reconstructive surgery mean that women who have breast cancer today have new choices.
More and more women with breast cancer are choosing surgery that removes less breast tissue than a mastectomy (removal of the entire breast). This is called breast conservation surgery (lumpectomy or segmental mastectomy). However, some women choose (or need) a mastectomy. Some of those who have a mastectomy also choose to have reconstructive surgery to restore the breast's appearance.
If you are thinking about having reconstructive surgery, it is a good idea to discuss it with your surgeon and a plastic surgeon experienced in breast reconstruction before your mastectomy. This allows the surgical teams to plan the treatment that is best for you, even if you decide to wait and have reconstructive surgery later.
Goals of Reconstruction
Women choose breast reconstruction for different reasons. The goals of reconstruction are:
- to make your breasts look balanced when you are wearing a bra
- to permanently regain your breast contour
- to give the convenience of not needing an external prosthesis
The difference between the reconstructed breast and the remaining breast can be seen when you are nude. When the breasts are in a bra though, they should be close enough to one another in size and shape that you will feel comfortable about how you look in most types of clothing.
Your body image and self-esteem may improve after your reconstruction surgery, but this is not always the case. Breast reconstruction does not fix things you were unhappy about before your surgery. Also, you may be disappointed with how your breast looks after surgery. You and those close to you must be realistic about what to expect from reconstruction.
You should decide to have breast reconstruction only after you are fully informed about the procedure. There are often many options to think about as you and your doctors discuss what is best for you. The reconstruction process may require one or more operations. You should discuss the benefits and risks of reconstruction with your doctors before the date of surgery to give yourself plenty of time to make the best decision for you.
Special Considerations in Breast Reconstruction
Several types of operations can be done to reconstruct your breast. You can have a newly shaped breast with the use of a breast implant, your own tissue flap, or a combination of the two. A tissue flap is a section of skin, fat, and muscle which is moved from your tummy, back, or other area of your body to the chest area.
Immediate or Delayed Reconstruction with Breast Cancer
Immediate reconstruction is reconstructive surgery that is done at the same time as the mastectomy, when the entire breast is removed. A plus with immediate reconstruction is that the chest tissues are undamaged by radiation therapy or scarring. Also, immediate reconstruction means one less surgery. Delayed reconstruction is surgery that is done at a later time. For some women, this may be advised if radiation is to follow mastectomy. This is because radiation therapy that follows breast reconstruction can increase complications after surgery.
Decisions about reconstructive surgery depend on many personal factors such as:
- your overall health
- the stage of your breast cancer
- the size of your natural breast
- the amount of tissue available (for example, very thin women may not have the excess body tissue to make flap grafts possible)
- your desire to match the appearance of the opposite breast
- your desire for bilateral reconstructive surgery and your insurance coverage for the unaffected breast and related costs
- the type of procedure
- the size of implant or reconstructed breast
Other important factors to consider:
You may choose to wait until after your initial breast surgery to decide about reconstruction if you do not want to think about this issue while you are coping with a diagnosis of cancer.
- You may simply not want to have any more surgery than is needed.
- Scarring is a natural outcome of surgery, but skin necrosis (cell death) may occur if your ability to heal is impaired.
- Not all surgery is completely successful, and you may not be pleased with your cosmetic result.
- You may be concerned if you have bleeding or scarring tendencies.
- Your ability to heal may be hindered by previous surgery, chemotherapy, radiation, smoking, alcohol, diabetes, various medications, and other factors.
- Is it your preference to have chemotherapy or radiation therapy after reconstruction or wait and have surgery after all treatment is completed?
Breast reconstruction restores the shape of the breasts but cannot restore your normal breast sensation. With time, the skin on the reconstructed breast can become more sensitive, but it will not give you the same kind of pleasure as before a mastectomy.
Surgeons may suggest you wait for one reason or another. This may happen if you smoke or have other health conditions. Many surgeons require you to quit smoking at least 2 months prior to reconstructive surgery to allow for better healing. You may not be a candidate for reconstruction at all if you are obese, too thin, or have circulatory problems.
The surgeon may recommend surgery to reshape the remaining breast to match the reconstructed breast. This could include reducing or enlarging the size of the breast or lifting the breast.
Knowing your reconstruction options before surgery can help you prepare for a mastectomy with a more realistic outlook for the future.
Types of Breast Reconstruction
Implant Procedures
The most common implant is a saline-filled implant that has an external silicone shell and is filled with sterile saline (salt water). Silicone gel-filled implants are another option for breast reconstruction, but they are not used as often as they were in the past because of concerns that silicone leakage might cause debilitating immune system diseases. However, the vast majority of recent studies indicate that implants do not increase the risk of immune system problems. Also, alternative breast implants that have different shells and are filled with different materials are being studied, but these are available only in a clinical trial.
One-stage immediate breast reconstruction may be done at the same time as your mastectomy. After the general surgeon removes the breast tissue, a plastic surgeon places a breast implant where the breast tissue was removed to form the breast contour.
Two-stage immediate or two-stage delayed reconstruction is performed if your skin and chest wall tissues are tight and flat. An implanted tissue expander, like a balloon, is placed beneath the skin and chest muscle. Through a tiny valve mechanism beneath the skin, the surgeon injects a salt-water solution at regular intervals to fill the expander over time. After the skin over the breast area has stretched enough, the expander is usually removed in a second operation, and a permanent saline implant is put in its place. Some expanders are left in place as the final implant.
There are some important factors for you to think about when deciding to have implants:
Your implants may not last a lifetime, so you may need additional surgeries to replace them.
You can have local complications with breast implants such as rupture, pain, capsular contracture (scar tissue forms around the implant), infection, and an unpleasing cosmetic result. This means that implants may become less attractive over time.
Tissue Flap Procedures
Tissue flap procedures use tissue from your tummy, back, thighs, or buttocks to reconstruct the breast. The 2 most common types of tissue flap surgeries are the TRAM flap (transverse rectus abdominis muscle flap), which uses tissue from the tummy area, and the latissimus dorsi flap, which uses tissue from the upper back. These operations leave 2 surgical sites and scars, both from where the tissue was taken and on the reconstructed breast. The scars fade over time, but they will never go away completely. There can also be complications at the donor sites, such as abdominal hernias, muscle damage or weakness, and differences in the size and shape of the 2 breasts. Because blood vessels are involved, these procedures usually cannot be offered to women with diabetes, connective tissue or vascular disease, or to smokers.
TRAM (transverse rectus abdominis muscle) flap: The TRAM flap procedure uses tissue and muscle from the lower abdominal wall (tummy tissue). The tissue from this area alone is often enough to create a breast shape, and an implant may not be needed. The skin, fat, blood vessels, and at least 1 of the abdominal muscles are moved from the abdomen to the chest area. This procedure also results in a tightening of the lower abdomen, or a "tummy tuck." There are 2 types of TRAM flaps:
Pedicle flap involves leaving the flap attached to its original blood supply and tunneling it under the skin to the breast area.
Free flap means that the surgeon cuts the flap of skin, fat, blood vessels, and muscle free from its original location and then attaches the flap to blood vessels in the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels and takes longer to finish than a pedicle flap. The free flap is not done as often as the pedicle flap but some doctors think that it can result in a more natural shape.
Latissimus dorsi flap: The latissimus dorsi procedure moves muscle and skin from your upper back when extra tissue is needed. The flap is made up of skin, fat, muscle, and blood vessels. It is tunneled under the skin to the front of the chest. This creates a pocket for an implant, which can be used for added fullness to the reconstructed breast. Though it is not common, some women may have weakness in their back, shoulder, or arm after this surgery.
DIEP (deep inferior epigastric artery perforator) flap: A newer type of flap procedure, the DIEP flap, uses fat and skin from the same area as in the TRAM flap but does not use the muscle to form the breast mound. This procedure results in a tightening of the lower abdomen, or a "tummy tuck." The procedure is done as a "free" flap meaning that the tissue is completely detached from the tummy and then moved to the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels. The procedure takes longer than the TRAM pedicle flap discussed above.
Donor Site DIEP Flap
Gluteal free flap: This is another newer type of surgery that uses tissue, including the gluteal muscle, from the buttocks to create the breast shape. It is an option for women who cannot use the tummy sites due to thinness, incisions, failed tummy flap, or patient preference. The procedure is similar to the free TRAM flap mentioned above. The skin, fat, blood vessels, and muscle are detached from the buttock and then moved to the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels.
Nipple and Areola Reconstruction
The decision to have your nipple and areola (the dark area around the nipple) reconstructed is up to you. Nipple and areola reconstructions are optional and considered the final phase of breast reconstruction. This separate surgery is done to make the reconstructed breast more closely resemble the original breast. It can be done as an outpatient under local anesthesia. It is usually done after the new breast has had time to heal (3-4 months after surgery).
The ideal nipple and areola reconstruction requires symmetry in position, size, shape, texture, pigmentation, and projection. Tissue used to rebuild the nipple and areola is taken from your own body, such as from the newly created breast, opposite nipple, ear, eyelid, groin, upper inner thigh, or buttocks. Tattooing may be done to match the color of the nipple of the other breast and to create the areola.
Though it is done, saving and using the nipple from the breast with cancer that has been removed (called nipple saving or nipple banking) is not a good idea. Cancer cells may still be hidden in the nipple and the tissue is often injured by the cryopreservation process necessary for storage. Further research is needed in this area.
Your Plastic Surgeon
Once you decide to have breast reconstruction, you will need to find a board-certified plastic surgeon experienced in breast reconstruction. Your breast surgeon can suggest doctors for you.
To find out if a surgeon is board certified, contact the American Society of Plastic Surgeons (ASPS). This organization has a Plastic Surgery Information Service that provides a list of ASPS members in a caller's area who are certified by the American Board of Plastic Surgery.
Questions to Ask
It is very important that you ask as many questions of your surgeon as you need to before having breast reconstruction. If you don't understand something, ask your surgeon about it. Here is a list of questions to get you started. Write down other questions as you think of them. You may want to record your conversations with your surgeons. It is also helpful to bring a friend or family member with you to the doctor to help you remember what was said. The answers to these questions may help you make your decisions.
Am I a candidate for breast reconstruction?
When can I have reconstruction done?
What types of reconstruction are possible in my specific case?
What is the average cost of each type? Does my insurance cover them?
What type of reconstruction is best for me? Why?
How much experience do you (plastic surgeon) have with this procedure?
What results are realistic for me?
Will the reconstructed breast match my remaining breast in size?
How will my reconstructed breast feel to the touch?
Will I have any feeling in my reconstructed breast?
What possible complications should I know about?
How much discomfort or pain will I feel?
How long will I be in the hospital?
Will I need blood transfusions? If so, can I donate my own blood?
How long is the recovery time?
What type of wound care will I need to do at home?
How much help will I need at home to take care of my drain and wound?
When can I start my exercises?
How much activity can I do at home?
What do I do if I get swelling in my arm (lymphedema)?
When will I be able to return to normal activity such as driving and working?
Can I talk with other women who have had the same surgery?
Will reconstruction interfere with chemotherapy?
Will reconstruction interfere with radiation therapy?
How long will the implant last?
What kinds of changes to the breast can I expect over time?
How will aging affect the reconstructed breast?
What happens if I gain or lose weight?
Are there any new reconstruction options that I should know about?
It is common to get a second opinion before having any surgery. Breast reconstruction and even mastectomy are not emergencies. It is more important for you to make the right decisions based on the correct information than to act quickly before you know all your options.
Before Surgery
Planning Your Surgery
You can begin talking about reconstruction as soon as you know you have breast cancer. You will want your breast surgeon and your plastic surgeon to work together to come up with the best possible plan for reconstruction.
After reviewing your medical history and overall health, your surgeon will explain which reconstructive options are best for your age, health, body type, lifestyle, and goals. Openly discuss your expectations. Your surgeon should be frank with you when talking about your risks and benefits for each option.
Breast reconstruction after a mastectomy can improve your appearance and renew your self-confidence. However, keep in mind that the desired result is improvement, not perfection.
If you would like to talk with someone who has had your type of surgery, our Reach to Recovery volunteers are trained to support people facing breast cancer, as well as those who have surgery, chemotherapy, radiation therapy, and who are thinking about breast reconstruction. Ask your doctor or nurse to refer you to a Reach to Recovery volunteer in your area, or call us at 1-800-ACS-2345.
Your surgeon should also explain the details of your surgery, including
the anesthesia he or she will use
where the surgery will take place
what to expect after surgery
the plan for follow up
costs
Health insurance policies often cover most or all of the cost of reconstruction after a mastectomy. Check your policy to make sure you are covered. Also, see if there are any limits on what types of reconstruction are covered.
Sometimes your insurance company will deny breast reconstruction costs if you have already submitted claims for a breast prosthesis.
Preparing for Your Surgery
Your breast surgeon and your plastic surgeon will give you specific instructions on how to prepare for surgery. These will likely include
guidelines on eating and drinking
tips to quit smoking
instructions to take or avoid certain vitamins and medications for a period of time before your surgery
You should arrange for someone to drive you home after your surgery and to help you out for a few days.
Where Your Surgery Will Be Performed
Breast reconstruction often involves more than 1 operation. The first stage involves creation of the breast mound. Whether this is done at the same time as the mastectomy or later on, it is usually done in a hospital.
Follow-up procedures, such as creating the nipple and areola, may also be done in the hospital or in an outpatient facility. This decision depends on the extent of surgery needed and what your surgeon prefers.
Types of Anesthesia
The first stage of reconstruction is almost always done using general anesthesia, so you'll be asleep during the surgery.
Follow-up procedures may only require a local anesthesia with a sedative to make you drowsy. You'll be awake, but relaxed and you may feel some discomfort.
Possible Risks
Almost any woman who must have her breast removed because of cancer can have reconstructive surgery. Certain risks go along with any surgery, and reconstruction may have certain unique problems associated with it.
Some risks of reconstruction surgery are:
bleeding
fluid collection with swelling and pain
excessive scar tissue
infection
tissue necrosis (death) of all or part of the flap
problems at the donor site (immediate and long-term)
changes in nipple and breast sensation
fatigue
the need for additional surgeries to correct problems
changes in the affected arm
problems with anesthesia
Risks of smoking: The use of tobacco causes constriction of the blood vessels and reduces the supply of nutrients and oxygen to tissues. As with any surgery, smoking can delay healing. This can result in scars that are more noticeable and a longer recovery time. Sometimes these complications are severe enough to require a second operation.
Risks of infection: Infection can develop with any surgery. This usually happens within the first 2 weeks after surgery. If an implant has been used, it may need to be removed until the infection clears. A new implant can later be inserted. If you have a tissue flap, surgical cleaning of the wound is usually done.
Risks of capsular contracture: The most common problem with breast implants is capsular contracture. This can occur if the scar or capsule around the implant begins to tighten and squeezes down on the soft implant. This can make the breast feel hard. Capsular contracture can be treated in several ways. Sometimes more surgery is needed to remove the scar tissue. The implant might also need to be removed or replaced.
After Breast Reconstruction Surgery
What to Expect
You are likely to feel tired and sore for a week or 2 after implant reconstruction and longer after flap procedures. Your doctor can give you medicines to control most of your discomfort.
Depending on the type of surgery, you should go home from the hospital in 1 to 6 days. You may be discharged with a surgical drain in place to remove excess fluids from the site. Follow your doctor’s exact instructions on wound and drain care. If you have any concerns or questions, call your doctor.
Getting Back to Normal
You should be up and around in 6 to 8 weeks. If implants are used without flaps, your recovery time may be less. Some things to remember:
Reconstruction does not restore normal sensation to your breast, but some feeling may return.
It may take as long as 1 to 2 years for tissues to completely heal and for scars to fade, but the scars never go away entirely.
Follow your surgeon's advice on when to begin stretching exercises and normal activities. As a rule, you'll want to avoid any overhead lifting, strenuous sports, and sexual activity for 4 to 6 weeks following reconstruction.
Women who have reconstruction months or years after a mastectomy may go through a period of emotional readjustment once they have their breast reconstructed. Just as it takes time to get used to the loss of a breast, you may feel anxious and confused as you begin to think of the reconstructed breast as your own. Talking with other women who have had reconstruction might be useful. Talking with a mental health professional may also help with these feelings.
Silicone gel implants may open up inside the body without causing symptoms. Women with this type of implant should have MRI scans of the breast starting 3 years after surgery and every 2 years after that to detect this problem. If the silicone device ruptures, another surgery will be required to replace it.
For more information on coping after cancer, see "After Diagnosis: A Guide for Patients and Families" and "Sexuality For Women and Their Partners."
Breast Reconstruction and Cancer Recurrence
Studies to date have shown that reconstruction has no known effect on the recurrence of breast cancer. It should not cause problems with chemotherapy or radiation treatment if cancer does recur.
If you are considering a breast reconstruction procedure, either an implant or flap, you need to know that reconstruction rarely, if ever, hides or obscures a return of breast cancer. You should not consider this a significant risk when deciding to have breast reconstruction after mastectomy.
It is important to have regularly scheduled mammograms on the opposite breast at a facility with technologists experienced in taking and reading mammograms.
All doctors may not recommend mammograms for a breast reconstructed with an implant. Mammogram pictures can be impaired by implants; more so by silicone than saline filled. If your reconstruction involves an implant, be sure to get your mammograms done at an accredited facility with technologists trained in manipulating the implant to get the best possible images of the rest of the breast.
While studies have supported mammograms of tissue flap breast reconstructions, no standard recommendation is in place. It is recognized that reconstructed breasts can have a fatty appearance, surgical clips, and surgical scars visible on the mammogram, but abnormalities can also be seen. Cancer can recur in the skin or any remaining breast tissue at areas of breast reconstruction. If you have a tissue flap reconstruction, you may need to continue mammograms on both breasts. Discuss this with your plastic surgeon and oncologist.
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