Breast reconstruction

Getting reconstruction is a personal choice. Many women choose not to have reconstruction. This is often called going flat. For some women, breasts are an intimate and essential part of their body image and sexual identity, and the idea of losing one or both breasts can trigger many intense emotions. If it’s upsetting to think about losing a breast, reconstruction can help restore a sense of wholeness. If you’re thinking about breast reconstruction, talk with your surgeon and plastic surgeon as early as possible to explore options and decide on timing that works best for your situation.

Breast reconstruction can often be done at the same time as mastectomy surgery, all in one step. It can also be done in multiple steps, with some steps happening during mastectomy and others happening in a later surgery. And it’s possible to wait weeks, months, or even years before having breast reconstruction surgery. Here are some situations that can affect timing:

• While reconstruction can be done at any stage of breast cancer, if you have an aggressive cancer, inflammatory breast cancer, or metastatic breast cancer, your doctor may recommend that breast reconstruction be delayed until you’ve had certain treatments.
• Radiation therapy can sometimes affect the cosmetic results of breast reconstruction. If your care team has recommended radiation therapy, you’ll work with your radiation oncologist and surgeon to decide if it’s best to have radiation treatment before or after breast reconstruction.

If you’re having a lumpectomy and you’re concerned about how your breast will look after surgery, ask your surgeon about oncoplastic lumpectomy. This approach uses plastic surgery techniques during lumpectomy to reduce the risk of visible scarring or indentations. These techniques can also be used later to make corrections. If oncoplastic lumpectomy is not available where you are, partial breast reconstruction techniques can be used to correct imbalances left after lumpectomy. Visit lumpectomy to learn more.

Types of reconstruction

There are two main types of reconstruction available today: reconstruction using your own body tissue, such as muscle or fat, and reconstruction using breast implants.

Tissue reconstruction

Tissue reconstruction, also called flap reconstruction, is a more complex surgery with a longer hospital stay and recovery time when compared with implant reconstruction. Still, reconstruction with a tissue flap often results in breasts that have a more natural look and feel than reconstruction using implants. To perform this type of reconstruction, a surgeon will take skin, fat, or muscle from a different part of your body and use it to reshape and rebuild the breast or breasts.

Types of flap reconstruction include:

• Pedicled TRAM flap reconstruction. In this surgery, skin, fat, and muscle from the lower abdomen are moved through a tunnel under the skin to the breast area. The tissues remain connected to the lower abdomen, so the surgeon does not need to reattach blood vessels.
• Free flap reconstruction. In these surgeries, surgeons remove skin or fat from the lower abdomen and place them in the breast area. Because the tissue is completely disconnected from the lower abdomen, these procedures require a microsurgeon who can reconnect blood vessels from transferred tissue, allowing blood supply to the new breast. Examples of free flaps include free TRAM, DIEP, MS-TRAM, SIEA, TUG, and GAP flaps, which can use tissue from the abdomen, inner thigh, or buttock.
• Latissimus dorsi flap reconstruction. During this procedure, the surgeon slides skin, fat, and muscle from the back to the chest, without disconnecting the tissue from your body.

Tissue flap reconstruction requires healthy blood vessels so that blood can get to the reconstructed breast or breasts. Certain medical conditions and lifestyle factors shrink or reduce blood vessels. Uncontrolled diabetes, poor circulation, connective tissue disease, and smoking can create challenges with this type of reconstruction surgery. If any of these apply to you, talk with your doctor about whether you’re eligible for this reconstruction approach. Visit Tissue reconstruction to learn more.

Implant reconstruction

In implant reconstruction, a silicone-covered breast implant is placed under the muscle and skin of the breast. The implant contains either silicone gel or saline (salt water). Silicone implants feel like a natural breast in texture and shape, while saline implants feel less firm. Either type of implant may be a good option if you do not have very large breasts or there is not enough tissue available in other parts of your body to create a breast. There are pros and cons to choosing saline or silicone implants. Be sure to talk with your doctor about which may best suit you and your lifestyle. Visit Implant reconstruction for more information.

Nerve repair during or after reconstruction

During mastectomy, surgeons have to cut through nerves to remove breast tissue. This can cause ongoing chest and breast numbness. For some people, numbness may:

• Interfere with sex and intimacy
• Increase the risk of burns or other injuries that can result from an inability to feel pressure or temperature on the breast skin

Some cancer centers offer nerve repair, sometimes called reinnervation, which aims to reconnect the cut nerves and restore feeling in the chest and breasts. One example is a technique called Resensation:

• This procedure uses donated, sterilized human nerve tissue (called a nerve graft) to connect cut chest nerves to reconstructed breast nerves.
• Over time, the graft guides the chest and breast nerves to grow together.

Resensation can be performed at the same time as breast reconstruction or aesthetic flat closure if you choose to go flat. It adds about 20 minutes to the surgery. In some cases, it can be performed as part of delayed reconstruction.

After Resensation with reconstruction:

• It takes some time for the nerves to grow back together.
• Many people report feeling little shocks, zaps, or itchiness around six months after the procedure. More feeling can return over the next couple of years.
• The sensation may be different than it was before mastectomy. There’s also a possibility that sensation won’t return.

Small studies have shown that some feeling is more likely to return after reconstruction with Resensation versus without Resensation. A larger study, Sensation NOW, is enrolling people having flap reconstruction to compare their outcomes with or without Resensation.

Some other things to keep in mind:

• Not all surgeons perform nerve repair. There is an online directory available that lists some, but not all, surgeons who offer Resensation. Ask your surgeon if they offer it, or if they can recommend someone who does.
• Eligibility for Resensation depends on your past medical history, breast size, type of mastectomy and reconstruction, and overall treatment plan.
• While health insurance usually covers breast reconstruction, it does not always cover Resensation. Talk with your health insurance provider and your surgeon about coverage.

Nipple reconstruction

In some cases, depending on the location of the cancer, surgeons may need to remove the nipple and areola, the area around the nipple. Breast reconstruction techniques can rebuild the nipple and recreate the areola. In both tissue and implant reconstruction, you may have the option of rebuilding the nipple. There are different ways to create a nipple, including using the skin of the affected breast or other techniques. Nipple reconstruction is usually a separate surgery that happens a few months after the main breast reconstruction surgery. This allows the reconstructed breast or breasts to heal and settle into a final position first. Visit Nipple reconstruction for more information.

Reconstruction during or after lumpectomy

If you decide to have oncoplastic lumpectomy, flap surgery techniques can sometimes be used. Oncoplastic breast surgery and reconstruction techniques can also be used at some point after lumpectomy.

You and your surgeon will decide on a reconstruction plan and schedule that works best for your needs.

Making decisions about reconstruction

The best time to gather information about breast reconstruction is before mastectomy surgery. While you and your doctors may be very focused on treating the cancer, your sense of physical identity and body image are also very important. Some women may feel completely empowered to start a reconstruction conversation with their surgeon and ask about options. For others, it can feel like, “I should just be grateful to be getting rid of the cancer. It’s too much to expect to come out of this actually looking good, too!” But for many women, breast reconstruction can help restore a feeling of physical completeness, identity, and quality of life after a diagnosis.

If your surgeon does not talk with you about breast reconstruction, ask about it. While reconstruction can be done at the time of mastectomy or months or years later, understanding all your options before mastectomy can help you make the best decisions for you. Many women have the option of having some or all of the reconstruction at the same time as mastectomy — so the earlier you talk to your surgeon about reconstruction, the better.

We know that making such an important decision about your body can feel overwhelming. Here are some pros and cons of having breast reconstruction.

Breast reconstruction can:

• Help restore body image
• Create a permanent breast shape
• Make your chest look and feel balanced
• Allow you to avoid wearing a prosthesis (a breast form inserted into your bra)

It can also:

• Require more surgery than mastectomy without reconstruction
• Have a higher risk of complications than mastectomy alone
• Require a longer time to recover from surgery than mastectomy alone
• Result in breasts that don’t look or feel the way you expect
• Cause scars on more than one area of your body
• Require more medical procedures in the future
• Cause pain or muscle weakness at the surgical site

Think about how you feel about your breasts and your body. Breast reconstruction is a very personal decision. You have options. Take the time you need to decide which one makes most sense for you and your lifestyle.

To help you decide, you may want to:

• Talk with a plastic surgeon experienced in breast reconstruction.
• Ask the plastic surgeon to share photos of their patients before and after reconstruction.
• Weigh the benefits of reconstruction against the possible risks of extra surgery.
• Consider how you might feel if your rebuilt breasts are not what you expected. You can also ask a plastic surgeon what they recommend in this situation.
• Talk with other women about their experiences, including those who chose to go flat or wear prostheses. Some women may even be willing to show you their reconstructed breasts in person. If you don’t know anyone, contact our Breast Cancer Helpline at (888) 753-5222 to talk with a woman who made this decision.
• You can also join our private Facebook groups to talk with others who’ve made reconstruction decisions:
  • Breast Cancer Support: All Ages, All Stages This group is a space for anyone at any stage of breast cancer to meet others for support and connection.
  • Breast Cancer Support: Young Women This group is a space dedicated to talking about breast cancer-related challenges unique to younger women.
  • Support Community for High Risk This community is for people with a high risk of developing breast cancer, ovarian cancer, or both due to a strong family history of cancer, personal health conditions, or inherited gene mutations.
• Online or in person, visit a store with mastectomy wear to see options. Some cancer centers and hospitals have shops with mastectomy prostheses, bras, and post-mastectomy clothing. You can also ask about stores in our private Facebook groups.

Concerns about pain, stiffness, or other side effects after reconstruction can also inform your decisions. Ask a plastic surgeon about what kinds of short-term and long-term side effects can happen after different kinds of reconstruction, and how they can be managed. For example, the surgeon or nurse can show you exercises that can help lower the risk of post-surgery stiffness or manage it if it happens. Hearing experiences from others who’ve had breast reconstruction can help, too.

Conditions that interfere with reconstruction

Not everyone is a candidate for breast reconstruction. Here are some conditions that may interfere with having reconstruction:

• Diabetes that is not well controlled, which can delay wound healing
• Autoimmune diseases
• Not meeting bodyweight recommendations for anesthesia and certain types of reconstruction
• Poor general health

Smoking can also interfere with tissue reconstruction because it constricts blood vessels, the passageways oxygen travels through to reach healing skin. Smokers are at a higher risk for tissue necrosis, the death of skin cells from lack of oxygen. If you smoke or have other medical conditions and want reconstruction, talk with a plastic surgeon as soon as possible to find out your options. Your surgeon may recommend you quit smoking and quit using other nicotine products for a certain amount of time before and after surgery.

Talking to the plastic surgeon

It’s important to find a plastic surgeon who listens to your goals and concerns. Along with the medical oncologist treating the cancer, your plastic surgeon can help you understand options and timing that work for your treatment plan.

In some cases, you may feel very comfortable with the first plastic surgeon you meet. In other situations, it can help to talk with more than one plastic surgeon. Some health insurance plans cover second opinion meetings with doctors. Talk with your health insurance company to understand if a second opinion visit is covered.

Here are some questions to consider asking when you meet your plastic surgeon for the first time:

• What percentage of your practice is breast reconstruction? How much experience do you have with it?
• What kinds of breast reconstruction do you do?
• Am I a candidate for implant reconstruction, tissue reconstruction, or both?
• What are the advantages and disadvantages of the type of reconstruction you recommend for me?
• Can I see before-and-after photos of women you’ve helped, who had the type of reconstruction you’re recommending?
• May I speak to some of your patients about their experiences?
• What are the short-term and long-term side effects of the surgery you’re recommending? How are they managed?
• What are complication rates in this practice, and what are the potential complications of my surgery?
• If complications happen, how do you manage them?
• How long will my recovery be?
• Will I need any follow-up or revision surgery?

If you are having trouble finding an experienced breast reconstruction surgeon in your area, you can ask your medical oncologist or breast surgeon to refer you to one or contact the American Society of Plastic Surgeons.

Preparing for reconstruction

Your doctor may suggest you follow some general health instructions ahead of surgery to prepare your body for healing. It’s important to follow these instructions, so be sure to ask any questions you have when you get them.

At home, it can be helpful to have a place ready for you to sit with easy access to necessary items (such as water, food, and entertainment) and where you can sleep comfortably, such as a recliner. You can prepare this ahead of time or ask a friend or loved one to create this space for you.

What to expect after reconstruction

When you leave the hospital, you will likely have temporary surgical drains attached to your body with small stitches near the surgery site. Drains are small, flexible tubes that suction accumulated fluid away from the surgery site. You will be given instructions on how to empty and clean the drains to help you avoid infection once you’re home. Your doctor may also recommend you avoid certain activities such as heavy lifting, intense sports or exercise, and some sexual activities for 4-6 weeks.

If you choose to have reconstruction with breast implants, surgery can sometimes be done all in one step, placing the permanent implant at the time of mastectomy. But in other cases, your plastic surgeon may recommend using two steps: a first surgery in which your surgeon places a temporary implant called an expander under the skin and muscle of your chest, where the permanent implant will eventually go. The expander is gradually filled with saline solution at in-office appointments over a period of weeks or months. This stretches the skin and muscle enough that the implant will fit comfortably beneath them. Once the skin and muscle have stretched enough, you’ll have a separate surgery to place the expanders with permanent implants.

If you have tissue reconstruction, the number of steps can vary. Some tissue reconstructions are completed all in one surgery at the time of mastectomy. For others, a plastic surgeon may include a second surgery for final adjustments. Most of the time, the expander phase is not needed for tissue reconstructions.

If you decide to have nipple reconstruction, this can be an extra step that happens after the main breast reconstruction surgery is finished.

In general, implant reconstruction has a shorter recovery time than tissue reconstruction. After implant reconstruction, healing and recovery can take about 4 weeks. For tissue reconstruction, it can take about 6-8 weeks. Tissue reconstruction means your body is healing from more than one area of surgery — the breast area and the location of tissue used to build the breast. Implant reconstruction can also involve fat transfer from another area of the body to supplement the implant.

During recovery, your motion may be limited because of pain or muscle tightness, and you may feel fatigued or weak. These are all common effects of major surgery. Be sure to keep track of how you feel and report any new or worsening side effects to your doctors. After the body has healed, physical therapy is sometimes recommended to retrain and strengthen muscles weakened by the surgery. Ask your plastic surgeon about physical therapists who have experience working with women recovering from mastectomy and reconstruction surgery.

Many women worry that reconstruction can make it difficult to diagnose potential future breast cancers. Know that research shows that reconstruction does not make it harder to find a new breast cancer. If you had a mastectomy, you may not be offered screening mammograms if there isn’t enough breast tissue to effectively perform one. But you’ll still get physical breast exams, and if an area of concern is found, a diagnostic mammogram will be done.

Side effects

Any kind of major surgery comes with the risk of side effects. Here are the main side effects that can happen with breast reconstruction:

• Pain and tightness in the breast or chest area
• Infection
• Problems caused by anesthesia, such as nausea, vomiting, chills, or a sore throat that can happen when a breathing tube is used during surgery
• Imbalanced or asymmetrical breasts, meaning one breast is now bigger or smaller than the other, if surgery was only performed on one breast
• Capsular contracture, in which scar tissue forms around an implant, causing pain and distorting the way the reconstructed breast
• Loss of sensation in the skin of the breast or the nipple

It’s important to know that there are ways to manage pain, tightness, capsular contracture, or breast asymmetry after surgery. These can include physical therapy and corrective surgery. If you are only having reconstruction done on one breast, the risk of an imbalanced look can sometimes be avoided by making surgical adjustments to the other breast. Group health insurance plans that cover mastectomy are required to cover mastectomy-related reconstructive surgeries, including procedures to one or both breasts that can create symmetry.