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Breast Reconstruction

  

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Breast Reconstruction and Prosthesis
Fact Sheet

 

Breast Reconstruction with Tissue Flap
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Breast Reconstruction with Implants
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Breast Cancer 101 (interactive tool): Breast Reconstruction 
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Timing of breast reconstruction

Breast reconstruction can help restore the look and feel of the breast after a mastectomy. Performed by a plastic surgeon, breast reconstruction can be done at the same time as the mastectomy ("immediate") or at a later date ("delayed").

Many women now get immediate breast reconstruction. However, the timing depends on your situation and the treatment you will have after surgery. Not all women can have immediate reconstruction. It is important to discuss your options with your plastic surgeon, breast surgeon and oncologist (and your radiation oncologist if you are having radiation therapy).

Benefits of breast reconstruction

Breast reconstruction can help you feel more comfortable about how you look. Although a reconstructed breast may never match the look or feel of your natural breast, this area of plastic surgery continues to improve.  

Komen Perspectives  

Read our perspective on breast reconstruction (May 2012).* 

 

Choosing the type of breast reconstruction that is right for you

Breast reconstruction can be done with:

  • Breast implants (filled with saline or silicone)
  • Natural tissue flaps (using skin fat and sometimes muscle from your own body)
  • A combination of these methods 

There is no one best reconstruction method. There are pros and cons to each. For example, breast implants require less extensive surgery than procedures using your own body tissues, but the results may look and feel less natural [103]. However, there are fairly few complications with any of the current techniques, especially when a woman is properly selected for a procedure.  

Your body shape and anatomy may affect the types of breast reconstruction likely to give you the best results. For women with larger breasts, breast reduction surgery on the opposite, natural breast may be needed to create a more even look. Your plastic surgeon will help you choose the type of reconstruction that will give you the best results. Although this decision may seem overwhelming, it may help to know that most women who have had breast reconstruction are happy with the method they chose [103].  

Most breast reconstruction methods involve several steps. Both immediate and delayed reconstructions require a hospital stay for the first procedure. However, follow-up procedures may be done on an outpatient basis.

Smoking, body weight and breast reconstruction

Smokers and women who are overweight have an increased risk of complications for all types of breast reconstructive surgery [14,103-105]. If you smoke or are overweight, talk to your plastic surgeon about problems after surgery such as wound healing, infection, reconstruction failure and problems with implant or flap procedures that may occur. Sometimes, delayed breast reconstruction after quitting smoking or weight loss is preferred to lower the risks of these problems. Your plastic surgeon may discuss ways to quit smoking and/or lose weight before you have breast reconstruction.

Basic types of breast reconstruction

The table below compares the basic types of breast reconstruction. Specific types of reconstruction are discussed in more detail below.

 

Breast implants 

Natural tissue flaps (grafts)  

Looks and feels like a natural breast

Less able to mimic the look and feel of a natural breast (silicone implants look and feel more natural than saline implants)

Better able to mimic the look and feel of a natural breast

Loss of sensation

Will likely lose some sensation in the breast  

Will likely lose some sensation in the breast and tissue donation site

Surgery

  • Less extensive

  • Time in surgery is shorter

 
 

Is a hospital stay needed?

Needed for the first procedure (one to two nights)  

Follow-up procedures may be done on an outpatient basis

Needed for the procedure (three to four nights)

Will the procedure need to be repeated?

Implants will likely need to be replaced during lifetime.

Tissue flaps will not need to be replaced during lifetime. However, if there are complications, some procedures cannot be repeated.

Recovery

  • Three to four weeks
  • Fewer scars
 
  • Four to six weeks
  • More scars

 

Risk of complications

Some risk of surgical complications

Some risk of surgical complications (certain procedures have more risks than others)

Adapted from selected sources [103,106-107].

Implants

Inserting a breast implant is a fairly simple procedure and may not require extra hospital time if it can be done at the same time as the mastectomy.  

The shape of the reconstructed breast with an implant may not look or feel quite like the natural, opposite breast, especially as you age and your natural breast changes shape. For this reason, implants are better for women with small or medium-sized breasts with little or no sagging [103].  

It is possible to have surgery to enlarge or reduce the size of the opposite, natural breast to help make both breasts look more alike. However, it is important to note that the natural breast will change in size and shape with weight changes and as a woman grows older, while the breast with the implant will not. This may lead to a less even look over time.

Types of implants

There are two basic types of breast implants: saline and silicone.  

For both saline and silicone implants, the outer cover of the implant (also called the implant shell) is made of a solid form of silicone. The two types of implants differ in the substance used to fill the implant shell.  

Saline implants are filled with saline, a saltwater solution similar to that found in IV fluids. Saline implants come deflated and are filled during surgery up to the desired volume.  

Silicone implants are filled with silicone gel, a semi-solid substance made from silicone. They come pre-filled with the desired volume.  

Different implant shapes are available to match the look of the natural breast. Implants can be round or teardrop-shaped and vary in the amount of projection.

Safety of implants

In the past, there were concerns that silicone implants caused health problems. However, the research to date clearly shows no link between silicone implants and lupus, immune system disorders, connective tissue disease or rheumatoid arthritis [108]. Silicone implants are a safe option to saline implants.  

The FDA is looking into a possible link between breast implants (both saline and silicone) and a slight increase in the risk of anaplastic large cell lymphoma (ALCL). ALCL is a very rare form of cancer of the cells of the immune system (occurs in breast tissue in about three in 100 million women) [109-111].

The implant procedure

Inserting a breast implant (saline or silicone) is a fairly simple process.  

Step one: A modified saline implant (called a tissue expander) is inserted in the envelope formed by the breast skin and chest muscle. The expander has a valve that allows more saline to be added (with a simple injection through the skin into the valve) after surgery.  

Step two: Over a period of four to six months (in repeated office visits), the skin-muscle envelope is slowly stretched by injecting more saline into the expander until it reaches the desired size of the final implant. The final volume may be limited by the quality and size of the envelope formed by the breast skin and chest muscle.  

Step three: A surgeon removes (in an operating room) the expander and replaces it with the permanent implant (saline or silicone). This is usually an outpatient surgery.  

Some women do not need tissue expansion and can have an implant (saline or silicone) directly inserted at the time of mastectomy. In these women, the size of the skin-muscle envelope at the time of the mastectomy is large enough to cover the desired final implant. For example, women who have small breasts or excess natural breast skin, or who want to have a reconstruction that is smaller than their natural breast size. These cases are exceptions rather than the rule.  

The size of a reconstructed breast cannot be changed without surgery to replace the implant.

Breast reconstruction with implants using acellular dermal matrix

The acellular dermis technique takes advantage of the entire skin envelope available at the time of the mastectomy [112]. It is often used in combination with an implant reconstruction. This technique creates a hammock under the mastectomy skin envelope to hold the expander or implant in place. The hammock is made from biologic material (called acellular dermal matrix) alone or in combination with your chest muscle. Most often, the biologic material is donated human skin. Acellular means that the human cells that may lead to tissue rejection have been removed.  

Implant reconstruction with acellular dermal matrix can allow a larger volume fill at the time of surgery. This can shorten the implant expansion process so that the final implant procedure can occur sooner. The use of acellular dermal matrix can allow for a single-step implant process. The final implant can be placed at the time of the mastectomy without the need for expansion.  

Not all women can have the acellular dermal matrix technique (depending on the quality of the mastectomy skin envelope). Talk with your plastic surgeon to find out if this procedure may be right for you.

Nipple reconstruction with implant procedures

Reconstruction of the nipple may be done when the permanent implant is inserted or at a later time. Learn more about nipple and areola reconstruction  

Saline versus silicone implants

There are pros and cons to each type of implant. These are described in the table below. However, you should discuss your options with a plastic surgeon to choose the type that is best for you.  

 

Saline implants 

Silicone implants 

Feels like a natural breast

Less able to mimic the feel of a natural breast (may feel like a water balloon)

Better able to mimic the feel of a natural breast

Can the size of the expander or implant be changed?

Size of the expander may be increased or decreased after the initial surgery  

Size of the implant cannot be changed without surgery to replace the implant

Size of the implant cannot be changed without surgery to replace the implant

Risk of rupture

Equal chance of rupture

Equal chance of rupture

What happens if rupture occurs?

The saline is absorbed harmlessly into nearby tissues. The reconstructed breast appears deflated, so you know right away the implant has ruptured.

Some silicone gel might leak into the soft tissue pocket around the implant and rest there. Since the silicone is not absorbed, the overall breast volume stays the same. So, a rupture in a silicone implant may take longer to be detected than a rupture in a saline implant. (Breast MRI can be used to check for implant rupture.)

Side effects that may occur with the implant procedure

  • Hardening of the tissues around the implant (called capsular contraction)
  • Infection
  • Pain
 
  • Hardening of the tissues around the implant (called capsular contraction)
  • Infection
  • Pain
 

Replacement

Typically lasts at least 10 years, but will likely need to be replaced during lifetime (replacement requires surgery)

Typically lasts at least 10 years, but will likely need to be replaced during lifetime (replacement requires surgery)

Adapted from FDA and American Society for Aesthetic Plastic Surgery and American Society of Plastic Surgeons materials [107,114].

Breast implants and radiation therapy

Radiation therapy can cause problems (such as changes in skin color and tissue shrinkage) for both implant and natural tissue reconstruction.  

If you will have an implant procedure and radiation therapy will be used after mastectomy, immediate rather than delayed breast reconstruction is recommended [14]. Skin that has received radiation and is later stretched to fit an implant is at high risk for complications and a poor cosmetic result [14,103]. Results are better when the procedures to expand the skin are done before radiation therapy begins.  

Natural tissue flap surgery

Reconstruction that uses skin and soft tissue flaps from your own body tends to look and feel more like a natural breast than reconstruction with implants. However, these procedures are more complex and invasive, and usually require a longer hospital stay and post-surgery recovery time. They also leave scars in the area of the body where the tissue was taken (donor site).  

The most common natural flap procedures use tissue from the back, abdomen or buttocks. In some procedures, part or all of a muscle needs to be taken to provide blood flow to the flap tissue. This may cause weakness in that area of the body and limit certain physical or athletic activities. If you are active, discuss this risk with your plastic surgeon.  

Latissimus dorsi muscle flap breast reconstruction

The latissimus dorsi muscle flap procedure removes a large muscle in the back along with skin and underlying fatty tissue and uses these tissues to reconstruct the breast [103].  

Using fatty tissue helps create a more natural looking breast. In most women, the amount of soft tissue available on the back is limited and the flap itself is only about one inch thick. Therefore, an implant is usually needed in addition to the latissimus flap to create enough volume for the reconstructed breast. The soft tissue of the latissimus flap goes over the implant so that the look and feel of the breast is more natural than with an implant alone.  

Transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction

The transverse rectus abdominis myocutaneous (TRAM) flap uses skin, fat and muscle from the lower abdomen to reconstruct the breast [103]. A TRAM flap creates a natural looking breast. It usually does not require an implant as long as there is enough excess skin and fatty tissue in the lower abdomen. If you do not have excess abdomen tissue, you may not be a candidate for a TRAM flap reconstruction.  

The TRAM flap has some drawbacks. The surgery is more complex than implant-based reconstruction. Once a TRAM flap has been done, it cannot be repeated. Since one of the abdominal muscles is removed to provide a blood supply to the flap, its loss can cause some weakness in this part of the body and can leave a large scar across the lower abdomen. If you are active, talk to your plastic surgeon about this drawback.  

Deep inferior epigastric perforator (DIEP) flap breast reconstruction

Breast reconstruction with a deep inferior epigastric perforator (DIEP) flap uses skin and fat tissue from the lower abdomen to form the reconstructed breast [103]. Unlike the TRAM flap, the DIEP flap procedure keeps the abdominal muscle intact, which may preserve abdominal strength after the procedure.  

As with the TRAM flap, a DIEP flap reconstruction cannot be repeated. It is more complex than the latissimus dorsi muscle flap and TRAM flap procedures and usually requires two microvascular surgeons. It also requires an intensive care unit (ICU) stay for close monitoring after surgery. The surgery takes much longer than natural flap techniques (due to the microvascular procedures), which can increase the risk of problems during surgery.  

At this time, it’s unclear whether the benefits of the DIEP flap procedure outweigh the risks when compared to other techniques [114]. The DIEP flap procedure should only be done by surgeons who are well-trained and experienced with this technique.  

Superficial inferior epigastric artery (SIEA) flap breast reconstruction

The superficial inferior epigastric artery (SIEA) flap breast reconstruction uses skin, fat tissue and blood vessels (including the superficial inferior epigastric artery) from the abdomen to form the reconstructed breast. It is not as common as the TRAM and DIEP flap procedures because few women have blood vessels large enough (or any at all) to allow the SIEA flap procedure to be performed [103].  

The SIEA flap leaves all of the muscles and most of the connective tissue of the abdomen untouched, so it leaves no weakness in the abdominal area, This can be important for women who are physically active.  

Blood clots and other problems are more common with SIEA flap procedures than with other techniques [115]. At this time, it’s unclear whether the benefits of the procedure outweigh these risks. The SIEA flap procedure should only be done by microvascular surgeons who are well-trained and experienced with this technique.    

Superior and inferior gluteal artery perforator (S-GAP and I-GAP) flap breast reconstruction

Gluteal artery perforator (GAP) flap procedures use skin and fatty tissue from the buttocks to reconstruct the breast. The superior GAP (S-GAP) procedure uses skin and fatty tissue from the upper part of a buttock. The inferior GAP (I-GAP) flap procedure uses skin and fatty tissue from the lower part of a buttock. Because no buttock muscle is used in either procedure, athletic ability after surgery is rarely affected [116].  

S-GAP or I-GAP flap reconstruction may be a good option for women with more fat tissue in their buttocks area than in their abdomen [116-117]. If the GAP procedure leaves the buttocks noticeably different in size, liposuction can be used later to remove fat from the opposite buttock to create a more even look.  

As with the DIEP flap, GAP flap procedures are more complex than other types of flap procedures and require a microvascular surgeon. They take longer than other types of tissue flap surgeries (even longer than the DIEP flap procedure), which may increase the risk of surgical complications [116-117].  

If an S-GAP or I-GAP flap procedure is not successful, it can be repeated using tissue from the opposite buttocks (either immediately or at a later time).

Natural tissue reconstruction and radiation therapy

Radiation therapy can cause problems (such as changes in skin color and tissue shrinkage) with both implant and natural tissue reconstruction.  

For women choosing flap breast reconstruction who will need radiation therapy after mastectomy, it is better to delay the flap reconstruction until after radiation therapy. This greatly lowers the chances that the look, feel and size of the reconstructed breast will be harmed by the radiation therapy [14]. Women may also consider having immediate reconstruction with a tissue expander and once radiation therapy is done, have flap reconstruction.  

Skin-sparing mastectomy

If you are having immediate breast reconstruction, your surgeon may perform a skin-sparing mastectomy to preserve as much of the skin of the breast as possible. The tumor and clean margins are removed, along with the nipple, areola, fat and other tissue that make up the breast. What remains is much of the skin that surrounded the breast. This skin can then be used to cover a tissue flap or an implant.  

The major benefit of a skin-sparing mastectomy is that it avoids having to use skin from other parts of the body for reconstruction. That skin can have a different color, texture and thickness compared to natural breast skin, creating a “patch” look.  

In the past, there were concerns that skin-sparing mastectomy may increase the risk of breast cancer recurrence. However, most studies to date have not found an increased risk and the procedure is considered safe [14,118-120].  

Nipple and areola reconstruction

Creating the nipple and areola is the last stage of breast reconstruction. Recreating the nipple and areola gives the reconstructed breast a more natural look and can help hide the mastectomy scars. These procedures are usually outpatient procedures and have few risks [103].

The nipple can be recreated using skin from the reconstructed breast itself after the implant or flap reconstruction has healed.  

The areola may be created with a tattoo or by grafting skin from the groin area. Skin in the groin area has a similar tone as the skin on the areola. The scar from where the skin is taken can be hidden in the bikini line.  

Nipple-sparing mastectomy

Nipple-sparing mastectomy is a newer procedure that removes the tumor with clean margins, as well as the fat and other tissue in the breast, but leaves the nipple and areola intact. This improves the overall look of the reconstructed breast. This may be an option for select women with breast cancer and for women having a prophylactic mastectomy [14,121-122].  

With nipple-sparing mastectomy, the nipple will likely lose sensation and some projection. In some cases, the tissues may break down and some or all of the nipple and areola may need to be removed [122].  

Clinical trials are studying whether nipple-sparing mastectomy increases the risk of breast cancer recurrence. Learn more about clinical trials of breast reconstruction.

After breast reconstruction

Most women feel tired and sore for several weeks after breast reconstruction. Your surgeon or plastic surgeon may prescribe medications to ease the pain.  

Talk to your plastic surgeon about specific instructions following your surgery. For some types of surgery, you may still have a surgical drain(s) in place when you go home from the hospital. This is a small tube that allows extra fluid from the surgery to escape. You will get instructions on care of the drain. You may need to wear a special bra while your reconstructed breast heals.  

Overhead lifting, strenuous sports and sexual activity should be avoided for four to six weeks after reconstructive surgery [123]. Most women can resume normal activity within eight weeks [123]. Talk to your health care provider about specific activities to avoid and when you can expect to get back to your normal routine.  

Remember that it may take some time to see the full results of your reconstructed breast. The bruising and swelling from the surgery may take up to eight weeks to go away [123]. Your satisfaction with the final results may depend on your expectations. Keep in mind a reconstructed breast will not look or feel exactly the same as a natural breast. Most of the scarring will fade and improve over time, but some scars may never go away. And, as you age and the opposite breast changes shape, the reconstructed breast may look or feel less natural.  

Most women have a period of emotional adjustment after breast reconstruction. Feeling anxious or depressed is common. It may help to talk with a counselor or to other women who have had breast reconstruction.  

Insurance coverage for reconstructive surgery

Medicare and Medicaid

Medicare is health insurance provided by the federal government to people who are 65 years of age or older, on renal dialysis or permanently disabled. Medicare covers breast reconstruction after a mastectomy.  

Medicaid provides health care to people who have a low-income. This program is run jointly by the federal and state governments, so benefits and eligibility (who can join) vary from state to state. Many states require all health insurance providers (including Medicaid) to cover breast reconstruction after a mastectomy (learn more).

Women's Health and Cancer Rights Act of 1998

The Women's Health and Cancer Rights Act of 1998 requires group health plans, insurance companies and health maintenance organizations (HMOs) that pay for mastectomy to also pay for [124]:

  • Reconstruction of the breast removed with mastectomy
  • Surgery and reconstruction of the opposite breast to get a symmetrical look
  • Prostheses  
  • Treatment of any complications of surgery, including lymphedema

The Women’s Health and Cancer Rights Act does not apply to some church and government insurance plans. For more information on the Women's Health and Cancer Rights Act, visit the Department of Labor website or call toll-free at 866-275-7922.  

State laws

Many states require all health insurance providers (including those not covered under the Women’s Health and Cancer Rights Act) to pay for reconstructive surgery after a mastectomy. Check with your state insurance commissioner's office or your health insurance provider to find out which services are covered by your state's laws and your health plan.  

For more information on coverage of breast cancer-related services by state, visit the American Society of Plastic Surgeons' website.   

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Questions to ask your doctor on breast reconstruction
Topic Card

Questions for your plastic surgeon

  • What types of breast reconstruction surgery can I have?
  • Which type is best for me and why?
  • When is the best time for me to have breast reconstruction — at the time of the mastectomy or later? Is there a time limit for having reconstruction done?
  • How many procedures are involved in the type of reconstruction I am having?
  • If I need to have radiation therapy after my mastectomy, how will that affect my reconstruction choices and cosmetic outcomes?
  • How many of these procedures have you performed?
  • Would you please show me photos of both your best and your more typical results?
  • What are the chances of infection and failure with my reconstructive surgery? Are there any other risks or side effects to consider?
  • What are the short- and long-term results with implant versus natural tissue reconstruction?
  • Will I have a surgical drain in place when I go home? If so, how will I care for it? When will it be removed?
  • Is there much pain after surgery?
  • Will I have any numbness after the surgery?
  • What side effects might I expect after surgery? What problems should I report to you right away?
  • Where will the surgical scar(s) be?
  • What body changes should I expect after surgery? How many hospital stays are needed? How long will each hospital stay be?
  • How can I expect the reconstructed breast to look and feel? How will it look compared to my healthy breast?
  • Will I be able to detect a possible return of cancer after reconstructive surgery?
  • What breast cancer screening is recommended for me?  

Clinical trials

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Clinical Trials
Fact Sheet

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Breast Cancer 101 (Interactive Multimedia) - Clinical Trials
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BreastCancerTrials.org in collaboration with Susan G. Komen® offers a custom matching service that can help you find a clinical trial on breast reconstruction that fits your needs.

Learn more about clinical trials and find a list of resources to help you find a clinical trial.  

 Komen Perspectives  

Read our perspective on clinical trials (July 2012).* 

* Please note, the information provided within Komen Perspectives articles is only current as of the date of posting. Therefore, some information may be out of date at this time.   

Updated 04/28/14

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