Breast Reconstruction

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 some time after the surgery ("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 are candidates for 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 and restore confidence in your sexuality. Although a reconstructed breast may never look or feel the same as your original breast, this area of plastic surgery continues to improve.

Choosing the type of breast reconstruction that is right for you

Breast reconstruction can be done using breast implants (filled with saline or silicone), skin, fat and muscle from your own body or a combination of these methods. There is no one best reconstruction method. There are pros and cons to each method. For example, breast implants require less extensive surgery than procedures using your own body tissues, but the results may look and feel less natural [121].

Your body shape and anatomy may affect the types of breast reconstruction likely to give you the best results. Discuss your options with your plastic surgeon. Most women are happy with the method they chose. And, there are fairly few complications with any of the current techniques [121].

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 and breast reconstruction

Smoking increases the risk of complications for all types of breast reconstructive surgery [121-122]. If you smoke, talk to your plastic surgeon about problems with wound healing and/or problems with flap procedures that may occur.

Implants

Inserting a breast implant is a fairly simple procedure and may not require extra hospital time if it can be done at the time of 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 [121].

It is possible to have surgery to enlarge or reduce the size of the natural breast to help make both breasts look the same.

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. Silicone implants are filled with silicone gel, a semi-solid substance made from silicone.

Safety of implants

The best available research today does not suggest silicone implants are linked to lupus, immune system disorders, connective tissue disease or rheumatoid arthritis [123]. Thus, women can consider silicone implants 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 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) [124-126]. Read our statement on breast implants and the possible link to ALCL.

The implant procedure

Inserting an implant is usually a two- or three-step process. In the first step, a tissue expander is inserted between the skin and chest muscle. This forms a skin-muscle envelope. The tissue expander is a modified saline implant with a valve that allows for more saline to be added after the first surgery. A simple injection of saline through the skin into the valve fills the implant. During repeated office visits over a period of four to six months, the skin-muscle envelope is slowly stretched until has reached the desired size of the final implant.

The next step is an outpatient surgery (in an operating room) where the expander is removed and replaced with a permanent implant (saline or silicone).

In some cases with saline implants, the expander is kept in place for a longer period of time. This allows the size of the reconstructed breast to be changed (by increasing or decreasing the amount of saline in the implant) at a later time without having to remove the implant.

A silicone implant is pre-filled with a specific amount of silicone gel. Therefore, with silicone implants, the size of the reconstructed breasts cannot be changed without surgery to replace the implant.

Some women do not need tissue expansion and can have an implant (saline or silicone) directly inserted. 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. These cases are exceptions rather than the rule.

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 [127-128]. This technique creates a hammock under the mastectomy skin envelope to hold the expander or implant in place. The hammock is made from donated tissues (called "acellular dermal matrix") alone or in combination with your chest muscle. Similar techniques have been used for other reconstructive procedures in the body.

The acellular dermis procedure is less invasive and the length of the surgery is shorter than some other techniques. It also allows a larger breast mound to be created at the time of the mastectomy. This decreases the number of office visits needed to reach the desired implant volume. And, the expander can be replaced with the final implant sooner than with other tissue expanding techniques. Under ideal conditions, an expander is not needed and the final implant can be placed into the created hammock at the time of the mastectomy with no further surgery required.

Not all women are candidates for this procedure. It depends on the quality of the mastectomy skin envelope. Talk with your plastic surgeon to find out if you are a good candidate for this procedure.

Nipple reconstruction with implant procedures

Reconstruction of the nipple is done when the permanent implant is inserted in the operating room or as a third step in the office. 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.  

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 [66]. Skin that has received radiation and is later stretched to fit an implant is at high risk for complications and a poor cosmetic result [66,121]. Results are better when the procedures to expand the skin are done before radiation therapy begins.  

Natural grafts/tissue flap surgery

Reconstruction using skin and tissue flaps (grafts) 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 prolong the hospital stay. They also leave scars in the area of the body where the tissue was taken [131].  

In some flap procedures, an entire muscle needs to be removed to reconstruct the breast. This can cause weakness in that area of the body and might have a negative impact on certain physical or athletic activities. If you are active, you should discuss this with your plastic surgeon.  

Today, the most common natural graft procedures use tissue from the back, abdomen or buttocks.

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.  

Using fatty tissue helps create a more natural looking breast. In most women, the flap itself is only about one inch thick. Therefore, even with the added fatty tissue, it usually requires an implant to make the reconstructed breast match the size of the opposite breast. Even so, because much of the reconstructed breast is formed with natural tissue, the look and feel of the breast will be more natural than with an implant alone.

Transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction

The transverse rectus abdominis myocutaneous (TRAM) flap is a common type of breast reconstruction. This procedure uses skin, muscle tissue and fat tissue from the lower abdomen to reconstruct the breast [121]. 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. Once it has been done, it cannot be repeated. And, the surgery is complex and invasive, and leaves a large scar across the abdomen. Since the abdominal muscle is used to form the reconstructed breast, its loss will cause some weakness in this part of the body. If you are athletic or physically 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, like the TRAM flap procedure, uses skin and fat tissue from the lower abdomen to form the reconstructed breast [121]. Unlike the TRAM flap, the DIEP flap procedure keeps the abdominal muscle intact. This speeds recovery and preserves abdominal strength after the procedure.  

However, as with the TRAM flap, a DIEP flap reconstruction cannot be repeated. It is also more complex than the latissimus dorsi muscle flap and TRAM flap procedures. It usually requires two surgeons well-trained in microvascular techniques. It also tends to take longer than other natural graft procedures, which can increase the risk of problems during surgery. At this time, it’s still unclear whether the benefits of the DIEP flap procedure outweigh the risks when compared to other techniques [132]. Therefore, 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

Like the DIEP flap, 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 perform the SIEA flap procedure [121].  

Compared to the TRAM and DIEP flap procedures, the SIEA flap leaves all of the muscles and most of the connective tissue of the abdomen untouched. Like the DIEP flap procedure, it leaves no weakness in the abdominal area after reconstruction, which can be important for women who are athletic.  

However, blood clots and other problems are more common with SIEA flap procedures than with other techniques [133]. It is unclear whether the benefits of the procedure outweigh these risks. Therefore, the SIEA flap procedure should only be done by surgeons who are well-trained and experienced with this technique.

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

The superior gluteal artery perforator (S-GAP) flap procedure uses skin and fatty tissue from the upper part of a buttock to reconstruct the breast. Because no buttock muscle is used, athletic ability after surgery is rarely affected [134].

S-GAP flap reconstruction may be a good option for women with more fat tissue in their buttocks area than in their abdomen [134]. If the 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.   

Like the DIEP flap, the S-GAP flap procedure is more complex than other types of natural tissue graft procedures and requires a surgeon well-trained in microvascular techniques. It takes longer than other types of tissue flap surgeries (even longer than the DIEP flap procedure) which may increase the risk of surgical complications [134].  

Unlike the DIEP flap, if an S-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 having natural tissue reconstruction who will have radiation therapy after mastectomy, it is better to delay 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 [66].  

Skin-sparing mastectomy

If you are having immediate breast reconstruction, your surgeon may perform a skin-sparing mastectomy to keep as much of the skin of the breast as possible intact. The tumor and 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. Thus, because natural breast skin is used, the reconstructed breast will look more like the opposite breast.  

Although it's been suggested that skin-sparing mastectomy may increase the risk of cancer recurrence, most studies to date have not found an increased risk [135-139].  

Nipple-areola reconstruction

The nipple and areola are the last stage of breast reconstruction. Recreating the nipple and areola gives the reconstructed breast a more natural look and can help hide scars. These procedures are usually outpatient procedures [121].  

The nipple can be recreated with tissue from the reconstructed breast itself after the skin on the breast has healed and had a chance to expand over the new tissue or implant.  

The areola may be created by tattooing the area 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 and 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.  

Radiation therapy to the nipple may be given during or after the surgery to reduce the chances of recurrence [140-142].  

Not all women are candidates for nipple-sparing mastectomy. Along with the risks of any surgery, there are other complications. The nipple will likely lose sensation and some projection. And, in some cases, the tissues may break down and some or all of the nipple and areola may need to be removed later [140-142].

After breast reconstruction

Most women feel tired and sore for two to three weeks after breast reconstruction. Overhead lifting, strenuous sports and sexual activity should be avoided for four to six weeks after reconstructive surgery [143]. Most women can resume normal activity within eight weeks [143]. Talk to your health care provider about specific instructions following your surgery.  

Remember that although reconstruction can improve appearance and boost self-confidence, the reconstructed breast will not look or feel the same as a natural breast. Most of the scarring will fade over time, but some scars may never go away.  

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

Insurance coverage for reconstructive surgery

State laws

Many states require health insurance providers to pay for reconstructive surgery after a mastectomy. However, no federal laws mandate this coverage.  

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 National Cancer Institute's State Cancer Legislative Database's website or the American Society of Plastic Surgeons' website.

Women's Health and Cancer Rights Act of 1998

The Women's Health and Cancer Rights Act of 1998 requires that all health insurance providers and health maintenance organizations (HMOs) that pay for mastectomy also pay for [144]:

• 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

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.
  

Questions for your plastic surgeon

• What are the types of breast reconstruction surgery?
• Which type is best for me and why?
• If I need to have radiation therapy after my mastectomy, will that affect my reconstruction choices?
• 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 rejection 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?
• Is there much pain after surgery? What body changes may I have after surgery, and for how long?
• 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?
• How many hospital stays are needed? How long will each hospital stay be?
• Will my insurance cover breast reconstruction?
• 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? Is mammography still recommended for me?

Updated 09/15/11 

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