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 at a later date ("delayed").

Many women now get immediate breast reconstruction. However, the timing depends on:

• Physical exam by the plastic surgeon
• Surgical risk factors (such as smoking and being overweight)
• Treatments you will need after surgery

Not all women can have immediate reconstruction.

It’s important to discuss your options with your plastic surgeon, breast surgeon and oncologist (and your radiation oncologist if you are having radiation therapy).

Benefits

Breast reconstruction may help you feel more comfortable about how you look after a mastectomy.

Although a reconstructed breast may never match the look or feel of your natural breast, this area of plastic surgery continues to improve.

Possible challenges

Travel

You may not live near the hospital where your reconstruction will be done. This can be a challenge because of the number of routine follow-up visits needed after reconstruction.

Most breast reconstruction methods involve several steps.

Immediate reconstructions and some delayed reconstructions require a hospital stay for the first procedure.

Follow-up procedures may be done on an outpatient basis.

If you need transportation, lodging, child care or elder care, there may be programs that can help.

Cost

Federal law requires most insurance plans cover the cost of breast reconstruction.

Learn more about insurance and breast reconstruction.

Choosing the type of breast reconstruction that’s 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 invasive surgery than procedures using your own body tissues, but the results may look and feel less natural [121].

Body shape

Your body shape and anatomy may affect the types of breast reconstruction likely to give you the best results.

For example, women with larger breasts may need breast reduction surgery on the opposite, natural breast to create a more even look.

Lifestyle

Your lifestyle may also affect the type of reconstruction you choose.

For example, some types use muscles from other parts of the body, causing weakness in the area. These may not be good options for athletic women.

Making an informed choice

Your plastic surgeon will help you choose the type of reconstruction that will give you the best results and fit your lifestyle.

Take time to study your options and make a thoughtful, informed choice after considering the pros and cons of each option.

Although this decision may seem overwhelming, it may help to know that most women who have had breast reconstruction do not regret the method they chose [122].

There are fairly few complications with any of the current techniques, especially if you are a good candidate for a procedure [121].

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 [12,123-125].

If you smoke or are overweight, talk with your plastic surgeon about problems after surgery such as delayed 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 these risks.

Your plastic surgeon may discuss ways to quit smoking and/or lose weight before you have 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.  

Implants

Inserting a breast implant is a fairly simple procedure.

It 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 [121].

It’s possible to have surgery to enlarge or reduce the size of the opposite, natural breast to help make both breasts look more alike.

However, the natural breast will change in size and shape with weight changes and as you grow older, while the breast with the implant will not. This may lead to a less even look over time.

More surgery may be needed to maintain a similar look.

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

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

Silicone implants

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

Implant shapes

Different implant shapes are available to match the look of the natural breast.

Implants can be round or teardrop-shaped. They vary in the amount of projection and base width.

The best implant shape and size will depend on:

• Your body shape
• The breast skin
• The quality of the envelope formed by the breast skin and chest muscle after mastectomy (this soft tissue envelope holds the implant)

Safety of implants

In the past, there were concerns that silicone implants might cause health problems.

However, research clearly shows no link between silicone implants and lupus, immune system disorders, connective tissue disease or rheumatoid arthritis [127].

Silicone implants are a safe option to saline implants.

Anaplastic large cell lymphoma

The FDA is studying a link between breast implants (both saline and silicone) and a slight increase in the risk of anaplastic large cell lymphoma (ALCL) [128].

ALCL is a very rare, treatable form of cancer of the cells of the immune system. It occurs in breast tissue in about 3 in 100 million women [128-130].

The implant procedure

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

Step one: A temporary, modified saline device (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 2-6 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 skin-muscle envelope.

Step three: A surgeon removes the expander and replaces it with the permanent implant (saline or silicone).

This is done in an operating room, but is usually an outpatient surgery.

Direct implant insertion

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 moderate-sized breasts or excess natural breast skin, or who want to have a reconstruction smaller than their natural breast size may be good candidates for direct implant insertion.

However, these cases are exceptions rather than the rule.

Changing the size of an implant

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

However, changes in weight can impact the look of the breast with an implant.

Weight gain may make the breast with an implant appear smaller. Weight loss may make it appear fuller.

Implants using acellular dermal matrix

The acellular dermis technique takes advantage of the entire skin envelope available at the time of the mastectomy [131].

It’s often used in combination with an implant reconstruction to help cover the lower half of the reconstructed breast. (The chest muscle may not be able to reach far enough to cover this area.)

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 the human cells that may lead to tissue rejection have been removed.

During the healing process, the hammock gets a blood supply from the overlying skin and soft tissue envelope and becomes part of your own tissue. This strengthens the support for the expander or implant.

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 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.

However, some findings show acellular dermal matrix may have a higher risk of complications compared to the multiple-step implant method using a tissue expander [121,132].

The acellular dermal matrix technique requires a high quality mastectomy skin envelope that’s big enough and thick enough to benefit from the procedure. So, some women are not good candidates for this procedure.

For example, women with very small breasts and minimal droop may not benefit from acellular dermal matrix.

Talk with your plastic surgeon to find out if this procedure may be right for you.

Pre-pectoral implant reconstruction

Breast implants are usually placed under the chest muscle (subpectoral) to give as much soft tissue coverage of the implant as possible. Some of the chest muscle is cut during the procedure to place to implants underneath.

As the chest muscle heals, it may become tighter and stiffer when the muscle is used. This can worsen the look of the reconstruction (because the implant is below the chest muscle). This can be a problem for women who use their chest muscles a lot (for example, during exercise).

A new technique places the implant above the chest muscle (pre-pectoral), just under the mastectomy skin envelope, and uses acellular dermal matrix to cover the implant [133].

A pre-pectoral implant reconstruction doesn’t cut through the chest muscle (since the implant is placed above it). So, this technique may limit some problems that can occur as the chest muscle heals after a subpectoral implant reconstruction [133]. This can be important for women who are physically active.

Not everyone can have a pre-pectoral implant reconstruction. It requires very thick mastectomy skin flaps.

The long-term results of this technique are not known at this time.

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.

Discuss your options with your plastic surgeon to choose the type that’s best for you.

Breast implants and radiation therapy

Radiation therapy can cause problems for both implant and natural tissue reconstruction, including:

• Changes in skin color 
• Changes in skin quality
• Tissue shrinkage 
• Tightness

If you will have an implant procedure using a tissue expander and radiation therapy will be used after mastectomy, immediate breast reconstruction is recommended (rather than delayed reconstruction) [12].

Delayed breast reconstruction using an implant may not be possible after radiation therapy.

Skin that has received radiation and is later stretched to fit an implant is at high risk for complications and a poor cosmetic result [12,121].

Results are better when the procedures to expand the skin are done before radiation therapy begins.

However, the effects of radiation therapy to the reconstruction tend to continue with time and longer-term problems can occur. Radiation therapy, even when done before reconstruction, increases the risk that the reconstruction may fail [135].

Natural tissue flap surgery

Reconstruction using 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, buttocks or thighs.

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 reconstruction

The latissimus dorsi muscle flap procedure removes a large muscle in the back along with skin and underlying fatty tissue. It uses these tissues to reconstruct the breast [121].

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 1 inch thick. An implant is usually also needed to create enough volume for the reconstructed breast.

The soft tissue of the latissimus flap goes over the implant so the look and feel of the breast is more natural than with an implant alone.

Transverse rectus abdominis myocutaneous (TRAM) flap reconstruction

The transverse rectus abdominis myocutaneous (TRAM) flap uses skin, fat and muscle from the lower abdomen to reconstruct the breast [121]. It creates a natural-looking breast.

A TRAM flap usually does not require an implant as long as there’s 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 a TRAM flap has been done, it can’t be repeated.
• The surgery can leave a large scar across the lower abdomen.

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.

If you are active, talk with your plastic surgeon about this drawback.

Deep inferior epigastric perforator (DIEP) flap reconstruction

Breast reconstruction with a deep inferior epigastric perforator (DIEP) flap uses skin and fatty 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 may preserve abdominal strength after the procedure.

The DIEP flap has some drawbacks.

• Once a DIEP flap has been done, it can’t be repeated.
• It’s more complex than the latissimus dorsi muscle flap and TRAM flap procedures and usually requires two microvascular surgeons.
• It requires an intensive care unit (ICU) stay for close monitoring after surgery.
• The surgery takes much longer than some other natural flap techniques (due to the microvascular procedures), which can increase the risk of problems during surgery.
• The surgery can leave a large scar across the lower abdomen.

The DIEP flap procedure should only be done by microvascular surgeons well-trained and experienced with this technique.

Superficial inferior epigastric artery (SIEA) flap reconstruction

The superficial inferior epigastric artery (SIEA) flap breast reconstruction uses skin, fatty tissue and blood vessels (including the superficial inferior epigastric artery) from the abdomen to form the reconstructed breast.

The SIEA flap is not as common as the TRAM and DIEP flaps because few women have blood vessels large enough (or any at all) for the procedure [121].

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 are more common with SIEA flap procedures than with other techniques [136].

The SIEA flap procedure should only be done by microvascular surgeons well-trained and experienced with this technique.  

Superior and inferior gluteal artery perforator (S-GAP and I-GAP) flap 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 [137].

S-GAP or I-GAP flap reconstruction may be a good option for women with more fatty tissue in their buttocks area than in their abdomen [137-138].

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 [137-138].

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

Transverse upper gracilis (TUG) flap reconstruction

Transverse upper gracilis (TUG) flap procedures use skin, fatty tissue and muscle from the upper inner thigh to reconstruct the breast [121].

TUG flap reconstruction uses the gracilis muscle, which helps bring the leg toward the body. This isn’t a critical muscle and most people don’t notice a lot of weakness.

TUG flap may be a good option for women with excess fatty tissue in their upper inner thigh area who are not good candidates for TRAM, DIEP, SIEA or GAP flap procedures.

As with other microvascular flap procedures, TUG flap is a complex surgery that requires a microvascular surgeon.

If a TUG flap isn’t successful, it can be repeated using tissue from the opposite upper inner thigh.

Natural tissue reconstruction and radiation therapy

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

Delayed reconstruction

For women choosing flap breast reconstruction who will need radiation therapy after mastectomy, it may be better to delay the flap reconstruction until after radiation therapy.

This greatly lowers the chances the look, feel and size of the reconstructed breast will be harmed by the radiation therapy [12].

Immediate reconstruction

Women may also consider having immediate reconstruction with a tissue expander to preserve the breast skin envelope.

Then, once radiation therapy is over, the expander can be removed and a flap reconstruction can be done.

Skin-sparing mastectomy

If you’re having immediate breast reconstruction, your surgeon may perform a skin-sparing mastectomy to keep as much of the skin of the breast as possible.

With a skin-sparing mastectomy, 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 skin-sparing mastectomy might increase the risk of breast cancer recurrence. However, although data are limited, most studies to date have not found an increased risk and the procedure is considered safe [12,139-141].

Nipple and areola reconstruction

Creating the nipple and areola is the last step of breast reconstruction.

These procedures give the reconstructed breast a more natural look and can help hide some of the mastectomy scars.

Nipple and areola reconstruction are usually outpatient procedures and have few risks [121]. However, those who have had radiation therapy may have more surgical risks.

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

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

Not all women can have these procedures.

Women who cannot have nipple reconstruction surgery (or choose not to have it) can consider a three-dimensional (3D) tattoo to create the look of the nipple and areola.

It’s a good idea to check with your insurance before getting a tattoo as this step may not be covered.

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.

Clinical trials are studying whether nipple-sparing mastectomy increases the risk of breast cancer recurrence.

Learn more about clinical trials of breast reconstruction.

Who can have nipple-sparing mastectomy?

Nipple-sparing mastectomy may be an option for some women with breast cancer and for women having a prophylactic mastectomy [12,142-143].

Not all women can have nipple-sparing mastectomy. For example, the breast cancer may be too close to the nipple and areola.

With nipple-sparing mastectomy, the nipple will likely lose sensation and some projection. Sometimes, the position of the nipple can move after nipple-sparing mastectomy.

In some cases, the tissues may break down and some or all of the nipple and areola may need to be removed [142].

Women with large, sagging breasts may not be good candidates for the procedure because they may have more risk of the nipple moving out of position after surgery and more risk of the nipple tissue breaking down.

Women with uneven breasts or nipple positions before surgery may not be good candidates for this procedure as the unevenness may become worse.

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 with your plastic surgeon about specific instructions after your surgery.

You may need to wear a special bra while your reconstructed breast heals.

Surgical drains

For some types of surgery, you may still have a small tube(s) called a surgical drain(s) in place when you go home from the hospital.

This allows extra fluid from the surgery to escape.

You will learn how to take care of the drain.

Getting back to your normal routine

Overhead lifting, strenuous sports and sex should be avoided for 4-6 weeks after reconstructive surgery [144].

Most women can resume normal activity within 8 weeks [144].

Talk with your health care provider about activities to avoid and when you can get back to your normal routine.

Look and feel of the breast

Remember, 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 8 weeks to go away [144].

How you feel about the final results may depend on your expectations. Keep in mind a reconstructed breast will not look or feel the same as a natural breast.

Most of the scarring will fade and improve over time, but some scars may never go away.

As you age and the opposite breast changes shape, the reconstructed breast may look or feel less natural.

Expectations

Although breast reconstruction techniques continue to improve, a reconstructed breast will never look or feel the same as your natural breast.

Reconstruction results vary.

How your reconstructed breast will look and feel depends on many factors including your natural breast anatomy and your treatment plan.

Sometimes, the types of treatments you will have (for example, if you need radiation therapy) limit your reconstruction options and can impact the final look and feel of your reconstructed breast.

Although this can be upsetting, keep in mind your treatment is planned to get rid of your breast cancer and keep it from coming back.

Your plastic surgeon will help you choose the reconstruction that will give you the best results.

Emotional impact

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 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. It covers breast reconstruction after a mastectomy.
• Medicaid provides health care to people with low income. It's 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

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 [145]:

• 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 866-444-3272.

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.

Transportation, lodging, child care and elder care assistance

You may not live near the hospital where you will have your surgery.

Sometimes, there are programs that help with local or long-distance transportation and lodging. Some also offer transportation and lodging for a friend or family member going with you.

There are also programs to help with child care and elder care costs.

Learn more about transportation, lodging, child care and elder care assistance. 

Questions for your plastic surgeon

• What types of breast reconstruction 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?
• How many hospital stays are needed? How long will each hospital stay be?
• 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 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?

Komen Perspectives

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

Learn More | Current Article

Clinical trials

BreastCancerTrials.org in collaboration with Susan G. Komen^® offers a custom matching service to 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).*

Learn More | Current Article

* 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.