What is breast reconstruction?

Breast reconstruction is surgery to create a new breast shape in place of a breast that has been removed (mastectomy). It can be done with implants or with tissue from another part of your body. Sometimes both are used to rebuild a breast shape. The breast mound created comes as close as possible to the shape and look of a natural breast.

Surgery may be done to reconstruct either one breast (unilateral) or both breasts (bilateral). The goal of the unilateral reconstruction is to create a breast mound that matches the other breast. If both breasts have been removed, the goal of the surgery is to create both breast mounds about the size of your natural breasts.

Making a decision about breast reconstruction

The decision to have breast reconstruction is a very personal one. It depends on how you think you'll feel after a mastectomy. If you think you would feel uncomfortable with a flat chest or wearing a false breast (prosthesis), you may want to consider breast reconstruction. If you don’t want to have any more surgeries, you may not want to do it.

If you’re thinking of having breast reconstruction, talk with your healthcare provider about it before your mastectomy. Your healthcare provider can tell you if reconstruction is an option for you. You can also talk about which type of reconstruction surgery might be best for you.

Your healthcare provider will talk with you about factors that can affect your surgery options. These include:

• The size of your breasts

• The size of the cancer and its location in your breast, which affects the amount of skin and tissue to be removed during the mastectomy

• The amount of tissue removed from your breast and chest

• Whether you'll need more treatment after surgery, like radiation therapy, which can affect wound healing

• Potential for complications

• Your willingness to have more than one surgery

• Your overall health and health history (for instance, if you smoke or your chest tissue has been damaged by radiation therapy, you may not be able to have reconstruction surgery)

• Your insurance coverage and possible out-of-pocket costs

When is the best time to have breast reconstruction?

Talk with your healthcare provider before your mastectomy. You may meet with a plastic surgeon. This is the healthcare provider who does the reconstruction surgery after the mastectomy is done. Your healthcare providers will then talk with you about your options for:

• Immediate reconstruction. This is reconstruction surgery done at the same time as the mastectomy.

• Delayed reconstruction. This is a surgery done after you recover from the mastectomy. If radiation therapy is part of your treatment plan, you may be advised to wait until after the radiation is finished.

Here are some things to keep in mind about the best time to schedule your surgery:

• Your emotional and psychological well-being. Some experts suggest that waking up from a mastectomy with the reconstruction already done is less traumatic than waking up without a breast. This varies greatly from person to person.

• Any other treatments you are having. If you’re getting radiation after your surgery, you may need to delay breast reconstruction. Radiation to the reconstructed breast can increase the chance of problems, like infection and poor wound healing.

• Recovery time. Having reconstruction surgery at the same time as your mastectomy may mean you’ll recover from both surgeries at the same time.

• The condition of your skin. If your skin isn’t ready for the stretching that goes on during reconstruction, you may need to have it done later on. For example, if you smoke or have diabetes, your skin may need extra healing time before reconstruction.

• The overall surgery plan. Breast reconstruction can involve many surgeries over a period of time to complete the reconstruction. Be sure to discuss this with your surgeon so you know what to expect.

Common risks of breast reconstruction

Any type of surgery has risks. The risks of breast reconstruction include:

• Bleeding

• Fluid collection in the surgical area (seroma)

• Infection

• Blood clots

• Scars

• Problems with the sleep medicines (anesthesia) used during surgery 

• Bruising and swelling

• Problems with breast implants

• Problems healing

• Possible future surgery, such as to replace a breast implant

The most common complication of breast reconstruction done with implants is called capsular contracture. This is when the scar tissue (capsule) around the implant tightens. It can make the breast mound feel hard and change the shape. In some cases, a second surgery is needed to fix this problem.

What are the different types of breast reconstruction?

There are two main types of reconstruction surgery: 

• Expander-implant. This method uses an expander that's filled over time to slowly stretch the skin to create a breast mound. This may be followed by the placement of a permanent breast implant. In some cases, an implant can immediately be placed at the time of the mastectomy.

• Autologous tissue. This method uses your own body tissues to reconstruct a new breast mound. These reconstruction surgeries leave you with two surgical wounds: your chest and the site where tissue was removed.

In some cases, you may have a combination of both types of reconstruction. You may also decide to have other procedures to improve how your new breast shape looks. For instance, you might decide to have reconstructive surgery on your other breast so that it matches your new breast shape. Or you may want to have a nipple or areola reconstructed.

Expander-implant surgery

Expanders are empty silicone "envelopes" put under the pectoralis muscle during the mastectomy surgery. This muscle is between the breast and the chest wall. The expander is filled with saline solution or air over several weeks. This is done to slowly and gently stretch the skin and soft tissues of your chest. The saline or air is injected into the expander through a valve or port in the expander that lies just under the skin. This is done over many weeks.

Once the expander has been completely filled, it's left in for several more weeks to months. This allows for maximum skin and soft tissue growth. Once your chest tissues are ready, a second surgery may be done to take out the tissue expander and put in the permanent implant. Sometimes, the expander is just left in place.

Implants are envelopes filled with liquid or silicone gel. They're put under the breast tissue and used to form the shape of the breast. Each type of implant has pros and cons. Your healthcare provider will discuss the types of implants with you and help you decide which to use.

Autologous tissue surgery

This surgery moves tissue from another part of your body and uses it to make a breast shape. There are different ways to do this surgery, such as:

• TRAM (transverse rectus abdominous muscle) flap. An area of fat, skin, and muscle is removed from your belly (abdomen) and moved to the chest. This surgery gives you a tummy tuck. TRAM flaps may change as you gain and lose weight. It’s important to know that removing stomach muscle can increase stress on the back, weaken your stomach muscles, and put you at risk for developing a hernia. This type of surgery leaves a horizontal scar across the lower abdomen plus a scar on your chest.

• DIEP (deep inferior epigastric perforator) flap. With this surgery, the surgeon takes fat and skin (but not muscle) from your lower belly and moves them to your chest. This surgery also gives you a tummy tuck.

• Gluteal free flap. The surgeon removes part of the skin, muscle, and fat from your buttocks and grafts it onto the chest. This is a more complex surgery. It's not offered at all surgical centers.

• Latissimus dorsi flap. For this surgery, muscle, fat, blood vessels, and skin are moved from your upper back to your chest. Sometimes an implant is also needed with this surgery.

• TUG (transverse upper gracilis) flap. In this type, muscle and fat are taken from the upper, inner thigh and moved to the chest. This newer surgery may not be available near you.

Healing after surgery

Immediate reconstruction surgery tends to have a longer recovery time than for mastectomy alone. Recovery from delayed reconstruction is much quicker. With autologous tissue surgery, there's a second surgery site that will need to be cared for as it heals.

It's important to know that it can take up to a year before the final results of breast reconstruction can be seen. Try to be patient as your body heals.

Nipple reconstruction or nipple tattooing

You may be interested in nipple reconstruction or tattooing. This step is typically done several months after breast reconstruction surgery so the breasts can heal. It's rare for nipple reconstruction to be done during breast reconstruction surgery because the nipples may be positioned poorly. Nipple reconstruction surgery is usually done by a plastic surgeon as an outpatient procedure. The surgeon may use skin from the breast area where the nipple will be. The reconstructed nipple may be tattooed later to add color. You likely won't have feeling in the reconstructed nipple. It may flatten over time.

Some people choose nipple tattooing instead of nipple reconstruction surgery if they don't want another surgery or prefer the appearance of the tattoo. 3D tattooing makes a nipple that appears to have shape but is actually flat. They can also recreate the areola. The tattoo may be done by a staff member at a surgeon's office or a qualified tattoo artist. Be sure to wait until you are cleared by your surgeon to have nipple tattooing. Ask your healthcare team if they recommend a certain trained tattoo artist.

Some people may not be able to have nipple reconstruction or tattooing. This includes people who have lymphedema that involves the chest, a history of infections in the breast area, breast skin damaged by radiation, or breast skin that is thin from surgery. Talk with your healthcare provider about what options they recommend for you.

Talk to your healthcare provider about what options they recommend for you. Visit breastcancer.org or American Cancer Society at www.cancer.org for more information.

Alternatives to breast reconstruction

Some people decide not to have breast reconstruction for a variety of reasons. Talk to your healthcare team for more information on these options:

• Aesthetic flat closure. This is a type of surgery where skin, fat, and tissue are removed so the chest wall is smooth and flat. You may be able to have other forms of reconstruction later, if you choose to do so.

• Prosthesis. Some people choose to wear a breast form or prosthesis. These are made to be a similar weight and feel as breast tissue.

• Going flat. This means that a person doesn't wear a breast prosthesis or have reconstructive breast surgery.

It's important to know all of your options before making a decision. Your healthcare team will answer your questions and support you along the way.