An Overview of Breast Reconstruction After Mastectomy

Breast cancer has a five-year survival rate of approximately 90%. After a mastectomy (surgical removal of one or both breasts) for breast cancer, you may consider breast reconstruction surgery. It is a very personal choice with different kinds of surgical approaches. Reconstruction is sometimes done during a mastectomy, months or years later, or not at all. 

Your surgical team may offer different kinds of breast reconstruction, including surgery to recreate breasts using your own tissue or the insertion of breast implants.

There are physical, emotional, and even logistical considerations to keep in mind when deciding on breast reconstruction surgery. Learning as much as you can about your choices and the process can help you feel confident in your decision.

This article discusses breast reconstruction including the benefits, surgical options, risks, decision making, and recovery.

Breast reconstruction process
 Verywell / Brianna Gilmartin

Benefits of Breast Reconstruction

The way a woman feels about her body and her breasts after breast cancer is personal and variable. Many women report that breast reconstruction has some positive psychological benefits. 

A 2019 study looked at women from 18-65 years old. Those who elected to have reconstruction reported higher scores on the Female Sexual Function Index, better body image, and lower frequency of depressive symptoms.

Other benefits worth taking into account include:

  • Restoration of balance: Losing a breast can make your body feel physically off-balance. Generally, if only one breast is removed, people experience changes in their spinal alignment. Reconstruction can restore symmetry.
  • Body appearance: Reconstruction can also help restore a more balanced appearance. For some women, this improves the fit of clothing and emotional well-being. Reconstruction can help some women with their sexuality.
  • Scar revision: Sometimes a mastectomy scar might be large and noticeable, or may cause discomfort and skin rashes, especially when they are in places that bra material covers. Reconstruction can minimize these problems.
  • Emotional closure: Early reconstruction has been associated with improvements in social and emotional wellness. Often, getting reconstruction is a final step in a woman’s cancer journey. For many, breast reconstruction helps mark the end of one chapter and the beginning of a new one.

Types of Reconstruction

Your surgeon may discuss a few different breast reconstruction options with you. Some choices may be more suitable for you than others. Ask any questions you need to understand your options and make an informed decision.

Body Tissue Reconstruction

Using your own body tissue for reconstruction, also called autologous tissue reconstruction, is the most common form of breast reconstruction surgery. It uses skin, fat, or muscle from your own body to recreate a breast. The skin comes from an area that would typically be covered by clothing, such as the buttocks or abdomen. 

With this approach, the new breast is created from living tissue. This technique is generally natural-looking and long-lasting. 

Body tissue flaps are often named by the donor site—the part of the body used to make the new breast flap. 

Types of body tissue breast flaps include:

  • TRAM flap is taken from the transverse rectus abdominis muscle (part of the stomach muscles), along with some fat and skin. This type of flap works best in women who have excess fat on their stomach or belly skin. It is also usually recommended for women who have reconstruction after chest wall radiation.
  • SIEA flap is taken from the superficial inferior epigastric artery in the lower belly near the bikini line. This surgery does not remove any muscle. It uses just the skin, underlying fat, and part of the blood vessels to give the new breast blood flow.
  • DIEP flap is taken from the deep inferior epigastric artery perforator flap below the bikini line and also uses abdominal skin and fat.​ Typically, no muscle is removed during this surgery.
  • Latissimus dorisi flap is when a portion of muscle and skin connected to the original blood supply (arteries and veins) in the upper back is moved to the breast.

​Your surgeon will examine and discuss possible donor sites with you, explain the procedure, the anticipated outcomes, and what both areas (breast and donor site) may look like after reconstruction surgery.

Implant Reconstruction

For some women, reconstruction involves using a breast implant instead of their own body tissue to shape and fill the breast. Breast implants may be recommended for women who do not have enough body fat tissue for a body tissue flap. 

Breast implant surgery involves inserting a saline or silicone implant to form a breast. This process typically involves two surgeries—one to insert a tissue expander, the other to place the implant itself.

The surgery is typically shorter than using your own tissue, and often has a faster recovery period. Two types of implants are approved for breast reconstruction:

  • Silicone implants are filled with a sterile saltwater solution. The incision for a saline implant is smaller, but they are more prone to wrinkles and ripples. It is obvious if the implant ruptures, but the saline inside is safe for your body.
  • Saline implants are filled with medical-grade silicone and are reported to create a more natural-looking breast. The members of the American Society of Plastic Surgeons use and recommend silicone for implants far more frequently than saline. However, there is a risk for silent rupture of silicone implants, so intermittent surveillance MRIs are typically recommended.

Your surgeon will discuss the different types of implants with you. Reconstruction with implants tends to have a higher rate of revision than reconstruction with body tissue.

Note that, with either option, you may need additional procedures down the road. The U.S. Food and Drug Administration (FDA) makes it clear that breast implants are not lifetime devices, and complication risk increases with time. For this reason, you may need implants removed or replaced. Additional future procedures may include nipple reconstruction and surgeries to refine breast tissue and balance out breast size.​

Tissue Expansion

Regardless of the method of reconstruction you choose, you may need a tissue expander. This is a temporary saline-filled implant that gradually stretches the skin and muscle to increase the size of the breast mound. Expanders are often inserted during a mastectomy and can be used for either kind of implant.

Implanting the expander is not usually painful, but some women may feel pressure during the procedure. The expander is initially filled with some saline, and the surgical site is allowed to heal. Gradual fillings (through a valve mechanism in the expander) start a few weeks after mastectomy. 

Additional saline filling will be added until the desired size is reached. This is typically when the expander size is slightly larger than the other breast. If both breasts have been removed, then the expander is filled until the size of the final reconstructed breasts is reached.

If you might need radiation therapy while your expander is in place, talk with your healthcare team. You may receive a recommendation for an expander with a plastic port instead of a metal one.

Nipple Reconstruction

For most mastectomies, the nipple and the areola are removed. Because of this, many times breast reconstruction involves nipple reconstruction as well. This recreates a darker-colored areola and elevated nipple atop the new breast mound.

Nipple and areola reconstruction is the final phase of breast reconstruction. It can be performed after the reconstructed breast has healed, which could take three to five months.

Depending on the technique used, a nipple surgery could take anywhere from a half-hour to an hour.

There are different surgical approaches, and the best approach is often based on the condition of the breast and the surgeon’s practices.

Some possible nipple reconstruction techniques include:

  • Skin flap: This involves taking small flaps of skin from the reconstructed breast, folding, and suturing them to build a rise that becomes the nipple. Additional skin or synthetic fillers can help make the nipple appear more erect, if necessary.
  • Skin graft: When there is not enough breast tissue to create a nipple, the surgeon may use a skin graft. The skin is usually taken from an area of the body that would usually be hidden under clothing, such as the buttocks or the abdomen.
  • Autologous graft/nipple sharing: If a single mastectomy was performed and the nipple in the unaffected breast is large enough, part of it can be grafted onto the new breast to create a nipple.
  • Medical tattooing: Tattooing can recreate a natural-looking areola and nipple. Medical tattooing can be done alone or in addition to nipple reconstruction. The pigment may fade and change, resulting in the need for a touch-up at a later time. 

Skin grafts have a higher rate of complications after the surgery compared to skin flap procedures and medical tattooing.

Serious complications with nipple reconstruction are rare, but possible. In some cases, the tissue will break down over time and need replacement. In addition, the reconstructed nipple may flatten with time and require additional surgery to repair.

Risks to Consider

It is important to have an idea of what to expect, including recovery, risks associated with surgery, and problems that may arise later on down the road.

Every surgery comes with potential risks. While most of these risks are rare, it is still a good idea to be aware of them. Discuss any questions or concerns with your surgical team before your procedure.

 Surgical risks include:

Some problems, although rare, may occur later on and could include:

  • Necrosis (dead tissue) in part or all of the reconstructed breast
  • Loss of feeling to the nipple or breast
  • Problems at the donor site include loss of muscle strength or abnormal appearance
  • Arm issues on the same side as the surgery
  • Implant issues include leaking, bursting, or scarring
  • Unbalanced breasts

Discuss any concerns or problems with your healthcare provider. Additional surgery to fix these issues may be required.

With any surgery, smoking can delay your healing time. Smokers may have additional surgical risks for scarring and a longer recovery time. Sometimes, a second surgery may be needed to manage these scars.

Making the Decision

If you are considering or have decided on breast reconstruction, consult a breast reconstruction surgeon as soon as possible after your cancer diagnosis. Together with your oncologist, your team will help you determine the options that may be right for you. Oncologists can help point you to a skilled plastic surgeon.

It is also a good idea to talk to other women who have had breast reconstruction after mastectomy. You may be able to ask about different surgeons, surgical approaches, and outcomes (some may be willing to share their before and after photos). Knowing others who have been through a similar experience can help to support you in your journey.

Timing

Deciding on the right time for your breast reconstruction is a determination you should reach together with your healthcare team.

Basically, reconstruction is grouped into two timelines:

  • Immediate reconstruction starts at the same time as your breast cancer surgery.
  • Delayed reconstruction starts sometime after your breast cancer surgery. The need for radiation therapy, being overweight, a smoker, or on blood-thinning medications may be reasons your healthcare team recommends delaying your reconstruction.

Some people choose not to have reconstruction at all.

While there are advantages to scheduling your breast reconstruction to start during your mastectomy, that timing is not possible for everyone. Talk with your healthcare team to understand the pros and cons of different timing options.

There are benefits to starting the reconstruction process while you are having your mastectomy. Immediate reconstruction with body tissue or implants has been found to have a low risk of postoperative complications and to maintain effective cancer treatment.

By starting reconstruction during your mastectomy, you may be able to avoid at least one additional procedure. In addition, early insertion and use of tissue expanders lead to better cosmetic outcomes than waiting.

Immediate reconstruction may not be a possible option for you if you need radiation after your mastectomy.

Waiting until radiation treatment is over is recommended because radiation can permanently affect the skin. It can change skin pigment, texture, and elasticity, which could affect the appearance of reconstructed breasts.

A 2018 report found that recent surgical advances have made one kind of breast reconstruction a possibility before radiation. The procedure is called prepectoral implant breast reconstruction. It is done using a smooth saline adjustable implant placed between the chest muscle and the skin. Effects of the radiation reconstructed breast(s) would still need to be monitored and managed.

Other considerations that can affect the timing of reconstructive surgery:

  • Women who will need treatment for intermediate or advanced breast cancer
  • Those with locally advanced or inflammatory breast cancer are strongly cautioned against immediate reconstruction. It is important to first make sure that all affected tissue has been removed and cancer has been treated completely.

If you feel unsure about choosing breast reconstruction, talk to your healthcare team, but you certainly can hold off on your decision. Delayed reconstruction is typically an option you can choose later.

Cost

The cost of breast reconstruction is frequently covered by health insurance plans. Generally, coverage does not change whether you have surgery right away, months after your mastectomy, or even years later. If you need procedures later to refine the breast appearance or create a balance between both breasts, those procedures should be covered as well.

In fact, the Women’s Health and Cancer Rights Act of 1988 requires the insurance company that paid for the mastectomy to also pay for prostheses and reconstructive procedures. Your plastic surgeon’s office will communicate with your insurance company and use language that clearly shows the reconstruction surgery is for medical purposes and not cosmetic preferences. 

If your coverage is denied, be persistent. You and your healthcare providers can clarify the procedure description and provide photos of your chest to illustrate problem areas.

Even if you are covered by insurance, you might still run into billing problems. Communicate with your health insurance provider ahead of time about what is covered so that there are no surprises later on. If cost continues to be a problem, check with your state health insurance agency and state commissioner, as some states have passed laws requiring coverage for breast reconstruction related to mastectomies. They can guide you on how to proceed with getting your insurance company to pay and other potential resources that can help with costs.

Some organizations may offer uninsured cancer survivors financial assistance. The Plastic Surgery Foundation’s Breast Reconstruction Awareness Fund and Campaign is one such organization whose mission is to provide funding to under-insured and uninsured breast cancer survivors seeking breast reconstruction surgery.

Recovery

After surgery, your healthcare provider will give you medication to manage discomfort and pain. You will be able to go home from the hospital in a few days. Expect to feel tired and sore for a week or two. Your team will let you know about any movement or activity restrictions you should follow.

The time it takes to recover depends on the type of reconstruction surgery you have. In general, most women start to feel better in a couple of weeks and resume normal activities a few weeks later.

Call your healthcare provider about unusual bleeding, swelling, lumps, extreme pain, fluid leaking from the breast or donor site, or any other symptoms that concern you. 

Follow your surgeon's instructions for managing wounds and use of support garments. Be sure that you ask any question you have and that you are clear about necessary follow-up breast care.

Summary

Breast reconstruction surgery includes several different kinds of procedures. Your team will help you understand what kind of surgical options are most appropriate for your body size, structure, and medical history. Reconstruction often requires multiple procedures to fully achieve the desired results.

A Word From Verywell

Remember that you have every right to your feelings about this decision—as does every other woman—and there is no "right" or "wrong." If you decide that breast reconstruction is not right for you, know that you are not alone.

Some women choose not to undergo further surgery and instead use things like pop-in breast forms (call a prosthesis) to recreate the look of a breast. Others move forward without any attempts at recreating the look of breasts, in some cases even embracing it as a sign of victory over their cancer.

Frequently Asked Questions

  • What percentage of people who had a mastectomy get reconstruction?

    A 2018 study showed that in 2016 over 40% of people who have a mastectomy choose to have some kind of breast reconstruction. Talk with your healthcare team about your situation and your options.

  • What is the most common form of breast reconstruction?

    Breast reconstruction techniques can use your tissue (skin, fat, and sometimes muscle), a silicone or saline implant, or a combination. All of these options are common, and the choice depends on multiple factors, including cancer size and staging, body size and shape, need for additional treatment like radiation therapy, and the personal preference.

  • What is the safest breast reconstruction surgery?

    All surgical procedures have different risks and benefits. Breast reconstruction surgery is generally safe and effective, but you should talk with your medical team about your particular situation before having any kind of surgery.

  • Is breast reconstruction after mastectomy painful?

    Breast reconstruction is a surgical procedure and pain typically lasts about two to eight weeks. Surgical sites may be inflamed, swollen, tender, bruised, and sore throughout the healing process. Your medical team will help you with pain medications and pain management strategies.

  • Does breast reconstruction affect the ability to check for breast cancer? recurrence?

    As a general guideline, mastectomy (surgical removal of the breast) usually means that you no longer need to have mammograms to check for breast cancer. However, if you have a remaining healthy breast, or only had one breast removed, your healthcare provider may still recommend checking for cancer.

Originally written by
Pam Stephan
Pam Stephan is a breast cancer survivor.
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