An Overview of Breast Reconstruction After Mastectomy

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Whether or not to have breast reconstruction after a mastectomy is a very personal choice that women make for various reasons. You may consider it before you have your breast(s) removed, long after, or never at all. If you think you might go this route, you'll have a few options to weigh: a surgery to recreate breasts using your own skin and fat (e.g., a TRAM flap) 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.

breast reconstruction process
 Verywell / Brianna Gilmartin

Benefits of Breast Reconstruction

Some women who've had breast reconstruction say it has helped them boost their confidence or achieve a sense of normalcy after their mastectomy—a return to feeling more like themselves. Others see their breasts as part of their sexual identities and say that reconstruction helps them feel whole again in this regard.

These perspectives are highly personal, but common, and they may be among some of the potential benefits of reconstruction that have you considering it in the first place.

Other benefits worth taking into account include:

  • Restoration of balance: Losing a breast can make your body feel physically off-balance, as weight that you once carried is no longer there. Reconstruction can add that back, making you feel more "even." It can also help restore aesthetic balance, which can have simple implications (like making your clothes fit better), as well as more profound emotional ones.
  • Scar revision: Mastectomies are not always done by skilled plastic surgeons. For this reason, scars might be large and quite noticeable. They may even cause discomfort and skin rashes, especially when they are in places that bra material covers. Reconstruction can minimize these concerns.
  • Closure: Often, getting reconstruction is a final step in a woman’s cancer journey. For many, breast reconstruction helps mark the end of chapter and the beginning of a new one.

Reconstruction Options

Your doctor may discuss a few different options with you. All may be appropriate for you, or only some may be possible (or recommended) in your case.

Autologous Tissue Breast Reconstruction

Autologous tissue reconstruction is the most common form of breast reconstruction surgery. It uses skin tissue 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 all living tissue, and is natural looking and long-lasting. 

One commonly used procedure is called the TRAM flap, named after the transverse rectus abdominis muscle, which used in the procedure. This works best in women who have excess fat on their stomachs or skin stretched out from pregnancy. It is also usually recommended for women who have reconstruction after radiation.

Newer types of autologous tissue reconstruction include superficial inferior epigastric artery flap (SIEA) and deep inferior epigastric artery perforator flap (DIEP), which also use abdominal skin and fat.​

Breast Implants

Breast implant surgery involves inserting a saline or silicone implant to form a breast. This is typically done with two surgeries—one to insert a tissue expander (more on this below), the other to place the implant itself.

Breast implants may be recommended for women who don't have enough body fat tissue for a TRAM to be carried out. If you are opting for implants, but there is still a potential that you may receive radiation in the future, make sure you receive an expander with a plastic port instead of a metal one.

Note that, with either option, may need additional procedures down the road. This can 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 essentially a saline-filled implant that gradually stretches the skin and muscle to increase the size of what's called the "breast mound." This allows for either enough skin for a flap procedure to be performed or for an implant to finally be placed. Expanders are often inserted at the same time of the mastectomy.

Implanting the expander usually isn’t painful, but some women may feel pressure during the procedure. After the initial saline fill, gradual fillings (through a valve mechanism in the expander) start a few weeks after mastectomy to allow time for healing. 

The saline filling will continue until the expander size is slightly larger than the other breast, or, if both breasts have been removed, until the desired size is reached. 

Nipple Reconstruction

For most mastectomies, the nipple and the areola are removed. Many women who undergo breast reconstruction, therefore, choose to have 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 ca 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 approaches a plastic surgeon can use. The determination is usually made based on the condition of the breast and the surgeon’s practices:

  • 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 isn’t 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 down the road. 

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

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

Risks to Consider

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

Every surgery comes with risks and breast reconstruction has some of its own potential risks. While most of these risks are rare, it still a good to be aware of them.

Surgical risks include:

  • Anesthesia problems, including allergic reaction
  • Bleeding
  • Blot clots
  • Surgical site infection
  • Wound healing difficulties
  • Fatigue
  • Fluid build-up in the breast or donor site, with pain and swelling

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

  • Necrosis in part or all of the reconstructed breast
  • Loss of or changes to nipple and breast sensation
  • Problems at the donor site (where tissue was removed to be used for the reconstructed breast), including loss of muscle strength
  • Changes or problems to the arm on the same side as the reconstructed breast
  • Problems with the implant, including leakage, rupture or scar tissue formation
  • Uneven breasts
  • The need for more surgery to fix problems that may arise

Smokers may have additional risks because, as with any surgery, smoking can delay your healing time, which means more scarring and a longer recovery time. Sometimes, a second surgery may be needed to manage scarring.

Making the Decision

If you are considering breast reconstruction (or have already decided on it), you should consult a breast reconstruction specialist (as well as your oncologist) as soon after your cancer diagnosis as possible to determine the options that may be right for you. Cancer doctors can be helpful in pointing you to a skilled plastic surgeon.

It is also a good idea to talk to other women who have had breast reconstruction after mastectomy, as they undoubtedly have plenty of personal insight that they may be comfortable offering, along with support. Some may even be willing to share before and after photographs.

Timing

There are benefits to starting the process while you are having your mastectomy, if possible. Most breast reconstruction requires more than one procedure, so beginning while still under anesthesia can help you eliminate the need to go under more times that is necessary. This often leads to better cosmetic outcomes than waiting.

The main determinant as to whether or not this is a possible option for you, however, is whether or not there is a need for radiation after mastectomy. Such treatment is often the case for advanced cases of breast cancer with four or more positive lymph nodes, or positive nodes and a large tumor—about half of all breast cancer patients.

Waiting until radiation treatment is over is recommended because, in the long run, the treatment can permanently affect the skin's pigment, texture, and elasticity, which could affect the appearance of reconstructed breasts.

However, one 2018 report found that recent surgical advances have made prepectoral implant breast reconstruction (using a smooth saline adjustable implant) a possibility for women yet to undergo planned radiation. This type of procedure involves placing the implant above the chest muscle. Effects to the radiation reconstructed breast(s) would still need to be monitored and managed.

Other considerations that can affect the timing of reconstructive surgery:

  • Women with intermediate or advanced breast cancer (those whose tumors are greater than 5 centimeters with affected lymph nodes) are generally advised to wait six months to a year, until treatments are completed, to have reconstruction.
  • Those with locally advanced or inflammatory breast cancer are strongly cautioned against going ahead with immediate reconstruction. It is important to first make sure that all affected tissue has been removed and the cancer has been treated completely.

If nothing is preventing you from getting breast reconstruction surgery other than doubt, know that you certainly can hold off on your decision.

Cost

Breast reconstruction should be covered by your health insurance plan, and it does not matter whether you have it right away, months after your mastectomy, or even years later. This also includes procedures that you will need later on to refine the breast and create balance between both breasts.

In fact, the Women’s Health and Cancer Rights Act of 1988 requires the insurance company that paid for the mastectomy also pay for prostheses and reconstructive procedures. Your plastic surgeon’s office should communicate with your insurance company and use language that clearly shows the reconstruction surgery is for medical proposes and not cosmetic. And if your coverage is denied, be persistent. You and your doctors can revise the procedure description and need, and even provide photos of your chest to illustrate problem areas.

Even if you are covered, you might still run into problems. It is, therefore, a good idea to 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, another potential source may be 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.

There are also organizations that 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 doctor will give you medicines to manage discomfort and pain. You will be allowed to go home from the hospital in a few days. Expect to feel tired and sore for a week or two.

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

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

Follow your doctor’s instructions for managing wounds, which may include support garments. Any questions or concerns should be brought to the attention of your doctor and his or her staff. Be sure that you are clear about necessary follow-up breast care.

A Word From Verywell

If after reviewing all of this you determine that breast reconstruction just isn't right for you, know that you're not alone. There are women who choose not to undergo further surgery and instead use things like pop-in breast forms to recreate the look of a breast, if desired. There are others who simply move forward with a flat chest, in some cases even embracing it as a sign of victory over their cancer. Remember that you have every right to your feelings about this decision—as does every other woman—and there is no "right" or "wrong."

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