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Breast Reconstruction

Reviewed by: Frederick J. Duffy, Jr., MD, FACS

Updated August 30, 2013

After breast cancer surgery, especially mastectomy or whole breast removal, you have choices. You might decide to reconstruct the affected breast or breasts, use an external breast form (prosthesis) or do nothing.

Reconstruction is optional surgery and typically a multistep process that:

  • Rebuilds the breast using body fat, muscle or an implant
    • Can also replace your nipple and areola (darker area around nipple)
  • Does not treat breast cancer
  • Does not increase your risk of cancer returning 

Most reconstruction occurs after mastectomy but may be appropriate for some women after lumpectomy, or removal of just part of the breast, and radiation therapy.

It helps to learn what reconstruction involves and how the new breast might look and feel, so you can make a decision based on realistic expectations.

Remember that each woman is different. The right choice for someone else might not be right for you.

Goals of Breast Reconstruction

You may be considering reconstruction to:

  • Create a permanent breast shape
  • Make your chest look and feel balanced
  • Help restore your body image

Sometimes reconstruction does not meet all your goals. Some women are unhappy with the physical, cosmetic or sensual results of the reconstruction process. But there are some things you can do to prepare.

Your goals are important. Talk with a board-certified plastic surgeon experienced in breast reconstruction. Ask to see photographs and speak with women who have had reconstruction with that surgeon—many women are open to speaking about their experiences. If you have doubts or concerns, consider a second opinion.

Who Can Have Breast Reconstruction?

Most women who have mastectomy can have reconstruction. Typically, it is used after lumpectomy only if your breast is very misshapen. If you are having a lumpectomy and think you may want breast reconstruction, talk with your surgeon as early as possible about your options. Some other facts: 

  • The cancer’s disease stage does not matter in most cases, though advanced, aggressive, or inflammatory cancers may prevent or delay reconstruction
  • Smokers may need to stop smoking two months before reconstruction to reduce risk of complications
  • Some medical conditions may prevent reconstruction:
    • Diabetes that is not well controlled
    • Autoimmune diseases
    • Extreme obesity or thinness
    • Poor general health

If you smoke or have other medical conditions and want reconstruction, talk with a plastic surgeon as soon as possible to find out your options.

Basics of the Breast Reconstruction Process

Reconstruction uses an artificial implant or your natural tissue (body fat, muscle) to build a breast. Using your body tissue may produce a more natural-feeling breast, but there are pros and cons to each method. Consider what makes most sense for you.  

With either method, you may not have sensation in all parts of the reconstructed breast. Your reconstructed breast might not look the same as the remaining breast. If your natural and reconstructed breasts are different sizes, your insurance may pay for you to have a breast reduction, breast lift or breast augmentation of your healthy breast. Ask your doctor for details.

Most reconstruction has several steps, spread out over months.

Types of Breast Reconstruction

Implant reconstruction uses breast implants filled with saline or silicone gel. It works well for thin or athletic women without much body fat.

  • How it’s done
    • After your breast is removed, the plastic surgeon puts in a tissue expander, which is a type of temporary breast implant with an injection port in the center
    • The expander is gradually filled with saline over several months in a brief office procedure to slowly stretch your skin and muscle in the breast area
    • Another surgery removes the expander and puts in the implant
  • Implant advantages
    • You can control breast size
    • You may have a shorter recovery
    • There are no additional scars
  • Implant disadvantages
    • Implants or expanders can become infected or exposed after surgery and require removal and more surgery
    • Scars can form and harden around the implants, causing a condition called capsule contracture
      • That can lead to deformity and pain in the reconstructed breast and typically requires more surgery to exchange the implant
      • Capsule contracture is significantly more likely in people who received radiation therapy
    • Implants may leak or rupture and need to be replaced
    • If you have only one breast reconstructed, it can be very difficult to match the natural breast with a breast reconstructed with an implant

An MRI may be needed from time to time to assess the implant. 

Tissue flap reconstruction uses your own body tissue to build a breast mound. There are several types:

  • TRAM (transverse rectus abdominis muscle) flap
    • Tissue is taken from tummy area
    • Removes core abdominal muscles, as well as skin and fat
    • Can cause weakness in your belly and increase hernia risk
    • Many surgeons now use DIEP procedure instead 
  • DIEP (deep inferior epigastic artery) flap
    • Similar to TRAM but newer microsurgery that uses only skin and fat, which avoids weakening abdominal muscles and hernia risk
    • Less pain than TRAM
    • SIEA (superficial inferior epigastric artery) flap is a related type
  • Latissimus dorsi flap
    • Skin and muscle are taken from your upper back
    • It can weaken back, arm or shoulder
    • Rarely done alone and almost always done with a tissue expander or breast implant
  • GAP (gluteal artery perforator) flap
    • Uses fat, skin and muscle from your buttocks
    • Not many surgeons have experience with this more difficult, newer microsurgery
    • Often leaves asymmetry and contour problems on buttocks
  • TUG (transverse upper gracilis) flap
    • Uses muscle and fat from bottom of your buttocks to inner thigh
    • Newer procedure, not many surgeons experienced with it
  • Tissue flap advantages
    • A better approach than implants if you receive or need radiation therapy
    • A breast reconstructed with your own tissues looks much more natural immediately and over time
  • Tissue flap disadvantages
    • This approach creates donor site scars where the tissue was taken from your body
    • Removes core abdominal muscles, as well as skin and fat
    • Can cause weakness if muscle removed
    • Procedures are longer and more complex

Nipple/areola reconstruction is another option. If you choose this surgery, it happens several months after breast reconstruction. A tattoo can be used to color the area.

Nipple projection can be difficult to achieve and the nipple never has normal sensation. Nipple-sparing breast cancer surgery is possible in some cases.

When Is Breast Reconstruction Done?

Depending on your situation, you may receive immediate reconstruction or delayed reconstruction.

Immediate reconstruction occurs immediately after mastectomy. Your breast surgeon and plastic surgeon are scheduled for the same operation. The pros and cons are:

  • Eliminates one extra surgery and anesthesia
  • May help preserve more breast skin
  • Makes the first procedure longer
  • May be delayed if you will receive radiation treatments after mastectomy

Delayed reconstruction may start months or years after your primary surgery. Consider it when:

  • You want more time to think about your options
  • You need radiation right after surgery
  • A first reconstruction needs to be redone

Your recovery from the first stage of your reconstruction depends on which procedure you choose. Follow-up procedures may include revision surgeries on the reconstructed breast or the opposite breast, as well as nipple-areola reconstruction.

How Do I Decide If I Want Breast Reconstruction?

First, take time to gather information. You may:

  • Talk with plastic surgeons with breast reconstruction expertise
  • Look at photos of women before and after reconstruction. Some women may even be willing to show you their reconstruction
  • Speak with women about their experiences, including those who chose prostheses or chose to do nothing; if you don’t know anyone, contact our Breast Cancer Helpline at (888) 753-LBBC (5222) to talk with a woman who made this decision
  • Visit a store specializing in mastectomy wear to see options
  • Weigh the benefits of reconstruction against the possible risks of extra surgery
  • Consider how you might handle the situation if your rebuilt breasts are not what you hoped for

Think about your emotions concerning your breasts and your body. Reconstruction is a very personal decision. You may choose to consider others’ thoughts, but in the end, the decision is yours.

Can I Afford Breast Reconstruction?

Reconstruction can be expensive because it involves surgeries and other procedures. If you have a group health insurance plan that covers mastectomy:

  • By federal law, your plan must cover breast reconstruction. It should also cover:
    • Surgery to the other breast for symmetry or balance
    • Breast prostheses and physical complications

Some states mandate reconstruction coverage. Check with your health insurer for plan specifics.

Get a written estimate of all costs before beginning reconstruction. Your plastic surgeon can help you find out whether you qualify for reduced rates. Some state Medicaid programs cover reconstruction. If you are uninsured or underinsured, you also may find help at My Hope Chest.

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This article was supported by Cooperative Agreement Number DP11-1111 from The Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. 

Denver, CO  ·  September 13, 2014

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