Breast reconstruction

Breast reconstruction surgery is a personal choice.

Many women choose not to have reconstruction. This is often called “going flat” or an “aesthetic flat closure”.

For some women, breasts are an intimate and essential part of their body image and sexual identity, and the idea of losing one or both breasts can trigger many intense emotions. If it’s upsetting to think about losing a breast, reconstruction can help restore a sense of wholeness.

If you’re thinking about breast reconstruction, ask your breast surgeon to refer you to a plastic surgeon as early as possible to explore options and decide on timing that works best for your situation.

Breast reconstruction surgery can often be done at the same time as mastectomy or lumpectomy surgery, all in one step. It can also be done in multiple steps over time. And it is possible to wait weeks, months, or even years before having breast reconstruction surgery. Here are some situations that can affect timing:

• While reconstruction can be done at any stage of breast cancer, if you have an aggressive cancer, inflammatory breast cancer, or metastatic breast cancer, your doctor may recommend that breast reconstruction be delayed until you’ve had certain treatments.
• Radiation therapy can sometimes affect the results of breast reconstruction surgery. If your care team has recommended radiation therapy, you will work with your radiation oncologist and surgeon to decide if it is best to have radiation treatment before or after breast reconstruction.

Learn more about immediate versus delayed breast reconstruction.

If you are having a lumpectomy and are concerned about how your breast will look after surgery, ask your surgeon about oncoplastic procedures. This approach uses techniques during lumpectomy to:

• Reduce the risk of visible scarring or indentations
• Make corrections later

If oncoplastic options at the time of lumpectomy are not available where you are, other breast reconstruction techniques can be used to correct imbalances left after lumpectomy. Visit lumpectomy to learn more.

There are two main types of reconstruction available today: reconstruction using your own body tissue, such as muscle or fat, and reconstruction using breast implants.

Tissue reconstruction

Tissue reconstruction, also called flap reconstruction, is a more complex surgery with a longer hospital stay and recovery time when compared with implant reconstruction.

Still, reconstruction with a tissue flap often results in breasts that have a more natural look and feel than reconstruction using implants. To perform this type of reconstruction, a surgeon will take skin and fat with varying amounts of muscle from a different part of your body and use it to reshape and rebuild the breast or breasts.

Types of flap reconstruction include:

• Free flap reconstruction. In these surgeries, surgeons remove skin or fat from the lower abdomen or other parts of the body and place them in the breast area. Because the tissue is completely disconnected from the donor area, these procedures require a microsurgeon who can reconnect blood vessels from transferred tissue, allowing blood supply to the new breast. Examples of free flaps include free TRAM, DIEP, MS-TRAM, SIEA, TUG, and GAP flaps, which can use tissue from the abdomen, inner thigh, or buttock.
• Pedicled flap reconstruction. In this surgery, skin, fat, and varying amounts of muscle is moved from one part of the body (such as the back or abdomen) through a tunnel under the skin to the breast area. The blood vessels remain connected to the original location, so the surgeon does not need to reattach blood vessels. Examples of pedicled flaps include pedicled latissimus dorsi (LAT or LD), TDAP, and ICAP flaps.

Tissue flap reconstruction requires healthy blood vessels so that blood can get to the reconstructed breast or breasts. Certain medical conditions and lifestyle factors shrink or reduce blood vessels. Uncontrolled diabetes, poor circulation, connective tissue disease, and smoking can create challenges with this type of breast reconstruction surgery. If any of these apply to you, talk with your doctor about whether you’re eligible for this reconstruction approach.

Implant reconstruction

In implant reconstruction, a silicone-covered breast implant is placed under the muscle and/or skin of the breast. The implant contains either silicone gel or saline (salt water). Silicone implants feel like a natural breast in texture and shape, while saline implants feel less firm. Either type of implant may be a good option if you do not have very large breasts or there is not enough tissue available in other parts of your body to create a breast.

There are pros and cons to choosing saline or silicone implants. Be sure to talk with your doctor about which may best suit you and your lifestyle. Visit Implant reconstruction for more information.

Your plastic surgeon may also use regenerative tissue—donated tissue that helps support an implant and develop new tissue—as part of an implant reconstruction. This is often referred to as acellular dermal matrix, mesh, or biologic mesh.

Implants last an average of 10 to 15 years. Implant exchange surgery is surgery to replace an implant due to leaking or other reasons.

Some people may decide to have their breast implants permanently removed in a procedure that is often called explant surgery. This surgery is done for different reasons, such as:

• Painful scar tissue around the implant (capsular contracture)
• Leaking
• Symptoms such as fatigue or joint pain, linked to breast implants in some people. This is known as breast implant illness.

Goldilocks procedure

The Goldilocks procedure combines mastectomy and breast reconstruction in one surgery. This involves:

• Removing all of the breast tissue
• Preserving the fatty tissue and healthy skin
• Using the preserved fatty tissue and skin create a new breast

Nerve repair during or after reconstruction

During mastectomy, surgeons have to cut through nerves to remove breast tissue. This can cause ongoing chest and breast numbness. For some people, numbness may:

• Interfere with sex and intimacy
• Increase the risk of burns or other injuries that can result from an inability to feel pressure or temperature on the breast skin

Some cancer centers offer nerve repair, sometimes called reinnervation, which aims to reconnect the cut nerves and restore feeling in the chest and breasts. One example is a technique called Resensation:

• This procedure uses donated, sterilized human nerve tissue (called a nerve graft) to connect cut chest nerves to reconstructed breast nerves.
• A nerve graft is a type of regenerative tissue—tissue that provides support for growing new cells in your body.
• Over time, the graft guides the chest and breast nerves to grow together.

Resensation can be performed at the same time as breast reconstruction or aesthetic flat closure if you choose to go flat. It adds about 20 minutes to the surgery. In some cases, it can be performed as part of delayed reconstruction.

After Resensation with reconstruction:

• It takes some time for the nerves to grow back together.
• Many people report feeling little shocks, zaps, or itchiness around 6 months after the procedure. More feeling can return over the next couple of years.
• The sensation may be different than it was before mastectomy. There’s also a possibility that sensation won’t return.

While small studies have shown that some feeling is more likely to return after reconstruction with Resensation versus without Resensation, the data are not definitive. More research needs to be done. A larger study, Sensation NOW, is enrolling people having flap reconstruction to compare their outcomes with or without Resensation.

Some other things to keep in mind:

• Not all surgeons perform nerve repair. Ask your surgeon if they offer it, or if they can recommend someone who does.
• Eligibility for Resensation depends on your past medical history, breast size, type of mastectomy and reconstruction, and overall treatment plan.
• While health insurance usually covers breast reconstruction, it does not always cover Resensation. Talk with your health insurance provider and your surgeon about coverage.

Secondary Reconstruction Procedures

Some reconstruction procedures can happen months or even years after initial reconstruction surgery. These surgeries continue or refine the reconstruction process. They can also make corrections. Examples include:

• Fat grafting
• Replacing a temporary breast implant (tissue expander) with a permanent one
• Correcting breast asymmetry
• Scar tissue removal

Nipple reconstruction

In some cases, depending on the location of the cancer, surgeons may need to remove the nipple and areola, the area around the nipple. Breast reconstruction techniques can rebuild the nipple and recreate the areola. In both tissue and implant reconstruction, you may have the option of rebuilding the nipple.

There are different ways to create a nipple, including using the skin of the affected breast or other techniques. Nipple reconstruction is usually a separate surgery that happens a few months after the main breast reconstruction surgery. This allows the reconstructed breast or breasts to heal and settle into a final position first.

3D Nipple Tattooing

If a nipple needs to be removed as part of mastectomy, 3D nipple tattoos can recreate the appearance of a physical nipple.

Reconstruction during or after lumpectomy

If you decide to have an oncoplastic procedure at the time of your lumpectomy, flap surgery techniques can sometimes be used. Oncoplastic breast surgery and reconstruction techniques can also be used at some point after lumpectomy.

You and your surgeon will decide on a reconstruction plan and schedule that works best for your needs.

Making decisions about reconstruction

The best time to gather information about breast reconstruction is before mastectomy surgery. While you and your doctors may be very focused on treating the cancer, your sense of physical identity and body image are also very important. Some women may feel completely empowered to start a reconstruction conversation with their surgeon and ask about options.

For others, it can feel like, “I should just be grateful to be getting rid of the cancer. It’s too much to expect to come out of this actually looking good, too!” But for many women, breast reconstruction can help restore a feeling of physical completeness, identity, and quality of life after a diagnosis.

If your surgeon does not talk with you about breast reconstruction surgery, ask about it. While reconstruction can be done at the time of mastectomy or months or years later, understanding all your options before mastectomy can help you make the best decisions for you. Many women have the option of having some or all of the reconstruction at the same time as mastectomy—so the earlier you talk to your surgeon about reconstruction, the better.

We know that making such an important decision about your body can feel overwhelming. Here are some pros and cons of having breast reconstruction.

Breast reconstruction can:

• Help restore body image
• Create a permanent breast shape
• Make your chest look and feel balanced
• Allow you to avoid wearing a prosthesis (a breast form inserted into your bra)

It can also:

• Require more surgery than mastectomy without reconstruction
• Have a higher risk of complications than mastectomy alone
• Require a longer time to recover from surgery than mastectomy alone
• Result in breasts that don’t look or feel the way you expect
• Cause scars on more than one area of your body
• Require more medical procedures in the future
• Cause pain or muscle weakness at the surgical site

Think about how you feel about your breasts and your body. Breast reconstruction is a very personal decision. You have options. Take the time you need to decide which one makes most sense for you and your lifestyle.

To help you decide, you may want to:

• Talk with a plastic surgeon experienced in breast reconstruction.
• Ask the plastic surgeon to share photos of their patients before and after reconstruction.
• Weigh the benefits of reconstruction against the possible risks of extra surgery.
• Consider how you might feel if your rebuilt breasts are not what you expected. You can also ask a plastic surgeon what they recommend in this situation.
• Talk with other women about their experiences, including those who chose to go flat or wear prostheses. Some women may even be willing to show you their reconstructed breasts in person. If you don’t know anyone, contact our Breast Cancer Helpline at (888) 753-5222 to talk with a woman who made this decision.
• You can also join our private Facebook groups to talk with others who’ve made reconstruction decisions:
  • Breast Cancer Support: All Ages, All Stages; This group is a space for anyone at any stage of breast cancer to meet others for support and connection.
  • Breast Cancer Support: Young Women;  This group is a space dedicated to talking about breast cancer-related challenges unique to younger women.
  • Support Community for High Risk;  This community is for people with a high risk of developing breast cancer, ovarian cancer, or both due to a strong family history of cancer, personal health conditions, or inherited gene mutations.
• Online or in person, visit a store with mastectomy wear to see options. Some cancer centers and hospitals have shops with mastectomy prostheses, bras, and post-mastectomy clothing. You can also ask about stores in our private Facebook groups.

Concerns about pain, stiffness, or other side effects after reconstruction can also inform your decisions. Ask a plastic surgeon about what kinds of short-term and long-term side effects can happen after different kinds of reconstruction, and how they can be managed. For example, the surgeon or nurse can show you exercises that can help lower the risk of post-surgery stiffness or manage it if it happens. Hearing experiences from others who’ve had breast reconstruction can help, too.

Conditions That Interfere with Reconstruction

Not everyone is a candidate for breast reconstruction. Here are some conditions that may interfere with having reconstruction:

• Diabetes that is not well controlled, which can delay wound healing
• Autoimmune diseases
• Not meeting bodyweight recommendations for anesthesia and certain types of reconstruction
• Poor general health
• Smoking or nicotine use

Smoking can interfere with tissue reconstruction because it constricts blood vessels, the passageways oxygen travels through to reach healing skin. Smokers are at a higher risk for tissue necrosis, the death of skin cells from lack of oxygen. 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. Your surgeon may recommend you quit smoking and quit using other nicotine products for a certain amount of time before and after surgery.

Finding a plastic surgeon

The breast surgeon performing mastectomy or lumpectomy can usually recommend a plastic surgeon who performs breast reconstruction. There are also other ways to find a breast reconstruction surgeon, including:

• Asking your medical oncologist or hospital social worker for a recommendation
• Talking with others in your area who have had breast reconstruction
• Joining an in-person or online breast cancer support group and asking for recommendations
• Visiting the American Society of Plastic Surgeons website

It’s important to find a plastic surgeon who listens to your goals and concerns. Along with the medical oncologist treating the cancer, your plastic surgeon can help you understand options and timing that work for your treatment plan.

In some cases, you may feel very comfortable with the first plastic surgeon you meet. In other situations, it can help to talk with more than one plastic surgeon. Some health insurance plans cover second opinion meetings with doctors. Talk with your health insurance company to understand if a second opinion visit is covered.

Here are some questions to consider asking when you meet your plastic surgeon for the first time:

• What percentage of your practice is breast reconstruction? How much experience do you have with it?
• What kinds of breast reconstruction do you do?
• Am I a candidate for implant reconstruction, tissue reconstruction, or both?
• What are the advantages and disadvantages of the type of reconstruction you recommend for me?
• Can I see before-and-after photos of women you’ve helped, who had the type of reconstruction you’re recommending?
• May I speak to some of your patients about their experiences?
• What are the short-term and long-term side effects of the surgery you’re recommending? How are they managed?
• What are complication rates in this practice, and what are the potential complications of my surgery?
• If complications happen, how do you manage them?
• How long will my recovery be?
• Will I need any follow-up or revision surgery?

Preparing for breast reconstruction surgery

Your doctor may suggest you follow some general health instructions ahead of surgery to prepare your body for healing. It’s important to follow these instructions, so be sure to ask any questions you have when you get them.

At home, it can be helpful to have a place ready for you to sit with easy access to necessary items (such as water, food, and entertainment) and where you can sleep comfortably, such as a recliner. You can prepare this ahead of time or ask a friend or loved one to create this space for you.

Recovering from breast reconstruction surgery

If you choose implant reconstruction, surgery can sometimes be done all in one step, placing the permanent implant at the time of mastectomy. But in other cases, your plastic surgeon may recommend using two steps: a first surgery in which your surgeon places a temporary implant called an expander under the skin and/or muscle of your chest, where the permanent implant will eventually go. Learn more in implant reconstruction.

If you choose tissue reconstruction, the number of steps can vary. Some tissue reconstructions are completed all in one surgery at the time of mastectomy. For others, a plastic surgeon may include a second surgery for final adjustments. Most of the time, the expander phase is not needed for tissue reconstructions. Learn more about tissue reconstruction.

In general, implant reconstruction has a shorter recovery time than tissue reconstruction.

• After implant reconstruction, healing and recovery can take about 4 weeks.
• Tissue reconstruction recovery can take about 6-8 weeks.
• With tissue reconstruction, your body is healing from more than one area of surgery—the breast area and the location of tissue used to build the breast.
• Implant reconstruction can sometimes involve fat transfer from another area of the body to supplement the implant. That part of the body will also need to heal.

For any type of reconstruction, here are some things to expect with recovery:

• When you leave the hospital, you will likely have temporary surgical drains attached to your body with small stitches near the surgery site.
• Drains are small, flexible tubes that suction accumulated fluid away from the surgery site.
• You will be given instructions on how to empty and clean the drains to help you avoid infection once you are home.
• Your doctor may recommend you avoid certain activities such as heavy lifting, intense sports or exercise, and some sexual activities for 4-6 weeks.
• Your motion may be limited because of pain or muscle tightness, and you may feel fatigued or weak. These are all common effects of major surgery.

Be sure to keep track of how you feel and report any new or worsening side effects to your doctors.

After the body has healed, physical therapy is sometimes recommended to retrain and strengthen muscles weakened by the surgery. Ask your plastic surgeon about physical therapists who have experience working with women recovering from mastectomy and reconstruction surgery.

If you decide to have nipple reconstruction, this can be an extra step that happens after the main breast reconstruction surgery is finished. Learn more in Nipple reconstruction.

Follow-Up Monitoring After Reconstruction

Many women worry that reconstruction can make it difficult to diagnose potential future breast cancers. It’s important to know that research shows reconstruction does not make it harder to find a new breast cancer.

If you had a mastectomy, you may not be offered screening mammograms if there isn’t enough breast tissue to effectively perform one. But you’ll still get physical breast exams, and if an area of concern is found, you and your doctor will talk about the next steps, such as imaging tests.

Breast reconstruction side effects

Any kind of major surgery comes with the risk of side effects. Here are the main side effects that can happen with breast reconstruction:

• Pain and tightness in the breast or chest area
• Infection
• Problems caused by anesthesia, such as nausea, vomiting, chills, or a sore throat that can happen when a breathing tube is used during surgery
• Imbalanced or asymmetrical breasts, meaning one breast is now bigger or smaller than the other, if surgery was only performed on one breast
• Capsular contracture, in which scar tissue forms around an implant, causing pain and distorting the way the reconstructed breast
• Loss of sensation in the skin of the breast or the nipple

It’s important to know that there are ways to manage pain, tightness, capsular contracture, or breast asymmetry after surgery. These can include physical therapy and corrective surgery. If you are only having reconstruction done on one breast, the risk of an imbalanced look can sometimes be avoided by making surgical adjustments to the other breast. Group health insurance plans that cover mastectomy are required to cover mastectomy-related reconstructive surgeries, including procedures to one or both breasts that can create symmetry.

Going flat

Some women decide not to have reconstruction after mastectomy. This is often called “going flat.” Surgeons can perform a procedure called aesthetic flat closure to remove excess breast skin and create a smooth chest. Learn more about Going flat.

Breast reconstruction results

Many different factors can impact how people feel about breast reconstruction results, including:

• How a person feels about their body before breast reconstruction
• The type of reconstruction done; each type has its own unique risks
• Treatments such as radiation therapy, which can affect how a reconstruction may look

Breast reconstruction results can affect your body image. Many people are happy with their results, but some people can feel disappointed. Some people feel like they should just be happy to have the cancer removed, even if the reconstruction results aren’t what they had hoped.

If you are not happy with your results, it’s important to know that there are options. Talk with your plastic surgeon about corrective procedures that can help create a balanced look.

In many cases, corrective procedures—sometimes called reconstruction revision—are covered by insurance. Call your insurance company and ask about coverage for reconstruction revision surgery related to a breast cancer diagnosis. Learn more below.

Paying for breast reconstruction

A federal law called the Women’s Health and Cancer Rights Act of 1998 (WHCRA) requires employer-based group health plans and individual health insurance policies to cover breast reconstruction after mastectomy. This includes coverage for:

• All phases of breast reconstruction for the breast that is removed
• Surgery and reconstructive procedures on the remaining breast to achieve a balanced look
• Breast prostheses
• Treatment for breast reconstruction complications, such as lymphedema
• Breast reconstruction revision procedures

Still, out-of-pocket expenses can vary significantly based on individual policies.

If you are concerned about paying for breast reconstruction surgery, talk with your healthcare team. Many cancer centers have financial counselors who can help you plan and find resources. You can also visit our Financial matters section for information on managing costs, finding assistance, and managing your insurance.