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Overview

In general: Breast reconstruction is a procedure performed by a plastic surgeon.in which the shape of the breast is rebuilt after a  mastectomy.

Most women who have breast reconstruction also have the nipple and areola (the darker area surrounding the nipple) reconstructed. The result is that the new breast looks as normal as possible.The procedure involves skin grafts from other parts of the body to reconstruct the nipple. The grafts can be tattooed to match the color of the patient’s own areola.This procedure is usually done a few months after the breast reconstruction.

 Breast reconstruction can either start at the time of the mastectomy or at a later time.

After breast reconstruction, a woman's silhouette can look just like it did before surgery. A reconstructed breast may not look exactly like a natural breast when you are naked. If the nipple and areola are removed, there may be a lack of sensation unless nerves can be repaired.

Women choose breast reconstruction for a variety of reasons. Common reasons include the following: 

  • To make breasts look balanced when wearing a bra.
  • To permanently regain a breast shape.
  • To avoid having to use a form that fits inside the bra (an external prosthesis) to make the breasts appear balanced in clothes.
  • Emotional well being.

There are two types of surgery for breast reconstruction: breast implants and tissue flap. There can also be a combination of the two. Breast reconstruction may require additional surgery to reduce or lift the healthy breast to achieve symmetry between both breasts. It may also require additional surgery to reconstruct the nipple and areola 

Paying for reconstruction: If your insurance covers a mastectomy, it likely covers reconstruction. In fact, the federal Women's Health and Cancer Rights Act (WHCRA) requires all health insurance providers and HMOs that pay for mastectomy to also cover certain services related to breast reconstruction after the procedure. Many states have similar laws. To check the law in your state, contact your state insurance department. You can find contact information at: www.naic.org offsite link.

 If your health insurance covers a mastectomy, it generally covers breast reconstruction.

Before agreeing to reconstruction, it is advisable to:

  • Choose a board certified plastic surgeon who has a great deal of recent experience doing the kind of reconstruction you are considering.
  • Ask the plastic surgeon all the questions that come to mind.
  • Talk with women who have had this surgery. Consider asking:
    • How satisfied the person is with the reconstruction
    • The recovery period
    • What problems, if any, did the person have
    • Would she make the same choice again. 
    • Whether you can see the reconstructed breast.  A reconstructed breast which is likely to look different than a photo or a model.
  • Consider getting a second opinion before having any surgery. Breast reconstruction and even mastectomy are not emergencies. It is more important for you to make the right decisions based on the correct information than to act quickly before you know all your options.

Follow-up care:

  • Everyone should receive a Breast Cancer Follow-Up Plan. Women who have reconstructive surgery are monitored carefully to detect and treat complications, such as infection, movement of the implant, or contracture (the formation of a firm, fibrous shell or scar tissue around the implant caused by the body's reaction to the implant). Women who have tissue flap reconstruction may want to ask their surgeon about physical therapy which can help adjust to limitations in activity and exercise after surgery.
  • Routine screening for breast cancer is also part of the follow-up, because the risk of cancer cannot be completely eliminated. When women with breast implants have mammograms, they should tell the radiology technician about the implant. Special procedures may be necessary to improve the accuracy of the mammogram and to avoid damaging the implant. However, women who have had reconstructive surgery on both breasts should ask their doctors whether mammograms are still necessary.

For additional information, see:

Breast Implants

In this kind of surgery, a reconstructive plastic surgeon puts a substance or object in the body as a prosthesis (implant). The implant is filled with either saline (salt water) or silicone gel. It is put under your skin or chest muscle to build a new breast-like shape. While this shape looks like a breast, you will have little feeling in it because the nerves have been cut.

The breast implant can be inserted at the time of the mastectomy or at a later date. The timing depends on individual preference and whether the radiation therapy or chemotherapy is required after surgery.

In general, breast implant surgery is a simpler procedure than surgery using tissue flaps.

Breast implants do not last a lifetime. If you choose to have an implant, chances are you will need more surgery later on to remove or replace it.

Implants can cause problems such as breast hardness, breast pain, and infection. The implant may also break, move, or shift. These problems can happen soon after surgery or years later.

According to Johns Hopkins Medicine: "Implants are best for women with small- to moderate sized breasts, younger women with resilient skin and good muscle tone, very thin women without enough of their own tissue for flap surgery, and those who don’t want scarring at another site....we generally avoid implants in patients with planned or prior radiation."

If a patient does not have enough skin to cover a breast implant of sufficient size to match the healthy breast, there is a two step operation. First the surgeon inserts a balloon-like device called a tissue expander under the skin and chest muscle. A saline solution is then injected into the tissue expander at regular intervals for a period of weeks to months until the overlying skin is stretched sufficiently to create a pocket for the breast implant. Once this is accomplished, the tissue expander is removed and the implant is inserted. This can take 4 to 6 months.

For more information about implants, see the FDA website offsite link or call the FDA at 800.638.2041.

For information about how to choose a plastic surgeon, click here.

NOTE: If the implant creates a breast with more upper fullness than the other breast, a breast lift on the remaining breast will make them look the same.

Tissue Flap Surgery

With tissue flap surgery, a surgeon builds a new breast-like shape from muscle, fat, and skin taken from other parts of the body, such as the abdomen or back.  (If the skin is taken from the lower abdomen, the procedure is sometimes referred to as a "tummy tuck." On the flip side, it may also result in a weakening of the abdominal wall.)

Tissue flap surgery produces excellent results. It is generally better than implants for older women and those with large breasts. Women who are very thin or obese, smoke, or have other serious health problems often cannot have tissue flap surgery.

This new breast-like shape should last a lifetime.

Tissue flap is major surgery and is more complicated than breast implant surgery. Healing often takes longer after this surgery than with breast implants. There may be other problems as well from tissue flap surgery. For example, there may be a loss of strength in the part of the body where muscle was taken to build a new breast. Or there may be an infection or difficulty healing.

Tissue flap surgery is generally not performed in heavy smokers, women with diabetes or women with connective tissue or vascular disorders.

Tissue flap surgery is best done by a reconstructive plastic surgeon who has done it many times before. For information about how to choose a plastic surgeon, click here.

Questions To Ask Before Agreeing To A Breast Reconstruction

It is very important that you get all of your questions answered by your plastic surgeon before having breast reconstruction. If you don't understand something, ask your surgeon about it. Here is a list of questions provided by the American Cancer Society to get you started. Write down other questions as you think of them. You may want to record your talks with your surgeons or take notes. Some people bring a friend or family member with them to the doctor to help remember what was said. The answers to these questions may help you make your decisions.

  • Can I have breast reconstruction?
  • When can I have reconstruction done?
  • What types of reconstruction could I have?
  • What is the average cost of each type? Will my insurance cover them?
  • What type of reconstruction do you think would be best for me? Why?
  • How many of these procedures have you (plastic surgeon) done?
  • What results can I expect?
  • Will the reconstructed breast match my other breast?
  • How will my reconstructed breast feel to the touch?
  • Will I have any feeling in my reconstructed breast?
  • What possible problems should I know about?
  • How much discomfort or pain will I feel?
  • How long will I be in the hospital?
  • Will I need blood transfusions? If so, can I donate my own blood?
  • How long it take for me to recover?
  • What will I need to do at home to care for my incisions (surgical wounds)?
  • Will I have a drain (tube that lets fluid out) when I go home?
  • How much help will I need at home to take care of my drain and wound?
  • When can I start my exercises?
  • How much activity can I do at home?
  • What do I do if my arm swells (this is called lymphedema)?
  • When will I be able to go back to normal activity such as driving and working?
  • Can I talk with other women who have had the same surgery?
  • Will reconstruction interfere with chemotherapy?
  • Will reconstruction interfere with radiation therapy?
  • How long will the implant last?
  • What kinds of changes to the breast can I expect over time?
  • How will aging affect the reconstructed breast?
  • What happens if I gain or lose weight?
  • Are there any new reconstruction options that I should know about?

What To Expect After Breast Reconstruction

What to expect

You are likely to feel tired and sore for a week or 2 after implants, and longer after flap procedures. Your doctor can give you medicines to control pain and other discomfort.

Depending on the type of surgery, you should go home from the hospital in 1 to 6 days. You may be discharged with a drain in place. The drain is an open tube that is left in place to remove extra fluid from the surgery site while it heals. Follow your doctor’s instructions on wound and drain care. Also be sure to ask what kind of support garments you should wear. If you have any concerns or questions, call your doctor.

Getting back to normal

You should be up and around in 6 to 8 weeks. If implants are used without flaps, your recovery time may be shorter. Some things to keep in mind:

  • Reconstruction does not restore normal feeling to your breast, but some feeling may return.
  • It may take up to about eight weeks for bruising and swelling to go away. Try to be patient as you wait to see the final result.
  • It may take as long as one to two years for tissues to heal and scars to fade, but the scars never totally go away.
  • Ask when you can go back to wearing regular bras. Underwires and lace may not be comfortable.
  • Follow your surgeon's advice on when to begin stretching exercises and normal activities. As a rule, you'll want to avoid any overhead lifting, strenuous sports, and sex for four to six weeks after reconstruction.
  • Women who have reconstruction months or years after a mastectomy may go through a period of emotional readjustment once they have their breast reconstructed. Just as it takes time to get used to the loss of a breast, you may feel anxious and confused as you begin to think of the reconstructed breast as your own. Talking with other women who have had breast reconstruction might be helpful. Talking with a mental health professional may also help you sort out these feelings.
  • Silicone gel implants may open up or leak inside the body without causing symptoms. Some surgeons will recommend that regular MRIs of the implant be done to make sure it isn't leaking. You will likely have your first MRI about  one year after your implant surgery and every two years from then on. Your insurance may not cover this. Talk to your doctor about long-term follow-up.