Breast Reconstruction Surgery: What Are the Options?

If you’ve had or are about to have a mastectomy or lumpectomy to treat breast cancer, you may be considering whether to undergo reconstruction after your treatment. Not everyone chooses to reshape one or both breasts following surgery, but having reliable information about the possibilities is important.

In 2017, the American Society of Plastic Surgeons reported that just 23 percent of those facing breast reconstruction surgery understood the range of options available to them. This article provides an overview of the different procedures to help in your decision-making process.

You have several options to restore the shape of your breasts after mastectomy for breast cancer. The option you choose may depend on:

• the amount of breast tissue removed
• the shape of your breasts
• whether your treatment plan includes radiation therapy
• other health factors that could complicate your healing

Below, we’ll discuss some of the many options available for breast reconstruction after mastectomy.

Implants

One of the most common reconstructive procedures uses implants to restore the shape of your breasts. Implants are strong, silicone sacs filled with liquid or gel.

Permanent Implant shells can be filled with a saline solution (sterile salt water) or with a silicone gel. Some doctors prefer to use silicone implants because they say they look and feel more natural than saline. Newer implants often use form-stable or cohesive gels, which are designed to hold their shape if the outer shell of the implant ever tears or breaks open.

As with many medical procedures, getting implants can carry some risks. Infection and bleeding are risks of any surgery, and an infected implant may need to be removed temporarily.

In the past, there have been health concerns associated with silicone in the body. However, these types of implants are generally thought to be safe. If you’re thinking about implants, talk with your oncologist or a plastic surgeon about the type of implant that may be safest for you.

The most common complication of implant surgery is called a capsular contracture. When the tissue around the implant heals, the scar tissue can tighten around the implant, changing its position in your body. If you experience a contracture, you might need additional procedures to correct this condition.

It’s also important to understand that breast implants aren’t considered lifelong prosthetics. Over time, they can degrade or rupture, which means you might need additional surgery to remove or replace them.

Tissue flap procedures

Sometimes, it’s possible to rebuild your breast using tissue from other parts of your body — typically the buttocks, back, abdomen, or thighs. These techniques are known as tissue flap procedures. Advocates say using your own body tissues creates a more natural-feeling result.

Types of tissue flap procedures include:

• Transverse rectus abdominis muscle (TRAM). These flaps are created using tissue (the sit-up muscles, skin, and fat) from your lower abdomen. Under the skin, TRAM flaps stay attached to their original blood supply in the abdomen.
• Deep inferior epigastric perforator (DIEP). Like a TRAM flap, the tissue for the DIEP flap comes from your abdomen. Unlike a TRAM flap, no muscle tissue is transferred, and surgeons will need to attach the transferred tissue to the blood supply in the chest using microvascular surgical techniques.
• Latissimus dorsi (LD). For an LD, tissue (the lat or “pull-up” muscle as well as skin and fat) is removed from your upper back, possibly extending under your arm. Sometimes an LD flap is used along with an implant.
• Gluteal artery perforator. With this option, tissue is removed from the underside of your buttocks near the top of your thigh.
• Transverse upper gracilis. These flaps are created with tissue removed from the inside of your upper thigh.

One potential downside of flap procedures is that tissue from your own body can increase or decrease in size as you gain or lose weight.

Another concern is that tissue flap procedures can take longer to heal, in part because there are two incisions: One where the donor tissue was removed and the other at the breast site. If your procedure involves removing muscle from a donor site, it’s likely to change the way your body functions in the donor area.

There are some risks associated with flap surgeries, including:

• infection
• blood clots
• hernia at the donor site
• blood supply to the transplanted tissue can be damaged, causing the tissue to die

Research shows that people who don’t smoke, have a body mass index under 30, and have not had radiation therapy have lower risks for developing complications after reconstruction surgeries.

Nipple reconstruction

In many cases, surgeons can rebuild your nipple and areola for a more natural appearance. The areola and nipple can be tattooed to match your natural coloring.

While the appearance of the nipple can be improved, you may not have sensation in the area, and you may need to touch up tattoos if they fade over time.

Oncoplastic reconstruction

If surgeons remove a small area of your breast tissue with a lumpectomy, you might be a good candidate for plastic surgery that changes the shape of your remaining breast tissue. This can help camouflage the effects of the lumpectomy surgery.

Most often, these procedures involve a breast lift or reduction.

Some people opt for immediate reconstruction, while others delay reconstruction until after their treatment is complete.

Immediate reconstruction

With immediate reconstruction, a plastic surgeon may place an implant under the skin or muscle tissue as soon as the oncological surgeon has removed the breast tissue. It’s also possible that your surgeon could put an extender in place to gradually stretch tissues enough to place an implant a few weeks later.

In some cases, tissue flap surgery can be performed the same day as the mastectomy as well.

One advantage of immediate reconstruction is that much of the breast skin is preserved, so your breast may look as natural as possible. For some, another benefit of an immediate reconstruction is less risk of emotional, psychological, or social adjustment issues after a mastectomy or lumpectomy.

It’s important to understand that while an implant is in place immediately after a mastectomy, you may need to have procedures later on to adjust the fit or appearance. Talk with your doctor about the typical course of treatment so you understand how many adjustments you may need and the recovery time involved.

Having an immediate reconstruction often means your recovery will often take longer because you’ve had two procedures, not one.

If you’re worried that having implants will make it more likely that cancer will return or that implants will make it harder to find breast cancer, it may be of some comfort that doctors at MD Anderson Cancer Center say that isn’t the case.

Additional mammogram views may be necessary to get a full picture. But the way implants are placed often means that breast tissue is in front of the implant where you can see or feel changes.

Delayed reconstruction

Some people delay breast reconstruction for a weeks, months, or years after treatment for many reasons, including:

• their treatment plan includes radiation therapy, which can further change tissue in the area and can damage implants
• they experience anxiety or distress about the results of a mastectomy
• at the time of surgery, they were undecided about whether to have reconstructive procedures
• their overall health or the stage of breast cancer made it necessary to wait

While delaying reconstruction makes sense in many cases, there are some drawbacks to consider. After a mastectomy, scar tissue is likely to form. Scar tissue can make it harder to rebuild the breast. The cosmetic results may not be the same after a delay.

In the first few days after reconstruction, you’re probably going to feel tired, and the areas where you had surgery are going to be very tender. Your doctor will prescribe medication to help manage the pain.

Depending on the type of reconstruction, you may spend one to several nights in the hospital recovering. With a tissue expander or implant, it’s common to spend 1 to 2 nights in the hospital.

With a flap surgery, you can remain in the hospital for a week or longer. This is because it’s a more invasive procedure, and the surgeons want to make sure the tissue is healing well after being moved from another part of your body.

At first, you will probably have tubes extending from the surgical sites. These tubes allow fluid to drain from wounds as you’re healing.

Because the tubes may still be in place when you go home from the hospital, a healthcare professional will teach you how to empty them and keep them clean.

Most people begin to feel better within a week or two. Depending on the type and extent of your surgery, you may be able to get back to many of your normal activities in around 8 weeks. Bruising, swelling, and tenderness may continue at least that long — or even longer.

It’s important to keep in mind that people respond differently to breast surgery and reconstruction. What you experience during recovery will be influenced by:

• the type of surgery and reconstruction you have
• how closely you follow the postsurgical recovery procedures
• your own pain tolerance
• whether or not you smoke
• your mental and physical health before and after surgery

The Women’s Health and Cancer Rights Act and the Affordable Care Act require most insurers to cover breast reconstruction if their plans cover mastectomies. These laws also provide coverage to have your other breast reconstructed so that both sides are symmetrical.

Some exceptions exist for religious or government plans. If you are insured under a plan provided by one of these organizations, you’ll need to verify coverage with your insurer.

Medicare and Medicaid

Medicare pays for reconstruction if you’ve had a mastectomy to treat breast cancer. Coverage under Medicaid varies from state to state, so you will need to check with your state Medicaid office to find out what the reconstruction benefits are where you live.

A study conducted in 2020 found that Medicaid recipients had breast reconstruction less often than people with private insurance but more often than people covered under Medicare.

Some researchers worry that because surgeons are compensated much less by government insurance plans (Medicare and Medicaid), people with those plans may not get breast reconstruction at the same rates as people with private insurance.

Your decision about reconstruction may be affected by a number of factors, including:

• the stage and location of the cancer
• the procedures covered by your insurance plan
• health issues that could affect the success of the procedure
• the size and shape of your breasts
• the recommendations of your oncologist

Deciding whether to reconstruct your breasts is a very personal choice, and you’re likely to be making the decision at a time when you’re worried about your health. It’s OK to ask your healthcare team a lot of questions, and it’s OK to be confused and emotional during the process.

These may be some of the questions you’re considering:

• How will the different procedures affect my body image?
• Which procedure is going to leave me feeling the most like “myself”?
• How will the appearance and feel of my breasts affect my ability to enjoy sex?
• How will these procedures affect my ability to do the activities that are important to me?
• How much support and assistance am I going to need from family or friends during recovery?
• How much time will I need to take off work with each procedure?
• Am I emotionally ready to make this decision right now?

You are not alone in having these questions. As soon as possible, discuss your concerns and questions with your doctors so you have the information and perspective you need to make the right decision for you.

It may also benefit you to talk with women who share your experience. Here are some places you can go to talk, listen, and learn about breast cancer treatment, recovery, and reconstruction:

• American Cancer Society (ACS). The ACS offers supportive conversations with trained specialists through their helpline (800-227-2345) and live chat option on their website. The ACS also offers the Reach to Recovery program that pairs you with a trained volunteer who can offer you support, guidance, and the benefit of their experience.
• Breast Cancer Healthline app. This app can help you access information and connect with a community of others who share your diagnosis.
• Young Survival Coalition. This group offers lots of information, virtual hangouts, local meetups and conferences, and online support for people under age 40 who have been diagnosed with cancer.
• Cancer Financial Assistance Coalition. This group of organizations offers a search tool to match you with financial and practical assistance programs near you.
• American Society of Plastic Surgery. This is a great resource to learn about all of the different breast reconstruction options that are available.

Breasts can be reconstructed using implants, your own body tissues, or reshaping procedures. Breast reconstruction can be done at the same time as a mastectomy or lumpectomy, or it can be done weeks, months, or years later.

Breast reconstruction is not a one-and-done process — multiple procedures may be necessary to achieve the desired results.

For many women, breast reconstruction is an important part of the breast cancer treatment and recovery journey. However, it is also important to remember that reconstructed breasts will usually look and feel different than your original breasts.

The procedure that’s best for you will depend on your diagnosis, your breast size and shape, and your overall health as well as whether you may need chemotherapy or radiation. Most health insurance plans are required to cover reconstruction if the plan also covers mastectomies for cancer treatment. However, there are some exceptions.

It’s OK to ask questions, to consider your own priorities and desires, and to make a decision that feels right for you, for now.