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Breast Reconstruction


Introduction

Breast reconstruction is a surgical procedure for rebuilding the shape of the breast after a mastectomy. The procedure is accomplished with breast implants or with the use of a woman's own tissue. While not all women who have a mastectomy will choose breast reconstruction, every woman should be counseled in her reconstructive options prior to surgery for her cancer. Caregivers and patients should be aware that women who undergo breast reconstruction appear to have significantly better psychosocial outcomes than women who do not. 1 2 Women should also be informed, however, about alternatives to breast reconstruction, which include wearing an external breast prosthesis or wearing no breast replacement at all.

Immediate or Delayed

Breast reconstruction can be performed at the time of mastectomy (immediate reconstruction) or any time later (delayed reconstruction).

Nearly all women who undergo a mastectomy are candidates for breast reconstruction. (Reconstruction is usually not needed for women who have had a lumpectomy.) Important clinical considerations include a women's overall health, coexisting medical conditions, future treatment plans, features of the contralateral breast, and potential for complications. Any woman who finds herself feeling unready or unsure should wait until she's certain before proceeding.3

Breast reconstruction can be performed at the time of mastectomy (immediate reconstruction) or at any time later (delayed reconstruction). The decision of when to begin reconstructive breast surgery depends upon the stage of the disease, comorbidities, the need for postoperative radiation therapy, and the patient’s personal preferences. 3 4 Studies have shown that immediate reconstruction has significant psychosocial benefits for women compared to delayed reconstruction.2 5 Immediate reconstruction is not, however, recommended for women with stage III or higher disease, who need postoperative radiation therapy, whose skin flap perfusion (circulation) is impaired after mastectomy, or for women who smoke, are obese, or have cardiopulmonary disease.4

Advantages of Immediate Reconstruction:3 4

  • awaking from cancer surgery with a reconstructed breast
  • fewer number of surgical procedures and recovery periods
  • lower surgery costs
  • cosmetic outcome may be improved

Disadvantages of Immediate Reconstruction:3 4

  • having less time to make decisions about reconstruction options
  • stress of dealing with cancer and breast reconstruction at the same time
  • possible increased risk with extent and duration of surgery
  • longer hospitalization and recovery time
  • potential complications with post-mastectomy treatments

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Types of Breast Reconstruction

There are two main types of breast reconstruction available to most mastectomy patients: breast implants and tissue reconstruction.

Implant Reconstruction

Implant Reconstruction. Source: Adapted from NCI Visuals Online. AV-0000-4124.
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While some patients may be able to undergo one-stage implant reconstruction immediately following mastectomy, a tissue expander is usually needed as a first step, in order to stretch the muscle and skin. Following the mastectomy, an expander (a balloon filled with saline) is inserted through the mastectomy incision, under the chest muscle. Over the course of several weeks, additional amounts of saline are periodically injected into the expander until it becomes inflated to an appropriate size. When the tissue has been adequately stretched, the expander is replaced with a permanent breast implant. The process usually takes several months.3 4

Advantages of Implant Reconstruction:4 6

  • less complex, shorter surgical procedure
  • does not involve tissue from other parts of the body
  • no risk of complication at the donor site
  • briefer hospital stay and recovery time

Disadvantages of Implant Reconstruction:3 4 6

  • may give a less natural breast shape
  • may be more difficult to match opposite breast
  • usually requires a second surgery to place implant
  • usually need frequent office visits for tissue expansion
  • may lead to complications, including rupture, migration, rippling of implant, or hard scar tissue (capsular contracture)
  • may not last a lifetime
  • implants in remaining breast may affect ability to breast feed
Silicone Implant. Source: Linda Bartlett (photographer). Adapted from NCI Visuals Online. AV-8000-0523.

In the United States, breast implants are filled with either saline or silicone gel. Alternative breast implants filled with materials other than silicone or saline are currently being studied and may be available to patients through participation in clinical trials.3

Silicone implants feel more like natural breast tissue than saline. In the 1980s, some medical experts believed that silicone leakage was associated with immune-related disorders and other illnesses. Since then, empirical studies have failed to provide evidence of a link between silicone implants and disease, and the 14 year ban on silicone implants was lifted by the U.S. Food and Drug Administration (FDA) in 2006.7

One of the most common problems with implants is rupture. If implants filled with saline leak, the saline is absorbed harmlessly into the body. When silicone implants rupture, however, women may experience deformities in the breast, including lumps and changes in the breast shape. They may also experience breast pain, tingling, burning, or numbness. In addition, silicone may migrate to other areas of the body and can cause lumps to form in other tissue, including the chest wall, armpit, or arm. It may be difficult or impossible to remove silicone that has moved to other parts of the body.8 Patients may be referred to the FDA’s booklet Things to Consider Before You Get Implants for more information.

The FDA recommends women with silicone implants undergo MRI screenings three years after the implants are placed and every two years thereafter.8 Although the use of MRI to screen for ruptures is supported by the FDA, other organizations, including the American Academy of Plastic Surgeons, do not support this recommendation, and many health insurance plans will not cover breast MRI for asymptomatic women.9

Women with breast implants may have a very small risk of developing anaplastic large cell lymphoma (ALCL), although no causal link has been proven between implants and ALCL. The United States Food and Drug Administration (FDA) has requested that health care professionals report any cases of ALCL in women with breast implants through the FDA’s MedWatch Safety Information and Adverse Event Reporting Program.10

Tissue Reconstruction

Tissue reconstruction (also called autologous reconstruction) is a flap procedure that uses the patient's own tissue to rebuild the shape and look of a breast after a mastectomy. Tissue may be taken from the back, abdomen, buttocks, or more rarely, the thighs. The flap of tissue may be transferred without severing the tissue from its original blood supply (pedicled) or it may be severed from its original blood supply and microsurgically attached to new blood vessels near the chest (free flap or free perforator flap). Because all tissue reconstruction methods involve the blood vessels, women who smoke or have diabetes or vascular or connective tissue diseases may not be good candidates for this type of procedure. Generally, both surgery and recovery take longer with tissue reconstruction than with implants.3 4 6

The most common tissue reconstruction techniques are the pedicled transverse rectus abdominis (TRAM) flap followed by the latissimus dorsi (LAT/LD) flap. Examples of newer flap techniques are the gluteal artery perforator (GAP) flap, the deep inferior epigastric perforator (DIEP) flap, the superficial inferior epigastric artery perforator flap (SIEA), and the transverse upper gracilis (TUG) flap.3 4

Rectus Abdominis Flap.  Source: Adapted from NCI Visuals Online. AV-0000-4124.
Fig. 1
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Fig. 4

TRAM Flap: The transverse rectus abdominis flap uses tissue and muscle from the lower abdomen. There are two types: pedicled and free. The pedicled is most common. With this procedure, the skin, fat, blood vessels, and at least one of the abdominal muscles are pulled through a tunnel under the upper abdominal skin to the chest area. There, the tissue is reshaped into the contour of a breast. The free TRAM flap removes less abdominal muscle but involves the severing of the flap from its original location before attaching it to blood vessels in the chest area. Both types of TRAM reconstructions result in a tightening of the lower abdomen. Women who have had previous abdominal surgery or women with insufficient lower abdominal tissue are not considered good candidates for this type of reconstructive surgery. In addition, there is a greater risk of complications with this procedure in women who smoke, have diabetes or collagen vascular disease, have undergone post-mastectomy radiation therapy, and who have certain abdominal scars.4 

Latissimus Dorsi Flap. Source: Adapted from NCI Visuals Online. AV-0000-4122.
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LAT/LD Flap: The latissimus dorsi flap may be used for women whose abdominal tissue is insufficient or cannot otherwise be used. It is also an alternative for women who cannot have TRAM flaps because they are smokers, are obese, or have significant medical co-morbidities. LAT/LD flaps may also be used to correct defects in the breast shape after breast-conserving surgery and radiation therapy. With this procedure, a portion of skin, fat, and muscle is mobilized from the back and pulled through a tunnel under the skin of the axilla to the site of the mastectomy. In women with larger breasts, a LAT/LD flap procedure may require the addition of an implant.3 4

DIEP Flap: The deep inferior epigastric perforator flap is a type of free flap procedure that uses fat and skin from the same area as the TRAM flap but leaves the abdominal muscle in place. As a result, some of the potential complications with the TRAM flap (e.g., hernia, muscle weakness) are greatly minimized. However, as a free flap procedure, it requires microvascular surgery which is technically more demanding and only available in select settings.3 4

SIEA Flap: The superficial inferior epigastric artery flap uses the same abdominal tissue as the DIEP flap but does not require blood vessels that go through or around the abdominal muscles. Because no muscle dissection or fascial incisions are required, this procedure takes less time and is associated with even fewer complications than the DIEP procedure. However, the superficial inferior epigastric vessels must be evaluated to ensure that the patient has sufficient vessels for the transfer, and only 15% of patients will be assessed as good candidates for this procedure. 4 11

GAP Flap: The gluteal artery perforator flap is another type of free flap surgery that uses tissue, including the gluteal muscle, from the upper buttock (superior gluteal artery perforator flap) or lower buttock (inferior gluteal artery perforator flap) to create the shape of the breast. It is generally used for women who are too thin for procedures using tissue from the abdominal area. GAP flaps do not require muscle dissection and, therefore, have minimal impact on postoperative patient functioning. However, the procedure is technically difficult, not widely available, and may result in sciatic nerve injury.3 4

TUG Flap: The transverse upper gracilis flap is a newer free flap option that uses muscle and tissue from along the bottom fold of the buttock extending to the inner thigh. This procedure is another option for women with insufficient abdominal fat. Best candidates are women with sufficient inner thigh tissue who need reconstruction of a smaller or medium sized breast. As with the DIEP and GAP flap procedures, the TUG flap requires microsurgical expertise and is not widely available. 3 4

Advantages of Tissue Reconstruction:3 4

  • soft and natural-appearing breast mound
  • reconstructed breast is more like the opposite breast
  • reconstructed breast changes with modest weight loss or gain, and with aging
  • no implant necessary with most procedures
  • the abdomen is flatter (with some procedures)

Disadvantages of Tissue Reconstruction:3 4

  • longer time in surgery
  • longer recovery time
  • longer time to accomplish reconstruction
  • considerable post-operative discomfort, extended healing
  • additional incision, scarring
  • possible decreased strength at donor site
  • risk of donor site complications
  • risk of flap failure

Nipple and Areola

Women who want to achieve the most realistic appearance possible may also choose to have the nipple and areola reconstructed. Nipple and areola reconstructions are usually done after the initial breast reconstruction has had time to heal (usually three to four months). Options for reconstructing the areola include a skin graft, tattooing, or a combination of both methods. A new nipple may be molded with a flap of skin from the reconstructed breast or constructed with tissue from another area of the body, such as the earlobe or opposite nipple. In general, most patients who have had a breast reconstruction are candidates for nipple and areola reconstruction as well.3 6

Potential Complications

Both implant and tissue reconstruction are associated with potential complications that vary with the type of procedure. Temporary pain, swelling, bruising, and tenderness are common with all surgeries. Rare complications from general surgery may also occur from breast reconstruction, such as bleeding, fluid collection, excessive scar tissue, infection, fatigue, and problems with anesthesia. Smoking and obesity are both considered to be relative contraindications for breast reconstruction. Obese patients and those who smoke should be made aware of the increased risk of complications. 3 12

One of the most common problems with
implants is capsular contracture.

With breast implants, one of the most common problems is capsular contracture, a condition that occurs when the scar around the implant begins to tighten, causing the breast to feel hard. The condition may be treated with additional surgery to remove the scar tissue. In some cases, the breast implant will need to be removed and replaced. Another possible complication is leakage or rupture of the implant. Patients may be referred to the FDA’s booklet Things to Consider Before You Get Implants for more information.3

Tissue reconstruction is a major operation. All types of flap procedures leave scars both from where the flap is taken and on the reconstructed breast. If there is a poor blood supply to the flap tissue, part or all of the tissue used for recreating the breast shape may not survive (tissue necrosis). Infection and poor wound healing are also potential complications.  Additional surgeries may be required to correct problems.3 4

Most breast reconstruction involves a series of procedures that occur over time. The initial reconstructive operation is usually the most complex. Follow-up surgery may be required to replace a tissue expander with a permanent implant or to reconstruct the nipple and the areola. Most often, the natural breast will require reduction, augmentation, or lifting (mastopexy) for optimum symmetry and balance.3 4

Radiation therapy after mastectomy has become more common and complicates reconstruction planning. Reconstruction may negatively impact the delivery of radiation therapy. Additionally, irradiated breasts may have compromised skin and tissue quality from fibrosis, leading to complications in reconstruction and poorer cosmetic results. The best way to integrate radiation therapy and breast reconstruction is controversial. The National Comprehensive Cancer Network (NCCN) recommends tissue reconstruction as the preferred method for previously irradiated breasts. In addition, NCCN guidelines state:

  • Women who have implant reconstruction and who require radiation should undergo immediate reconstruction with an expander.
  • Women undergoing tissue reconstruction should delay reconstruction until radiation therapy is complete.4 12

Regardless of the type of surgery, a woman's decision to have or not to have breast reconstruction should be an informed and thoughtful process that compares all of the potential benefits and risks. Many women choose this additional surgery as a way of restoring their sense of body identity and to feel more attractive. However, it should be made very clear to women that the new breast, no matter how successful the surgery, will never match exactly their natural breast nor will it have the same sensations as the breast that they lost to cancer. Moreover, breast reconstruction will require additional time for healing and recovery.3

The American Cancer Society offers a comprehensive guide for patients considering post-mastectomy breast reconstruction. This guide describes different options for reconstruction and includes a list of issues to consider when making decisions about reconstruction.

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Finding a Plastic Surgeon

A woman who has decided to have breast reconstruction will need to find a qualified plastic surgeon. It is important to make sure that the plastic surgeon is certified by the American Society of Plastic Surgeons (ASPS). To find out if a surgeon is board certified and an ASPS member or candidate, visit the website of the American Society of Plastic Surgeons. Surgeons can be searched by geographical area or name.  Also, look for the copyrighted ASPS symbol to ensure board certification. Only members of the American Society of Plastic and Reconstructive Surgeons can display the ASPS symbol.

The American Cancer Society recommends that women be prepared with a list of questions to ask their plastic surgeons before they schedule reconstruction. A sample list can be found on the ACS website.

Women's Health and Cancer Rights Act of 1998

The Women's Health and Cancer Right Act of 1998 (WHCRA) contains important protections for breast cancer patients who choose breast reconstruction in connection with a mastectomy. For women whose group health plans, insurance companies, or health maintenance organizations cover mastectomy, the law also requires coverage for:

  • all stages of reconstruction of the breast on which the mastectomy was performed
  • surgery and reconstruction of the other breast to produce a symmetrical appearance
  • prostheses
  • treatment of physical complications at all stages of the mastectomy, including lymphedema

WHCRA is administered by the U.S. Departments of Labor and Health and Human Services. For more information, please visit the U.S. Department of Labor website: Your Rights After A Mastectomy... Women's Health & Cancer Rights Act of 1998. Several states have their own laws regarding reconstructive surgery after a mastectomy, including California. (See California Insurance Code 10123.8

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Breast Prostheses

Breast Prostheses.

Breast prostheses are external breast forms that can be worn after a mastectomy to help achieve symmetry and balance. Choosing to wear a prosthesis is an option for women who either delay breast reconstruction or decide against the additional surgery.

Breast prostheses are made from a range of materials, such as silicone gel, foam, and fiberfill. Custom-made forms can feel similar to natural breast tissue and are usually weighted to match the remaining breast. Some prostheses attach directly to the chest and others fit into pockets of a post-mastectomy bra. Prostheses may also include an artificial nipple. Partial prostheses are available for women who have had a part of a breast removed.

As with surgical options, a woman should be informed about the various prosthetic products available to her before cancer surgery. In addition, healthcare providers should recommend that their patients contact their insurance company to ask about coverage details. While usually not required, a prescription is recommended.

For women considering a breast prosthesis, the American Cancer Society has the following additional recommendations:13

  • Contact a local chapter of Reach to Recovery®, a support group for women with breast cancer, for information and ideas.
  • Wear a breast form (external prosthesis) while waiting for reconstructive surgery.
  • Small prostheses ("equalizers") are available for women who have had part of a breast removed (through lumpectomy or a segmental mastectomy).
  • Nipple prostheses are available for breast reconstruction when the nipple cannot not be saved. External nipple prostheses are also sold to cover flat or missing nipples.
  • External prostheses are sold in surgical supply stores, lingerie shops, and in the lingerie department of many department stores. Call before you go to make sure that a professional fitter will be there.
  • Wear a form-fitting top when you shop for a prosthesis, so that you can better see how it looks when you move.
  • Have your partner or a good friend go with you.
  • Try many different types. Prostheses vary in shape, weight, and consistency. Custom-made forms are also available.
  • Shop around; find the best fit and the right price.
  • Prostheses may feel heavy, but they should feel comfortable, show natural contour and consistency, and stay in place when you move.
  • Ask if the prosthesis absorbs perspiration and how to care for it.
  • Talk with your partner about your feelings about reconstructive surgery and changes in your body.

No Breast Replacement

Some women are comfortable with their body image after surgery and prefer not to wear a breast prosthesis. Wearing no replacement may be viewed as simpler and more convenient. It may also be viewed by some women as a way of coming to terms with the changes to their body. As with most things in life, people respond differently to similar situations. Whatever a woman's personal decision - reconstruction, no reconstruction, prosthesis, or nothing - her adjustment to living with a changed body will be made easier with ongoing support from her healthcare team.

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Notes

1University of Michigan Health System Department of Surgery. (2010, January 18). Michigan breast reconstruction outcome study results. Retrieved from: http://surgery.med.umich.edu/plastic/patient/breast/mbros/studyresults.shtml#recon

2Atisha, D., Alderman, A. K., Lowery, J. C., Kuhn, L. E., Davis, J., & Wilkins, E. G. (2008). Prospective analysis of long-term psychosocial outcomes in breast reconstruction. Two-year postoperative results from the Michigan breast reconstruction outcome study. Annals of Surgery, 247(6), 1019-1028. doi: 10.1097/SLA.0b013e3181728a5c

3American Cancer Society. (2013, June 12). Breast reconstruction after mastectomy. Retrieved from: http://www.cancer.org/acs/groups/cid/documents/webcontent/002992-pdf.pdf

4Nahabedian, M. (2013, December 26). Breast reconstruction in women with breast cancer. Retrieved from the Up to Date website: http://www.uptodate.com/contents/breast-reconstruction-in-women-with-breast-cancer

5Al-Ghazal, S. K., Sully, L., Fallowfield, L., & Blamey, R .W. (2000). The psychological impact of immediate rather than delayed breast reconstruction. European Journal of Surgical Oncology, 26(1), 17-19.

6National Cancer Institute. (2013, February 12). Breast reconstruction after mastectomy. Retrieved from: www.cancer.gov/cancertopics/factsheet/Therapy/breast-reconstruction

7U.S. Food and Drug Administration. (2013, September 26). FDA update on the safety of silicone gel-filled breast implants (2011) - executive summary. Retrieved from: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/
BreastImplants/ucm259866.htm

8U.S. Food and Drug Administration.(2013, September 25). Risks of implants. Retrieved from: www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/ BreastImplants/ucm064106.htm

9American Society of Plastic Surgeons. (2011, March 29). Do women with silicone breast implants need follow-up MRI scans? Retrieved from: http://www.plasticsurgery.org/news/press-release-archives/2011-press-release-archives/do-women-with-silicone-breast-implants-need-follow-up-mri-scans-.html

10U.S. Food and Drug Administration. (2013, August 19). Anaplastic large cell lymphoma (ALCL). Retrieved from: www.fda.gov/medicaldevices/productsandmedicalprocedures/implantsandprosthetics/ breast implants/ucm239995.htm.

11Johns Hopkins Medicine Breast Center. (n.d.) Superficial inferior epigastric artery (SIEA) flap. Retrieved from: http://www.hopkinsmedicine.org

12National Comprehensive Cancer Network.(2014, March 6). NCCN clinical practice guidelines in oncology. Breast Cancer. Version 2.2014. Retrieved on Mar. 10, 2014 at: www.nccn.org

13American Cancer Society. (2013, September 11). Prostheses. Retrieved from: www.cancer.org/Treatment/TreatmentsandSideEffects/PhysicalSideEffects/Dealingwith
SymptomsatHome/caring-for-the-patient-with-cancer-at-home-prostheses


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Last updated: March 24, 2014

The Breast Cancer Review is sponsored by the Department of Health Care Services (DHCS), Every Woman Counts (EWC) program, with the goal of providing healthcare professionals a general reference for breast cancer screening, diagnosis, and treatment. The Breast Cancer Review is not an expression of medical opinion, diagnosis, prognosis, or treatment recommendation for any particular patient. It should be used for informational purposes only. EWC does not dispense clinical advice or patient care consultation. Links to other web resources are offered as a courtesy; no endorsement is made or implied.  While every care has been taken in their selection, EWC makes no claims as to the validity, quality, or viability of their content.

 

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