Breast reconstruction is a type of surgery for women who have had all or part of a breast removed. It is performed by a plastic reconstructive surgeon, who rebuilds the breast mound and restores the patient’s breast shape and look. The nipple and the darker area around the nipple (areola) can sometimes be saved, or added on in a subsequent surgery.
Women who have had only the part of the breast around the cancer removed (lumpectomy) do not need reconstruction. Most women who have had a breast removed (mastectomy) can have reconstruction.
Breast Reconstruction Options:
Breast Implant Reconstructions
The most common method of breast reconstruction currently performed in the United States uses tissue expanders and breast implants. The breast is usually reshaped in two stages, or surgeries. During the first stage, a tissue expander is placed. An implant is placed during the second stage. Sometimes the implant is inserted in a single stage.
The shape of the reconstructed breast with an implant may not look or feel quite like the natural, opposite breast, especially as you age and your natural breast changes shape. For this reason, implants are better for women with small or medium-sized breasts with little or no sagging.
It is possible to have surgery to enlarge or reduce the size of the opposite, natural breast to help make both breasts look more alike. However, it is important to note that the natural breast will change in size and shape with weight changes and as a woman grows older, while the breast with the implant will not. This may lead to a less even look over time.
Types of Implants
There are two basic types of breast implants: saline and silicone.
For both saline and silicone implants, the outer cover of the implant (also called the implant shell) is made of a solid form of silicone. The two types of implants differ in the substance used to fill the implant shell.
- Saline implants are filled with saline, a saltwater solution similar to that found in IV fluids. Saline implants come deflated and are filled during surgery up to the desired volume.
- Silicone implants are filled with silicone gel, a semi-solid substance made from silicone. They come pre-filled with the desired volume.
Different implant shapes are available to match the look of the natural breast. Implants can be round or teardrop-shaped and vary in the amount of projection.
Safety of Implants
In the past, there were concerns that silicone implants caused health problems. However, the research to date clearly shows no link between silicone implants and lupus, immune system disorders, connective tissue disease or rheumatoid arthritis. Silicone implants are a safe option compared to saline implants, and is generally preferred by most plastic surgeons due to the resulting more natural shape and feel.
Breast Implants & Radiation Therapy
Radiation therapy can cause problems (such as changes in skin color and tissue shrinkage) for both implant and natural tissue reconstruction.
If you will have an implant procedure and radiation therapy will be used after mastectomy, immediate rather than delayed breast reconstruction is recommended. Skin that has received radiation and is later stretched to fit an implant is at high risk for complications and a poor cosmetic result. Results are better when the procedures to expand the skin are done before.
Natural Tissue Flaps
Latissimus Dorsi Flap Reconstruction
During a latissimus dorsi flap procedure, a section of tissue (muscle and skin) from your back is moved to your chest to reconstruct the breast.
TRAM (Transverse Rectus Abdominus Myocutaneous) Flap Reconstruction
During a TRAM flap procedure, the surgeon removes skin, fat and muscle from your abdomen and moves it to your chest to reconstruct the breast.
DIEP (Deep Inferior Epigatric Perforator) Flap Breast Reconstruction
This is similar to a free TRAM flap, only no abdominal muscle is used. This is state-of-the-art microsurgical breast reconstruction technique and requires specialized training and experience by your surgeon. As with the TRAM flap, the fat and skin of the abdomen are moved to create a new breast mound. Microsurgery is involved in order to allow for the reattachment of the blood supply to the tissue. It is more complex than TRAM flap procedures and usually requires two microvascular surgeons. The major advantage of the DIEP flap is that all the abdominal muscle is preserved and abdominal wall function is maintained. This is particularly critical for bilateral (both sides) breast reconstructions. No artificial mesh is required to repair the abdominal flap donor site.
Combination of Flag & Implant
Which Reconstruction Surgery Is Right for Me?
There is no one best reconstruction method. There are pros and cons to each. Your body shape and anatomy may affect the types of breast reconstruction likely to give you the best results. For women with larger breasts, breast reduction surgery on the opposite, natural breast may be needed to create a more even look. Your plastic surgeon will help you choose the type of reconstruction that will give you the best results.
Most breast reconstruction methods involve several steps. The initial reconstructive surgery usually requires a hospital stay. However, follow-up procedures may be done on an outpatient basis.
Decisions about reconstructive surgery may depend on many personal factors such as:
- Your overall health
- The stage of your breast cancer
- The size of your natural breast
- The amount of tissue available (for example, very thin women may not have enough extra body tissue to make flap grafts)
- Whether you want reconstructive surgery on both breasts
- Your insurance coverage and related costs for the unaffected breast
- The type of procedure you are thinking about having
- The size of implant or reconstructed breast
- Your desire to match the look of the other breast
When Should Breast Reconstruction Surgery Be Performed?
The timing of breast reconstruction is one of the most discussed topics in reconstruction research. It’s important that your entire team of doctors — breast surgeon, plastic surgeon, radiation oncologist, medical oncologist, and other caregivers — meet as a group and discuss your unique situation. Because each breast cancer is unique, each reconstruction surgery and its timing are unique. Together, you and your team can decide on an approach that is best for you.
Immediate Breast Reconstruction
As soon as the breast is removed by the breast cancer surgeon, the plastic surgeon reconstructs the breast either with tissue from another location on your body or with an implant (and sometimes both). The surgery is coordinated between your surgeon and a plastic reconstructive surgeon. Studies have shown that this is a safe approach and may result in a better cosmetic result.
Delayed Breast Reconstruction
The reconstructive surgery is performed sometime after the mastectomy, and any additional therapies that are given including chemotherapy, radiation, or targeted therapies. Radiation therapy in particular is known to cause undesirable changes to a reconstructed breast. Some stage II and all stage III breast cancers are likely to need radiation therapy after mastectomy. Therefore, some surgeons advise patients to wait until after chemotherapy and radiation are finished before having reconstruction. This means reconstruction might be done 6 to 12 months after mastectomy.
In some cases, doctors aren’t sure if a woman will need chemotherapy or radiation until after the cancer and some lymph nodes are removed and analyzed. It can take up to a week for this analysis to be done. In these cases, a tissue expander is inserted under the chest muscle after the breast is removed, thus holding open the mastectomy space until definitive reconstruction can be performed once chemotherapy and/or radiation are completed. The breast reconstruction is usually completed about 4 to 6 months after radiation.
How Do I Decide What Timing is Right for Me?
- Your aesthetic goals – Do you want to look good in your clothes? Or do you want to “look good naked”?
- How much time and effort are you willing and able to invest in your recovery? Implant-based reconstruction generally involves a shorter recovery time and faster return to usual activities, compared to autologous flap reconstruction.
- Whether radiation therapy is planned or anticipated after surgery – this is based on your cancer stage.
As with any surgery, Breast Reconstruction surgery does carry some risk.
Learn more by downloading our Breast Reconstruction Risks PDF and discuss the information with your medical team.
Medicare & Medicaid
Medicare is health insurance provided by the federal government to people who are 65 years of age or older, on renal dialysis or permanently disabled. Medicare covers breast reconstruction after a mastectomy.
Medi-Cal provides health care to people who have a low-income. This program is run jointly by the federal and state governments, so benefits and eligibility (who can join) vary from state to state. Many states require all health insurance providers (including Medi-Cal) to cover breast reconstruction after a mastectomy.
Women’s Health and Cancer Rights Act of 1998
The Women’s Health and Cancer Rights Act of 1998 requires group health plans, insurance companies and health maintenance organizations (HMOs) that pay for mastectomy to also pay for:
- Reconstruction of the breast removed with mastectomy
- Surgery and reconstruction of the opposite breast to get a symmetrical look
- Breast prostheses
- Treatment of any complications of surgery, including lymphedema
The Women’s Health and Cancer Rights Act does not apply to some church and government insurance plans. For more information on the Women’s Health and Cancer Rights Act, visit the Department of Labor website or call toll-free at (866) 275-7922.
Many states require all health insurance
providers (including those not covered under the Women’s Health and Cancer
Rights Act) to pay for reconstructive surgery after a mastectomy. Check with
your state insurance commissioner’s office or your health insurance provider to
find out which services are covered by your state’s laws and your health plan.
For more information on insurance coverage of breast cancer-related services by state, visit the American Society of Plastic Surgeons’ website.