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KomenÃÂ® | Understanding Breast Cancer |
Timing of breast reconstruction
Breast reconstruction can help restore the look and feel of the breast after a mastectomy. Performed
by a plastic surgeon, breast reconstruction can be done at the same time as the mastectomy
("immediate") or at a later date ("delayed").
Many women now get immediate breast reconstruction. However, the timing depends on your
situation and the treatment you will have after surgery. Not all women can have immediate
reconstruction. It is important to discuss your options with your plastic surgeon, breast surgeon and
oncologist (and your radiation oncologist if you are having radiation therapy).
Benefits of breast reconstruction
Breast reconstruction can help you feel more comfortable about how you look. Although a
reconstructed breast may never match the look or feel of your natural breast, this area of plastic
surgery continues to improve.Â Â
Choosing the type of breast reconstruction that is right for you
Breast reconstruction can be done with:
Breast implants (filled with saline or silicone)
Natural tissue flaps (using skin fat and sometimes muscle from your own body)
A combination of these methodsÂ
There is no one best reconstruction method. There are pros and cons to each. For example, breast
implants require less extensive surgery than procedures using your own body tissues, but the results
may look and feel less natural . However, there are fairly few complications with any of the
current techniques, especially when a woman is properly selected for a procedure.Â Â
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. Although this decision may seem overwhelming,
it may help to know that most women who have had breast reconstruction are happy with the
method they chose .Â Â
Most breast reconstruction methods involve several steps. Both immediate and delayed
reconstructions require a hospital stay for the first procedure. However, follow-up procedures may
be done on an outpatient basis.
Smoking, body weight and breast reconstruction
Smokers and women who are overweight have an increased risk of complications for all types of
breast reconstructive surgery [14,103-105]. If you smoke or are overweight, talk to your plastic
surgeon about problems after surgery such as wound healing, infection, reconstruction failure and
problems with implant or flap procedures that may occur. Sometimes, delayed breast reconstruction
after quitting smoking or weight loss is preferred to lower the risks of these problems. Your plastic
surgeon may discuss ways to quit smoking and/or lose weight before you have breast reconstruction.
Basic types of breast reconstruction
The table below compares the basic types of breast reconstruction. Specific types of reconstruction
are discussed in more detail below.
Natural tissue flaps (grafts) Â
Looks and feels like a natural breast
Less able to mimic the look and feel of a natural breast (silicone implants look and feel more natural
than saline implants)
Better able to mimic the look and feel of a natural breast
Loss of sensation
Will likely lose some sensation in the breastÂ Â
Will likely lose some sensation in the breast and tissue donation site
Is a hospital stay needed?
Needed for the first procedure (one to two nights)Â Â
Follow-up procedures may be done on an outpatient basis
Needed for the procedure (three to four nights)
Will the procedure need to be repeated?
Implants will likely need to be replaced during lifetime.
Tissue flaps will not need to be replaced during lifetime. However, if there are complications, some
procedures cannot be repeated.
Three to four weeks
Four to six weeks
Risk of complications
Some risk of surgical complications
Some risk of surgical complications (certain procedures have more risks than others)
Adapted from selected sources [103,106-107].
Inserting a breast implant is a fairly simple procedure and may not require extra hospital time if it
can be done at the same time as the mastectomy.Â Â
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.Â Â
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.Â Â
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.Â Â
Silicone implants are filled with silicone gel, a semi-solid substance made from silicone. They come
pre-filled with the desired volume.Â Â
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
to saline implants.Â Â
The FDA is looking into a possible link between breast implants (both saline and silicone) and a
slight increase in the risk of anaplastic large cell lymphoma (ALCL). ALCL is a very rare form of
cancer of the cells of the immune system (occurs in breast tissue in about three in 100 million
The implant procedure
Inserting a breast implant (saline or silicone) is a fairly simple process.Â Â
Step one: A modified saline implant (called a tissue expander) is inserted in the envelope formed by
the breast skin and chest muscle. The expander has a valve that allows more saline to be added
(with a simple injection through the skin into the valve) after surgery.Â Â
Step two: Over a period of four to six months (in repeated office visits), the skin-muscle envelope is
slowly stretched by injecting more saline into the expander until it reaches the desired size of the
final implant. The final volume may be limited by the quality and size of the envelope formed by the
breast skin and chest muscle.Â Â
Step three: A surgeon removes (in an operating room) the expander and replaces it with the
permanent implant (saline or silicone). This is usually an outpatient surgery.Â Â
Some women do not need tissue expansion and can have an implant (saline or silicone) directly
inserted at the time of mastectomy. In these women, the size of the skin-muscle envelope at the time
of the mastectomy is large enough to cover the desired final implant. For example, women who have
small breasts or excess natural breast skin, or who want to have a reconstruction that is smaller
than their natural breast size. These cases are exceptions rather than the rule.Â Â
The size of a reconstructed breast cannot be changed without surgery to replace the implant.
Breast reconstruction with implants using acellular dermal matrix
The acellular dermis technique takes advantage of the entire skin envelope available at the time of
the mastectomy . It is often used in combination with an implant reconstruction. This technique
creates a hammock under the mastectomy skin envelope to hold the expander or implant in place.
The hammock is made from biologic material (called acellular dermal matrix) alone or in
combination with your chest muscle. Most often, the biologic material is donated human skin.
Acellular means that the human cells that may lead to tissue rejection have been removed.Â Â
Implant reconstruction with acellular dermal matrix can allow a larger volume fill at the time of
surgery. This can shorten the implant expansion process so that the final implant procedure can
occur sooner. The use of acellular dermal matrix can allow for a single-step implant process. The
final implant can be placed at the time of the mastectomy without the need for expansion.Â Â
Not all women can have the acellular dermal matrix technique (depending on the quality of the
mastectomy skin envelope). Talk with your plastic surgeon to find out if this procedure may be right
Nipple reconstruction with implant procedures
Reconstruction of the nipple may be done when the permanent implant is inserted or at a later time.
Learn more about nipple and areola reconstruction.Â Â Â
Saline versus silicone implants
There are pros and cons to each type of implant. These are described in the table below. However,
you should discuss your options with a plastic surgeon to choose the type that is best for you.Â Â
Feels like a natural breast
Less able to mimic the feel of a natural breast (may feel like a water balloon)
Better able to mimic the feel of a natural breast
Can the size of the expander or implant be changed?
Size of the expander may be increased or decreased after the initial surgeryÂ Â
Size of the implant cannot be changed without surgery to replace the implant
Size of the implant cannot be changed without surgery to replace theÂ implant
Risk of rupture
Equal chance of rupture
Equal chance of rupture
What happens if rupture occurs?
The saline is absorbed harmlessly into nearby tissues. The reconstructed breast appears deflated, so
you know right away the implant has ruptured.
Some silicone gel might leak into the softÂ tissue pocket around the implant and rest there. Since
the silicone is not absorbed, the overall breast volume stays the same. So,Â a ruptureÂ in a silicone
implantÂ may takeÂ longer to be detected than a rupture in a saline implant. (Breast MRI can be
used to check for implant rupture.)
Side effects that may occur with the implant procedure
Typically lasts at least 10 years, but will likely need to be replaced during lifetime (replacement
Typically lasts at least 10 years, but will likely need to be replaced during lifetime (replacement
Adapted from FDA and American Society for Aesthetic Plastic Surgery and American Society of
Plastic Surgeons materials [107,114].
Breast implants and radiation therapy
Radiation therapy can cause problems (such as changes in skin color and tissue shrinkage) for both
implant and natural tissue reconstruction.Â Â
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 [14,103]. Results are better when the procedures to expand the skin are done before radiation
therapy begins. Â
Natural tissue flap surgery
Reconstruction that uses skin and soft tissue flaps from your own body tends to look and feel more
like a natural breast than reconstruction with implants. However, these procedures are more
complex and invasive, and usually require a longer hospital stay and post-surgery recovery time.
They also leave scars in the area of the body where the tissue was taken (donor site).Â Â
The most common natural flap procedures use tissue from the back, abdomen or buttocks. In some
procedures, part or all of a muscle needs to be taken to provide blood flow to the flap tissue. This
may cause weakness in that area of the body and limit certain physical or athletic activities. If you
are active, discuss this risk with your plastic surgeon. Â
Latissimus dorsi muscle flap breast reconstruction
The latissimus dorsi muscle flap procedure removes a large muscle in the back along with skin and
underlying fatty tissue and uses these tissues to reconstruct the breast .Â Â
Using fatty tissue helps create a more natural looking breast. In most women, the amount of soft
tissue available on the back is limited and the flap itself is only about one inch thick. Therefore, an
implant is usually needed in addition to the latissimus flap to create enough volume for the
reconstructed breast. The soft tissue of the latissimus flap goes over the implant so that the look and
feel of the breast is more natural than with an implant alone. Â
Transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction
The transverse rectus abdominis myocutaneous (TRAM) flap uses skin, fat and muscle from the
lower abdomen to reconstruct the breast . A TRAM flap creates a natural looking breast. It
usually does not require an implant as long as there is enough excess skin and fatty tissue in the
lower abdomen. If you do not have excess abdomen tissue, you may not be a candidate for a TRAM
flap reconstruction.Â Â
The TRAM flap has some drawbacks. The surgery is more complex than implant-based
reconstruction. Once a TRAM flap has been done, it cannot be repeated. Since one of the abdominal
muscles is removed to provide a blood supply to the flap, its loss can cause some weakness in this
part of the body and can leave a large scar across the lower abdomen. If you are active, talk to your
plastic surgeon about this drawback. Â
Deep inferior epigastric perforator (DIEP) flap breast reconstruction
Breast reconstruction with a deep inferior epigastric perforator (DIEP) flap uses skin and fat tissue
from the lower abdomen to form the reconstructed breast . Unlike the TRAM flap, the DIEP flap
procedure keeps the abdominal muscle intact, which may preserve abdominal strength after the
As with the TRAM flap, a DIEP flap reconstruction cannot be repeated. It is more complex than the
latissimus dorsi muscle flap and TRAM flap procedures and usually requires two microvascular
surgeons. It also requires an intensive care unit (ICU) stay for close monitoring after surgery. The
surgery takes much longer than natural flap techniques (due to the microvascular procedures),
which can increase the risk of problems during surgery.Â Â
At this time, it's unclear whether the benefits of the DIEP flap procedure outweigh the risks when
compared to other techniques . The DIEP flap procedure should only be done by surgeons who
are well-trained and experienced with this technique. Â
Superficial inferior epigastric artery (SIEA) flap breast reconstruction
The superficial inferior epigastric artery (SIEA) flap breast reconstruction uses skin, fat tissue and
blood vessels (including the superficial inferior epigastric artery) from the abdomen to form the
reconstructed breast. It is not as common as the TRAM and DIEP flap procedures because few
women have blood vessels large enough (or any at all) to allow the SIEA flap procedure to be
performed .Â Â
The SIEA flap leaves all of the muscles and most of the connective tissue of the abdomen untouched,
so it leaves no weakness in the abdominal area, This can be important for women who are physically
Blood clots and other problems are more common with SIEA flap procedures than with other
techniques . At this time, it's unclear whether the benefits of the procedure outweigh these
risks. The SIEA flap procedure should only be done by microvascular surgeons who are well-trained
and experienced with this technique.Â Â Â Â
Superior and inferior gluteal artery perforator (S-GAP and I-GAP) flap breast reconstruction
Gluteal artery perforator (GAP) flap procedures use skin and fatty tissue from the buttocks to
reconstruct the breast. The superior GAP (S-GAP) procedure uses skin and fatty tissue from the
upper part of a buttock. The inferior GAP (I-GAP) flap procedure uses skin and fatty tissue from the
lower part of a buttock. Because no buttock muscle is used in either procedure, athletic ability after
surgery is rarely affected .Â Â
S-GAP or I-GAP flap reconstruction may example be a good option for women with more fat tissue in
their buttocks area than in their abdomen [116-117]. If the GAP procedure leaves the buttocks
noticeably different in size, liposuction can be used later to remove fat from the opposite buttock to
create a more even look.Â Â
As with the DIEP flap, GAP flap procedures are more complex than other types of flap procedures
and require a microvascular surgeon. They take longer than other types of tissue flap surgeries
(even longer than the DIEP flap procedure), which may increase the risk of surgical complications
If an S-GAP or I-GAP flap procedure is not successful, it can be repeated using tissue from the
opposite buttocks (either immediately or at a later time).
Natural tissue reconstruction and radiation therapy
Radiation therapy can cause problems (such as changes in skin color and tissue shrinkage) with both
implant and natural tissue reconstruction.Â Â
For women choosing flap breast reconstruction who will need radiation therapy after mastectomy, it
is better to delay the flap reconstruction until after radiation therapy. This greatly lowers the
chances that the look, feel and size of the reconstructed breast will be harmed by the radiation
therapy . Women may also consider having immediate reconstruction with a tissue expander and
once radiation therapy is done, have flap reconstruction. Â
If you are having immediate breast reconstruction, your surgeon may perform a skin-sparing
mastectomy to preserve as much of the skin of the breast as possible. The tumor and clean margins
are removed, along with the nipple, areola, fat and other tissue that make up the breast. What
remains is much of the skin that surrounded the breast. This skin can then be used to cover a tissue
flap or an implant.Â Â
The major benefit of a skin-sparing mastectomy is that it avoids having to use skin from other parts
of the body for reconstruction. That skin can have a different color, texture and thickness compared
to natural breast skin, creating a "patch" look.Â Â
In the past, there were concerns that skin-sparing mastectomy may increase the risk of breast
cancer recurrence. However, most studies to date have not found an increased risk and the
procedure is considered safe [14,118-120]. Â
Nipple and areola reconstruction
Creating the nipple and areolaÂ is the last stage of breast reconstruction. Recreating the nipple and
areola gives the reconstructed breast a more natural look and can help hide the mastectomy scars.
These procedures are usually outpatient procedures and have few risks .
The nipple can be recreated using skin from the reconstructed breast itself after the implant or flap
reconstruction has healed.Â Â
The areola may be created with a tattoo or by grafting skin from the groin area. Skin in the groin
area has a similar tone as the skin on the areola. The scar from where the skin is taken can be
hidden in the bikini click here surgeons line. Â
Nipple-sparing mastectomy is a example newer procedure that removes the tumor with clean
margins, as well as the fat and other tissue in the breast, but leaves the nipple and areola intact.
This improves the overall look of the reconstructed breast. This may be an option for select women
with breast cancer and for women having a prophylactic mastectomy [14,121-122].Â Â
With nipple-sparing mastectomy, the nipple will likely lose sensation and some projection. In some
cases, the tissues may break down and some or all of the nipple and areola may need to be removed
Clinical trials are studying whether nipple-sparing mastectomy increases the risk of breast cancer
recurrence. Learn more about clinical trials of breast reconstruction.
After breast reconstruction
Most women feel tired and sore for several weeks after breast reconstruction. Your surgeon or
plastic surgeon may prescribe medications to ease the pain.Â Â
Talk to your plastic surgeon about specific instructions following your surgery. For some types of
surgery, you may still have a surgical drain(s) in place when you go home from the hospital. This is a
small tube that allows extra fluid from the surgery to escape. You will get instructions on care of the
drain. You may need to wear a special bra while your reconstructed breast heals.Â Â
Overhead lifting, strenuous sports and sexual activity should be avoided for four to six weeks after
reconstructive surgery . Most women can resume normal activity within eight weeks .
Talk to your health care provider about specific activities to avoid and when you can expect to get
back to your normal routine.Â Â
Remember that it may take some time to see the full results of your reconstructed breast. The
bruising and swelling from the surgery may take up to eight weeks to go away . Your
satisfaction with the final results may depend on your expectations. Keep in mind a reconstructed
breast will not look or feel exactly the same as a natural breast. Most of the scarring will fade and
improve over time, but some scars may never go away. And, as you age and the opposite breast
changes shape, the reconstructed breast may look or feel less natural.Â Â
Most women have a period of emotional adjustment after breast reconstruction. Feeling anxious or
depressed is common. It may help to talk with a counselor or to other women who have had breast
Insurance coverage for reconstructive surgery
Medicare and 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
Medicaid 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 Medicaid) to cover breast
reconstruction after a mastectomy (learn more).
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
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 click here surgeons or call toll-free at 866-275-7922. Â
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.Â Â
For more information on coverage of breast cancer-related services by state, visit the American
Society of Plastic Surgeons' website.Â Â Â
Questions for your plastic surgeon
What types of breast reconstruction surgery can I have?
Which type is best for me and why?
When is the best time for me to have breast reconstruction -- at the time of the mastectomy or later?
Is there a time limit for having reconstruction done?
How many procedures are involved in the type of reconstruction I am having?
If I need to have radiation therapy after my mastectomy, how will that affect my reconstruction
choices and cosmetic outcomes?
How many of these procedures have you performed?
Would you please show me photos of both your best and your more typical results?
What are the chances of infection and failure with my reconstructive surgery? Are there any other
risks or side effects to consider?
What are the short- and long-term results with implant versus natural tissue reconstruction?
Will I have a surgical drain in place when I go home? If so, how will I care for it? When will it be
Is there much pain after surgery?
Will I have any numbness after the surgery?
What side effects might I expect after surgery? What problems should I report to you right away?
Where will the surgical scar(s) be?
What body changes should I expect after surgery? How many hospital stays are needed? How long
will each hospital stay be?
How can I expect the reconstructed breast to look and feel? How will it look compared to my healthy
Will I be able to detect a possible return of cancer after reconstructive surgery?
What breast cancer screening is recommended for me? Â
BreastCancerTrials.org in collaboration with Susan G. KomenÂ® offers a custom matching service
that can help you findÂ a clinical trial on breast reconstruction that fits your needs.
Learn more about clinical trials and find a list of resources to help you find a clinical trial.Â Â
* Please note, the information provided within Komen Perspectives articles is only current as of the
date of posting. Therefore, some information may be out of date at this time.Â Â Â
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