If you chose to have a mastectomy, you may decide to undergo reconstruction of your breast(s). Reconstruction is not a requirement—it’s a personal choice. Learn as much as you can about the process before making a decision.
In the basic operation, a plastic surgeon restores the size and shape of your breast following a mastectomy. There are several ways to accomplish this:
After restoring the breast’s shape, your surgeon can restore the nipple and areola (the darker area of skin surrounding the nipple) in a later procedure, usually 3-6 months afterward. This optional procedure uses your own tissue for the nipple. In another step, doctors can tint the areola with tattoo dye. Some new procedures—called nipple-sparing mastectomies—can make nipple reconstruction unnecessary.
Understand that mastectomies result in a loss of sensation and breast function—and that breast reconstruction cannot completely restore them.
Under the Women’s Health and Cancer Rights Act, insurers covering mastectomy must also cover breast reconstruction, surgery and reconstruction of the other breast to achieve symmetry, prostheses, and treatment of physical complications of mastectomy including lymphedema. This means insurance companies must pay for any procedure that is required to help you achieve symmetry in your breasts, even years later.
One of the first decisions to make about breast reconstruction concerns timing. You can have it done right away or wait until later.
Immediate reconstruction takes place at the same time as your mastectomy, with the surgeon and plastic surgeon working together as a team. Immediate reconstruction saves skin, lessens scarring and avoids an extra surgery. However, immediate reconstruction with implants can cause complications if you need radiation later.
Delayed reconstruction occurs at some point in time after the mastectomy, most often because you need radiation treatment. Doctors usually recommend 6-12 months between radiation and reconstruction.
Some women undergo breast reconstruction immediately after breast cancer surgery because they wish to avoid subsequent reconstructive surgeries, as well as waking up from surgery with the loss of either one or both breasts. However, many women feel they need more time to decide on a type of breast reconstruction in order to consider all options. Immediate reconstruction may not be an option with some treatments or when radiation is required. Make sure to research all options thoroughly. You might consider talking with other women who have had reconstructive surgery to determine what is best for you.
Breast implants are silicone sacs filled with either saline or silicone that are placed behind your chest muscle. Usually, the implant form of reconstruction is a two-step process. The plastic surgeon will implant a tissue expander first. A tissue expander is like an implant, but it is not fully inflated, and so at first, it is smaller than your implant will be. In the weeks following surgery, your plastic surgeon will inject saline into the tissue expander until it is fully expanded. Then, in the second step of the process, you will undergo surgery to remove the tissue expander and replace it with your “permanent” implant. Implants are not truly permanent and will likely need to be replaced at some time during your life.
Flap reconstruction depends upon your body type and anatomy. In flap reconstruction, tissue and muscle from another part of your body (tummy, back, thigh, buttocks) is used to make a new breast. There are a number of different techniques:
Flaps that Use Muscle
There are currently four types of breast reconstruction that use a muscle from another part of your body to reconstruct a breast:
Transverse Rectus Abdominis Myocutaneous (TRAM) Flap takes tissue from your abdomen in a "tummy tuck" procedure to create a breast. It removes the muscle of the abdominal wall and results in a hip-to-hip scar. Women who are very thin and lacking excess abdominal fat are not usually candidates for this type of procedure.
Latissimus Dorsi Flap involves the latissimus dorsi muscle (a back muscle located underneath the shoulder), which is turned around to recreate a breast. Normally, an implant will also accompany this procedure in order to create a symmetrical breast. Women with smaller to moderately sized breasts are the best candidates for this procedure. While it should not affect upper body strength, it may cause unevenness in the back's appearance.
Gluteal Flap uses skin, fatty tissue and muscle from the buttocks to create the breast shape. This flap can be slightly more firm than other donor sites and leaves a scar in the center of the bottom of the buttocks. This procedure is rarely performed today.
Transverse Upper Gracilis (TUG) Flap is taken from the upper inner-thigh area in a crescent shape. Only a small amount of the gracilis muscle is taken with the flap to ensure a reliable blood supply. There is no functional consequence to removing the gracilis muscle, which is the same muscle used to reconstruct facial paralysis or forearm injuries. This flap is coned to create a projecting breast shape. An immediate nipple and areola reconstruction are also possible with this flap.
There are three breast reconstruction options that do not require the removal of muscle to create a breast mound.
Deep Inferior Epigastric Perforator (DIEP) Flap is similar to the TRAM flap, except the muscles of the abdomen are preserved in this procedure. It is a delicate microsurgery where the blood vessels from the belly tissue are reconnected to the blood vessels in the chest.
Superficial Inferior Epigastric Artery (SIEA) Flap is otherwise the same as the DIEP procedure and represents a second choice for women whose superficial vessels are more dominant than the deep inferior epigastric perforators (DIEPs). It is not known before surgery whether a woman has an adequately sized SIEA blood vessel. These are looked at by the microsurgeon during surgery, and a determination will be made at that time if they are suitable to supply a flap.
Gluteal Artery Perforator (GAP) Flap allows for reconstruction using your own body’s tissue when there is inadequate abdominal fat to restore your breast to its proper size and shape. Skin and fatty tissue are collected from the buttocks/hip region (without sacrificing underlying muscles) and sculpted into the new breast mound. There is a donor site scar on the buttocks.
It is common to wonder what your reconstructed breast will look like and how it will be different than your natural breast.
The goal of breast reconstruction is to make your breasts look balanced when you are wearing a bra or swimsuit and to alleviate the need for an external prosthesis, if desired. Your body image and self-esteem may improve after your reconstruction surgery, but this is not always the case. You and those close to you must be realistic about what to expect from reconstruction.
The difference between the reconstructed breast and the remaining breast may be seen when you are nude. It will not look the same, and you will likely have scarring, although it will fade over time. Ask your plastic surgeon to show you pictures of the results of the different types of reconstruction you are considering. Most plastic surgeons will have picture books.
Reconstructed breasts do not have the same feeling and sensation as natural breasts. Talk with women who have had the type of reconstruction you are considering in our private Facebook groups. Although no surgery can make your breasts look the same as they did before, or erase the pain caused by your breast cancer diagnosis, for some women reconstruction can be a tool to restoring a sense of normalcy.
Reconstruction is not for everyone. There are plenty of women who choose not to have reconstruction and are happy with their decision. If you want to have the appearance of a breast mound in swimsuits or clothing, without reconstruction, you may wear prostheses that fit into a pocket sewn into your bra or swimsuit. These prosthesis are soft and can be made of silicone, foam or fiberfill.
Once you have healed from surgery, it’s best to be fitted by a certified fitter who can recommend the best type and size of prostheses for you. Some stores, such as Nordstrom, will sew pockets into any bra you purchase there at no extra charge. Prostheses may also be covered by your insurance company.
The decision to undergo breast reconstruction is very personal. Investigate your options so you can feel confident with your choice. You can speak with another young woman who has had breast reconstruction—or who has opted not to—through our Peer Mentor program.