What You Need to Know About Reconstruction After Mastectomy

If your treatment includes a mastectomy, you will have several reconstructive options. Finding what works best for you will be a very personal decision. It will depend on different factors, including your treatment plan, the type of reconstruction you choose, your overall health and your physical body. And remember - reconstruction is not a requirement; it’s a personal choice.

Types of Reconstruction

• Skin-sparing mastectomy (for later breast mound reconstruction)
   
• Breast mound reconstruction, which restores the size and shape of your breast
  • Breast mound reconstruction using breast implants
  • Breast mound reconstruction using your own body tissue referred to as a FLAP procedure
• Mastectomy with an aesthetic flat closure

Do all reconstruction choices require surgery and will my insurance cover them?

All reconstruction requires surgery. Selecting a surgical team you feel comfortable with is important. A surgeon should explain the limits, risks and benefits of your reconstruction options.

• Breast mound reconstructive surgeries are performed with not only a general surgeon, but also a plastic surgeon.
• Aesthetic flat closure requires a general or breast surgeon.

Under the Women’s Health and Cancer Rights Act, insurers covering mastectomy must also cover reconstructive surgery (which now includes aesthetic flat closure) and reconstruction of the other breast to achieve symmetry, treatment of physical complications of mastectomy and revisions. This means insurance companies must pay for any procedure that falls under those categories, even years later.

What should I know about reconstruction and nipples?

Nipples-sparing mastectomies are an option for some individuals. In this type of surgery, your nipple and areola will remain intact with all of the tissue underneath being removed. The extent and location of your cancer will determine if you are a good candidate to preserve your nipple-areola complex.

If your nipple-areola complex is removed, a plastic surgeon can also recreate the nipple and areola (the darker area of skin surrounding the nipple) at a later date, usually 3-6 months afterward. This optional procedure uses your own tissue for the nipple.

In another procedure, a doctor, nurse or tattoo artist can tint the areola with tattoo dye. A reconstructed nipple will have no sensation or function.

Immediate or Delayed Reconstruction

One of the first decisions to make about reconstruction concerns timing. You can have it done right away or wait until later.

Immediate Reconstruction:

Immediate breast mound reconstruction takes place at the same time as your mastectomy. The general or breast surgeon and plastic surgeon work together as a team. Immediate reconstruction can save skin, can sometimes lessen scarring and can minimize the number of extra surgeries.

However, it is not unusual that more than one procedure will be required to complete the reconstruction process. Some individuals undergo breast mound reconstruction immediately after mastectomy because they wish to avoid subsequent reconstructive surgeries. Immediate reconstruction may not be an option with some treatments or when radiation is required.

Aesthetic flat closure is completed at the time of mastectomy and may require a revision later. Aesthetic flat closure rebuilds the chest wall after the breast is surgically removed. Extra skin, fat and tissue are removed, and the scar is made to appear flat and smooth.

Delayed Reconstruction:

Delayed reconstruction occurs at some point after the mastectomy. There are many reasons why someone may undergo a delayed breast reconstruction.

Some have advanced disease and need to progress to chemotherapy and/or radiation therapy as quickly as possible; a mastectomy without breast mound reconstruction usually offers the quickest procedure with the quickest healing time.

Some are not sure whether or not they want to undergo breast reconstruction and decide to undergo mastectomy and delay the decision until a later date.

Usually, when a patient opts not to undergo breast reconstruction at the same time as mastectomy, the breast surgeon will close the mastectomy in a simple flat line. If a woman would like to preserve the option of the best possible reconstruction later on, then she can request a nipple-sparing mastectomy with no reconstruction, but many breast surgeons will be hesitant to do this because of the deflated appearance of the excess skin, problems fitting a prosthesis, and irregular scarring.

The most common reason patients do not undergo immediate reconstruction is because it is not offered - especially if there is no plastic surgeon available.

Make sure to research all options thoroughly. You might consider talking with others who have had reconstructive surgery to determine what is best for you. Remember to talk with your surgeon openly about your preferences. Be sure to voice any concerns and the priorities that you have about mastectomy and your surgical options.

Types of Breast Mound Reconstruction

Reconstruction with Implants

Breast implants are silicone sacs filled with either saline or silicone. These are used to recreate a breast mound.

Traditionally, breast implants were placed under your chest muscle, but more surgeons are placing breast implants above your chest muscle, just under your breast skin. It is much less painful to have breast implants placed above your chest muscle, and it is also where your breast tissue was originally located so it is more anatomically accurate to place a breast implant above the muscle.

Usually, the implant form of reconstruction is a 2-step process. The plastic surgeon will place a tissue expander first. A tissue expander is like an implant, but it has a port that allows the plastic surgeon to add and remove saline or air from the tissue expander while it is in your body.

The tissue expander may not be fully expanded when it is first placed, but there is a magnet that allows the plastic surgeon to find the port in the office to add or subtract saline or air as needed. If the tissue expander is not fully expanded at the time it is placed, then the surgeon will add saline or air through the port in his or her office.

Once the tissue expander is fully expanded, a second surgery will take place to remove the tissue expander and replace it with your “permanent” implant. Implants are usually not truly permanent and will likely need to be replaced at some time during your life.

Natural Tissue Reconstruction

There are several different types of natural tissue (or autologous tissue) reconstruction, which is reconstruction using your body’s own tissue to recreate a living breast.

Natural tissue reconstruction consists of either some type of a flap or some type of a graft. A flap is tissue from another part of the body that comes with its own blood supply to keep it alive, and the flap tissue can consist of skin, fat, muscle, and/or bone or a combination of the above.

Flap reconstruction depends upon your body type and anatomy. In flap reconstruction, tissue from another part of your body is used to make a new breast. The most common donor sites are the lower abdomen, back, thighs and buttocks.

A graft is tissue from another part of the body that does not come with its own blood supply, and thus depends on osmosis for nutrients to diffuse to the cells to stay alive. Again, grafting also depends on your body type, but it is easier to obtain tissue for grafts from more areas of the body.

When it comes to breast reconstruction, flap reconstruction is usually either a musculocutaneous flap that consists of skin, fat and muscle with attached blood vessels or a perforator flap (type of fasciocutaneous flap) that consists of skin and fat only with blood vessels. Grafts in breast reconstruction usually means fat grafting, but occasionally skin grafts. Fat grafting involves liposuction, processing the fat cells and then injecting the fat cells to build a breast mound over time. Skin graft involves cutting or slicing away skin from another part of the body and sewing it to the breast to create a nipple or an areola.

Flaps that Use Muscle

There are currently four types of breast reconstruction that include muscle from another part of your body to reconstruct a breast:

Transverse Rectus Abdominis Myocutaneous (TRAM) Flap takes skin, fat and muscle  from your lower abdomen to create a breast mound. It results in a hip-to-hip scar similar to a “tummy tuck” scar. The TRAM flap can either be a “pedicled” flap, in which the blood vessels stay attached, the entire rectus abdominis muscle is removed, and the tissue is tunneled through the bottom of the breast to recreate the breast mound. A TRAM flap can also be a microvascular “free” flap, in which the blood vessels are disconnected, a smaller portion of the rectus abdominis muscle is removed, and the flap is transferred to the chest wall with blood vessels from the TRAM flap sewn to the blood vessels of the chest wall under an operating microscope. Women who are very thin and lack excess abdominal fat may not have enough donor site tissue to recreate a large breast, unless the surgeon is able to take more than the average amount of abdominal tissue.

The Latissimus Dorsi Flap involves the latissimus dorsi muscle (a back muscle located underneath the shoulder), which is turned around to recreate a breast. Sometimes, an implant will also accompany this procedure in order to create more breast volume. There are numerous studies that show that the latissimus dorsi flap affects upper body strength, and it may be difficult to swim or climb ladders after this type of flap reconstruction. The scar from the latissimus dorsi flap is in the back, so it may be hard to see - especially if the plastic surgeon designs it to be hidden in the bra line. The latissimus dorsi is almost always a pedicled flap, which means that the blood vessels stay connected and the skin, fat, and muscle from the back is tunneled through an opening at the side of the breast.

The Gluteal Flap uses skin, fatty tissue and muscle from the buttocks to create the breast shape. The fat from the buttocks is usually firmer than other donor sites, so that the flap tends to create a firmer breast. The gluteal flap leaves a scar in the center or upper portion of the of the buttocks and can be deforming. It requires several positional changes in the operating room, so it is the longest and most complex type of flap reconstruction. It requires microsurgery, and blood vessels are usually very small.  Thus, this procedure is rarely performed today.

The Transverse Upper Gracilis (TUG) Flap is taken from the upper inner-thigh area in a crescent shape. A portion of the gracilis muscle is taken with the flap to ensure a reliable blood supply. There is minimal functional consequence to removing the gracilis muscle.. This flap is coned to create a projecting breast shape, and the TUG flap is a microvascular free flap.The scar is usually hidden in the buttock crease.

Perferator Flap Breast Reconstruction

There are multiple types of perforator flap breast reconstruction, which preserve the muscle in the donor site so that the flap is elevated with the blood vessels while leaving the donor site muscle intact. Perforator flaps were developed because the muscle in musculocutaneous flaps is not actually used in the breast reconstruction, and the muscle atrophies after it is removed from the donor site. Perforator flaps were developed to avoid the problems that result from removing muscle from the donor site such as hernias, bulges, weakness and other issues. Since the muscle is not cut, perforator flap reconstruction has also been shown to be less painful than musculocutaneous flap reconstruction.

Deep Inferior Epigastric Perforator (DIEP) Flap is similar to the TRAM flap, except the muscles of the abdomen are preserved in this procedure so as not to violate the abdominal wall integrity. For this reason, the DIEP flap lowers the risk of abdominal bulges and hernias. The DIEP flap is a microsurgical free flap in which the blood vessels from the lower abdomen tissue are reconnected to the blood vessels in the chest wall under an operating microscope. The same tissue is taken as in a tummy tuck, with the same scar afterwards. In the DIEP flap, the nerves can be dissected with the perforators so that they can be reconnected to nerves in the chest wall to provide sensory restoration to the breast.

Since the DIEP flap is the most common type of perforator flap, a number of variations have arisen. The Superficial Inferior Epigastric Artery (SIEA) Flap uses the same tissue as a DIEP flap, but it is based on different blood vessels that are above the fascia covering the muscle. It is even less invasive than the DIEP flap because there is no need to touch the muscles at all. It is only possible in a small minority of women whose superficial vessels are larger than the deep inferior epigastric perforators (DIEPs). It is not known before surgery whether a woman has adequately sized SIEA blood vessels. 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.

For thin women, the DIEP flap can be extended by including the Deep Circumflex Iliac Artery (DCIA) for a combined DIEP and DCIA flap that includes tissue that extends out to the hips. This allows for more volume from the donor site to create a larger breast in women without a lot of abdominal fat. The DIEP and DCIA flaps require dissecting and sewing together extra blood vessels so that it is a longer operation. The scar is similar to the DIEP flap, except it may be slightly longer.

The Profunda Artery Perforator (PAP) 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. It is similar to the TUG flap in that it uses skin and fat from the upper inner thighs, but unlike the TUG flap it does not use any muscle. The PAP flap usually has the softest tissue of all the flaps, and like the TUG flap the tissue is coned to recreate the breast mound to create a perky appearance to the breast. The scar is hidden in the groin crease. The PAP is most commonly done in women who are too thin to have a DIEP flap, who have had a previous tummy tuck, or who simply prefer to have a flap using fat from their inner thighs where the scar is hidden. Like the DIEP or SIEA flaps, a nerve can be dissected with the perforators to create a sensate flap so that sensation can be restored to the reconstructed breast. For very thin women, the DIEP flap and the PAP flap can be stacked on top of each other by sewing together extra blood vessels. The PAP flap is a microvascular free flap.

The Superior Gluteal Artery Perforator (SGAP) Flap uses skin and fat from the upper buttock/hip to recreate the breast mound. Like the Gluteal flap, the fat from this donor site is firmer than other areas. Since there is no muscle removed in the SGAP flap, the donor site does not appear as deformed as in the gluteal flap. Since the patient has to be repositioned multiple times during this procedure, it is a longer operation than the other flaps. The blood vessels are usually shorter too, so it is a more complex operation. The scar is on the upper buttocks, and the SGAP flap is a microvascular free flap.

The Inferior Gluteal Artery Perforator (IGAP) Flap uses skin and fat from the lower buttock to recreate the breast mound. Like the Gluteal and SGAP flaps, the fat from this donor site is firmer than other areas. Again, since there is no muscle removed in the IGAP flap, the donor site does not appear as deformed as in the gluteal flap. One disadvantage of this flap is that the sciatic nerve often loses its padding, which can cause pain and discomfort after surgery. Since the patient has to be repositioned multiple times during this procedure, it is a longer operation than the other flaps. The blood vessels are usually shorter too, so it is a more complex operation. The scar is in the lower buttock crease, which allows it to be concealed. The IGAP flap is a microvascular free flap.

The Thoracodorsal Artery Perforator (TDAP) Flap uses skin and fat from the back to recreate the breast mound. Like the latissimus flap, the TDAP flap is a pedicled flap so that the blood vessels are not disconnected, and no microsurgery is needed. Unlike the latissimus flap, the TDAP flap does not take any muscle so that the upper body strength is preserved. The scar is in the upper back, and the surgeon can design the flap to conceal it in the bra line.

Fat Grafting

For women who want natural tissue breast reconstruction, but want to avoid the long scars from flap surgery, it is possible to reconstruct the breast with fat grafting. Fat grafting involves liposuction of excess fat from various parts of the body, processing the fat to eliminate impurities from the fat cells, and then injecting the fat cells into the chest wall to create a breast mound. Since there is no blood supply in the fat cells, the fat will only survive if nutrients travel through the fat cell wall by osmosis. Thus, the survival of the fat cells is unpredictable, and only a limited amount of fat can be injected at a time, since there needs to be capillaries near the fat cells. About 30-70% of the fat cells will be resorbed by the body, so it is unpredictable how much of the injected fat will survive. For this reason, fat grafting usually involves multiple operations to build up a breast mound layer by layer, and it usually works best for smaller breasts or to improve symmetry and shape in flap reconstructions at a second stage.

Skin Graft

One type of nipple reconstruction involves using skin grafts, usually from the upper inner thigh, to reconstruct the nipple-areola complex. The skin graft is cut out from the donor site, and sutured to the reconstructed breast mound to form a nipple. The skin graft needs to be completely immobilized for 5-7 days, so that nutrients can diffuse through to the cells to keep the skin alive.

Your Reconstructed Breast

It is common to wonder what your reconstructed breast will look like and how it will be different from your natural breast.

The goal of breast mound reconstruction is usually 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. Depending on the type of reconstruction, the skill of your surgeon, and your treatment (i.e., whether or not you need radiation), the difference between the reconstructed breast and the remaining breast may be seen when you are nude.

If you have a traditional mastectomy with a transverse incision and reconstruction with implants, your breasts will definitely not look the same, and your scars will be visible. With this type of mastectomy and reconstruction, if you only have a mastectomy on one side you will almost certainly have asymmetry between your two breasts.

If you have a nipple-sparing mastectomy, then it will be easier to keep your breast shape and conceal your scars - although it will still be difficult to obtain symmetry if you only have mastectomy on one side.

If you have nipple-sparing mastectomy and natural tissue breast reconstruction - especially without radiation therapy - then it may be possible to reconstruct your breasts so that it is difficult to tell the difference between your original breasts and your reconstructed breasts.

If you are only having mastectomy on one side, it is easier to obtain symmetry with nipple-sparing mastectomy and natural tissue breast reconstruction. Ask your plastic surgeon to show you pictures of the results of the different types of reconstruction you are considering, so you can discuss your preferences and realistic expectations.

Feeling and Sensation

Reconstructed breasts usually do not have the same feeling and sensation as natural breasts, although sensory restoration may be possible with perforator flap breast reconstruction. Talk with women who have had the type of reconstruction you are considering in our private Facebook groups. Although surgery may not make your breasts look the same as they did before or it may not erase the pain caused by your breast cancer diagnosis, for some women reconstruction can help restore a sense of normalcy.

Choosing No Reconstruction (Aesthetic Flat Closure)

Breast mound reconstruction is not for everyone. There are plenty of people who choose not to and are happy with their decision.

When people decide not to undergo breast reconstruction, most breast surgeons will simply perform a traditional mastectomy and close the wound in a straight line. If a person is unsure about whether or not they want later breast reconstruction, some plastic surgeons may suggest leaving extra skin to make later reconstruction easier.

If you are certain that you do not want breast reconstruction in the future, you can request an “aesthetic flat closure” without extra breast skin. This will leave you with a completely flat chest wall with no extra skin or fat. Although you cannot later take back any skin that has been removed, the remaining skin can be stretched if you change your mind later. That said, discarding the extra skin will change the shape of the breast mound if you do decide to undergo breast reconstruction at a later date.

People choose aesthetic flat closure for several reasons.

• Health issues and treatment options that make one or more surgeries involved in breast mound reconstruction unfeasible.
• The desire to resume daily life and activities more quickly.
• Concern about losing muscle strength with older techniques of musculocutaneous flap reconstruction or implant reconstruction under the muscle. Perforator flap breast reconstruction and above-the-muscle implant reconstruction preserves the muscle to avoid any damage to muscle strength.
• Concern about cost, insurance coverage and loss of income due to longer healing times associated with breast reconstruction. All insurance companies in the United States are required to cover breast reconstruction, but there may be copayments or deductibles to take into consideration. In addition, taking time off to heal from breast reconstruction may be a consideration for women who need to get back to work.
• Personal mindset and understanding that going flat with no breast reconstruction after mastectomy is a perfectly valid and beautiful option.

 If you want to have the appearance of a breast mound in swimsuits or clothing without undergoing surgical breast reconstruction, you may wear external prostheses that fit into a pocket sewn into your bra or swimsuit.

These prostheses and swimming forms are soft and can be made of silicone, foam or fiberfill. Silicone prostheses are usually expensive, but are often covered by your insurance company. Foam prostheses are inexpensive and are not usually covered by your insurance company. Silicone prostheses tend to be heavier, and the ones created for swimming float. Foam prostheses are very light, and fit into any bras, camisoles or bathing suits that have pockets for removable pads. Foam prostheses are also washable.

Talk to Someone Who has Been There

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 adult who has had breast reconstruction—or who has opted not to—through our Peer Mentor program.