Breast cancer treatment often involves the partial or total removal of one or both breasts. This procedure is called a mastectomy. Breast reconstruction can take place after a mastectomy to reduce the psychological impact of the procedure.
This reconstruction process can help a person find their self-confidence again and feel better during their cancer recovery.
In this article, we will cover the types of breast reconstruction surgery available, how to decide which is best, recovery, and risks.
The goal of breast reconstruction is to reform or reshape one or both breasts after a mastectomy or lumpectomy.
A mastectomy is a surgical procedure during which a surgeon removes the entire breast, usually including the nipple and areola, to treat or prevent breast cancer.
A lumpectomy is the removal of a breast section that contains a smaller tumor.
Although many factors can help determine the most suitable type of breast reconstruction, there are two main options:
- Implants or prosthetics: This type of surgery uses silicone or saline implants.
- Autologous or skin flap surgery:
This methoduses tissue from another part of the body.
In some cases, a surgeon might use a combination of both techniques to create a more natural reconstruction of the breast or breasts.
Additional techniques can help the surgeon reconstruct the nipple and surrounding area if cancer treatment has affected these.
Breast reconstruction may take place at the time of mastectomy or lumpectomy. This is called immediate reconstruction.
However, delayed reconstruction is also an option. A person might choose to undergo reconstruction after the mastectomy has healed and other cancer treatments have come to an end.
This section provides more detail on implants and skin flap surgery.
When reconstructing a breast with implants, a surgeon will insert silicone or saline implants underneath the skin or muscle, in the place of the previous breast tissue.
For most people, this is a two stage procedure. During the first stage, a surgeon places a tissue expander underneath the remaining breast skin, or pectoralis muscles. The expander serves as a temporary saline implant that gradually stretches the remaining tissue.
After the person has fully healed following surgery, a surgeon will inject sterile saline or salt water through the skin into the tissue expander on a weekly basis. This balloon gradually grows, stretching the overlaying skin and muscle until the breast reaches a size with which the person is comfortable.
When the chest tissues heal and the surgeon has added enough saline to the tissue expander in preparation for the implants, they will perform the second procedure to insert the implants.
The surgeon removes the tissue expanders and replaces them with either a silicone or saline implant. They will usually reopen the original scar. This often means that the procedure leaves no new scars on the chest.
In some cases, a surgeon may place a permanent saline or silicone implant at the time of the mastectomy, without use of a tissue expander.
Skin flap surgery
With skin flap surgery, the surgeon takes tissue from another part of the body and moves it to the chest to rebuild the breast.
The surgeon usually removes this tissue from the abdomen. However, it may come from other places on the body, including the buttock, back, or thigh.
Skin flap surgery highly complex, as it involves transferring tissue from one area of the body to another. Two methods are available for this surgery:
- free flap surgery
- pedicle flap surgery
In free flap surgery, a surgeon completely removes the tissue and the blood vessels that provide it with circulation for placement in the breast.
They stitch the blood vessels into other blood vessels in the chest at the intended site of placement. These blood vessels are very small, so the surgeon will use a microscope to sew them together in a procedure called microsurgery.
In pedicle flap surgery, a surgeon will not entirely remove the transplanted tissue from its blood vessels. Instead, the tissue remains attached to the body, and the surgeon usually rotates this into the chest to form the breast.
A surgeon usually uses tissue from the abdomen or back for pedicle flap surgery.
Choosing to undergo breast reconstruction surgery is a personal choice. Many people mourn the loss of their breasts or experience severe anxiety and self-image problems after undergoing mastectomy.
Many choose to have breast reconstruction surgery for this reason. However, after choosing breast reconstruction, some important decisions still remain, including:
- the type of surgery to have
- when to have the surgery
- whether to have surgery on both breasts to match the reconstructed breast to the other breast
Some factors that help a person and their surgeon decide the best kind of breast reconstruction include:
the person's body type, as slimmer people may not have enough tissue elsewhere on the body to perform skin flap surgery
- overall health, including whether or not they smoke
- the location, severity, and types of cancer
- other cancer treatments, such as radiation therapy or chemotherapy, that the person may have received
- whether surgery is necessary on one or both breasts
- the number of surgeries a person is willing to have
- how quickly the person wishes to recover from surgery
- whether their insurance policy covers cosmetic or elective treatment
Breast reconstruction is major surgery. A person can expect to spend several days in the hospital after both implant reconstruction and flap reconstruction.
People may need more than one surgery to fully reconstruct the breast(s). Skin flap surgery has a longer recovery time than reconstruction using implants.
Both types of surgery leave someone unable to perform most daily activities for up to 2 months. However, the psychological impact of losing one or both breasts may last for longer than this.
In the first 2 months of recovery from breast reconstruction surgery, people might experience:
- pain, bruising, swelling, or soreness in the breasts and at the site from which the surgeon removed tissue during skin flap surgery, such as the abdomen, back, or buttocks
- restrictions on movement, such as lifting the arms overhead
A person will likely require stitches and drainage tubes following the surgery.
During the initial recovery period, a doctor may prescribe pain relief medication to keep the individual comfortable. They may also advise wearing an elastic support bra to reduce swelling.
Reconstructed breasts will not exactly resemble the person's natural breasts or provide the same level of sensation. However, with time, some sensation may return.
The risks and complications a person may experience while breast reconstruction is taking place include:
- bleeding or blood clots
- potential complications with anesthesia
- fluid buildup in the breast or at the donor site (for skin flap surgery)
- extreme fatigue
- slow or disrupted wound healing
Additional complications that can occur after surgery include:
- tissue death, or necrosis, which may develop in the skin, fat, or tissue flap
- a loss of muscle strength at the donor site (for skin flap surgery)
- changes in breast or nipple sensation
- a need for more surgical procedures if complications occur
- uneven breasts
- problems with the implant, such as movement, rupture, leakage, or scar tissue
- a need to have the implants removed
Additional procedures are sometimes required after the first stages of surgery. Minor revision surgeries usually take place several months to several years after the mastectomy and implant or flap reconstruction, and well after any additional treatments such as chemotherapy or radiation therapy.
Nipple reconstruction may be necessary. During this procedure, a surgeon sews together small pieces of skin on the reconstructed breast to make a bump that resembles a nipple. A person may then choose to have this nipple and the skin around it tattooed to create the appearance of an areola.
Some people choose not to have the nipple reconstructed, and instead get a 3D nipple tattoo that uses shading to create the appearance of an elevated nipple.
Other revision surgeries may include fat grafting, during which a surgeon performs liposuction on the trunk or thighs to obtain fat, which they will then inject around the reconstructed breasts to improve the appearance of any hollowing, divots, or contour irregularities.
A person may require several sessions of fat grafting, as over time, the body can absorb some of the fat the surgeon places in the breasts.
These smaller surgeries require minimal recovery time, so a doctor can usually discharge the person on the same day as the procedure.
Not all people who undergo mastectomies choose or need breast reconstruction. Everyone has a different journey through breast cancer recovery, and a range of options are available to help support them through what is often a difficult and transformative time.
Some people choose to wear a prosthetic breast from either inside their bras or attached to their bodies. These artificial body parts resemble the look and feel of the natural breast and provide the body with balancing weight that supports their posture.
Doctors will recommend that a person who chooses this option only starts wearing prosthetics after the body has fully healed. Some insurance companies cover breast prosthetics for people who have had a mastectomy.
Other people may choose not to make cosmetic adjustments after a mastectomy. They may not want to undergo further surgeries, or they might find prosthetics uncomfortable. However, other people will quickly adjust to the new shape of their breasts.
Having an altered body shape presents no health risks following the removal of breast tissue from one side of the chest.
However, people who have had one breast removed may be aware of posture issues, and they may experience back pain due to the imbalance of weight — particularly if they have large breasts.
A person should talk to a breast surgeon and plastic surgeon to see whether or not breast reconstruction is suitable.
Is breast reconstruction more successful following a skin sparing mastectomy?
For people with small breasts, people with small tumors, and people who do not have cancer but a strong family history of it, a surgeon may suggest a nipple sparing mastectomy.
In this procedure, the nipple and areola remain intact, and all the deep breast tissue is removed with a smaller scar. Most plastic surgeons will say that nipple sparing mastectomy gives the best cosmetic outcome for a mastectomy procedure. However, it is also a riskier procedure due to the technical aspects of working through a smaller incision, and the skin left behind — including the nipple — will often take longer to heal.
Today, most traditional mastectomies are skin sparing (not radical), which means that most of the breast skin — as well as the pectoralis and most lymph nodes — is left behind. Because radical and modified radical mastectomies are not as common today, it would not be accurate to say that a skin sparing mastectomy offers a more successful reconstruction.
Plastic surgeons will advise people, however, that the best cosmetic outcomes are achieved with bilateral mastectomy and reconstruction, because symmetry is easier to achieve. If a person only has a mastectomy on one side, that remaining natural breast is usually somewhat droopy, while the reconstructed breast is more elevated and perky. Therefore, people tend to notice a greater difference between the reconstructed and natural breast, which can lead to lower satisfaction rates.Catherine Hannan, MD Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.