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Your Guide to Breast Reconstruction After Breast Cancer Surgery
Getting diagnosed with breast cancer is stressful enough. Needing a mastectomy — surgery to remove one or both breasts — in the process can have negative repercussions on your body image, sense of femininity, and self-esteem.
Breast reconstruction is a way to restore the shape and symmetry of your breasts. Around half of women choose to have a reconstructive procedure after breast cancer surgery, which can be done at the time of the initial surgery or even years later. Others opt not to have this additional surgery, choosing instead to “go flat.”
It’s important to discuss reconstruction with your surgeons before breast cancer surgery, so that you can make the best decision for yourself.
Breast reconstruction isn’t only for women who’ve had a mastectomy. It’s also available after a lumpectomy, which is a breast-conserving surgery where a small area of breast tissue and the tumor are removed. A lumpectomy may leave the shape or size of the breasts asymmetrical, but there are surgical techniques that can restore symmetry.
Oncoplastic Reduction
This procedure is an option for women with larger breasts who undergo a lumpectomy. Once the surgical oncologist has removed the cancer, the plastic surgeon reconstructs both breasts to make them look even. The surgeon can also lift the breasts and make them smaller at the same time. The lumpectomy and reconstruction can be performed at the same procedure, or the reconstruction can be done at a later time, after ensuring clear margins on the lumpectomy.
This option may not be suitable for women with smaller breasts or those who have had more than one lumpectomy.
Fat Grafting
In a fat grafting procedure, the plastic surgeon collects fat via liposuction, most commonly from the belly, buttocks, or thighs. “We concentrate that fat and then we inject it into the void that was left behind from the lumpectomy,” says Paris Butler, MD, MPH, a board-certified plastic surgeon at Yale Medicine and an associate professor of surgery (plastic) at Yale School of Medicine in New Haven, Connecticut.
You’ll have to wait to do fat grafting until your body heals from lumpectomy and the radiation therapy that follows. “I usually don’t offer that to patients until they’re at least a year out from their cancer care,” says Dr. Butler.
Fat grafting can also be used after a mastectomy, usually along with other reconstruction procedures to help fill out the reconstructed breast and create a more natural shape.
To rebuild the breast mound after a mastectomy, the choice is either implant reconstruction or tissue (flap) reconstruction. Which of these procedures you and your doctor pick depends on your body type, breast size, and preference.
Implant Reconstruction
During implant reconstruction, the plastic surgeon rebuilds your breast with either a saline or silicone implant. This is the most common type of breast reconstruction. “The advantages include an easier recovery and no functional loss in other areas of the body,” says Amy Colwell, MD, a plastic surgeon at Mass General Cancer Center in Boston.
Implant reconstruction can be done at the same time as a mastectomy (called direct to implant), but it may not be the ideal method. “The revision rate [having additional surgery later] of direct-to-implant is higher than if you do the procedure in two stages,” says Butler. That’s because the skin over the breast may get stressed or injured during a mastectomy. “If I then place a large implant into that skin pocket, I’m stressing the skin even more, which can lead to complications such as implant extrusion [when the implant pushes through the skin] or infection.”
Instead, the procedure is usually done in stages. First, the surgeon places a tissue expander under the skin at the time of the mastectomy. “Then we inflate the tissue expander, sort of like inflating a balloon, every few weeks in the office until we reach the right size. Once we reach the right size, then we bring the patient back for a small outpatient procedure where we remove the tissue expander and place the implant,” says Lyle Leipziger, MD, chief of plastic surgery at North Shore University Hospital and Long Island Jewish Medical Center in New York.
Flap Reconstruction
The flap reconstruction procedure uses your own tissues to rebuild your breast(s), often at the same time as a mastectomy. Your surgeon removes a section of tissue from your belly, back, butt, or thigh, with its blood vessels attached, and connects it to blood vessels in your chest so that it receives a blood supply.
One advantage to flap reconstruction is that it uses your own tissue instead of a foreign implant. “A second, smaller surgery is typically needed to adjust the tissue and shape the breast,” Dr. Colwell says.
Nipple and Areola Reconstruction
With a mastectomy, in most cases, the surgeon is able to preserve the skin of the breast and only removes the tissue underneath. “It is often also possible to keep the nipple of the breast in a nipple-sparing mastectomy procedure,” says Colwell.
For anyone who doesn’t have a nipple-sparing mastectomy, the last stage in the reconstruction process is to rebuild the nipple and areola (the ring of colored skin around the nipple). “You create the nipple by making little flaps of tissue, turning them and twisting them and elevating them so it has projection and roundness,” says Dr. Leipziger.
Years ago, plastic surgeons would recreate the areola with a skin graft. Today they typically use 3D tattoos, which are so realistic looking that they’re hard to tell apart from a real nipple and areola, says Leipziger.
Normally, you’ll stay in the hospital overnight after an implant-based surgery. The hospital stay is around four days after flap surgery, because your medical team will need to monitor your flap, says Butler.
After implant surgery:
- Plan to take about four weeks off from work and other activities.
- You’ll have drainage tubes in for the first two to three weeks.
- Avoid lifting anything heavier than 10 pounds for at least a month after your surgery.
- Stay out of tubs, pools, lakes, and oceans for six weeks to allow your incisions to heal.
Most people are back to their normal activities six weeks after surgery.
The recovery after flap surgery is longer:
- You’ll need to take it easy for six to eight weeks.
- Don’t lift anything heavier than 10 pounds for four to six weeks.
- Avoid soaking in a tub, pool, lake, or ocean for six weeks.
After that time, you can gradually transition back to activities like jogging or lifting weights, says Butler.
At around three months, you shouldn’t have any activity restrictions following either surgery. “However, it may take one to two years to completely recover and adjust to the reconstruction,” Colwell says.
Your surgeon will do everything possible to minimize scarring — for example, by hiding the incision in the fold of your reconstructed breast in a hidden scar mastectomy. The goal is to make your new breast(s) look as realistic as possible in clothes, and potentially even in a bathing suit. “However, when you take your bathing suit or undergarments off, you’re going to see scars. There’s no such thing as scarless surgery,” says Butler.
The scars should get lighter and thinner over time. Massaging your scars or applying a silicone-based gel, tape, or sheet can soften and fade them faster.
Although complications are rare today, thanks to improved surgical techniques, any surgery can have side effects. The most common ones from breast reconstruction are infection, bleeding, and wound healing problems.
Rarely, after flap surgery, the blood vessels from the flap that were attached to the blood vessels in your chest can get blocked or develop a clot. If this happens, the flap can fail. Sometimes, a bulge or hernia can form in the belly, or the area where the surgeon removed the flap may become weak or lose function. Implants can rupture — and the risk increases the longer you’ve had them. It’s also possible for a wall of scar tissue to form around the implant, creating a painful and aesthetically unpleasant complication known as capsular contracture.
Reconstructed breasts are not guaranteed to last a lifetime. “Somewhere around the 10-year mark, you [may] need to go back and have the implants replaced,” says Butler. Flap surgery can also require a second or third operation to adjust the tissue or reshape the breasts if they start to sag.
Is Reconstruction Worth the Risk?
Breast reconstruction isn’t right for everyone. The choice of whether to have this surgery, and which type (implant or flap) to have, should be made after careful consultation with your medical team.
Some risk factors that increase the chance of complications include:
- Smoking
- Obesity
- Older age
- Previous radiation therapy
- Having surgery on both breasts
Before your mastectomy procedure, meet with a plastic surgeon to discuss your breast reconstruction options. “By weighing the risks and benefits of reconstruction, [you] can feel [that you] made an informed decision,” Colwell says.
If you do decide to have this procedure, Leipziger suggests finding a plastic surgeon who specializes in the type of surgery you want. Inquire about the surgeon’s results, and ask to see before and after photos of their breast reconstruction patients before making your decision. “The patient should get a clear understanding of the risks and benefits of the procedures and feel comfortable with the person who’s going to be operating on them,” Leipziger says.
Not everyone who has a mastectomy is a good candidate for, or wants to have, breast reconstruction. You might be perfectly fine with your new look without it.
The choices, if you don’t have breast reconstruction, are to either “go flat” or use a breast prosthesis. You can also try these out if you’re unsure if you want to pursue breast reconstruction in the future.
Going flat on one side if you’ve only had one breast removed can lead to imbalance and even discomfort if the other breast is large. In that case, you might prefer to wear an artificial breast that simulates the size and feel of your natural breast. Your surgical team can give you advice on choosing a breast prosthesis.
Costs for breast reconstruction can vary depending on where you live, the plastic surgeon you see, which procedure you choose, and whether you’re having one or both breasts reconstructed. The average cost for breast reconstruction in 2022 was $6,221, which didn’t include the cost of mastectomy.
The good news is that health insurance should cover the cost of reconstruction. The Women’s Health and Cancer Rights Act of 1998 requires all group health plans that cover mastectomy to also pay for reconstructive surgery. If you don’t have health insurance, your care team can help you get Medicaid coverage or other financial assistance.
If you are uninsured or underinsured, or the plastic surgeons in your area don’t accept your insurance, organizations such as Alliance in Reconstructive Surgery, United Breast Cancer Foundation, and My Hope Chest provide grants to individuals who need help paying for breast reconstructive surgery.
Contemplating another surgery on top of a mastectomy can add to the stress you’re already experiencing. Having support will help you navigate the difficult decisions ahead.
Your treatment team can recommend resources such as:
- Online or in-person support groups
- Peer mentorship programs
- A patient navigator or social worker at your cancer hospital
- A psychologist, therapist, or other mental health provider who works with breast cancer patients
You might also look to organizations like these for advice and support:
- Deciding whether to have breast reconstruction after breast cancer surgery is a personal choice that should only be made after careful consultation with a plastic surgeon.
- Breast reconstruction can be done after either a lumpectomy or a mastectomy, and there are several reconstruction options to choose from.
- If you decide not to go ahead with breast reconstruction but change your mind later, reconstruction is still possible months or years afterward. Having people to support you along the way will help you navigate this difficult decision and the road ahead.
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