Breast Reconstruction

Many women who have a mastectomy—surgery to remove an entire breast to treat or prevent breast cancer—have the option of having the shape of the removed breast rebuilt.

Women who choose to have their breasts rebuilt have several options for how it can be done. Breasts can be rebuilt using implants (saline or silicone). They can also be rebuilt using autologous tissue (that is, tissue from elsewhere in the body). Sometimes both implants and autologous tissue are used to rebuild the breast.

Surgery to reconstruct the breasts can be done (or started) at the time of the mastectomy (which is called immediate reconstruction) or it can be done after the mastectomy incisions have healed and breast cancer therapy has been completed (which is called delayed reconstruction). Delayed reconstruction can happen months or even years after the mastectomy.

In a final stage of breast reconstruction, a nipple and areola may be re-created on the reconstructed breast, if these were not preserved during the mastectomy.

Sometimes breast reconstruction surgery includes surgery on the other, or contralateral, breast so that the two breasts will match in size and shape.

Implants are inserted underneath the skin or chest muscle following the mastectomy. (Most mastectomies are performed using a technique called skin-sparing mastectomy, in which much of the breast skin is saved for use in reconstructing the breast.)

Implants are usually placed as part of a two-stage procedure.

• In the first stage, the surgeon places a device, called a tissue expander, under the skin that is left after the mastectomy or under the chest muscle (1,2). The expander is slowly filled with saline during periodic visits to the doctor after surgery.
• In the second stage, after the chest tissue has relaxed and healed enough, the expander is removed and replaced with an implant. The chest tissue is usually ready for the implant 2 to 6 months after mastectomy.

In some cases, the implant can be placed in the breast during the same surgery as the mastectomy—that is, a tissue expander is not used to prepare for the implant (3).

Surgeons are increasingly using material called acellular dermal matrix as a kind of scaffold or “sling” to support tissue expanders and implants. Acellular dermal matrix is a kind of mesh that is made from donated human or pig skin that has been sterilized and processed to remove all cells to eliminate the risks of rejection and infection.

In autologous tissue reconstruction, a piece of tissue containing skin, fat, blood vessels, and sometimes muscle is taken from elsewhere in a woman’s body and used to rebuild the breast. This piece of tissue is called a flap.

Different sites in the body can provide flaps for breast reconstruction. Flaps used for breast reconstruction most often come from the abdomen or back. However, they can also be taken from the thigh or buttocks.

Depending on their source, flaps can be pedicled or free.

• With a pedicled flap, the tissue and attached blood vessels are moved together through the body to the breast area. Because the blood supply to the tissue used for reconstruction is left intact, blood vessels do not need to be reconnected once the tissue is moved.
• With free flaps, the tissue is cut free from its blood supply. It must be attached to new blood vessels in the breast area, using a technique called microsurgery. This gives the reconstructed breast a blood supply.

Abdominal and back flaps include:

• DIEP flap: Tissue comes from the abdomen and contains only skin, blood vessels, and fat, without the underlying muscle. This type of flap is a free flap.
• Latissimus dorsi (LD) flap: Tissue comes from the middle and side of the back. This type of flap is pedicled when used for breast reconstruction. (LD flaps can be used for other types of reconstruction as well.)
• SIEA flap (also called SIEP flap): Tissue comes from the abdomen as in a DIEP flap but includes a different set of blood vessels. It also does not involve cutting of the abdominal muscle and is a free flap. This type of flap is not an option for many women because the necessary blood vessels are not adequate or do not exist.
• TRAM flap: Tissue comes from the lower abdomen as in a DIEP flap but includes muscle. It can be either pedicled or free.

Flaps taken from the thigh or buttocks are used for women who have had previous major abdominal surgery or who don’t have enough abdominal tissue to reconstruct a breast. These types of flaps are free flaps. 

• IGAP flap: Tissue comes from the buttocks and contains only skin, blood vessels, and fat.
• PAP flap: Tissue, without muscle, that comes from the upper inner thigh.
• TUG flap: Tissue, including muscle, that comes from the upper inner thigh.

In some cases, an implant and autologous tissue are used together. For example, autologous tissue may be used to cover an implant when there isn’t enough skin and muscle left after mastectomy to allow for expansion and use of an implant (1,2).

After the chest heals from reconstruction surgery and the position of the breast mound on the chest wall has had time to stabilize, a surgeon can reconstruct the nipple and areola. Usually, the new nipple is created by cutting and moving small pieces of skin from the reconstructed breast to the nipple site and shaping them into a new nipple. A few months after nipple reconstruction, the surgeon can re-create the areola. This is usually done using tattoo ink. However, in some cases, skin grafts may be taken from the groin or abdomen and attached to the breast to create an areola at the time of the nipple reconstruction (1).

Some women who do not have surgical nipple reconstruction may consider getting a realistic picture of a nipple created on the reconstructed breast from a tattoo artist who specializes in 3-D nipple tattooing.

A mastectomy that preserves a woman's own nipple and areola, called nipple-sparing mastectomy, may be an option for some women, depending on the size and location of the breast cancer and the shape and size of the breasts (4,5).

One factor that can affect the timing of breast reconstruction is whether a woman will need radiation therapy. Radiation therapy can sometimes cause wound healing problems or infections in reconstructed breasts, so occasionally some women may prefer to delay reconstruction until after radiation therapy is completed. However, because of improvements in surgical and radiation techniques, immediate reconstruction with an implant or autologous tissue is usually still an option for women who will need radiation therapy. 

Another factor is the type of breast cancer. Women with inflammatory breast cancer usually require more extensive skin removal. This can make immediate reconstruction more challenging, so it may be recommended that reconstruction be delayed until after completion of adjuvant therapy.

Even if a woman is a candidate for immediate reconstruction, she may choose delayed reconstruction. For instance, some women prefer not to consider what type of reconstruction to have until after they have recovered from their mastectomy and subsequent adjuvant treatment. Women who delay reconstruction (or choose not to undergo the procedure at all) can use external breast prostheses, or breast forms, to give the appearance of breasts. 

What factors can affect the choice of breast reconstruction method?

The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that requires group health plans and health insurance companies that offer mastectomy coverage to also pay for reconstructive surgery after mastectomy. This coverage must include all stages of reconstruction and surgery to achieve symmetry between the breasts, breast prostheses, and treatment of complications that result from the mastectomy, including lymphedema. More information about WHCRA is available from the Department of Labor and the Centers for Medicare & Medicaid Services.

Some health plans sponsored by religious organizations and some government health plans may be exempt from WHCRA. Also, WHCRA does not apply to Medicare and Medicaid. However, Medicare may cover breast reconstruction surgery as well as external breast prostheses (including a post-surgical bra) after a medically necessary mastectomy.

Medicaid benefits vary by state; a woman should contact her state Medicaid office for information on whether, and to what extent, breast reconstruction is covered.

A woman considering breast reconstruction may want to discuss costs and health insurance coverage with her doctor and insurance company before choosing to have the surgery. Some insurance companies require a second opinion before they will agree to pay for a surgery.

Any type of reconstruction increases the number of side effects a woman may experience compared with those after a mastectomy alone. A woman’s medical team will watch her closely for complications, some of which can occur months or even years after surgery (1,2,10).

Women who have either autologous tissue or implant-based reconstruction may benefit from physical therapy to improve or maintain shoulder range of motion or help them recover from weakness experienced at the site from which the donor tissue was taken, such as abdominal weakness (11,12). A physical therapist can help a woman use exercises to regain strength, adjust to new physical limitations, and figure out the safest ways to perform everyday activities.

Studies have shown that breast reconstruction does not increase the chances of breast cancer coming back or make it harder to check for recurrence with mammography (13).

Women who have one breast removed by mastectomy will still have mammograms of the other breast. 

A woman with a breast implant should tell the radiology technician about her implant before she has a mammogram. Special procedures may be necessary to improve the accuracy of the mammogram and to avoid damaging the implant.

More information about mammograms can be found in the NCI fact sheet Mammograms.

• Oncoplastic surgery. In general, women who have lumpectomy or partial mastectomy for early-stage breast cancer do not have reconstruction. However, for some of these women the surgeon may use plastic surgery techniques to reshape the breast at the time of cancer surgery. This type of breast-conserving surgery, called oncoplastic surgery, may use local tissue rearrangement, reconstruction through breast reduction surgery, or transfer of tissue flaps. Long-term outcomes of this type of surgery are comparable to those for standard breast-conserving surgery (14).
• Autologous fat grafting. A newer type of breast reconstruction technique involves the transfer of fat tissue from one part of the body (usually the thighs, abdomen, or buttocks) to the reconstructed breast. The fat tissue is harvested by liposuction, washed, and liquified so that it can be injected into the area of interest. Fat grafting is mainly used to correct deformities and asymmetries that may appear after breast reconstruction. Although concern has been raised about the lack of long-term outcome studies, this technique is considered safe (1,6).