If you’ve decided to have breast reconstruction following mastectomy, you have a lot to think about.

For instance, you may be able to start reconstruction immediately, or you might have to delay it for some time. If you have inflammatory breast cancer, for example, you may need more skin removed, which complicates immediate reconstruction. And sometimes reconstruction needs to be delayed until you’ve completed radiation therapy.

Other things to consider are:

  • your age and general health, including whether you smoke or use tobacco products
  • past surgeries and surgical risk factors
  • the extent of the disease
  • whether or not autologous (your own) tissue is available
  • your personal preferences

There are many different approaches to breast reconstruction. Your surgeon will explain your options and help you choose the appropriate surgery for you.

Implants

Implants are inserted underneath skin or chest muscle. For an implant to work, there has to be enough skin and muscle left after the mastectomy to cover them.

It can be done in a single surgery, but it usually takes two separate procedures. After your mastectomy, the surgeon will place a tissue expander under the skin or chest muscle. At later appointments, your doctor will slowly fill the expander with saline (sterile salt water). They do this by using a magnet to locate a port in the tissue expander under the skin. Then, they use a needle to inject saline into the device every one to two weeks, filling it to its capacity or to a size with which you and your surgeon are satisfied.

Once your chest tissue has healed a bit, the expander will be removed and replaced with a permanent implant. This generally happens two to six months after your mastectomy.

In some cases, a special mesh is used to support the tissue expanders and implants. The mesh is made from donated, sterile, processed human or pig skin (acellular dermal matrix).

Risks of any surgery include:

  • bad reaction to anesthesia
  • infection
  • bleeding
  • blood clots

Some potential risks of reconstruction with breast implants are:

  • buildup of fluid in the breast
  • pooling of blood (hematoma) in the breast
  • the implant breaking through the skin (extrusion)
  • the implant rupturing and leaking saline or silicone
  • scar tissue forming around the implant (contracture)

Your doctor may advise against implants if you will likely have or have had radiation therapy to the chest or have very large breasts. It’s important to note that implants don’t necessarily last for the rest of your life. You are likely to need them removed or replaced at some point.

Silicone implants may feel more natural than saline. Talk to your doctor about the pros and cons of each. You may need occasional MRI screenings to check the implants for ruptures.

Autologous tissue reconstruction

Autologous tissue breast reconstruction is performed using your body’s own tissue, usually from the abdomen, back, or buttocks. Because it’s your own healthy tissue, it’s the preferred form of reconstruction for patients who’ve had or will likely need radiation after their mastectomy.

This technique involves taking skin, fat, blood vessels, and sometimes muscle from somewhere else on your body to reconstruct the breasts (flap). There are two main types of flaps.

  • A pedicled flap is when tissue and attached blood vessels are moved through the body to the breast. The blood supply remains connected, so there’s no need to reconnect blood vessels.
  • A free flap is when tissue is cut from the blood supply and completely removed from the body. The tissue must then be attached to blood vessels in the breast area.

Flaps can be taken from the abdomen, back, buttocks, or thighs.

  • For a TRAM flap, skin, fat, muscle, and blood vessels are taken from the lower abdomen. A TRAM flap can be pedicled or free. A variable amount of the rectus, or sit-up muscle, is removed with this flap.
  • A DIEP flap is a variety of TRAM flap in which almost no rectus muscle is removed.
  • The latissimus dorsi flap is a type of pedicled flap using tissue from the middle and side of the back.
  • A SIEA flap is another type of free flap. In this procedure, tissue is taken from the abdomen, but using a different set of blood vessels than the DIEP flap. The abdominal muscle is not cut. Because these blood vessels aren’t always adequate, SIEA flaps are not as common.
  • The IGAP and SGAP flaps use skin, blood vessels, and fat from the buttocks.
  • For the PAP and TUG flaps, tissue is taken from the upper inner thigh.

It takes a little longer to recover from autologous tissue breast reconstruction than for implants alone. Potential complications are:

  • pain or weakness where tissue was taken
  • scarring
  • poor blood circulation
  • death of relocated tissue (necrosis)

Nipple and areola reconstruction

In some cases, the nipple and areola can be spared during a mastectomy (nipple-sparing mastectomy). Factors that determine if you can keep your nipple and areolae include size and number of tumors, breast size and shape, and type and stage of cancer.

Otherwise, the nipple and areola can be reconstructed after you recover from breast reconstruction surgery. Small pieces of skin from your reconstructed breast are cut, moved, and shaped into a new nipple. The areola can be created using skin grafts from the groin or abdomen, but it’s often done with tattoo ink. Alternatively, you can have a tattoo artist create a 3D nipple tattoo.

Plastic surgery after lumpectomy

You probably won’t need breast reconstruction following breast-conserving surgery (lumpectomy). But you can have plastic surgery to reshape your breasts during the same surgery (oncoplastic surgery).

Your surgeon can rearrange local tissue, perform breast reduction surgery, or use tissue flaps. In a procedure called autologous fat grafting, tissue is taken from the abdomen, thighs, or buttocks through liposuction. Then, it’s injected into the breast. This is performed when there is a depression or divot in the breast.

Points to ponder

  • Federal law requires health insurers that pay for mastectomy to pay for reconstruction surgery after mastectomy.
  • You may eventually gain more feeling in your breasts, but you’ll never regain normal feeling.
  • It can take two months or more to fully heal. Scars may fade, but they won’t go away.
  • It’s normal to have mixed emotions following mastectomy and breast reconstruction, so allow an adjustment period.
  • You can choose not to have breast reconstruction after mastectomy. You can go flat or wear breast forms. You can also be fitted for prosthetic breasts, which are worn in special pocketed bras.