Breast Reconstruction After Mastectomy

Who can have breast reconstruction

Most people who have a mastectomy can have reconstruction. Factors that affect the choice and timing include:

• the stage of breast cancer and whether radiation therapy is planned
• body shape and available tissue
• smoking, diabetes and weight, which raise complication risk
• personal preferences about surgery length, recovery and scars
• whether one or both breasts are involved, including risk-reducing mastectomy for BRCA mutations

Some people choose not to have reconstruction and use a breast form (prosthesis) or opt for a flat chest. Both are valid choices.

Types of breast reconstruction

Implant-based reconstruction

• Tissue expander first: a deflated expander is placed under the skin or chest muscle at the time of mastectomy and gradually filled with saline over weeks, then exchanged for a permanent implant.
• Direct-to-implant: a permanent implant is placed at the time of mastectomy, often with a supporting mesh.
• Implants are filled with saline or silicone gel.

Pros: shorter surgery, no additional scars elsewhere. Cons: implants may need replacement over time, and radiation therapy increases complications such as hardening.

Flap (autologous) reconstruction

Your own skin, fat and sometimes muscle are moved to the chest:

Pros: natural look and feel, ages with the body, tolerates radiation better. Cons: longer surgery (4 to 8 hours or more), longer recovery, scars at the donor site, and risk of flap failure.

Oncoplastic reconstruction after lumpectomy

Reshaping the remaining breast tissue, local flaps, or a lift or reduction on both sides to keep symmetry after breast-conserving surgery.

Nipple and areola reconstruction

Completed months later: a nipple formed from local skin, a skin graft, or 3D medical tattooing. Nipple-sparing mastectomy keeps the patient's own nipple in suitable cases.

Immediate vs delayed reconstruction

"Delayed-immediate" reconstruction places an expander at mastectomy while radiation needs are confirmed.

What to expect

Before surgery

Meet a plastic surgeon early, ideally before mastectomy. Discuss goals, options, number of stages, recovery and costs. Stop smoking at least 4 weeks before surgery.

Recovery

• Hospital stay: often same day or 1 night for implants; 2 to 4 nights for flaps.
• Drains may stay in for 1 to 2 weeks.
• Activity: no heavy lifting for 4 to 6 weeks.
• Return to work: often 3 to 4 weeks after implant surgery and 6 to 8 weeks after flap surgery.
• Revisions: many people have 1 or 2 smaller procedures for symmetry, nipple reconstruction or adjustments.

Sensation in the reconstructed breast is usually reduced or absent. Some sensation may return over months to years. Nerve reconnection (neurotization) is offered in some flap surgeries.

Risks and complications

• bleeding, infection and wound healing problems
• seroma: fluid collection under the skin
• flap loss (partial or complete), uncommon in experienced centers
• abdominal weakness or hernia after abdominal flaps
• capsular contracture: scar tissue tightening around an implant
• implant rupture or rippling
• BIA-ALCL: a rare lymphoma linked mainly to textured implants, usually presenting as late swelling around the implant years later
• breast implant illness: a range of symptoms some people attribute to implants, still being studied
• blood clots
• asymmetry and need for revisions

Reconstruction does not prevent detection of cancer recurrence. Follow-up imaging recommendations depend on the type of surgery.

Insurance and rights

In the US, the Women's Health and Cancer Rights Act requires group health plans that cover mastectomy to cover reconstruction of the affected breast, surgery on the other breast for symmetry, prostheses, and treatment of complications such as lymphedema.

Frequently asked questions

Which is better, implant or flap reconstruction?

Neither is best for everyone. Implants involve shorter surgery and recovery but may need future replacement and are more affected by radiation. Flaps feel more natural and last longer but involve longer surgery, donor-site scars and longer recovery. A plastic surgeon helps match the option to your body and goals.

How long does it take to recover from breast reconstruction?

Most people return to light activity within 2 to 3 weeks and normal activity within 4 to 8 weeks, depending on the method. Flap surgery has a longer recovery. Final results may take several months and additional smaller procedures.

Can I have breast reconstruction years after a mastectomy?

Yes. Delayed reconstruction can be done months or many years after mastectomy and radiation. Flap reconstruction is often preferred after radiation because the treated skin may not stretch well over an implant.

Will a reconstructed breast have feeling?

Usually sensation is reduced or absent, because the nerves to the breast skin are cut during mastectomy. Some feeling returns over time in many people, and nerve-reconnection techniques can improve sensation after some flap procedures.

Does insurance cover breast reconstruction?

In the US, the Women's Health and Cancer Rights Act requires most health plans that cover mastectomy to cover reconstruction, symmetry surgery on the other breast, prostheses, and treatment of complications. Check your plan's details and get preauthorization.