Breast Reconstruction: Know Your Options

Breast reconstruction after cancer isn’t for everyone, but federal law protects your right to make that choice. The 1998 Women’s Health and Cancer Rights Act requires that insurance plans cover reconstruction at any time after a medically necessary mastectomy. More women are choosing breast reconstruction, so it’s important to know about all of your options. Check out these common breast cancer reconstruction questions and answers to help you get the information you need.

Dr. Minas ChrysopouloWhen can I get my breasts reconstructed?

Reconstruction can be performed at the same time as the mastectomy (“immediate reconstruction”) or any time after (“delayed reconstruction”). Generally speaking, immediate reconstruction provides the best cosmetic results with less scarring. Some reasons to consider delaying reconstruction include personal preference, a diagnosis of advanced breast cancer (stage III or IV) or inflammatory breast cancer, radiation treatment, or if you do not have a reconstructive plastic surgeon in your area.

Is it possible to save my nipples?

Maybe. Ask your doctor if you are a candidate for a nipple-sparing mastectomy (NSM), which preserves the nipple and areola as well as all the breast skin. NSM is an option for patients with smaller cancers located away from the nipple-areola. When combined with immediate breast reconstruction, NSM provides superior cosmetic results without compromising cancer treatment.

What should I know about implants?

Implant reconstruction is the most common method and can provide excellent results in patients with good-quality mastectomies. However, some women find implants make their breasts feel cooler to the touch. Implant reconstruction is usually performed as a multiple-step procedure, starting with tissue expanders. In certain cases, it can be performed as a single stage (“direct to implant”). Implant reconstruction usually entails an overnight stay in the hospital, and recovery can take three to four weeks.

Over time, common side effects include hardening around the implant due to scar tissue (capsular contracture) or rippling (visible “waves” through the skin). Implants can also become infected, rupture, or become exposed through the skin, especially in patients who undergo radiation therapy. The FDA also recommends replacing implants every 10 years. Talk to your plastic surgeon about the possible side effects of implant reconstruction during your consultation.

Do I have other options besides implants?

Yes. You may also be a candidate for a flap procedure, which involves removing tissue from one part of your body (back, abdomen, buttock, or thigh) and transferring it to the chest. These surgeries recreate “natural,” warm, soft breasts, but they also leave scars on the area of the body from where the tissue was taken. The most common types of flaps use the patient’s abdominal tissue.

What should I know about flaps?

Flaps that sacrifice muscle are associated with some loss of strength, but most patients find this does not impact everyday activities. Abdominal flaps can create an abdominal bulge (“pooch”) or hernia, but these are rare after muscle-preserving procedures like the Deep Inferior Epigastric Perforator (DIEP) flap and the Superficial Inferior Epigastric Artery (SIEA) flap. The DIEP and SIEA procedures also allow for reconstruction of the nerves that can help restore some feeling in your breast after a mastectomy.

Flaps require longer surgery than implants, a longer stay in the hospital, and a longer recovery time (four to six weeks). Unlike implants, flaps do not rupture, leak, or need to be replaced. Flap breast reconstruction has a very high success rate in experienced hands, over 99% at some high-volume centers, but not all plastic surgeons offer these more complex procedures.

I need radiation treatment. What should I know?

Most plastic surgeons recommend delayed reconstruction if you need to have radiation treatment after the mastectomy. Studies show that flaps have fewer complications than implants in patients receiving radiation after mastectomy and immediate reconstruction. When radiation is planned, delayed reconstruction with flaps yields higher patient satisfaction and fewer complications than immediate reconstruction with implants or flaps.

Will I need more than one surgery?

Regardless of the reconstructive procedure, you will likely require more than one surgery for the best cosmetic results. A second procedure is often performed to “fine-tune” the reconstruction. The exact details of this revision surgery will depend on the type of reconstruction initially performed by your plastic surgeon, but it can include fat grafting, scar revision, and nipple reconstruction.  

What’s the “best” option?

While you may be better suited for some options, there is no “best technique.” The best option is the one that suits your preferences, situation, and overall medical health. If you are interested in breast reconstruction, consult a board-certified plastic surgeon, preferably one specializing in breast reconstruction. If possible, talk to your plastic surgeon soon after the diagnosis, before any cancer surgery is scheduled so that immediate reconstruction can be considered.

About the author

Dr. Minas Chrysopoulo

Dr. Minas Chrysopoulo is a board-certified plastic surgeon, breast reconstruction surgeon, and microsurgeon at PRMA Plastic Surgery in San Antonio, Texas. As a patient advocate, he believes shared decision-making between the physician and breast cancer patient is crucial to achieving the best results.

The statements and opinions in this blog post are those of the author and do not necessarily represent the views of the U.S. Department of Health and Human Services Office on Women's Health.