If you’ve had a mastectomy because of breast cancer, you may choose to have reconstructive plastic surgery. It can restore balance between the two breasts by replacing skin, breast tissue, and the removed nipple.
The amount of reconstruction will depend on the mastectomy and the width, size, and location of the removed tumor.
Is Breast Reconstruction Right for Me?
The idea of living without a breast or without part of one affects each woman differently. It’s a personal decision, and it's often not easy to make.
You don’t have to have reconstruction. You can wear external breast forms or pads, or change nothing at all.
The operation changes your appearance, but it can have psychological benefits as well. It can add to a sense of wellness for you and your family.
Is It Cosmetic Surgery?
Restoring a breast isn’t considered a cosmetic procedure. It’s reconstructive surgery. Since it’s considered part of the treatment of a disease, the law says insurance providers must provide coverage.
When’s the Best Time to Have Breast Reconstruction?
The timing is based on what you want to do, your medical conditions, and your cancer treatment. You can have it done during the operation to remove the breast, or you can have it months or years after a mastectomy.
What Are the Different Reconstruction Options?
Before you decide, you and your doctor will need to discuss your wants and needs, your medical condition, and any previous surgery.
Implants involve stretching the skin with a tissue expander that goes inside your body and then inserting a silicone-gel or saline (saltwater) implant weeks later. The tissue expander is filled to a certain volume by adding saline, usually once a week for a few sessions. You may have some pain, but many women are pleased with the final result.
Implants can rupture, causing pain and infection. You may need surgery to remove or replace them.
TRAM flap procedures use the tissue from a woman’s abdomen to create a mound to reconstruct the breast. In general, this means cutting away at least some of your stomach muscles, fat and blood supply to use for the reconstruction.
Sometimes, the tissue that’s being moved is kept attached to its blood supply. This is called a pedicle or tunneling procedure. The flap has a better chance of surviving because the blood supply remains in place, but the breast may not look exactly the way you want.
In a free-flap procedure, the tissue is disconnected and then attached to a blood supply near the new location. This is a more complicated procedure. The biggest risk is that the blood vessels may get clogged and the flap might die. The benefit is that the reconstruction looks more like a natural breast.
A new version of the procedure, called the muscle sparing free TRAM flap, cuts away far less abdominal muscle. This often makes for a quicker recovery and less risk of losing core strength after surgery.
For all TRAM surgeries, you can expect a scar across your belly from one hip to the other, typically below the bikini line. You might also notice a flatter and tighter stomach because of the missing fat, skin, and muscle. The surgery lasts from 4 to 8 hours and you usually stay in the hospital for about 5 days total. Your health care provider will give you detailed instructions on how best to care for your surgical wounds after surgery. It should take 6 to 8 weeks to fully recover from your surgery.
Though it’s the most common flap procedure, TRAM flap isn't for everyone. It may not be for you if you:
- Have had numerous prior surgeries in the belly area
- Are especially thin or don’t have enough extra belly tissue
- Are concerned about losing core strength, especially in lower abdomen
In addition, talk to your doctor if you plan to become pregnant as the TRAM surgeries could be a problem in some cases.
Other, less common tissue flap procedures use tissue from different areas. Taking tissue from the back is called a latissimus dorsi flap.
Aesthetic flat closure (AFS) may be considered. This is a surgical repair procedure that removes or rearranges excess breast skin and fat after a mastectomy. This corrects contour deformities and can be done at the time of mastectomy or as a second procedure. If needed, fat grafting can also be done for the best cosmetic outcome.
The shape, feel, and contour of a breast made from a woman's own tissue are more like those of a natural breast. But flap surgery is more involved than implant surgery. And, as with all major surgeries, you could have complications, such as bleeding, infection, or poor healing.
Nipple reconstruction is typically an outpatient procedure done with local anesthesia. You may have it after breast reconstruction. This allows the new tissue to heal and settle into place. Your doctor can make small changes in size and position of the breast when the nipple and areola are rebuilt.
Surgeons can make a nipple out of tissue taken from the back or abdominal flap. It’s then tattooed to resemble the color of a nipple.
In rare cases, the nipple from the original breast can be reattached, but only if the surgeon is convinced that the tissue is cancer-free. Because of a lack of nerve connections, the nipple won’t rise or flatten in response to touch or temperature.
A prosthetic nipple is another option. The plastic surgeon makes a copy of your natural nipple and colors the areola. It can be glued to the breast and re-glued every week or so.
How Long Does Breast Reconstruction Surgery Take?
Preparation for the procedure, including anesthesia, may take 2 hours. The reconstruction will take 1 to 6 hours.
After the surgery, you'll spend about 2 to 3 hours in recovery before being transferred to a hospital room.
Recovery From Breast Reconstruction Surgery
You may have some discomfort for the first few days afterward. You’ll get pain medication as needed. Throughout your hospital stay, the staff will closely watch you.
Soon after surgery, you’ll be encouraged to move your arms, but not for any forceful activity like pulling yourself up, getting out of bed, or lifting heavy objects. Nurses will help you in and out of bed. The day after surgery, you may be able to sit in a chair beside the bed. On the second day, most patients are walking without help.
You’ll probably get IV fluids for a day or two. You may have a urinary catheter overnight or until you can walk to the bathroom. And where the surgeon made cuts (the incision sites), you’ll have drains. If you go home with these drains in place, you’ll get instructions on how to care for them.
The length of your hospital stay depends on the type of operation and how your recovery goes. If you got implants, the average hospital stay is 1 to 2 days. Flap procedures may require a stay of 5 to 6 days.
Follow-Up Care for Breast Reconstruction
After you go home, you can expect some soreness, swelling, and bruising for 2 to 3 weeks. You may be told to put medications on the suture area or change bandages at home. Your plastic surgeon will advise you about showering, bathing, and wound care.
Most women return to regular activities within 6 to 8 weeks after surgery. It may be several weeks before you can do strenuous exercise.
The mastectomy and breast reconstruction will leave areas of numbness where the surgery was done. Instead of pain where the tissue was taken, you may feel numbness and tightness. In time, some feeling may return to your breasts. Most scars will fade over time.
The shape of your reconstructed breast will slowly improve.
You'll need regular checkups at first. If you have a temporary expander, it will be expanded with saline once a week, on average, until the desired size is reached (usually within six to 10 office visits).
Keep doing self-exams of your breasts every month, and have an annual mammogram.
Breast reconstruction doesn’t change the chance of cancer coming back, and it generally doesn’t interfere with treatment. If the disease does come back, your medical team can still treat you with surgery, radiation, chemotherapy, and targeted therapy.
What Are the Possible Side Effects?
- Infection at the surgery site. As with any surgery, infection is a risk. An antibiotic will usually get rid of the infection.
- Pain and discomfort. Your doctor will advise you on a pain relief medication. Some women have more pain than others.
- Itching. The wound will itch as it heals. But no matter how strong the urge, avoid scratching it. Your doctor can recommend an ointment or cream to calm the itching.
- Numbness or tingling. You may have these sensations because the nerves have been affected. They can last up to 12 months after surgery.
- Fluid collection under the wound. Fluid may build up under the wound, even after your drainage tubes are removed several days after the operation. If there’s not much fluid, it may go away by itself. But if there’s a lot, your surgeon may have to drain the site using a needle and syringe.
Call your doctor right away if you have any of the following:
- A fever above 100 F
- Fluid leaking from incision sites
- Any change in color in the breast or scar area
- Increased pain or swelling in the surgical areas