Question 1

What is breast reconstruction surgery?

Accepted Answer

What is breast reconstruction surgery?

Breast reconstruction surgery restores a more natural, symmetrical appearance to a breast that has been removed by a mastectomy or altered by a lumpectomy as part of breast cancer treatment. Reconstruction can happen simultaneously with cancer surgery, but many women choose to (or must) wait months or even years before having breast reconstruction after cancer—and some end up deciding not to have reconstruction at all.

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Question 2

Should you have breast reconstruction after mastectomy?

Accepted Answer

The decision to have breast reconstruction after mastectomy (or not) is completely personal.

You’ll know what matters most to you in making the choice, but consider your lifestyle, your finances, how long you can take off work for recovery, and your desired aesthetic outcome.

You may be a good candidate for breast reconstruction if:

You’re in a good place mentally and emotionally
Your immune system and health have bounced back after cancer treatment enough that a potentially long surgical procedure won’t be too risky, and you’ll be able to heal normally afterward
You have realistic expectations for your breast reconstruction results. Your new breasts—whether they’re rebuilt with implants, flaps, fat transfer, or a combination—likely won’t have the same look or feel as your natural breasts. Scars are an inevitable, permanent part of the procedure, and you may have some asymmetry or changes in skin tone (especially if you have flap reconstruction that includes a skin graft).

If you’re debating whether to go ahead with breast reconstruction, it can help to discuss it with more than one plastic surgeon. Most reputable surgeons won’t push you into a decision that doesn’t feel right to you.

It can also help to connect with other women on RealSelf who’ve been through a breast reconstruction after mastectomy, look at before and after photos, and get a realistic sense of what to expect.

RealSelf Tip: Dr. Christine Fisher, a plastic surgeon in Austin, Texas, who specializes in breast reconstruction surgery, offers this advice: “Try to find a surgeon who has a specialty in reconstruction—and, ideally, you want a doctor who can do autologous techniques as well as implant surgery, so they have all the tools in their toolbox. Reconstruction is quite technical and challenging, so I would suggest finding a surgeon who does at least 50 of these surgeries a year.”

Question 3

How much does breast reconstruction cost?

Accepted Answer

The price you pay will depend on your health insurance copay and deductible, your surgeon’s level of experience, what kind of reconstruction techniques they use, where your procedure is performed, and whether you opt for additional complementary procedures.

See our complete guide to breast reconstruction costs

Question 4

Breast reconstruction before and after pictures

Accepted Answer

The breast reconstruction photos in our gallery have been shared by the surgeon who performed the procedure, with the patient's consent.

Question 5

Does insurance cover breast reconstruction?

Accepted Answer

The Women’s Health and Cancer Rights Act of 1998 (WHCRA) requires health insurance companies that cover mastectomies to provide coverage for breast reconstruction.

In practice, that means the insurance company will cover at least some cost of the procedure—but you may still pay significant out-of-pocket expenses. Organizations like BRAVE can help you navigate (and potentially even cover) those costs.

If you had only one breast removed or altered, the law also requires coverage for surgery on the opposite breast, to ensure symmetry.

You might also decide you need a “redo” to get the best results, and your insurance should also cover at least a portion of this revision reconstruction.

Talk to your insurance company representative about your benefits before your surgery—but know that they might not be forthcoming about everything the company should legally cover. Some providers have legal support that can advocate on your behalf.

Also be aware that if your insurance company is paying for part of your procedure, they may limit your choice of providers. Dr. Jonathan Zelken, a plastic surgeon in Newport Beach, California, believes it’s important for patients to “explore both in- and out-of-network options and to choose the doctor most qualified to suit your needs.” He recalls one patient who sought him out after being assigned an in-network head-and-neck surgeon who had never performed a breast reconstruction.

Question 6

How soon do you need to do breast reconstruction?

Accepted Answer

Discovering that you have breast cancer or the BRCA gene is stressful and scary. Add to that the pressure of deciding if and when you want reconstruction and what type it should be, and you may feel completely overwhelmed.

The good news is that there’s no set timetable for when you have to make a decision. Here are the most common timelines for breast cancer reconstruction patients.

Immediate reconstruction

Immediate reconstruction means that your cancer surgeon and reconstruction surgeon will perform the mastectomy or lumpectomy and reconstruction in one combined procedure, working one after the other.

After the cancer surgeon removes the breast tissue, the plastic surgeon rebuilds the breast(s) by inserting an implant, using a tissue flap from elsewhere on the body—or going with a combination of these reconstruction techniques.

There are benefits to immediate reconstruction.

You never have to be without breasts, which can help normalize a stressful situation.
Having only one surgery and one recovery period means that you’ll need general anesthesia just once and you won’t need to take time off work for two surgeries.

The best candidates for this option are people who are removing their breasts prophylactically after a BRCA diagnosis, or those who won’t have to undergo any radiation treatment after the surgery. (Radiation has been shown to negatively affect implant surgery by shrinking the skin “breast envelope,” increasing the risk of infection and capsular contracture down the road. Capsular contracture is an abnormal scar-tissue response that’s a potential complication of any breast implant surgery.)

Delayed reconstruction

Delayed reconstruction can be performed months or even several years after a mastectomy or lumpectomy, after the body has fully healed. There’s no expiration date on opting for a delayed reconstruction, so even people who think initially that they won’t want reconstruction may opt for it later.

This option gives you time to complete your cancer treatments, heal, and take all the time you need to figure out what you want to do for your reconstruction. This can alleviate some psychological (and financial) pressure at an emotionally taxing time.

“However, delaying reconstruction may come with a less than ideal aesthetic result,” cautions Dr. John Paul Tutela, a plastic surgeon based in Livingston, New Jersey. “The skin that remains will shrink to the chest wall, which will make the reconstruction more challenging to achieve the optimal shape.”

Women who undergo radiation after their mastectomy or lumpectomy may have delayed reconstruction as their only option.

Delayed-immediate reconstruction

Delayed-immediate reconstruction sounds like an oxymoron, but there is a logic to it. This approach typically involves inserting a tissue expander (Dr. Fisher calls it a babysitter), an inflatable device that creates space for a future implant or donor tissue.

The expander is like a balloon that’s placed under the breast skin. It’s periodically filled with saline fluid, stretching the skin each time. When it’s time for your reconstruction, your expanders will be removed and your implants or tissue flaps will be inserted.

Delayed-immediate reconstruction is a good option for patients who know they want reconstruction but aren’t certain whether they will opt for implants, tissue flaps, or a combination. It can also work for women who have to undergo radiation therapy and won’t be able to have immediate reconstruction.

Benefits include the fact that you never have to be without a breast mound, and that expanders make the reconstruction process easier later on by preserving a pocket for the reconstructed breast.

Question 7

What are your breast reconstruction options?

Accepted Answer

There are two primary types of breast reconstruction: implant based and autologous (or “flap”) reconstruction.

The former uses the same type of implants as cosmetic breast augmentation surgery, while the latter uses your own tissue—including skin, fat, blood vessels (which are reattached in a new location) and sometimes muscle—from another part of the body to rebuild the breast. In some cases, patients have a combination of the two procedures.

The case for implant-based reconstruction

More plastic surgeons have experience doing implant-based breast reconstruction. Flap reconstruction requires specialized training in reconstructive microsurgery, which not all breast surgeons have.
Implant surgery is a less complicated procedure. It can be done in half the time, and it’s considerably easier to recover from, with a shorter hospital stay (one or two nights vs. three or four, with flap reconstruction) because only one part of your body has been operated on.
A single surgery site means scars are limited to the breast(s).
Choosing implants allows you to customize your cup size and the degree of projection.
Implants are a better option for patients who don’t have enough extra fat or tissue elsewhere on their body for an autologous procedure.

The case for autologous reconstruction

Surgeons can create very realistic-looking breasts from soft, living donor tissue taken from your abdomen, back, thighs, or hips. Because autologous procedures use your own tissue, the breasts expand or shrink as you gain or lose weight, as natural breasts typically would.
Autologous reconstruction means avoiding implants, which appeals to women who aren’t comfortable with the idea of having a foreign body or prosthesis in their chests as well as those who would rather not accept the risks, monitoring, and additional surgeries that come with breast implants.
Following flap surgery, “there’s no need for additional surgery, with the exception of optional second-stage details like fat grafting or scar revision,” says Dr. Karen Horton, a plastic surgeon in San Francisco, California.
Not all women who’ve had a mastectomy have enough remaining tissue to cover an implant, so flap reconstruction may be the only viable option for some.
Flap reconstruction may be the less risky option for reconstruction patients facing radiation therapy. “Complications from implant-based reconstruction increase considerably if the patient has had or will require radiation treatment,” says Dr. Tutela.
Flap procedures have seen the biggest boost in surgical innovation in recent years and are becoming increasingly popular, as more plastic surgery training programs offer microsurgical training.

You’ll make the decision on what type of breast reconstruction is best for you with the help of your oncologist and plastic surgeon, taking into account these factors as well as whether your mastectomy is therapeutic or prophylactic; your health and body shape; and how much tissue needs to be removed as part of your treatment.

Related: 5 Things You Need to Know About Your Breast Reconstruction Options

Question 8

How does breast reconstruction with implants work?

Accepted Answer

The surgery

The operation takes two to four hours.

First, an anesthesiologist will administer either local anesthesia with IV sedation or general anesthesia, so you’ll feel no pain during the procedure.
Patients having delayed implant-based breast reconstruction will first be given tissue expanders, to create a pocket for the implants. According to the American Society of Plastic Surgeons, “It usually requires several office visits over 1-2 months after placement of the expander to gradually fill the device with saline through an internal valve to expand the skin. Newer air-filled devices may allow patient-controlled expansion at home using a remote dosage controller.” A second procedure is then needed to replace the expanders with implants.
During the implant reconstruction procedure, a plastic surgeon will place the breast implant either over the chest muscle (prepectoral) or under the muscle (submuscular). Surgeons will generally insert the implant through the mastectomy incision.
A piece of mesh-like tissue, made from purified donated tissue or an absorbable surgical mesh, may be used to reinforce your breast tissues and to cover and/or keep the implant in place.
Drains may be placed, to remove fluid and minimize complications during recovery.
Breast incisions are closed with removable sutures and covered with Steri-Strips.

Related: Silicone or Saline? 5 Things to Know About Picking the Right Breast Implants

The recovery

“Implant reconstructions tend to have a slightly shorter recovery [than flap surgeries],” says Glasgow plastic surgeon Dr. Russell Bramhall. “Most people stay in the hospital for at least a night. After that, you’ll be home, puttering around the house, making yourself some food, and being okay getting in and out of the shower.”

If your implants were placed above the muscle, you may have an easier recovery than if they were placed below the muscle, because the pectoralis hasn’t been cut or elevated.

Stitches are removed after one week. If you have drains, they’ll be removed in one to three weeks.

Dr. Bramhall recommends arranging for help with shopping and housework for the first couple of weeks. “You should be back to doing pretty much everything you usually do after four weeks and feel virtually back to normal by six to eight weeks, though you’ll still probably get the odd twinge” as severed nerves regrow.

Question 9

How does autologous or flap breast reconstruction surgery work?

Accepted Answer

There are several flap reconstruction techniques. The primary difference is the donor site—abdominal flaps are most common—and whether or not the flap remains attached to its original blood supply (pedicle) or is detached and reconnected to a new blood supply upon relocation.

These are some of the most common flap methods.

TRAM (transverse rectus abdominis muscle) flap uses tissue from the lower abdomen. It typically involves borrowing a portion of (or at least cutting into) the rectus muscle, which often results in abdominal weakness.
DIEP (deep inferior epigastric perforator) flap uses skin and fat from the lower abdomen, leaving the abdominal muscle and fascia untouched.
Latissimus dorsi flap uses skin, fat, and muscle from the upper back.
SGAP (superior gluteal artery perforator) flap (or gluteal free flap) uses tissue from the buttocks or hip.
TUG (transverse upper gracilis) flaps uses tissue from the inner thigh.

The surgery

The recovery

Recovery after autologous surgery is also considerably more intensive than implant surgery. (Breast reconstruction recovery for combination surgery—flap plus implant—is similar to that for flap reconstruction alone.)

“With tissue reconstructions, the operations can take three to six hours and usually involve several nights in the hospital [where blood flow to the flap is closely monitored]. You’ll then have two sore areas while you’re recovering: your new breast reconstruction and wherever your surgeon has taken the tissue from,” says Dr. Bramhall. “Expect to need help around the house for the first few weeks and fully recover within eight weeks.”

Stitches and drains will be removed according to your surgeon’s specific timetable, but usually within a week to 10 days.

Question 10

How can fat grafting help reconstruct the breast?

Accepted Answer

Fat transfer (aka grafting) is another reconstruction option, but it’s unpredictable—less than half of the grafted fat sticks around permanently. As a standalone procedure, it’s rarely the best choice for mastectomy patients. “It’s just not possible to reconstruct an entire breast using fat alone,” says Dr. Horton.

That said, fat transfer can be an excellent option for reconstruction after a lumpectomy, especially to fill in a divot. Breast reconstruction surgeons also often rely on fat grafting to enhance both implant and flap reconstructions, smoothing contours and filling in areas that need a little more volume after your initial recovery.

Stem cells within the grafted fat can even help rejuvenate the breast tissues, in some cases.

When fat is combined with flaps or implants, the procedure is commonly called a “hybrid” or “composite” breast reconstruction. (However, some surgeons also use these terms to describe the pairing of autologous flap reconstruction with implants, so be sure to ask your doctor for clarity when discussing “hybrid” options.)

Question 11

How does nipple reconstruction work?

Accepted Answer

Most doctors now agree that as long as the cancer has not impacted the nipple, there’s no risk in leaving it intact. Whenever possible, the cancer surgeon performing a mastectomy should try to preserve it with a nipple-sparing mastectomy. “The underlying glandular breast tissue is completely removed while the overlying skin and nipple are preserved, allowing the reconstructive surgeon to recreate the breast shape while retaining the patient’s actual nipple,” says Dr. Fisher. “The result is a more natural-looking breast, without compromising the effectiveness of the cancer treatment.”

In cases where preservation cannot happen, nipple reconstruction surgery is an option. In most cases, this is done after the reconstructed breast heals, usually three to four months after the initial reconstructive surgery. Your surgeon cuts flaps of skin from the breast or elsewhere on the body (like the abdomen), elevates the tissue, then shapes and forms it so it mimics a natural-looking nipple.

This technique doesn’t preserve nipple sensation, but it can look almost natural. After healing, the new nipple and areola color gets tattooed onto the breast, by either the plastic surgeon or a tattoo artist.

Tattooing nipples with a three-dimensional effect, called “3D tattooing” (without actual nipple reconstruction), is another popular option that’s increasingly being offered by experienced tattoo artists.

RealSelf Tip: Whether nipples are spared or reconstructed, loss of sensation throughout the breasts can be an upsetting side effect of surgery. Some plastic surgeons are now offering a technique called resensation at the same time as breast reconstruction. The procedure uses allograft nerve tissue to mend severed nerves, allowing nerve fibers to regenerate over time and restoring sensation.

Question 12

What are the risks and side effects of breast reconstruction?

Accepted Answer

Some risks of breast reconstruction surgery are similar to those of most other surgeries: infection, poor scars, seroma, problems with anesthesia, and bleeding. These complications are rare, but your doctor will address them with you before your surgery.

Other risks with either implant or flap reconstruction include a loss of sensation in the nipples and breasts, as well as uneven breasts. Some women seek out revision surgery to correct these problems.

According to Dr. Zelken, the overall likelihood of complications is higher with breast reconstruction than with purely cosmetic breast surgeries. “Operations tend to be longer and involve multiple surgeons, with less healthy tissue coverage and a greater likelihood of a compromised immune system than in elective breast surgery.”

Patients are also more likely to be dissatisfied with their results, primarily due to “loss of a natural, soft tissue envelope, one-sided reconstruction, or radiation,” says Dr. Zelken. Again, radiation tightens the breast tissue, making it more difficult to stretch around an implant.

Risks of implant-based reconstruction

Malposition
Implant rupture
Implant rippling
Capsular contracture
Complications related to the acellular dermal matrix or mesh
The development of rare implant-associated cancers (BIA-ALCL and BIA-SCC) in the capsule surrounding the implant
The development (particularly in patients with autoimmune conditions) of systemic symptoms associated with breast implant illness or BII
The need for future surgeries to revise, replace, or remove the implant

See our complete breast implant safety guide

Risks of autologous reconstruction

To sidestep some of these implant-based issues, your surgeon may recommend autologous reconstruction. Flaps offer added benefits, as well, particularly to women undergoing radiation therapy. “The reason I recommend autologous reconstruction following radiation is that the new tissue that’s brought to the radiated site brings new nonirradiated soft tissue, new blood supply, and perhaps new healing potential to a radiated chest wall,” says Dr. C. Bob Basu, a Houston-based plastic surgeon. It also “eliminates any risk of foreign-body implant scar tissue and postradiation capsular contracture.”

That said, flap reconstruction comes with its own risks, which include:

Tissue death (necrosis) of all or part of a flap, resulting from poor blood flow
The need for additional surgeries
Loss of sensation at both the donor site and the breasts
Problems at the donor site, such as loss of muscle strength

Question 13

How soon can you expect to see your final results?

Accepted Answer

Regardless of the type of breast reconstruction you have, it can take about three months for the swelling to resolve enough that you can really see your initial result, and up to a year to see your final breast reconstruction results.