Breast reconstruction after mastectomy

If you need a mastectomy, you have a choice about whether or not to have surgery to rebuild the shape of the breast. Breast reconstruction surgery is done by a plastic surgeon. Instead of breast reconstruction, you could choose to wear a breast form that replaces the breast, wear padding inside your bra, or do nothing. All of these options have pros and cons. What is right for one woman may not be right for another.

Breast reconstruction may be done at the same time as the mastectomy (“immediate”) or it may be done later on (“delayed”). If radiation therapy is part of the treatment plan, your doctor may suggest waiting until after radiation therapy.

Breast reconstruction may help you feel more comfortable about how you look after a mastectomy.

Although a reconstructed breast will never match the look or feel of your natural breast, this area of plastic surgery continues to improve.

If you’re thinking about breast reconstruction, talk to a plastic surgeon before the mastectomy, even if you plan to have your reconstruction later on.

A surgeon can reconstruct the breast in many ways. Some women choose to have breast implants, which are filled with saline or silicone gel. Another method uses tissue taken from another part of your body. The plastic surgeon can take skin, muscle, and fat from your lower abdomen, back, or buttocks.

The type of reconstruction that is best for you depends on your age, body type, and the type of cancer surgery that you had. A plastic surgeon can help you decide.

Expectations

Although breast reconstruction techniques continue to improve, a reconstructed breast will never look or feel the same as your natural breast.

Reconstruction results vary and may depend on the quality of the tissue left after a mastectomy.

How your reconstructed breast will look and feel depends on many factors including your natural breast anatomy and your treatment plan.

Sometimes, the types of treatments you will have (for example, if you need radiation therapy) limit your reconstruction options and can impact the final look and feel of your reconstructed breast.

Although this can be upsetting, keep in mind your treatment is planned to get rid of your breast cancer and keep it from coming back.

Your plastic surgeon will help you choose the reconstruction that will give you the best results.

Final look of the breast

Remember, it may take some time to see the full results of your reconstructed breast.

How you feel about the final results may depend on your expectations. Keep in mind a reconstructed breast will not look or feel the same as a natural breast.

Most of the scarring will fade and improve over time, but some scars may never go away.

As you age and the opposite breast changes shape, the reconstructed breast may look or feel less natural.

Emotional impact

Most women have a period of emotional adjustment after breast reconstruction.

Feeling anxious or depressed is common.

It may help to talk with a counselor or other women who have had breast reconstruction.

Body shape

Your body shape and anatomy may affect the types of breast reconstruction likely to give you the best results.

For example, women with larger breasts may need breast reduction surgery on the opposite, natural breast to create a more even look.

Lifestyle

Your lifestyle may also affect the type of breast reconstruction you choose.

For example, some types use muscles from other parts of the body, causing weakness in the area. These may not be good options for athletic women.

Smoking and body weight

Smokers and women who are overweight have an increased risk of complications for all types of breast reconstructive surgery ¹.

If you smoke or are overweight, talk with your plastic surgeon about problems after surgery such as delayed wound healing, infection, reconstruction failure and problems with implant or flap procedures that may occur.

Sometimes, it’s best to delay breast reconstruction until after quitting smoking or weight loss to lower these risks.

Your plastic surgeon may discuss ways to quit smoking and/or lose weight before you have reconstruction.

Making an informed choice

Your plastic surgeon will help you choose the type of reconstruction that will give you the best results and fit your lifestyle while minimizing the risk of complications.

Take time to study your options and make a thoughtful, informed choice after carefully considering the pros and cons of each option.

Each person is unique. Your breast cancer treatment, your body and your lifestyle affect not only your reconstruction options, but also the pros and cons of your options.

Although this decision may seem overwhelming, it may help to know that most women who have had breast reconstruction do not regret the method they chose ².

If you are a good candidate for a procedure, there are fairly few complications with any of the current techniques ².

Skin-sparing mastectomy

If you’re having immediate breast reconstruction, your surgeon may perform a skin-sparing mastectomy to keep as much of the skin of the breast as possible.

With a skin-sparing mastectomy, the tumor and clean margins are removed, along with the nipple, areola, fat and other tissue that make up the breast.

What remains is much of the skin that surrounded the breast. This skin can then be used to cover a tissue flap or an implant.

The major benefit of a skin-sparing mastectomy is that it avoids having to use skin from other parts of the body for reconstruction. That skin can have a different color, texture and thickness compared to natural breast skin, creating a “patch” look.

In the past, there were concerns skin-sparing mastectomy might increase the risk of breast cancer recurrence. However, although data are limited, most studies to date have not found an increased risk and the procedure is considered safe ³.

Nipple-sparing mastectomy

A nipple-sparing mastectomy is a skin-sparing mastectomy that leaves the nipple and areola intact. This usually improves the overall look of the reconstructed breast.

For women who are good candidates for nipple-sparing mastectomy, the risk of breast cancer recurrence appears to be low ⁴.

Nipple-sparing mastectomy is a newer procedure and long-term outcomes are still under study.

Who can have nipple-sparing mastectomy?

Not all women can have nipple-sparing mastectomy. For example, if the breast cancer is close to the nipple and areola, the nipple and areola are removed during surgery (to ensure all of the tumor is removed).

At this time, nipple-sparing mastectomy is only an option for ⁴:

• Some women with breast cancer who have small breasts and clean margins in the nipple area
• Women having a prophylactic mastectomy

Some women are not good candidates for nipple-sparing mastectomy because of the size and/or shape of their breasts. For example:

• Women with large, sagging breasts may not be good candidates because they may have more risk of the nipple moving out of position after surgery and more risk of the nipple tissue losing its blood supply and breaking down.
• Women with uneven breasts or nipple positions before surgery (naturally or due to past surgery near the nipple and areola) may not be good candidates as the unevenness may become worse.

After a nipple-sparing mastectomy

With nipple-sparing mastectomy, the nipple will likely lose sensation and some projection. Sometimes, the position of the nipple can move after nipple-sparing mastectomy.

In some cases, the tissues may lose its blood supply and break down, and some or all of the nipple and areola may need to be removed ⁵.

Timing of breast reconstruction

Breast reconstruction can be done at the same time as the mastectomy (“immediate”) or at a later date (“delayed”).

Many women now get immediate breast reconstruction. However, the timing depends on:

• Physical exam by the plastic surgeon
• Surgical risk factors (such as smoking and being overweight)
• Treatments you will need after surgery

Not all women can have immediate reconstruction.

It’s important to discuss your options with your plastic surgeon, breast surgeon and oncologist (and your radiation oncologist if you are having radiation therapy).

Getting a second opinion

Your plastic surgeon should be comfortable with you getting a second opinion.

Seeing a plastic surgeon from a different hospital or group practice can:

• Instill confidence in the first plastic surgeon by confirming your reconstructive options
• Provide another perspective on your reconstructive options
• Give you a chance to meet with another plastic surgeon, who may be better suited to perform your surgery

Breast reconstruction possible challenges

Travel

You may not live near the hospital where your reconstruction will be done. This can be a challenge because of the number of routine follow-up visits needed after reconstruction.

Most breast reconstruction methods involve several steps.

Immediate reconstructions and some delayed reconstructions require a hospital stay for the first procedure.

Follow-up procedures may be done on an outpatient basis.

If you need transportation, lodging, child care or elder care, there may be programs that can help.

Cost

Federal law requires most insurance plans cover the cost of breast reconstruction.

Insurance coverage for reconstructive surgery

Medicare and Medicaid

Medicare is health insurance provided by the federal government to people who are 65 years of age or older. It covers breast reconstruction after a mastectomy.
Medicaid provides health care to people with low income. It’s run jointly by the federal and state governments, so benefits and eligibility (who can join) vary from state to state.

Many states require all health insurance providers (including Medicaid) to cover breast reconstruction after a mastectomy.

Women’s Health and Cancer Rights Act

The Women’s Health and Cancer Rights Act of 1998 requires group health plans, insurance companies and health maintenance organizations (HMOs) that pay for mastectomy to also pay for ⁶:

• Reconstruction of the breast removed with mastectomy
• Surgery and reconstruction of the opposite breast to get a symmetrical look
• Breast prostheses
• Treatment of any complications of surgery, including lymphedema

The Women’s Health and Cancer Rights Act does not apply to some church and government insurance plans.

State laws

Many states require all health insurance providers (including those not covered under the Women’s Health and Cancer Rights Act) to pay for reconstructive surgery after a mastectomy.

Check with your state insurance commissioner’s office or your health insurance provider to find out which services are covered by your state’s laws and your health plan.

Breast reconstruction after radiation

Radiation therapy can cause problems for both implant and natural tissue reconstruction, including:

• Changes in skin color
• Changes in skin quality
• Tissue shrinkage
• Tightness

If you will have an implant procedure using a tissue expander and radiation therapy will be used after mastectomy, immediate breast reconstruction is recommended (rather than delayed reconstruction) ¹.

Delayed breast reconstruction using an implant may not be possible after radiation therapy.

Skin that has received radiation and is later stretched to fit an implant is at high risk for complications and a poor cosmetic result ¹.

Results are better when the procedures to expand the skin are done before radiation therapy begins.

However, the effects of radiation therapy to the reconstruction tend to continue with time and longer-term problems can occur. Radiation therapy, even when done before reconstruction, limits the size of the reconstruction and increases the risk the reconstruction may fail ⁷.

Many women who get radiation therapy to the reconstruction have chronic tightness and stiffness in the chest and upper arm areas. They may need physical therapy or long-term range of motion exercises.

Radiation therapy and natural tissue breast reconstruction

Radiation therapy can cause problems for both natural tissue and implant breast reconstruction, including:

• Changes in skin color
• Changes in skin quality
• Tissue shrinkage
• Tightness

Delayed breast reconstruction

• For women choosing flap breast reconstruction who will need radiation therapy after mastectomy, it may be better to delay the flap reconstruction until after radiation therapy. This greatly lowers the chances the look, feel and size of the reconstructed breast will be harmed by the radiation therapy ¹.

Immediate breast reconstruction

• Women may also consider having immediate reconstruction with a tissue expander to preserve the breast skin envelope. Then, once radiation therapy is over, the expander can be removed and a flap reconstruction can be done.

Types of breast reconstruction

Breast reconstruction options

Breast reconstruction can be done with:

• Breast implants (filled with saline or silicone)
• Natural tissue flaps (using skin, fat and sometimes, muscle from your own body)
• A combination of these methods

There is no one best reconstruction method. There are pros and cons to each.

For example, breast implants require less invasive surgery than procedures using your own body tissues, but the results may look and feel less natural ⁸.

Basic types of breast reconstruction

The table below compares the basic types of breast reconstruction. Specific types of reconstruction are discussed in more detail below.

Table 1. Breast reconstruction options

	Breast implants	Natural tissue flaps
Mimic the look and feel of a natural breast	Less able to mimic the look and feel of a natural breast (silicone implants look and feel more natural than saline implants)	Better able to mimic the look and feel of a natural breast
Loss of sensation	Will lose some sensation in the breast	Will lose some sensation in the breast and tissue donation site
Surgery	Less extensive Time in surgery is shorter	More extensive Time in surgery is longer DIEP, SIEA, S-GAP and I-GAP procedures require well-trained microvascular surgeons
Is a hospital stay needed?	Needed for the first procedure (1-2 nights) when done at the same time as a mastectomy (immediate reconstruction) Follow-up procedures may be done on an outpatient basis	Needed for the procedure (3-4 nights) Follow-up procedures may be done on an outpatient basis
Will the procedure need to be repeated?	Implants may need to be replaced during your lifetime.	Tissue flaps will not need to be replaced during your lifetime. However, if there are complications, some procedures cannot be repeated.
Recovery	3-4 weeks Fewer scars	4-6 weeks More scars
Risk of complications	Some risk of surgical complications	Some risk of surgical complications (certain procedures have more risks than others)

Abbreviations: DIEP = deep inferior epigastric perforator flap reconstruction; SIEA = superficial inferior epigastric artery flap reconstruction; I-GAP = Inferior gluteal artery perforator flap reconstruction; S-GAP = Superior gluteal artery perforator flap reconstruction

[Sources ⁸, ⁹ ]

Breast reconstruction with implants

Inserting a breast implant is a fairly simple procedure. It may not require extra hospital time if it can be done at the same time as the mastectomy.

The shape of the reconstructed breast with an implant may not match the look or feel of the natural, opposite breast, especially as you age and your natural breast changes shape.

For this reason, implants are better for women with small or medium-sized breasts with little or no sagging ⁸.

It’s possible to have surgery to enlarge or reduce the size of the opposite, natural breast to help make your breasts look more alike.

However, the natural breast will change in size and shape with weight changes and as you grow older, while the breast with the implant will not. This may lead to a less even look over time.

More surgery may be needed to maintain a similar look.

Types of breast implants

There are 2 basic types of breast implants: saline and silicone.

For both saline and silicone implants, the outer cover of the implant (also called the implant shell) is made of a solid form of silicone.

The 2 types of implants differ in the substance used to fill the implant shell.

Saline implants

• Saline implants are filled with saline, a saltwater solution similar to that found in IV fluids.
• Saline implants come deflated and during surgery, are filled to the desired volume.

Silicone implants

• Silicone implants are filled with silicone gel, a semi-solid substance made from silicone.
• Silicone implants come pre-filled with the desired volume.

Breast Implant shapes

Different implant shapes are available to match the look of the natural breast.

Implants can be round or teardrop-shaped. They vary in the amount of projection and base width.

The best implant shape and size will depend on:

• Your body shape
• The breast skin
• The quality of the envelope formed by the breast skin and chest muscle after mastectomy (this soft tissue envelope holds the implant).

Breast implants using acellular dermal matrix

The acellular dermis technique takes advantage of the entire skin envelope available at the time of the mastectomy ¹⁰. It’s often used in combination with an implant reconstruction to help cover the lower half of the reconstructed breast. The chest muscle may not be able to reach far enough to cover this area.

This technique creates a hammock under the mastectomy skin envelope to hold the expander or implant in place. The hammock is made from biologic material (called acellular dermal matrix) alone or in combination with your chest muscle. Most often, the biologic material is donated human skin. Acellular means the human cells that may lead to tissue rejection have been removed.

During the healing process, the hammock gets a blood supply from the overlying skin and soft tissue envelope and becomes part of your own tissue. This strengthens the support for the expander or implant. So, the technique requires a high quality mastectomy skin envelope that’s thick enough give a blood supply.

Implant reconstruction with acellular dermal matrix can allow a larger volume fill at the time of surgery. This can shorten the implant expansion process.

Sometimes, acellular dermal matrix can be a 1-step implant process. The final implant can be placed at the time of the mastectomy without the need for expansion.

Some findings show acellular dermal matrix may have a higher risk of complications (such as seroma (fluid collection)) compared to the multiple-step implant method ¹¹.

Women with loose breast skin and women having a nipple-sparing mastectomy (so, keeping the entire breast skin envelope) generally benefit from the procedure ¹².

Women with very small breasts and minimal droop may not benefit from adding acellular dermal matrix.

Talk with your plastic surgeon to find out if this procedure may be right for you.

Pre-pectoral implant reconstruction

Breast implants are usually placed under the chest muscle (subpectoral) to give as much soft tissue coverage of the implant as possible. Some of the chest muscle is cut during the procedure to place to implants underneath.

When women use and contract the chest muscle (pectoralis major muscle), the subpectoral implant breast reconstruction can look distorted (because the implant is below the chest muscle). This can be a problem for women who use their chest muscles a lot (for example, during upper body exercise, such as push-ups).

A new technique places the implant above the chest muscle (pre-pectoral), just under the mastectomy skin envelope, and uses acellular dermal matrix to cover the entire implant ¹³.

A pre-pectoral implant reconstruction doesn’t cut through the chest muscle (since the implant is placed above it). So, this technique may limit some problems that can occur when the chest muscle contracts after a subpectoral implant reconstruction ¹³. This can be important for women who do a lot of upper body exercises.

Not everyone can have a pre-pectoral implant reconstruction. It requires very thick mastectomy skin flaps (not everyone has thick skin flaps after a mastectomy).

The long-term results of this technique, and how it is affected by radiation therapy to the breast, are not known at this time.

Nipple and areola reconstruction

Creating the nipple and areola is the last step of breast reconstruction.

These procedures give the reconstructed breast a more natural look and can help hide some of the mastectomy scars.

Nipple and areola reconstruction are usually outpatient procedures and have few risks ⁸. However, those who have had radiation therapy may have more surgical risks.

The nipple can be recreated using skin from the reconstructed breast itself after the implant or flap reconstruction has healed.

The areola can be created with a tattoo or by grafting skin from the groin area. Skin in the groin area may have a similar tone as the skin on the areola. The scar from where the skin is taken can be hidden in the bikini line.

Not all women can have these procedures.

Women who can’t have nipple reconstruction surgery (or choose not to have it) can consider a 3-dimensional (3D) tattoo to create the look of the nipple and areola.

It’s a good idea to check with your insurance provider before getting a tattoo as this step may not be covered.

Saline versus silicone breast implants – pros and cons

There are pros and cons to each type of implant. These are described in the table below.

Discuss your options with your plastic surgeon to choose the type that’s best for you.

Table 2. Pros and cons of saline versus silicone breast implants

	Saline implants	Silicone implants
Mimic the look and feel of a natural breast	Less able to mimic the feel of a natural breast (may feel like a water balloon) More likely to see rippling or an uneven contour (especially if the skin-muscle envelope is thin)	Better able to mimic the feel of a natural breast Less likely to see rippling or an uneven contour
Can the size of the expander or implant be changed?	Size of the expander may be increased or decreased after the initial surgery Size of the implant cannot be changed without surgery to replace the implant	Size of the implant cannot be changed without surgery to replace the implant
Risk of rupture	Equal chance of rupture	Equal chance of rupture
What happens if rupture occurs?	The saline is absorbed harmlessly into nearby tissues. The reconstructed breast appears deflated, so you know right away the implant has ruptured. The implant should be replaced before the entire surgical pocket that holds the implant has collapsed. (This is especially important after radiation therapy. Radiation to the pocket can cause it to collapse and it may not be possible to replace the implant.)	Some silicone gel might leak into the soft tissue pocket around the implant and rest there. Since the silicone is not absorbed, the overall breast volume stays the same. So, a rupture in a silicone implant may take longer to be detected than a rupture in a saline implant. Breast MRI can be used to check for implant rupture.
Side effects that may occur	Hardening of the tissues around the implant (called capsular contraction) Infection (may require removal of the implant) Pain	Hardening of the tissues around the implant (called capsular contraction) Infection (may require removal of the implant) Pain
Replacement	Typically lasts at least 10 years, but will likely need to be replaced during your lifetime (replacement requires surgery)	Typically lasts at least 10 years, but will likely need to be replaced during your lifetime (replacement requires surgery)

[Sources ¹⁴, ⁸ ]

Safety of breast implants

In the past, there were concerns that silicone breast implants might cause health problems.

However, most studies show no link between silicone implants and lupus, immune system disorders, connective tissue disease or rheumatoid arthritis ¹⁵.

Silicone implants are as safe as saline breast implants.

Anaplastic large cell lymphoma

Anaplastic large cell lymphoma is a very rare, treatable form of cancer of the cells of the immune system. It occurs in breast tissue in about 3 in 100 million women ¹⁶.

The U.S. Food and Drug Administration (FDA) ¹⁴ is studying a link between breast implants (both saline and silicone) and a slight increase in the risk of anaplastic large cell lymphoma ¹⁶.

Although the reasons are unclear at this time, the risk of anaplastic large cell lymphoma appears to be linked to textured breast implants rather than smooth implants ¹⁶.

Breast implant procedure

Inserting a breast implant (saline or silicone) is a fairly simple process.

• Step 1: A temporary, modified saline device (called a tissue expander) is inserted in the envelope formed by the breast skin and chest muscle. The expander has a valve that allows more saline to be added (with a simple injection through the skin into the valve) after surgery.
• Step 2: Over a period of 2-6 months (in repeated office visits), the skin-muscle envelope is slowly stretched by injecting more saline into the expander until it reaches the desired size of the final implant. The final volume may be limited by the quality and size of the skin-muscle envelope.
• Step 3: A surgeon removes the expander and replaces it with the permanent implant (saline or silicone). This is done in an operating room, but is usually an outpatient surgery.

Direct breast implant insertion

Some women don’t need tissue expansion and can have an implant (saline or silicone) directly inserted at the time of mastectomy.

In these women, the size of the skin-muscle envelope at the time of the mastectomy is large enough to cover the desired final implant.

For example, women who have moderate-sized breasts or excess natural breast skin, or who want to have a reconstruction smaller than their natural breast size may be good candidates for direct implant insertion.

However, these cases are exceptions rather than the rule.

Changing the size of an implant

The size of a reconstructed breast can’t be changed without surgery to replace the implant.

However, changes in weight can impact the look of the breast with an implant. Weight gain may make the breast with an implant appear smaller. Weight loss may make it appear fuller.

Breast reconstruction with tissue flap

Breast reconstruction using skin and soft tissue flaps from your own body tends to mimic the look and feel of a natural breast better than reconstruction with implants. However, these procedures are more complex and invasive, and usually require a longer hospital stay and post-surgery recovery time.

Breast reconstruction using skin and soft tissue flaps leave scars in the area of the body where the tissue was taken (donor site).

The most common natural flap procedures use tissue from the back, abdomen, buttocks or thighs.

In some procedures, part or all of a muscle needs to be taken to provide blood flow to the flap tissue. This may cause weakness in that area of the body and limit certain physical or athletic activities. If you are active, discuss this risk with your plastic surgeon.

Latissimus dorsi muscle flap breast reconstruction

The latissimus dorsi muscle flap procedure removes a large muscle in the back along with skin and underlying fatty tissue. It uses these tissues to reconstruct the breast ⁸.

Using fatty tissue helps create a more natural looking breast.

In most women, the amount of soft tissue available on the back is limited and the flap itself is only about an inch thick. An implant is usually also needed to create enough volume for the reconstructed breast.

The soft tissue of the latissimus flap goes over the implant so it mimics the look and feel of a natural breast better than an implant alone.

Transverse rectus abdominis myocutaneous flap breast reconstruction

The transverse rectus abdominis myocutaneous (TRAM) flap uses skin, fat and muscle from the lower abdomen to reconstruct the breast [130]. It creates a natural-looking breast.

A transverse rectus abdominis myocutaneous (TRAM) flap usually does not require an implant as long as there’s enough excess skin and fatty tissue in the lower abdomen.

If you don’t have excess abdomen tissue, you may not be a candidate for a transverse rectus abdominis myocutaneous (TRAM) flap reconstruction.

The transverse rectus abdominis myocutaneous (TRAM) flap has some drawbacks:

• Once a transverse rectus abdominis myocutaneous flap has been done, it can’t be repeated.
• The surgery can leave a large scar across the lower abdomen.

Since an abdominal muscle is removed to provide a blood supply to the flap, its loss can cause some weakness in this part of the body. If you are active, talk with your plastic surgeon about this drawback.

Deep inferior epigastric perforator flap breast reconstruction

Breast reconstruction with a deep inferior epigastric perforator (DIEP) flap uses skin and fatty tissue from the lower abdomen to form the reconstructed breast ⁸.

Unlike the transverse rectus abdominis myocutaneous (TRAM) flap, the deep inferior epigastric perforator (DIEP) flap procedure keeps the abdominal muscle intact. This may preserve abdominal strength after the procedure.

The deep inferior epigastric perforator (DIEP) flap has some drawbacks:

• Once a deep inferior epigastric perforator flap has been done, it can’t be repeated.
• It’s more complex than the latissimus dorsi muscle flap and transverse rectus abdominis myocutaneous (TRAM) flap procedures and usually requires 2 microvascular surgeons.
• It may require an intensive care unit (ICU) stay for close monitoring after surgery.
• The surgery takes much longer than some other natural flap techniques (due to the microvascular procedures), which can increase the risk of problems during surgery.
• The surgery can leave a large scar across the lower abdomen.

The deep inferior epigastric perforator (DIEP) flap procedure should only be done by microvascular surgeons well-trained and experienced with this technique.

Superficial inferior epigastric artery flap reconstruction

The superficial inferior epigastric artery (SIEA) flap breast reconstruction uses skin, fatty tissue and blood vessels (including the superficial inferior epigastric artery) from the abdomen to form the reconstructed breast.

The superficial inferior epigastric artery (SIEA) flap isn’t as common as the transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps because few women have blood vessels large enough (or any at all) for the procedure ⁸.

The superficial inferior epigastric artery (SIEA) flap leaves all of the muscles and most of the connective tissue of the abdomen untouched, so it leaves no weakness in the abdominal area. This can be important for women who are physically active.

Blood clots are more common with superficial inferior epigastric artery (SIEA) flap procedures than with other techniques ¹⁷.

The superficial inferior epigastric artery (SIEA) flap procedure should only be done by microvascular surgeons well-trained and experienced with this technique.

Superior and inferior gluteal artery perforator flap reconstruction

Gluteal artery perforator (GAP) flap procedures use skin and fatty tissue from the buttocks to reconstruct the breast.

• The Superior gluteal artery perforator (S-GAP) procedure uses skin and fatty tissue from the upper part of a buttock.
• The Inferior gluteal artery perforator (I-GAP) flap procedure uses skin and fatty tissue from the lower part of a buttock.

Because no buttock muscle is used in either procedure, athletic ability after surgery is rarely affected ¹⁸.

Superior gluteal artery perforator (S-GAP) or Inferior gluteal artery perforator (I-GAP) flap reconstruction may be a good option for women with more fatty tissue in their buttocks area than in their abdomen ¹⁹.

If the gluteal artery perforator (GAP) procedure leaves the buttocks noticeably different in size, liposuction can be used later to remove fat from the opposite buttock to create a more even look.

As with the deep inferior epigastric perforator (DIEP) flap, gluteal artery perforator (GAP) flap procedures are more complex than other types of flap procedures and require a microvascular surgeon.

They take longer than other types of tissue flap surgeries (even longer than the deep inferior epigastric perforator (DIEP) flap procedure), which may increase the risk of surgical complications ¹⁹.

If an Superior gluteal artery perforator (S-GAP) or Inferior gluteal artery perforator (I-GAP) flap procedure isn’t successful, it can be repeated using tissue from the opposite buttocks (either immediately or at a later time).

Transverse upper gracilis flap breast reconstruction

Transverse upper gracilis (TUG) flap procedures use skin, fatty tissue and muscle from the upper inner thigh to reconstruct the breast [130].

Transverse upper gracilis (TUG) flap reconstruction uses the gracilis muscle, which helps bring the leg toward the body. This isn’t a critical muscle and most people don’t notice a lot of weakness.

Transverse upper gracilis (TUG) flap may be a good option for women with excess fatty tissue in their upper inner thigh area who are not good candidates for TRAM, DIEP, SIEA or GAP flap procedures.

As with other microvascular flap procedures, transverse upper gracilis flap is a complex surgery that requires a microvascular surgeon.

If a transverse upper gracilis (TUG) flap isn’t successful, it can be repeated using tissue from the opposite upper inner thigh.

Breast reconstruction surgery risks

Possible risks during and after reconstruction surgery

Any type of surgery has risks, and breast reconstruction may pose certain unique problems for some women. Even though many of these are not common, it’s important to have an idea of the possible risks and side effects.

Some of the risks during or soon after breast reconstruction surgery include:

• Problems with the anesthesia
• Bleeding
• Blood clots
• Fluid build-up in the breast or the donor site (for a tissue flap), with swelling and pain
• Infection at the surgery site(s)
• Wound healing problems
• Extreme tiredness (fatigue)

Problems that can occur later on include:

• Tissue death (necrosis) of all or part of a tissue flap, skin, or fat
• Loss of or changes in nipple and breast sensation
• Problems at the donor site, such as loss of muscle strength
• The need for more surgery to fix problems that come up
• Changes in the arm on the same side as the reconstructed breast
• Problems with a breast implant, such as movement, leakage, rupture, or scar tissue formation (capsular contracture)
• Uneven breasts

Risks of infection

• Infection can happen with any surgery, most often in the first couple of weeks after surgery. If an implant has been placed, it might have to be removed until the infection clears. A new implant can be put in later. If you have a tissue flap, surgery may be needed to clean the wound.

Risks of capsular contracture

• The most common problem with breast implants is capsular contracture. A scar (or capsule) can form around the soft implant. As it tightens, it can start to squeeze the implant, making the breast feel hard. Capsular contracture can be treated. Sometimes surgery can remove the scar tissue, or the implant can be removed or replaced.

Additional risks for smokers

• Using tobacco narrows blood vessels and reduces the supply of nutrients and oxygen to tissues. As with any surgery, smoking can delay healing. This can cause more noticeable scars and a longer recovery time. Sometimes these problems are bad enough that a second operation is needed to fix them. You may be asked to quit smoking a few weeks or months before surgery to reduce these risks. This can be hard to do, so ask your doctor for help.

Breast reconstruction surgery recovery time

The time it takes you to recover from breast reconstruction surgery will depend on the type of reconstruction you have. Most women begin to feel better in a couple of weeks and can return to usual activities in a couple of months. Talk to your doctor about what you can expect. Be sure you understand how to take care of your surgery sites and how to follow up with your breast care, including regular mammograms and when they are needed depending on the breast reconstruction surgery you have had.​

You’re likely to feel tired and sore for a week or 2 after breast implant surgery, or longer after a flap procedure (which will leave you with 2 surgical wounds). Your surgeon or plastic surgeon will give you medicines to help control pain and other discomfort.

Depending on the type of breast reconstruction surgery you have, you will most likely be able to go home from the hospital within a few days. You may be discharged with one or more drains in place. A drain is a small tube that’s put in the wound to remove extra fluid from the surgery site while it heals. In most cases, fluid drains into a little hollow ball that you’ll learn how to empty before you leave the hospital. The doctor will decide when the drains can be safely removed depending on how much fluid is collecting each day. Follow your doctor’s instructions on wound and drain care. Also be sure to ask what kind of support garments you should wear. If you have any concerns or questions, ask someone on your cancer care team. Talk with your plastic surgeon about specific instructions after your surgery.

You may need to wear a special bra while your reconstructed breast heals.

Surgical drains

For some types of surgery, you may still have a small tube(s) called a surgical drain(s) in place when you go home from the hospital.

This allows extra fluid from the surgery to escape. You will learn how to take care of the drain.

Pain and discomfort after surgery

You will likely have some pain after surgery. For most people, this pain is temporary.

The bruising and swelling from the surgery may take up to 8 weeks to go away ²⁰.

Getting back to normal

Most women can start to get back to normal activities within about 6 to 8 weeks.

• Overhead lifting, strenuous sports and sex should be avoided for 4-6 weeks after reconstructive surgery ²⁰.
• Most women can resume normal activity within 8 weeks ²⁰.
• Talk with your health care provider about activities to avoid and when you can get back to your normal routine.

If breast implants are used without flaps, your recovery time may be shorter. Some things to keep in mind:

• Breast reconstruction does not restore normal feeling to your breast, but some feeling may return over a period of years.
• It may take up to about 8 weeks for bruising and swelling to go away. Try to be patient as you wait to see the final result.
• It may take as long as 1 to 2 years for tissues to heal fully and scars to fade, but the scars never go away completely.
• Ask when you can go back to wearing regular bras. Talk with your surgeon about the type of bra to wear – sometimes it will depend on the type of surgery you had. After you heal, underwires and lace might feel uncomfortable if they press on scars or rub your skin.
• Follow your surgeon’s advice on when to begin stretching exercises and normal activities, because it’s different with different types of reconstruction. As a basic rule, you’ll want to avoid overhead lifting, strenuous sports, and some sexual activities for 4 to 6 weeks after reconstruction. Check with your surgeon for specific guidance.
• Women who have reconstruction months or years after a mastectomy may go through a period of emotional adjustment once they’ve had their breast reconstructed. Just as it takes time to get used to the loss of a breast, it takes time to start thinking of the reconstructed breast as your own. Talking with other women who have had breast reconstruction might be helpful. Talking with a mental health professional might also help you sort out anxiety and other distressing feelings.
• Silicone gel implants can open up or leak inside the breast without causing symptoms. Surgeons usually recommend getting regular magnetic resonance imaging (MRI) of implants to make sure they aren’t leaking. (This isn’t needed with saline implants.) You’ll likely have your first MRI 1 to 3 years after your implant surgery and every 2 years from then on, although it may vary by implant. Your insurance might not cover this. Be sure to talk to your doctor about long-term follow-up.
• Call your doctor right away if you notice any new skin changes, swelling, lumps, pain, or fluid leaking from the breast, armpit, or flap donor site, or if you have other symptoms that concern you.

Talk to your doctors about the need for mammograms

Women who have had a mastectomy to treat breast cancer generally do not need routine screening mammograms on the side that was affected by cancer (although they still need them on the other breast). There isn’t enough tissue remaining after a mastectomy to do a mammogram. Cancer can come back in the skin or chest wall on that side, but if this happens it’s more likely to be found on a physical exam.

It’s possible for women with reconstructed breasts to get mammograms, but experts agree that women who have breast reconstruction after a mastectomy don’t need routine mammograms. Still, if an area of concern is found during a physical exam, a diagnostic mammogram may be done. (Ultrasound or MRI may also be used to look at the area closely.)

If you have a breast implant and you need a mammogram, be sure to get it done at a facility with technologists trained in moving the implant to get the best possible images of the rest of the breast. Pictures can sometimes be impaired by implants, more so by silicone than saline. Be sure your technologist knows about your implant before starting the mammogram.

If you’re not sure what type of mastectomy you had or whether you need to get mammograms, ask your doctor.

1. National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology: Breast cancer. https://www.nccn.org/professionals/physician_gls/default.aspx[↩][↩][↩][↩]
2. Zhong T, Hu J, Bagher S, et al. Decision regret following breast reconstruction: the role of self-efficacy and satisfaction with information in the preoperative period. Plast Reconstr Surg. 132(5):724e-734e, 2013.[↩][↩]
3. Mota BS, Riera R, Ricci MD, et al. Nipple- and areola-sparing mastectomy for the treatment of breast cancer. Cochrane Database Syst Rev. 11:CD008932, 2016.[↩]
4. Smith BL, Tang R, Rai U, et al. Oncologic safety of nipple-sparing mastectomy in women with breast cancer. J Am Coll Surg. 225(3):361-365, 2017.[↩][↩]
5. Tang R, Coopey SB, Merrill AL, et al. Positive nipple margins in nipple-sparing mastectomies: rates, management, and oncologic safety. J Am Coll Surg. 222(6):1149-55, 2016.[↩]
6. U.S. Department of Labor. Your rights after a mastectomy. https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/publications/your-rights-after-a-mastectomy.pdf[↩]
7. Kronowitz SJ. Current status of implant-based breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg. 130(4):513e-523e, 2012.[↩]
8. Mehrara BJ and Ho AY. Chapter 36: Breast reconstruction, in Harris JR, Lippman ME, Morrow M, Osborne CK. Diseases of the Breast, 5th edition. Lippincott Williams and Wilkins, 2014.[↩][↩][↩][↩][↩][↩][↩][↩]
9. Christensen BO, Overgaard J, Kettner LO, Damsgaard TE. Long-term evaluation of postmastectomy breast reconstruction. Acta Oncol. 50(7):1053-61, 2011.[↩]
10. Lee KT, Mun GH. Updated evidence of acellular dermal matrix use for implant-based breast reconstruction: a meta-analysis. Ann Surg Oncol. 23(2):600-10, 2016.[↩]
11. Dikmans RE, Negenborn VL, Bouman MB, et al. Two-stage implant-based breast reconstruction compared with immediate one-stage implant-based breast reconstruction augmented with an acellular dermal matrix: an open-label, phase 4, multicentre, randomised, controlled trial. Lancet Oncol. 18(2):251-258, 2017.[↩]
12. Colwell AS, Christensen JM. Nipple-sparing mastectomy and direct-to-implant breast reconstruction. Plast Reconstr Surg. 140(5S Advances in Breast Reconstruction):44S-50S, 2017.[↩]
13. Caputo GG, Marchetti A, Dalla Pozza E, et al. Skin-reduction breast reconstructions with prepectoral implant. Plast Reconstr Surg. 137(6):1702-5, 2016.[↩][↩]
14. Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239995.htm[↩][↩]
15. Janowsky EC, Kupper LL, Hulka BS. Meta-analyses of the relation between silicone breast implants and the risk of connective-tissue diseases. N Engl J Med. 342(11):781-90, 2000.[↩]
16. Leberfinger AN, Behar BJ, Williams NC, et al. Breast implant-associated anaplastic large cell lymphoma: a systematic review. JAMA Surg. 152(12):1161-1168, 2017.[↩][↩][↩]
17. Sarik JR, Bank J, Wu LC, Serletti JM. Superficial inferior epigastric artery: learning curve versus reality. Plast Reconstr Surg. 137(1):1e-6e, 2016.[↩]
18. LoTempio MM, Allen RJ. Breast reconstruction with SGAP and IGAP flaps. Plast Reconstr Surg. 126(2):393-401, 2010.[↩]
19. Mirzabeigi MN, Au A, Jandali S, Natoli N, Sbitany H, Serletti JM. Trials and tribulations with the inferior gluteal artery perforator flap in autologous breast reconstruction. Plast Reconstr Surg. 128(6):614e-24e, 2011.[↩][↩]
20. What to Expect After Breast Reconstruction Surgery. https://www.cancer.org/cancer/breast-cancer/reconstruction-surgery/what-to-expect-after-breast-reconstruction-surgery.html[↩][↩][↩]