Plastic Surgery Procedures

Breast Reconstruction Surgery

Information on breast reconstruction surgery including find a specialist feature. Information on surgical procedure, implants, timing, immediate and delayed reconstruction, surgery without implants and more.

Whether you decide to have breast reconstruction depends on your own individual case, medical condition, general health, lifestyle, emotional state, and breast size and shape. You may consider consulting your family, friends, breast implant support groups, and breast cancer support groups to help you in making this decision. If you are considering breast reconstruction and do not have a plastic surgeon, use our doctor finder for the names of experienced, board certified plastic surgeons in your area. Your general surgeon, plastic surgeon, and oncologist should work together to plan your mastectomy and reconstruction procedure to give you the best possible result.

Your surgeon will decide whether your health and medical condition makes you an appropriate candidate for breast implant reconstruction. Women with larger breasts may require reconstruction with a combination of a tissue flap and an implant. Your surgeon may recommend breast implantation of the opposite, uninvolved breast in order to make them more alike (maximize symmetry) or he/she may suggest breast reduction (reduction mammoplasty) or a breast lift (mastopexy) to improve symmetry. Mastopexy involves removing a strip of skin from under the breast or around the nipple and using it to lift and tighten the skin over the breast. Reduction mammoplasty involves removal of breast tissue and skin. If it is important to you not to alter the unaffected breast, you should discuss this with your plastic surgeon, as it may affect the breast reconstruction methods considered for your case.

What Are the Choices in Breast Reconstructive Procedures?

The type of breast reconstruction procedure available to you depends on your medical situation, breast shape and size, general health, lifestyle, and goals. Women with small or medium sized breasts are the best candidates for breast reconstruction. Breast reconstruction can be accomplished by the use of a prosthesis (a breast implant, either silicone gel or saline-filled), your own tissues (a tissue flap), or a combination of the two.

A tissue flap is a section of skin, fat and/or muscle which is moved from your stomach, back or other area of your body, to the chest area, and shaped into a new breast. Whether or not you have breast reconstruction with or without breast implants, you will probably undergo additional surgeries to improve symmetry and appearance.

For example, because the nipple and areola are usually removed with the breast tissue in mastectomy, the nipple is usually reconstructed by using a skin graft from another area of the body or the opposite breast, in addition to tattooing the area. Nipple reconstruction is usually done as a separate outpatient procedure after the initial reconstruction surgery is complete.

Breast Reconstruction Procedures with Implants - The Timing of Your Breast Implant Reconstruction

The following description applies to reconstruction following mastectomy, but similar considerations apply to reconstruction following breast trauma or for reconstruction for congenital defects. The breast reconstruction process may begin at the time of your mastectomy (immediate reconstruction) or weeks to years afterwards (delayed reconstruction). Immediate reconstruction may involve placement of a breast implant, but typically involves placement of a tissue expander, which will eventually be replaced with a breast implant. It is important to know that any type of surgical breast reconstruction may take several steps to complete. Two potential advantages to immediate reconstruction are that your breast reconstruction starts at the time of your mastectomy and that there may be cost savings in combining the mastectomy procedure with the first stage of the reconstruction. However, there may be a higher risk of complications such as deflation with immediate reconstruction, and your initial operative time and recuperative time may be longer.

A potential advantage to delayed reconstruction is that you can delay your reconstruction decision and surgery until other treatments, such as radiation therapy and chemotherapy, are completed. Delayed reconstruction may be advisable if your surgeon anticipates healing problems with your mastectomy, or if you just need more time to consider your options. There are medical, financial and emotional considerations to choosing immediate versus delayed reconstruction. You should discuss with your surgeon, plastic surgeon, and oncologist, the pros and cons with the options available in your individual case.

One-Stage Immediate Breast Implant Reconstruction

Immediate one-stage breast reconstruction may be done at the time of your mastectomy. After the general surgeon removes your breast tissue, the plastic surgeon will then implant a breast implant that completes the one-stage reconstruction. In breast reconstruction following mastectomy, a breast implant is most often placed submuscularly.

Two-Stage (Immediate or Delayed) Breast Implant Reconstruction

Breast reconstruction usually occurs as a two-stage procedure, starting with the placement of a breast tissue expander, which is replaced several months later with a breast implant. The tissue expander placement may be done immediately, at the time of your mastectomy, or be delayed until months or years later.

Stage 1: Tissue Expansion

During a mastectomy, the general surgeon removes skin as well as breast tissue, leaving the chest tissues flat and tight. To create a breast shaped space for the breast implant, a tissue expander is placed under the remaining chest tissues. The tissue expander is a balloon-like device made from elastic silicone rubber. It is inserted unfilled, and over time, sterile saline fluid is added by inserting a small needle through the skin to the filling port of the device. As the tissue expander fills, the tissues over the expander begin to stretch, similar to the gradual expansion of a woman's abdomen during pregnancy. The tissue expander creates a new breast shaped pocket for a breast implant. Tissue expander placement usually occurs under general anesthesia in an operating room. Operative time is generally one to two hours. The procedure may require a brief hospital stay, or be done on an outpatient basis. Typically, you can resume normal daily activity after two to three weeks.

Because the chest skin is usually numb from the mastectomy surgery, it is possible that you may not experience pain from the placement of the tissue expander. However, you may experience feelings of pressure, tightness or discomfort after each filling of the expander, which subsides as the tissue expands but may last for a week or more. Tissue expansion typically lasts four to six months.

Stage 2: Placing the Breast Implant

After the tissue expander is removed, the unfilled breast implant is placed in the pocket, and then filled with sterile saline fluid. In reconstruction, following mastectomy, a breast implant is most often placed submuscularly. The surgery to replace the tissue expander with a breast implant (implant exchange) is usually done under general anesthesia in an operating room. It may require a brief hospital stay or be done on an outpatient basis.

Breast Reconstruction Procedures without implants

The breast can be reconstructed by surgically moving a section of skin, fat and muscle from one area of your body to another. The section of tissue may be taken from such areas as your abdomen, upper back, upper hip, or buttocks. The tissue flap may be left attached to the blood supply and moved to the breast area through a tunnel under the skin (a pedicled flap), or it may be removed completely and reattached to the breast area by microsurgical techniques (a free flap). Operating time is generally longer with free flaps, because of the microsurgical requirements.

Flap surgery requires a hospital stay of several days and generally a longer recovery time than breast implant reconstruction. Flap surgery also creates scars at the site where the flap was taken and on the reconstructed breast. However, flap surgery has the advantage of being able to replace tissue in the chest area. This may be useful when the chest tissues have been damaged and are not suitable for tissue expansion. Another advantage of flap procedures over implantation is that alteration of the unaffected breast is generally not needed to improve symmetry.

The most common types of tissue flaps are the TRAM (transverse rectus abdominus musculocutaneous flap) (which uses tissue from the abdomen) and the Latissimus dorsi flap (which uses tissue from the upper back). It is important for you to be aware that flap surgery, particularly the TRAM flap, is a major operation, and more extensive than your mastectomy operation. It requires good general health and strong emotional motivation. If you are very overweight, smoke cigarettes, have had previous surgery at the flap site, or have any circulatory problems, you may not be a good candidate for a tissue flap procedure. Also, if you are very thin, you may not have enough tissue in your abdomen or back to create a breast mound with this method.

The TRAM Flap (Pedicle or Free)

During a TRAM flap procedure, the surgeon removes a section of tissue from your abdomen and moves it to your chest to reconstruct the breast. The TRAM flap is sometimes referred to as a "tummy tuck" reconstruction, because it may leave the stomach area flatter. A pedicle TRAM flap procedure typically takes three to six hours of surgery under general anesthesia; a free TRAM flap procedure generally takes longer. The TRAM procedure may require a blood transfusion.

Typically, the hospital stay is two to five days. You can resume normal daily activity after six to eight weeks. Some women, however, report that it takes up to one year to resume a normal lifestyle. You may have temporary or permanent muscle weakness in the abdominal area. If you are considering pregnancy after your reconstruction, you should discuss this with your surgeon. You will have a large scar on your abdomen and may also have additional scars on your reconstructed breast.

The Latissimus Dorsi Flap With or Without Breast Implants

During a Latissimus Dorsi flap procedure, the surgeon moves a section of tissue from your back to your chest to reconstruct the breast. Because the Latissimus Dorsi flap is usually thinner and smaller than the TRAM flap, this procedure may be more appropriate for reconstructing a smaller breast. The Latissimus Dorsi flap procedure typically takes two to four hours of surgery under general anesthesia. Typically, the hospital stay is two to three days. You can resume daily activity after two to three weeks. You may have some temporary or permanent muscle weakness and difficulty with movement in your back and shoulder. You will have a scar on your back, which can usually be hidden in the bra line. You may also have additional scars on your reconstructed breast.

Post-Operative Care

Depending on the type of surgery you have, the post-operative recovery period will vary. Note: If you experience fever, or noticeable swelling and/or redness in your implanted breast(s), you should contact your surgeon immediately.

More articles

DIEP Reconstruction
Breast Reconstruction - Most Common Risks
The Timing of your Breast Reconstruction
Who is a Candidate for Breast Implant Reconstruction
Reconstruction With Tissue Flaps
Other Surgical Procedures Related to Breast Reconstruction
Choices in Reconstructive Procedures
Questions You Should ask your Surgeon about Breast Reconstruction
Warranty for Implants
Breast Reconstruction Considerations
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