Surgical Procedures: Breast Reconstruction
Do I need to have breast reconstruction?
It is never medically necessary to have breast reconstruction. This is considered an elective procedure, meaning you can choose to have it done or not. Some women choose to have a mastectomy (removal of all of the breast tissue) without reconstruction. Although it is considered elective, it is not considered solely cosmetic. This means that almost all insurance plans pay for breast reconstruction.
What is the difference between immediate and delayed reconstruction?
Many patients prefer to have reconstruction done (or at least the process started) at the same time as their mastectomy for a number of reasons. If you have breast reconstruction done at the same time as your mastectomy, this is called immediate reconstruction. Delayed reconstruction is the term used if you have the mastectomy done first, then wait for reconstruction to be done months, or even years, later. Possible benefits of immediate reconstruction include decreasing your overall number of surgeries and recovery time, better chance of optimal cosmetic result and, for many women, there is a psychological benefit to immediately pursuing reconstruction.
Are all women candidates for immediate breast reconstruction?
The vast majority of women are candidates for breast reconstruction. There are a variety of reconstructive options, and you may not be a candidate for all types. You and your surgeon will discuss which type of breast reconstruction best fits your situation.
What are the major types of breast reconstruction available?
There are 3 major types of breast reconstruction. The first is implant based reconstruction. The second uses your own tissues, typically from the abdomen and sometimes from other parts of the body including the buttock or thighs. The third option is a combination of the 2 methods using your own tissues and/or muscle in combination with an implant.
I am interested in implant reconstruction. What is involved?
Implant reconstruction is often a two-step procedure. At the time of mastectomy, a tissue expander is placed. A tissue expander is a balloon device that is placed underneath the skin and muscles of the chest wall. At the time of surgery, the surgeon will put in a small amount of saline (salt water) into the expander through a valve in the device. Likely you will wake up essentially flat or with a small breast mound to start the expansion process. The surgery often involves an overnight (1 night) stay and post-operative recovery time with restrictions is about 4 weeks to allow for healing related to your mastectomy.
After the skin heals from the mastectomy, at about 3-4 weeks, you will begin the process of tissue expansion. This means that you will need to come into the office typically on a weekly basis for expansion or "fills". At your office visit, a small needle will be inserted through the skin in the chest wall and into a valve of the tissue expander. A small amount of saline is added at each visit. The chest muscle and skin are slowly stretched to accommodate the appropriate sized implant. Once your tissue expanders have the adequate amount of saline in them you will need to wait at least 4 weeks to allow the skin and muscle to stretch before the exchange surgery. If you need to have chemotherapy, your exchange surgery will be delayed until at least 4 weeks after chemotherapy is done.
In the second stage (exchange surgery), your surgeon will go in through the same incision on the breast, remove the tissue expander and place implants. You have the options of either silicone (gel) or saline filled implants. Both types of implants are made of a silicone shell, the difference is what the implants are filled with. Both are safe and approved by the FDA. There is another type of implant that is textured. These implants have a higher risk of a rare type of lymphoma called Breast Implant Associated Anaplastic Large Cell Lymphoma. These implants should not be used. Your surgeon will help you choose the best implant for you. This is a same-day surgery with minimal recovery time although you may have lifting restrictions for an additional 4-6 weeks after surgery.
The implant reconstruction process typically takes at least 4-6 months, possibly longer depending on the treatment plan and any revision surgeries.
Do my implants last forever?
Implants are not lifetime devices, and both saline and silicone implants can rupture and leak. If you have saline implants, you will likely notice a slow deflation of the implant if it ruptures. The body is able to absorb the salt water leaking out of the implant and over a few days to weeks, you will notice that your implant gets smaller. If you have silicone implants, there may be a change in the shape of the implant. However, there is often no change in size or shape. A ruptured silicone implant can be detected on MRI. If you choose silicone implants, MRI will be scheduled by your doctor when clinically indicated to ensure that your implants are intact. Implants can rupture at anytime after being placed but often last 10-15 years.
Why do you need to do tissue expansion?
Placing implants after mastectomy is very different than putting in implants for cosmetic augmentation. When women have an augmentation, their skin and breast tissue are left intact. These healthy tissues are better able to stretch to accommodate and cushion the breast implant. After a mastectomy, your breast skin is very thin. The breast surgeon needs to make sure that all breast tissue is removed and in order to do this you are left with a very thin layer of breast skin. This breast skin may not be able to stretch in the way it needs to in order to accommodate an implant. This is why often implants are a 2 stage process so the expander can slowly and gently stretch the tissues and muscle. Sometimes the expansion process can be eliminated and the implant placed at the time of the mastectomy. This is called direct to implant reconstruction. Your surgeon will help you determine which surgical option is best for you.
I may need chemotherapy. Can I still have implants?
Women who need post mastectomy chemotherapy are still candidates for implants. Surgery dates can be changed based on the schedule for your chemotherapy. For example, you may postpone your second stage surgery (to remove the tissue expanders and place the implants) until you are a safe period of time from your last chemotherapy. This time period can vary from 4 weeks to several months and will be determined by your surgeon and medical oncologist. This gives your body the necessary time to recover. Women undergoing chemotherapy may also take longer to heal their incisions. This is normal and expected.
I may need (or have already had) radiation to my breast area. Can I still have implants?
Radiation and the impact on implants is something that needs to be discussed carefully with your surgeon. It is true that women who have implants and radiation can be at higher risk for multiple complications, such as capsular contracture, infection, and wound healing issues. However, the timing of the radiation and implant surgery, as well as the type and size of the implant, can be adjusted to help minimize this risk.
Autologous (Tissue-Based) Reconstruction
I keep hearing about TRAM flap reconstruction. What is this all about?
The TRAM flap stands for transverse rectus abdominus myocutaneous flap. This type of reconstruction is when the skin, fat, and blood vessels are taken from your abdomen and transferred to the chest and made into a breast mound. There are two very different types of TRAM flap reconstruction and it is important to understand the difference.
One type of TRAM flap is a pedicled TRAM, this means that the flap is left attached to its original blood supply and is tunneled under the skin to the breast area. This type of surgery can significantly decrease the strength that you have in your abdomen.
The other type of TRAM flap is a free TRAM, In this type of flap, the surgeon cuts the flap of skin, fat, blood vessels, and only a small portion of the muscle from its original location, and sutures the blood vessels to donor blood vessels in the chest. Although this type of flap requires more skill, it preserves the strength and function of your abdominal wall.
There are 2 other special flaps that can be taken from the abdomen called the DIEP or SIEA flap, that also require suturing the blood vessels together. These flaps take NO muscle from your abdomen.
The most common flaps performed are the free TRAM and DIEP flaps. The remainder of this Q&A will only address this type of surgery.
Why do people choose this type of breast reconstruction? Doesn’t it take longer to recover from than implant surgery?
It is true that breast reconstruction using a free flap requires longer recovery compared to implant reconstruction. The hospital stay is 3-4 nights with a 6-8 week recovery including activity and lifting restrictions. However, there are many advantages to this type of breast reconstruction. Below is a brief summary of advantages and disadvantages. You will need to speak to your surgeon to decide what reconstruction option is best for you.
Advantages of a free flap breast reconstruction:
- You have your own tissue being used to reconstruct your breast.
- The flap reconstruction does not require maintenance/replacement.
- This may be a better match to provide a more natural looking breast, especially women undergoing unilateral (one-sided) reconstruction.
- Tissue reconstruction is a better option if you have had or will need radiation.
- Possible decreased fullness to the lower abdomen similar to the result of cosmetic abdominoplasty (tummy tuck).
Disadvantages of a free flap reconstruction:
- This operation can take longer, lasting 4-8 hours. The hospital stay is longer (3-4 nights).
- There is a risk that the flap will fail.
- Risk of abdominal hernia.
I do not want any muscle taken from my abdominal wall. Can you guarantee this prior to surgery?
Although it is always a priority to take no abdominal wall muscle it is impossible to guarantee this prior to surgery. This type of surgery is based on blood vessels. Your surgeon is unable to know the specific anatomy of your deep blood vessels until you are in surgery. If you choose to have this type of surgery you must understand that there is a chance your surgeon will need to take a small piece of muscle from your abdomen to ensure the success of the breast reconstruction. Mesh is often used to reconstruct the abdomen if muscle is taken to reduce the risk of post-operative hernia.
Are there different types of free flap breast reconstructions?
Yes, there are several different types of free flap breast reconstruction.
Usually, the tissue is taken from your lower abdomen. There are 3 possible types of free flap reconstruction from the lower abdomen. As discussed previously, the decision of which of these three is best for you is not finalized until the surgery is started and we can look at the anatomy of your abdominal wall.
- Free TRAM flap = Free Transverse Rectus Abdominus Myocutaneous Flap. In this surgery skin, fat, blood vessels and a small piece of muscle are taken.
- DIEP flap = Deep Inferior Epigastric Perforator flap. In this surgery the abdominal muscle is cut in order to get the vessels but no muscle is taken.
- SIEA flap = Superficial Inferior Epigastric Artery flap. There is no trauma to the abdominal muscle. All vessels taken are from on top of the muscle. This type of surgery is not often an option since most individuals do not have large enough vessels for the reconstruction.
If you have had a previous major abdominal surgery such as an abdominoplasty (tummy tuck) or if you do not have enough tissue on your lower abdomen sometimes tissue from the buttocks or inner thigh may be used. Many abdominal operations, such as Cesarean sections, do not limit the ability to use the tissue of the lower abdomen.
Tell me about the hospitalization period
After surgery, you will be admitted to an intermediate care floor (level of care between a regular bed and an intensive care unit bed). A nurse will be checking the blood flow to your flap every hour during your hospital stay. This is done using an ultrasound Doppler which is not painful or uncomfortable.
You will have several drains called Jackson-Pratt or "JP" drains postoperatively. These drains will help to remove the excess fluid from the surgical sites that would otherwise collect under the skin. You will be sent home with these drains. A provider will teach you how to take care of the drains before you go home.
How long will I need to be out of work for?
For implant reconstruction, most women take 3-4 weeks off of work following the mastectomy and placement of the tissue expanders and 1-2 weeks off of work after the second stage surgery (removal of tissue expanders and placement of the permanent implant). Many women are able to return to work during the tissue expansion process.
For tissue flap reconstruction women generally take 6-8 weeks off from work.
When can I drive?
It is safe to resume driving when all the drains are out (more about these below), when you are off narcotic pain medication and when you have regained safe range of motion of your arms. For most women, this is about 3 weeks after the mastectomy/reconstruction.
Tell me about the surgical drains.
Jackson Pratt (JP) drains are placed under the skin during surgery to remove a collection of blood and other fluids. The drain looks like a narrow plastic tubing that connects to a drainage bulb (which is about the size of a closed fist). The JP drains allow an exit pathway for blood and swelling fluid and help decrease the right of infection. You will go home with most or all of the drains. On average, drains will stay 1 to 3 weeks. You will have at least one drain underneath the arms on the side of your mastectomy. If you use your own tissue you will have at least two drains in the abdominal area. The drains are fairly easy to take care of. You will be taught to care for them while you are in the hospital. Generally three times per day you will need to strip the tubing (clean it from the outside to make sure the tube stays open) and empty the fluid in the collection bulb. You will need to keep track of the 24 hour total of fluid coming out of each drain. These totals will help determine when the drains can be removed. The drains are removed in the office.
What activity limitations do I have?
While the drains are in you can shower, but you must avoid baths or submerging yourself in water. You also want to limit reaching and excessive stretching of your arms immediately after your mastectomy. Once the drains for the breasts are removed you may be given exercises which you can often start 48 hours after the drains are removed.
If you have had tissue taken from your abdomen you will have restrictions of no lifting more than 5-10 lbs for 6-8 weeks after surgery. Walking after surgery is encouraged to help with recovery and avoid complications, such as blood clots in your legs. It will also assist you in not becoming deconditioned after surgery.
Do I need to have any special supplies at home for my recovery?
Bring to the hospital a shirt that either buttons or zips up the front. Just after surgery, it can be painful to raise your arms overhead.
Sometimes your surgeon may request that you buy a sports bra to wear after surgery. This should be a bra without underwires and one that ideally closes/clasps in the front. Many department stores sell these in the sports bra section. There are specialty boutiques that specialize in post-mastectomy products and bras. You can ask your team about which garments will work best for you regarding your reconstruction and healing process. There are prescription bras that may be covered by your insurance company for your post-operative recovery period.
When can I expect to follow up after surgery?
You can expect to visit your provider's office 1-3 weeks after surgery for removal of your drains. You will often see the surgeon 2-4 weeks after surgery.
American Cancer Society. Breast Reconstruction Options. 2016. Found at: http://www.cancer.org/cancer/breast-cancer/reconstruction-surgery/breast-reconstruction-options/breast-reconstruction-using-your-own-tissues-flap-procedures.html
Baek WL, et al. A retrospective analysis of ruptured breast implants. Archives of Plastic Surgery. 2014. Nov; 41(6): 734–739.
FDA. Questions and Answers about Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). 2019.