How is a breast reconstruction procedure performed?

The three basic options for breast reconstruction:

• Using breast implants (saline or silicone).
• Reconstructing the breast using your own skin, fat and muscle.
• A combination of these methods.

Most breast reconstruction methods involve several steps. The majority of breast reconstruction procedures are done as outpatient surgery; however, some may require a hospital stay for the initial procedure (especially if it is done in conjunction with the initial mastectomy). Implant or expander insertion may not require extra hospital time if it can be done at the time of the mastectomy. Your plastic surgeon will help you weigh the pros and cons and select the method to benefit you the most.

Implant reconstruction procedures
This is usually a two-or three-step process.

• In the initial procedure, your surgeon inserts a tissue expander beneath the skin and chest muscle, forming a skin-muscle envelope. The tissue expander is a modified saline implant with a valve, allowing more saline to be added after the first surgery. Serial injections of saline through the skin into the valve slowly fill the implant and will subsequently expand your breast mound. During office visits over two to six months, the skin-muscle envelope is slowly stretched until it reaches the size you want for the final implant.
• In the next stage, you will undergo outpatient surgery during which the expander is removed and replaced with a softer breast implant (saline or silicone).
• Sometimes, with saline implants, the expander is kept in place for a longer period, allowing the size of the reconstructed breast to be changed (by increasing or decreasing the amount of saline) without implant removal. With a silicone implant, your breast size cannot be changed without another surgery.
• It is rare for a woman to have an implant (saline or silicone) inserted directly without first having tissue expansion. In this situation, the size of the skin-muscle envelope at the time of mastectomy is large enough to cover the desired final implant.

Breast reconstruction with implants using acellular dermal matrix
Acellular dermal matrix (ADM) is a sheet of tissue that has had its cells removed leaving a framework of collagen and elastin for support and cover. This tissue is specifically prepared to allow your body tissues to gradually grow into this material, ultimately replacing it with your own collagen and blood vessels.

In the case of breast reconstruction:

• The acellular dermal matrix acts like a hammock under the mastectomy skin-muscle envelope that supports the tissue expander and can also improve implant placement. This framework of molecules allows your body’s cells to grow into the matrix, promoting the regenerative process that takes place during tissue expansion. ADM is usually combined with your chest muscle to cover the expander and maintain its position, and subsequently the position of the implant.
• The ADM procedure can be less invasive than other techniques, permitting a larger breast mound to be created at the time of the mastectomy and decreasing the number of office visits needed to reach the desired implant volume. When ADM is used, the expander can often be replaced with the final implant sooner than with other tissue-expansion techniques. In rare circumstances, an expander is not needed and the final implant can be placed into the created hammock at the time of the mastectomy with no further surgery required.
• The use of ADM products has enabled plastic surgeons to offer immediate breast reconstruction to more patients and to improve the overall results of breast reconstruction. Whether or not you’re a candidate for this technique depends on the quality of your mastectomy skin envelope.
• ADM has been available since 1994 and has become popular in breast reconstruction within the past ten years. Different ADM products have different properties and your surgeon may recommend one over the other, depending on your situation.

Natural grafts/tissue flap surgery
In certain circumstances, especially if you have radiation-damaged tissues, your surgeon may recommend the use of a flap of your own tissue, which can provide coverage or replacement of the damaged tissues with healthy, non irradiated tissue.

• Reconstruction using skin and tissue flaps from your own body (autologous tissue) can look and feel more like a natural breast than reconstruction with implants. However, these procedures are more complex and invasive, usually prolong the hospital stay and leave scars in the areas from which the tissue was taken.
• The most common natural flap procedures use tissue from the back, abdomen or buttocks. In some procedures an entire muscle needs to be moved to reconstruct the breast, causing weakness in that area of the body.
• Autologous fat grafting or fat transfer is another option for treating radiation-damaged tissues or small areas of contour irregularities. Fat transfer has pros and cons, including graft loss and fatty cysts and may require multiple surgical sessions. Your surgeon can discuss the advantages and limitations of this surgery with you after he or she has evaluated you. Surgeons sometimes use autologous fat grafts to improve the results from implant reconstruction or to correct contour irregularities.

Skin-sparing mastectomy

• If you are having immediate breast reconstruction, your surgeon may perform a skin-sparing mastectomy to keep as much of your breast skin intact as possible. The tumor and clean margins (areas free of cancer cells) are removed along with the nipple, areola (pigmented skin surrounding the nipple), 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 using skin from other body parts for reconstruction, which can have a different color, texture and thickness compared with natural breast skin.
• A patient who has large or droopy breasts may be at a potential disadvantage of a skin-sparing mastectomy; the loose skin may continue to sag and compromise the reconstructive result. It is best to discuss this with your plastic surgeon before your mastectomy surgery if you are considering breast reconstruction.

Nipple-sparing mastectomy

• This is a newer procedure that removes the tumor and clean margins as well as the fat and other tissue in the breast, but leaves the nipple and areola intact, improving the overall look of the reconstructed breast. Not all women are candidates for this and there may be other complications. The nipple will likely lose sensation and some projection. In some cases, the tissues may break down and some or all of the nipple and areola may have to be removed later.
• There is still debate as to the risk of leaving the nipple and areola in terms of breast cancer recurrence and this should be discussed with your surgeon and oncologist, who can assess your individual risk based on your tumor type, family history and other factors.

Nipple reconstruction with implant procedures

• Nipple reconstruction can be done when the permanent implant is inserted in the operating room or, more commonly, as a third step in the office. Recreating the nipple and areola gives the reconstructed breast a more natural look and can help hide scars.
• The nipple is usually recreated by lifting a flap of skin from the reconstructed breast itself and folding it in such a way as to create a small piece of tissue with projection. There are a number of methods to achieve this and most can be done in an office setting under local anesthesia. Many surgeons prefer to delay the nipple reconstruction until the breast implant has settled into its final position, since this may affect the final position of the reconstructed nipple.
• The areola is usually created by tattooing the area or by grafting skin from the groin area, which has a tone similar to the skin of the areola. The scar from where the skin is taken can be hidden in the bikini line.

What are my options?

Your plastic surgeon will tell you what your options are based on the specific physical characteristics of your breast and your preferences. Most reconstruction options have already been discussed in the section “How is breast reconstruction performed?”

Here is some more information:

• A mastectomy may leave insufficient tissue on the chest wall to cover and support a breast implant. Breast reconstruction following radiation therapy with a breast implant may require a flap procedure prior to tissue expansion. In the flap technique, the surgeon repositions your own muscle, fat and skin, creating or covering the breast mound. There are different flap techniques and your surgeon will present the best options for you.
• Following mastectomy surgery, the most popular option is the tissue expander and implant, since this is usually performed in a few short, outpatient procedures. In some cases an implant may be used alone, but this is usually not the case.
• You may also be given the option of deciding between silicone and saline breast implants. Silicone better mimics the look and feel of the breast, but there are advantages and disadvantages to each type of device that you should discuss with your surgeon. An advantage of saline is that you immediately notice an implant rupture because the breast deflates; with silicone you may need further testing to confirm this.
• Fat transfer is sometimes used to fill in deformities left by lumpectomies and mastectomies.
• In very carefully selected patients, nipple-sparing mastectomy with autologous breast reconstruction provides good results. Your doctor will tell you if you are an appropriate candidate for this procedure.

What will my breast reconstruction incisions and scars be like?

How your scars look when fully healed depends on your age, genetics, the way your body heals, and how your incisions and underlying tissues are sewn together.

• Even the best reconstruction can’t eliminate mastectomy scars, but when immediate reconstruction is performed, most of the breast skin is preserved to hold the implant or tissue flap and mastectomy incisions may be hidden in the inframammary fold under the breast or around the areola. When hidden around the areola, the small scars are covered when the areola is tattooed later on.
• Flap reconstruction does leave a lengthy scar at the donor site, but scars on the abdomen or buttocks can be hidden by bathing suits and underwear. In some cases, lateral or vertical incisions from the nipple are required to accommodate reconstruction. These scars become less noticeable over time, but never disappear completely.
• If you have a mastectomy without reconstruction, your surgeon will remove most of the breast skin through a long incision across your chest. The resulting scar is permanent. If you have reconstruction later, it will be done through this mastectomy scar, which is reopened to accommodate the implant or tissue flap. The mastectomy scar remains on the reconstructed breast, but grows pale over time.

Take care of your scars by keeping them moist, massaging the scar line, and use a scar management product to smooth and flatten scars, making them less noticeable. When these techniques don’t work, re-excising the scar − cutting away the hard scar tissue and reclosing the incision − may significantly improve a scar.

Select a surgeon you can trust

It’s important to choose your surgeon based on:

• Education, training and certification
• Experience with breast reconstruction surgery
• Your comfort level with him or her

Members of the American Society for Aesthetic Plastic Surgery are experienced and qualified to perform your aesthetic procedure. Learn how to select a surgeon.

After finding a board-certified plastic surgeon in your area that is experienced in performing breast reconstruction, you will need to make an office appointment for your consultation. Generally, because of the in-depth nature of the consultation, there is a cost associated with the initial visit.

Your initial consultation appointment

During your initial consultation, you will have the opportunity to discuss with your surgeon everything you feel is important related to the appearance of your breasts. Your surgeon will evaluate you as a candidate for breast reconstruction and clarify what a breast reconstruction surgery can do for you. Understanding your goals and medical condition, both alternative and additional treatments may be considered (see related procedures).

Your plastic surgeon will examine, measure and photograph your breasts for your medical record. Your surgeon will consider:

• The current size and shape of your breasts.
• The breast size and shape that you desire.
• The quality and quantity of your breast tissue.
• The quality of your skin.
• The placement of your nipples and areolas.

Complete candor during consultation will lead to a successful and safe breast reconstruction procedure. You’ll be asked a number of questions about your health, desires and lifestyle. Be prepared to discuss:

• Why you want reconstructive surgery, your expectations and desired outcome.
• Medical conditions, drug allergies and medical treatments.
• Current use of medications, vitamins, herbal supplements, alcohol, tobacco and drugs.
• Previous surgeries.
• Current medications.
• The options available in breast reconstruction surgery.
• Likely outcomes of breast reconstruction and any risks or potential complications.
• The course of treatment recommended by your plastic surgeon, including procedures to achieve breast symmetry.
• Risks or potential complications.

Your treatment plan

Based on your goals, physical characteristics and the surgeon’s training and experience, your surgeon will share recommendations and information with you, including:

• An approach to your surgery, including the type of procedure or combination of procedures.
• The outcomes that you can anticipate.
• Your financial investment in the procedure.
• Associated risks and complications.
• Options for anesthesia and surgery location.
• What is needed to prepare for the surgery.
• What you can expect to experience after surgery.
• Show before-and-after photos of cases similar to yours and answer any questions.

Questions to ask your aesthetic plastic surgeon

It is important for you to take an active role in your surgery, so please use this list of questions as a starting point for your initial consultation.

• Am I a good candidate for breast reconstruction?
• Are the results I am seeking reasonable and realistic?
• How many breast reconstruction procedures have you performed?
• Where will you perform my surgery and how long will it take?
• Do you have before-and-after photos I can look at for the procedure I am undergoing?
• Will my scars be visible? Where will my scars be located?
• What kind of anesthesia do you recommend for me?
• What will be the costs associated with my surgery?
• What will you expect of me to get the best results?
• What kind of recovery period can I expect and when can I resume normal activities?
• What are the risks and complications associated with my procedure?
• How are complications handled?
• What are my options if the cosmetic outcome of my surgery does not meet the goals we agreed on?

How do I prepare for a breast reconstruction procedure?

Your surgeon will provide thorough preoperative instructions, answer any questions you may have, take a detailed medical history, and perform a physical exam to determine your fitness for surgery.

In advance of your procedure, your surgeon will ask you to:

• Follow the instructions given to at your preoperative appointment. These will likely include having blood tests, a chest x-ray and an electrocardiogram (ECG).
• Stop smoking at least six weeks before undergoing surgery to promote better healing.
• Avoid taking aspirin, certain anti-inflammatory drugs and some herbal medications that can cause increased bleeding.
• Regardless of the type of surgery to be performed, hydration is very important before and after surgery for safe recovery and good outcomes.

Prepare your home for your recovery
The most important thing you can do to ensure a smooth transition from the hospital to home is to prepare as much as you can in advance.

• Lifting restrictions apply to every type of reconstruction; it is essential that you adhere to them. For many flap reconstructions, your restrictions may include not lifting anything heavier than five pounds for up to six weeks.
• Planning meals in advance or having friends assist with meals can be very helpful.
• You should not vacuum or do laundry and you should avoid repetitive motion such as scrubbing pots and pans.

Prepare for a comfortable discharge
Prepare for recovery by garment shopping ahead of time.

• You will probably not be able to pull a shirt over your head. Have on hand some soft, oversized button-down shirts or a front zipper sweatshirt. You can find sweatshirts with pockets on the insides, which are great for pinning or tucking surgical drains into.
• If you’re having TRAM (abdominal muscle) flap reconstruction or any abdominal microsurgery, you may want to purchase loose-fitting pants that do not have an elastic waistband, which may pull on your scar. Oversized cotton snap-down pants, one or two sizes too big, work well. You can pin or tuck the hip drains into the pants pockets.
• You may find it uncomfortable to bend over to put on shoes. Wear a slip-on mule, clog or sandal with a grip on the sole.

Bring these garments to the hospital or have the person taking you home bring them on your day of discharge.
Getting home from the hospital
You will be more comfortable in a sedan than getting in and out of an SUV.

Bring pillows to support your back and neck, especially if you have a long drive home. You can use a pillow to press against your abdomen when you laugh, cough, sneeze, or when you put the seat belt on.

Set up your bed and bedside table before your surgery
Many women feel anxious before surgery. Getting your house in order, and enlisting friends and family to help you care for children and help with household chores can let you relax. The most important thing is to get plenty of rest after surgery. Knowing everything is taken care of in advance will give you the peace of mind you need.

• You will need a lot of pillows on your bed, including extra pillows for behind your back and under your legs, to keep you in a position with your hips and knees flexed. You may want soft pillows for under your arms as well.
• On your bedside table you should have (within arm’s reach), a handheld mirror, a tube of Bacitracin or Aquaphor ointment, your phone (if portable, then take the charger), antibiotics and pain medication. The remote control and a few good magazines or books belong there, too.
• In the bathroom, store the measuring cups your doctor gives you to empty your drains into and keep a pad and pen to write down the volume the drains put out every time you empty them.
• You will probably see your doctor weekly until all drains are removed.

Breast reconstruction is usually performed on an outpatient basis. Be sure to arrange for someone to drive you home after surgery and to stay with you at least the first night following surgery.

What can I expect on the day of breast reconstruction surgery?

Your breast reconstruction surgery may be performed in an accredited hospital, free-standing ambulatory facility or office-based surgical suite. Most breast reconstruction procedures take at least two to six hours to complete but may take longer.

• Medications are administered for your comfort during the surgical procedure.
• General anesthesia is commonly used during your breast reconstruction procedure, although local anesthesia or intravenous sedation may be desirable in some instances.
• For your safety during the surgery, various monitors will be used to check your heart, blood pressure, pulse, and the amount of oxygen circulating in your blood.
• Your surgeon will follow the surgical plan discussed with you before surgery.
• After your procedure is completed, you will be taken into a recovery area where you will continue to be closely monitored.
• Afterward you can expect to feel groggy, tired, disoriented and possibly nauseated. All are common side effects of the anesthesia.

You will probably be permitted to go home after a short observation period unless you and your plastic surgeon have made other plans for your immediate postoperative recovery.

Your surgeon will discuss how long it will be before you can return to your normal level of activity and work. After surgery, you and your caregiver will receive detailed instructions about your postsurgical care, including information about:

• Drains, if they have been placed
• Normal symptoms you will experience
• Potential signs of complication

Immediately after your breast reconstruction surgery
Your surgeon will prepare you for the experience, but here are a few things you can expect:

• You may wake up from surgery feeling groggy and/or very tired.
• You may have compression sleeves on your legs to help with circulation.
• Although you may be receiving pain medication, you may still feel sore.
• You may have drains coming out of your underarms to assist in healing (and from your stomach if you had an autologous reconstruction using tissue from your abdominal area).

If you have an autologous flap breast reconstruction:

• You may have a catheter in your bladder, which will be removed after surgery.
• The area from which tissue was taken to form your new breast(s) may also be sore.
• It may be difficult for you to get out of bed alone.

If you have a breast implant reconstruction:

• Your armpit region may be a little sore following surgery, but it is important to move your arms and maintain the range of motion in your shoulders. Certain exercises can help with this, and your doctor will discuss this with you.
• Your surgeon will encourage you to get out of bed with assistance; early ambulation is very important to prevent the formation of clots in your legs.
• You will be able to use the bathroom by yourself but may need assistance during the first week following certain types of reconstructive procedures.

You must plan to have someone drive you home from the hospital and stay with you during your first days of recovery.

When the anesthesia wears off, you may have some pain. If the pain is extreme or long-lasting, contact your physician. You will also have some redness and swelling after the surgery. Contact your surgeon to find out if your pain, redness and swelling are normal or are signs of a problem.

Recovery time frame after breast reconstruction
It is vitally important that you follow all patient care instructions provided by your surgeon. This will include information about wearing compression garments, care of your drains, taking an antibiotic if prescribed and the level and type of activity that is safe. Your surgeon will also provide detailed instructions about the normal symptoms you will experience and any potential signs of complications. It is important to realize that the amount of time it takes for recovery varies greatly among individuals.

Implant-based reconstruction is the simplest and least painful and has the shortest recuperation time. Typically, most women are able to do most routine activities within two to three weeks. Flap-based procedures, which require surgery in two areas, are more demanding and recuperation varies, depending on which flap procedure was performed.

In the hospital
Surgeries involving muscle flaps usually require a hospital stay and may involve restriction of your activities. After a TRAM flap surgery, you are not allowed to strain or lift for six weeks.

• Soon after surgery you will be asked to move your arms, but not forcefully. Nurses will help you in and out of bed. Most expander/implant reconstruction surgeries are performed as outpatient procedures and you are encouraged to walk the day of your surgery, which aids circulation and decreases the risk of clots forming in your legs.
• The length of your hospital stay will depend on your general health, the type of operation you have and how your recovery progresses. You may spend anywhere from one to six nights in the hospital. Flap procedures require a stay of two to six days, depending on the type of flap procedures performed and the blood supply to that flap.
• Your incisions will most likely be covered with bandages following flap reconstruction surgery but may simply have been closed with skin glue or tape following implant reconstruction.
• Your surgeon may recommend an elastic bandage or a soft bra to minimize swelling and support the reconstructed breast(s).
• Make sure you are clear about what is expected of you before you are discharged from the hospital or surgical center. Having a loved one or patient advocate with you is a good way to help make sure you take it all in.

At home

• Depending on what type of reconstruction you have, you may be spending significant time in bed or a chair during the first few days. Most patients can walk without assistance by the second or third day after a flap reconstruction and your surgeon will encourage you to walk at least three or four times a day to stimulate the circulation in your legs.
• You may be too tired to shower during the first week, but if your surgeon gives you permission and you feel up to it, you can shower. You may need someone to help you. You will need to pin all of your drains to a Velcro drain belt or you may be given something in the hospital such as a gauze necklace to support the drains around your neck. It may help if you have a shower stool, so you can sit down in the shower. When the drain is removed, it will be much easier to shower.
• Make sure you ask for pain-relieving medicines if you need them. In general, if your pain is well controlled, you’ll recover more quickly.
• Early in your recovery, you will most likely see your surgeon weekly until the last drain has been removed. You cannot rush removal of the drains; as bothersome as they may be, they are essential to proper wound healing. Generally, once a drain produces less than twenty to thirty milliliters in a twenty-four–hour period, your surgeon will remove it. In most patients, drain removal does not hurt.
• At first your new breasts may be larger due to swelling, which can happen after surgery. As the swelling subsides, your breasts will assume the shape you desired over a few weeks or months.
• You will be given exercises to perform at home to help your recovery. At first you may have some discomfort when you move your arms, but it is important to continue to use your arms and do the exercises suggested.
• How soon you can return to work depends on the type of work you do and your surgery. If your job doesn’t involve heavy manual work, you may be able to go back to work sooner, but remember that you’re likely to feel more tired than usual for a while.
• In general, you can resume driving once you are no longer taking any pain medications and are able to use the gearshift and parking brake. You must be able to do an emergency stop or move the steering wheel suddenly if necessary, and driving while taking pain medications is not only a bad idea, it is illegal in most states.
• Your wounds may feel itchy as they heal, but you must not scratch them. The itching will lessen as the wounds heal. It usually takes about six weeks for the wounds to heal enough that the itching subsides. Remember that wounds go through phases, and the inflammatory phase of healing may last months (in this phase the incisions appear pink, flushed, and are usually slightly raised or firm). Your scars will take a year to fully mature, so be patient and follow the advice of your surgeon in regard to treatments to help minimize your scar.

For implant-based reconstruction, you can feel secure that both saline and silicone implants are safe and effective when used according to their labeling. Saline and silicone implants have lifetime warranties from their manufacturers; however, the longer you have implants, the more likely you are to experience complications. Recent data suggest that over 95% of implants are intact after seven years, but other data demonstrate that half of women who receive implants for breast reconstruction will require removal or exchange within ten years after implantation.

• For patients who are having reconstruction of a single breast, changes in that breast will, over time, be different from that in the other breast. The patient’s own natural breast tissue is more likely to sag and lose elasticity compared with an implant-reconstructed breast, which tends to stay youthful, with less drooping over time.
• For patients who undergo a bilateral mastectomy and bilateral reconstruction with implants, it is quite common for them to have well-projected, young-appearing breasts with no sagging even in their eighth decade of life.
• Breast reconstruction using tissue flaps are subjected to the same forces of gravity as natural breast tissue. The tissues may not age the same because the tissues are from other parts of the body.
• The skin and fat from the upper back or buttocks region is much thicker and more fibrous and does not tend to droop or sag as much over time as breast tissue.
• The skin and fat of the abdomen is very similar to that of breast tissue and tends to droop or sag over time, similar to natural breast tissue. These tissues do not “know” that they have been moved from another part of the body, and may their growth or shrinkage in response to weight loss may be different from your natural breast tissue.

Maintain a relationship with your aesthetic plastic surgeon

For safety, as well as the most beautiful and healthy outcome, it’s important to return to your plastic surgeon’s office for follow-up evaluation at prescribed times and whenever you notice any changes. Do not hesitate to contact your surgeon when you have any questions or concerns.

The cost of breast reconstruction surgery varies from doctor to doctor and from one geographic area to another.

These numbers only reflect the physician/surgeon fees last year and do not include fees for the surgical facility, anesthesia, medical tests, prescriptions, surgical garments or other miscellaneous costs related to surgery.

Fortunately, significant complications from breast reconstruction are infrequent. Your specific risks for breast reconstruction will be discussed during your consultation.

All surgical procedures have some degree of risk. Some of the potential complications of all surgeries are:

• Adverse reaction to anesthesia
• Hematoma or seroma (an accumulation of blood or fluid under the skin that may require removal)
• Infection and bleeding
• Changes in skin sensation
• Scarring
• Allergic reactions
• Damage to underlying structures
• Unsatisfactory results that may necessitate additional procedures

Other risks specific to breast reconstruction are outlined below:

• Fat necrosis and/or fatty cysts
• Blood clots in the legs or lungs
• Partial or complete loss of the flap
• Loss of sensation at both the donor and reconstruction site.

Donor site complications

• Hernia
• Delayed wound healing with poor scar formation.
• Breast hardening (capsular contracture)
• Implant malposition
• Implant rupture

You can help minimize certain risks by following the advice and instructions of your board-certified plastic surgeon, both before and after your breast reconstruction surgery.

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