The Who, What, Where, When and Sometimes, Why.

Breast Reconstruction

Breast reconstruction can help restore the look of the breast after a mastectomy. The surgery is done by a plastic surgeon. Although most breast reconstruction is done in women, men may get reconstruction if they wish.

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.

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

It’s always OK to get a second opinion. Your plastic surgeon should be comfortable with it.

Getting a second opinion from 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

However, getting a second opinion shouldn’t delay your breast cancer treatment.

Learn more about getting a second opinion.

Benefits

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.

Possible challenges

Travel

You may not live near the hospital where the 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 to cover the cost of breast reconstruction after a mastectomy.

Learn more about insurance and breast reconstruction.

Choosing the type of breast reconstruction that’s right for you

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’s 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 [150].

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 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.

General health

Some women with chronic medical conditions or suppressed immune systems may not be good candidates for breast reconstruction.  

Smoking and body weight

Smokers and women who are overweight have an increased risk of complications for all types of breast reconstructive surgery [6,151-154].

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 losing weight 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

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

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.

Study your options and make a thoughtful, informed choice after carefully considering the pros and cons of each option.

Although this decision may seem overwhelming, it may help to know that most women who’ve had breast reconstruction don’t regret the method they chose [155].

If you’re a good candidate for a procedure, there are fairly few complications with any of the current techniques [150].

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.  

 

Breast implants

Natural tissue flaps

Mimic the look and feel (to the touch) 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 in the area of the body where the tissue was taken to create the reconstructed breast

Surgery

  • Less extensive

  • Time in surgery is shorter (1-2 hours)

 

 

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 in your lifetime.

Tissue flaps won’t need to be replaced in your lifetime. 

However, if there are complications, some procedures can’t be repeated.

Recovery

  • 3-4 weeks

  • Fewer scars

 

  • 4-6 weeks

  • More scars

 

Risk of complications

  • Some risk of surgical complications in the breast area

 

  • Some risk of surgical complications in the breast area and in the area where the natural tissue flap is taken
  • Certain procedures have more risks than others

 

Risk of complete reconstruction failure

  • Low risk, but higher than with natural tissue flaps

  • Successful reconstruction depends on the breast skin quality after mastectomy and radiation therapy (if radiation therapy is needed)

 

  • Risk of a complete flap loss is lower than a complete loss of an implant

  • Risk of a partial flap loss is higher than a complete loss of an implant

  • Certain procedures have a higher risk than others

 

Adapted from selected sources [150,156-157].

Implants

Inserting a breast implant is a fairly simple procedure.

It may not require extra time in the hospital 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 over time. 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 change. This may lead to a less even look and more surgery may be needed to maintain a similar look.

For this reason, implants are better for women with small or medium-sized breasts with little or no sagging [150].

If the shape of the reconstructed breast does not match the natural, opposite breast, 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.

Learn about managing pain after reconstructive surgery.

Learn about breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

Types of 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. They 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. During surgery, they 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.

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 (including the shape of your natural breast, the shape of your chest wall and the amount of fatty tissue available)
  • 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)

Safety of silicone implants

Most studies show no link between silicone implants and lupus, immune system disorders, connective tissue disease or rheumatoid arthritis [158-159].

Silicone implants are as safe as saline implants.

Learn about breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

The 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 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.

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.

Implants using acellular dermal matrix

The acellular dermis technique uses the entire skin envelope available at the time of the mastectomy. It’s used in combination with a reconstruction with an implant 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 to give a blood supply.

This 2-step tissue expander reconstruction with acellular dermal matrix can allow a larger volume fill at the time of surgery. This can shorten the implant expansion process because the expander begins at a larger size.

If the final implant can be placed at the time of the mastectomy, without the need for expansion, this can be done in one step.

Some findings show implant reconstruction with acellular dermal matrix may have a higher risk of complications (such as seroma (fluid collection)) compared to implant reconstruction without acellular dermal matrix [150,160].

Women having a nipple-sparing mastectomy (so, keeping the entire breast skin envelope) and women with loose breast skin generally benefit from the procedure [161]. Women with very small breasts and minimal sag may not benefit.

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 healthy soft tissue coverage of the implant as possible. Some of the chest muscle is cut during the procedure to place the implant 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).

Pre-pectoral implant reconstruction places the implant above the chest muscle (pre-pectoral), just under the mastectomy skin envelope [162]. So, it may limit the problem described above.

With a pre-pectoral implant reconstruction, a larger amount of acellular dermal matrix is used to cover the entire implant than with an implant placed beneath the chest muscle [162].

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) with a healthy blood supply.

The long-term results of this technique, and how it is affected by radiation therapy to the breast (for example, the risk of capsular contracture, a hardening of the tissues around the implant), are not known.

Nipple reconstruction with implant procedures

Reconstruction of the nipple may be done when the permanent implant is inserted or at a later time.

Learn more about nipple and areola reconstruction.

Saline versus silicone implants

The table below describes some pros and cons of saline versus silicone implants.

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

 

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 can’t be changed without surgery to replace the implant

Size of the expander may be increased or decreased after the initial surgery

Size of the implant can’t 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 isn’t absorbed, the overall breast volume stays the same. So, it may take longer to notice a rupture in a silicone implant than a rupture in a saline implant. 

Breast MRI can be used to check for an implant rupture if a health care provider notices a change on a clinical breast exam.

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 in your lifetime (replacement requires surgery)

Typically lasts at least 10 years, but will likely need to be replaced in your lifetime (replacement requires surgery)

Adapted from selected sources [150,165].

Radiation therapy and breast implants

With both implant and natural tissue reconstruction, radiation therapy can cause:

  • Changes in skin color
  • Changes in skin quality
  • Tissue shrinkage
  • Tightness
  • Scars that get worse over time

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) [6].

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 [6,150]. Results are better when the procedures to expand the skin are done before radiation therapy begins.

The effects of radiation therapy to the reconstruction tend to continue with time and longer-term problems can occur after many years. Radiation therapy, even when done before reconstruction, limits the size of the reconstruction and increases the risk the reconstruction may fail [163].

Many women who get radiation therapy to the reconstructed breast have chronic tightness and stiffness in the chest and upper arm areas [163]. They may need physical therapy or long-term range of motion exercises. 

Implant information card

After an implant breast reconstruction, you will get a card with your implant information (including the style and size). This information is important and can be useful if you need a replacement or future surgery.

If you lose your implant information card, you can get this information from the hospital where you had your breast reconstruction surgery. The implant information will be in your surgery notes (called the operative notes). 

Anaplastic large cell lymphoma (ALCL) is a rare cancer of the cells of the immune system [164-166]. When ALCL occurs in women with breast implants it’s called breast implant-associated ALCL (BIA-ALCL).

BIA-ALCL is typically found in the scar tissue and fluid near the implant [164]. BIA-ALCL is very treatable.

The FDA, the American Society of Plastic Surgeons and the Plastic Surgery Foundation are collaborating to research and understand BIA-ALCL in women with breast implants.

Let your health care provider know if you notice any changes to your implant(s) or have any swelling or pain in the area.

How many cases of BIA-ALCL have occurred?

As of July 2019, the U.S. Food and Drug Administration (FDA) estimated there were about 570 confirmed cases of BIA-ALCL in the world [167-168]. As of February 2020, about 300 suspected or confirmed cases of BIA-ALCL were reported in the U.S. [168].

BIA-ALCL and textured implants

Although the reasons are unclear, the risk of BIA-ALCL is higher with textured breast implants than with smooth implants [164-169]. Teardrop-shaped implants are textured implants.

The estimated lifetime risk of BIA-ALCL among women with textured implants is between 1 in 2,207 women to 1 in 86,029 women [168].

Some manufacturers have voluntarily taken their textured breast implants and tissue expanders off the market. So, some textured implants and tissue expanders are no longer used.

Since the risk of developing BIA-ALCL is low, the FDA does not recommend removing textured breast implants or tissue expanders unless there are symptoms. Symptoms may include fluid build-up around the implant, swelling, pain and a lump in the breast or underarm.

Let your health care provider know if you have any of these symptoms.

Should textured breast implants be removed?

Although women may choose to have textured implants removed, the surgical risks are much greater than the risk of developing BIA-ALCL.

If you are considering having textured implants removed, discuss the risks and benefits of the surgery with your health care provider and make an informed decision.

How to find out what type of breast implant(s) you have

The hospital should have given you an implant information card at the time of your implant reconstruction. If can’t find the card, you can contact the hospital where you had your breast reconstruction surgery. Information on the implant(s) will be in your surgery notes (called the operative notes).

Natural tissue flap surgery

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. So, they usually require a longer hospital stay and a longer post-surgery recovery time.

They also 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 abdomen or back. Flaps can also be taken from the buttocks or thighs (a microvascular surgeon is needed for these surgeries).

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.

Learn about managing pain after reconstructive surgery.

Latissimus dorsi muscle flap 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 [150].

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

The fatty 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 (TRAM) flap reconstruction

The transverse rectus abdominis myocutaneous (TRAM) flap uses skin, fat and muscle from the lower abdomen to reconstruct the breast [150]. It creates a natural-looking breast.

A TRAM flap usually doesn’t require an implant as long as there’s enough excess skin and fatty tissue in the lower abdomen. If you don’t have excess abdominal tissue or you’ve had abdominal surgery in the past, you may not be a candidate for a TRAM flap reconstruction.

The TRAM flap has some drawbacks:

  • Once a TRAM flap has been done, it can’t be repeated.
  • The surgery leaves a large scar across the lower abdomen.

The loss of an abdominal muscle (removed to provide a blood supply to the flap) can cause weakness in the abdominal area. If you’re active, talk with your plastic surgeon about this drawback. 

Deep inferior epigastric perforator (DIEP) flap 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 [150].

Unlike the TRAM flap, the DIEP flap procedure keeps the abdominal muscle intact. This may preserve abdominal strength after the procedure. It also reduces the risk of abdominal site complications, such as hernia.

The DIEP flap has some drawbacks:

  • Once a DIEP flap has been done, it can’t be repeated.
  • It’s more complex than the latissimus dorsi muscle flap and 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 leaves a large scar across the lower abdomen.

The DIEP flap procedure should only be done by microvascular surgeons well-trained and experienced in this technique.

Superficial inferior epigastric artery (SIEA) 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 SIEA flap isn’t as common as the TRAM and DIEP flaps because few women have blood vessels large enough (or any at all) for the procedure [150].

The 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 SIEA flap procedures than with other techniques [171].

The SIEA flap procedure should only be done by microvascular surgeons well-trained and experienced with this technique.  

Superior and inferior gluteal artery perforator (S-GAP and I-GAP) flap reconstruction

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

  • The superior GAP (S-GAP) procedure uses skin and fatty tissue from the upper part of a buttock.
  • The inferior GAP (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 [172].

S-GAP or I-GAP flap reconstruction may be a good option for women with more fatty tissue in their buttocks area than in their abdomen [172-174].

If the 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 DIEP flap, 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 DIEP flap procedure), which may increase the risk of surgical complications [172-174].

If an S-GAP or 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 (TUG) flap and diagonal upper gracilis (DUG) reconstruction

Transverse upper gracilis (TUG) flap and diagonal upper gracilis (DUG) procedures use skin, fatty tissue and muscle from the upper inner thigh to reconstruct the breast [150].

TUG and DUG flap reconstruction use 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.

TUG and DUG differ slightly in the location of their scars. With TUG, the scar goes across the thigh and with DUG, the scar is angled down the thigh.

TUG flap or DUG 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, TUG flap and DUG flap are complex surgeries that require a microvascular surgeon.

If a TUG flap or DUG flap isn’t successful, it can be repeated using tissue from the opposite upper inner thigh.

Profunda artery perforator (PAP) flap reconstruction

Profunda artery perforator (PAP) flap procedures use skin, fatty tissue, and a blood vessel from the back of the upper thigh to reconstruct the breast. It leaves a scar in the crease of the thigh and buttocks.

Typically, the amount of tissue available in the back of the upper thigh is limited, so PAP flaps work better for women with small breasts.

PAP flap may be an option for women who are not good candidates for abdominal or other flap procedures.

As with other microvascular flap procedures, PAP flap is a complex surgery that requires a microvascular surgeon.

Radiation therapy and natural tissue reconstruction

With both natural tissue and implant reconstruction, radiation therapy can cause:

  • Changes in skin color
  • Changes in skin quality
  • Tissue shrinkage
  • Tightness
  • Scars that get worse over time

Delayed reconstruction

For women 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 [6].

Delayed reconstruction using flaps after radiation therapy generally requires using a larger patch of the donor site skin (for example, a larger area of the abdominal skin). Most of the chest skin damaged by the radiation therapy is removed during surgery. So, there’s less chest skin available after radiation therapy and the larger patch helps cover the reconstructed breast.

Immediate 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.

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, most studies to date have not found an increased risk and the procedure is considered safe [6,175-177].

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 [150]. However, those who have had radiation therapy may have more surgical risks, and the procedure may not be recommended.

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 company before getting a 3D tattoo, as this step may not be covered.

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 [178-181].

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

Learn about clinical trials of breast reconstruction.

Who can have nipple-sparing mastectomy?

Not everyone 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).

Nipple-sparing mastectomy is only an option for [6,178-179,182]:

  • 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 natural breasts. For example:

  • Women with large, sagging breasts may not be good candidates because they may have an increased risk of the nipple moving out of position after surgery and an increased risk of the nipple tissue losing its blood supply and breaking down. The excess skin may cause unevenness and problems with shaping the breast reconstruction.
  • Women with uneven breasts or uneven 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.
  • Women getting radiation therapy after nipple-sparing mastectomy may not be good candidates as radiation therapy may change the nipple position.

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 [178].

After breast reconstruction

Most women feel tired and sore for several weeks after breast reconstruction. Your surgeon or plastic surgeon may prescribe medications to ease the pain.

Talk with your plastic surgeon about specific instructions after 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(s).

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 [183].

Learn about managing pain after surgery.

Getting back to your normal routine

Most women can get back to their normal activities within 8 weeks [183].

Overhead lifting, strenuous sports and sex should be avoided for 4-6 weeks after reconstructive surgery [183].

Talk with your health care provider about activities to avoid and when you can get back to your normal routine.

Expectations

Although breast reconstruction techniques continue to improve, a reconstructed breast will never look or feel the same as your natural breast. It’s important to have a realistic expectation of the final look of the breast.

Reconstruction results vary and 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.

This can be upsetting. However, the goal of treatment is to get rid of the breast cancer and keep it from coming back.

Your plastic surgeon will help you choose the reconstruction method that will give you the best results. Keep in mind, your overall health and breast cancer treatment come first.

Final look of the breast

It will take some time to see the final results of your reconstructed breast.

How you feel about the final results may depend on your expectations. A reconstructed breast will never look or feel (to the touch) the same as a natural breast.

Most of the scarring will fade and improve over time, but it doesn’t go away completely.

As you age and the opposite breast changes shape, the reconstructed breast may look and 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.

 SUSAN G. KOMEN® SUPPORT RESOURCES 

  • If you or a loved one needs more information about breast health or breast cancer, call the Komen Breast Care Helpline at 1-877 GO KOMEN (1-877-465-6636). All calls are answered by a trained specialist or oncology social worker in English and Spanish, Monday through Friday from 9:00 a.m. to 10:00 p.m. ET. You can also email the helpline at helpline@komen.org
  • We offer an online support community through our closed Facebook Group – Komen Breast Cancer group. The Facebook group provides a place where those with a connection to breast cancer can discuss each other’s experiences and build strong relationships to provide support to each other. Visit Facebook and search for “Komen Breast Cancer group” to request to join the closed group.
  • Komen Affiliates offer breast health education and some fund breast cancer programs through local community organizations. Your local Affiliate may also help you find breast cancer resources in your area. Find your local Affiliate.
  • Our fact sheets, booklets and other education materials offer additional information.     

 

Insurance coverage for reconstructive surgery

Medicare and Medicaid

  • Medicare is health insurance provided by the federal government to people 65 years 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 companies (including Medicaid) to cover breast reconstruction after a mastectomy (learn more).

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 [184]:

  • 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 doesn’t 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.

Transportation, lodging, child care and elder care assistance

You may not live near the hospital where you’ll have your surgery.

Sometimes, there are programs that help with local or long-distance transportation and lodging. Some also offer transportation and lodging for a friend or family member going with you.

There are also programs to help with child care and elder care costs.

Learn more about transportation, lodging, child care and elder care assistance

Questions for your plastic surgeon

  • What types of breast reconstruction can I have?
  • Which type is best for me and why?
  • When is the best time for me to have breast reconstruction — at the time of the mastectomy or later? Is there a time limit for having reconstruction done?
  • How many procedures are involved in the type of reconstruction I am having?
  • How many hospital stays are needed? How long will each hospital stay be?
  • If I need to have radiation therapy after my mastectomy, how will that affect my reconstruction choices and cosmetic outcomes?
  • How many of these procedures have you performed?
  • Would you please show me photos of both your best and your more typical results?
  • What are the chances of infection and failure with my reconstructive surgery? Are there other risks or side effects to consider?
  • If I have implant reconstruction, am I at risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)?
  • What are the short- and long-term results with implant versus natural tissue reconstruction?
  • Will I have a surgical drain in place when I go home? If so, how will I care for it? When will it be removed?
  • Is there much pain after surgery?
  • Will I have any numbness after the surgery?
  • What side effects might I expect after surgery? What problems should I report to you right away?
  • Where will the surgical scar(s) be?
  • What body changes should I expect after surgery?
  • How can I expect the reconstructed breast to look and feel? How will it look compared to my natural breast?
  • Will I be able to detect a possible return of cancer after reconstructive surgery?
  • What breast cancer screening is recommended for me?

Learn more about talking with your health care provider.

It may be helpful to download and print Susan G. Komen®‘s Questions to Ask Your Doctor About Breast Reconstruction resource and take it with you to your next doctor appointment. There’s plenty of space to write down the answers to these questions, which you can refer to later.

There are other Questions to Ask Your Doctor resources on many different breast cancer topics you may wish to download. They are a nice tool for people newly diagnosed with breast cancer, who may be too overwhelmed to know where to begin to gather information.

Clinical trials

Susan G. Komen® Breast Cancer Clinical Trial Information Helpline

If you or a loved one needs information or resources about clinical trials, call our Clinical Trial Information Helpline at 1-877 GO KOMEN (1-877- 465- 6636) or email clinicaltrialinfo@komen.org.

BreastCancerTrials.org in collaboration with Susan G. Komen® offers a custom matching service to help find clinical trials on breast reconstruction that fit your needs.

Learn more about clinical trials and find a list of resources to help you find a clinical trial

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Komen Perspectives

Read our perspective on clinical trials.*

* Please note, the information provided within Komen Perspectives articles is only current as of the date of posting. Therefore, some information may be out of date.