Breast Reconstruction After Mastectomy and Lumpectomy: A Complete Guide

Breast reconstruction is a surgical process designed to restore the shape and symmetry of the chest following the removal of breast tissue. This procedure is often a critical component of the healing process for patients who have undergone a mastectomy or lumpectomy, helping them address shifts in body image and self-esteem.

Reconstruction is not a requirement, and options vary based on a patient’s health, body type, and individual goals. While many choose reconstructive surgery, some patients opt for a flat closure, commonly referred to as going flat.

Reconstruction Options After Mastectomy

When a mastectomy is performed, surgeons typically offer two primary categories for rebuilding the breast mound: implant-based reconstruction and autologous (tissue-based) reconstruction.

Implant reconstruction is the most common method and utilizes either saline or silicone gel implants. This is often a staged procedure. In the first stage, a temporary inflatable device called a tissue expander is placed under the skin or chest muscle to stretch the skin and maintain a breast pocket.

The tissue expander is filled with saline injections, typically every two to three weeks. After a period of at least three months, or between two to six months, a second surgery is performed to remove the expander and place the permanent implant.

Autologous reconstruction, also known as flap reconstruction, uses the patient’s own tissue. Surgeons remove a section of tissue from the belly, back, butt, or thigh, keeping the blood vessels attached to connect them to blood vessels in the chest.

A primary advantage of flap reconstruction is the use of the patient’s own tissue rather than a foreign implant. However, a second, smaller surgery is typically required to adjust the tissue and shape the breast.

Reconstruction After Lumpectomy

Reconstruction is also available after a lumpectomy, which is a breast-conserving surgery where only the tumor and a small area of tissue are removed. Because this can leave the breasts asymmetrical, specific techniques are used to restore balance.

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• Oncoplastic Reduction: An option for women with larger breasts where the surgeon reconstructs both breasts to make them even. This may include lifting or reducing the size of the breasts.
• Fat Grafting: This involves collecting fat via liposuction from the belly, buttocks, or thighs and injecting it into the void left by the lumpectomy.

Fat grafting is generally not offered until a patient is at least one year removed from cancer care to allow the body to heal from the lumpectomy and subsequent radiation therapy. It can also be used in conjunction with mastectomy reconstruction to create a more natural shape.

Timing and Additional Procedures

Surgery to reconstruct the breasts can be immediate, meaning it is started at the time of the mastectomy, or delayed. Delayed reconstruction occurs after mastectomy incisions have healed and treatment is complete, which can be months or years later.

In the final stage of reconstruction, if the nipple was not preserved during a nipple-sparing mastectomy, the nipple and areola may be re-created. Surgeons create the nipple using flaps of tissue to provide projection and roundness. For the areola, 3D tattoos are now commonly used to create a realistic appearance.

In some cases, surgery is also performed on the contralateral breast—the breast without cancer—to match the size and shape of the reconstructed breast. This may involve a lift, reduction, or the placement of an implant.

Recovery and Long-Term Maintenance

Recovery timelines differ significantly based on the procedure. Implant-based surgery typically requires an overnight hospital stay, while flap surgery requires approximately four days of hospitalization for monitoring.

Following implant surgery, patients are generally advised to take four weeks off from work, avoid lifting more than 10 pounds for a month, and avoid soaking in tubs or pools for six weeks. Most return to normal activities after six weeks.

Flap surgery recovery is longer, requiring six to eight weeks of taking it easy and avoiding heavy lifting for four to six weeks. While activity restrictions are usually gone by three months, full recovery and adjustment can take one to two years.

Reconstructed breasts may require long-term maintenance. Implants may need to be replaced around the 10-year mark. Flap surgery may require subsequent operations to adjust tissue or reshape breasts if they sag over time.

Risks and Considerations

Common surgical risks include infection, bleeding, and wound healing problems. Specific complications include:

• Implant Risks: Implants can rupture or develop capsular contracture, where a wall of scar tissue forms around the implant.
• Flap Risks: Blood vessels can develop clots, leading to flap failure. Patients may also experience hernias or weakness in the area where tissue was removed.

Certain risk factors may increase the chance of complications, including obesity, older age, smoking, previous radiation therapy, or having surgery on both breasts.

Costs and Insurance

The average cost for breast reconstruction in 2022 was $6,221, excluding the cost of the mastectomy. Under the Women’s Health and Cancer Rights Act of 1998, all group health plans that cover mastectomies are required to also pay for reconstructive surgery.

For those who are uninsured or underinsured, organizations such as the United Breast Cancer Foundation, My Hope Chest, and Alliance in Reconstructive Surgery provide grants to assist with costs.