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 several 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. 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 called autologous reconstruction, 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.

Implant Reconstruction

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 chest wall’s skin and above or below the chest muscles. This is called “pre-pectoral” and “sub-pectoral” implant placement. Your surgeon will help you determine which approach and placement of implant is best for you.

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 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 (or to your surgeon’s preference based on your treatment plans) 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 skin and/or muscle are slowly stretched to accommodate the appropriately sized implant. Once your tissue expanders have the adequate amount of saline in them you will need to wait about one month to allow the skin and/or 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. If you need radiation treatment, this could impact the scheduling of your exchange surgery.

In the second stage (exchange surgery), your surgeon will likely 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 are safe and approved by the FDA. However, there are potential risks associations with all implants that your surgeon will review with you. 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 4 or more weeks after surgery.

The implant reconstruction process typically takes at least 4-6 months or longer depending on the treatment plan and any additional revision surgeries.

Do my implants last forever?

Implants are not lifetime devices, and both saline and silicone implants will eventually break, called an implant “rupture”. If a saline implant ruptures, you will likely notice a slow deflation of the implant. The body can absorb the salt water leaking out of the implant and over a few days to weeks, you will notice that your implant gets smaller. When a silicone implant breaks, there is no implant deflation. Instead, with silicone rupture, over time you may notice a change in the feel or shape of the implant. This may be detected with ultrasound and/or MRI. All implants have a life expectancy of about 10-15 years and will require additional surgeries for replacement. The FDA has placed new guidelines for implants as of 2021 regarding their risks and maintenance. Your surgeon will have you review this information and will need your informed consent. You may also review the guidelines at the link at the bottom of this article.

Why do you need to do tissue expansion?

Placing implants after mastectomy is quite 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 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 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. In some cases, although not routinely performed, the implant may be placed at the time of the mastectomy. This is called “direct to implant reconstruction” allowing to skip the expansion process altogether. Your surgeon will help you determine if this is a practical option.

I may need chemotherapy. Can I still have implants?

Women who will undergo chemotherapy after their surgery 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 considered healthy after your last chemotherapy infusion. This timing 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 and to avoid potential risks of surgery.

I may need (or have already had) radiation to my breast area. Can I still have implants?

Radiation and the impact on implants must be discussed carefully with your surgeon. It is true that women who have implants and radiation can be at higher risk for complications, such as capsular contracture, infection, and wound healing issues. However, the timing of the radiation and implant surgery, the type of surgery being performed, and the implant size may 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 vastly different types of TRAM flap reconstruction and it is important to understand the difference.

One type of TRAM flap is a “pedicled TRAM flap”. This means that the flap is left attached to its original blood supply and is tunneled under the skin to the breast area. When this type of flap is taken from the abdomen, it can significantly decrease core strength and has an increased risk of hernia.

The other type of TRAM flap is a called “free TRAM flap”. In this type of flap, the skin, fat, blood vessels, are completely disconnected or “freed” from the body. This allows the belly tissue to move to another part of the body to be made and shaped into a breast. The blood vessels are then reattached (or resewn) to the blood vessels that live in the chest allowing tissue to now live on the chest. This type of surgery preserves as much abdominal muscle as possible.

There are 2 other special flaps that can be taken from the abdomen called the DIEP or SIEA flap, that also requires suturing the blood vessels together. These flaps take NO muscle from your abdomen. These types of free TRAM flaps require more skill and surgical expertise by a trained microsurgeon.

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:

1. You have your own tissue being used to reconstruct your breast.
2. The flap reconstruction does not require maintenance/replacement.
3. This may be a better match to provide a more natural-looking breast, especially for women undergoing unilateral (one-sided) reconstruction.
4. Tissue reconstruction is a better option if you have had or will need radiation.
5. Possible decreased fullness to the lower abdomen similar to the result of cosmetic abdominoplasty (tummy tuck).

Disadvantages of a free flap reconstruction:

1. Longer operating time, longer hospital stay, typically longer initial recovery.
2. Although rare, there is a risk of flap failure.
3. Although uncommon, risk of abdominal hernia.

I do not want any muscle taken from my abdominal wall. Can you guarantee this prior to surgery?

Although the goal is to remove zero muscle from the abdomen, this is not always possible. This type of surgery is based on blood vessels. Also, even if muscle is not removed, it can likely be manipulated in order to access the blood supply. Sometimes your surgeon may order pre-operative imaging to assist them with surgical planning. However, even with imaging, your surgeon will only know the specific anatomy of your deep blood vessels when 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. If/when muscle needs to be taken, synthetic mesh is often used to reconstruct the abdominal wall in order to reduce the risk of post-operative hernia and/or abdominal bulging. The mesh used during surgery is usually dissolvable and considered safe. Your surgeon can review the risks and benefits with you.

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.

1. Free TRAM flap = Free Transverse Rectus Abdominus Myocutaneous Flap. In this surgery skin, fat, blood vessels and a small piece of muscle are taken.
2. 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.
3. 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.

Post-Operative Period

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 very frequently 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). Most patients are able to return to work during the tissue expansion process.

For tissue flap, most patients are off work for 6-8 weeks.

When can I drive?

Your surgical team can help you determine when you can resume driving. Typically, it is safe to resume driving when all the drains are out (more about these below), when you are off prescription and/or opiate pain medication and when you have regained safe range of motion of your arms. For most women, this is about 3-4 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 rate of infection. You will go home with most or all of the drains. On average, drains will stay for 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. About 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 be in charge of keeping track/logging fluid output coming from each drain. These totals will help determine when the drains can be removed. The drains are removed in the office or at your home with a visiting nurse. Home health nursing will be set up before you leave the hospital.

What activity limitations do I have?

Your surgeon will discuss the specific post-operative limitations and restrictions with you before and after your surgery. Most patients will be allowed to shower after surgery, however, bath and water submerging need to be avoided until you are cleared to do so.

You will have lifting restrictions as well as range of motion restrictions following your mastectomy with any type of reconstruction. Walking and being mobile after surgery is encouraged to aid in recovery and avoid potential complications.

Do I need to have any special supplies at home for my recovery?

Your surgical team can help guide you with any supplies that may be recommended to have at home after surgery. This may include surgical bras for after surgery, garments to help hold the drains, or basic medical supplies like foam gauze for dressing changes. Loose and comfortable clothing and clothing that button or zips in the front are recommended for after surgery.

When can I expect to follow up after surgery?

Your surgical team can help you with your specific post-operative follow-up plan. Generally, you can expect to meet with your surgeon about 2-4 weeks after surgery followed by several more appointments over the next several months to a year based on the type of surgery and your specific recovery.