On this page: Who will do the reconstruction? | Types of reconstruction | Implant reconstruction | Flap reconstruction | Nipple adhesives and reconstruction | The remaining breast | Recovery after the operation | Concerns after surgery | Costs | Which health professionals will I see? | Question checklist | Making treatment decisions | Key points
If you choose to have a breast reconstruction, your own breast cancer surgeon may have the expertise to do this (this is known as an oncoplastic surgeon). Or, you may be referred to a reconstructive surgeon (also known as a plastic surgeon). The breast cancer surgeon and a reconstructive surgeon may work together to do the breast cancer surgery and reconstruction during the same operation.
Ask to be referred to an expert in breast reconstruction. Make sure that they are a member of BreastSurgANZ, and, if a reconstructive surgeon, a member of the Australian Society of Plastic Surgeons.
See information about other health professionals who will care for you when you have a reconstruction.
The major types of breast reconstruction are implant reconstruction, flap reconstruction and a combination of both. These techniques can be done as immediate reconstruction or delayed reconstruction. They can be combined with total, skin-sparing or nipple-sparing mastectomy (see below).
In an implant reconstruction, an implant is placed under the skin and muscle to recreate the shape of the breast. In a flap reconstruction, skin, fat and muscle are taken from elsewhere in the body to make the breast mound. These operations can be done in different ways. Some operations are more difficult than others – both surgically and for your recovery.
Most reconstructions involve two or more operations several weeks or months apart. Your reconstructive surgeon will discuss the different methods and suggest the best one for you. Make sure you understand why your surgeon recommends a particular method. The recommendation will depend on:
Ask your surgeon to show you photos of different reconstructions, including the type recommended to you. You may want to see a range of photos of the surgeon’s work before deciding.
Remember there are variations in results, so your reconstruction may turn out better or worse than others. See information see making treatment decisions.
If you are medically suitable and wish to have an immediate breast reconstruction, you may have the option of a skin-sparing mastectomy or a nipple-sparing mastectomy.
In these operations the breast tissue is removed, as it is in a total mastectomy, but most of the skin (and sometimes the nipple) is preserved. This can make the reconstruction appear more natural.
These operations may not be appropriate for all types of breast cancer, so you should discuss it with your breast cancer surgeon.
Implants are made from a silicone envelope and filled with either silicone gel or a saltwater solution (saline). Saline implants used to be common but are rarely used now – see below.
Implants are more commonly used for women who are not going to have radiotherapy. Women who do have radiotherapy won’t have an implant reconstruction until afterwards.
There are advantages and disadvantages in using implants, and specific issues related to each type of implant – see the table below. You need to discuss this with your surgeon. You may also find it helpful to talk with someone who has an implant – Cancer Council 13 11 20 or a breast care nurse may be able to put you in touch with someone.
Silicone implants are used in almost all operations.
A softer, honey-like type of gel was previously used, but implants are now made of a soft, semi-solid filling called cohesive gel. This gel is quite firm and holds its shape like jelly.
Some silicone implants are covered with a thin layer of polyurethane foam, which may hold the implant in place. A polyurethane foamcovered implant can reduce the risk of capsular contraction and movement of the implant (see risks of having an implant).
Saline implants, which are made of a solid silicone envelope containing saltwater, are another type of implant. They are no longer commonly used in reconstruction.
Saline breast implants are not as naturally shaped as silicone implants – they may look rounder than a real breast, and problems such as the skin wrinkling and ‘sloshing’ may occur. A saline implant may also gradually lose volume, deflate without warning or wear out.
Implants will not last a lifetime. They can leak or break (rupture) because of gradual weakening of the silicone. According to the US Food and Drug Administration, about one in 10 of all silicone implants break or leak within 10 years of being implanted. The average implant lasts about 15 years.
With a silicone gel implant, because the gel is often contained within the body’s capsule of scar tissue, it may not be possible to tell whether the implant has ruptured. If the silicone leaks outside the capsule it may cause a lump, which can be swollen and painful. If this happens, make an appointment with your doctor. Usually, if an implant is known to have ruptured, it is replaced.
If a saline implant ruptures, salty water will leak out into your body and the implant will collapse. The salty water is not harmful, but you will need to have surgery (usually a day procedure) to remove the empty silicone envelope and replace the implant.
If there are safety concerns about an implant, it is withdrawn from the market.
Some silicone implants were voluntarily taken off the market in the 1990s due to safety concerns and speculation. Since then, regulatory authorities such as the Therapeutic Goods Administration (TGA) approve brands for use in Australia.
In April 2010, the French brand Poly Implant Prothèse (PIP) was withdrawn due to safety concerns and a possible increased likelihood of ruptures. About 5000 Australians had a PIP implant between 1998 and 2010, but most of these were cosmetic procedures. These women should discuss concerns with their surgeon.
If you have healthy chest muscle and enough skin, an implant can be inserted under the chest muscle. An inflatable tissue expander may be used first – see below.
Implants come in many shapes and sizes. You can choose one with your surgeon, otherwise the surgeon will select one to match your own breast.
The mastectomy scar may be re-opened for the implant to be put in. This is why there is no further scarring.
The operation takes about an hour and you will probably be in hospital for one or two nights. You may feel some pain afterwards but you will be given medication for this.
After a mastectomy there is often not enough room to fit an implant of the desired size. In this case, an inflatable tissue expander can be used to stretch the skin.
The expander, a balloon-like bag, is placed under the skin and muscle, either at the time of the mastectomy or some time later.
Afterwards, the balloon is gradually filled by injecting it with saline through a port that sits just under the skin. These injections are given every couple of weeks until the tissue is the desired size. This may take several months.
Expanders are generally designed to be temporary, but there are also permanent ones. If a temporary expander is used, the surgeon will replace it with a permanent silicone or saline implant in another operation.
You won’t need to stay in hospital when the expander is being filled, but if the expander is replaced with a permanent implant, the operation will take about an hour and requires an overnight stay in hospital. You should be able to manage any pain with mild pain-killers.
A breast reconstructed with a tissue expander and/or an implant usually feels firmer than a natural breast. While it won’t move and behave like a natural breast, it usually looks symmetrical in a bra.
The saline injections cause little pain because the chest is often numb after a mastectomy. However, you may feel discomfort or pressure for a few days due to the tissue stretching. Check with your doctor about suitable pain relief medication.
Left: This shows the left side of the chest before the operation to insert a tissue expander. The tissue is mostly flat, because breast tissue was removed during the mastectomy.
Middle: When the tissue expander is in place, it creates a pocket where the implant will eventually be inserted. There is a port through which the saline can be injected.
After using the inflatable tissue expander, there may be enough skin and muscle to cover an implant. However, sometimes an acellular dermal matrix (ADM) is inserted under the skin to replace the muscle covering the lower half of the implant.
ADMs are flat, white sheets of real tissue. They may be made from animal or human tissue (a cow, or more commonly, a human cadaver). The ADM is processed and sterilised for use in surgery. It is cut to size and modelled to the shape of the breast. When in place, ADM works like building scaffolding – it is there to support and contain the breast implant. Your existing skin will grow into the ADM as the area heals.
For many women, the ADM provides a good result – talk to your surgeon for more information.
Before your operation, the surgeon will discuss the risks of the implant with you. The following list outlines the most common potential problems:
A capsule of scar tissue (fibrous tissue) tends to form around a breast implant. If this thickens over time, it may make the reconstructed breast feel firm. This condition is called a capsular contracture and is more likely if you have had radiotherapy. Capsular contracture can be uncomfortable or painful and may change the shape of the implant. Further surgery may be needed to remove and/or replace the implant.
The implant may move slightly in the body after the operation. This may happen over time. It is sometimes called implant displacement, descent or rotation. In a small number of cases, the implant shifts a lot and the appearance of the breast changes. Surgery can return the implant to its original position.
See breast implants and rupture above.
Sometimes implants adhere to the surface of the skin and this can affect how smooth the breast is.
Some people are concerned about implants causing certain health problems. Research has not established a link between silicone breast implants and autoimmune disorders such as scleroderma, rheumatoid arthritis or lupus. There is also no evidence that implants cause breast cancer.
There have been reports of a type of lymphoma occurring in the capsule of breast implants. There are only about 35 cases to date out of the millions of implants used – and six cases reported in Australia – but medical authorities are monitoring this issue. Talk to your surgeon about the risks.
Flap reconstruction is the use of muscle and skin from other parts of the body to build the shape of a breast. One of several flap methods may be used. The different types are named after the type of muscle used in the reconstruction.
Flap reconstruction depends on whether there is enough tissue and
fat to do the procedure. It is particularly suited to women with large
breasts, women who don’t have enough skin to cover an implant,
and women who have had radiotherapy.
The latissimus dorsi is a broad, flat muscle on the back below the shoulder blade.
Depending on the mastectomy technique used, you may have an oval-shaped scar on your reconstructed breast and a straight scar on your back. The back scar may be covered by your bra strap.
Some surgeons use a scarless LD reconstruction technique. This involves re-opening the mastectomy scar and using special instruments to tunnel into the body and bring the latissimus dorsi forward toward the breast. Ask your surgeon if this technique is possible in your situation.
Your surgeon will draw a pointed ellipse shape on your back to plan the incision. When the muscle tissue is cut and shifted to your breast area, its blood supply will stay intact.
TRAM flap reconstruction refers to a flap made out of tissue and muscle from the tummy (abdomen). It is short for transverse rectus abdominis myocutaneous flap reconstruction. One of the pair of long, flat stomach muscles called the rectus abdominis is used to create the reconstructed breast.
The reconstructive surgeon moves the muscle, along with local skin and fat, to the chest where it is shaped into the form of a breast. TRAM flap reconstruction can be done in two ways: pedicle TRAM flap method and free TRAM flap method.
TRAM flap reconstructions leave a long scar across the lower abdomen from one hip to the other. There will also be a scar on the reconstructed breast, and no feeling will remain in the skin over the breast.
About two weeks before the main operation, a smaller operation may be needed to improve the blood supply to the tissue that will be used in the breast reconstruction. This is more common for women with larger breasts.
The surgeon may also arrange to bank your blood in case you need a transfusion during surgery.
A pedicle TRAM flap operation usually takes 3–4 hours. A free TRAM flap operation takes 5–7 hours.
Both types of TRAM flap operation require 4–7 days in hospital. However, full recovery from either surgery takes at least six weeks.
In this method, the muscle is left attached to its original blood supply and tunnelled under the skin of your upper abdomen to the breast.
With a free TRAM flap, the reconstructive surgeon uses microsurgery to completely divide (detach) the muscle from its blood vessels, and then re-attach them to new vessels in the chest or under the arm. This method is better for creating a larger breast. It is also easier for the surgeon to shape the breast for a more accurate final result, but it is a more complicated and longer operation requiring special facilities and expertise.
Removing the abdominal muscle in both TRAM flap methods can weaken the abdominal wall. This can result in a hernia, which is when part of the bowel juts out through the abdominal wall. To reduce this risk, the surgeon may insert mesh into the abdomen to replace the muscle. You will be advised to avoid heavy lifting after the operation.
Blood vessels supplying the flap may kink or get clots, leading to bleeding and a loss of circulation. This may cause a partial or complete loss of the flap due to the tissue dying (necrosis). This is more common in women who smoke or recently quit, although quitting smoking before surgery helps to decrease the risk.
An uncommon side effect is when fat used to make the reconstructed breast doesn’t get a blood supply, which causes it to die (fat necrosis). These areas in the reconstructed breast can feel firm and are easily seen and diagnosed on a mammogram. They can be left in place or surgically removed. The risk of fat necrosis is much higher in smokers.
Some surgeons now perform what is known as a DIEP flap method. DIEP is short for deep inferior epigastric artery perforator flap. It is a complicated operation that is similar to the TRAM flap operation, but it only uses abdominal skin and fat to reconstruct the breast (no muscle is used).
Advantages of this method are a quicker return to normal activities, a smaller risk of hernia and no need to use supporting mesh in the abdomen. It may also be possible to do a bilaterial reconstruction (both sides), which is not possible with the TRAM flap operation. However, there is still a risk of loss of the flap and fat necrosis. Your surgeon will discuss these risks with you.
If a TRAM flap or DIEP flap is not an option for you, other techniques may use fat and a blood supply from other areas of the body, such as the buttock or inner thigh.
The surgeon may remove fat from another part of the body (liposuction) then inject it into the breast to contour it. This is known as lipofilling.
Another option may be volume replacement of miniflap. This may be used for women with smaller breasts who have not had a full mastectomy, to preserve the healthy part of their breast. In this operation, the surgeon takes a small flap of muscle and fat from the woman’s back and puts it in the breast to fill the area where the breast cancer has been removed. Talk to your breast surgeon about these less common procedures.
After a breast reconstruction, you may use adhesive nipples to achieve a more natural look. These stick to the skin and stay in place for several days. They are available from breast prostheses suppliers.
You may choose to have a small operation to reconstruct a nipple and the area around it (the areola). Because the reconstructed breast may sag slightly after surgery, this operation generally isn’t done until at least three months after a reconstruction.
Nipple reconstruction is done using tissue from your remaining nipple, if you have one, or with tissue from the new implant or flap. The new nipple won’t have nerves, so it will not feel any sensation.
If you have a natural breast remaining, the new nipple can be tattooed to match the colour of the opposite one. Most reconstructive surgeons can do the tattooing or have a trained nurse do it, but you may prefer to have the nipples tattooed by a professional medical tattooist or beauty therapist. Initially, the tattoo will look darker than the remaining nipple, but it will fade with time to match in colour.
Some women may be advised or choose to have a bilateral mastectomy. This means both breasts are surgically removed. This procedure may be recommended because of:
This procedure combines a lumpectomy (lump removal) with a breast reduction. It is often used as an alternative to mastectomy in suitable cases. Usually a reduction mammaplasty is done on the other breast at the same time.
How quickly you recover from a breast reconstruction depends on the type you’ve chosen, how many operations you need, and your body’s ability to cope with the surgery. Some women find that they get back to normal quite quickly, while others find that they need several weeks to recover at home.
The main operation for a breast reconstruction usually requires you to spend 2–10 days in hospital. A general anaesthetic will be used and you will probably feel some pain or discomfort afterwards. If you have had a flap reconstruction, you will be sore in the area where the muscle and other tissue were taken, as well as in the breast area.
For any type of operation, you will be given pain relievers to control your discomfort. You will also probably have small tubes inserted into the operation site so fluid can drain away.
You may need to be careful when moving around immediately after the operation, to help the healing process and because of any pain. It’s usually advisable not to do housework or drive for 4–6 weeks. This is because you need to avoid repetitive arm movements such as hanging out washing or vacuum cleaning. Your surgeon or nurse can suggest particular arm exercises to help aid arm movement recovery.
After a TRAM flap reconstruction, you should also avoid heavy lifting – including lifting small children – and driving for about six weeks. The surgery will also cause a tightening of the abdomen similar to a ‘tummy tuck’ operation. You may have some weakness in your abdomen, which you may notice when getting up from a low chair or sitting up in bed. Ask your surgeon for advice about getting back to your regular activities.
Your surgeon will continue to care for you until your body has healed properly. Then your usual check-ups with your breast specialist will continue – see below for more information. Once healed, your reconstructed breast will not need any special care.
As with all operations, recovery will take longer if problems occur. These might be related to the anaesthetic, to infection or to healing.
You should discuss possible problems with your surgeon or breast care nurse before the operation so that you understand the risks of the procedure and you can make the necessary arrangements for your work, home help or childcare.
It’s not possible to make an exact copy of your remaining breast. Although the surgeon can attempt to make them as similar as possible, there may be differences in the size, shape or position of the two breasts.
If your weight changes, you may find that one of your breasts changes in size while the other one stays the same. This is more common with an implant.
You may also find differences in the feeling of your breasts. Your reconstructed breast may feel either numb or extremely sensitive.
You may also suffer some loss of feeling if you have had surgery to your remaining breast (for example, a breast reduction). If you have a nipple reconstruction, the nipple will no longer have any feeling.
Sometimes there may be healing problems within the first week or so after surgery. This can be caused by infection, poor blood supply or problems with an implant. Any infection must be treated to reduce the possibility of further complications. If an implant has been used, it might need to be taken out. However, it may be possible to have a new implant put in later on.
Sometimes, shortly after the operation, extra blood collects in or under the wound. This is called a haematoma and it causes swelling and pain. A large haematoma may need to be surgically removed.
Sometimes after the operation or when drains have been removed, extra fluid collects in or under the wound. This is called a seroma. It causes swelling and pain, and it may need to be drained by a health professional using a needle.
All people heal differently and the final appearance of a scar will vary from person to person, even if the surgery is the same. Most scars have a thickened, red appearance early on. The scar will begin to fade after about three months.
Sometimes the scar stays thick for a long time and can become itchy and uncomfortable. Let your surgeon know if you already have any existing raised, irregular scars (sometimes called keloid scars), as this may show that you are prone to getting these types of scars.
Your surgeon or breast care nurse can advise you about treatments to reduce the discomfort. You may be able to have surgery later on to improve the scar’s appearance.
Some women are concerned that their breast reconstruction will hide cancer that has returned (a recurrence). This is unlikely to happen because most recurrences of breast cancer occur in the skin or in the tissue just underneath the skin.
If a flap reconstruction is done, any recurrence would usually only occur in the skin that belonged to the original breast. The flap used to make the reconstructed breast would not hide this. If a breast implant is used, it is placed underneath the chest muscle. Again, it should not be difficult to detect a recurrence.
Having a reconstruction does not affect your chances of long-term survival. After reconstruction, it is a good idea to examine both your breasts every month. Your surgeon will arrange to see you regularly to examine the reconstructed breast. If you have a remaining best, your surgeon will advise you on how often you need to have a mammogram. You will have the mammogram at a hospital breast clinic or radiology practice.
Discuss any concerns with your general practitioner or surgeon.
Whether or not to become pregnant after breast cancer and if so, when, can be an issue. Discuss any concerns with your oncologist and breast surgeon.
Pregnancy after a breast reconstruction is possible, regardless of the type of reconstruction. Mesh put into the abdominal wall during a TRAM flap operation supports the abdominal muscles and will help decrease the risk of a hernia during pregnancy.
Breastfeeding is not possible with the reconstructed breast. Most women can successfully breastfeed with their other breast, although this may be difficult if you have had a reduction. A breast care nurse or lactation consultant can advise you on any concerns you have about breastfeeding after a reconstruction.
"I really wanted to breastfeed my daughter with my remaining natural breast. I saw a lactation consultant who helped me to stimulate my milk supply." – Lara
Find out how much it will cost to have a breast reconstruction. Check with your surgeon, the hospital, Medicare and your private health fund before deciding to go ahead. You may need to pay for extras such as pain medication, post-surgical bras and check-ups with your surgeon.
Financial assistance may be available for transport costs to medical appointments and prescription medicines. Ask the social worker at your hospital if you are eligible for assistance.
If you have your nipple tattooed, it is covered by Medicare if a doctor does the tattooing. If a professional tattooist does the work, it is not covered and you will have to pay yourself.
"With my private insurance, I was significantly out of pocket, due to the anaesthetist charging well above the schedule fee. However, the advantage gained with the reconstruction was well worth the cost." – Gwen
In hospital, you will be cared for by a range of health professionals
who specialise in different aspects of a reconstruction procedure.
This multidisciplinary team will probably include the health
professionals listed below.
|breast surgeon||specialises in the surgical treatment of breast cancer, including mastectomy, breast conserving surgery and lymph node surgery|
|oncoplastic breast surgeon||a breast cancer surgeon who has extra skills and expertise in breast-preserving techniques and some forms of breast reconstruction|
|reconstructive or plastic surgeon||trained in aesthetic (appearance) and reconstructive techniques and may specialise in the full range of breast reconstruction options|
||administers a general anaesthetic before an
operation so you lose consciousness and
don’t feel any pain
|breast care nurse
||advises women about all aspects of caring
for their breasts, including pre- and postreconstruction
||link you to support services and help you with
any emotional, physical or practical problems
||offers counselling so you can talk
through your options and helps with the
You may find this checklist helpful when thinking about the questions you want to ask your health care team about getting a breast reconstruction.
If you don’t understand the answers from the surgeon, it is okay to ask for clarification.
Breast Cancer Network Australia has a number of personal stories about breast reconstruction.
Having a breast reconstruction is a personal choice. It can involve a great deal of thought and discussion. Take time to get a good understanding of what a reconstruction involves and make sure that you have realistic expectations of the end result. A breast care nurse or counsellor can also help you think through the issues.
Breast reconstruction is a specialised form of surgery. You should talk about your options, including the best time to have the procedure, with your breast surgeon first. Many women can have a reconstruction, but there are some situations where your surgeon may advise against it. This might be due to the type of breast cancer or treatment you had, because you need further treatment for the cancer, or due to your general health.
If you are referred to a reconstructive surgeon, ask to see photographs of their work. You may also be able to talk to some of their previous patients.
It’s important for you to make your decision in your own time. Although it’s useful to talk to other people, try not to feel pressured into a decision based on what they think. You also have the right to accept or refuse any treatment.
The question checklist can help you think through the information you need to understand the surgical procedures and make your decision. If your doctors use medical terms you don’t understand, it’s okay to ask for a simpler explanation.
There is no urgency to decide to have a reconstruction unless you ant one at the time of your mastectomy. As long as you are well nough for surgery, you can have a reconstruction in the future.
Getting a second opinion from another breast surgeon or plastic surgeon may be a valuable part of your decision-making process. It can confirm or clarify the first doctor’s recommendations and reassure you that you have explored different options.Some people feel uncomfortable asking their doctor for a second opinion, but specialists are used to patients doing this. It is important that you feel comfortable with, and have trust in, your surgeon. Ask your surgeon or general practitioner about getting a second opinion if you want to. You can then decide which surgeon you would prefer to do your breast reconstruction.