Know your options: A complete guide to breast reconstruction
"There is a sense of recovery that occurs with the reconstruction. It's important. It's about restoring your body."

"When my mom was diagnosed with breast cancer at the young age of 35, she had mastectomies but no reconstruction," said Warren Ellsworth, IV, MD, explaining that in the '70s, much of breast reconstruction as we know it today wasn't an option. "She underwent reconstruction beautifully 24 years later, and it changed her. I saw the impact on her, on my family, and it was remarkable."

The experience influenced Dr. Ellsworth's career path. He is a plastic surgeon specializing in breast reconstruction and is well aware of how "these options are so important – validated studies of women who undergo breast reconstruction have shown time and time again that their confidence is higher, their scores in femininity and sexual identity are higher, their openness to their partner sexually and physically is higher. The studies have shown that it impacts not only the woman, but the family, as well, in a positive way."

One goal with breast reconstruction surgery is to make it so that a patient does not have to wake up completely flat after a mastectomy. "Psychologically, that can be really hard, as you can imagine," said Dr. Ellsworth. When you're talking about a mastectomy, it is "essentially a damaging amputation-like procedure, and there is a sense of recovery that occurs with the reconstruction," said Scott Hollenbeck, MD, FACS. "For many patients, there's a certain aspect of identity and of femininity that's associated with breast reconstruction. It's important. It's about restoring your body."

There are several options for breast reconstruction, and of course there's the option to have no reconstruction at all. Advances in surgical technique have made it possible to preserve more sensation in the breast, and to deliver more natural-looking results with less pain for patients.

"Every woman should have various options, because every woman is not the same," said Dr. Ellsworth. "Her cancer is different, her body is different, her stage in life can be different. We respect all of those facets, and they come together in a personalized approach to breast reconstruction."

Plastic surgeons work closely with breast surgeons – and may even talk with patients the same day that they receive their diagnosis – in order to support patients through decision-making processes. During his first meeting with patients, "my hope and dream is to make their fears less. Women come in with such remarkable fear of the mortality and morbidity associated with cancer and of what it's going to do to their body," said Dr. Ellsworth. "I always open the conversation with the fact that my hope and dream is that they leave our meeting with hope that their future can be beautiful and bright, with a retained femininity and confidence that is so critical."

"Giving patients all of the options helps them to be more empowered," said Alicia Billington, MD, PhD. "They didn't ask to have breast cancer. They didn't ask to have surgery on their breasts. But if they're going to have it, at least they're going into it knowing what all of their options are and feeling like they have a voice in that part of the process."

Here are the main forms of breast reconstruction available to patients who are having a mastectomy or lumpectomy:

Reconstruction using implants

With a mastectomy, one of the two major options is breast reconstruction using implants.

"For patients who are very young, very thin or having a double mastectomy, we will often think about implants as a good option," said Dr. Hollenbeck. "With a double mastectomy, both sides will essentially look the same, because the implants are the same."

Depending on a patient's anatomy and size goals, breast reconstruction with implants can be a "one-stage or two-stage procedure," said Dr. Ellsworth, adding that either the implant itself or a tissue expander will be placed at the time of the mastectomy.

"I prefer to put an implant in at the time of the mastectomy whenever possible, so it's only one surgery – but I never promise the patient one surgery – and tissue expanders are more prone to complications like infections," said Dr. Billington.

However, sometimes after a mastectomy or double mastectomy, the blood supply to the skin isn't adequate enough for an implant to be placed.

"An implant would be putting a lot of tension on the skin, and that could cause the skin to die," said Dr. Billington.

In that case, she would use a tissue expander to gradually create a pocket in which an implant can be placed during a second surgery.

"The tissue expander is basically a water balloon that has a little port in it that can be accessed with a needle in clinic," said Dr. Billington. It starts off "deflated and flat, so it's not putting tension on the skin, and we can slowly fill it up with fluid." That gradually stretches the skin over about four to six weekly treatments, and then the tissue expander can be removed and the breast implant placed in the space the expander created.

Placing a breast implant during a reconstruction is a different type of procedure than a cosmetic breast augmentation and comes with its own nuances because the patient's own tissues have been removed, so rippling from the implant may show through the skin.

"All implants have a little bit of rippling, and if you don't have a lot of tissue on top of that, you can see it underneath the skin," said Dr. Billington. "In addition, you can have a higher risk of bleeding, a higher risk of infection, and a higher risk of capsular contracture, which is hardening of the scar tissue that forms around the implant."

There may also be a misconception that breast reconstruction using implants is basically breast augmentation.

"I think patients get very frustrated when someone finds out they have breast cancer and tries to be kind and says, 'Oh, well you get a boob job out of it,'" said Dr. Billington. "That is definitely not the case."

Patients should know that "implants don't last forever. On average, they last about 15 to 17 years," said Dr. Ellsworth. That means that if you're getting implants around the age of 40, "you are most likely going to have multiple [implant revision] surgeries throughout your life," said Dr. Billington.

But it can also help to know that major advancements in surgical technique over the last 10 to 15 years have brought "real change for the better of the patient – less pain, a better look, better outcomes," said Dr. Hollenbeck. Instead of placing the implant below the muscle, "now we typically place it above the muscle, in the same place where the natural breast actually exists. It's way less painful for the patients and looks way more natural."

If needed, acellular dermal matrices (ADMs) or mesh materials can help position an implant and keep it in place, helping prevent drooping and making rippling less noticeable.

Obvious rippling can be covered with fat grafting. This may be done at a follow-up appointment three to six months after the implant is placed.

"Most of us like to use fat grafting, because it can help you shape the reconstruction, almost like clay, and make things even more beautiful and natural-looking," said Dr. Ellsworth. In order to perform fat grafting, fat is liposuctioned from another part of a patient's body, purified and "transferred to the breast to add additional volume or to camouflage an implant or the edges of the reconstruction, so that it blends in a little bit better with the natural areas of the body," said Dr. Hollenbeck.

"We're always trying to achieve symmetry," said Dr. Ellsworth, "And oftentimes, we can achieve better symmetry than a patient had before. When I meet a patient, I tell her, 'Your breasts are always sisters, not twins.' That's true for what you were born with, and that will be true after reconstruction, but we always work with an eye towards symmetry."

Autologous reconstruction

Sometimes a patient's own tissues, often taken from elsewhere on the body, such as the lower abdomen, are placed over an implant, "so that the implant is covered in a soft layer of tissue," said Dr. Hollenbeck. Other times, the tissue is used by itself to reconstruct the breast following a mastectomy. This is called an autologous reconstruction.

Autologous reconstruction uses a technique called microsurgery.

"Trained plastic surgeons can use a tummy tuck-like incision [to remove] skin and fat from the lower belly, and instead of throwing it away like we would in a tummy tuck, a cosmetic procedure, we use a microscope and dissect arteries and veins, and often nerves, that give it life, disconnecting it from the body, and then reconnecting it to arteries and veins on the chest," said Dr. Ellsworth. This is often done at "the very same time as the mastectomy, depending on the treatment needs of the patient. It is a bigger procedure [than an implant reconstruction], and one that requires microsurgical expertise."

But one benefit is that "once it works, it works for her whole life, which is a very big deal," said Dr. Ellsworth. "I always tell patients that using their own tissue, if it's an option, can often provide the most natural-looking and feeling reconstruction, because fat feels a lot like breast tissue, and it's warm to the touch because there's blood flow going through it. Those are important things that patients need to learn about in the consultation."

When a patient is having a single mastectomy, "we try to match their natural breast on the other side with the reconstruction, and for many of those patients, using their own tissue does become the best option for matching their natural breast," said Dr. Hollenbeck. "An implant in some cases simply does not match a natural breast, especially for older patients who have a little bit of natural sagging, so we often will use their own tissue [instead of an implant]."

When tissue is taken from the lower abdomen, the incision is usually made from hip to hip and around the belly button. If a patient does not have enough fat on their stomach, tissue may be taken from their back, thigh, sides of the torso or lower buttocks. Plastic surgeons may tweak the look of an autologous reconstruction using fat grafting after the initial procedure. And "the tissue is going to age with you, just like a natural breast gets droopy over time, the autologous tissue will get droopy over time, and you might need to revise that," said Dr. Billington. "But it is not a foreign body [like an implant], so if the tissue takes and it lives, it becomes a part of you. If you gain weight or lose weight, it gains and loses weight."

Recovery after autologous reconstruction is longer than after implant reconstruction because both the breast and the area the tissue was taken from need to heal. Usually, patients stay in the hospital for two nights, then recover at home over four to six weeks.

"That doesn't mean they're in bed; they're walking around their house, and towards that third to fourth week, they're walking around their neighborhood," said Dr. Ellsworth. "I take care of so many young moms, and I always ask them about their work – both at home and at their job setting – because they can't be the primary driver of their six-year-old; they can't pick up their toddler for several weeks. So, we have to rally the troops and get a circle of love around these women that will support them through the process."

Breast reconstruction with a lumpectomy

When a patient is having a lumpectomy, which is removal of a tumor, also known as a partial mastectomy, "oftentimes we can do a breast lift or a shaping procedure to fill in the defect using the patient's own tissues with an outpatient surgery, so that's a beautiful option for some women," said Dr. Ellsworth.

Fat grafting can fill a deformity created by tumor removal, or a breast reduction may be performed.

"The patient typically receives a similar procedure on the other breast, so that symmetry can be achieved," said Dr. Hollenbeck. When breast shaping techniques are combined with a lumpectomy, "that is broadly termed oncoplastic surgery."

Radiation may be part of the patient's course of cancer treatment.

"The surgery needs to go well, so that the tissue heals properly and is ready to get and tolerate the radiation, and then we're usually done with [the reconstruction] – it's one surgery typically, and the remaining tissue is natural," said Dr. Hollenbeck. However, "radiation can cause some damage to the remaining tissue, and it can be difficult to know what's healthy tissue in the future and what may be a recurrence – for those reasons, some patients will choose not to have this approach and instead pursue a mastectomy."

Implants and radiation

"These often don't play well together; there's a higher risk of complication," said Dr. Billington. "It's not impossible to do it, and I often have patients who are receiving radiation that [want] implants, but I tell them they're at a higher risk."

For these patients, implants may be placed in both breasts, so they appear to be the same size.

"We might put a smaller implant on the side that has not been affected, and a larger implant on the other side," said Dr. Billington. "It depends on the situation."

Radiation may cause shrinkage of the breast, said Dr. Billington, and without using implants, "we can do a lift, and, on the opposite side, we might do a reduction and a lift to try to get the [breasts] to match."

Restoring and preserving sensation in the breast

"This is something that we are passionate about, and board-certified plastic surgeons across the country work to preserve sensation during both implant reconstruction and autologous reconstruction with a patient's tissue from the tummy," said Dr. Ellsworth. "It's a newer technique, but there's more and more data supporting it, and we at ASPS are working hard to advocate for insurance companies to cover this."

During a mastectomy, a lot of sensation can be lost from the breast. "The nerve runs through the breast tissue, and the nerve is removed with the tissue during the mastectomy," said Dr. Hollenbeck. If the mastectomy is performed with implant reconstruction, however, a plastic surgeon can "actually try to preserve some of the nerves from removal, and then we use a nerve graft from cadavers – that has been sterilized and is commercially available – to bridge the gap to the nipple or to the skin," said Dr. Ellsworth.

With autologous reconstruction, "tissue from your tummy obviously has nerves, so I dissect nerves that are giving that tissue life, and I use a nerve graft to connect the patient's own nerves on the chest to [the ones from the tummy]," said Dr. Ellsworth. The nerves can "grow, almost like plants grow, through the tissue, but it takes a long time. I tell patients we won't know the final outcome for a year, or a year and a half."

Advances in nerve grafting and nerve restoration have made this possible.

"I tell my patients preoperatively that it's never the same sensation that God gave you, but as the nerves grow over the course of a year, they can feel the hug of their children, they can feel the shirt coming over their chest," said Dr. Ellsworth. "Sensation offers protection, of course, from burns – those things matter."

The nipple

"There has been a paradigm shift; oftentimes, we can actually save the nipple, not always, but sometimes, and that, of course, achieves the most natural results, similar to a patient's previous pre-cancer state," said Dr. Ellsworth. "When we cannot save the nipple or when it's best not to for various reasons, we have reconstruction that we can do to build a projecting nipple, usually in a second stage [procedure]."

Now, there are tattoo artists who specialize in 3D tattooing that makes "the nipple look almost exactly like it did. It's just amazing, and interestingly some women choose to get the 3D tattoo, and not the projecting nipple," said Dr. Ellsworth. It's often because, after reconstruction, "their breasts are perky, they don't need or want to wear a bra, and they don't want to deal with nipple projection through shirts."

Aesthetic flat closure

"It's important to recognize that reconstruction is not for everybody," said Dr. Hollenbeck. "It's not necessary. And there are options that are different from full-force reconstruction."

Patients can have their breast tissue removed and go completely flat. In that case, a plastic surgeon can "be involved in closing up the skin, so that it is nice and flat, and doesn't have ridges or extra, redundant skin," said Dr. Hollenbeck. That's important for preventing chafing and discomfort, as well as for hygiene, so a patient doesn't have moisture between the chest and excess, sagging skin on top of it, said Dr. Billington, and it makes it easier for a patient to wear a prosthetic (which can be placed in a bra or swimsuit) if they choose.

Called an aesthetic flat closure, this technique has "become more and more popular; many times, patients themselves will request it," said Dr. Hollenbeck. "We as plastic surgeons are equipped to handle and rearrange the skin in a way to achieve a nice aesthetic flat closure, and many of us offer that, as well."

Reconstructive procedures for men

"Men are kind of the forgotten group, but they can also get breast cancer, and there are options for reconstruction for men, as well," said Dr. Billington. About one percent of breast cancer cases in the U.S. occur in men. Fat grafting can reshape the area, and nipple tattoos can be customized for women or men, whose areolas tend to be more oval, whereas women's are more round. "I think a lot of men are afraid to talk about it or feel uncomfortable," said Dr. Billington.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.