Breast reconstruction options after a mastectomy

Breast reconstruction is an option for women and men after undergoing mastectomy for breast cancer. It is also a consideration for women who have tested positive for a gene mutation (such as BRCA) and wish to have a prophylactic mastectomy to greatly decrease the chances of getting cancer. The decision to undergo breast reconstruction is ultimately personal, a choice that is not for everyone, but a choice that everyone deserves to know about.

What are the options for breast reconstruction? There are three types:

1. Reconstruction using implants, either saline or silicone gel
2. Reconstruction using your own tissue called autologous reconstruction
3. Reconstruction using a combination of implants and autologous tissue

It is important to research all options. There are reasons why you may choose one option over the other, and it is possible to switch from one type of reconstruction to another (such as autologous reconstruction for failed implants). There are still many challenges that individuals face when it comes to considering their reconstruction preference. They might include the following:

1. Your overall health and the stage of your breast cancer. You may have an advanced breast cancer that requires adjuvant therapy before reconstruction begins. Radiation can also delay reconstruction. Treating your cancer should always take precedence over reconstruction. Your plastic surgeon should guide you through a shared decision-making process to optimize your health before surgery and decide on the best individualized reconstruction plan for you.
2. The visibility and location of resulting scars from surgery is also of concern to those seeking reconstruction. Planning for scar location depends on many factors such as nipple preservation, breast surgeon experience, type of reconstruction, and timing of reconstruction.
3. Availability of a qualified plastic surgeon and a medical facility that performs reconstruction that is geographically nearby can be a deterrent for some patients due to lack of funds for travel or fear of travel after surgery. This can be a particular challenge for those living in rural areas.
4. Time off work. Women must consider a possible 4-6 weeks off work for recovery depending on the type of reconstruction they choose. This may vary for men and for each stage of reconstruction.
5. Insurance. Although a 1998 federal mandate requires reconstruction to be covered by insurance, there are those still facing barriers with insurance coverage depending on the facility and what insurance is carried by that facility.

There are many resources available to begin research for breast reconstruction choices. Technical details can be reviewed with your surgeon, but it is far more important to find a surgeon who understands your goals and establishes a shared-decision making environment. There are survivors and advocates who write informative blogs about their own breast reconstruction experience and provide helpful information about choosing their surgeon and the recovery process. It is to your benefit to consult with a plastic surgeon soon after your diagnosis to consider your options and timing.

The American Society of Plastic Surgeons (ASPS) features a "surgeon finder" with board-certified plastic surgeons who perform breast reconstruction. If you are considering autologous reconstruction, the American Society of Reconstructive Microsurgery (ASRM) also has a "surgeon finder" for patients. When choosing autologous reconstruction, it is important to find an experienced microsurgery team that performs a high volume of these specialized procedures.

Important questions to ask your plastic surgeon, whether for implant based or autologous reconstruction, include but are not limited to the following questions:

• How many procedures have they performed?
• What is their success rate?
• Do they work with a team? The shared expertise is a factor as well and often minimizes time for the patient in surgery.
• Do they have before and after photos?
• What aesthetic outcomes can I expect based on my individual health history and case?
• What type of insurance carriers do they take?
• Will they accept insurance from out of state?

Breast reconstruction often involves more than one procedure. It can take two or more surgeries to complete the process and allow time to heal and recover between surgeries. Revision and symmetry procedures, as well as nipple and areola reconstruction or tattooing (for those who have not had a nipple-sparing mastectomy – NSM), can be part of this process.

For more information, including a list of ASPS plastic surgeons in your community, please use our Find a Plastic Surgeon tool.