What is breast reconstruction?

Breast reconstruction is an operation to rebuild the shape of a breast by creating a breast mound after mastectomy (removal of the breast) or lumpectomy/wide-local excision (removal of part of the breast).

Breast reconstruction can be performed at the same time as a mastectomy, as an immediate reconstruction, or after a mastectomy, as a delayed procedure for breast cancer. It may also be carried out for genetic reasons (e.g. BRCA 1 or 2 or TP53 gene mutations). You may be considering having one breast reconstructed (unilateral) or both breasts (bilateral).

Clinical findings support evidence showing those patients undertaking a delayed reconstruction may be more emotionally accepting that those having immediate reconstruction. It may be possible to preserve your breast tissue using an expander at time of mastectomy if you cannot make a decision at that time to proceed with immediate reconstruction.

The surgeon may recommend surgery to re-shape the remaining breast to match the reconstructed breast. This could include reducing or enlarging the size of the breast or lifting the breast at a later stage.

Breast reconstruction surgery is usually performed during several operations over a period of approximately 12 to 24 months. The first procedure is usually to create a breast mound, followed by symmetrising surgery (if necessary), to balance and sculpt the breast, followed by nipple reconstruction, if required and finishing with micro-pigmentation (tattooing).

Surgeons can create a breast mound using your own tissue (autologous reconstruction). These reconstructions involve using tissue (flap) from your abdomen (MS TRAM flap, SIEA flap or a DIEP flap), inner thigh (TUG/TMG or DUG flap), back (LD flap) or bottom (SGAP or IGAP flap). Surgeons can also reconstruct a breast using a breast implant or tissue expander, which is usually put underneath the skin and sometimes the chest muscle (PEC Major) and sometimes they can be used in conjunction with skin, fat and muscle from another part of your body (e.g. your back- LD flap).

Some women may have contour defects on their breast(s) from breast-conserving surgery (lumpectomy or wide-local excision). These women may not need to have an entire breast reconstructed but perhaps a small area. In these cases, surgeons may suggest smaller flaps called TDAP/TAP or LICAP to replace the missing tissue.

The types of breast reconstruction available differ between hospitals and surgeons and therefore the pre and post-operative support and care will vary. Please consult with your breast team at your own hospital to discuss personal care. The different types of reconstruction will be explained in more detail later on.

The realistic goal of breast reconstruction is comfort and symmetry within your clothing.

Why have breast reconstruction?

Surgery for breast cancer is likely to affect how you look and feel. Some women find it harder than others to come to terms with losing one or both of their breasts.
You may be considering breast reconstruction because breasts are an important part of your body image, self-esteem and sexuality. How your partner feels may also play a part. Some women choose to have a reconstruction as they think it will make a difference to their partner, or that it may help them feel more confident during intimacy and sex. However, any decision you make about having a reconstruction should be based on whether it’s right for you.

If you’re not in a relationship at the time of your breast cancer surgery, you may be worried about the prospect of meeting someone new. Breast reconstruction may help you feel more at ease in new relationships, and help you to talk about your breast cancer and feel more confident about showing your body to your partner.

Risks and complications of breast reconstruction surgery

All surgery and anaesthesia carry some uncertainty and risks. Find out more about the risks and complications associated with breast reconstruction surgery.

Important considerations

In order to be able to decide whether reconstruction is the right thing for you, you must first feel fully informed about all the types of reconstruction available and the ones suitable for you. There are many things to consider when exploring what may be the most appropriate reconstructive surgery for you.

  • Breast reconstruction does not prevent you from having any other breast cancer treatments, such as chemotherapy, radiotherapy or hormone treatment. However, having radiotherapy may affect your reconstruction or delay some of the reconstruction options available to you. Some units may request you wait 1 year following completion of radiotherapy before considering a free-flap reconstruction because of the possibly damage to your tissue and blood vessels. Other units may offer radiotherapy before mastectomy (as part of a trial).
  • Delayed wound healing is a risk to any breast surgery, and if you experience significant problems with wound healing after a mastectomy and breast reconstruction; and need to have chemotherapy, then the start of your chemotherapy could be delayed until your wounds are fully healed.
  • The breast reconstruction journey usually requires more than 1 operation, and can take 12 – 24 months to complete.
  • Breast reconstruction surgery takes longer than mastectomy surgery alone. Some forms of breast reconstruction are major operations and your overall inpatient stay and recovery is likely to be longer than having a mastectomy alone.
  • Not all forms of breast reconstruction are suitable for every patient. There are a number of considerations such as your general health, the amount of “spare” tissue you have, the quality of your skin, your wishes and your lifestyle. Your surgeon will discuss what options are most suitable for you.
  • Reconstructed breasts will not feel and look exactly the same as a natural breast – they will often be a slightly different size and shape. They are unlikely to have sensation and tend to be numb.
  • A natural breast will change over time and droop as you get older. Reconstructed breasts (especially following implant-based reconstruction) will not change in the same way. Over time the differences between a natural and reconstructed breast may become more obvious.
  • You may have scars on other parts of your body depending on the type of reconstruction you choose.
  • Reconstructed breasts don’t usually have a nipple, but one can be created with surgery and tattooing, often at a later date.
  • Any differences should not be noticeable when you are clothed, even in a bra or in swimwear. When you are undressed, the differences are more obvious. You’ll be able to see some scarring, although this will fade over time.

However, most women find the results after reconstructive surgery acceptable and say they feel confident about the way they look; they are also often pleased to no longer have to wear an external prosthesis in their bra.

Smoking

If you smoke, you are unlikely to be considered for breast reconstruction surgery until you have stopped. Some units may ask you to stop smoking for a specific number of weeks before surgery. This is variable between units; please ensure you check with your own team.

If you are considering a free-flap reconstruction (using your own tissue), then your unit may also ask you not smoke or to use any nicotine replacement products for a number of weeks before surgery. Nicotine replacement products may include e-cigarettes, vaping, lozenges, nicotine gum and patches.

The reason for this is that smoking can reduce the blood flow to surgical sites. Studies have shown that nicotine and other substances that are found in cigarettes can be harmful to your heart, lungs, and your skin. Smoking can have an adverse effect on the healing of all surgical wounds and cause infection. The same applies to the use of nicotine replacement therapy as, although this may reduce the craving for a cigarette, the nicotine will also reduce the ability of the blood to carry enough oxygen to the tissues.

You may wish to consider visiting www.smokefree.nhs.uk or calling the 0800 022 4332 for smoking cessation advice. Alternatively, your GP may be able to advise you.

Body Mass Index (BMI)

There is written evidence to show that wound healing is impaired dramatically the higher your body mass index (BMI). Many surgeons will ask that your BMI falls between a healthy range and does not exceed 35, this is in order to reduce the chance of a complication arising. Your surgeon may ask you to lose weight before agreeing to operate in order to achieve the best long-term results for you. The BMI limit is variable between units.