What is breast reconstructive surgery?
Reconstructive breast surgery creates a balanced and natural look to breasts that have been removed by a mastectomy or modified during a lumpectomy to treat breast cancer. The reconstruction procedure can be performed in conjunction with the cancer surgery itself. However, many patients prefer or are required, to delay the reconstructive surgery for several months or possibly years post their cancer treatment. Furthermore, some ultimately choose to forego reconstructive surgery altogether.
Should I have breast reconstruction after mastectomy?
Choosing to undergo breast reconstruction following a mastectomy is a deeply personal choice, with considerations encompassing your lifestyle, financial situation, potential recovery time, and your anticipated cosmetic result.
Factors that could make you a suitable candidate for breast reconstruction are:
- Good mental and emotional well-being.
- An immune system and overall health that has adequately recovered from cancer treatment and can withstand an extended surgical operation plus the required healing afterwards.
- Sensible expectations concerning the outcome of your breast reconstruction. Be aware that the newly constructed breasts, whether created using implants, flaps, fat grafting, or a mixed approach, will most likely not mirror the original look or feel. Scarring is also an unavoidable, lasting aspect of the procedure, and there could be potential asymmetry or variations in skin colour, particularly if you undergo flap reconstruction involving a skin graft.
If you are unsure about your breast reconstruction, a useful step is to begin consulting multiple plastic surgeons. Reputable practitioners will not coerce you into a decision that doesn't resonate with you.
Engaging with women who have undergone the same procedure, scrutinizing before & after images, and developing a pragmatic perspective on what is to come can also be beneficial.
Melon Hint: Strive to find a surgeon specializing in reconstruction. Ideally, a medical professional skilled in both autologous techniques and implant surgery ensures a comprehensive range of options. Considering the technical complexity and difficulty of reconstruction, it's recommended to seek a surgeon who performs a minimum of 50 such procedures annually.
How much does breast reconstructive surgery cost?
Average Cost: $15,200
Range: $6,000 - $19,150
The cost of reconstruction will be contingent on factors such as Medicare coverage, your private health insurance, the expertise of your surgeon, the types of reconstruction methods used, the location of the operating theatre, and whether you choose to include any supplementary procedures.
Does Medicare or private health insurance cover breast reconstruction?
Patients can choose either a public or private hospital for their reconstruction after a mastectomy, but bear in mind this choice may impact the financial implications and scheduling of your surgery.
If you elect to have the procedure as a public patient, Medicare will typically cover the majority, if not all, of the costs. All breast reconstruction claims undergo review by the Medicare Claims Review Panel, with decisions made on a case-by-case basis. It's worth noting that individuals might be expected to cover the cost of a permanent prosthesis.
Should you select a private hospital for your reconstruction, Medicare will still provide coverage for 75% of the procedure's scheduled fee. However, remember that many surgeons and anesthetists may charge fees exceeding the scheduled rate.
As a public patient in a public hospital:
- There are no costs involved as the procedure is classified as reconstructive rather than cosmetic
- You will not be able to select the surgeon performing your breast reconstruction
- Coordinating schedules for a breast surgeon (for a mastectomy) and a breast reconstruction surgeon for immediate reconstruction can be challenging
- Expect a waiting period that could extend from months to years
As a private patient in a public hospital:
- There are no charges for the hospital stay
- The choice of surgeon is up to you
- Additional surgeon fees may apply
- Anticipate a waiting time ranging from months to years
As a private patient with private health cover in a private hospital:
- You're free to choose your reconstruction surgeon
- Scheduling for immediate reconstruction with the breast surgeon and the reconstructive surgeon is achievable
- Waitlists from public hospitals won’t apply
- Your private health insurance will cover part of your expenses
- However, your private health insurance may not fully cover the cost; gap payments for the surgeon and anesthetist can range from $6,000 to $10,000
- Waiting periods and limitations may apply, depending on when you joined your private health fund
- Upfront payment may be required prior to surgery
As a private patient without private health insurance in a private hospital:
- The choice of surgeon is in your hands
- Arranging for immediate reconstruction with the breast and breast reconstruction surgeons is possible
- Waitlists from public hospitals won’t apply
- All hospital and gap costs for the surgeon and anesthetist will be your responsibility
- Upfront payment may be required prior to surgery
What are the risks and side effects of breast reconstructive surgery?
Certain risks associated with breast reconstruction surgery mirror those of many other surgical procedures, such as infection, suboptimal scarring, seroma, anesthesia complications, and bleeding. Although these potential complications are rare, your healthcare provider will discuss these concerns with you prior to your operation.
Additional risks with both implant and flap reconstruction are a loss of sensation in the nipples and breasts, as well as asymmetry. Some patients pursue corrective surgery to address these issues.
Medical professionals indicate that the overall probability of complications is greater with breast reconstruction compared to aesthetic breast surgeries. This is due to the fact that operations often last longer, require multiple surgeons, there is less healthy tissue present, and the patient may have a weakened immune system.
Patients also tend to be less satisfied with their outcomes, mainly due to the loss of natural, soft tissue, unilateral reconstruction, or radiation. Chemotherapy can also lead to a contraction of the breast tissue, making it harder to accommodate an implant.
Risks of implant-based reconstruction
- Misplacement of the implant
- A ruptured implant
- Visible implant folds or wrinkles
- Capsular contracture, a complication where the tissue capsule around the implant hardens
- Issues related to the dermal matrix or mesh
- Rare implant-associated cancers (BIA-ALCL and BIA-SCC) in the tissue around the implant
- Systemic symptoms linked to breast implant illness or BII, especially in patients with autoimmune disorders
- The requirement for additional surgeries to maintain or remove the implant.
Risks of autologous or flap reconstruction
To circumvent certain implant complications, your surgeon may suggest autologous reconstruction. Flaps come with added advantages, especially for women undergoing chemotherapy. Autologous reconstruction is recommended post-radiation because the fresh tissue brought to the treated area brings new, non-irradiated soft tissue, new blood supply, and potentially new healing capabilities to a radiated chest. It also prevents any risk of foreign implant scar tissue and post-radiation capsular contracture.
However, it should be noted that flap reconstruction still has its own potential complications, such as:
- Necrosis (tissue death) of all or part of a flap due to insufficient blood flow
- The requirement for future surgeries
- Loss of sensation at both the source site and the breasts
- Issues at the donor area, like reduced muscle strength
How soon after mastectomy can you do breast reconstruction?
Receiving a diagnosis of breast cancer or the BRCA gene can be an intimidating and nerve-wracking experience. Coupled with the burden of determining if, when, and what kind of reconstruction you want; it's understandable to feel completely swamped.
However, the reassuring news is there's no definitive timeframe by which you have to decide. Below are the most common scenarios concerning timelines for breast cancer reconstruction:
In immediate reconstruction, your oncology surgeon and reconstructive surgeon collaborate to perform the mastectomy/lumpectomy and then a reconstruction, in one single procedure.
Following the removal of the breast tissue, the reconstructive surgeon reshapes the breasts by introducing an implant, utilizing tissue from another body area, or applying a mixture of these methods.
The advantages of immediate reconstruction include not having to exist without breasts, potentially easing an already stressful time, and having only a single operation and recovery period. This approach eliminates multiple anesthesia injections and the need for multiple instances away from work.
Ideal candidates for this approach are individuals prophylactically removing their breasts following a BRCA diagnosis or those not requiring any post-operative chemotherapy treatment. Radiation can detrimentally affect breast implant surgery, increasing infection risk and the likelihood of capsular contracture, a potential complication associated with any implant surgery.
Delayed reconstruction can occur several months to years following a mastectomy or lumpectomy, once the body has completely healed. There is no specific deadline for choosing delayed reconstruction, even those initially deciding against reconstruction may later reconsider.
This alternative allows you more time to finalize your cancer treatments and fully heal, before making an informed decision about your reconstruction, all at your own pace. This can relieve both emotional and financial stress during a challenging period.
However, delaying reconstruction may result in suboptimal aesthetic outcomes due to the remaining skin tightening around the chest wall; ultimately making it harder to achieve the desired shape.
Although it may seem paradoxical, delayed-immediate reconstruction does make sense. This process usually involves placing a tissue expander, an inflatable apparatus to create room for a future implant or donor tissue.
The expander, similar to a balloon, is situated under the skin and gradually filled with saline, slowly stretching the skin. At the time of reconstruction, your expanders are removed, and your implants or tissue flaps are inserted.
Delayed-immediate reconstruction serves as an excellent choice for patients who are sure they want reconstruction but uncertain whether they'll choose implants, tissue flaps, or a blended approach. This method is also suitable for women needing chemotherapy, and therefore, cannot proceed with immediate reconstruction.
Advantages include the consistent presence of a breast area, and the expanders simplify the later reconstructive surgery by retaining a pocket for the breast.
The different types of breast recontructions
Breast reconstructions are completed using 2 main approaches, implant-based reconstruction and autologous or "flap" reconstruction.
The first method uses implants similar to those utilized in breast augmentation, while the second leverages your own body tissue, including skin, fat, blood vessels, and occasionally muscle from different body areas to remodel the breast. Sometimes, patients undergo a blend of the two procedures.
- It is more common for plastic surgeons to have experience performing implant breast reconstruction. Flap reconstruction demands specialized training in reconstructive microsurgery.
- Implant reconstruction is easier and less intricate. It can be completed far quicker than flap surgery, and recovery is considerably more manageable, with a shorter hospital stay (1 to 2 nights compared to 3 to 4) since only one body region has undergone surgery.
- Having a single incision area confines scars to the breast(s).
- Opting for implants enables you to choose your cup size and the amount of projection.
- Patients without sufficient fat or tissue elsewhere on their body are better suited for implant reconstruction.
Autologous Flap Reconstruction
- Surgeons can craft very natural-looking breasts using soft donor tissue from your stomach, back, thighs, or hips. As autologous reconstruction uses your own tissue, the breasts will grow and shrink as you gain or lose weight, just like natural breasts.
- Autologous surgery means steering clear of implants, which appeals to women who are uneasy with the concept of housing a foreign object or prosthesis in their chests, as well as those who would prefer not to deal with the risks, monitoring, and extra surgeries that accompany breast implants.
- After flap reconstruction, there's no requirement for additional surgery, barring optional second-stage procedures like fat transfer or scar revision.
- Some patients who have undergone a mastectomy may not have sufficient residual tissue to accommodate an implant, leaving autologous reconstruction as the only option.
- Flap surgery can be a safer choice for reconstruction patients who are due to undergo chemotherapy. Complications from implant surgery rise considerably if the patient has had or will need radiation treatment.
- Autologous procedures have witnessed a significant increase in surgical innovation in recent times and are gaining popularity, as a growing number of plastic surgery institutions provide microsurgical training.
The type of breast reconstruction that is most suitable for you will be made in consultation with your oncologist and plastic surgeon. Factors to consider include whether your mastectomy is therapeutic or prophylactic, your overall health and body shape, and the amount of tissue removed as part of treatment.
What happens during breast reconstruction with implants?
Implant Reconstruction Surgery
The procedure typically lasts between 2 to 4 hours.
- To ensure you experience no discomfort throughout the operation either local anesthesia with intravenous sedation or general anesthesia will be provided.
- For patients undergoing delayed implant-based breast reconstruction, tissue expanders are initially inserted to create space for the implants. Several appointments, spread across 1-2 months post-expander placement, are generally required to slowly inflate the device with saline through an inbuilt valve for skin expansion. More recent air-filled devices might enable at-home expansion controlled by the patient using a remote dosage controller. A subsequent operation is then necessary to swap the expanders with implants.
- During the implant reconstruction process, a plastic surgeon will position the breast implant either above the chest muscle (prepectoral) or beneath the muscle (submuscular). The implant is typically inserted using the mastectomy incision.
- A mesh-like material, derived from purified donor tissue or a dissolvable surgical mesh, may be employed to strengthen your breast tissues and to envelop and/or secure the implant.
- Drains may be installed to prevent fluid build-up and reduce complications during the recovery phase.
- Incisions are sealed with stitches and covered with bandages.
Implant Reconstruction Recovery
Recoveries from implant reconstructions are generally quicker than flap surgeries. Most patients spend at least one night in the hospital. After this, you will be at home, moving about, preparing your meals, and managing to shower independently.
If your implants were inserted above the muscle, your recovery should be smoother compared to when they are positioned beneath the muscle, as the pectoralis isn't disturbed or cut.
Stitches are typically taken out after one week. If you have drains, expect them to be removed within 1 to 3 weeks.
Doctors suggest setting up assistance with grocery shopping and household chores for the initial 2 weeks. By the end of the 4th week, you should be capable of returning to the majority of your routine activities, and you'll likely feel almost completely normal between 6 to 8 weeks. However, you may still experience occasional twinges as the severed nerves regenerate.
What happens during autologous or flap breast reconstruction surgery?
There are various flap reconstruction methods, primarily differentiated by the donor tissue area (usually the stomach) and whether the flap retains its original blood supply (pedicle) or is disconnected and reattached to a blood source at its new location.
Here are some of the most commonly used flap techniques:
- TRAM (transverse rectus abdominis muscle) flap takes tissue from the lower belly. It usually takes a part of the rectus muscle, which can potentially lead to ab weakness.
- DIEP (deep inferior epigastric perforator) flap gathers skin and fat from the bottom of the tummy while leaving the ab muscles and fascia undisturbed.
- Latissimus dorsi flap utilizes skin and fat from the upper back muscle area.
- SGAP (superior gluteal artery perforator) flap, also known as the gluteal free flap, takes tissue from the butt or hips.
- TUG (transverse upper gracilis) flap utilises tissue from the thighs.
Autologous or Flap Reconstructive Surgery
- Once the anesthesia has taken effect, an incision at the donor area is made, and the requisite tissue is extracted.
- Depending on the flap procedure, the tissue could be left attached and maneuvered via a connecting passageway of adjacent tissue to the chest wall. Alternatively, it may be detached from its initial blood source and placed on the chest where it will be connected to blood vessels.
- To enhance volume and shape, a breast implant may be inserted behind the flap. This could happen simultaneously during the flap reconstruction or be postponed by a few months. This is a desirable approach for patients needing a flap, but desiring a fuller reconstruction or greater size than the donor tissue can provide. Research indicates that there are fewer issues when implant placement is delayed rather than occurring during flap reconstruction.
- To prevent fluid accumulation during recovery, surgical drains may be used.
- Finally, the tissue donation and reception areas are stitched up secured with bandages.
Autologous or Flap Reconstructive Recovery
Recovery from autologous reconstruction is typically more difficult than implant surgery. The recovery period for combined flap and implant surgery is similar to just flap surgery.
Flap procedures can take anywhere from 3 to 6 hours, and usually necessitate a few days in the hospital during which the blood flow to the new flap is carefully supervised. During recovery, you will experience discomfort from two areas: the newly reconstructed breast and the area from where the tissue was taken. You should anticipate needing assistance with daily chores for the initial weeks, with full recovery expected by the 8th week.
The timeline for the removal of sutures and surgical drains depends on your surgeon's specific schedule, but it's typically within 7 to 10 days.
Can I get a fat transfer breast reconstruction?
Fat grafting, also known as fat transfer, is another alternative for breast reconstruction. However, its reliability can be inconsistent with less than half of the grafted fat becoming permanent. As a standalone procedure, it is seldom the best option for reconstruction after a mastectomy, as it is impractical to reconstruct an entire breast using only fat.
Nevertheless, fat grafting can be a great solution for reconstruction after a lumpectomy, particularly to rectify a dent. It is frequently used by surgeons to enhance both implant and flap reconstructions, perfecting curves and providing additional volume to areas that need it after the initial recovery.
Interestingly, the stem cells present in the transferred fat can sometimes contribute to rejuvenating the breast tissue.
When fat grafting is used in combination with flaps or implants, the procedure is often referred to as a 'hybrid' or 'composite' breast reconstruction. These terms can also denote the pairing of autologous flap reconstruction with implants, so it's essential to seek clarification from your doctor when describing 'hybrid' options.
What happens during nipple reconstruction?
Contemporary medical consensus generally agrees that if the cancer hasn't affected the nipple, there's no inherent risk in preserving it. When feasible, the oncological surgeon carrying out the mastectomy should aim to keep the nipple intact via a nipple-sparing mastectomy. This procedure involves the complete removal of the underlying breast tissue, while keeping the overlying skin and nipple, enabling the reconstructive surgeon to restore the breast shape while keeping the patient's original nipple. This results in a more natural-looking breast, without jeopardizing the efficacy of the cancer treatment.
In instances where the nipple cannot be preserved, nipple reconstruction surgery is a possible alternative. This is typically performed once the reconstructed breast has healed, generally 3 to 4 months post-initial reconstructive surgery. The surgeon uses skin flaps, either from the breast or another part of the body (like the stomach), raises the tissue, and then transforms it to imitate a natural nipple.
While this method does not retain nipple sensation, the aesthetic result can be strikingly natural. Following healing, the new nipple and areola colour are tattooed onto the breast, either by a plastic surgeon or a skilled tattoo artist.
3D nipple tattooing, which creates a three-dimensional effect without actual nipple reconstruction, is another increasingly popular option offered by tattoo artists.
Melon Hint: Regardless of whether nipples are saved or reconstructed, the loss of sensation across the breasts can be a distressing consequence of surgery. Some plastic surgeons now offer a technique called resensation with breast reconstruction. This procedure utilizes allograft nerve tissue to repair severed nerves, which allows nerve fibres to regenerate over time, ultimately restoring feeling.
When can you expect to see your breast reconstruction results?
Irrespective of the kind of breast reconstruction you undergo, it generally takes around 3 months for the swelling to subside enough, allowing you to get a first look, and up to 1 year for your full breast reconstruction results.
You will notice some instant results from breast implants, but even these require time to completely settle into position, in a process commonly referred to as 'drop and fluff.'
Flap reconstruction, involving larger incisions, typically results in more swelling, which can obscure results until the healing process is completed.
Sources & Studies
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Cancer Australia 2020, Comparison of public versus private breast reconstruction surgery | Cancer Australia, Canceraustralia.gov.au, viewed 24 July 2023, <https://www.canceraustralia.gov.au/cancer-types/breast-cancer/treatment/comparison-public-versus-private-breast-reconstruction-surgery>.
Choi, M, Small, K, Levovitz, C, Lee, C, Fadl, A & Karp, NS 2013, ‘The volumetric analysis of fat graft survival in breast reconstruction’, Plastic and Reconstructive Surgery, vol. 131, no. 2, pp. 185–191, viewed 24 July 2023, <https://journals.lww.com/plasreconsurg/Abstract/2013/02000/The_Volumetric_Analysis_of_Fat_Graft_Survival_in.1.aspx>.
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Spear, SL & Arias, J 1995, ‘Long-Term Experience with Nipple-Areola Tattooing’, Annals of Plastic Surgery, vol. 35, no. 3, pp. 232–236, viewed 24 July 2023, <https://journals.lww.com/annalsplasticsurgery/Abstract/1995/09000/Long_Term_Experience_with_Nipple_Areola_Tattooing.2.aspx>.