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Surgery & recovery
Reconstruction
Rebuilding the shape of a breast after a mastectomy is a choice, not an obligation. It can happen during the cancer operation or years later. Some people want it, some people are certain they do not, and plenty of people are undecided for a while. All three are normal.
Two ways to rebuild: implants and flaps
Implants
uses a silicone or saline device to recreate the shape of the breast. It is often done in two stages. A goes in first and is filled gradually over several office visits to stretch the skin, then it is swapped for the permanent implant in a second, smaller operation. Sometimes the implant can go straight in at the time of the mastectomy.
Flaps
builds the breast from your own skin, fat, and sometimes muscle, taken from somewhere else on your body. The lower abdomen is the most common source. The back and the thighs are also used.
The result is your own warm, soft tissue, which changes with your weight and ages as you do. The trade is a much longer operation, a longer recovery, and a second surgical site where the tissue was taken from.
Implants and flaps compared
| Implant | Flap | |
|---|---|---|
| Length of operation | Shorter | Considerably longer |
| Recovery | Shorter | Longer, and there are two areas healing |
| Second scar | No | Yes, where the tissue came from |
| How it feels | Firmer. It does not change with weight. | Softer and warmer. Changes with weight, ages with you. |
| Over a lifetime | An implant is a device. It may need replacing or revising. | Once healed, usually stays as it is. |
| Main risks | Infection, the implant needing removal, scar tissue tightening around it, rupture | Infection, poor blood supply to the transferred tissue, partial or complete loss of the flap, weakness or bulging at the donor site |
| With radiation | More prone to problems | Generally tolerates it better |
An implant is the faster road with more maintenance later. A flap is the harder road with less maintenance later. Neither is the correct answer, and body shape, health, smoking history, previous abdominal surgery, and whether radiation is planned all narrow the choice before preference gets a say.
Immediate or delayed reconstruction
Immediate means reconstruction is started during the same operation as the mastectomy. One anesthetic, one recovery, and you do not wake up with a completely flat chest, which matters to many people. It also makes and techniques worth doing, because the skin envelope is being kept for a purpose.
Delayed means it happens later, sometimes years later. That gives you time to finish cancer treatment, time to see how you feel about your chest as it is, and time to decide without a deadline attached to it.
Neither delays cancer treatment and neither affects your chance of the cancer coming back. You are allowed to take the time.
Reconstruction if you are having radiation
Radiation after a mastectomy changes this conversation. Radiated skin heals differently and holds an implant less reliably, and radiation delivered to a completed reconstruction can change its shape and firmness.
There are ways around this, including placing a tissue expander first and doing the definitive reconstruction after radiation is finished, or choosing a flap. What matters is that the plastic surgeon and the radiation oncologist talk to each other before the mastectomy, not after. If you are considering reconstruction, ask for that conversation to happen early.
Choosing not to reconstruct
Plenty of people decide against reconstruction, and it is a real choice rather than a failure to make one. Reasons include not wanting another operation, not wanting an implant, wanting to be finished with surgery, and simply not feeling that it matters to them.
If that is your decision, ask your surgeon specifically about an aesthetic flat closure. That means the chest is deliberately closed smooth and flat, with excess skin and any dog-ears trimmed, rather than simply sewn shut with the assumption that something will be built there later. It is a technique, it takes intention, and it is worth asking for by name.
You can also change your mind afterward. Deciding not to reconstruct now does not close the door.
Breast prostheses
A breast prosthesis, or breast form, sits in a pocket in a special bra or attaches to the chest. It is another way to restore your outline, without surgery, and you can wear one some days and not others.
A proper fitting makes an enormous difference to comfort and to how it looks under clothes, so use a fitter rather than guessing. The American Cancer Society TLC catalog carries mastectomy products, and there are more places listed on the support page.
What insurance must cover for reconstruction
Under the Women’s Health and Cancer Rights Act of 1998, a group health plan that covers mastectomy must also cover:
- All stages of reconstruction of the breast that had the mastectomy
- Surgery and reconstruction of the other breast to produce a symmetrical appearance
- Breast prostheses
- Treatment of physical complications of the mastectomy, including lymphedema
Normal deductibles and coinsurance still apply. If a plan tells you that surgery on the unaffected breast for symmetry is cosmetic and not covered, that is worth challenging. The US Department of Labor publishes a fact sheet you can print and take with you.
Questions for the plastic surgeon
- Given my body, my health, and my treatment plan, which options are actually open to me?
- Am I likely to need radiation, and how does that change what you would recommend?
- How many operations will this take from start to finish, and over what period?
- What will recovery look like week by week, and when could I go back to work?
- What are the most common complications in your hands, and how often do they happen?
- If I choose an implant, what is realistic about how long it lasts?
- If I choose a flap, what will the donor site look like and how will it feel?
- Can I see photographs of results from your own patients, including ones that did not go perfectly?
- What would an aesthetic flat closure look like for me, if I chose that instead?
- What will my share of the cost be?
Where this comes from
- Susan G. Komen, Breast Cancer Surgery patient fact sheet, supplied by Dr. Perkins’ office. komen.org
- American Cancer Society, Women’s Health and Cancer Rights Act
- US Department of Labor fact sheet on the Women’s Health and Cancer Rights Act
- American Society of Plastic Surgeons, listed on the resource sheet Dr. Perkins’ patients receive, 1-847-228-9900
Reconstruction decisions depend heavily on your own anatomy and your own treatment plan. Nothing here replaces a consultation with a plastic surgeon who has examined you.