This page was reviewed under our medical and editorial policy by
Daniel Liu, MD, Plastic and Reconstructive Surgeon
This page was reviewed on February 18, 2022.
The decision to undergo breast reconstruction after a mastectomy is a personal one. Not all women are candidates for breast reconstructive surgery, and some choose not to pursue this option. For many women, however, restoring the appearance of one or both breasts may help improve their physical, emotional and social well-being.
It is important to recognize that breast reconstructive surgery is an elective process tailored to each patient’s needs and goals. While breast reconstruction in a single operation is possible for some women, the majority of women will require more than one procedure, typically over several months.
Patients may have many breast implant options, and each technique has a unique set of considerations. Recommendations are based on many factors, including the patient’s overall health status, breast size and shape (both natural and desired), as well as the specifics of her cancer, such as its type, size and location within the breast.
In most cases, the reconstructive process may begin at the time of mastectomy—a technique known as immediate reconstruction. However, the surgeon may not recommend immediate reconstruction for a number of reasons, such as when the patient is using nicotine products, has an advanced tumor or is morbidly obese. In these cases, or for any woman who has already had a mastectomy without reconstruction, delayed breast reconstruction is often a viable option.
This article will cover:
The process of total breast reconstruction depends heavily on the type of mastectomy performed, as well as the additional therapies used to treat the cancer, such as chemotherapy and/or radiation therapy. The process may be different for women who choose to remove both breasts (bilateral mastectomy), compared to those who have just the affected breast removed (unilateral mastectomy).
During reconstruction, the surgeon creates a mound and a skin envelope to resemble a natural breast. This may require a staged approach involving two or three procedures. In most cases, the skin required for reconstruction is preserved at the time of mastectomy, and in many cases, the nipple and areola may also be preserved. Both the breast surgeon and reconstructive surgeon will evaluate and discuss each patient’s breast reconstruction options.
Breast reconstruction is divided into two general categories: implant-based reconstruction and autologous reconstruction, which uses the patient’s own tissue.
Breast reconstruction may be performed at the same time as a mastectomy, or it may be delayed for some time. When the procedure is done simultaneously with a mastectomy, it’s called immediate breast reconstruction. Breast reconstruction performed after a mastectomy or after treatment ends is called delayed breast reconstruction.
Most breast cancer patients who undergo a mastectomy may choose between immediate or delayed breast reconstruction.
Having immediate reconstruction may be preferable because it allows for two surgeries to be completed at once. Immediate reconstruction may also render more natural-looking results, as the skin of the breast may be more easily preserved. Those who are concerned about living for some time without breasts may also prefer this option.
However, delayed reconstruction may be the preferred option for patients who want to focus on treatment or need more time to decide. It may also be the safest option for some, particularly those who:
Such health conditions or treatments may delay or complicate the healing process. When the breast tissue doesn’t heal properly after reconstruction, recovery time may be longer, and scarring and infections may occur. Complications related to improper wound healing may require additional surgery.
People who smoke are often advised to delay breast reconstruction until they have abstained from smoking for at least two months. Likewise, those who require radiation therapy after surgery usually need to delay breast reconstruction, as radiation therapy increases the chances of scarring, improper healing and infections.
While delayed reconstruction may be the right option for some, the appearance of the reconstructed breast may not be as natural-looking afterward, as it would be following immediate reconstruction. When reconstruction is delayed, skin from another area of the body may be needed to cover the new breast, as less of the original skin may be preserved.
It’s important for patients interested in breast reconstruction to discuss all options with their care team before having a mastectomy. Doctors can explain the potential risks and develop a plan that minimizes the risk of complications and is best suited to the patient’s wishes.Patients shouldn’t hesitate to ask questions about breast reconstruction, including:
This technique uses a silicone gel implant to create the breast mound. Saline implants may be an option, but they are not typically recommended, mostly because the newer generation of silicone gel implants offers a more natural look and feel. Multiple implant options are available to provide volume, shape and projection, allowing each patient to choose an option tailored specifically to her.
The surgeon may place the silicone gel implant at the time of the mastectomy in a process called direct-to-implant reconstruction. However, the process is typically completed in two operations, known as two-stage implant-based reconstruction. In the first stage, the surgeon places a temporary tissue expander after the breast tissue is removed, then gradually fills the expander over time to stretch or shape the skin envelope. In the second stage, the surgeon removes the tissue expander and inserts the more natural silicone gel implant into the skin envelope.
Traditional implant-based reconstruction involved placing the devices completely or partially beneath the chest muscle, in a process known as subpectoral reconstruction. In the majority of today’s cases, this is no longer necessary. Instead, a prepectoral reconstruction technique is used, leaving the muscles attached to the chest wall and placing the implant above them, similar to a natural breast. This procedure often reduces post-operative pain and recovery time, in addition to providing better aesthetic results.
Surgeons do not typically recommend implant-based reconstruction for women who have had, or who will require, radiation therapy as part of their treatment. Implant-based reconstruction operations do not take as long as autologous procedures, and recovery often takes two to three weeks. Implants come with a unique set of considerations and possible risks, and our reconstructive surgeons discuss these with each patient. Our surgeons also discuss how acellular dermal matrix, a biologic mesh often used to hold or support the implants, may play a role in the reconstruction.
Compared to implant-based reconstruction, autologous procedures typically require more time and a longer recovery period. However, because they take advantage of the patient’s own tissue, these techniques may yield more natural and longer-lasting results.
In these procedures, fat and skin may be transplanted from various areas of the patient’s body to create the reconstructed breast, with the area and method chosen depending on the amount and quality of tissue available. The tissue (called a flap) may be removed from the lower abdomen, back, buttock or inner thigh—areas generally referred to as donor sites.
Reconstructive microsurgical techniques are often used to improve the outcomes of autologous reconstruction procedures, creating natural-looking breasts while reducing damage to donor sites. Specially trained microsurgeons use these techniques to remove skin and fat, along with their blood supply (called a free flap), from the donor site. The surgeon then transplants the tissue to the chest, where it is connected to nearby blood vessels and shaped into a breast. This free flap process allows the surgeon flexibility in shaping the breast, and using the primary blood supply aids in the healing process. The procedure is also designed to decrease recovery time compared to other techniques that may cause more damage to the donor site.
Autologous breast reconstruction procedures include:
Deep inferior epigastric artery perforator (DIEP) flap: This reconstructive microsurgical procedure uses skin and fat of the lower abdomen, with its primary blood supply carefully removed from the rectus muscle beneath. Skin and fat may be taken from both sides of the lower abdomen to create two breasts if necessary or desired. The DIEP flap procedure has become the standard of care for autologous breast reconstruction using abdominal tissue, compared to the outdated TRAM flap procedure, which involves completely removing a muscle from the abdomen and inserting mesh. Some muscle weakness may result from DIEP flap reconstruction, but this side effect is uncommon.
“Stacked” DIEP flap reconstruction: In this procedure, reconstructive microsurgery techniques are used to transfer both sides of the lower abdomen to create a single breast, allowing women with limited donor tissue to take advantage of autologous reconstruction.
Superficial inferior epigastric artery (SIEA) flap: In this procedure, a free flap of skin and fat is harvested from the lower abdomen, but a different blood supply is used. This blood vessel is completely above the muscle and does not require manipulation of the muscle. Not all women have this blood supply; in many other cases, the blood supply is not sufficient. Because of the anatomy of this blood supply, many women who undergo reconstruction with a SIEA flap experience less post-operative pain than with a DIEP flap, without any risk of muscle weakness.
Medial thigh-based flaps (TUG, VUG, DUG, PAP): These procedures use the skin and fat from the inner thigh, along with blood vessels that may be removed from the muscles. In some cases, a small muscle from the inner thigh (the gracilis) may be removed with little to no impact on the leg’s muscle function. These procedures may be beneficial for women who are not candidates for the DIEP or SIEA flap.
Buttock-based flaps (SGAP and IGAP): These procedures use the skin and fat from either the upper or lower portion of the buttock, along with blood vessels that may be removed from the gluteal muscles. These techniques may also benefit women who are not candidates for the DIEP or SIEA flap.
Thoracodorsal artery perforator (TAP) flap: This procedure uses skin and fat from the upper back and a small portion of the latissimus dorsi muscle. The technique is not a free flap procedure and is usually used to reconstruct defects caused by a partial mastectomy. It also may be used in combination with an implant for total breast reconstruction, particularly for women who may not be candidates for any of the above-mentioned flaps.
Latissimus dorsi (LD) flap: The LD flap is similar to the TAP flap, in that it involves taking muscle, skin and fat from the upper back. One of the main differences is the LD flap transfers more muscle than the TAP flap.
Your doctors may also recommend that some patients undergo additional techniques and procedures to complete the breast reconstruction process, including:
Symmetry procedures on the unaffected breast: Breast reconstruction is designed to create a breast with a more lifted, rejuvenated appearance. For women who undergo a unilateral mastectomy and reconstruction, standard procedures may be performed on the unaffected breast to improve symmetry. These may include a breast reduction, breast lift or breast augmentation. Discuss available options with your surgeon during an initial consultation.
Autologous fat grafting: This technique uses liposuction to carefully remove fat from one area of the body, then transfers it to the reconstructed breast, allowing the surgeon to fine-tune the breast’s volume and shape. Fat is a rich source of stem cells, which are critical to healing. In addition to improving breast shape and volume, transferring fat may help stimulate the formation of new blood vessels and improve skin texture.
Nipple reconstruction: For women who are not candidates for a nipple-preserving mastectomy, traditional nipple reconstruction may be performed using the skin of the reconstructed breast to create small flaps, which are shaped to resemble a nipple that projects from the breast. Once the nipple heals, tattooing may be used to create a more natural pigmentation.
3-D nipple tattoo: Instead of using tissue to build a nipple that projects from the reconstructed breast, some women choose to have a more detailed tattoo applied, using shading to create the illusion of a three-dimensional structure.