Types of breast reconstruction

There are different types of breast reconstruction. Your surgeon and breast cancer nurse will talk you through the different options available to you. They can help you choose the best option for you.

The main types of breast reconstruction are:

• implants to replace all or some of your breast tissue
• having a breast shape made from your own body tissue 
• a combination of an implant and your own body tissue

How to choose

Your surgeon might offer you a choice between different types of reconstruction. There are benefits and drawbacks to all types. You can talk about these with your breast surgeon, plastic surgeon, or your breast care nurse.

There might be good reasons why one type of reconstruction is much better for you than another. But to help you decide, we’ve listed some of the main points here.

Implant breast reconstruction

This operation means that you have a silicone gel or salt water filled silicone balloon to recreate a breast shape after removal of a breast.

Advantages

• Reconstruction with an implant is simpler than other types of reconstruction.
• It causes less scarring because tissue isn't normally taken from other areas of the body.
• It gives a reasonable shape for small or medium sized breasts.
• The reconstructed breast doesn't change in size if you gain or lose weight.

Disadvantages 

• The implant is a foreign body so you are more likely to have long term problems compared to other types of reconstruction using your own tissue.
• The implant feels less natural, colder and less mobile than a body tissue reconstruction.
• You are more likely to have problems if you have had radiotherapy or are going to have it afterwards.
• This might not be possible if you have had radiotherapy or your chest wall skin isn't healthy.
• You might need two operations: one to stretch the skin (using a tissue expander), and the other to put a silicone implant in.
• You may notice wrinkling under the skin.
• There is a risk that the silicone implant could leak or break (rupture). If this happens you would need further surgery to remove and replace the implant.
• Over time the capsule of the implant can shrink and become hard. This can cause your breast to be painful, harden and the shape may change. This is known as capsular contracture and usually needs surgery.
• A small risk of developing a rare type of cancer called breast implant associated anaplastic large cell lymphoma (BIA-ALCL)

The implant tends to rise up and get tighter after some time, so the breasts may be out of alignment. An implant reconstruction is more likely to need further surgery than after body tissue reconstruction.

Body tissue (autologous) reconstruction surgery

Autologous reconstruction means using your own body tissue to create a breast shape. With this operation, your surgeon takes skin, fat, and sometimes muscle (a flap) from another part of your body and makes it into a breast shape. 

Advantages

• Body tissue reconstruction can usually be done in one or two operations, but you may need minor adjustments to the new or opposite breast.
• The reconstructed breast is warm and gives a more natural shape and feel compared to an implant (thought it will still probably feel different to your other breast).
• Women with small or large breasts can have this type of surgery.

Disadvantages

• It is a much bigger and longer operation than implant reconstruction.
• The operation leaves you with two wound sites and two sets of scars.
• There is the risk of arm weakness if you have tissue taken from your back (latissimus dorsi reconstruction).
• There is a risk of tummy weakness if you have tissue taken from your tummy (TRAM or DIEP flap).

The reconstructed breast tends to match the other breast well at first but may droop after some time. So then the breasts may be out of alignment.

Body tissue reconstruction with back tissue (latissimus dorsi or LD flap)

The latissimus dorsi is a muscle in your back, under your shoulder blade. Your surgeon uses the muscle, and the skin and fat covering it, to make a new breast.

This type of reconstruction is a slightly simpler operation than an abdominal flap (TRAM or DIEP flaps) and so recovery may be quicker and easier. Unlike the most common type of abdominal flap (a DIEP flap), this reconstruction keeps its original blood supply. So there is less chance of complications following surgery.

Some women with larger breasts may also need to have an implant alongside the tissue reconstruction.

The skin from your back is thicker and paler, so it is worth being aware that the patch of skin on your reconstructed breast might look a bit different to the rest of your chest.

Body tissue reconstruction with abdominal tissue (TRAM or DIEP flap)

The rectus abdominis muscle is in your abdomen and runs from your breastbone to your pubic bone. For a TRAM flap reconstruction, the surgeon takes part of this muscle, with its skin, fat, and blood vessels. They move it to your chest wall to make a new breast.

This type of reconstruction will give you a flatter tummy and the reconstruction will lose or gain weight as you do. But this operation may not be possible if you are very slim and don’t have enough tummy tissue. Also, it may not be the right reconstruction for you if you already have surgical scars on your tummy. 

Having this surgery can increase the risk of hernias in the future (weakening of the abdominal wall). A hernia can be repaired with a fairly simple operation if this happens to you.

A DIEP flap is very similar to the TRAM flap reconstruction. The surgeon only takes skin and fat from the abdomen to make the breast shape. They separate the flap from the abdomen. The blood vessels of the flap are reconnected to bigger blood vessels near the chest wall to keep the flap alive. The DIEP flap is also called a free flap.

Recreating a nipple and areola

The nipple is the centre of the breast and the darker area of skin around it called the areola. This is also known as the nipple areola complex (NAC).

Breast reconstruction methods create a smooth breast shape without a nipple or areola. For most people the breast reconstruction doesn’t feel complete until there is a nipple and areola. 

Some people choose not to have anything and are happy with the breast reconstruction and this is okay too. Your surgeon and breast care nurse will talk to you about your options and how what is right for you.

The options for reconstruction are:

• having a tattoo (also known as micropigmentation) 
• having the nipple and areola made from your own body tissue
• using a stick on nipple and areola

All the options create the appearance of a nipple and areola. But the new nipple won’t have any feeling and won’t stand up when cold or touched as a real one would.

Sometimes the real nipple and skin from the breast are not removed during mastectomy. This is called a nipple sparing mastectomy. The sensation in the nipple is usually different after the operation.

Nipple reconstruction options

Nipple and areola tattoo 

You can have a nipple and areola tattooed onto the reconstructed breast. 

The tattoo is flat and doesn't give you the shape of a nipple. But a skilled plastic surgeon or medical tattoo professional can use colour in shades that make the tattoo look 3-dimensional.

You might need to make several visits so the colouring of the nipple and areola match as close as possible. Also in the future you may have to return if the colour fades.

Nipple and areola made from your own body tissue 

A surgeon can make a nipple and areola from your own body tissue. You can usually have this done from a few months after your breast reconstruction surgery. The reason for the wait is to make sure everything has settled down. If you have it done too early, the new nipple and areola might not end up in the right place.  

There are a few ways for the surgeon to create a nipple shape from body tissue. These methods of creating a nipple are minor surgery. You usually go home the same day.  

One way is where the surgeon gathers up some tissue from the centre of the reconstructed breast and makes it into a nipple shape. About 4 to 6 weeks later, you can have the nipple and the area around it (the areola) tattooed to match your other nipple.

Some nipples made like this gradually flatten and shrink until they are almost gone. You can have the surgery again but unfortunately the nipple might flatten and shrink again after a while.

Another less common way of recreating the nipple is removing darker skin from another area of the body. This might be from the inner thigh, armpit or labia (lips of the vulva ).

Another way is for women with large nipples. This technique is not used very often. Your surgeon can take tissue from the normal nipple and stitch it onto the reconstructed breast. This gives the most realistic appearance. But the new nipple doesn't flatten and both nipples are smaller than before.

The sensation in the normal nipple is usually unaffected.

Stick on nipple and areloa

You can get stick on nipple and areola if you don't want to have surgery or a tattoo. You can get them ready made that you can buy. Or you might have one made specifically for you.

If you are having a nipple areola complex made you first have a mould made from the nipple on your other breast. A technician fills the mould with silicone to make a stick on nipple that closely matches your natural one. If you are having a mastectomy to both breasts then the mould of the nipple is usually taken before you have surgery.

You stick the nipple and areola on every day. It’s easy to take off for washing, and the glue you use is good enough to keep it in the right place all day.

There are advantages to the silicone nipple. It is very realistic and closely matches your real one. And you don’t need any more operations. The disadvantages are that you have to put it on every day and it might not stay put. The glue can be a bit sticky and messy.

Surgery to your other breast

Some people have surgery to their opposite unaffected breast. This is called contralateral breast surgery.

Your surgeon aims to make your new breast matches your other breast as closely as possible. But this might not be possible unless you have surgery to the other breast.

Some women having reconstruction need surgery to their opposite breast to do one of the following things:

• make it bigger to match the new breast
• make it smaller to match the new breast
• tighten it up so it doesn’t droop more than the new breast

The after effects of each operation are different. So you will need to ask your own surgeon how your operation will affect you.

Making the breast bigger

To make your other breast bigger, the surgeon will put in an implant. You have a scar that is hidden. This is usually in the skin fold under the breast.

Making the breast smaller or less droopy

After surgery to make the breast smaller or less droopy, you have scars on the breast. The position of the scars varies, depending on the technique your surgeon uses.

You might have a scar around the areola, a scar in the skin fold beneath the breast, and a vertical scar joining the two.

Choosing to go flat after a mastectomy

Women decide to do this for various reasons. Your surgeon and breast care nurse will talk to you about all your options. They will explain the pros and cons to help you make the right decision for you. You may need time to make your decision. Talking to family and friends about how you feel can help.