What is breast reconstruction?

Breast reconstruction is surgery to make a new breast after removal of the breast or part of the breast. The aim is to make a breast of similar size and shape to your original breast. But they won't be identical.

Some people choose not to have breast reconstruction. Your surgeon and breast care nurse will talk to you about all your options. They will explain the advantages and disadvantages to help you make the right decision for you. 

Types of reconstruction

The main ways of making a new breast include:

• implants to replace all or some of your breast tissue
• using tissue taken from another part of your body (autologous or "flap" reconstruction)
• or a combination of both 

The tissue your surgeon might use includes skin, fat or muscle. Or you might have a combination of these. 

Your surgeon will talk to you about the different types of reconstruction that are suitable for you. They aim to match your other breast as much as possible. 

Your surgeon can show you pictures of different types of breast reconstruction. You can see how the reconstruction looks straight after surgery and several months later.

After reconstruction surgery you might consider more surgery to:

• create a new nipple (a nipple reconstruction)
• change the shape of your other breast to match

When to have breast reconstruction

Breast reconstruction can be done:

• at the same time as the cancer surgery (immediate reconstruction)
• after your cancer surgery (delayed reconstruction) 

When discussing reconstruction options with you, doctors will consider:

• the type and stage of your cancer 
• other treatments that you might need 
• your feelings and preferences

Immediate breast reconstruction

An immediate reconstruction gives you a new breast straight away. Surgeons try to match the reconstructed breast to your other breast, but it will not be exactly the same.

The new breast will feel and look different from the one removed. But some women find that immediate reconstruction helps them to cope more easily with their feelings about the loss of a breast.

Advantages of immediate breast reconstruction

• You will have your new reconstructed breast when you wake up after your mastectomy or breast conserving surgery.
• You usually have fewer operations, so fewer anaesthetics.
• Your finished breast might look better because the surgeon is usually able to use the breast skin already there.
• You will have less scarring on the reconstructed breast itself – you might have a small patch of skin where your nipple was, with a scar around it. But sometimes the surgeon may not need to remove the nipple.

Disadvantages of immediate breast reconstruction

• You might not have as much time to decide on the type of reconstruction you want.
• If you are having radiotherapy after surgery, it might change how the reconstruction looks. 
• Your doctor might advise you not to have implant reconstruction if you are having radiotherapy afterwards. In this case you may have two operations: one to stretch the skin (using a tissue expander), and the other after radiotherapy to exchange the tissue expander with a silicone implant.   
• Recovery time after surgery is longer with a reconstruction compared to having a mastectomy only.
• You may have more scars on your body, this depends on the type of reconstruction you have.
• It is likely you will need more surgery, this is usually minor surgery to get the best cosmetic effect, and can include creating a new nipple.  
• If you have complications after surgery, it might delay any further treatment you need such as chemotherapy or radiotherapy.

Chemotherapy, radiotherapy and targeted cancer drugs can sometimes stop the body from being able to heal itself so well. So if you have any problems with the wound after your surgery, you won’t be able to start these treatments until the wounds have healed. Radiotherapy, chemotherapy or targeted cancer drugs at this time would stop the wound healing and you could get a serious infection.

The timing of chemotherapy is important. There is good research evidence that chemotherapy works best if you start it within 6 weeks of your cancer surgery. That might not be possible if things don’t go according to plan with the reconstruction.

Delayed breast reconstruction

Some people prefer to get over the mastectomy and breast cancer treatment before they think about having a reconstruction.

Advantages of delayed breast reconstruction

• You have more time to look at your options and discuss them with a specialist surgeon.
• Your breast cancer treatment will be finished and won’t be affected by your reconstruction surgery.
• Your recovery is generally quicker as you have time to prepare yourself for your surgery.

Disadvantages of delayed breast reconstruction

• You have a time after the mastectomy with no breast tissue, you can choose to wear a false breast (prosthesis) if you want to.
• You might have a larger scar on the reconstructed breast than after immediate reconstruction.
• You may need more surgery afterwards to get a good cosmetic effect. This is usually minor surgery that you may have as a day case.

Who can have breast reconstruction

Breast reconstruction might be possible for you even if you have:

• a radical mastectomy (removal of the breast and the muscle behind it)
• radiotherapy
• large breasts 

If you are well enough you can have breast reconstruction at any age. There is a higher risk of complications if you smoke, are very overweight, or have other serious medical conditions.

Your surgeon might be able to improve the appearance of the chest with more surgery after mastectomy.

For men, the implants currently available don't recreate the correct shape of a man’s breast. In the NHS breast reconstruction with implants for men isn’t done routinely.

Reconstruction after breast conserving surgery

Breast conserving surgery removes only part of the breast. The appearance of the breast is usually very good after this type of surgery followed by radiotherapy.

Few women need reconstructive surgery when only part of their breast is removed. But some women may need reconstruction of the remaining breast tissue. It may be possible to have a partial reconstruction or breast re-shaping.

Having a partial reconstruction

The amount of breast tissue taken when having a lumpectomy varies from person to person. If you have a large amount of breast tissue taken you may be left with a dent in the breast. This means the treated breast ends up looking much smaller than the other breast. But it is sometimes possible to get back the shape. Your surgeon may suggest a partial reconstruction of the breast. They fill the dent with a small area of living tissue. 

Some surgeons use tissue from your back to fill in the dent. This is called a latissimus dorsi flap (Mini LD flap). But this happens less often now.

There are now other ways to do this such as by using spare tissue from under your armpit, upper back or around the breast. This is known as partial reconstruction using tissue from different blood vessels in the chest. These are called:

• lateral intercostal artery perforator flap (LICAP)
• anterior intercostal artery perforator flap (AICAP)
• medial intercostal artery perforator flap (MICAP)
• thoraco dorsal artery perforator flap (TDAP)
• lateral thoracic artery perforator flap (LTAP)

The following list explains the meanings of some of the words listed above:

• lateral, anterior, dorsal and medial is the medical name of the position of the tissue the surgeon takes for the reconstruction
• intercostal means the space between the ribs
• thoracic and thoraco means your chest
• artery perforator means the blood vessel that supplies blood to the soft tissue

Your surgeon will explain these to you.

You may still need radiotherapy to the remaining breast tissue to reduce the risk of the cancer coming back.

Reshaping the breast

Reshaping might be an option if you need part of your breast removed and you have quite large breasts. It is called therapeutic mammoplasty. The surgeon removes the tumour and an area of surrounding healthy tissue. They then reshape the remaining breast tissue to create a smaller breast.

You will need radiotherapy to this remaining breast tissue to reduce the risk of the cancer coming back. 

At the same time as your reconstructive surgery, you can also have surgery to make your other breast smaller (breast reduction), so they match in size. Or you can choose to have this at a later time.

Helping yourself before breast reconstruction

There is a higher risk of complications if you are having breast cancer surgery and you:

• smoke
• are very overweight
• have other serious medical conditions

You will recover more quickly after reconstruction surgery if you do the following things before your operation.

Stop smoking 

Smoking can lower the blood supply to tissue. This can cause problems with wound healing after the operation to remove the cancer or with breast reconstruction.

It can also increase your risk of getting an infection.

If tissue is taken from your tummy (abdomen), smoking increases the risk of hernia. 

Maintain a healthy weight

There is an increased risk of complications from an anaesthetic and the outcomes of the surgery if you are overweight. Ask for a referral to a dietitian if you would like to lose weight before the operation.

Keep physically active

You might have exercises to do before breast surgery to help strengthen the muscles involved. For example, if tissue is going to be taken from your abdomen for breast reconstruction, it can be useful to do sit ups and gradually build these up. Talk to your doctor or specialist nurse before starting any exercise.

Surgery to your other breast

Some people need surgery to their opposite unaffected breast so they look symmetrical. This is called contralateral breast symmetrisation surgery.

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

You might have surgery to your other breast to:

• 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.

Risk reducing mastectomy and breast reconstruction

This is also known as contralateral risk reducing mastectomy. After having a mastectomy some people worry about getting breast cancer in their other breast. This may mean they want to have surgery to remove the other breast. This is usually only offered to people with a high risk of developing breast cancer in their other breast.

Speak with your breast cancer team about your worry and the risk of developing breast cancer in your other breast.

Your breast surgeon

Surgeons specialising in breast reconstruction for cancer are called oncoplastic surgeons. Your surgery might involve a breast and plastic surgeon working together. 

You can ask your surgeon:

• what your operation will involve
• how it might affect you 
• about their experience and expertise
• about the risks and benefits of different types of surgery 

Your surgeon will need to take photographs of your breasts before and after your reconstruction. These are an important record of your surgery. They show your chest area only, and won't show your face. They are kept with your confidential medical records and are not shared anywhere else.

Feelings about reconstruction

Breast reconstruction options can be a lot to think about. 

You might feel worried about:

• the surgery and how to find the right surgeon for your type of reconstruction 
• how you might look afterwards and how you might feel about your body 
• what your partner might think 
• how surgery might affect sex and your relationships
• how long it will take you to recover and how this will affect your family, job and being able to get back to your daily routine

It can be helpful to discuss your feelings with someone close to you.