Breast Reconstruction

Breast reconstruction restores the shape and appearance of the breast following mastectomy or major breast surgery, most commonly performed as part of breast cancer treatment. It’s a substantial area of reconstructive plastic surgery, with a range of techniques that suit different patients and different clinical situations. Reconstruction can be performed at the time of the mastectomy (immediate reconstruction) or as a delayed procedure some time afterwards, and it typically involves more than one operation regardless of the technique chosen.

The decision about whether to have reconstruction, when to have it, and which technique to use is worked through carefully with the treating team, including the breast surgeon and (where relevant) the oncologist and radiation oncologist. The information on this page is a general overview. The specific approach for any individual patient depends on the clinical situation, the anatomy, the cancer treatment plan, and personal preference.

Reconstruction can be performed at the same time as the mastectomy or as a separate operation later. Both approaches have advantages and disadvantages, and the right choice depends on the specifics of the cancer treatment and the patient’s preferences.

Immediate reconstruction takes place at the time of the mastectomy, so the patient wakes up with a reconstructed breast rather than a flat chest. The advantage is that it combines two operations into one, with a single recovery period, and it often produces a better cosmetic result because the skin envelope of the breast can be preserved (in a skin-sparing mastectomy) or the nipple and areola can sometimes be preserved (in a nipple-sparing mastectomy). The disadvantage is that reconstruction adds complexity and time to the mastectomy operation, and where post-mastectomy radiation is likely to be needed, radiation to a reconstructed breast (particularly an implant-based reconstruction) can produce a worse cosmetic result.

Delayed reconstruction takes place weeks, months or sometimes years after the mastectomy. The advantage is that it allows the cancer treatment to be completed first, including any radiation, before the reconstruction is planned. The disadvantage is that the skin envelope has already contracted after the mastectomy, and reconstruction has to work with the tissue that remains rather than preserving the original skin. Delayed reconstruction is a valid choice for many patients and can produce good results.

The choice between immediate and delayed reconstruction is worked through with the treating team, taking into account the cancer treatment plan, the reconstruction options available, and personal preference. There’s no single right answer, and both approaches are established parts of breast cancer treatment.

Implant-based reconstruction uses a breast implant to restore breast volume and shape. It’s the most commonly performed type of reconstruction worldwide, in part because it’s a shorter operation than reconstruction using the patient’s own tissue and doesn’t involve creating a scar in a different part of the body.

The reconstruction is typically performed in two stages. The first stage places a tissue expander, a temporary device that’s gradually filled with saline over several weeks or months to stretch the skin and muscle envelope after mastectomy. The second stage removes the expander and replaces it with a permanent implant. Some patients are candidates for direct-to-implant reconstruction, where the permanent implant is placed at the time of the mastectomy without an intervening expander stage. This depends on the specifics of the mastectomy and the anatomy involved.

Implant-based reconstruction has its own risks, some of which are shared with cosmetic breast augmentation and some of which are specific to reconstruction. These include capsular contracture (where scar tissue around the implant tightens and can distort the shape of the breast), implant rupture, malposition, and the rare but recognised condition of breast implant associated anaplastic large cell lymphoma (BIA-ALCL), which has been associated with certain textured implants. Radiation to an implant-based reconstruction can significantly affect the cosmetic result and increase the risk of capsular contracture and other complications.

Autologous reconstruction uses the patient’s own tissue transferred from another part of the body to reconstruct the breast. The tissue commonly used includes skin, fat, and sometimes muscle. Autologous reconstruction produces a breast that’s made of the patient’s own soft tissue, which can look and feel more natural than an implant, particularly over the long term, and which responds to weight changes in the same way as the rest of the body.

The most commonly used autologous technique in modern breast reconstruction is the DIEP flap (deep inferior epigastric perforator flap), which uses skin and fat from the lower abdomen. The tissue is completely separated from the abdomen, transferred to the chest, and reconnected using microsurgical techniques to blood vessels in the chest area. The abdominal muscle is preserved during the procedure, which distinguishes DIEP from older techniques that included the muscle in the transferred tissue. The abdominal donor site is closed similar to the way an abdominoplasty is closed, producing an abdominal scar.

Other autologous techniques include the latissimus dorsi flap (which uses tissue from the upper back and can be combined with an implant), and less commonly used flaps from other body areas. The choice between autologous techniques depends on the anatomy, the specific reconstruction goals, and other individual factors.

Autologous reconstruction is a longer and more complex operation than implant-based reconstruction, and it produces scarring at both the reconstruction site and the donor site. The recovery is generally longer, and the risks include the possibility of partial or complete failure of the transferred tissue, which is a specific concern with any flap that relies on microsurgical connections.

Nipple and areolar reconstruction is a separate procedure that can be performed after the main breast reconstruction is complete, typically as a smaller operation once the breast shape has settled. The nipple can be reconstructed using local tissue from the reconstructed breast, and the areola can be reconstructed using a skin graft or tattoo. Some patients elect not to have nipple and areolar reconstruction and are comfortable with the reconstructed breast as it is. This is a personal decision, and both choices are valid.

Where a nipple-sparing mastectomy has been performed as part of immediate reconstruction, the original nipple and areola are preserved, and no separate nipple reconstruction is needed. Whether a nipple-sparing mastectomy is appropriate depends on the specifics of the cancer and is determined by the breast surgeon.

Breast reconstruction is performed under general anaesthesia in an accredited hospital. Operating time varies considerably depending on the technique. Implant-based reconstruction typically takes two to three hours. DIEP flap reconstruction and other autologous techniques can take six to ten hours or longer, particularly for bilateral reconstruction.

Hospital stay varies with the technique. Implant-based reconstruction typically requires one to two nights. Autologous reconstruction requires four to seven days or longer, with the first days spent in an environment where the transferred tissue can be monitored closely. Drains are commonly placed and are removed as fluid production reduces. Compression garments are worn after autologous reconstruction to support the donor site.

Recovery from breast reconstruction depends on the technique and the specifics of the operation. Implant-based reconstruction has a recovery similar in some respects to cosmetic breast augmentation, with tightness across the chest for several weeks and gradual return to normal activity over six to eight weeks. Recovery from tissue expander placement includes the additional consideration of the expansion process, which involves regular clinic visits over several weeks to months.

Autologous reconstruction has a longer recovery because there are two operative sites (the reconstruction and the donor site). Recovery from DIEP flap reconstruction typically involves several weeks of restricted activity, with abdominal restrictions similar to those following an abdominoplasty. Most patients are back to normal activity by around three months, with the final result continuing to settle over six to twelve months.

Several follow-up procedures are typically part of the overall reconstruction pathway, including nipple and areolar reconstruction (where chosen), symmetrisation procedures on the other breast to match the reconstructed side, and revision procedures to refine the result. The overall pathway from mastectomy to completed reconstruction typically spans one to two years.

Breast reconstruction is major surgery and carries significant risks. The recognised risks depend on the technique used and include:

Breast reconstruction following mastectomy for breast cancer is generally covered by Medicare, with the specific rebates depending on the technique used and the specific components of the reconstruction. Private health insurance also generally covers breast reconstruction at Medicare-eligible levels, with the specifics depending on individual policies. Any gap between the Medicare and private rebate combined and the surgical, anaesthetic and hospital fees is covered by the patient.

A written quote is provided at consultation covering all costs, including any expected gap. Where the reconstruction includes cosmetic elements (for example, symmetrisation of the other breast where this doesn’t meet Medicare criteria), the cosmetic elements aren’t covered and are quoted separately.

Dr Henry Shepherd, BMed MD MS (Plast.) FRACS (Plast.) | Specialist Plastic Surgeon | AHPRA registration: MED 0001860545