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Understanding BRCA & HBOC > Breast Reconstruction > Reconstruction Overview

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Reconstruction Overview

This section outlines the many options available and information about reconstructing breasts following mastectomy.

Reconstruction basics

Breast reconstruction is surgery to recreate breasts after mastectomy. Choosing whether or not to have reconstruction after mastectomy and deciding on the type of reconstruction is very personal and can be challenging. Each procedure has advantages and disadvantages and no one type of reconstruction is perfect for everyone. Not all surgeons perform all procedures, and often, surgeons recommend only the techniques they perform. The most important actions a woman considering reconstruction can take is to learn about her options, decide which is best for her, then consult with and choose a surgeon who is experienced and expert in the technique she prefers.

The Breast Reconstruction Guidebook by Kathy Steligo is an outstanding resource to help women understand all their options in order to make an informed decision about reconstruction. FORCE's post-mastectomy photo gallery has pictures submitted by women and FORCE's Show & Tell book are two great resources with post mastectomy photos of women with and without reconstruction. 

There are two major categories of reconstruction With "tissue flap reconstruction" surgeons use fat, and/or muscle and skin from other areas of the body to recreate a breast. For "implant reconstruction" surgeons use breast implants filled with silicone or saline to reconstruct breasts.

Most reconstruction involves two or more operations over several months. The initial surgery forms the breast mounds, breasts without nipples. Depending on the procedure used, a shorter revision surgery refines the shape and size of the new breasts and add nipples. With unilateral reconstruction, the opposite healthy breast may be modified at this time for better symmetry. Tattooing the area around the nipples simulates the areolas and completes the process. As nipple-sparing surgery becomes more common - reducing the need for a second surgery to reconstruct the nipple - some surgeons offer women the option for reconstruction in one surgery. 

Types of reconstruction

Women who choose to undergo reconstruction after mastectomy have many options.

There are several types of reconstruction. It is helpful to learn about all the different options before choosing a type of reconstruction or surgeon. 

Tissue flap vs. implant reconstruction

  • Tissue flap reconstruction uses fat, and/or muscle and skin from other areas of the body to recreate a breast. 
  •  Breast implant reconstruction uses implants filled with silicone or saline to reconstruct breasts. 

Types of flaps

  • Attached flap reconstruction uses skin, muscle, blood supply and fat from the back or the stomach to recreate a breast. The surgeon rotates the tissue from the donor area to the chest area, leaving part of the tissue attached at the donor site to provide blood supply to the reconstruction. There are two main donor sites for attached flap reconstruction, the back and the abdomen. 
  • Free flap reconstruction also uses skin, muscle, blood supply and fat to recreate a breast. For free flaps, the surgeon removes the tissue from the donor site entirely and uses "microsurgery" to reconnect the blood vessels to provide blood supply to the new breast. 
  • Perforator flap reconstruction is similiar to free flap reconstruction and uses skin, blood supply and fat, but spares the muscle. 

Types of implants

Breast implant reconstruction can be categorized by the type of implant used. All implants have a silicone exterior.

  • Saline implants have silicone exterior filled with "saline" (salt water) to provide volume. 
  • Silicone implants have silicone exterior and are filled with silicone to provide volume. 

Breast implants can also be categorized by the shape and profile of the implant. 

Expander-implants vs. direct-to-implant
Implant reconstruction can be done as a one-step or a two-step surgical process.

  • Expander-implant reconstruction involves two phases: temporary implants called expanders are placed in pockets formed under the chest muscles. Over several weeks the expanders are gradually inflated with saline to stretch the skin and muscles. During a second shorter surgery, the expanders are replaced with implants that best fit your anatomy and desired size.
  • Direct-to-implant is a type of reconstruction that places the final implant at the time of initial surgery. There are two types of direct-to-implant, one uses saline implants called "permanent expanders" and the other involves silicone implants and synthetic tissue. 

Immediate vs. delayed reconstruction

Reconstruction can be done almost anytime after mastectomy.

  • Immediate reconstruction” is performed at the same time as the mastectomy. When immediate reconstruction is performed, the breast skin is preserved and less visible incisions are made for the best cosmetic result. 
  • Delayed reconstruction” can be performed weeks, months, or even years after mastectomy—sometimes treatment delays reconstruction, or a woman may choose not to be reconstructed at the time of her mastectomy and then change her mind some time later. When a woman doesn’t have immediate reconstruction, most of her breast skin is removed along with the breast tissue during mastectomy. The longer and wider mastectomy incision creates a slanting scar across her chest. Even though delayed reconstruction produces very good results, this mastectomy scar remains on the new breast (but it does fade considerably in time).