Do I need to have breast reconstruction?

No, it isn't medically necessary. Breast reconstruction is considered an elective procedure, meaning you may choose to have it done. Some patients decide to have a mastectomy (removal of all breast tissue) without reconstruction.

I'm having autologous reconstruction using abdominal tissue, and I don't want my surgeon to remove any muscle. Can my surgeon commit to avoiding this?

In our experience, leaving the abdominal wall intact isn't always the prudent approach. The type of flap you receive will depend on the anatomy of your blood vessels and the amount of tissue needed to give you an aesthetically pleasing result. If you choose this type of surgery, you should understand that there's a chance we’ll need to take a small piece of abdominal muscle to ensure the success of the reconstruction. This is usually no more than 10% of the muscle.

Will insurance cover my breast reconstruction?

Yes. Although it's an elective procedure, it isn't considered solely cosmetic. If a mastectomy is indicated, federal law mandates that all insurance plans cover breast reconstruction.

What's the difference between immediate and delayed reconstruction?

If you have breast reconstruction done at the same time as your mastectomy, this is called immediate reconstruction. Delayed reconstruction is the term used if you choose to have the mastectomy done and then wait to have reconstruction surgery. At UCSF, we perform both immediate and delayed breast reconstruction. For a number of reasons, many patients prefer not to wait. With immediate reconstruction, the patient needs fewer surgeries and may have a better cosmetic result. In addition, there can be a psychological benefit to having reconstruction right away rather than waiting.

What are the pros and cons of autologous reconstruction compared with implants?

Autologous reconstruction has several advantages: Unlike implants, free flap reconstruction can't rupture or leak. The result tends to look and feel more natural than with implants. A successful autologous reconstruction can last a lifetime, whereas implants may need to be replaced. When compared with implants, autologous reconstruction also has some disadvantages: The recovery period may be longer and more painful because you'll have two surgical sites. You'll also have scars at both sites. If blood flow to the transferred tissue is lost, the tissue may not survive. This is a major complication, though the risk is low. Should it happen, the patient is taken back to the operating room so the team can evaluate the flap and, if possible, salvage the reconstruction.

How long do breast implants last?

Implants are not lifetime devices. Both saline and silicone implants can rupture and leak. If there's a rupture, saline implants gradually deflate. The body absorbs the leaking salt water and you'll notice your breast getting smaller over the course of a few days or week. If a silicone implant ruptures, you may see a change in the breast shape, although often there's no change. Many times, an MRI is needed to detect a leak in a silicone implant. If you choose silicone implants, you'll have periodic MRIs to check that your implants remain intact. Rupture rates for both saline and silicone implants are about 1% per year. An implant can rupture at any time after placement. Most implants need to be replaced every 15 to 20 years.

Why do I need tissue expansion to get implants? My friend had breast augmentation and didn't go through tissue expansion.

Placing implants after a mastectomy is different from placing implants for cosmetic augmentation. When people have breast augmentation, the skin and tissue are left intact. These healthy tissues are capable of stretching to accommodate the implant. During a mastectomy, the breast surgeon removes all breast tissue, leaving a very thin layer of skin. Thin skin can't easily stretch to accommodate an implant, so we use an expander to stretch it slowly and gently.

I may need chemotherapy after my mastectomy. Can I still have implants?

Yes. However, we may need to adjust your surgery dates. For example, we'll postpone your second procedure (to replace the tissue expander with the implant) until enough time has passed since your last chemo treatment. This time period can vary from three weeks to several months and will be determined by your plastic surgeon and medical oncologist. Your body needs this time to recover. If you're having chemotherapy, your incisions may heal more slowly. This is to be expected.

I may need (or already had) radiation therapy to my breast area. Can I still have implants?

You should discuss radiation and its impact on implants thoroughly with your care providers. Patients who have implants and radiation have a higher risk for several complications, such as capsular contracture. This is when the scar tissue that forms around the implant tightens and squeezes on the implant, making the breast feel hard and look distorted.

How much time will I need to take off work?

For implant reconstruction, most people take four weeks off after the mastectomy and placement of the tissue expander and then one week off after the tissue expander is replaced with a permanent implant. Many people are able to return to work during the tissue expansion process. After autologous reconstruction, people generally take four to six weeks off work.

Breast Reconstruction

Breast reconstruction is a surgical procedure to rebuild the breast after a mastectomy. While a reconstructed breast will not look or feel exactly as it did before surgery, the goal is to create a breast that looks and feels as natural as possible.

There are two main types:

Implant reconstruction. The surgeon first places a tissue expander (an empty implant that's filled over several weeks to create space for the permanent implant). Later, in a separate procedure, the expander is replaced with a permanent implant. The permanent implant may be filled with either silicone gel or saline (salt water).
Autologous reconstruction (also called free tissue transfer or free flap). The surgeon takes tissue (skin, fat, blood vessels and sometimes muscle) from another area of the body and uses it to rebuild the breast.

Some women combine autologous reconstruction with an implant to get the breast size they want.

Whether to have breast reconstruction is a personal choice. You don't need to decide right away. Some reconstruction patients begin the process when they have their mastectomy, while others wait months or even years.

If you're considering reconstruction, you may find it helpful to speak with other patients about their experiences through our peer support programs. You can also find books, articles and patient stories about breast reconstruction at the UCSF Patient and Family Cancer Support Center.

Consultation

When you meet with your breast cancer surgeon, you can ask to be referred to a plastic surgeon for a consultation.

During your consultation, the plastic surgeon will go over the benefits and risks of various reconstruction techniques. If you're considering implants, we can show you tissue expanders and implants.

Most people can have some sort of breast reconstruction, but not everyone is a candidate for all procedures. Your options depend on the type of mastectomy you had, your medical history, and your body shape and size. You and your plastic surgeon will discuss which option best fits your situation and preferences.

We encourage you to ask lots of questions at your consultation. Our Patient Support Corps service can help you come up with a list of questions before your appointment.

Preparation

Before your procedure, you'll have an appointment with the Prepare Program to ensure you're ready for surgery. Your care provider will also give you instructions on where to check in on the day of your procedure, plus any changes to make to your diet or medications before surgery.

To minimize your risk of complications, don't use tobacco or nicotine products for at least one to four weeks before and after surgery. Nicotine narrows blood vessels, decreasing blood flow to the surgical site and raising your risk for wound healing problems, infection and even the failure of your reconstruction procedure. The UCSF Fontana Tobacco Treatment Center offers resources to help people quit for good.

Procedure

Reconstruction with expander and implant

Implant-based reconstruction is almost always a two-step procedure. To begin, the surgeon places a tissue expander either above or below your pectoralis (chest muscle). A small amount of saline or air is injected into the expander through a valve, but you'll have very little breast volume and projection when you wake from surgery.

Next, you begin the process of tissue expansion, which requires coming into the office weekly or every other week. At each visit, we use a narrow needle to add some saline to the expander. This process gradually stretches the chest muscle and skin to accommodate your implant.

After your last tissue expansion visit, you need to wait another four to six weeks before having the second stage of the surgery. (If you're having chemotherapy, the second procedure is delayed until you've completed the course.)

In the second procedure, the surgeon removes the expander and replaces it with a permanent implant.

If you have immediate reconstruction with implants, the entire process – from the mastectomy to placing the permanent implants – takes three to six months, on average.

For more information, please see our FAQ on implants.

Reconstruction with your own tissue (autologous reconstruction)

For autologous reconstruction, the "donor tissue" is usually taken from the patient's lower belly, but the back, buttocks or inner thighs may also be used. To establish blood supply to the transferred tissue, surgeons connect its tiny blood vessels to blood vessels in the chest.

Free flap reconstruction from the abdomen

Several free flap approaches use tissue from the lower abdomen. These include:

TRAM flap. The surgeon takes skin, fat, blood vessels and a small portion of muscle from the lower belly to reconstruct the breast.
DIEP flap. The surgeon takes skin, fat and blood vessels from the lower belly to reconstruct the breast but leaves the underlying muscle intact. However, an incision is made in the muscle to collect the vessels needed to supply blood to the transferred tissue.
SIEA flap. The surgeon takes skin, fat and blood vessels from the lower belly without making an incision in the underlying muscle. This technique is possible only for patients with a certain anatomy.

At UCSF, the autologous techniques we use most are the TRAM, DIEP and SIEA flaps.

Free flap reconstruction from other areas

Latissimus dorsi flap. The surgeon uses the latissimus dorsi (a large, flat back muscle) and some skin from the patient's back to support the breast skin and, in some cases, to help re-create part of the breast mound. A breast implant may also be needed.
S-GAP flap. The surgeon uses skin and fat from the upper portion of a buttock to reconstruct the breast.
I-GAP flap. The surgeon uses skin and fat from the lower portion of a buttock.
TUG, VUG or DUG flap. The surgeon uses skin, fat, muscle and blood vessels from the upper thigh. The different names refer to the orientation of the thigh incision.

For more information, see Types of Autologous Breast Reconstruction.

Recovery

After a mastectomy and the first stage of implant reconstruction, you'll spend one to two days in the hospital, followed by about four weeks of recovery at home. You'll have your first tissue expansion two to four weeks after the first stage of your surgery. The second operation typically doesn't require an overnight stay in the hospital, and recovery takes about two weeks.

If you have a mastectomy and autologous free flap reconstruction, you'll spend three to five days in the hospital, followed by about six weeks of recovery at home. About one week after your hospital discharge, you'll have a follow-up visit with your plastic surgeon.

To prepare for your recovery at home, we recommend having "distraction therapies," such as books, magazines and movies, on hand. Wearing comfortable button-down shirts or zip-up tops can make changing clothes easier.

Recovery times vary, with pain and fatigue resolving in anywhere from two to 12 weeks.

Infection is a risk after any surgery. Signs of infection include:

Redness at the surgical site that gets worse over time
Pain around the surgical site that gets worse over time
Flu-like symptoms
Excessive swelling

Contact your surgeon's office immediately if you notice any of these symptoms.

Breast reconstruction FAQs

Do I need to have breast reconstruction?
No, it isn't medically necessary. Breast reconstruction is considered an elective procedure, meaning you may choose to have it done. Some patients decide to have a mastectomy (removal of all breast tissue) without reconstruction.
Will insurance cover my breast reconstruction?
Yes. Although it's an elective procedure, it isn't considered solely cosmetic. If a mastectomy is indicated, federal law mandates that all insurance plans cover breast reconstruction.
What's the difference between immediate and delayed reconstruction?
If you have breast reconstruction done at the same time as your mastectomy, this is called immediate reconstruction. Delayed reconstruction is the term used if you choose to have the mastectomy done and then wait to have reconstruction surgery. At UCSF, we perform both immediate and delayed breast reconstruction.

For a number of reasons, many patients prefer not to wait. With immediate reconstruction, the patient needs fewer surgeries and may have a better cosmetic result. In addition, there can be a psychological benefit to having reconstruction right away rather than waiting.
What are the pros and cons of autologous reconstruction compared with implants?
Autologous reconstruction has several advantages:
- Unlike implants, free flap reconstruction can't rupture or leak.
- The result tends to look and feel more natural than with implants.
- A successful autologous reconstruction can last a lifetime, whereas implants may need to be replaced.
When compared with implants, autologous reconstruction also has some disadvantages:
- The recovery period may be longer and more painful because you'll have two surgical sites. You'll also have scars at both sites.
- If blood flow to the transferred tissue is lost, the tissue may not survive. This is a major complication, though the risk is low. Should it happen, the patient is taken back to the operating room so the team can evaluate the flap and, if possible, salvage the reconstruction.
How long do breast implants last?
Implants are not lifetime devices. Both saline and silicone implants can rupture and leak.

If there's a rupture, saline implants gradually deflate. The body absorbs the leaking salt water and you'll notice your breast getting smaller over the course of a few days or week.

If a silicone implant ruptures, you may see a change in the breast shape, although often there's no change. Many times, an MRI is needed to detect a leak in a silicone implant. If you choose silicone implants, you'll have periodic MRIs to check that your implants remain intact.

Rupture rates for both saline and silicone implants are about 1% per year. An implant can rupture at any time after placement. Most implants need to be replaced every 15 to 20 years.
Why do I need tissue expansion to get implants? My friend had breast augmentation and didn't go through tissue expansion.
Placing implants after a mastectomy is different from placing implants for cosmetic augmentation. When people have breast augmentation, the skin and tissue are left intact. These healthy tissues are capable of stretching to accommodate the implant.

During a mastectomy, the breast surgeon removes all breast tissue, leaving a very thin layer of skin. Thin skin can't easily stretch to accommodate an implant, so we use an expander to stretch it slowly and gently.
I may need chemotherapy after my mastectomy. Can I still have implants?
Yes. However, we may need to adjust your surgery dates.

For example, we'll postpone your second procedure (to replace the tissue expander with the implant) until enough time has passed since your last chemo treatment. This time period can vary from three weeks to several months and will be determined by your plastic surgeon and medical oncologist. Your body needs this time to recover.

If you're having chemotherapy, your incisions may heal more slowly. This is to be expected.
I may need (or already had) radiation therapy to my breast area. Can I still have implants?
You should discuss radiation and its impact on implants thoroughly with your care providers. Patients who have implants and radiation have a higher risk for several complications, such as capsular contracture. This is when the scar tissue that forms around the implant tightens and squeezes on the implant, making the breast feel hard and look distorted.
How much time will I need to take off work?
For implant reconstruction, most people take four weeks off after the mastectomy and placement of the tissue expander and then one week off after the tissue expander is replaced with a permanent implant. Many people are able to return to work during the tissue expansion process.

After autologous reconstruction, people generally take four to six weeks off work.
I'm having autologous reconstruction using abdominal tissue, and I don't want my surgeon to remove any muscle. Can my surgeon commit to avoiding this?
In our experience, leaving the abdominal wall intact isn't always the prudent approach. The type of flap you receive will depend on the anatomy of your blood vessels and the amount of tissue needed to give you an aesthetically pleasing result.

If you choose this type of surgery, you should understand that there's a chance we’ll need to take a small piece of abdominal muscle to ensure the success of the reconstruction. This is usually no more than 10% of the muscle.