Many women diagnosed with breast cancer will undergo a mastectomy or surgery to remove the breast. Other women may choose to undergo a procedure to prevent breast cancer if they are at particularly high risk and have a troubling family history.
After removal, patients have the option of using implants to reconstruct the breast. There can be many reasons why a patient may decide to have this procedure – a desire to regain their previous breast shape, fit better into existing clothing, body deformity, to name a few – as well as reasons why they may to hesitate. Not all women will be willing to undergo another surgery after the stressful experience of breast cancer treatment. However, mastectomy patients should be educated about their options and how the procedure works. What should your patients know about breast reconstruction surgery?
Types of breast implants
Breast implants in breast reconstruction surgery are often made with either saline or silicone. They can also be made with autologous tissue from other parts of the body or a combination of that tissue and saline or silicone.¹
Saline breast implants are filled with sterile water, while silicone implants are usually made of a thick, cohesive silicone gel.² Saline implants are designed to provide a natural look and feel to the breast. Silicone implants are often tighter, but are also considered less likely to break.
Autologous tissue is often used for breast cancer patients who have undergone radiation therapy, as it can help replace tissue in the breast and chest wall that was affected by radiation.¹ This tissue usually contains skin, fat, and blood vessels, and referred to as a fin. If healthcare professionals intend to use autologous tissue for a graft, they should thoroughly evaluate the abdomen to ensure there are no hernias or incisions that could potentially affect the blood supply to the potential flaps.³ Abdominal flap options include myodermal transverse rectus abdominis (TRAM) flap, a broad dorsal flap and a deep inferior epigastric flap (DIEP).
If a patient cannot use abdominal tissue, flaps may be taken from the thigh or buttocks. Implants can also be used alongside these flaps to provide more volume. These types of flaps are also free flaps – flaps where the tissue is cut off from the blood supply and must be connected to new blood vessels in the breast area through microsurgery. The tissue from the back and abdomen is more likely to be a pedicled flap, in which the blood vessels remain attached to the body during the reconstruction operation.
Reconstruction of Nipples
In some cases, a nipple-sparing mastectomy may be performed, depending on the location and size of the cancer. However, surgeons can also reconstruct a new nipple for patients outside of the skin from the reconstructed breast after reconstructive surgery when the breast is more stable. After the nipple, surgeons can recreate the nipple with skin grafts or tattoo ink.
How is breast reconstruction done?
Breast reconstruction, if done after breast cancer diagnosis rather than a preventive measure, it can be started during the mastectomy or after a waiting period. If patients choose a delayed reconstruction, they must wait months, if not years, to allow the mastectomy incisions to heal and the rest of the breast cancer treatment to be completed.
Breast reconstruction surgery is generally performed in multiple operations. The first operation involves placing a tissue expander under the skin or chest muscle. Over the course of several clinician visits, the expander, a balloon-like sac, is inflated until the patient’s desired size is achieved.² In the next surgery, the tissue expander is removed and replaced with the implant. If desired, areola and areola relaxation can occur after the patient has further healed from the initial surgical procedures.
Depending on the patient’s circumstances, such as their age, desired breast size, and whether they are otherwise healthy, they may be able to have the breast implant placed without a tissue expander during the mastectomy. In these cases, mesh can be used to hold it in place.
There are medical reasons to have delayed recovery as opposed to starting it during the mastectomy. The patient’s health care professional can determine that the patient’s body is healthy enough to undergo the mastectomy. The type of treatment they will receive for the cancer is another possible factor. However, some patients choose to delay to avoid putting their bodies under additional stress or because they don’t feel they can handle another procedure while managing the stress of cancer treatment. Patients and their clinicians should discuss these issues at medical appointments.
Risks of breast reconstruction surgery
Breast reconstruction surgery offers many potential benefits – it can boost a patient’s self-esteem, does not hide cancer recurrence, and is not associated with breast cancer recurrence. However, it carries risks that patients should be aware of before making a decision. As with any surgical procedure, patients are at potential risk of infection, bleeding, pain, complications of anesthesia, and difficulties in wound healing.4 Patients may experience tissue necrosis in part of the flap and implant displacement or rupture later.
Some healthcare professionals may also see smoking as a barrier to breast reconstruction, as smoking reduces blood supply to the tissues and is associated with a greater chance of complications.4 Patients may be asked to stop smoking for a long period of time before from the surgery.
In rare cases, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a form of non-Hodgkin’s lymphoma, may develop.² This is a very uncommon side effect and is generally associated with larger textured implants. According to the US Food and Drug Administration, as of April 1, 2022, 1130 cases of BIA-ALCL had been diagnosed worldwide with at least 59 deaths attributed to it.5 In March 2023, the European Commission’s Scientific Committee on Health , the environment and the environment Emerging Risks concluded that there was a documented causal relationship between textured breast implants and the risk of BIA-ALCL.
Care after breast reconstruction
The most important thing you can encourage your patients to do for themselves after breast reconstruction is to be patient and take the healing process slowly. Pain is typical for the first week or two, and bruising may remain for even longer. There are a number of strenuous activities that should be avoided for the first month, if not longer, based on the patient’s discussion with their surgeon.
Patients not only have to be patient with the physical reaction to breast reconstruction, but also with their emotional state. After undergoing the stress of breast cancer treatment, breast reconstruction can cause a significant emotional reaction and may take time to adjust to.
Healthcare professionals should discuss post-operative care with their patients to provide them with the best possible care for their particular surgery. These discussions should include what a patient should and should not do after surgery and what side effects constitute an emergency that warrants medical attention. The more the benefits, risks, and specifics are discussed, the more informed your patients can make about whether they believe breast reconstruction surgery is right for them.
bibliographical references
1. Breast reconstruction after mastectomy. National Cancer Institute. https://www.cancer.gov/types/breast/reconstruction-fact-sheet. Updated February 24, 2017. Accessed October 16, 2023.
2. Breast construction using implants. American Cancer Society. https://www.cancer.org/cancer/types/breast-cancer/reconstruction-surgery/breast-reconstruction-options/breast-reconstruction-using-implants.html. Updated September 19, 2022. Accessed October 16, 2023.
3. Regan JP, Casaubon JT. Breast Reconstruction. [Updated 2023 Jul 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
4. What to expect after breast reconstruction surgery. American Cancer Society. https://www.cancer.org/cancer/types/breast-cancer/reconstruction-surgery/what-to-expect-after-breast-reconstruction-surgery.html. Updated September 19, 2022. Accessed October 17, 2023.
5. Swanson E. Implant-related anaplastic large cell lymphoma: a nomenclature update. Ann Plast Surg. 2023 Sep 1;91(3):321-323. doi: 10.1097/SAP.0000000000003628. PMID: 37566814; PMCID: PMC10430670.
