Breast reconstruction surgery: what to expect

There are two scenarios where you might want breast reconstructive surgery: either at the time of a mastectomy (referred to as ‘immediate reconstruction’) or at a later date after a simple mastectomy (‘delayed reconstruction’).

The two main methods of reconstruction are either using your own tissues (autologous reconstruction) or silicone implants.

In this article, consultant plastic and reconstructive surgeon Theodore Nanidis talks through the pros and cons of each method, as well as factors and risks to take into account with breast reconstruction surgery.

Types of breast reconstruction

The breast can be thought of in crude terms as composed of skin, which includes the nipple complex and underlying breast tissue. An analogy I use with patients is that of a pillow inside a pillowcase. When a patient requires a mastectomy, the breast (pillow) is removed and the surrounding skin (with or without the nipple, pillowcase) can be preserved.

In this scenario, reconstruction requires only the replacement of volume (pillow) and not skin. This can be achieved with either implants or your own tissue fat from somewhere else, usually the abdomen. This is immediate reconstruction.

If, however, both the skin and the breast tissue have been removed (pillow and pillowcase), then usually we require the use of your own tissue to import both skin and volume – this is delayed reconstruction.

The commonest areas in the body where this tissue comes from are the abdomen and the inner thighs.

Implant based reconstruction

In this procedure, breast implants — silicone devices filled with silicone gel or salt water (saline) — are used to reshape your breasts.

Implant based reconstruction is mainly, but not always, done as immediate reconstruction and usually in women who do not have very ptotic (droopy) breasts.

What happens during surgery

The implant size and type is chosen and this is placed in the breast pocket with the skin closed over it like a line.  Usually a synthetic mesh might also be used, known as an acellular dermal matrix (ADM). This is an animal derivative so please speak to your surgeon about your individual preferences.

What are the advantages of implant based reconstruction?

Implant based reconstruction involves shorter surgery (and usually requires a 1-2 night stay in hospital) than autologous reconstruction, a slightly faster recovery (of about 4 weeks) and no scars left in other parts of the body apart from the breasts.

What are the disadvantages of implant based reconstruction?

As implants do not last forever, this form of reconstruction requires a lifelong commitment and future maintenance surgery (this can range from every couple of years to every ten or so years).

Implants are also generally not a good option if a patient requires post-operative radiotherapy, as they tend to harden and become misshapen.

The skin over the implants is numb and cold, which can feel slightly uncomfortable in winter and when swimming in cold water. There can also be visible irregularities such as rippling of the underlying implant. Implants also do not tend to droop or adopt a natural shape over time.

Autologous (own tissue) reconstruction

This form of surgery uses tissue — skin, fat, and sometimes muscle — from another place on your body (often the tummy) to form a breast shape.

What happens during surgery

The breast surgeon removes the breast through a circular incision around the nipple.  The breast is carefully removed from inside leaving the skin of the breast intact (if the nipple is spared then the incisions are very bespoke).

The plastic surgeon prepares the tissue on the tummy at the same time, with a second team. Once the mastectomy is finished, the plastic surgery team prepares the vessels on your chest, which will be used to accept the tummy transplant (DIEP flap) and the flap is transferred and connected on the chest using a microscope.

Once the desired volume of breast needed is decided, the tummy fat is trimmed to size and the skin is removed, keeping only a circular piece of skin that will take the place of the removed nipple and areola.

The whole flap is then gently coaxed into the breast pocket through this small circular hole and the breast is then shaped by the plastic surgeon. The tummy is then closed like a tummy tuck.

What are the advantages of autologous reconstruction?

This is a very popular option as the long-term benefits are indisputable: it will usually last a lifetime.  It can be used for both immediate and delayed reconstruction. It is a soft, warm reconstruction that over time adopts a natural breast shape and it is part of you.

What are the disadvantages of autologous reconstruction?

The upfront investment for both the patient and the surgeon is high, and it is longer surgery with a slightly longer recovery – you’ll need 2-4 nights in hospital with a recovery time of about 6 weeks.

As tissue is taken from another part of the body in this surgery, it is two surgeries in one, as compared to implants. Your plastic surgeon needs to have specialist microsurgical skills. It is a prerequisite that you have enough tissue available for use, either in your tummy or another suitable site.

All forms of reconstruction will require you to avoid heavy exercise for 3 months.

What factors should I take into account for breast reconstruction surgery?

This is a very personal decision. Shared decision making is now the cornerstone of any patient doctor consultation. You will need all the relevant information from your doctor to decide if reconstruction is right for you.

Ultimately, breasts define femininity for some and reconstruction may be as important to you as your cancer management. Or you might feel differently: this should also be respected.

It is important that you meet a plastic surgeon so you know all the options available to you.

Are there any risks associated with breast reconstruction surgery?

All surgery carries risk. These can be divided into general surgical risks and specific risks based on the type of reconstruction offered.

General risks include clots in the legs/lungs (DVT/PE), chest infections, scarring, wound infections, collections of blood or fluid in the tissues and, nowadays, the chance of contracting COVID-19.

There is a 2-4% risk that you will require an urgent reoperation whilst an inpatient, usually due to bleeding from the mastectomy. This is something that your team will monitor and act upon quickly if required.

Please speak to your doctor for more information on the particular risks associated with each type of reconstruction.

Common misconceptions about breast reconstruction

Some of the major misconceptions about this surgery include:

• Your reconstructed breast will have normal sensation. It regains some sensation, but never exactly as before.
• You can’t have autologous reconstruction if you are undergoing radiotherapy. The DIEP flap is the best tissue to withstand radiation. Radiation, can however affect the final aesthetic result somewhat.
• Your BMI is too high to have autologous reconstruction (a bespoke discussion is needed).
• Because of previous abdominal surgery, you cannot be considered for autologous reconstruction (a bespoke plan is needed).
• Autologous reconstruction is major surgery. It is long surgery, but no body cavity is entered.
• You have to spend weeks in hospital (I regularly discharge my patients on day 3 or even day 2, post-operatively after autologous reconstruction).
• The reconstructed breast will be identical (it will be similar but not identical).
• You will not require any further surgery. All forms of reconstruction require short adjustment surgeries a few months down the line, for fine-tuning.
• You are too old for reconstruction.

Resources for support

You may still be feeling somewhat overwhelmed and unsure about the options available. If you need further information or support, the Facebook group DIEP reconstruction UK is very useful, as is the Diep C Foundation website and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) website. Another helpful source is the Breast Advocate app, which is US-based but has some great informative videos and content.

And remember, breast reconstruction is a very bespoke topic and there is no ‘one size fits all’ solution. Discuss all the options with your surgeon and pick the one that is right for you.

More information

• King Edward VII’s Breast Health Centre is a fully equipped unit, staffed by experts with access to the most up to date tests and treatments.
• Theodore Nanidis is a breast reconstructive surgeon, with particular expertise in autologous reconstruction, and can provide expert treatment, advice and guidance. Make an enquiry.