Breast Reconstruction

Read our blog, Renee’s Story: Complications During Breast Cancer Treatment and Reconstruction.

Breast reconstruction can help restore the look of the breast after a mastectomy. The surgery is done by a plastic surgeon.

Although most breast reconstruction is done in women, men may get reconstruction if they wish.

Timing of breast reconstruction

Breast reconstruction can be done at the same time as the mastectomy (“immediate”) or at a later date (“delayed”).

Many women now get immediate breast reconstruction. However, the timing depends on:

Physical exam by the plastic surgeon
Surgical risk factors, such as smoking and being overweight
Treatments you will need after surgery

Not all women can have immediate reconstruction.

Discuss your options with your plastic surgeon, breast surgeon and oncologist (and your radiation oncologist if you are having radiation therapy).

Benefits of breast reconstruction

Breast reconstruction may help you feel more comfortable about how you look after a mastectomy.

Although a reconstructed breast will never match the look or feel (sensation) of your natural breast, this area of plastic surgery continues to improve.

Visit the FORCE website for a photo gallery of images of people who have had breast reconstruction after a mastectomy.

Possible challenges of breast reconstruction

Travel

You may not live near the hospital where the reconstruction will be done. This can be a challenge because of the number of follow-up visits needed after reconstruction. Most breast reconstruction methods involve several steps.

Immediate reconstructions and some delayed reconstructions require a hospital stay for the first procedure. Follow-up procedures may be done on an outpatient basis.

If you need transportation, lodging, childcare or eldercare, there may be programs that can help.

Cost

Federal law requires most insurance plans to cover the cost of breast reconstruction after a mastectomy.

Learn more about insurance and breast reconstruction.

Choosing the type of breast reconstruction that’s right for you

Breast reconstruction can be done with:

Breast implants (filled with saline or silicone)
Natural tissue flaps (using skin, fat and sometimes, muscle from your own body)
A combination of these methods

There’s no one breast reconstruction method that works best for everyone. You may be a good candidate for one reconstruction method, but not another. There are pros and cons to each method.

For example, breast implants require less invasive surgery than procedures using your own body tissues, but the results may look and feel less natural [185].

It’s important to keep in mind multiple factors determine the best reconstruction method for you, as well as the final result.

Most women are satisfied with their reconstructed breasts [329].

Body shape

Your body shape and anatomy may affect the types of breast reconstruction likely to give you the best results.

For example, women with larger breasts may need breast reduction surgery on the opposite, natural breast to create a more even look.

Lifestyle

Your lifestyle may affect the type of reconstruction you choose.

For example, some types use muscles from other parts of the body, causing weakness in the area. These may not be good options for athletic women or women who rely on those muscles to function.

General health

Some women with chronic medical conditions or suppressed immune systems may not be good candidates for breast reconstruction.

Smoking and body weight

Smokers and women who are overweight have an increased risk of complications for all types of breast reconstructive surgery [10,186-189].

If you smoke or are overweight, talk with your plastic surgeon about problems that may occur after surgery with implant or flap procedures, such as delayed wound healing, infection and reconstruction failure.

Sometimes, it’s best to delay breast reconstruction until after quitting smoking or losing weight to lower these risks.

Your plastic surgeon or health care provider may discuss ways to quit smoking and/or lose weight before you have reconstruction.

Making an informed choice

Each person is unique. Your breast cancer treatment, your body, your breast shape and your lifestyle affect not only your reconstruction options, but also the pros and cons of your options.

Your plastic surgeon will help you choose the type of reconstruction that will give you the best results and fit your lifestyle, while minimizing the risk of complications.

Study your options and make a thoughtful, informed choice after carefully considering the pros and cons of each option.

Although this decision may seem overwhelming, it may help to know most women who’ve had breast reconstruction don’t regret the method they chose [190-192].

If you’re a good candidate for a procedure, there are fairly few complications with any of the current methods [185].

Choosing to go flat

You can choose not to have breast reconstruction. If you decide not to have breast reconstruction, you can have a flat closure after a mastectomy by the breast surgeon. This is also called going flat.

Learn more about going flat.

Getting a second opinion

It’s always OK to get a second opinion. Your plastic surgeon shouldn’t discourage you from getting a second opinion.

Getting a second opinion from a plastic surgeon from a different hospital or group practice can:

Instill confidence in the first plastic surgeon by confirming your reconstructive options
Give another perspective on your reconstructive options
Give you a chance to meet with another plastic surgeon, who may be better suited to perform your surgery

However, getting a second opinion shouldn’t delay your breast cancer treatment.

Learn more about getting a second opinion.

Basic types of breast reconstruction

The table below compares the basic types of breast reconstruction.

Specific types of breast implant reconstruction and natural tissue flap reconstruction are discussed in more detail below.

	Breast implants	Natural tissue flaps
Mimic the look and feel (to the touch) of a natural breast	Less able to mimic the look and feel of a natural breast (silicone implants look and feel more natural than saline implants)	Better able to mimic the look and feel of a natural breast
Loss of sensation (feeling)	Will lose most sensation in the breast	Will lose most sensation in the breast and in the area of the body where tissue was taken to create the reconstructed breast
Surgery	Less extensive Time in surgery is shorter (1-2 hours)	More extensive Time in surgery is longer (4-10 hours) DIEP, SIEA, S-GAP, I-GAP, TUG, DUG and PAP procedures require specially-trained microvascular surgeons
Is a hospital stay needed?	Needed for the first procedure (1 night) when done at the same time as a mastectomy (immediate reconstruction) Follow-up procedures may be done on an outpatient basis	Needed for the procedure (2-3 nights) Follow-up procedures may be done on an outpatient basis
Will the procedure need to be repeated?	Implants may need to be replaced in your lifetime.	Tissue flaps won’t need to be replaced in your lifetime. However, if there are complications, some procedures can’t be repeated.
Recovery	3-4 weeks Fewer scars	4-6 weeks More scars
Risk of complications	Some risk of surgical complications in the breast area	Some risk of surgical complications in the breast area and in the area where the natural tissue flap is taken Some procedures have more risks than others
Risk of complete reconstruction failure	Low risk, but higher than with natural tissue flaps Successful reconstruction depends on the quality of the breast skin after the mastectomy and radiation therapy (if radiation therapy is needed)	Risk of a complete flap loss is lower than a complete loss of an implant Risk of a partial flap loss is higher than a complete loss of an implant Some procedures have a higher risk than others
Adapted from selected sources [185,193-194].

Implants

Reconstruction using a breast implant is the least invasive breast reconstruction procedure.

It may not require extra time in the hospital if it can be done at the same time as the mastectomy.

The shape of the reconstructed breast with an implant may not match the look or feel (to the touch) of the natural, opposite breast over time. The natural breast will change in size and shape with weight changes and as you grow older, while the breast implant will not change. This may lead to a less even look. More surgery may be needed to maintain a similar look.

For this reason, implants are better for women with small or medium-sized breasts with little or no sagging [185].

If the shape or the size of the reconstructed breast doesn’t match your natural, opposite breast, it’s possible to have surgery to lift, enlarge or reduce the size of your natural breast to help make your breasts look more alike.

Learn about managing pain after reconstructive surgery.

Learn about breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

Learn about follow-up care to check for ruptures in silicone implants.

Click on the topics below to learn more.

There are 2 types of breast implants: saline and silicone.

For both saline and silicone implants, the outer cover of the implant (also called the implant shell) is made of a solid form of silicone. Implants differ in the substance used to fill the shell.

Saline implants

Saline implants are filled with saline, a saltwater solution similar to that found in IV fluids.
Saline implants come deflated. During surgery, they are filled to the desired volume.

Silicone implants

Silicone implants are filled with silicone gel, a semi-solid substance made from silicone.
Silicone implants come pre-filled with the desired volume.

Saline versus silicone implants

The table below describes some pros and cons of saline versus silicone implants.

Discuss your options with your plastic surgeon and choose the implant that’s best for you.

	Saline implants	Silicone implants
Mimic the look and feel (to the touch) of a natural breast	Less able to mimic the feel of a natural breast (may feel like a water balloon) More likely to see rippling or an uneven contour, especially if the skin-muscle envelope is thin	Better able to mimic the feel of a natural breast Less likely to see rippling or an uneven contour
Can the size of the expander or implant be changed?	Size of the expander may be increased or decreased after the initial surgery by injecting more saline or removing some saline (this can be done in your doctor’s office) Size of the implant can’t be changed without surgery to replace the implant	Size of the expander may be increased or decreased after the initial surgery by injecting more saline or removing some saline (this can be done in your doctor’s office) Size of the implant can’t be changed without surgery to replace the implant
Risk of rupture	Equal chance of rupture	Equal chance of rupture
What happens if the implant ruptures?	The saline is absorbed harmlessly into nearby tissues, but the silicone implant shell (lining) remains. The reconstructed breast appears deflated, so you know right away the implant has ruptured. The implant should be replaced before the entire surgical pocket that holds the implant has collapsed. This is especially important after radiation therapy. Radiation to the pocket can cause it to collapse very quickly. If this happens, it may not be possible to replace the implant.	Some silicone gel might leak into the soft tissue pocket around the implant and rest there. Since the silicone isn’t absorbed, the overall breast volume stays the same. So, it may take longer to notice a rupture in a silicone implant than a rupture in a saline implant. Breast MRI or breast ultrasound can be used to check for an implant rupture if a health care provider notices a change on a clinical breast exam. If there are no symptoms or changes, the FDA recommends breast implants should be screened for a rupture with breast MRI or breast ultrasound 5-6 years after the surgery to place the implant, and then every 2-3 years.
Side effects that may occur	Capsular contraction (hardening of the tissues around the implant) Infection (may require removal of the implant) Pain	Capsular contraction (hardening of the tissues around the implant) Infection (may require removal of the implant) Pain
Replacement	Typically lasts at least 10 years, but will likely need to be replaced in your lifetime (replacement requires surgery)	Typically lasts at least 10 years, but will likely need to be replaced in your lifetime (replacement requires surgery)
Adapted from selected sources [185,195].

Safety of silicone implants

Some people with breast implants have reported symptoms such as fatigue, joint and muscle pain, mental fogginess, memory loss, and rash [196]. However, there are no known direct links between breast implants and these symptoms [196]. The U.S. Food and Drug Association (FDA) and other researchers are actively studying these topics [195,197].

Most studies show no link between silicone implants and lupus, immune system disorders, connective tissue disease or rheumatoid arthritis [195-197]. Silicone implants are as safe as saline implants.

Learn about the FDA’s research on breast implants and health.

Learn about breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

Implant size

Different implant sizes are available to match the look of the natural breast.

The best implant size for you will depend on:

Your body shape, including the shape of your natural breast, the shape of your chest wall and the amount of fatty tissue available
The breast skin
The quality of the envelope formed by the breast skin and chest muscle after the mastectomy (this soft tissue envelope holds the implant)
Past radiation therapy or upcoming radiation therapy after mastectomy
Your personal preference

Implant shape

Implants can be round or teardrop-shaped. They vary in the amount of projection and base width.

Teardrop-shaped implants are no longer routinely used in the U.S. because they have a textured surface. Implants with a textured surface are linked to a rare cancer called breast implant associated-anaplastic large cell lymphoma (BIA-ALCL) [198-203]

Inserting a breast implant (saline or silicone) is a fairly simple process.

Step 1: A tissue expander (a temporary, modified saline device) is inserted in the envelope formed by the breast skin and chest muscle.

The expander has a port that allows more saline to be added after surgery (with a simple injection through the skin into the port).

Step 2: Over a period of 2-6 months (in repeated office visits), the skin-muscle envelope is slowly stretched by injecting more saline into the expander until it reaches the desired size of the final implant.

The final volume may be limited by the quality and size of the skin-muscle envelope.

Step 3: A surgeon removes the expander and replaces it with the final implant (saline or silicone).

This is done in an operating room but is most often an outpatient surgery. Recovery time is shorter than with natural tissue reconstruction.

Direct implant insertion

Some women don’t need tissue expansion and can have an implant (saline or silicone) directly inserted at the time of the mastectomy.

These women have healthy enough skin and the size of their skin-muscle envelope immediately after the mastectomy is large enough to cover the desired final implant.

For example, women who have moderate-sized breasts or excess natural breast skin, or who want to have a reconstruction smaller than their natural breast size may be good candidates for direct implant insertion.

The size of a reconstructed breast can’t be changed without surgery to replace the implant.

However, changes in weight can impact the look of the breast with an implant. Weight gain may make the breast with an implant appear smaller than before. Weight loss may make it appear fuller.

If a silicone-filled implant ruptures, some silicone gel might leak into the soft tissue pocket around the implant and rest there.

Since the silicone isn’t absorbed, the overall breast volume stays the same. So, it may take longer to notice a rupture in a silicone implant than a rupture in a saline implant.

Breast MRI or breast ultrasound can be used to check for an implant rupture if you notice a change or if your health care provider notices a change on a clinical breast exam.

When there are no symptoms of rupture or other changes, silicone breast implants should be routinely screened with breast MRI or breast ultrasound. The FDA recommends this screening begin 5-6 years after the surgery to place the implant (when your final implant was inserted), and then every 2-3 years [204].

Learn more about FDA screening recommendations for rupture in silicone implants.

Breast reconstruction with an implant and acellular dermal matrix

Acellular dermal matrix is used in combination with an implant reconstruction. It helps cover the lower half of the reconstructed breast when a subpectoral (under the chest muscle) reconstruction is done. (The chest muscle may not be able to reach far enough to cover this area.)

The technique using acellular dermal matrix creates a hammock under the mastectomy skin envelope to hold the tissue expander or implant in place. The hammock is made from biologic material called acellular dermal matrix. It may be used alone or in combination with your chest muscle. Most often, the biologic material is donated human skin. Acellular means the human cells that may lead to tissue rejection have been removed.

The technique requires a high-quality mastectomy skin envelope that’s thick enough to give a blood supply during the healing process.

Implant reconstruction with acellular dermal matrix can allow a larger volume fill at the time of surgery. This can shorten the implant expansion process because the expander begins at a larger size.

If the final implant can be placed at the time of the mastectomy, without the need for expansion, this can be done in one step.

Risk of complications

Some findings show implant reconstruction with acellular dermal matrix may have a higher risk of complications after surgery, such as seroma (fluid build-up) and infection, compared to implant reconstruction without acellular dermal matrix [205].

Is breast reconstruction using acellular dermal right for you?

Women having a nipple-sparing mastectomy (keeping the entire breast skin envelope) and women with loose breast skin generally benefit from this procedure. Women with very small breasts and minimal sag may not benefit.

Talk with your plastic surgeon to find out if this procedure may be right for you.

Although acellular dermal matrix is FDA-approved for other uses, it does not yet have FDA approval for use in breast reconstruction. However, it has been used “off-label” in breast reconstruction for years and is typically covered by insurance.

There are growing number of other products, such as absorbable mesh, which are becoming available for providing coverage and support for implant-based breast reconstruction. These are also “off-label” at this time. Studies are comparing these different techniques.

Pre-pectoral versus subpectoral implant reconstruction

Breast implants are usually a subpectoral (meaning under the chest muscle) type of reconstruction. This gives as much healthy soft tissue coverage of the implant as possible. Some of the chest muscle is cut during the procedure to place the implant underneath.

When women use and contract the pectoralis major muscle (the chest muscle), the subpectoral implant breast reconstruction can look distorted (because the implant is below the chest muscle). This is called animation deformity. For women who use their chest muscles a lot (for example, during upper body exercise, such as push-ups), this can be bothersome.

Pre-pectoral implant reconstruction places the implant above the chest muscle (pre-pectoral), just under the mastectomy skin envelope. So, it may avoid the distorted look described above.

With a pre-pectoral implant reconstruction, a larger amount of acellular dermal matrix (a biological material) is used to cover the entire implant than with a subpectoral implant. Most often, the biologic material is donated human skin.

Acellular means the human cells that may lead to tissue rejection have been removed.

Given more acellular dermal matrix is used, pre-pectoral reconstruction may have higher risk of seroma (fluid build-up) than subpectoral reconstruction [206].

Who can have a pre-pectoral implant reconstruction?

Not everyone can have a pre-pectoral implant reconstruction. It requires very thick mastectomy skin flaps (not everyone has thick skin flaps after a mastectomy) with a healthy blood supply.

Given the limited thickness of the skin flaps without the muscle coverage, this technique may require additional procedures, such as fat grafting, to improve the uneven contour and visible rippling of the implant reconstruction.

The long-term results of this technique, and how it’s affected by radiation therapy to the breast (for example, the risk of capsular contracture, a hardening of the tissues around the implant), are under study.

Talk with your plastic surgeon to find out if this procedure may be right for you.

Reconstruction of the nipple may be done when the permanent implant is inserted or at a later time.

Learn more about nipple and areola reconstruction.

With both implant and natural tissue reconstruction, radiation therapy can cause:

Changes in skin color and skin quality
Changes in the shape and contour of the breast
Tissue shrinkage
Tightness and pain
Scars that get worse over time

If you will have an implant procedure using a tissue expander and radiation therapy will be used after mastectomy, immediate breast reconstruction is recommended (rather than delayed reconstruction) [10]. This allows the reconstruction pocket to be created before radiation therapy begins.

Delayed breast reconstruction using an implant is extremely rare after radiation therapy due to radiation damage to the skin.

Skin that’s received radiation and is later stretched to fit an implant is at high risk for complications and a poor cosmetic result [10,185]. Results are better when the procedures to expand the skin are done before radiation therapy begins.

The effects of radiation therapy on the reconstructed breast tend to continue with time. Longer-term problems can occur after many years. Radiation therapy, even when done before breast reconstruction, limits the size of the reconstruction and increases the risk the reconstruction may fail [207-208].

Many women who get radiation therapy to the reconstructed breast have chronic tightness and stiffness in the chest and upper arm areas [207]. They may need physical therapy or long-term range of motion exercises. Having a smaller implant reconstruction may lead to less long-term tightness.

After an implant breast reconstruction, you’ll get a card with your implant information, including the style and size. This information is important and can be useful if you need a replacement or future surgery.

If you lose your implant information card, you can get this information from the hospital where you had your breast reconstruction surgery. The implant information will be in your surgery notes (called the operative notes).

Anaplastic large cell lymphoma (ALCL) is a rare cancer of the cells of the immune system [198-201]. When ALCL occurs in women with breast implants it’s called breast implant-associated ALCL (BIA-ALCL).

BIA-ALCL is typically found in the scar tissue and fluid near the implant [200]. BIA-ALCL is very treatable.

The FDA, the American Society of Plastic Surgeons and the Plastic Surgery Foundation are working together on research to understand BIA-ALCL in women with breast implants.

Let your health care provider know if you notice any changes to your implant(s) or have any swelling or pain in the area.

How many cases of BIA-ALCL have occurred?

BIA-ALCL is rare. As of May 2024, more than 1,350 cases of BIA-ALCL have been reported in the world, and 430 suspected or confirmed cases of BIA-ALCL have been reported in the U.S. [203].

BIA-ALCL and textured implants

Although the reasons are unclear, the risk of BIA-ALCL is higher with textured breast implants than with smooth implants [198-203]. Teardrop-shaped implants are textured implants.

The estimated lifetime risk of BIA-ALCL among women with textured implants is between about 1 in 3,800 women to 1 in 30,000 women [203].

Some manufacturers have voluntarily taken their textured breast implants and tissue expanders off the market. In the U.S., textured implants are no longer routinely used.

Should textured breast implants be removed?

The FDA does not recommend removing textured breast implants or tissue expanders unless you have symptoms. Symptoms may include fluid build-up around the implant, swelling, pain and a lump in the breast or underarm.

Let your health care provider know if you have any of these symptoms.

Some women who have textured breast implants, but have no symptoms, may choose to have textured implants removed. However, the surgical risks of removing implants (with or without a switch to smooth implants) can be greater than the risk of developing BIA-ALCL. (The risk of developing BIA-ALCL is low.)

If you’re considering removal of a textured breast implant(s), talk with your health care provider about the possible surgical risks for you and make an informed decision. These risks should be weighed against the risk of BIA-ALCL before choosing to have textured implants removed.

How to find out what type of breast implant(s) you have

You should have been given an implant information card at the time of your implant reconstruction. If you can’t find the card, contact the hospital where you had your breast reconstruction surgery. Information on the implant(s) will be in your surgery notes (called the operative notes).

The FDA recently reported on very rare cases of squamous cell carcinoma (SCC) and lymphomas found in the scar tissue around a breast implant [209-210]. As of January 2023, fewer than 20 cases of SCC and fewer than 20 cases of lymphomas (lymphomas that aren’t BIA-ALCL) have been reported [209-210].

The reasons behind a possible increased risk of SCC and lymphomas in women who have breast implants are unclear. The FDA is currently collecting data and these topics are under study.

Natural tissue flap surgery

Natural tissue flaps are soft tissues from your own body (such as skin, fat and muscle) that can be used to help create a reconstructed breast. Reconstruction using skin and tissue flaps tends to mimic the look and feel (to the touch) of a natural breast better than reconstruction with implants.

However, natural tissue flap procedures are more invasive and complex than reconstruction with implants. So, they usually require a longer hospital stay and a longer recovery time.

These procedures require surgery to the donor site (the area of the body where the tissue for the reconstruction is taken). The surgery will leave scars at the donor site.

The most common natural flap procedures use tissue from the abdomen or back. Flaps can also be taken from the buttocks or thighs (a microvascular surgeon is needed for these surgeries).

In some procedures, part or all of a muscle needs to be taken from the donor site to provide blood flow to the flap tissue. This may cause weakness in that area of the body and limit certain physical or athletic activities. If you’re active, discuss this risk with your plastic surgeon.

Learn about managing pain after reconstructive surgery.

Click on the topics below to learn more.

The latissimus dorsi muscle flap procedure removes a large muscle from the back along with skin and underlying fatty tissue. It uses these tissues to reconstruct the breast.

In most women, the amount of soft tissue available on the back is limited and the flap itself is only about an inch thick or less. So, an implant is usually needed to create enough volume for the reconstructed breast.

The fatty tissue of the latissimus flap goes over the implant, so it mimics the look and feel (to the touch) of a natural breast better than an implant alone.

Talk with your plastic surgeon to find out if this procedure may be right for you.

The transverse rectus abdominis myocutaneous (TRAM) flap uses skin, fat and muscle from the lower abdomen to reconstruct the breast. It creates a natural-looking breast.

A TRAM flap usually doesn’t require an implant as long as there’s enough excess skin and fatty tissue in the lower abdomen. If you don’t have excess abdominal tissue or you’ve had abdominal surgery in the past, you may not be a candidate for a TRAM flap reconstruction.

The TRAM flap has some drawbacks:

Once a TRAM flap has been done, it can’t be repeated.
The surgery leaves a large scar across the lower abdomen.

The loss of an abdominal muscle (removed to provide a blood supply to the flap) can cause weakness in the abdominal area. Although mesh is used to reconstruct the area of the missing muscle, there is a risk of hernia or bulge. This risk may be greater in bilateral breast reconstruction procedures for double mastectomy. If you’re active, talk with your plastic surgeon about this drawback.

Talk with your plastic surgeon to find out if this procedure may be right for you.

Breast reconstruction with a deep inferior epigastric perforator (DIEP) flap uses skin and fatty tissue from the lower abdomen to form the reconstructed breast.

Unlike the TRAM flap, the DIEP flap procedure keeps the abdominal muscle intact. This may preserve abdominal strength after the procedure. It also reduces the risk of abdominal site complications, such as hernia.

You may not be a candidate for a DIEP flap based on your abdominal blood vessel anatomy. This is often checked with an abdominal CT scan before surgery.

The DIEP flap has some drawbacks:

Once a DIEP flap has been done, it can’t be repeated.
It’s more complex than the latissimus dorsi muscle flap and TRAM flap procedures and usually requires 2 microvascular surgeons.
The surgery takes longer than some other natural flap techniques due to the microvascular procedures. This can increase the risk of problems during surgery.
The surgery leaves a large scar across the lower abdomen.

The DIEP flap procedure should only be done by microvascular surgeons specially-trained and experienced in this technique.

Talk with your plastic surgeon to find out if this procedure may be right for you.

The superficial inferior epigastric artery (SIEA) flap breast reconstruction uses skin, fatty tissue and blood vessels (including the superficial inferior epigastric artery) from the abdomen to form the reconstructed breast.

The SIEA flap isn’t as common as the DIEP and TRAM flaps because few women have blood vessels large enough (or any at all) for the procedure.

The SIEA flap leaves all of the muscles and most of the connective tissue of the abdomen untouched, so it leaves no weakness in the abdominal area. This can be important for women who are physically active.

Blood clots are more common with SIEA flap procedures than with other techniques [211].

The SIEA flap procedure should only be done by microvascular surgeons specially-trained and experienced with this technique.

Talk with your plastic surgeon to find out if this procedure may be right for you.

Gluteal artery perforator (GAP) flap procedures use skin and fatty tissue from the buttocks to reconstruct the breast.

The superior GAP (S-GAP) procedure uses skin and fatty tissue from the upper part of a buttock.
The inferior GAP (I-GAP) flap procedure uses skin and fatty tissue from the lower part of a buttock.

Because no buttock muscle is used in either procedure, athletic ability after surgery is rarely affected.

S-GAP or I-GAP flap reconstruction may be a good option for women with more fatty tissue in their buttocks area than in their abdomen. However, it leaves a large scar across the buttock area.

If the GAP procedure leaves the buttocks noticeably different in size, liposuction can be used later to remove fat from the opposite buttock to create a more even look.

As with other microvascular flap procedures, GAP flap procedures are complex surgeries that require a microvascular surgeon.

They take longer than other types of tissue flap surgeries (even longer than the DIEP flap procedure), which may increase the risk of surgical complications [212].

If an S-GAP or I-GAP flap procedure isn’t successful, it can be repeated using tissue from the opposite buttock (either immediately or at a later time).

Talk with your plastic surgeon to find out if one of these procedures may be right for you.

Transverse upper gracilis (TUG) flap and diagonal upper gracilis (DUG) procedures use skin, fatty tissue and muscle from the upper inner thigh to reconstruct the breast.

TUG and DUG flap reconstruction use the gracilis muscle, which helps bring the leg toward the body. This isn’t a critical muscle, and most people don’t notice a lot of weakness.

TUG and DUG differ slightly in the location of their scars. With TUG, the scar goes across the thigh and with DUG, the scar is angled down the thigh.

TUG flap or DUG flap may be a good option for women with excess fatty tissue in their upper inner thigh area who are not good candidates for TRAM, DIEP, SIEA or GAP flap procedures.

As with other microvascular flap procedures, TUG flap and DUG flap are complex surgeries that require a microvascular surgeon.

If a TUG flap or DUG flap isn’t successful, it can be repeated using tissue from the opposite upper inner thigh.

Talk with your plastic surgeon to find out if one of these procedures may be right for you.

Profunda artery perforator (PAP) flap procedures use skin, fatty tissue, and a blood vessel from the back of the upper thigh to reconstruct the breast. It leaves a scar in the crease of the thigh and buttocks.

Typically, the amount of tissue available in the back of the upper thigh is limited, so PAP flaps work better for women with small breasts.

PAP flap may be an option for women who are not good candidates for abdominal or other flap procedures.

As with other microvascular flap procedures, PAP flap is a complex surgery that requires a microvascular surgeon.

Talk with your plastic surgeon to find out if this procedure may be right for you.

With both natural tissue and implant reconstruction, radiation therapy can cause:

Changes in skin color and skin quality
Changes in the shape and contour of the breast
Tissue shrinkage
Tightness and pain
Scars that get worse over time

Delayed reconstruction

For women who will need radiation therapy after mastectomy, it may be better to delay the flap reconstruction until after radiation therapy. This delay may be at least 6 months up to one year after radiation therapy is completed. This greatly lowers the chances the look, feel (to the touch) and size of the reconstructed breast will be harmed by the radiation therapy [10].

Delayed reconstruction using flaps after radiation therapy generally requires using a larger patch of the donor site skin (for example, a larger area of the abdominal skin). Most of the chest skin damaged by the radiation therapy is removed during surgery. So, there’s less chest skin available after radiation therapy and the larger patch helps cover the reconstructed breast.

Immediate-delayed reconstruction

Women may also consider having immediate reconstruction with a tissue expander to preserve the breast skin envelope. Then, once radiation therapy is over, the expander can be removed, and a flap reconstruction can be done as a delayed reconstruction.

This may help to preserve the breast skin as much as possible so less skin from the abdominal donor site will be needed. However, radiation therapy can also cause complications related to the tissue expander while it’s in place before the flap reconstruction.

Lymphatic surgery

Lymphedema

Some of the lymph vessels can become blocked when axillary lymph nodes are removed during breast surgery (with sentinel lymph node biopsy or axillary lymph node dissection) or are treated with radiation therapy. This may prevent lymph fluid from leaving the tissue in your arm below the area where the lymph nodes were removed.

Lymphedema occurs when lymph fluid collects in your arm, causing edema (swelling). Lymphedema can also occur in your hand, fingers, chest/breast or back.

Learn more about lymphedema.

Lymphatic surgery to reduce the risk of lymphedema

Lymphatic surgery is an emerging field. The goal of lymphatic surgery is to prevent or treat lymphedema.

Lymphatic surgery is performed by trained plastic surgeons using microsurgery and supermicrosurgery techniques.

Preventive lymphatic surgery involves connecting lymphatic channels to nearby veins. This procedure is called lymphatic microsurgical preventing healing approach (LYMPHA) [213]. It may be done at the time of axillary lymph node dissection in people at high risk of lymphedema.

Learn more about lymphedema.

Skin-sparing mastectomy

If you’re having immediate breast reconstruction, your surgeon may perform a skin-sparing mastectomy to keep as much of the skin of the breast as possible.

With a skin-sparing mastectomy, the tumor and clean margins are removed, along with the nipple, areola, fat and other tissue that make up the breast.

What remains is much of the skin that surrounded the breast. This skin can then be used to cover a tissue flap or an implant.

The major benefit of a skin-sparing mastectomy is that it avoids having to use skin from other parts of the body for reconstruction. That skin can have a different color, texture and thickness compared to natural breast skin, creating a “patch” look.

In the past, there were concerns skin-sparing mastectomy might increase the risk of breast cancer recurrence. However, most studies to date have not found an increased risk and the procedure is considered safe [10,214-216].

A skin-sparing mastectomy that leaves the nipple and areola intact is called a nipple-sparing mastectomy.

Nipple and areola reconstruction

Creating the nipple and areola is the last surgical step of breast reconstruction (if you choose to do this procedure).

These procedures give the reconstructed breast a more natural look and can help hide some of the mastectomy scars.

Nipple and areola reconstruction are usually outpatient procedures and have few risks [185]. However, those who have had radiation therapy may have more surgical risks, and these procedures may not be recommended.

Methods of recreating the nipple and areola

The nipple can be recreated using skin from the reconstructed breast itself after the implant or tissue flap reconstruction has healed.

The areola can be created with a tattoo or by grafting skin from the groin area. Skin in the groin area may have a similar tone as the skin on the areola. The scar from where the skin is taken can be hidden in the bikini line.

Not all women can have these procedures.

Women who can’t have nipple reconstruction surgery (or choose not to have it) can consider a 3-dimensional (3D) tattoo to create the look of the nipple and areola.

It’s a good idea to check with your insurance company before getting a 3D tattoo, as it may not be covered.

Read our blog, Corina’s Story: Breast Cancer Inspired Me to Help Others.

Nipple-sparing mastectomy

A nipple-sparing mastectomy is a skin-sparing mastectomy that leaves the nipple and areola intact. This usually improves the overall look of the reconstructed breast.

For women who are good candidates for nipple-sparing mastectomy, the risk of breast cancer recurrence appears to be low [217-221].

Learn about clinical trials for breast reconstruction.

Who can have a nipple-sparing mastectomy?

Not everyone can have a nipple-sparing mastectomy. For example, if the breast cancer is close to the nipple and areola, the nipple and areola are removed during surgery (to make sure all of the tumor is removed).

Nipple-sparing mastectomy is an option for [10,217-218,222-223]:

Some women with breast cancer who have small breasts and clean margins in the nipple area at the time of surgery
Women having a risk-reducing (preventive) mastectomy

Some women are not good candidates for nipple-sparing mastectomy because of the size and/or shape of their natural breasts. For example:

Women with large, sagging breasts may not be good candidates. These women may have an increased risk of the nipple moving out of position after surgery and an increased risk of nipple tissue loss due to a poor blood supply. Also, the excess skin may cause unevenness and problems with shaping the breast reconstruction.
Women with uneven breasts or uneven nipple positions before surgery (naturally or due to past surgery near the nipple and areola) may not be good candidates as the unevenness may become worse.
Women getting radiation therapy after a mastectomy may not be good candidates as radiation therapy may change the nipple position if a nipple-sparing mastectomy is done.

Some women who are poor candidates for nipple-sparing mastectomy due to the large, sagging shape of their natural breasts may have the option of getting breast reduction first, healing completely and then having a nipple-sparing mastectomy and reconstruction. However, this is only possible in the risk-reducing (preventive) mastectomy setting.

After a nipple-sparing mastectomy

With nipple-sparing mastectomy, the nipple will likely lose sensation and some projection. Sometimes, the position of the nipple can move after surgery.

In some cases, the tissue may lose its blood supply and become nonviable (the tissue dies), and some or all of the nipple and areola may need to be removed [217].

After breast reconstruction

Most women feel tired and sore for several weeks after breast reconstruction. Your surgeon or plastic surgeon may prescribe medications to ease the pain. You will need to limit upper body and arm activities after surgery.

Talk with your plastic surgeon about specific instructions after surgery.

You may need to wear a special bra while your reconstructed breast heals.

Surgical drains

For some types of surgery, you may still have surgical drains in place when you go home from the hospital. A drain is a small tube that allows extra fluid from the surgery to escape. This is fluid that the body cannot absorb.

You will have surgical drains in the reconstructed breast and in the donor tissue site (if you have a natural tissue flap reconstruction).

You will learn how to take care of the drains.

Pain and discomfort after surgery

You will likely have some pain after surgery. For most people, this pain is temporary and can be treated.

The bruising and swelling from the surgery may take up to 8 weeks to go away [224].

Learn about managing pain after surgery.

Getting back to your normal routine

Most women can get back to their normal activities within 8 weeks after surgery [224]. Overhead lifting, strenuous sports and sex should be avoided for 4-6 weeks [224].

Talk with your health care provider about activities to avoid and when you can get back to your normal routine.

Expectations

Although breast reconstruction techniques continue to improve, a reconstructed breast will never look or feel (have the same sensation) the same as your natural breast.

It’s important to have a realistic expectation of the final look of the breast. Reconstruction results vary and depend on the quality of the tissue left after a mastectomy.

How your reconstructed breast will look and feel (to the touch) depends on many factors including your natural breast anatomy and your treatment plan.

Sometimes, the types of treatments you will have (for example, radiation therapy) limit your reconstruction options and can impact the final look and feel of your reconstructed breast.

This can be upsetting. However, the goal of treatment is to get rid of the breast cancer and keep it from coming back.

Your plastic surgeon will help you choose the reconstruction method that will give you the best results, but your overall health and breast cancer treatment come first.

Final look of the breast

It will take some time to see the final results of your reconstructed breast.

How you feel about the final results may depend on your expectations. A reconstructed breast will never look or feel (to the touch) or have sensation the same as a natural breast.

Most of the scarring will fade and improve over time, but it doesn’t go away completely.

As you age and the opposite breast changes shape, the reconstructed breast may look and feel less natural.

Most women are satisfied with their reconstructed breasts [329].

Visit the FORCE website for a photo gallery of images of people who have had breast reconstruction after a mastectomy.

Numbness

Right after the mastectomy, you’ll be numb across your chest (from your collarbone to the top of your rib cage). This numbness usually doesn’t go away completely. You typically get some feeling back over time, but it won’t be the same as before surgery.

Researchers are studying whether the use of nerve grafts may improve breast sensation after a mastectomy and breast reconstruction.

Emotional impact

Most women have a period of emotional adjustment after breast reconstruction. Feeling anxious or depressed is common. Give yourself time and be gentle with yourself.

You may feel many different emotions at different times. You may be grieving the loss of your natural breast(s). You may be concerned about your appearance and feel vulnerable for a period of time.

You may not feel like being intimate or having sex as you adjust to the look and feel of your new breasts. It’s OK. It may help to talk with your partner about your feelings.

This is all normal. Social support can help with the emotional impact of breast reconstruction. It may help to talk with a counselor or other women who’ve had breast reconstruction.

It may be helpful to know that most women are satisfied with their reconstructed breasts [329].

Learn more about sexuality, intimacy and breast cancer.

Learn more about support.

Susan G. Komen^® Support Resources

Do you need help? We’re here for you. The Komen Patient Care Center is your trusted, go-to source for timely, accurate breast health and breast cancer information, services and resources. Our navigators offer free, personalized support to patients, caregivers and family members, including education, emotional support, financial assistance, help accessing care and more. Get connected to a Komen navigator by contacting the Breast Care Helpline at 1-877-465-6636 or email helpline@komen.org to get started. All calls are answered Monday through Thursday, 9 a.m. to 7 p.m. ET and Friday, 9 a.m. to 6 p.m. ET. Se habla español.
The Komen Breast Cancer and Komen Metastatic (Stage IV) Breast Cancer Facebook groups are places where those with breast cancer and their family and friends can talk with others for friendship and support.
Our fact sheets, booklets and other education materials offer additional information.

Insurance coverage for reconstructive surgery

Medicare and Medicaid

Medicare is health insurance provided by the federal government to people 65 and older. It covers breast reconstruction after a mastectomy.
Medicaid provides health care to people with low income. It’s run jointly by the federal and state governments, so benefits and eligibility (who can join) vary from state to state.

Many states require all health insurance companies, including Medicaid, to cover breast reconstruction after a mastectomy.

Women’s Health and Cancer Rights Act

The Women’s Health and Cancer Rights Act of 1998 requires group health plans, insurance companies and health maintenance organizations (HMOs) that pay for mastectomy to also pay for [225]:

Reconstruction of the breast removed with a mastectomy (all types)
Surgery and reconstruction of the opposite breast to get a symmetrical look
Breast prostheses
Treatment of any complications of surgery, including lymphedema

The Women’s Health and Cancer Rights Act doesn’t apply to some church and government insurance plans.

State laws

Many states require all health insurance companies (including those not covered under the Women’s Health and Cancer Rights Act) to pay for reconstructive surgery after a mastectomy.

Check with your state insurance commissioner’s office or your health insurance company to find out which services are covered by your state’s laws and your health plan.

Transportation, lodging, childcare and eldercare assistance

You may not live near the hospital where you’ll have your surgery. It’s OK to ask for help.

There may be resources available if you need a ride to and from surgery or help with childcare or eldercare. Family and friends often want to help but don’t know how. These are great ways for them to get involved.

There may be some programs that help with local or long-distance transportation and lodging (if you need a place to stay overnight).

There may also be programs to help you with childcare or eldercare costs.

Learn more about transportation, lodging, childcare and eldercare assistance programs.

Komen Financial Assistance Program

Susan G. Komen^®created the Komen Financial Assistance Program to help those struggling with the costs of breast cancer treatment by providing financial assistance to eligible individuals.

To learn more about this program and other helpful resources, call the Komen Breast Care Helpline at 1-877 GO KOMEN (1-877-465-6636) or email helpline@komen.org.

Se habla español.

Questions you may want to ask your plastic surgeon

What types of breast reconstruction can I have? Which types do you perform? Which types would require another plastic surgeon with special training to perform?
Which type is best for me and why?
When is the best time for me to have breast reconstruction — at the time of the mastectomy or later? Is there a time limit for having reconstruction done?
How many procedures are involved in the type of reconstruction I’m having?
How long will the reconstruction surgery (or mastectomy and reconstruction surgery) take?
How many hospital stays are needed? How long will each hospital stay be?
If I need to have radiation therapy after my mastectomy, how will that affect my reconstruction options and cosmetic outcomes?
How many of these procedures have you performed?
Would you please show me photos of both your best and your more typical results?
What are the chances of infection and failure with my reconstructive surgery? Are there other possible complications or side effects to consider?
If I have implant reconstruction, am I at risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)?
What are the short-term and long-term results with implant versus natural tissue reconstruction?
Will I have any surgical drains in place when I go home? If so, how many will I have and where will they be placed? How will I care for them? When will they be removed?
What can I expect regarding pain after surgery?
Will I have any numbness after surgery?
What side effects might I expect after surgery? What problems should I report to you right away?
What restrictions will I have on my activities after the surgery? For how long?
Where will the surgical scar(s) be?
What body changes should I expect after surgery?
How can I expect the reconstructed breast to look and feel? How will it look compared to my natural breast?
Will I be able to detect a possible return of cancer after reconstructive surgery?
What breast cancer screening is recommended for me?

Learn more about talking with your health care provider.

If you’ve been recently diagnosed with breast cancer or feel too overwhelmed to know where to begin to gather information, Susan G. Komen® has a Questions to Ask Your Doctor About Breast Reconstruction resource that might help.

You can download and print it to take with you to your next doctor’s appointment or you can save it on your computer, tablet or phone using an app such as Adobe. Plenty of space and a notes section are provided to write or type the answers to the questions.

There are other Questions to Ask Your Doctor resources on many different breast cancer topics you may wish to download.

Clinical trials

Susan G. Komen^® Patient Care Center

If you or a loved one needs information or resources about clinical trials, the Patient Care Center can help. Contact the Komen Breast Care Helpline at 1-877-465-6636 or email clinicaltrialinfo@komen.org.

Se habla español.

BreastCancerTrials.org in collaboration with Komen offers a custom matching service to help find clinical trials for breast reconstruction that fit your needs.

Learn what else Komen is doing to help people find and participate in breast cancer clinical trials, including trials supported by Komen.

Learn more about clinical trials and find a list of resources to help you find a clinical trial.

Komen Perspectives

Read our perspective on clinical trials.*

Learn More

* Please note, the information provided within Komen Perspectives articles is only current as of the date of posting. Therefore, some information may be out of date.

Updated 06/06/24

TOOLS & RESOURCES

Fact Sheet

Breast Reconstruction or Prosthesis After Mastectomy

Questions to Ask Your Doctor

Breast Reconstruction

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