OVERVIEW

Of the estimated 330,000 American women who will be diagnosed with in situ or invasive breast cancer this year,1 more than 100,000 will undergo a mastectomy (surgery that removes the entire breast to treat or prevent breast cancer). Women who get a mastectomy have the option to restore one or both breasts to near normal shape, size and appearance through breast reconstruction surgery. Women undergoing a lumpectomy (the removal of the breast section that contains the tumor) also have the option of breast reconstruction in the form of implants, a bilateral breast reduction or breast lift procedure.

Breast reconstruction can be an important part of a woman's overall care plan when she is affected by breast cancer. Many studies have found that breast reconstruction surgery improves a woman's well-being and enables her to retain her sense of self after breast cancer. Although a reconstructed breast will not look or feel the same as your natural breast, there are many surgical options to rebuild your breast to near normal shape, appearance, symmetry and size.

Breast reconstruction is not a one-size-fits all procedure: there are many surgical techniques to rebuild your breasts and the surgery can be done either at the same time as the mastectomy/lumpectomy or months or even years later. Breast reconstruction may be one surgery or a series of surgeries that restores shape to your breast(s). During reconstructive surgery, a plastic surgeon creates a breast shape using an artificial implant, a flap of tissue from another place on your body, or a combination of both methods. Due to advances in techniques, there has been a steady growth in breast reconstruction over the past two decades. According to the American Society of Plastic Surgeons (ASPS), more than 100,000 breast reconstruction procedures were performed in the US in 2018, a jump of 29 percent over 2017.

Candidates for Breast Reconstruction

Most women are a candidate for some type of breast reconstruction. In fact, a 2016 study in the Journal of the American College of Surgeons finds that older and younger women benefit equally from breast reconstruction and that age should not disqualify a woman from having reconstruction.

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PROCEDURES

Breast Reconstruction Procedures

There are many different techniques to reconstruct the shape of your breast(s) depending on whether the surgery is performed with breast implants or natural tissue flaps.

  1. Breast Reconstruction Using Implants
    This type of operation, known as "implant-based breast reconstruction," uses both saline and silicone-gel implants for breast reconstruction. There are several techniques that can be used:
    • Immediate Breast Reconstruction
      Also known as "direct-to-implant reconstruction," the surgery is done, or at least started, at the same time as the mastectomy. This surgery allows the breast skin to be preserved, which produces better-looking results. After the breast tissue is removed, a plastic surgeon places the breast implant under the skin or above or below the pectoral muscle on the chest. An absorbable mesh is sometimes used to hold the implant in place, much like a hammock or sling. With some techniques, the surgery is a one-staged procedure, but others require an additional surgery to achieve the final shape and appearance of the breast.

    • Delayed Breast Reconstruction –
      "Delayed breast reconstruction" takes place after mastectomy, allowing time for women to undergo chemotherapy or radiation therapy as part of their treatment plan. With this type of reconstruction, the surgeon inserts an inflatable tissue expander during mastectomy to make room for a future breast implant. Designed to stretch the skin and chest muscle over weeks or months, the tissue expander is a balloon-like sac with a tiny valve that allows a member of the breast care team to inject a salt-water solution gradually to fill the expander. Once the skin over the breast area has stretched enough and the woman is ready for reconstruction, a second surgery is done to remove the expander and put in the permanent implant.

    • Tissue Support for Implants –
      There are times when added skin tissue is needed for implant-based breast reconstruction. In some cases, surgeons use a woman's own body tissues, from the abdomen or back, to create a kind of pocket to hold the implant in place or for added skin coverage over the implant. Another option is to use donated human skin or pig skin, called "acellular dermal matrix products," where the human or pig cells have been removed to reduce any risk of disease. This tissue extends and supports natural tissues and help them grow and heal.
  2. Breast Reconstruction With Tissue Flap Procedures –
    A tissue flap procedure, also known as "autologous tissue reconstruction," uses skin and soft tissue flaps from your abdomen, back, thighs, buttocks and other parts of the body to create a mound to reconstruct the breast. There is a more natural look and feel of the reconstructed breast with flap procedures, and in some cases, an implant is used with the flap. However, tissue flap procedures are more invasive than implant-based breast reconstruction and leave scars on the body where the tissue was taken. The most common types of tissue flap procedures are:
    • The TRAM (transverse rectus abdominis muscle) flap, which uses tissue from the abdomen

    • The DIEP (deep inferior epigastric perforator) flap, which uses tissue from the abdomen

    • The latissimus dorsi flap, which uses tissue from the upper back

    • GAP (gluteal artery perforator) flaps (also known as a gluteal free flaps), which uses tissue from the buttocks

    • TUG (transverse upper gracilis) flaps, which uses tissue from the inner thigh

    • Fat grafting, which is a newer technique that uses liposuction to obtain fat from a part of the body (buttocks, thighs or abdomen) and injects the fat into the reconstructed breast to help fix any shape abnormalities.
    During mastectomy, the nipple is typically removed along with the breast. Therefore, the final phase of reconstruction surgery is an outpatient procedure to recreate the nipple. For many women, nipple reconstruction surgery entails taking tissue from the newly created breast, and less frequently from another part of the body, to rebuild the nipple and areola. The surgeon tries to match the position, size, shape, texture, color, and projection of the new nipple to the remaining natural breast or to the other breast (if the procedure follows a double mastectomy). Another option is a 3D nipple tattoo, which is a real tattoo that is permanent and usually does not fade. 3D nipple tattoos use oscillating needles coated with pigment, which are inserted into the skin to create the appearance of a nipple and can look quite real.

Procedure Steps

A breast reconstruction procedure includes the following steps:

1. Anesthesia
Medications are administered for your comfort during the surgical procedure. The choices include intravenous sedation and general anesthesia. Your doctor will recommend the best choice for you.

2. Flap techniques reposition a woman's own tissue to create or cover the breast mound
Sometimes a mastectomy or radiation therapy will leave insufficient tissue on the chest wall to cover and support a breast implant. In these cases, breast reconstruction usually requires either a flap technique or tissue expansion.

A TRAM flap uses donor muscle, fat and skin from a woman's lower abdomen to reconstruct the breast. The flap may either remain attached to the original blood supply and be tunneled up through the chest wall, or be completely detached, and formed into a breast mound.

Alternatively, your surgeon may choose the DIEP flap or SIEA flap techniques, which do not use abdominal muscle but transfer only skin and fat to the chest from the abdomen. If there is insufficient tissue on the lower abdomen, other donor sites such as the buttocks or thighs may be selected (SGAP flap, TUG flap, PAP flap).
A latissimus dorsi flap uses muscle, fat and skin from the back tunneled to the mastectomy site and remains attached to its donor site, leaving blood supply intact.

Latissimus dorsi flap

A latissimus dorsi flap uses muscle, fat and skin from the back tunneled to the mastectomy site and remains attached to its donor site, leaving blood supply intact.

Latissimus dorsi flap back view

Occasionally, the flap can reconstruct a complete breast mound, but often the latissimus flap provides the muscle and tissue necessary to cover and support a breast implant.

Latissimus dorsi flap front view

3. Tissue expansion stretches healthy skin to provide coverage for a breast implant
For women who do not require breast radiation and would like to avoid a separate donor site, implant-based reconstruction is an option. Reconstruction with tissue expansion allows an easier recovery than flap procedures, but it can be more lengthy reconstruction process.

It usually requires several office visits over 1-2 months after placement of the expander to gradually fill the device with saline through an internal valve to expand the skin. Newer air-filled devices may allow patient-controlled expansion at home using a remote dosage controller.

A second surgical procedure will be needed to replace the expander if it is not designed to serve as a permanent implant.

4. Surgical placement of a breast implant creates a breast mound
A breast implant can be an addition or alternative to flap techniques. Surgeons may also use an implant as a temporary placeholder during other breast cancer treatments until you are ready for more involved flap reconstruction techniques. Saline and silicone implants are available for reconstruction.

Your surgeon will help you decide what is best for you. Reconstruction with an implant alone usually requires tissue expansion. Direct-to-implant breast reconstruction may be an option for some women undergoing mastectomy with certain tumor characteristics and breast shapes.

Creating a breast mound

5. Reconstructing a nipple and areola, breast revision techniques

For women who are not candidates for nipple-sparing mastectomy, breast reconstruction is completed through a variety of techniques that reconstruct the nipple and areola. Techniques usually involve folding skin to create the shape of a nipple followed by tattooing. Three-dimensional nipple-areolar tattooing may be used alone to create the appearance of a realistic nipple with the illusion of projection. Breast reconstruction outcomes can often be enhanced with staged revision procedures that improve symmetry, use liposuction with fat grafting and improve the appearance of the donor site.

Risks and Safety

The possible risks of breast reconstruction include:

  • Bleeding
  • Infection
  • Blood clots
  • Fluid build-up with swelling and pain in the breast or the area of your body where tissue was taken for a tissue flap
  • Wound healing problems
  • Anesthesia risks

Further, flap surgery can lead to partial or complete loss of sensation where the tissue was taken from and on the reconstructed breast. There is also the risk for lumps in the reconstructed breast if the blood supply to some of the fat used to rebuild the breast is cut off over time and is replaced by scar tissue. This is called fat necrosis.

IMPLANTS

Implant Risks and Safety

With implant-based breast reconstruction, surgery carries the risks associated with implants, which are medical devices that are regulated by the FDA and only approved after extensive safety testing. Under what is called the Premarket Approval Process (PMA), the FDA requires the manufacturer to conduct clinical trials and other studies before approval to demonstrate that the implant is safe and effective. This is followed by post-marketing studies that monitor the safety of the implant once it is on the market.

As with any medical device, breast implants can pose health risks. Further, because breast implants are not designed to last a lifetime, the risk of complications goes up the longer the implants are in place. The most likely complications include:

  • Scar tissue that distorts the shape of the breast implant (capsular contracture)
  • Rupture of the saline or silicone-filled implants or implant leakage
  • Changes in nipple and breast sensation, which are often temporary
  • Breast pain
  • Infection

In light of these potential problems, women who have silicone gel-filled implants will need to get an MRI scan three years after the surgery and then MRI scans about every two years to check for silent rupture (one that is not causing signs or symptoms).

Besides these complications, questions have been raised about a possible link between breast implants and such conditions as lupus, rheumatoid arthritis and other connective tissue (autoimmune) diseases. This concern has prompted extensive scientific research, including a thorough review by the Institute of Medicine (IOM) in 2000 and an FDA evaluation in 2019. Based on the evidence to date, the FDA concludes there is not enough evidence to show an association between breast implants and autoimmune diseases.

Another area of study involves a cluster of symptoms – fatigue, memory loss, rash, photosensitivity, chronic pain, sleep disturbances and other problems – reported by some women who received breast implants for breast augmentation and unofficially called "breast implant illness" or BII. Scientists are investigating the range of symptoms to better understand their origins.

About Breast Implant Associated Lymphoma (BIA-ALCL)

In 2019, the FDA updated its safety information on breast implants due to research establishing a link between certain saline and silicone-gel breast implants and a rare cancer called breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Found in women with textured (have a rough surface) implants, BIA-ALCL is not a cancer of the breast tissue. Rather, it is a slow-growing cancer of the lymph system that when caught early, can be cured in most women.

BIA-ALCL develops in the scar tissue that naturally forms around the implant and may affect the lymph nodes but rarely spreads to tissues further away. Common symptoms include:

  • Breast enlargement
  • Hardening of the breast
  • Lump in the breast or armpit
  • Pain in the area of the beast
  • Overlying skin rash
  • A large fluid collection, usually more than a year after receiving the implant

In most women, BIA-ALCL is treated successfully with surgery to remove the implant and surrounding scar tissue. However, some women also require chemotherapy and radiation therapy. Following treatment, women are commonly followed for two years with imaging tests.

The FDA urges all women who have implants or are thinking about getting them to be aware of the risks and symptoms of BIA-ALCL.

On July 24, 2019, Allergan issued a voluntary worldwide withdrawal of its BIOCELL® textured breast implants and tissue expanders. Through this withdrawal, Allergan stopped the distribution or sale of all BIOCELL® saline-filled and silicone-filled textured implants and tissue expanders around the world and asked cosmetic surgeons to return any unused BIOCELL® implants to the company. Allergan took this step as a precaution following notification of recently updated global safety information concerning the uncommon incidence of BIA-ALCL provided by the FDA. Allergan's announcement with the list of the recalled implants is here.

For women who have BIOCELL®, the FDA concluded that the risk of developing BIA-ALCL is low. Therefore, the agency did not recommend removal of BIOCELL® saline-filled and silicone-filled textured implants. The exception is if a woman with these implants experiences the symptoms of BIA-ALCL, which include pain, lumps, swelling, fluid collections or unexpected changes in breast shape, including asymmetry. In this case, women are urged to contact their plastic surgeon.

More information about BIA-ALCL is available at PlasticSurgery.org/ALCL. This includes links to FDA resources that provide recommendations for patients with BIOCELL® textured implants, as well as recommendations for health care providers and anyone with implants in general.

AFTER SURGERY CARE

Knowing about the recovery time and the need for follow-up care and screenings is important when planning for breast reconstruction surgery. Although the time for recovery will depend on the type of reconstruction you have, in general, most women start to feel better in a couple of weeks following surgery and are able to return to work and normal life after six weeks. By the end of the third month, the reconstructed breast has time to heal, allowing for nipple reconstruction, which is usually the final stage of breast reconstruction. At the end of a year, most women stop seeing their plastic surgeon for regular checkups.

On an ongoing basis, practicing good self-care includes performing monthly breast self-exams and having an annual breast exam by your healthcare provider. Mammograms are not needed for reconstructed breasts. However, breast specialists recommend screening tests as follows:

  • A yearly cancer screening with mammography or another imaging test, like an MRI, for women who have one normal breast (reconstruction in the other breast) or a lumpectomy with some reconstruction.
  • An MRI scan three years after implant-based breast reconstruction with silicone gel-filled implants and then MRI scans about every two years to check for silent rupture.

Explant Surgery

Breast implants are not lifelong devices. On average, the majority of implants will last from 10 to 20 years without complications. But over time, breast implants can change shape or size, overlying breast tissue can change, or the outside shell of the implant may break down causing silicone to leak and the scar tissue around the implant to harden. The American Society of Plastic Surgery states it is important to have breast implants exchanged or removed approximately every 10 to 15 years.

In the breast cancer community, the word "explant" refers to a woman's decision to remove the breast implant after reconstruction surgery, due to such problems as numbness, pain, implant rupture, capsular contracture, inflammation around the implants, and concern about breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). In 2018, 19,149 women had their implants removed, according to the American Society of Plastic Surgeons.

Usually performed on an outpatient basis, explant surgery involves the surgeon removing the implant by making an incision along the lower fold of the breast (the inflammatory fold) or around or below the areola. The surgeon may also remove silicone material if the woman has an implant that may have leaked. The possible risks of explant surgery include bleeding, blood clots, infection, skin loss, skin discoloration and prolonged swelling, numbness and fat necrosis (a lump of dead or damaged breast tissue).

PAYING FOR RECONSTRUCTION

Although breast reconstruction is considered part of treatment for invasive breast cancer, studies show that less than half of all women who required mastectomy in 2017 were offered breast reconstruction surgery, and fewer than 20 percent elected to undergo immediate reconstruction. A key reason for the gap is many women are not aware that breast reconstruction is covered under most health plans. This is true regardless of whether reconstruction occurs when the mastectomy is performed, soon after breast cancer surgery, or many years later.

Under federal law, the Women's Health and Cancer Rights Act of 1998 requires most group insurance plans that cover mastectomies to also cover breast reconstruction. At the same time, Medicare covers breast reconstruction, while Medicaid coverage can vary from state to state.

Also, under the Affordable Care Act (ACA), group health plans, health insurance companies, and HMOs that cover the costs for mastectomy must also cover reconstruction, although there may be a yearly deductible and you may have some out-of-pocket costs.

Specifically, the ACA requires coverage for:

  • Reconstruction of the breast removed by mastectomy
  • Surgery and reconstruction of the other breast so the breasts look symmetrical
  • Breast forms that fit into your bra that are needed before and during reconstruction
  • The complications of mastectomy, including lymphedema (fluid build-up in the arm and chest on the side of the surgery)

It is still possible to experience coverage issues, especially if the plastic surgeon is outside your health plan's network. For this reason, it is important to check with your health plan before the surgery to find out exactly what is covered or to work with the specialist in your plastic surgeon's office who handles insurance claims. Most hospitals also have social workers or financial assistance counselors who can help explain your options and direct you to resources that provide assistance in paying for medical care.

If your health plan refuses to cover breast reconstruction, you have the right to appeal the insurance company's decision. To find out what to do, Facing Our Risk of Cancer Empowered (FORCE) has a health insurance appeals page with information on insurance appeals.

DECISION-MAKING

When diagnosed with invasive breast cancer, many women opt for breast reconstruction surgery after a mastectomy. There a number of reasons a woman may choose to get surgery: to restore the look and shape of her breast(s); to feel better about her body; to give her chest a balanced look; and to renew her self-confidence. Additionally, women at extremely high risk of developing inherited breast cancer often elect to have both breasts removed (bilateral mastectomy) as a preventive measure and then undergo breast reconstruction to rebuild the shape of the breasts. Breast reconstruction is major surgery and requires having all the facts before making decisions about the type of procedure and where and when to have the operation.

Weighing Your Options

If you are considering breast reconstruction surgery, it is best to discuss options before having a mastectomy. This is because you may have a choice of having breast removal and reconstruction surgeries at the same time. Even if you decide to wait and have reconstruction later, it is important to know the possibilities so you can plan for the treatment course ahead. Here is what you need to know to take charge of the decision-making process.

Choosing A Qualified Plastic Surgeon

Because breast reconstruction is a complex surgical procedure, a key first step is selecting a plastic surgeon with the training and technical skill to restore the near normal shape and appearance of your breast(s) after mastectomy.

The surgeon performing your mastectomy may already work with a plastic surgeon as part of the breast cancer care team. However, in most cases, identifying a plastic surgeon who specializes in reconstruction is up to you. This requires thoroughly "vetting" (evaluating) a list of recommended plastic surgeons to learn about their training in reconstruction surgery, their skills and knowledge, their hospital affiliations, and past work.

To begin this process, ask your breast surgeon for a list of plastic surgeons and get referrals from your oncologist. You can also read reviews of plastic surgeons in your region, search the websites of local medical centers, and get recommendations from women in the area who had reconstruction surgery. Once you have the names of some recommended plastic surgeons, schedule a consultation with each potential surgeon so you can ask your questions, discuss your goals and concerns, and learn more about the surgery and your options.

What to Expect During a Consultation for Breast Reconstruction

A consultation with a plastic surgeon who specializes in breast reconstruction involves a meeting to understand all aspects of surgery and get a professional opinion on a recommended procedure specific to your needs.

During the consultation, the plastic surgeon will review your medical history and overall health, describe the different types of surgical procedures, and discuss the reconstruction options he or she recommends. The surgeon will also address whether immediate reconstruction (at the time of mastectomy) is an option, or delaying reconstruction is suggested. In the case of breast cancer patients, decisions about timing are usually based on factors that can delay healing, such as being a smoker or being treated with chemotherapy or radiation.

More importantly, the consult is your time to ask questions, learn about the surgeon's expertise in breast reconstruction, and "get a feel" of the surgeon's style and openness. To make the most of these meetings, remember to:

  • Bring information about your medical history with you or ask if you can fill out your medical information in advance.
  • Compile a full list of medications and supplements you are taking.
  • Write down a list of questions to ask the surgeon and bring the list to the consult.
  • Use the same list of questions for each surgeon you meet with so you can compare the different surgeons' experience, techniques, approaches and personal styles.

Getting the Answers

Because there are many factors to consider when choosing the surgeon and type of procedure, specialists in breast health recommend following these steps to guide your decision-making:

  • Look for board certification in plastic surgery. Before scheduling a consultation, make sure the surgeon is board certified by the American Board of Plastic Surgery. This means the surgeon graduated from an accredited medical school, completed at least six years of surgical training after medical school (with a minimum of three years of plastic surgery residency training), passed oral and written exams, and performs surgery in accredited, state-licensed, or Medicare-certified surgical facilities. Also, check if the surgeon is a member of the American Society of Plastic Surgeons, which requires the surgeon to follow rigorous training and patient safety standards.

  • Ask about the surgeon's experience. When choosing a plastic surgeon, an important factor is the surgeon's level of skill and the range of reconstruction procedures he or she performs. In many practices, a surgeon either specializes in implant surgeries or mostly knows how to perform tissue flaps. For this reason, be prepared to ask questions about which procedures the surgeon does the most. Of equal importance is finding specialists who spend a lot of time performing breast reconstructions. This means asking how many reconstructions the surgeon performs each month and the percentage of his or her time spent on reconstruction surgery.

  • Study the surgeon's style and approach . During the consultation, ask to review the surgeon's gallery of patient cases and before-and-after photos to get a sampling of his or her work.

  • Get different professional opinions. Having a range of recommendations is a good way to understand the options available to you.

  • Find a surgeon you trust . Finding a surgeon that you connect with and have easy communication with can improve your experience. The right surgeon will understand your goals, encourage open discussions about your concerns, give you honest and straightforward guidance on the best surgical approach, and give you a realistic perspective on timeline for recovery and results you can expect.

Making the Decision

If you are considering breast reconstruction during or after mastectomy or are thinking about a preventive (prophylactic) mastectomy with reconstruction to eliminate risk of an inherited cancer, it is important to have the facts. This means asking a lot of questions – about the surgeon's qualifications and experience, your options for surgery, how the different procedures are performed, potential complications and recovery time, and what is covered by your insurance plan.

The other option is not to have reconstruction surgery – either because you are not sure about reconstruction or you decided to "go flat" and possibly wear a breast form inserted into a bra. If you may want reconstruction in the future, the choice is breast mound reconstruction where the plastic surgeon performs a skin sparing procedure to keep some of the tissue to create a new breast at a later time.

However, if you choose to go flat, it is important to make your wishes known in writing to ensure the surgeon creates a flat contour on the chest wall. If this does not happen, women undergoing mastectomy may experience concavity where the chest muscles and ribcage are more exposed, large tabs of skin on the chest bulge significantly, or large pockets of fat, called “dog ears," wrap around under the arm and are unsightly and very uncomfortable. Preventing these problems requires talking to the breast surgeon or a plastic surgeon about procedures that remove excess tissue in advance of the mastectomy, such as having an aesthetic flat closure that rebuilds the shape of the chest wall after one or both breasts are removed.

Whatever your reconstruction options, HealthyWomen created these lists of questions to ask a surgeon or healthcare provider about breast reconstruction. The goal is to have the answers so you can make the best decisions for you and your body.

QUESTIONS TO ASK

Questions to Ask Yourself

Regardless of why you had a mastectomy, the decision to undergo breast reconstructive surgery, use a breast prosthesis under your clothes or make no changes after mastectomy can be complex and difficult.

In making the decision, ask yourself the following questions:

  • How do I feel about my breasts?
  • How important are my breasts to my self-image?
  • What will it be like living without one or both breasts after surgery?
  • Will I be able to exercise with a prosthesis?
  • Am I willing to undergo the surgery and recovery that is required?
  • Will the fact that I may not have much sensation in the reconstructed breast bother me?

Questions to Ask About Breast Reconstruction After Mastectomy

To help you make the most informed and intelligent decisions about having breast reconstruction surgery, use this checklist to guide your discussion with the plastic surgeon:

Questions About the Surgeon's Training and Performance

  1. Are you certified by the American Board of Plastic Surgery?
  2. How many years of plastic surgery training do you have?
  3. How long have you been performing breast reconstruction surgery?
  4. How many breast reconstruction surgeries do you do a year?
  5. Which types of reconstruction are you most experienced in?
  6. Do you have hospital privileges to perform this surgery? If so, at what hospitals?
  7. Is your office surgical facility accredited by a nationally- or state-recognized accrediting agency, or is it state-licensed or Medicare-certified?
  8. Can I see some patient before-and-after photos?
  9. What are my options if I am dissatisfied with the outcome of the surgery?

Questions About the Surgery

  1. What kind of breast reconstruction can I have?
  2. Which type is best for me and why?
  3. When is the best time for me to have breast reconstruction, at the time of the mastectomy or later?
  4. Is there a time limit for having reconstruction surgery?
  5. What are the short and long-term results of implants versus natural tissue reconstruction?
  6. Can I have the nipple reconstructed? How would this be done?
  7. How many procedures are involved in the type of reconstruction I am having?
  8. How many hospital stays are needed? How long will each hospital stay be?
  9. What are the risks and complications with this procedure?
  10. Will I have a surgical drain when I go home? When will it be removed?
  11. Is there a lot of pain after surgery?
  12. How long of a recovery period can I expect, including time away from work? What kind of help will I need during my recovery?
  13. Where will the scars be?

Questions About Expected Outcomes

  1. Will I have numbness after surgery?
  2. What body changes should I expect?
  3. How will my reconstructed breast(s) feel to the touch? Will I have any feeling in this breast?
  4. How will my reconstructed breast(s) look compared with my natural breast(s)?
  5. What kinds of changes to the breast(s) can I expect over time?
  6. How will aging affect my reconstructed breast(s)?
  7. What breast cancer screening is recommended for me?
  8. What kind of additional follow-up will I need?
  9. (For implants) How often will I need to have the reconstructed breast(s) checked for any leaks or other problems?
  10. (For implants) How long should I anticipate the implant will last?

Questions to Ask About Reconstruction and Bilateral Mastectomy

Finding out you are at high risk for inherited breast cancer leads to difficult decisions, including whether to have preventive (prophylactic) mastectomy to remove one or both breasts combined with breast reconstruction surgery. Use this checklist to discuss this option with your breast health specialist, genetic counselor, breast surgeon and plastic surgeon to guide your decision-making:

Questions About the Surgery

  1. How much will preventive mastectomy reduce my risk of breast cancer?
  2. What are the risks of having a preventive mastectomy?
  3. Are there other options for reducing the risk of breast cancer?
  4. What are my options for breast reconstruction following bilateral preventive mastectomy?
  5. Can I have breast reconstruction at the same time as the mastectomy?
  6. How long can I delay breast reconstruction after bilateral preventive mastectomy?
  7. What are the short and long-term results of implants versus natural tissue reconstruction?
  8. Can I have the nipple reconstructed? How would this be done?
  9. How many procedures are involved in breast reconstruction after preventive mastectomy?
  10. How many hospital stays are needed? How long will each hospital stay be?
  11. What are the risks and complications with this procedure?
  12. Will I have a surgical drain when I go home? When will it be removed?
  13. Is there a lot of pain after surgery?
  14. How long of a recovery period can I expect, including time away from work? What kind of help will I need during my recovery?
  15. Where will the scars be?

Questions About Expected Outcomes

  1. Will I have numbness after surgery?
  2. What body changes should I expect?
  3. How will my reconstructed breast(s) feel to the touch? Will I have any feeling in this breast?
  4. How will my reconstructed breast(s) look?
  5. What kinds of changes to the breasts can I expect over time?
  6. How will aging affect my reconstructed breast(s)?
  7. What kind of additional follow-up will I need?
  8. (For implants) How often will I need to have the reconstructed breast checked for any leaks or other problems?
  9. (For implants) How long should I anticipate the implant will last?

Questions About the Surgeon's Training and Performance

  1. Are you certified by the American Board of Plastic Surgery?
  2. How many years of plastic surgery training do you have?
  3. How long have you been performing breast reconstruction surgery?
  4. How many breast reconstruction surgeries do you do a year?
  5. Which types of reconstruction are you most experienced in?
  6. Do you have hospital privileges to perform this surgery? If so, at what hospitals?
  7. Is your office surgical facility accredited by a nationally- or state-recognized accrediting agency, or is it state-licensed or Medicare-certified?
  8. Can I see some before-and-after photos?
  9. What are my options if I am dissatisfied with the outcome of the surgery?

Questions to Ask About Not Having Breast Reconstruction

While most women choose to have some type of reconstruction after a mastectomy, you may decide to wait and see or opt to "go flat" and possibly wear an artificial breast inserted into a bra.
If you may want reconstruction in the future, the choice is to leave some tissue that can be used to create a new breast later. Deciding to go flat, however, means talking to the breast surgeon or a plastic surgeon about procedures that remove excess tissue, such as having an aesthetic flat closure that rebuilds the shape of the chest wall after one or both breasts are removed. Use this list of questions to have a candid conversation about your options:

Questions About the Surgeon's Training and Performance

  1. Are you board certified?
  2. How many years of breast surgery or plastic training do you have?
  3. Do you perform flat closures after mastectomy? How long have you been doing this procedure?
  4. Do you have hospital privileges to perform this surgery? If so, at what hospitals?
  5. Is your office surgical facility accredited by a nationally- or state-recognized accrediting agency, or is it state-licensed or Medicare-certified?
  6. Can I see some before-and-after photos?
  7. What are my options if I am dissatisfied with the outcome of the surgery?

Questions About Choosing No Reconstruction

  1. How many women treated by your practice have opted for no reconstruction?
  2. How will you make sure that the mastectomy scars lay flat on my chest?
  3. Are you able to create a flat contour on the chest wall in one surgery? If not, how many?
  4. Should I expect concavity? How will this be addressed?
  5. How far will the incisions extend on the lateral chest to get a flat contour?
  6. Can I have nipples made? If so, when it this done? How is this done? Where is this done?
  7. How long after the nipples are made can the tattooing being done?
  8. What are the risks and complications of the flat closure procedure?
  9. How long of a recovery period can I expect?

Questions About Expected Outcomes

  1. How much pain will I experience following surgery?
  2. What results are realistic for me?
  3. How will my chest area feel to the touch? Will I have any feeling in the chest area?
  4. What kind of additional follow-up will I need?

Questions to Ask About Cost and Coverage Issues

Under federal law, most health plans must cover breast reconstruction, including surgery and reconstruction of the other breast to make the breasts look symmetrical, breast forms (breast prostheses), and treatment for complications of mastectomy and breast reconstruction. Many states also require employer health plans to cover breast reconstruction. Yet, no federal law requires coverage of reconstruction after prophylactic mastectomy and state laws vary regarding this type of surgery. Therefore, it is important to know what your health plan will cover and what costs you will be responsible for paying. Here are questions to ask your plastic surgeon and your insurance company:

Questions to Ask the Surgeon

  1. What do you charge for a surgical consult?
  2. If I choose you as my surgeon, will the consult fee be waived?
  3. What are the costs involved with breast reconstruction?
  4. What is included in the surgical fee? What is not covered?
  5. Will my health plan cover surgery on the non-reconstructed breast?
  6. How much is the cost of anesthesia? Do I pay this separately?
  7. Are there any other costs I should know about? For lab work, postoperative checkups, additional medications?
  8. Are all the specialists involved in my operation (anesthesia, pathology, radiology) covered by my insurance?
  9. Will I be billed separately for the professional services of others involved in my case?
  10. What is the difference in cost between having the surgery in your office versus a hospital?
  11. How much is the surgical deposit fee? When will I have to pay this?
  12. If I change my mind and cancel the surgery, will my money be refunded?
  13. If I am not satisfied and need revision surgery, is that included in the initial fee?
  14. Will your administrative staff offer me help on my health insurance claim?

Questions to Ask Your Health Plan

  1. Does my health plan cover reconstruction surgery after mastectomy?
  2. Does my health plan cover surgery on the non-reconstructed breast?
  3. Does my health plan cover reconstruction surgery for prophylactic mastectomy?
  4. Does the health plan cover breast prothesis?
  5. Are there any costs the plan will not cover?
  6. Will I have a deductible for this surgery? If so, what is the amount?
  7. Will I have a co-pay for the costs of the surgery? If so, what is the amount?
  8. Will the plan pay for a second opinion?
  9. Is my surgeon in the health plan's network of doctors? If not, what percentage of the surgeon's fees will the plan cover?
  10. Are all the specialists involved in my operation (anesthesia, pathology, radiology) in the plan's network? If not, what does this mean in terns of costs for me?

SUPPORT AND COMMUNITY

Becoming Your Best Self

There are many factors to consider when thinking about breast reconstruction surgery – including your different surgical options, when to have the surgery, whether you will you need several surgeries to get the desired results, and the cost. You may also want to consider not having reconstruction and going breast-free or giving yourself time to get reconstruction at a later date.

Although these considerations may seem daunting, there is a way to take control. It is called patient empowerment and is defined by the World Health Organization (WHO) as "a process through which people gain greater control over the decisions and actions affecting their health.

What is necessary to be empowered about breast surgery? Research shows that empowered patients do online research, ask a lot of questions, are in contact with other patients, talk to their healthcare providers about options, often seek a second opinion, and access their own health data (like electronic health records). Going through these steps is especially important when considering breast reconstruction because it prepares you to make informed discussions and be involved in your care.

Whether you are just beginning to think about having breast reconstruction, are interviewing potential plastic surgeons, or looking into the option of going breast-free, HealthyWomen has assembled links to evidence-based information from leading medical societies and breast health organizations so you will have the resources you need. Knowledge is power and the way to become your best self.

  • The Aesthetic Society: Professional organization of board-certified plastic surgeons who are solely dedicated to the art, science, and safe practice of aesthetic surgery and cosmetic medicine of the face and body. Their mission includes medical education, public education and patient advocacy.
  • American Society of Plastic Surgeons: The largest plastic surgery specialty organization in the world; advances quality care to plastic surgery patients by encouraging high standards of training, ethics, physician practice and research in plastic surgery.
  • Breastcancer.org: A resource designed to help people make sense of the complex medical and personal information about breast health and breast cancer, so they can make the best decisions for their lives.
  • FORCE: A resource for improving the lives of individuals and families affected by hereditary breast, ovarian, and related cancers by improving awareness, supplying information and support, advocating for and supporting research, and working with the research and medical communities to help people dealing with hereditary breast, ovarian and related cancers.
  • Living Beyond Breast Cancer: A resource for connecting people with trusted breast cancer information and a community of support.
  • Susan G. Komen Foundation: Organization with a mission to save lives by meeting the most critical needs in our communities and investing in breakthrough research to prevent and cure breast cancer.

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