Breast reconstruction is a procedure used to restore and improve the shape of the breasts following a mastectomy for breast cancer treatment, trauma, or medical conditions causing loss of breast tissue.
Breast surgery is part of the standard treatment for most women with breast cancer. Surgery may include mastectomy – where the entire breast is removed – and lumpectomy or segmental mastectomy – where only a portion of the breast is removed – followed by radiation. About half of women in the U.S. with breast cancer undergo total mastectomy. (1)
For cancer patients, cancer survivors, and trauma survivors, breast reconstruction provides the possibility of restoring the breasts to a natural and feminine shape, improving their self-confidence. In the U.S., about 40% of women who have undergone a mastectomy have gone on to have breast reconstruction surgery. (1)
During breast reconstruction, additional tissue and/or implants are added to the breast area to increase breast volume. The natural tissues of the breast area are also sculpted to optimize the appearance of the breasts.
Candidates for breast reconstruction are seeking a more natural silhouette by restoring the normal shape, size, and appearance of the breasts. Whether the breast has been removed to treat breast cancer or as a pre-emptive treatment in women with a high risk of cancer due to family history, breast reconstruction can restore the natural look of the breast. This procedure is available for women who have lost one or both breasts.
Unlike many other plastic surgery options, breast reconstruction is not intended for purely cosmetic purposes. Breast reconstruction following mastectomy has been shown to have lasting benefits that include improved self-esteem, body image, sexuality, and even quality of life. (2)
If you are facing mastectomy surgery for any reason, you may wish to consult with a plastic surgeon to determine whether breast reconstruction during or after your mastectomy is right for you.
Breast reconstruction can be performed either at the time of the mastectomy – immediate reconstruction – or at a later time – delayed construction. (3) Most (about 75%) of women in the U.S. opt for immediate reconstruction. (4) Immediate reconstruction is generally associated with better esthetic outcomes, better psychological satisfaction, and lower costs. (5) However, for women who have had radiation treatments following their mastectomy, delayed reconstruction may be necessary. (5)
In addition to the timing, the type of breast reconstruction is also a decision-point. There are two main types of reconstructions: (3)
- Implant-based (alloplastic) reconstruction – these involve using a prosthesis (breast implant), and may be done as:
- Single-stage implant placement, also known as direct-to-implant placement. This is where the surgery is done all at once, and about 18% of all implant-based reconstructions are single-stage. (4)
- Two-stage implant placement, a tissue expander is put in place in order to make room for the implants, then exchanged for the implant at a later date. About 82% of all implant-based reconstruction procedures are two-stage. (4)
- Tissue-based (autologous) reconstruction – the breast reconstruction is performed with tissue that is “harvested” from your own body. This has advantages and disadvantages, but it is particularly useful for women who have undergone radiation therapy. While this method can result in a more natural texture in the reconstructed breast, it also requires a donor site, and is typically a longer procedure with an extended recovery period, which can include one or two additional nights in the hospital, as well as a scar in the donor area.
The majority (about 82%) of reconstruction procedures done in the U.S. are implant-based, while the rest are autologous. (4)
Women who choose an implant-based reconstruction have other choices to make with their surgeon:
- Type of implant – silicone or saline. About 94% of implant-based reconstructions in the U.S. involve silicone implants, largely because of their more natural appearance, feel, and their greater overall patient satisfaction. (4)
- Use of adjunctive acellular dermal matrix (ADM) – this is a tissue graft that may be harvested from your own body, obtained from an animal, or synthetic that is used to provide a scaffold on which your body will produce new tissue. This may be beneficial for some patients depending on their particular anatomical situation.
- Anatomic placement of the implant – the choices can affect the potential complications, esthetics, and cost. The choices are:
- Total submuscular – under the chest muscle
- Partial submuscular – under the muscle with ADM
- Prepectoral – placement under the skin but on top of the chest muscles.
In cases in which the nipple and areola must be reconstructed in addition to adding volume to the breast tissue, skin grafting is most often used, as it results in the most natural appearance.
Regardless of the exact type of breast reconstruction being performed, the procedure requires general anesthesia. It can take anywhere from two to six hours; longer procedures are typically those combined with the initial mastectomy or using donor tissue.
Breast reconstruction, a procedure that takes two to six hours, is performed with general anesthesia. Afterwards, you can expect to feel groggy, tired, disoriented, and possibly nauseous. All are common side effects of the anesthesia. Depending on your overall health and the extent of the surgery, you may spend anywhere from one to six nights in the hospital.
Most breast reconstruction surgery patients experience some degree of pain, soreness, or tenderness, as with any invasive surgical procedure. Other common side effects include bruising and swelling.
Because mastectomy and breast reconstruction are open surgeries (i.e. involve incisions), it is important to realize that there will be scars. The position of the scars depends on the surgeon’s strategy for accessing the underlying tissues to build up the size and shape of the breasts. These scars may fade over time to blend in with the surrounding skin. In addition, the reconstructed breast may never feel completely normal, as the inserted breast tissue is unable to feel sensations.
Although most of the side effects will likely begin to subside by the time you leave the hospital, arm swelling (lymphedema) can last for months. This common side effect is experienced by nearly all breast reconstruction patients as their body adjusts to the new tissue. Mastectomy is especially notorious for causing persistent arm swelling, particularly if lymph nodes were also dissected from under the arm.
Lymphedema typically develops gradually, and may be associated with numbness and tingling, achy pain, tightness, a feeling of heaviness in the limb, and difficulty in bending the elbow and fingers.
Compression sleeves and garments, bandages and Schneider pads, elevation, and massages (“manual lymphatic drainage”) are the mainstays of treating post-operative swelling. As well, your surgeon may leave drainage tubes in place for a period of time after your surgery. However, here are a few additional tips to help reduce swelling:
- Watch for skin breakdown – lymphedema can cause tightness and other changes that lead to skin breakdown. Good skin care is in order. Protect yourself from cuts and burns, and watch for signs of infection.
- Maintain a proper diet that is low in sodium
- Get plenty of rest
- Avoid medications that may exacerbate swelling
- Consider an exercise program that is approved by your surgeon
- Weight loss helps reduce lymphedema
Your surgeon and staff will be sure to give you lots of information and guidance on managing lymphedema and swelling. Be sure to ask questions and inform yourself. This is something that you will mainly self-manage at home.
In addition to the above tips, a surgical support bra or vest, and compression garment can also reduce swelling as well as alleviating discomfort and even reducing the overall recovery period.
Compression garments include a sleeve worn on the arm, sometimes with a fingerless glove that is worn with the sleeve. Sleeves come in daytime and night-time versions. They can be purchased off-the-shelf or custom-made.
A surgical bra is specially designed to provide support to the breast tissues as they heal. It is especially important to wear the recommended garments for the first few weeks after breast reconstruction, as the skin and natural breast tissues are still getting used to the new shape and size of the breasts. During this time, it is recommended to avoid underwire bras or those that do not provide adequate support.
Here are a few tips to consider when purchasing compression garments:
- They should be fitted for you by someone with experience.
- Consider buying two of each garment so that they can be alternated for washings.
- Avoid applying moisturizers to your skin prior to putting on the garment.
- Ask your surgeon and staff for their recommendations on where to purchase your garments.
The time it takes to return to normal activity levels depends on each individual’s overall health, as well as the extent of the procedure. The recovery period is typically longer when breast reconstruction is combined with the mastectomy. The recovery process is also longer and more complicated when tissue-based reconstruction is performed rather than implant-based reconstruction, and when ADM is used. This is because the donor tissue site must also heal in addition to the breast area. In addition to the usual swelling, bruising, and tenderness, patients can also expect some numbness in the breast and areas surrounding the reconstructed breast.
Generally, individuals can expect to have limitations on their ability to perform some daily activities for up to two months. This may be due to the cancer treatment and effects of surgery. The main limitations are from fatigue, pain and soreness, swelling, and limitations in the ability to move the arm on the affected side.
The cost of breast reconstruction surgery depends heavily on the type and extent of the surgery, as there are large differences in the time and resources needed for different types. It also depends on whether or not prostheses (implants) are used. Since there is such a variety of procedures and factors involved, the American Society of Plastic Surgeons does not report average surgeon’s fees for breast reconstruction following mastectomy.
The total cost includes the surgeon’s fee, anesthesia, the surgical facility, and miscellaneous expenses (cost of implants, hospital stay, compression garments, prescriptions, etc.), which can push the total cost up to $5,000 to $8,000. The full cost for breast reconstruction may be even higher depending on the extent of the surgery.
Fees can vary significantly from case to case, making it difficult to generalize the costs of breast reconstruction. In general, more complicated procedures tend to be more expensive. For example, reconstructing both breasts tends to be more expensive than surgery performed only on one side. A procedure involving both mastectomy and breast reconstruction is lengthier and more expensive than either procedure performed alone.
The fee also varies depending on the procedure method, such as whether donor tissue or breast implants are used.
In addition to factors related to the procedure itself, the cost of breast reconstruction is also impacted by the surgical facility and the geographic location. In general, surgery tends to be more expensive in large cities. The facility fee can also vary from place to place even within the same metropolitan area. The length of stay in hospital after the surgery can also have a significant impact on the cost. Finally, the surgeon’s fee is dependent upon the surgeon you choose, based on skill level, qualifications, and experience.
Although cosmetic surgery is not usually covered by health insurance, in many cases insurance will cover all or part of your breast reconstruction procedure, depending on the circumstances surrounding it. Breast reconstruction following a mastectomy is typically covered by health insurance; in fact U.S. federal regulations (the Women’s Health and Cancer Right Act of 1998) require that insurers who cover mastectomy also cover breast reconstruction. (6) That includes reconstruction of the breast that was removed, surgery on the other breast to ensure symmetry, the cost of implants, and costs associated with recovery.
If you are considering breast reconstruction, inquire with your insurance carrier before scheduling the surgery so that you know which, if any, expenses will be your responsibility. Insurance carriers often have complicated rules regarding precisely which expenses are covered and under what circumstances. They may only cover some types of expenses, or they may limit you to certain types of reconstructive surgeries. If some of the expenses for the particular surgery you choose are not covered, most surgeons offer affordable payment options.
- Jonczyk, M.M., Jean, J., Graham, R., & Chatterjee, A. (2019). Surgical trends in breast cancer: a rise in novel operative treatment options over a 12 year analysis. Breast Cancer Research and Treatment, 173(2), 267–274.Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6486837/
- Albornoz, C.R., Bach, P.B., Mehrara, B.J., Disa, J.J., Pusic, A.L., McCarthy, C.M., et al. (2013). A paradigm shift in U.S. breast reconstruction: Increasing implant rates. Plastic and Reconstructive Surgery, 131(1), 15-23. Retrieved from https://d1wqtxts1xzle7.cloudfront.net/39189651/A_Paradigm_Shift_in_U_S__Breast_Reconstruction__.3.pdf?1444862403=&response-content-disposition=inline%3B+filename%3DA_Paradigm_Shift_in_U_S_Breast_Reconstru.pdf&Expires=1602791893&Signature=CVCeBSJX5nmEKtNQJbkmBHXFB4NfgckGurbwdWXMg867q1V3ExpMwCj3ztBwDYPdaP2xXKzW19ONDHktqobh75zAKEi0KKyWx7x~2idAuDFjeDPLul6m8kfK6nYaNOsUO9LwYWY1YGf4IKFp5U-ibceKAr20NLciVW6AJ8VzGQ31s4jSaTxMGAiQ-QVdVIvhOdsp5Q1jMAM5UgamnNkTYUTHTfyOpw6ECCPCFPS1VAzWxA8mY9esfY4RXI629Uz58Hsty2gvw1agwablQAE2VYPIxXz4-WbRTwexGkhNvfWQru1xAmFDd4KH8KY4kFAiI3WFktw2ZAKPAC-i2bv8BA__&Key-Pair-Id=APKAJLOHF5GGSLRBV4ZA
- Somogyi, R.B., Ziolkowski, N., Osman, F., Ginty, A., & Brown, M. (2018). Breast reconstruction: Updated overview for primary care physicians. Canadian Family Physician, 64(6), 424–432. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5999246/
- American Society of Plastic Surgeons (ASPS). (2019). Plastic surgery statistics report. Retrieved from https://www.plasticsurgery.org/documents/News/Statistics/2019/plastic-surgery-statistics-full-report-2019.pdf
- Wilkins, E.G., Hamill, J.B., Kim, H.M., Kim, J.Y., Greco, R.J., et al.. (2018). Complications in postmastectomy breast reconstruction: One-year outcomes of the Mastectomy Reconstruction Outcomes Consortium (MROC) Study. Annals of Surgery, 267(1), 164–170. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5904787/
- U.S. Department of Labor: Employee Benefits Security Administration. (2018). Your rights after a mastectomy. Retrieved from https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-center/publications/your-rights-after-a-mastectomy.pdf