Breast Reconstruction Surgery

Immediate breast reconstruction is performed at the same time that breast tissue is surgically removed either via a lumpectomy or mastectomy.

When breast reconstruction is performed immediately after a lumpectomy, your plastic surgeon will rearrange the remaining breast tissue and optimize the breast shape, typically by performing a breast lift or a breast reduction. This option may be available if you have small localized tumors. It usually requires radiation and will be determined by your oncology care team.

When breast reconstruction is performed immediately following a mastectomy, your plastic surgeon will fill the space where the breast tissue was removed with a tissue expander, an implant, or a tissue flap.

Benefits of Immediate Breast Reconstruction
Choosing immediate breast reconstruction has several benefits including:

• preserving the skin in a breast shape
• a psychological sense of wholeness
• the ability to fill clothes without the need for an external prosthesis. 

Delayed Breast Reconstruction
Some women choose to delay breast reconstruction for months or years after breast cancer treatment ends. They may not be ready to commit to immediate breast reconstruction and the complexity it adds to their breast cancer care. You can arrange an appointment with your plastic surgeon for delayed reconstruction at your convenience. We believe delayed breast reconstruction achieves optimal quality of life by improving your psychological and physical wellness.

Breast Reconstruction Following Radiation and Chemotherapy
The use of chemotherapy and/or radiation to treat aggressive tumors can impact the type of reconstruction options available to you. This is because radiation therapy can damage the breast skin, which makes implant reconstruction challenging. If you are undergoing chemotherapy or radiation therapy, your plastic surgeon will help you determine the best timing and choose an option that is right for you.

Silicone or saline implants may be used to replace the entire breast following mastectomy, and to enhance the breast size and shape.

Overall, implant surgery is associated with shorter surgeries and hospital stays than tissue flap surgery, which is described below. However, it can be a challenge to match a natural breast on the opposite side with an implant. It’s also important to note that the quality of implant reconstruction is usually dependent on the quality of the skin that remains after the mastectomy. Your surgeon will discuss your implant options and help you determine if this approach is right for you.

Direct to Implant Reconstruction
In certain circumstances, your plastic surgeon will replace the breast tissue with a silicone or saline implant at the same time as your mastectomy. Since implants are not adjustable after surgery, this limits the option of changing the breast size. Postoperative concerns with size, shape or volume may still require an additional revision surgery. Your surgeon will discuss the pros and cons of this approach when you consider your options.

Breast Reconstruction with Tissue Expander
At the time of the mastectomy, your plastic surgeon will place a temporary tissue expander to hold the breast skin in breast shape. The expander is filled with saline in the office to increase its size. In general, tissue expanders give your plastic surgeon more flexibility regarding your reconstruction. It gives you more time to decide whether you want implants or flap-based reconstruction following mastectomy and decisions about your cancer treatment. I

f you choose implant reconstruction, the final implant is typically placed about three to six months later. This two-staged approach is common. Under certain circumstances, a delayed tissue expander placement can also be done years after a mastectomy and allows for permanent implant placement in the future.

Fat Grafting Breast Reconstruction with Implants
Fat grafting uses liposuction to transfer fat from another part of your body, such as your abdomen or buttocks. This can improve contour irregularities in your breast reconstruction and may help the overall shape, volume, and symmetry between your breasts. Your breast reconstruction surgeon may use this method and other plastic surgical techniques, such as breast reduction or breast lift to create symmetry between your breasts.

Goldilocks Procedure
In this procedure, the skin and fat that remains after the mastectomy are rearranged to create a small breast mound. While this typically does not provide enough tissue to create a breast, it helps prevent the concavity associated with a mastectomy. If you want additional volume, fat grafting can be done during a later surgery. Your breast reconstructive surgeon may discuss this option with you.

Autologous breast reconstruction uses your own skin, fat, blood vessels, and sometimes muscle from other parts of your body to create a breast mound that has a more natural look and feel than implants. Also called flap surgery, it can be done:

• immediately after the mastectomy.
• in a staged approach after mastectomy with tissue expander placement.
• many years after the mastectomy with or without prior reconstruction.
• following radiation therapy.
• to replace implants that are not working well.

DIEP Flap Breast Reconstruction
The most common type of breast reconstruction flap surgery performed at Duke is the DIEP flap, which stands for deep inferior epigastric perforator flap. Tissue is taken from the lower belly and moved to the chest to recreate the breast mound.

Benefits of DIEP Flap Breast Reconstruction
The DIEP flap preserves the abdominal muscles that allow you to recover faster, and with a lower risk of losing core muscle strength. This is an important distinction from TRAM flap reconstruction, which removes abdominal muscle and tissue. DIEP flap breast reconstruction also leaves you with a flatter tummy, similar to the results of a tummy tuck.

Advanced Surgical Skills Required
DIEP flap breast reconstruction is an intricate surgery that requires advanced microsurgical skills to successfully move blood vessels from one area of the body to another. Our breast reconstruction surgeons have advanced training in microsurgery and specialize in DIEP flap breast reconstruction. This microsurgical skill is also important when other tissue flaps are used in breast reconstruction.

Other Tissues May Be Used for Flap Breast Reconstruction
If you do not have enough abdominal tissue, the tissue is not surgically available or another tissue area is preferred, flap breast reconstruction may be performed with tissue from the backside of the upper inner thigh (PAP, TUG /DUG/VUG flap), the lower back or buttocks (LAP flap or SGAP flap), or the back muscle (Lat dorsi/TDAP flap). In some cases, your surgeon may recommend using two flaps for one breast. This may be done if extra tissue is needed to fill the breast mound.

Success Rate, Complications
Overall, breast reconstruction flap surgery at Duke has a 98% success rate. In rare cases, the flap does not receive adequate blood flow and the tissue must be removed. Other risks of surgery include infection and slow wound healing. As part of your breast cancer team, we meet with you regularly after your surgery to ensure you are healing appropriately. We watch for complications that may arise so we can treat them immediately.

Additional Surgeries May Be Needed
No matter what type of reconstructive procedure you undergo, there is a good chance that secondary revision surgery will be needed. It may be difficult to achieve your goals in one surgery. Typically it takes two or three procedures, performed over one to two years, to achieve the final result. We work with you and your schedule to achieve realistic goals in the safest manner possible.

Sensory Restoration with Nerve Reconstruction
Following a mastectomy, it is common for women to lose feeling within the breast area. Our plastic surgeons use microsurgical techniques to perform nerve reconstruction when possible. Talk to your doctor during your consultation to see if this is an option for you.

Nipple and Areola Reconstruction
When possible, you can have a “nipple-sparing” mastectomy, which preserves your natural nipple and areola. When that is not possible, we use techniques to reconstruct the nipple and areola. They include surgical creation of a projecting nipple, skin grafting, and skin tattooing. Nipple and areola reconstruction are typically done at the end of the reconstruction process. Our team includes several experienced specialists in nipple and areola tattooing.

Hospital stays and recovery periods vary by procedure.

• A mastectomy and immediate breast reconstruction with a tissue expander or implant can be a same-day discharge or involve an overnight hospital stay; recovery will take about four weeks.
• A mastectomy and flap breast reconstruction involves a two- or three-day hospital stay. Recovery will take about six to eight weeks.
• Delayed breast reconstruction with flap surgery involves a two-to three-day hospital stay, followed by a six-week recovery.
• Delayed breast reconstruction with a tissue expander and implant is an outpatient procedure. Recovery takes about three weeks.
• Revisions, fat grafting, and nipple reconstruction are typically performed as outpatient procedures, followed by a two-week recovery.

Surgical Drains Are Needed
Most breast reconstruction procedures require a surgical drain to be placed to remove fluid from the surgical area after the procedure. Surgical drains may remain in place for two to three weeks after surgery.

Enhanced Recovery After Surgery
We are leaders in developing new ways to make the surgical experience more tolerable. For breast flap procedures we've implemented a proven process to help you leave the hospital sooner and recover faster. It also reduces the need for opioids. The process involves implementing pain control methods including nerve block techniques before and after surgery, allowing you to eat and move immediately after surgery. It has dramatically improved the recovery process following flap breast reconstruction. 

Prehabilitation
There are many things you can do before surgery to help your recovery and decrease your risk of complications. Eating a nutrient-dense, high-protein diet will help the healing process. In addition, optimizing your stress and sleep around the time of surgery can improve your recovery and outcomes. Discuss with your breast reconstructive surgeon what you can do before surgery to set yourself up for success.