Breast reconstruction

If you are having a mastectomy, it is important to talk to your breast surgeon about the options for breast reconstruction before your mastectomy surgery and the specialist surgeon that may need to be involved.

Breast reconstruction surgery recreates the shape of the breast following a mastectomy or, occasionally, breast-conserving surgery. It can be done at the same time as your surgery (immediate reconstruction) or as a separate procedure at a later time, even many years later (delayed reconstruction). Breast reconstruction may involve several operations to achieve the final result.

There is much to consider when choosing to undergo breast reconstruction or not after a mastectomy, which we describe in the sections below. Sometimes it may seem overwhelming.

Ask your breast surgeon about referral to a plastic surgeon who specialises in breast reconstructive surgery so that you can fully discuss your options and decide what is the right type of reconstructive surgery for you.

Ask as many questions as you need to in order to understand the options available to you. If you have already had breast cancer surgery, it is not too late to consider breast reconstruction. You can talk to a breast care nurse or your breast surgeon or make an appointment to see a plastic surgeon who specialises in breast reconstructive surgery.

If considering breast reconstruction, research surgery/surgeon, recovery times and possible problems thoroughly beforehand. Talk to people who have had the different procedures performed and ask to see pictures of final results.

Robin, BCNA Member

You may also consider not having a breast reconstruction after a mastectomy, at all. This is sometimes referred to as “staying flat”. This decision is a personal one and completely yours to make. The most important thing is that you are comfortable with how your body looks and feels. If you think that you want to stay flat, you need to talk with your breast surgeon and/or reconstructive surgeon to ensure the best possible cosmetic outcome.

I had private health insurance, but having said that, we were still out of pocket by more than $12,000.

Robin, BCNA Member

It’s important to ask your surgeon (and anaesthetist) for a written quote before committing to any surgery. Some specialists are willing to negotiate their fees if you ask them. If you are not happy with the quote you receive, you can ask your GP or surgeon for a referral to another surgeon.

If you have private health insurance, you can ask your fund what is covered by your insurance and what the gap will be between how much you are charged and how much is paid by your fund. There can be a substantial gap between the cost of surgery and the amount you receive from your insurance fund that is not covered by Medicare.

You can also ask your insurance provider for the names of any plastic or reconstructive surgeons who have entered into “gap cover” agreements with them. If your surgery is provided by a surgeon who has a gap agreement with your insurer, the surgeon will charge your health fund directly, and there should be no out-of-pocket cost to you.

Types of breast reconstruction

The different types of breast reconstruction include:

Reconstruction using a tissue expander and silicon or saline implant that are placed under the skin and muscle of the chest.
Reconstruction using tissue from another part of your body, called autologous reconstruction.
Reconstruction which is a combination of both implants and your own body tissue.

Implant reconstruction

Sometimes people are able to have a breast implant inserted at the time of a mastectomy. However, it is usually a two-step process involving the insertion of a tissue expander first, which creates space for an implant to be inserted later.

A tissue expander is like an empty breast implant that is usually put in place while having a mastectomy. Over a period of weeks, liquid is injected into the expander using a small needle via a port that is just under the skin. This gradually stretches the tissue. The series of tissue expansion procedures is done in the surgeon’s consulting rooms and is simple, quick and generally causes little discomfort apart from a feeling of tightness. Once the tissue expander is the same size as the permanent implant, no further filling of the tissue expander is needed.

The expander will be replaced with the permanent implant approximately six weeks later, although this can be longer depending on whether you are having other treatments such as chemotherapy. The surgeon will use the same incision as that used for the insertion of the tissue expander to remove it and replace with the permanent implant.

Some advantages of implants include:

it is a relatively straightforward operation
it involves a short stay in hospital and faster recovery time (than autologous reconstruction)
surgery and scarring is generally only in the breast area.

Some disadvantages of implants include:

the breast may not feel as natural as it would with other types of reconstruction options
it can be harder to match the shape of the existing breast
if you lose or gain weight, the implant may no longer match your other breast as it will not change size
scar tissue can form around the implant.

Autologous reconstruction

There are several different types of “autologous” breast reconstruction, which use tissue taken from different parts of your body. Whether an autologous reconstruction is recommended for you will depend on several factors, including your body shape, general health, any previous surgery and your personal preferences.

The types of autologous breast reconstruction include:

DIEP (deep inferior epigastric perforators) flap – this involves removing some of lower abdominal (tummy) skin and fat – similar to a tummy tuck – and moving it to your chest. It creates a natural, warm and soft breast. Because the abdominal muscles are preserved, there is generally less pain, a quicker recovery and a lower risk of complications than a TRAM flap (see next type).
TRAM (transverse rectus abdominis muscle) flap – a flap of skin, fat and muscle from the abdomen is moved to the chest to create a new breast shape. This can sometimes be done without using the muscle which helps to maintain the function of the abdominal wall.
Latissimus dorsi flap – a flap of skin, muscle and fat from your upper back is moved to the chest to create a new breast mound.
Other types can use tissue from other parts of your body, including from your inner thigh.
Lipofilling – for people who have small breasts, fat transfer from another part of the body can be used to create a small breast mound. This is called lipofilling. It generally requires multiple transfers over one to two years.

Some advantages of autologous reconstruction include:

it produces a more natural looking breast
the breast will gain and lose weight as your body gains and loses weight.

Some disadvantages of autologous reconstruction include:

it requires longer surgery and recovery time
you will have a scar on other parts of your body where tissue has been removed to create the breast mound. For example, your stomach, back or leg.
you may lose strength in your stomach muscles if your reconstruction uses abdominal muscle
there is a risk that the flap tissue may die due to lack of blood supply; if this happens, the tissue may need to be removed in another operation.

Not all types of reconstruction are suitable for all people. For example, if you do not have enough tissue on your stomach, it may not be possible for you to have a DIEP reconstruction.

Breast reconstruction is a significant operation and needs a substantial recovery period. Ask your treating team any questions you may have.

Nipple reconstruction

Nipple reconstruction is an optional procedure after a breast reconstruction if your nipple was removed during a mastectomy. Some people are happy with the look of their new breast without a nipple, while others prefer to have the look of a nipple.

There are two ways that a surgeon can reconstruct a nipple:

using the tissue on the new breast, or
using a skin graft from another part of the body.

Sometime after the nipple has been created surgically, the area can be tattooed to give the appearance of an areola and match the colour of your other breast’s areola. As the new breast has little or no sensation, the tattooing is usually painless.

Some public hospitals offer a free nipple tattooing service. If you have had your breast reconstruction in the private health system, your breast reconstruction surgeon may provide tattooing in her/his practice or may be able to refer you to someone else. There is a Medicare rebate for nipple tattooing, however, to receive a rebate your tattooing will need to be done by a health professional who has a Medicare provider number. It is a good idea to check before you make your appointment about any out-of-pocket costs for your tattooing.

You can also check with your private health insurance fund whether they will cover nipple reconstruction and/or tattooing, if you choose to.

If you don’t want to make a new nipple but would like the look of a nipple, you can opt for a nipple prosthesis, which is attached to the breast with special glue. Your surgeon or breast care nurse will be able to give you more information about nipple prostheses.

Outcomes

When deciding about breast reconstruction, understanding what to expect in terms of outcomes can be difficult. Keeping in mind the questions below may help you better understand what is reasonable in terms of your outcomes from surgery.

What are your aims with breast reconstruction surgery? In broad terms, the aim of breast reconstruction surgery is to create a natural shape when you are clothed. After reconstruction post-single mastectomy, the new breast may not look or feel the same as your existing breast and your new breast will not look the same, or feel the same, as the breast you have had removed. You may also have reduced sensitivity or no sensation at all in the new breast.
What might my scars be like after surgery? Depending on the type of reconstruction you choose, you may have scars on your breast and on other parts of your body. Many people who have been through breast reconstruction find that their scars have faded over time.
How many surgeries will I need to achieve my ideal outcome? For some people, breast reconstruction can require several procedures over many months to achieve the final result. Depending on the size and shape of your breasts, you may also choose to have surgery on your non-affected breast at some point to correct their symmetry.
How will my breasts change over time? A natural breast changes over time and will droop as you get older. Reconstructed breasts, especially those using implants, will not change in the same way. The changes in symmetry between a natural and reconstructed breast may become more obvious over time and you may want to have further surgery to restore symmetry. Speak to your surgeon about the costs associated with procedures to create symmetry between your breasts.

Understanding the options and potential impacts of breast reconstruction after mastectomy can be challenging. Speak with your surgeon and treating team and ask them any questions you may have about breast reconstruction. In addition, BCNA has several resources and tools available to support you (see below).

Access to breast reconstruction

Breast reconstruction following a mastectomy for breast cancer is available in the public hospital system as well as through the private health system. It is considered a medical procedure, not cosmetic surgery.

In a public hospital

There is no charge to you if you have your breast reconstruction through the public health system. If you would like to consider this option, your breast surgeon or breast care nurse can refer you to a public hospital that offers breast reconstruction surgery. Not all public hospitals are able to provide breast reconstruction surgery, and waiting times will vary from hospital to hospital and across different states and territories. You can talk to your treating team about what's available and where you can go to have your preferred procedure.

If you are considering an immediate breast reconstruction and would like to have your surgery in a public hospital, it is important that you talk to your breast surgeon about this as soon as possible. If you would like to have your surgery in a public hospital and are seeing a surgeon who works only in the private sector, you may need a referral to someone who works in a public hospital.

If you choose to have delayed reconstruction at a public hospital, you will be put on the hospital’s elective surgery waiting list. Waiting times can be up to two years or more in some places. Keep in mind that you can “shop around” to find a hospital where the waiting list times may be shorter.

It is possible to put your name on a public hospital waiting list even if you’re not sure that you will want a breast reconstruction. Try to do this as soon as you can. You can then use the waiting time to explore your options and make your decision. If you decide not to have a breast reconstruction, you can remove your name from the waiting list.

In a private hospital

You can choose to pay for treatment as a private patient even if you don't have private health insurance. If you choose to have breast reconstruction surgery through the private health system, there can be considerable out-of-pocket expenses, even if you have a high level of private health insurance.

Some people have told BCNA that their out-of-pocket expenses have reached up to $15,000, while others report much less.

I requested details of surgery beforehand and called my health fund to check how much they would cover and if the anaesthetic was covered.

Sharon, BCNA Member

Finding a surgeon

Your breast surgeon may be able to recommend a plastic surgeon, or you can visit the Australian Society of Plastic Surgeons website, which has a tool to help you ‘Find a Surgeon’ in your area, or call 1300 367 446 for a list of surgeons who specialise in breast reconstruction.

Considerations

BCNA members have provided the following useful tips for other people considering breast reconstruction:

If you are unsure if breast reconstruction is right for you, you can sign up for BCNA’s free online breast reconstruction decision aid - BRECONDA
Join BCNA's Online Network and connect with people in the private online group, “Choosing Breast Reconstruction”. You will hear from people who have shared their breast reconstruction experience through words and pictures.
Read the personal stories of others that have been through breast reconstruction.
Ask for referrals to more than one breast reconstructive surgeon, so you can find one you feel comfortable and confident with.
Get more than one quote – charges can vary considerably from surgeon to surgeon.
Ask whether an immediate reconstruction (i.e. at the time of your breast cancer surgery) may be appropriate for you.
Ask lots of questions of your surgeon and treating team.
Ask to see before-and-after photos of the surgeon's previous breast reconstruction surgeries.
Talk to other health professionals, such as a breast care nurse, about breast reconstruction and any concerns you have.

Things you can do now

Watch BCNA's video Breast Reconstruction- Options and Expectations.
Watch BCNA's video Breast reconstruction - know your options
Listen to BCNA's podcast Breast reconstruction.
Read more about Physical preparation and recovery after breast reconstruction.
Read the Cancer Council booklet Understanding breast prostheses and reconstruction, for comprehensive information on breast prostheses and breast reconstruction.
Visit Cancer Australia, which includes information for people considering breast reconstruction after mastectomy.
Visit Reclaim Your Curves, which offers support and information about breast reconstruction from people who have been through reconstruction.
Visit My Journey, BCNA’s online tool for information tailored to your diagnosis.
Contact BCNA’s Helpline on 1800 500 258 between 9.00 am and 5.00 pm AEST Monday to Friday, for information about the services and support that may be available for you and your family.

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