Breast Reconstruction

Overview

Of the estimated 330,000 American women who will be diagnosed with in situ or invasive breast cancer this year, many 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, which can take the form of rearrangement of adjacent breast tissue, a bilateral breast reduction, a breast lift procedure or implants, although this option is not always possible.

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. 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, 107,238 breast reconstruction procedures were performed in the U.S. in 2019.

Most women who seek some type of breast reconstruction are good candidates for the procedure. 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. However, women may be at higher risk for a poor surgical outcome if they are a current or former smoker, have certain medical conditions that may make it harder to heal (such as diabetes) or interfere with wound healing or blot clotting, or are taking drugs that weaken the body's resistance to disease.

Procedures

Breast Reconstruction Procedures

There are various techniques to reconstruct the shape of your breast(s).

1. Breast Reconstruction Using Implants
   Using a breast implant is one option for reconstructing the shape of your breast after surgery to remove the cancer. Both saline and silicone-gel implants can be used, and the surgery can be done at the same time as the cancer surgery or after the mastectomy incisions have healed. The following describes the different techniques:
   • Immediate Breast Reconstruction
     If you decide to reconstruct your breast shape at the time of mastectomy, or at least get the process started, you can have an immediate breast reconstruction. The procedure involves the plastic surgeon putting in a breast implant after the breast tissue is removed. The implant can be put under the skin or muscle on your chest. While most of the work on reconstruction occurs immediately after cancer surgery, the procedure may require additional surgery later to get the final shape and appearance of the breast.
     
     
   • Delayed Breast Reconstruction
     You can also opt to postpone breast reconstruction surgery months or even years after a mastectomy and have a successful outcome. There are many reasons delayed breast reconstruction may be a better option for some women, such as finishing their chemotherapy or radiation regimen, having more time to consider their reconstruction options or for other medical and personal reasons. With this procedure, a short-term tissue expander is placed 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 used 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 silicone or saline breast implant.
2. Breast Reconstruction With Tissue Flap Procedures
   Another way to rebuild the shape of your breast is to opt for a tissue flap procedure (also called autologous tissue reconstruction), which uses skin and soft tissue flaps from your abdomen, back, thighs, buttocks or other parts of the body to create a mound to reconstruct the breast. As with reconstruction with implants, this surgery can occur at the time of mastectomy or be delayed. Compared to implant-based breast reconstruction, tissue flap procedures are more invasive and leave scars on the body where the tissue was taken. However, there is a more natural look and feel of the reconstructed breast with flap procedures. The most common types of tissue flap procedures are:
   
   • TRAM (transverse rectus abdominis muscle) flap, which uses tissue from the abdomen
     
     
   • DIEP (deep inferior epigastric perforator) flap, which uses tissue from the abdomen
     
     
   • Latissimus dorsi flap, which uses tissue from the upper back
     
     
   • GAP (gluteal artery perforator) flap (also known as a gluteal free flap), which uses tissue from the buttocks
     
     
   • TUG (transverse upper gracilis) flap, which uses tissue from the inner thigh

Re-creating the Nipple

During mastectomy, the nipple is often removed along with the breast. Therefore, the final phase of reconstruction surgery is an outpatient procedure to re-create the nipple. For many women, nipple reconstruction surgery entails taking tissue from the newly created breast or, 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. Another option is a 3D nipple tattoo, which is a tattoo that can look quite real.

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

Approximately 5 million to 10 million women worldwide have breast implants, according to the U.S. Food and Drug Administration (FDA). All breast implants have an outer shell made of silicone, but they differ in design and filling materials used, providing a range of options tailored to meet a woman's individual needs.

Implant Filling Types

There are two basic types of breast implants: saline and silicone gel. Both types come in different sizes and have either smooth or textured shells. Here are the types of implants and how they are used.

• Saline Breast Implants
  Saline implants contain a silicone outer shell that is filled with sterile saltwater. Some are prefilled while others are inserted empty into the pocket created during the surgery and then filled once they are in place in the breast. Available in different sizes, saline implants provide a uniform shape, firmness and feel. Should the implant shell leak, the implant will collapse, and the saline will be absorbed and naturally expelled by the body.

• Silicone Breast Implants
  Silicone breast implants are prefilled with silicone gel, a thick, sticky fluid that closely mimics the feel of human fat. Many women believe that silicone breast implants look and feel more like natural breast tissue. If the implant leaks, the gel may remain within the implant shell or may escape into the breast implant pocket.

Implant Shapes

There are two basis breast implant shapes — round and teardrop. Both come in many sizes and have either smooth or textured surfaces.

• Round Breast Implants
  Round implants can be filled with silicone or saline, creating a soft, round, well-rounded appearance. They are designed to make breasts appear fuller at the top portion of the breast, and higher-profile options can achieve even more projection. Because round implants are the same shape all over, they are less likely to wrinkle and there is less concern about them rotating out of place.

• Anatomical Teardrop Breast Implants
  Teardrop implants are filled with a thicker silicone gel that holds its shape, which is why they are sometimes called "form-stable" implants. The advantage of teardrop implants is they mimic the shape of real breasts and have a natural look and feel. Teardrop implants often have a textured surface that helps keep the implant in its original position created by the surgeon. However, textured-surface implants have a higher risk of "breast implant associated lymphoma" (BIA-ALCL), a rare type of non-Hodgkin's lymphoma.

Implant Risks and Safety

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, 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. 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:

• Capsular contracture, which may be painful; it can distort the shape and make the breast implant feel firm.
• Rupture or leak of the saline or silicone-filled implants or implant leakage. When a saline implant ruptures, it often deflates quickly. With silicone gel implants, rupture is often silent, and women may not notice any changes
• Breast pain.
• Infection.
• Wrinkling of the implant that can be felt or seen through the skin.

In light of these potential problems, women who have silicone gel-filled implants will need to get an MRI scan five to six years after the implant surgery and then about every two to three years to check for silent rupture (one that is not causing signs or symptoms).1 Women should also be aware that they may need other surgeries related to their breast implants at some point.

Along with 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 in 20002 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 or reconstruction and unofficially called "breast implant illness" or BII. BII is not a recognized medical condition in terms of diagnosis, but researchers are investigating the range of symptoms to better understand their origins.

About Breast Implant Associated Lymphoma

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 implants, BIA-ALCL is a slow-growing cancer of the lymph system, not the breast tissue, which can be cured in most women if caught early.

BIA-ALCL develops in the scar tissue that naturally forms around the implant and may affect the lymph nodes but rarely spreads to tissues farther away. Symptoms that may occur after surgical incisions have healed include:

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

More information about BIA-ALCL is available here.

Explant Surgery

Breast implants are not lifelong devices. On average, most 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.2 Implants also may move from their original placement and may create asymmetry or cause sagging over time. The American Society of Plastic Surgery states it is important to be evaluated for exchange or removal every 10 to 15 years.

In the breast cancer community, the word "explant" refers to a woman's decision to remove breast implants. Usually performed on an outpatient basis, explant surgery involves removing the breast capsule and implant using a variety of techniques. The surgeon may also remove silicone material if the woman has an implant that may have leaked. Possible risks of explant surgery include bleeding, blood clots, infection, skin loss, skin discoloration, prolonged swelling, numbness and fat necrosis (a lump of dead or damaged breast tissue).

After Surgery Care

Knowing about recovery time and the need for follow-up care and screenings is important when planning for breast reconstruction surgery. Although the time for recovery varies, most women start feeling better in a couple of weeks following surgery and can return to work and normal life after six weeks. Sometimes, a second surgery is performed, or the woman has chemotherapy or radiation therapy. In general, however, by the end of the third month, the reconstructed breast has time to heal. Breast surgeons recommend implant checkups every one or two years for follow-up.

Practicing ongoing good self-care includes performing monthly breast self-exams and having an annual breast exam by your health care provider. Mammograms may not be needed after mastectomy (but are still required after a lumpectomy) and, although unlikely, they may cause breast implants to rupture or leak. 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 or a lumpectomy with some reconstruction. A woman should let the technician know about her implants and ask about additional views to improve the accuracy of the imaging.
  
  
• An MRI or ultrasound five to six years after implant-based breast reconstruction with silicone gel-filled implants and then MRI or ultrasound every two to three years in asymptomatic patients to check for silent rupture.

Paying for Reconstruction

Although breast reconstruction is considered part of treatment for breast cancer, many women remain unaware that breast reconstruction may be 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.

The Women's Health and Cancer Rights Act of 1998, a federal law, requires most group insurance plans that cover mastectomies to also cover breast reconstruction. 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 may be 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 your health care provider 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. In addition, even if health insurance covers a procedure, there are often fees that a woman may have to cover, including a copay or deductibles that are specific to a woman's insurance plan.

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.

Procedures that may not be covered by health insurance include:

• MRIs that check for silent rupture of silicone gel breast implants
• Treatment for BIA-ALCL
• Surgeries needed for future cosmetic reasons to improve the look or appearance of breasts after the initial reconstruction surgery
• Explant surgery with or without implant replacement
• Scar revisions

Decision-Making

When diagnosed with 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
• To renew her self-confidence

Additionally, women at extremely high risk of developing inherited breast cancer often elect to have both breasts removed (prophylactic 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 their 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 surgeon so you can ask 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 involves a meeting to understand all aspects of surgery and get a professional opinion on your needs.

During the consultation, the plastic surgeon will review your medical history and overall health, describe the types of surgical procedures and discuss your reconstruction options. The surgeon will also address whether immediate reconstruction is an option, or if delaying reconstruction is right for you.

The consult also is your time to ask questions, learn about the surgeon's expertise in breast reconstruction and "get a feel" for 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

Breast health specialists 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 later.

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 health care 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

The decision to undergo breast reconstructive surgery, use a breast prosthesis or make no changes after mastectomy can be complex and difficult.

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 these checklists 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?
11. (For implants) What are the possible complications with the implant? How will you manage any of these complications?

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?
10. (For implants) What are the possible complications with the implant? How will you manage any of these complications?

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. 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, which may seem daunting. However, there is a way to take control by becoming empowered about your breast surgery. Research shows that empowered patients do online research, ask a lot of questions, are in contact with other patients, talk to their health care 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 are 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: This is a 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. Its mission includes medical education, public education and patient advocacy.
  
• American Society of Plastic Surgeons: The largest plastic surgery specialty organization in the world, it advances quality care to plastic surgery patients by encouraging high standards of training, ethics, physician practice and research in plastic surgery.
  
• Breastcancer.org: This resource is 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: This resource helps improve 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.
  
• Living Beyond Breast Cancer: This resource connects people with trusted breast cancer information and a community of support.
  
• Susan G. Komen Foundation: This organization's mission is to save lives by meeting the most critical needs in communities and investing in breakthrough research to prevent and cure breast cancer.

Organizations and Support

For information and support on Breast Reconstruction, please see the recommended organizations and Spanish-language resources listed below.

American Society for Aesthetic Plastic Surgery
Website: https://www.surgery.org
Address: Central Office
11081 Winners Circle
Los Alamitos, CA 90720
Hotline: 1-888-ASAPS-11 (1-888-272-7711)
Email: asaps@surgery.org

American Society of Plastic Surgeons
Website: https://www.plasticsurgery.org
Address: 444 East Algonquin Road
Arlington Heights, IL 60005
Phone: 847-228-9900

FDA Breast Implant Information Hotline
Website: https://www.fda.gov/medical-devices/implants-and-prosthetics/breast-implants
Address: U.S. Food and Drug Administration
5600 Fishers Lane
Rockville, MD 20857
Hotline: 1-888-INFO-FDA (1-888-463-6332)

Spanish-language resources

Medline Plus Breast Reconstrucion
Website: https://www.nlm.nih.gov/medlineplus/spanish/breastreconstruction.html
Address: Customer Service
US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

References

1. BreastCancer.org. US Breast Cancer Statistics. Accessible at: https://www.breastcancer.org/symptoms/understand_bc/statistics
2. Brigham and Women's Hospital. Mastectomy and Double Mastectomy. Accessible at: https://www.brighamandwomens.org/surgery/surgical-oncology/resources/mastectomy
3. American Society of Plastic Surgeons. Breast Reconstruction: Know Your Post-Mastectomy Options. Accessible at: https://www.plasticsurgery.org/reconstructive-procedures/breast-reconstruction
4. American Society of Plastic Surgeons. Plastic Surgery Statistics Report 2019. ASPS National Clearinghouse of Plastic Surgery Procedural Statistics. Accessible at: https://www.plasticsurgery.org/documents/News/Statistics/2019/plastic-surgery-statistics-full-report-2019.pdf
5. Healthgrades. Are You a Good Candidate for Breast Reconstruction? April 2, 2018. Accessible at: https://www.healthgrades.com/right-care/mastectomy/are-you-a-good-candidate-for-breast-reconstruction
6. Santosa KB, et al. Effect of Patient Age on Outcomes in Breast Reconstruction: Results From a Multicenter Prospective Study. AJ Am Coll Surg. 2016 Dec;223(6):745-754
7. U.S. Food and Drug Administration. Breast Implants – Certain labeling recommendations to improve patient communication. September 29, 2020. Accessible at: https://www.fda.gov/media/131885/download
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