Breast Reconstruction

Breast reconstruction uses a combination of different plastic surgery techniques to recreate or restore breast shape after surgery for breast cancer or other breast conditions. Breast reconstruction is usually performed after mastectomy or lumpectomy and can build one or both breasts to appear more like a natural breast.

Immediate breast reconstruction is done at the time of mastectomy or lumpectomy, while delayed breast reconstruction is performed after a period of time when the woman has finished healing from mastectomy or lumpectomy.

Some women who undergo immediate breast reconstruction will seek an additional procedure at a later date to correct or fine-tune the appearance of their breasts. This is called a breast reconstruction revision.

Dr. Ginger Xu specializes in both delayed breast reconstruction and breast reconstruction revision. Both surgical approaches focus on improving the appearance of the breast, and Dr. Xu uses her technical training and understanding of aesthetics to make sure each woman’s appearance ultimately aligns with her unique identity. Dr. Xu is a Board-certified plastic surgeon with specialty training in aesthetic plastic surgery at Harvard and is now based in the San Francisco Bay area.

What Is Breast Reconstruction?

A woman’s sense of identity, self-esteem, and femininity is often tied to the appearance of her breasts. Treatment for breast cancer may require partial or complete breast removal, which can create a defect or deformity that negatively affects how a woman feels about her own body. This leads many women to seek breast reconstruction to improve the appearance of their breasts.

Without breast reconstruction, mastectomy or lumpectomy may leave women feeling their breasts have an unattractive appearance with characteristics such as:

  • Indentation or distortion in the area where tissue was removed
  • Asymmetry – especially when only one breast is treated

Breast reconstruction can:

  • Correct distortions left behind after breast tissue is removed
  • Create breasts that are more symmetrical in appearance
  • Reconstruct or improve nipple appearance and symmetry
  • Improve the overall appearance of the breasts

Almost all women who have had a mastectomy or lumpectomy are candidates for reconstruction. Many women have an immediate breast reconstruction at the time of their mastectomy or lumpectomy, but others are not ready to pursue it yet and opt to have delayed reconstruction months or years after their initial surgery.

The two major breast reconstruction options are implant reconstruction and flap reconstruction (using tissue from another part of your body). The best option for each woman will depend on factors such as the:

  • Type of surgery that was originally used to treat the breast – mastectomy or lumpectomy
  • Amount of tissue removed
  • Whether radiation was used
  • Woman’s body type, age and skin condition

Women who have an entire breast removed (mastectomy) will need reconstruction with an implant or a tissue flap from their own body (autologous tissue).

When only some of the breast is removed (lumpectomy), surgeons often rearrange breast tissue to camouflage the distortion. After lumpectomy, women usually then have radiation therapy.

Radiation after either lumpectomy or mastectomy can affect the timing of breast reconstruction and the choice of technique. Radiation can change the appearance of the breast in several ways including:

  • Radiation-induced breast deformity – sunken and puckered appearance to the breast after radiation causes hardening and contraction of the remaining breast tissue
  • Capsular contracture in women who have had a previous breast implant – radiation promotes the formation of scar tissue around the implant causing hardening
  • Radiation-induced skin damage – darkened, hardened, shiny skin that is less pliable than before and does not yield to an implant
  • Microscopic damage to small blood vessels which increases the risk of wound healing problems

What Types of Breast Reconstruction Does Dr. Xu Perform?

Dr. Xu does not perform immediate breast reconstruction at the time of a mastectomy or lumpectomy. She also does not offer autologous tissue transfer options – these are best performed by plastic surgeons with specialized training in microsurgery.

Dr. Xu specializes in surgical techniques focusing on the appearance of the breast including:

  • Breast reconstruction revision – additional surgery to correct or fine-tune the appearance of a woman’s breasts that is performed after an immediate reconstruction
  • Delayed breast reconstruction – performed at a later date when a woman initially opted out or did not receive immediate reconstruction

Dr. Xu specializes in techniques that can be used after both mastectomy and lumpectomy such as:

  • Implant placement
  • Fat grafting
  • Other plastic surgery techniques – eg. nipple and areola reconstruction, nipple revision or scar revision

How Do I Work with My Plastic Surgeon to Decide Which Technique Is Best for Me?

Breast reconstruction revision and delayed breast reconstruction are complex techniques. The surgery must be customized for each woman and often involves a process of fine-tuning the appearance of the breasts.

Dr. Xu’s goal is to reach aesthetic satisfaction for each woman by arming her with the knowledge to make decisions about her breast reconstruction. It is important women have a realistic understanding of:

  • How the breasts will look after surgery
  • The limitations of the surgery
  • The differences between types of implants
  • Any short- and long-term side effects – such as the potential need for more surgery
  • Any possible complications

After mastectomy or lumpectomy, many women live with dissatisfaction about the appearance of the breasts or with disturbing symptoms such as:

  • Pain or discomfort
  • Increasing tightness in the reconstructed breast
  • Changes in breast shape, size, or position
  • A breast implant that is not in the correct position
  • A lump or area of firmness in the breast

Dr. Xu recommends that women with queries or problems with their breasts visit a plastic surgeon experienced in revision techniques to find out how breast reconstruction revision could improve their quality of life. The complexities and subtleties of breast reconstruction revision are best reviewed in a consultation.

During a consultation, Dr. Xu can review your past surgeries and your future goals and then recommend a customized approach to your breast reconstruction plan to give you the best possible result.

Breast Reconstruction Revision

Many women choose to have breast reconstruction at the time of their surgery to treat breast cancer or other breast conditions. But with time, some women who have had an immediate breast reconstruction choose to have additional surgery – a breast reconstruction revision – because they:

  • Want to further improve or fine-tune the appearance of their breasts
  • Are not satisfied with the appearance of their breasts after immediate breast reconstruction
  • Found that radiation therapy treatments after the breast reconstruction affected the condition and appearance of their breasts and skin

Fine-tuning the appearance of the breasts: The results of any type of surgery can change with time. After immediate reconstruction, the breast tissue and skin condition will naturally settle and over time the breasts may change in appearance. This may lead some women to seek additional surgery to further improve their breast appearance.

Dissatisfaction with the results of immediate breast reconstruction: Breast implants are commonly used in immediate breast reconstruction after mastectomy. Some women may not be happy with their results. Problems with implants can be caused by:

  • Implant malfunction – eg. implant rupture or leak
  • Problems with the surgical approach used to place the implant – eg. pocket creation, implant malposition, etc.
  • The response of the woman’s body to the type of implant used – eg. capsular contracture or implant migration

Surgery to improve satisfaction might involve choosing a different implant type, implant size or implant shape. The shape of the breast can also be adjusted with skin tucking. Bulging skin at the ends of scars (“dog ears”) and problems with skin envelopes can be improved with revision surgery and scar revision can help with the appearance of scars.

Radiation therapy treatments – Women who have had a lumpectomy followed by radiation often want to improve the appearance of indentations, breast contour, or asymmetry. Post-surgical radiation therapy can damage skin though, and this limits the approaches available to the surgeon and the results that can be achieved. Implants or remodeling with fat grafting are potential options depending on skin quality.

Delayed Reconstruction of the Breast

Some women do not have breast reconstruction at the time of their mastectomy or lumpectomy. Reasons for a delay include when a woman:

  • Is not a candidate for immediate reconstruction for medical reasons
  • Chooses to focus on her health after a breast cancer diagnosis
  • Does not have access to a plastic surgeon who specializes in breast reconstruction
  • Does not know plastic surgery is an option to improve the appearance of her breasts

For women who wish to pursue reconstruction at a later date, delayed breast reconstruction can be an option after both mastectomy and lumpectomy.

After a mastectomy, the breast skin envelope may have been mostly removed creating a flat chest. In this case, there will not be enough skin left to place an implant right away, so the remaining skin must be stretched using an “expander” (see below) to first make room for the implant. This would then be followed by replacing the expander with an implant and is a two-staged process for breast reconstruction. Another option is autologous flap surgery (see below), which is a technique not offered by Dr. Xu.

After lumpectomy and radiation therapy, the skin or tissue may be damaged and thickened and its ability to heal is decreased. While this might decrease the ability of the surgeon to remodel breast tissue, remodeling with an implant or fat grafting might still be possible.

What Are Some of the Techniques Used in Breast Reconstruction?

Reconstruction with Implants

Implants can be used for both reconstruction revision and delayed reconstruction.

For reconstruction revision of implants, the issues around the types of implants and complications are similar to other breast implant revisions. These revisions might also involve the use of an acellular dermal matrix as an interface between the implant and skin, or a surgical scaffold to help support the breast to hold a new implant in position.

For delayed reconstruction after mastectomy, the process is often performed in two stages. During the first stage, the skin over the breast is gradually stretched with a tissue expander. The surgeon places an empty implant and during consultations over two to three months, the surgeon gradually fills the expander with saline until it reaches the preferred breast size. The expander is then removed and replaced with a permanent implant. Women should discuss with Dr. Xu the pros and cons of placing the implant either under the chest muscle (sub-pectoral) or on top of the chest muscle (pre-pectoral – see below for more information).

Fat Grafting

Fat grafting can be used to fine-tune the breast contour or add modest volume to the breast. The fat is taken from your body (e.g. from the belly or buttocks) and can be used to fill indentations after lumpectomy or smooth out irregular areas around implants.

Nipple and Areola Reconstruction

Issues with the nipple and areola after breast cancer surgery can include:

  • Nipple and areola removal during surgery
  • Nipple flattening
  • Loss of nipple tissue

Nipple and areola reconstruction options can help to give the breast a more natural look. A nipple can be reconstructed and shaped using the skin of the breast and the appearance of an areola can be created using tattoos. If the skin on other parts of the body (e.g. the groin) has a darker color similar to an areola, another option is to use a skin graft from that area to create the appearance of an areola.

If women do not wish to have a nipple reconstruction or are unable to have one, 3D tattooing can give the appearance of a nipple and areola. For women who find their nipples have moved and are out of position after breast surgery, nipple revision surgery can help to move the nipple to a more natural location.

Scar Revision

Although scars cannot be erased completely, surgical scar revision and non-surgical techniques can help to decrease any discomfort, make scars less noticeable and improve the function of the skin in and around the scar.

Flap Reconstruction

Also known as autologous tissue breast reconstruction, flap reconstruction is another option for women who cannot have or do not want breast implants. The term “autologous” means the woman’s own tissue is used to reconstruct the breast. Flap reconstruction involves taking tissue (including its original blood vessels) from one part of the body and using it to reconstruct the breast. The flap either:

  • Remains attached to the body and is moved with its blood vessels and circulation intact (pedicle flap)
  • Is totally removed from the body (free flap) and its blood vessels are reconnected to blood vessels in the chest – these flaps can come from various locations on the body.

Note, Dr. Xu does not offer autologous tissue transfer options – these are best performed by a plastic surgeon with specialized training in microsurgery.

Breast Reconstruction in Large-breasted Women

For women with larger breasts who undergo mastectomy, the maximum size of a breast reconstructed with a silicone implant is limited by the maximum available implant size (approximately 800 cc). Options for women whose natural breast size cannot be matched with silicone implants include:

  • Saline-filled implants that can be overfilled with saltwater – but only to a certain extent
  • Flap reconstruction – not offered by Dr. Xu
  • Breast reduction of the intact breast (if only one side required reconstruction) to match the size of a new implant in the reconstructed breast

For women with larger breasts who undergo lumpectomy and radiation, the treated breast might have a higher position and may have contracted. In these cases, a breast reduction on the intact breast can help to restore symmetry to the chest.

Pre-pectoral Vs Sub-pectoral Implant-based Breast Reconstruction

Depending on the condition of the breast and skin, implants can be placed either:

  • Under the breast tissue (pre-pectoral placement) – results in faster recovery time and less discomfort
  • Under the chest muscle (sub-pectoral placement) – results in a more natural appearance in the upper chest, and less risk of rippling or hardening of the tissue around the implant

Breast reconstruction surgery is constantly evolving to provide better options for women. For some time, sub-pectoral placement was the preferred option for breast reconstruction. But more surgeons are now performing pre-pectoral placement of implants for breast reconstruction after mastectomy because:

  • The use of additional techniques such as fat transfer help to give the breast a better appearance with pre-pectoral implants
  • The surgery creates less discomfort
  • Implants are less likely to be damaged or move in women who are likely to use their chest muscles during physical activity

All About Implants: Types and Sizes

Breast implants are medical devices filled with either saline (a saltwater solution) or silicone gel. Both saline and silicone implants have an outer silicone shell, which can be either smooth or textured. They can be either round or have and anatomic tear-drop shape. They can be filled with:

  • Saline – smaller incisions are needed to place these but they have a less natural look and feel and rupture causes immediate deflation
  • Silicone gel – these give a more authentic feel and they are more robust
  • A new type of silicone gel – called “gummy bear implants”, these can hold their shape better

Anatomic-shaped implants only come as textured implants, which have been linked to Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). Dr. Xu never uses textured implants for this reason. She only uses smooth implants, which have not been linked to this condition.

Dr. Xu is passionate about preventing issues related to breast implants in women having breast reconstruction revision. It is of paramount importance to her that all issues are reviewed and discussed, so each woman can make the best decision for her body.

There are many options for all aspects of your breast reconstruction revision. Once Dr. Xu understands all aspects of your situation, Dr. Xu will help you to choose the best implants and surgical techniques for your situation.

Breast Reconstruction and Recovery

Preparing for Breast Reconstruction Surgery

Once you and Dr. Xu have agreed on an approach to your surgery, Dr. Xu will book your surgery time and give you instructions on what to do before and after your surgery.

Dr. Xu will also let you know which medications you should and should not take prior to your surgery and what to do on the day of your surgery. It is important to stop smoking at least 6 weeks prior to surgery.

You may need to get a blood test or undergo additional workup depending on your medical history. Dr. Xu may also correspond with your primary care doctor to ensure you are in an optimal state of health prior to surgery.

In the weeks before surgery, recommendations to help you prepare include:

  • Making sure you get enough sleep and rest
  • Eating a healthy diet with adequate protein and nutrition
  • Exercising or engaging in physical activity to strengthen your body
  • Maintaining a positive state of mind
  • Prioritizing your well-being and reducing stress levels

It is essential that you feel comfortable about your upcoming procedure and fully understand the process. Dr. Xu encourages her patients to ask any questions about their surgery or recovery.

Recovering from Breast Reconstruction

Both breast reconstruction revision and delayed reconstruction have much shorter recovery times than the original mastectomy or lumpectomy. Recovery after implant placement typically takes up to four weeks, whereas flap reconstruction (not performed by Dr. Xu) can take up to six weeks. If performed alone, minor surgeries such as fat transfer or nipple and areola reconstruction have shorter recovery times.

After your breast reconstruction revision, you will feel mild to moderate discomfort. The amount of pain you feel depends on a number of factors such as:

  • The type of breast surgery you had previously – mastectomy or lumpectomy
  • The type of reconstruction or revision surgery you had
  • Whether you have had other surgeries completed at the same time (e.g. nipple and areola reconstruction or breast reduction)
  • Your age
  • Your health before the surgery

Prescription pain medications might be needed for the first few days. After this time, any pain should be relieved with over-the-counter or non-opioid medications.

During recovery, you should avoid lifting any heavy weights. Once bruising and tenderness have gone, you can return to normal activities. Strenuous exercise should be avoided for up to two months after implant-based reconstructive surgery. Ask Dr. Xu when you can return to the full range of activities.

If you have had any combination of plastic surgeries, Dr. Xu can advise you of any additional recovery needs.