Breast reconstruction

If you have a breast reconstruction during the mastectomy, it may be possible to save most of the skin but not the nipple (skin-sparing mastectomy). Sometimes it may be possible to leave the nipple in place (nipple-sparing mastectomy). Having a skin- or nipple-sparing mastectomy often means a more natural look and fewer scars.

Sometimes you won’t be able to have an immediate reconstruction because of medical and cancer treatment or the surgery schedule at the hospital. You may also need to have the reconstruction in a number of stages to achieve the desired result. Talk to your surgeon about these issues.

When considering having a reconstruction, ask to be referred to an expert in breast reconstruction. Check that the breast surgeon is a member of Breast Surgeons of Australia and New Zealand (BreastSurgANZ) and that the reconstructive (plastic) surgeon is a member of the Australian Society of Plastic Surgeons.

In hospital, you will be cared for by a range of health professionals who specialise in different aspects of the reconstruction procedure. Specialists and other health professionals will take a team-based approach to your care as part of a multidisciplinary team (MDT). The health professionals listed below may be in your MDT.

Health professionals you may see

• breast surgeon – performs breast surgery and biopsies; some breast surgeons also perform breast reconstruction
• oncoplastic breast surgeon – performs breast surgery and biopsies; performs some types of breast reconstruction
• reconstructive (plastic) surgeon – uses a variety of plastic surgery techniques to reconstruct the breast’s appearance after surgery
• anaesthetist – assesses your health before surgery; administers anaesthesia and looks after you during the surgery; commonly plans your pain relief after surgery 
• breast care nurse – provides breast cancer care; provides information, support and referrals during and after treatment 
• radiation oncologist – treats cancer by prescribing and overseeing a course of radiation therapy
• medical oncologist – treats cancer with drug therapies such as chemotherapy, targeted therapy and immunotherapy
• occupational therapist, physiotherapist – assist with physical and practical problems, including restoring movement and mobility after surgery and recommending aids and equipment; provide treatment if lymphoedema occurs
• social worker – links you to support services and helps you with any emotional, practical and financial issues
• counsellor, psychologist, psychiatrist – help you manage your emotional response to diagnosis and treatment

These stick to the skin or breast prosthesis and stay in place for several days. They are made from soft silicone and are available in a variety of colours. You can buy them from breast prostheses suppliers.

A small operation can reconstruct a nipple and the areola. This operation is generally done a number of months after a reconstruction to give your body time to heal from the original operation and because the reconstructed breast may drop slightly after surgery.

The nipple is made from tissue on your reconstructed breast. It is folded to create a nipple shape. The new nipple won’t have nerves, so it will not feel any sensation or become erect to touch. Sometimes the nipple can flatten out and sometimes it can be permanently erect.

Reconstructed breast and nipple (no tattoo)

After the reconstruction you will have a new nipple.

The new nipple can be tattooed to match the colour of the other nipple. The tattoo can be done by a reconstructive (plastic) surgeon, trained nurse, professional medical tattooist or specially trained cosmetic therapist. Initially, the tattoo will look darker than the remaining nipple, but it will fade with time to match in colour.

A new technique called 3D nipple tattoos uses different shading to create the appearance of a nipple. Your breast care nurse can give you more information about this new procedure.

You may be advised or choose to have a bilateral mastectomy – also called a double mastectomy. This means both breasts are removed at the same time.

You may have a bilateral mastectomy for several reasons:

• the type of breast cancer you have
• your risks and/or anxiety about developing another breast cancer
• family history or a gene fault that increases your breast cancer risk
• the amount of surgery required to achieve a symmetrical result with the breast reconstruction
• choosing an abdominal flap reconstruction – because surgery on the abdomen can only be done once, the flap procedure can’t be repeated at a later date if cancer develops in the other breast.

You can consider reconstructing both breasts or going flat. Discuss your options with your doctor and get a second opinion if you wish.

This procedure combines surgery to treat breast cancer (breast-conserving surgery or wide local excision) with surgery to reduce the size of the breast (breast reduction).

It is often used as an alternative to mastectomy in suitable cases. Sometimes a breast reduction is done on the other breast at the same time, or at a later date.

It's common to feel nervous when the bandages and dressings are first removed. It will take time for the bruising and swelling to fade, and the appearance of a breast reconstruction using a tissue flap may take longer to settle. If you're disappointed with the appearance of the breast, you may have other operations or procedures to improve the look and shape of the breast. Find out ways to feel better about how your body looks.

After any type of operation, you will be given pain medicines to ease your discomfort. You will also probably have small tubes (drains) inserted into the operation site to remove excess fluid, and may go home with them. If you have had a flap reconstruction, you will be sore in the area where the other tissue and/or muscle were taken, as well as in the breast area.

Sometimes the area will not heal well within the first week or so after surgery. This can be caused by infection, poor blood supply or problems with an implant or flap.

Any infection must be treated to reduce the possibility of further complications. If an implant has been used, it might need to be taken out. It may be possible to have a new implant put in at a later date.

Blood may build up in or under the wound. This is called a haematoma, and it causes swelling and pain. A large haematoma may need to be removed by surgery.

In some cases, when drains have been removed, extra fluid collects in or under the wound. This is called a seroma, and it causes swelling and pain. It may need to be removed by a health professional using a needle. You can wear a special bra called a compression bra to help relieve the pain.

All types of breast reconstruction will leave a scar. Everyone heals differently, and the final appearance of a scar will vary, even if the surgery is the same. Most scars have a thickened, red appearance at first, but they will usually fade after about 3 months.

Sometimes the scar stays thick and becomes itchy and uncomfortable. Before the surgery, let your surgeon know if you have other raised, irregular scars (sometimes called keloid scars), as this may show that you are prone to getting these types of scars. Your surgeon or breast care nurse can advise you about treatments to reduce the discomfort. You may be able to have further surgery to improve the scar’s appearance.

Breast reconstruction doesn’t affect your ability to become pregnant or carry a baby. There is a small risk of having a hernia during pregnancy if you had an abdominal flap reconstruction. Your doctor will talk to you about any risks you may have and how to manage them.

It will not be possible to breastfeed with the reconstructed breast. You may be able to breastfeed successfully with the other breast, although this may be difficult if you have had reduction surgery in this breast. You can ask a breast care nurse or lactation consultant any questions you have about breastfeeding after a reconstruction.

When you get home from hospital, you will need to take things easy for the first few weeks. Ask family and friends to help you with chores so you can rest.

Avoid repetitive arm movements (e.g. hanging out washing, vacuuming), heavy lifting (more than 5 kg, so this may include shopping bags) and activities that strain your arm. You can gradually return to your usual activities after 4–8 weeks.

You will probably need to avoid driving for 4–6 weeks after surgery. Discuss this timing with your breast surgeon.

After abdominal flap surgery, you may have weaker abdominal muscles. Get up from a low chair or sit up in bed carefully. Wearing supportive underwear will help. If the weakness continues after 6 weeks, ask your doctor for a referral to a physiotherapist or an exercise physiologist for an exercise program.

Until the area is healed, wear loose-fitting comfortable clothing.

Continue to see the specialist who performed the reconstruction until your body has healed.

Every state and territory has a government scheme that provides financial help to people who need to travel long distances for specialist medical treatment that is not available in their local area. Many schemes also assist with the cost of accommodation. Ask the hospital social worker about services you are eligible to receive.

Talk to a qualified professional about your situation. Cancer Council offers free legal and financial services in some states and territories for people who can’t afford to pay – call Cancer Connect on 13 11 20 to ask if you are eligible.

There is a Medicare rebate if the tattooing is done by a health professional with a Medicare provider number. If you have private health insurance, it may cover the cost of the tattooing.

• Reconstruction after a mastectomy is a medical procedure, not a cosmetic one, so the costs are covered through Medicare for a public patient in a public hospital.
• There may be some extra charges if an implant is used.
• There may be some extra charges for private patients who have a reconstruction in a public hospital.
• If you choose to have a delayed reconstruction, you will be put on the hospital’s elective surgery waiting list. Ask your surgeon how long you might have to wait.
• You can change your mind and decide not to proceed with the reconstruction even if you are on a waiting list.

• Private patients may be covered by their private health insurance or may have to pay the cost themselves.
• In a private hospital, Medicare will cover some of the surgeon’s and anaesthetist’s fees. Your health fund may cover some or all of the remaining costs, but you may need to pay a gap fee or a hospital admission fee.
• Part of or the entire cost of an inflatable tissue expander and any permanent implant may also be covered by your health insurance provider.
• If you decide to join a health fund before your operation, you will have to wait the qualifying period before you can make a claim. This may be up to 12 months. Check with the different health funds.

For more information, see Cancer and your finances.