Types of Breast Reconstruction

Breasts can be reconstructed using implants, living tissue or a combination of the two. Most reconstruction involves two or more operations over several months. The initial surgery forms the breast mounds (breasts without nipples). A shorter revision surgery later refines the shape and size of the new breasts and (if needed) creates nipples. Tattooing adds color to the nipples, simulates the areolas and completes the reconstructive process. 

Reconstruction with breast implants

Most breast reconstruction involves implants, which are filled with soft, thick silicone gel (saline implants are used less often). Implants may be placed under or over the pectoral chest muscle. Implants are not lifetime devices, and eventually must be replaced.

Implant procedures include:

• Expander-to-implant reconstruction: A temporary expandable implant is placed into a pocket under the chest muscle and is then gradually inflated over a few weeks in a plastic surgeon’s office. Expansion stretches the chest skin and muscle until the pocket is large enough to fit the desired implant. A shorter surgery then replaces the expanders with implants that best fit the chest anatomy and desired size. 
• Direct-to-implant reconstruction (also known as "one-step): Nipple-sparing mastectomy and reconstruction can be completed in a single operation. This is known as "direct-to-implant" reconstruction. A full-sized implant is secured into place with an FDA-approved acellular dermal matrix (a type of tissue graft made from animal, human or synthetic tissue), so no expansion is needed. With this reconstruction the implants may be placed under or over the muscle, depending on patient and surgeon preferences. Not all surgeons perform this type of reconstruction.  

Breast implants (and especially a type known as textured silicone implants) have been linked to a very rare cancer known as Breast Implant Associated Anaplastic Large Cell Lymphoma or BIA-ALCL. Although the cancer is rare, the FDA issued a recall of Allergan BIOCELL textured implants and expanders (see full list of devices here). This means that surgeons will no longer be able to use these implants for breast reconstruction or augmentation in the future. The FDA does not recommend removal of textured implants when there are no symptoms of BIA-ALCL or other implant-related complications because the risk of developing this disease is low.

Screening for breast implant rupture

The FDA recommends periodic imaging (e.g., MRI, ultrasound) of silicone gel-filled breast implants to screen for implant rupture. In fact, they require implants be labeled with the these recommendations. Even if there are no symptoms, patients should have an ultrasound or MRI at 5-6 years after their initial implant surgery and then every 2-3 years thereafter. The FDA also recommends that any person who has symptoms at any time or uncertain ultrasound results for breast implant rupture should undergo a breast MRI.

Visit our section on Preparation and Recovery for additional risks associated with breast implants and other types of reconstruction. 

Reconstruction with living tissue

Breasts can be reconstructed using excess fat, skin, and/or muscle removed from the tummy, hips, back, buttocks or thighs. This is known as "autologous breast reconstruction." 

Older flap techniques, including TRAM and Latissimus Dorsi, remove muscle from the donor site, which can lead to pain or muscle weakness. Newer flap techniques, known as "perforator flaps" include DIEP, PAP, GAP, TUG and others. These flap methods produce similar cosmetic results using only fat and skin and sparing the muscle. These muscle-sparing methods require a specially trained microsurgeon who connects blood vessels in the flap to blood vessels in the chest. The overall timeframe for completing flap reconstruction is shorter than breast reconstruction with tissue expansion, but it is more invasive and requires longer surgery and recovery times. Unlike breast implants, tissue flaps last a lifetime without needing to be replaced.