What To Ask Your Plastic Surgeon Before Breast Reconstruction Surgery
Your consultation appointment with a plastic surgeon for breast reconstruction surgery is likely to take more than 30 minutes and should allow you to get all your questions answered. It’s a good idea to go to the appointment with a list of questions so you don’t forget anything.
Are you certified by the American Board of Plastic Surgery?
Are you a member of the American Society of Plastic Surgeons?
Do you accept my health insurance?
How long have you been doing breast reconstruction?
How many breast reconstruction procedures do you do each year?
Which types of reconstruction are you most experienced in?
What type of breast reconstruction would you recommend for me?
Are there any new reconstruction options I should know about?
Am I a good candidate for breast reconstruction?
What are the risks of this type of reconstruction?
What is the best reconstruction timing for me? (Be sure to tell the surgeon if you’re scheduled to have radiation therapy or chemotherapy after breast cancer surgery.)
How should I prepare for surgery?
How long does the surgery usually take?
What kind of anesthesia will I have?
What will my breast look like after reconstruction?
Do you have photos of similar reconstructions you’ve performed?
What results are realistic for me?
Will the reconstructed breast match my remaining breast in size and shape (if applicable)?
How will my reconstructed breast feel to the touch?
Will I have any feeling in my reconstructed breast?
How much discomfort or pain will I feel?
How long will I be in the hospital?
Will I need blood transfusions? If so, can I donate my own blood?
Can you connect me with other women who have had the same surgery?
How will the surgery affect the tissue donor site (if you’re considering flap reconstruction)?
How long is the recovery time?
What type of wound care do I need to do at home?
Will you insert surgical drains?
How much help will I need at home to take care of my drains and wounds?
When can I bathe and can I take a bath or only shower?
How long do I need to sleep on my back?
Are there exercises I need to do after surgery? If so, when should I start?
How much activity can I do at home?
What do I do if I get swelling (lymphedema) in my hand, arm, or trunk?
When will I be able to return to activities such as driving and working?
What kinds of changes to the breast can I expect over time?
How will aging affect the reconstructed breast?
What happens if I gain or lose weight?
How long will the implant last (if you’re considering implant reconstruction)?
Surgeons answer your breast reconstruction questions
Read what breast reconstruction specialists have to say about revision surgery, how radiation therapy affects reconstruction, and going flat after reconstruction.
Question: Can implants be replaced years after the initial reconstruction with DIEP flaps under the spared skin? Can nipple reconstruction be preserved in this case?
— farmerlucy
Answer: Yes. It is quite common for women to have implants replaced with their own tissue. They may desire this for a number of reasons, including capsular contracture, in which the tissue around the implant becomes tight and uncomfortable. They may not like the feel, the size, the position, or the shape of the implant.
In these cases, the implants and any associated capsular contracture can be removed and replaced with their own healthy natural fatty tissue all while sparing the abdominal muscles in the case of the DIEP flap. If a successful nipple reconstruction has already been performed, it can often be preserved.
— Craig Blum, MD, FACS
Q: I had a lumpectomy and radiation more than years ago. My skin did great during the radiation — no burns, just a bit of redness — and no chemo. I recently discovered that for genetic reasons I should have a prophylactic mastectomy. I have read up on implants and am clear that I don’t want them. I live in a major city where they do both DIEP and SIEP. I want SIEP if I can have it. I have plenty of belly fat to use so no issues there.
My breast surgeon has retired so I looked for recommendations for a plastic surgeon as I consider their work the most important since I don’t currently have BC. The first office I called the nurse was very negative because I am 60 years old. It never occurred to me that I wouldn’t qualify for a tram flap due to my age. I am healthy but sedentary. I do take blood pressure and cholesterol medication, but they keep things under control. The concern is apparently because it is a long surgery. Am I too old for reconstruction using my own tissue?
— ktfelder
A: We do not have a specific age cutoff for surgery. We prefer to evaluate each patient independently and determine if breast reconstruction is a safe option based on their overall health. We have performed breast reconstruction on patients well into their 70s safely and with excellent outcomes. Prior to surgery, each patient’s medical history is discussed amongst our team of well-trained nurses, surgeons, and anesthesiologists. If any concerns arise, we may ask the patient to see their medical physician prior to surgery to address these concerns in order to make the surgery as safe as possible.
— Craig Blum, MD, FACS
Q: I’m wondering can you do a DIEP flap and fat grafting to make a full breast at same time during same surgery procedure?
— FreeYourMelons1
A: Generally, we will perform the DIEP flap first and allow the patient to heal and recover. Then we can re-evaluate the volume and projection of the breast. The reconstructed breast may need a breast lift at the time of revision, which will certainly improve the projection of the breast, making it appear fuller and more youthful. Fat grafting may be used in addition to add volume and smooth out any contour irregularities to make the best possible result.
— Craig Blum, MD, FACS
Q: I was wondering if anything can be done about post-surgical adhesions. My lovely surgeons did multiple surgeries (for my mastectomy and subsequent reconstruction) as I threw a hematoma after my lumpectomy. They were trying to limit how many scars I ended up with, so they used the same incision site for my drain tube for each surgery.
What I’ve ended up with is a scar that has adhered to the tissue underneath and, so, the skin doesn’t move freely or lay flat. This leaves me with a bunch of skin and tissue that sort of sticks off the right side of my chest close to my armpit and looks pretty funny with any sleeveless top, tank top, or bathing suit. Can anything (short of an additional surgery) be done?
— MTwoman
A: There are some things that can be done that can improve scar tethering and adhesions short of surgery. First-line treatments can include silicone gels and sheeting for the external feel and appearance. Combine this with massage to the area to improve the mobility of the scar. Physical therapy can help to improve range of motion to the shoulder as well as alleviate some of the discomfort.
However, I suspect that you would do best with an additional surgery. We often extend incisions towards the armpit and bra line to remove excess axillary skin and refine the outer breast shape. If you have cording (bands extending from the arm to the chest wall) the cords can be released at the same time. Drain sites can be excised and re-sutured to correct tethering as well. Seek out reconstructive surgeons specializing in breast reconstruction and offering implant and flap reconstructions.
— M. Whitten Wise, MD
Q: I have had 16 rounds of chemo, three chemo medications, and 35 rounds of radiation. I’m triple-negative, BRCA-positive. Bilateral mastectomy removed two metaplastic sarcoma tumors with good margins and no spreading to lymph system. I’ve had a complete hysterectomy post-treatment to prevent recurrence.
I have had three fat grafts with not-so-great results on my affected side (radiation). I do not want any flap surgery. I’m only interested in fat grafts. I asked my surgeon if a very small implant could be done. I have been advised by my plastic surgeon I cannot have implants after 35 rounds of radiation without a flap surgery (skin cooked and too thin). Is there any option for women like me other than the extreme flap surgery? Is flap surgery really my only option?
— Eva1962
A: I am glad you have done so well. With triple-negative breast cancer and a BRCA genetic diagnosis, we would also have recommended bilateral-double mastectomy. Post-mastectomy radiation does indeed make implant reconstruction very difficult. Implants in the setting of radiation are prone to capsular contracture (painful scar tissue around the implant), infection, and extrusion (the implant actually coming out of the incision).
Alternatively, we would love to believe that fat grafting (fat injections) alone can rebuild a breast, but it is almost universally unsuccessful. Breasts rebuilt from fat grafting alone are firm, fibrotic, and filled with oil cysts and half-dead fat. This is even worse in the setting of radiation. In addition, it takes multiple sessions and operations to see even modest results.
The best answer for you and most patients is autologous breast reconstruction (flap surgery). I can tell that you are apprehensive about flap surgery. However, it should not be considered extreme. Some plastic surgeons portray it as such because it is time-consuming and technically difficult for them. However, the results are almost invariably better than implant reconstructions. The surgery takes a bigger up-front commitment, but the results are worth it.
Flap surgeries require less frequent long-term surgeries than both implants and fat grafting. The results both feel and look more natural. The reconstructed breasts will age naturally as you age. Flaps are definitely the best option for you. Seek out a group that specializes in breast reconstruction and offers both implant and flap reconstructions.
Specifically, you want to see a group that does perforator flap breast reconstruction (the names of those procedures are DIEP flaps, GAP flaps, PAP flaps, TDAP flaps). Experienced reconstructive surgeons will work with you to pick the ideal donor site for your body shape and desired breast size.
— M. Whitten Wise, MD
Q: I had bilateral mastectomy with implant reconstruction about a year ago. The implant exchange was done three months ago. I am very unhappy with the silicone implants, although they look fine and healed well. My question is: How difficult is it to go flat after implant surgery? Will the function of the pectoral muscles ever be back to normal? Are the Alloderm grafts removed? How is the excess skin and tissue handled? My plastic surgeon has never removed implants and so can’t answer these questions.
— momten
A: I’m sorry that you are having difficulties with your implant breast reconstruction. We see a large volume of patients who have a variety of symptoms from implant reconstructions. Some report animation where the breast moves around when they contract their pectoralis muscle. Others report discomfort, tightness, cold feeling, and other problems related to the shape or size of the implants. Many of these problems can be improved with a revision.
Alternatively, many of our patients seek to have their implants out and replaced with flap reconstruction. Invariably the flap reconstructions look and feel more natural. The implants are removed, the pectoralis muscle is returned to its natural position and the reconstruction is done in the same location that the breasts were prior to the mastectomy — above the muscle.
However, if you want to go flat, that is easily accomplished. The implant and cellular dermal matrix (Alloderm) are easily removed. Some of the excess skin is removed as well. The muscle is returned to its natural position and function should improve. Seek out a reconstructive plastic surgeon specializing in breast reconstruction and offering both implant and autologous perforator flap breast reconstruction.
— M. Whitten Wise, MD
Q: Why do a lat flap and not just implants? Can radiated skin not hold up the implants? I’m going with a C cup so I’m really confused. I have lots more questions to ask my plastic surgeon. Just thought I’d try another opinion. I was now told she wants to do the lat flap on my right and implant on my left. Not happy about going through that surgery if I don’t have to. Why is implant reconstruction usually not recommended after radiation therapy?
— pab
A: Thank you for your question. I’ll start out by stating that, BY FAR, the most important factor determining outcomes in implant-based breast reconstruction is quality of the mastectomy and, thus, quality of the post-mastectomy skin. ANY implant placed in the human body — from joint replacements to breast implants — is only as good as the tissue and skin that covers it.
With respect to implant breast reconstruction, the implants are separated from the outside world by a very thin layer of breast skin. Post-mastectomy skin is always stressed out to some degree as its primary source of blood flow — your breast tissue — is removed and, thus, requires the small vessels and capillaries under your skin to survive.
Even in the highest-quality mastectomies, other variables, such as:
prior or impending radiation
quality of the breast skin (amount of stretch marks)
size of the breast
prior surgery
amount of ptosis, or sagging
other medical issues (diabetes, smoking)
play a tremendous role in determining the ultimate ability of the breast skin to support an implant both in the near- and long-term.
That said, and specific to your question, the relationship between radiated skin and breast implants is rocky at best. Permanent, progressive, and irreversible stress is being added to already stressed skin. Further, capsular contracture of varying degrees of severity is the norm with implants in a radiated field.
Based on your surgeon’s recommendation, it sounds as if she is anticipating a thinner skin envelope on the side with the cancer, is anticipating radiation therapy post-operatively, or both. In this situation, the addition of additional vascularized tissue, such as a latissimus flap, is used to better protect and completely cover the implant. While implants are usually placed underneath the pectoralis muscle, it is not complete coverage. At most, two-thirds of the implant is covered by the pectoralis and, more often than not, over time there is retraction or window shading of the pectoralis over the implant and often leaves only one-third of the implant covered in the long-term.
The latissimus flap is a very common flap performed in this setting. It is safe, technically easy to perform with high success rate, and has a relatively straightforward recovery. The major drawback is that the operation involves sacrifice of a large trunk muscle and increases the animation deformity (when you move or strain, the breast will distort significantly until muscles are at complete rest) due to action of both the pectoralis and latissimus over the implant.
The donor sites can also be difficult, as risk of a seroma — fluid collection — at the donor site is high and there is obvious difference in appearance of the back on the side with latissimus versus the side where the latissimus flap was taken from. Further, the degree to which losing the normal function of the latissimus muscle affects daily life is controversial and is often individual-dependent based upon line of work and hobbies, but is a legitimate concern.
Taking all of this into consideration, while I agree that likely adding your own tissue is necessary in your situation and reduces risk of implant-related complication, there are other reliable options that do not involve sacrifice of muscle and have more favorable donor sites such as the DIEP, SGAP, and TUG flaps. These options involve microsurgical transfer of fat from areas of natural excess, while sparing muscle. While these options may have slightly longer recoveries, the trade-off is permanence. The DIEP flap, for example, is regarded as the gold standard for tissue restoration of the breast. Outcomes relative to these options are optimized in centers that perform large volumes of microsurgical procedures using organized and experienced teams and, thus, it is not uncommon for people to travel for these procedures.
It’s worth learning about these options as they are frequently used in situations where there is dissatisfaction with implant-based results, or failed implant reconstructions due to exposure, severe capsular contracture, or need for many revisions over time.
In any case, I commend you for sharing your concerns and advocating for yourself regarding these complex issues. You should be informed of ALL options available to you in an environment where questions are welcomed and shared decision-making between you and your surgeon is valued. I encourage you to seek more than one opinion and wish you all the best.
— Chris Trahan, MD, FACS
This information made possible in part through the generous support of www.BreastCenter.com.
— Last updated on July 18, 2023 at 6:07 PM