There are two types of breast surgery for early breast cancer: breast conserving surgery and mastectomy.

Breast conserving surgery followed by radiotherapy is as effective as mastectomy for most women with early breast cancer. This means that for most women the chance of breast cancer spreading to other parts of the body and the chance of dying from breast cancer is the same after either treatment.

However, with breast conserving surgery followed by radiotherapy there’s a higher chance that the cancer could come back in the breast area. This is called local recurrence and doesn’t increase the chance of the cancer spreading to other parts of the body. Checking for local recurrence is one of the reasons why follow-up tests are important after treatment for breast cancer.

Both types of breast surgery usually also involve surgery to remove of one or more lymph nodes from the armpit (axilla).

Surgery is not used routinely in the treatment of metastatic breast cancer but may be important for some women.

Find out more about:

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Guidance for the management of early breast cancer 

Visit Guidance for the management of early breast cancer

Breast-conserving surgery

Breast conserving surgery may also be called a lumpectomy, complete local excision, partial mastectomy or wide local excision.

Breast conserving surgery involves removing the breast cancer and a small amount of healthy tissue around it (called the surgical margin). Some women also have one or more lymph nodes removed from the armpit.

Breast conserving surgery is an option if the breast cancer is small enough compared to the size of the breast to allow removal of the cancer and some healthy tissue around it and still give an acceptable appearance.

Radiotherapy to the breast is usually recommended after breast conserving surgery. Sometimes radiotherapy is also given to lymph nodes in the armpit and/or lower neck.

How long does breast conserving surgery take?

Breast conserving surgery usually takes up to one-and-a-half hours. There will also be preparation time and time to recover from the general anaesthetic. A woman could be hospital anywhere between 1 day and 1 week, depending on her individual situation.

What happens after breast conserving surgery?

After breast conserving surgery, a pathologist will look at the breast tissue and lymph nodes that have been removed. The results will help the woman and her doctors decide what other treatments are best. If there are cancer cells in the surgical margin around the breast cancer, the woman may need more surgery. For some women this may mean having a mastectomy.

What does breast conserving surgery look like?

After breast conserving surgery, there will be a scar on the breast. The scar will become less obvious with time. The size and shape of the breast is also likely to change. The position of the scar and the shape of the breast after surgery will depend on where the breast cancer is and how much breast tissue is removed.

In some cases, the shape and size of the breast may be different to the other breast and may affect symmetry. Some women choose to use an external breast prosthesis or have further surgery to improve symmetry (ie breast reconstruction or reducing the size of the other breast).

Side effects of breast conserving surgery

Everyone responds differently to breast conserving surgery. Some side effects happen to most people, others happen only occasionally. Some side effects happen straight after surgery, others take longer to develop. Most side effects can be reduced or managed with appropriate care.

Common side effects of breast conserving surgery:

• pain, discomfort or numbness in the breast and/or armpit while the wounds are healing – this usually settles after a few weeks
• bruising or swelling around the wound in the breast (or under the arm if lymph nodes have been removed)
• stiffness in the arm or shoulder – it may be helpful to do some approved exercises after surgery
• tingling in the arm or shoulder if lymph nodes have been removed – this may improve with time, but feeling in these areas may change permanently
• fluid may collect in or around the scar in the breast or armpit – this is called a seroma and may need to be drained using a fine needle and a syringe; this can be done by a breast care nurse or another health professional in the clinic or by a GP
• mild pain in the arm and/or armpit – this can last a year or more after surgery if lymph nodes have been removed.

Side effects that sometimes develop after breast conserving surgery:

• if lymph nodes have been removed, there may be swelling in the arm, breast, hand or chest that lasts after the initial side effects of surgery are over; this is called lymphoedema and can develop a few months or years after surgery.

Rare side effects of breast conserving surgery:

• infection or bleeding in the scar in the breast or armpit; some women may need further surgery.

Find out more about:​

• Breast prostheses
• Breast reconstruction
• Lymphoedema

Mastectomy

Mastectomy involves removal of the whole breast (usually including the nipple) and usually removal of one or more lymph nodes from the armpit.

Mastectomy is usually recommended if the breast cancer is large compared to the size of the breast or there’s more than one cancer in the breast (multifocal disease).

Mastectomy may also be recommended after breast conserving surgery if:

• there are cancer cells in the surgical margin around the breast cancer that was removed
• breast cancer comes back in the same breast
• the woman has previously had radiotherapy to the breast area.

Some women choose to have a mastectomy as their first surgery to avoid having radiotherapy or further surgery to the breast.

Radiotherapy to the chest wall may be recommended after mastectomy if there’s an increased risk of breast cancer coming back in the chest area. Some women also have radiotherapy to lymph nodes at the base of the neck and occasionally to the armpit.

Breast reconstruction may be possible after a mastectomy or a woman  may choose to have her chest wall reconstructed and the excess skin and tissue removed – known as aesthetic flat closure, or “going flat”.

More information about aesthetic flat closure is available via the Breast Cancer Network of Australia.

How long does a mastectomy take?

Everyone responds differently to mastectomy. Some side effects happen to most people, others happen only occasionally. Some side effects happen straight after surgery, others take longer to develop.

Most side effects can be reduced or managed with appropriate care.

Common side effects of mastectomy:

• pain, discomfort or numbness in the breast and/or armpit while the wounds are healing – this usually settles after a few weeks
• fluid may collect in or around the scar in the breast or armpit – this is called a seroma and may need to be drained using a fine needle and a syringe; this can be done by a breast care nurse or another health professional in the clinic or by a GP
• stiffness in the arm or shoulder – it may be helpful to do some approved exercises after surgery
• numbness or tingling in the arm or shoulder if lymph nodes have been removed – this may improve with time, but feeling in these areas may change permanently
• mild pain in the armpit or upper arm – this can last a year or more after surgery if lymph nodes have been removed

Side effects that sometimes develop after mastectomy:

• swelling or bruising around the wound in the chest or armpit – this usually settles in a few weeks
• if lymph nodes have been removed, there may be swelling in the arm, breast, hand or chest that lasts after the initial side effects of surgery are over; this is called lymphoedema and can develop a few months or years after surgery.

Rare side effects of breast conserving surgery:

• infection or bleeding in the scar on the chest; some women might need further surgery.

Find out more about:​

• Breast prostheses
• Breast reconstruction
• Lymphoedema

Surgery to the armpit (axilla)

There are two types of surgery to the axilla: axillary dissection/axillary clearance and sentinel node biopsy. 

Whether a woman has surgery to the armpit and the type of surgery recommended depends on how likely the surgeon thinks it is that there are cancer cells in the lymph nodes.The lymph nodes in the armpit (axilla) are often the first place that breast cancer will spread to outside the breast.

The aim of removing lymph nodes from the armpit is to:

• find out whether breast cancer has spread to the lymph nodes
• remove any breast cancer that may be in the armpit area
• help plan further treatment.

What does it mean if cancer cells are found in the lymph nodes?

If cancer cells are found in the lymph nodes removed from the armpit, it means there’s a higher chance that cancer has spread into the bloodstream as well. In this case, treatment with systemic therapies such as chemotherapy or hormonal therapy will probably be recommended.

If a large number of lymph nodes contain cancer cells, radiotherapy to the armpit may be recommended to destroy any cancer cells that may be left in the armpit but cannot be removed by surgery.

Axillary dissection/axillary clearance

Axillary dissection involves removing several or all of the lymph nodes from the armpit.

If possible, this will be done during breast surgery (breast conserving surgery or mastectomy) and may be done through the same incision as the breast surgery itself. However, it may be done as a separate operation.

Because the number of lymph nodes in the armpit varies from person to person, the number of lymph nodes removed and the length of the operation will be different for each woman.

After axillary dissection, the lymph nodes are examined by a pathologist. The number of lymph nodes that have cancer cells in them will help the doctors decide what other treatments are best.

Treatment may involve systemic therapies (therapies that treat the whole body), such as chemotherapy or hormonal therapy, and less commonly, radiotherapy to the armpit.

Questions to ask

Listed below are some useful questions that may be helpful when discussing surgery to the armpit:

• Do I need surgery to my armpit?
• What type of surgery to the armpit do you recommend?
• When will I have surgery to the armpit? Will I have surgery to the armpit at the same time as my breast surgery?
• How long will the operation take?
• What can I do to make myself more comfortable during the procedure?
• What are the risks and benefits of the surgery you are recommending?
• What kind of training and experience do you have in sentinel node biopsy? How long have you been undertaking sentinel node biopsy?
• Can you refer me to someone who has training in sentinel node biopsy?
• Will I need further surgery if you find cancer cells in my sentinel node?
• Are there any clinical trials I can join?

Sentinel node biopsy 

Sentinel node biopsy involves removing the first lymph node (or nodes) in the armpit to which cancer cells are likely to spread from the breast. It’s important that sentinel node biopsy is done by a surgeon who is trained and experienced in this method.

Sentinel node biopsy is usually done during breast surgery (breast conserving surgery or mastectomy). Sometimes it may be performed as a separate procedure. The length of time it takes to do sentinel node biopsy varies for individual women.

The sentinel node(s) removed from the armpit are examined by a pathologist. If there are cancer cells in the sentinel node, further surgery (axillary dissection) may be needed to remove more lymph nodes from the armpit to check how many lymph nodes are affected. If the sentinel node is examined during surgery, it may be possible to remove the remaining lymph nodes during the same operation. However, for many women, a second operation is needed.

In a small number of cases, it’s not possible to find the sentinel node at the time of surgery. In this situation, an axillary dissection will be recommended.

What is the sentinel node?

The sentinel node is the first lymph node to which breast cancer cells may spread outside the breast. Although some women may have one sentinel node, some may have two or three sentinel nodes. Usually the sentinel node is in the armpit (axilla). Sometimes the sentinel node is in another part of the body — for example, in the chest between the ribs under the breast or above or under the collarbone. View a picture of lymph nodes near the breast.

How is the sentinel node found?

There are different ways of finding the sentinel node. The best way is to use a combination of two substances — one is a low-grade radioactive fluid (isotope) and the other is a blue dye. The dye and radioactive fluid show the surgeon to which lymph node(s) breast cancer cells are most likely to travel.

Sometimes, either the blue dye or the radioactive fluid alone is used to look for the sentinel node. However, fewer studies have been done using blue dye or radioactive fluid alone to show whether these are as good at finding the sentinel node as the combined method.

What does the procedure involve?

The radioactive fluid (usually about 1–2 ml) is injected into the breast around the cancer or under the areola before surgery. A special scan is done to find out to which lymph node(s) the radioactive fluid has travelled. During surgery, the blue dye is also injected into the breast. The blue dye will travel to the lymph nodes via the lymphatic vessels and the sentinel lymph node(s) should turn blue.

The surgeon can see the blue sentinel node(s) and detect the radioactive substance using a type of Geiger counter called a gamma probe. The surgeon can then remove the sentinel node(s). If more than one sentinel node is found, all the sentinel nodes are removed. If another enlarged lymph node is found in the armpit without dye in it, the surgeon will usually remove this node as well. If the sentinel node is not in the armpit, the surgeon will remove it if this can be done safely.

Is sentinel node biopsy always accurate?

In a small number of women, the sentinel node doesn’t have cancer cells, even though there are cancer cells in other lymph nodes in the armpit. This is called a ‘false-negative result’.

A false-negative result sometimes occurs because lymphatic vessels running to the lymph nodes that have cancer cells in them are blocked by cancer cells. This means that the dye goes into other normal lymph nodes instead.

To minimise the chance of a false-negative result, the surgeon may remove any enlarged nodes that are found at the time of surgery, even if they do not contain the dye.

Side effects of sentinel node biopsy

Clinical trials have shown that sentinel node biopsy is associated with a lower risk of arm problems than axillary dissection. This means that the risk of numbness, shoulder stiffness and lymphoedema is lower than with axillary dissection.

There’s a small risk of allergic reaction to the radioactive fluid or blue dye used to find the sentinel node. Allergic reactions are usually mild and easily treatable.

Rarely, women may experience a severe allergic reaction (less than 1 in 5000 cases). A doctor may decide not to use the blue dye for sentinel node biopsy if there’s reason to think a woman may be at significant risk of allergy to the blue dye.

If blue dye is used to find the sentinel node, the urine may turn blue for 24 hours after surgery. The skin of the breast may also become blue but this will fade with time.

There will be some pain associated with sentinel node biopsy, and injection of the radioactive isotope sometimes stings.

Surgery for metastatic breast cancer

Surgery is not used routinely in the treatment of metastatic breast cancer but may be important for some women.

Metastatic breast cancer and breast surgery

If metastatic breast cancer is a woman’s first diagnosis of breast cancer, a breast biopsy will usually be done to confirm the diagnosis and find out what receptors are on the breast cancer cells.

Metastatic breast cancer and bone surgery

If metastatic breast cancer has spread to the bone, surgery can be used to:

• prevent or treat a fracture
• replace a joint that has been damaged by cancer
• remove cancer in or around the spine that is putting pressure on the spinal cord.

Surgery to the bone is often followed by radiotherapy.

Metastatic breast cancer and lung surgery

If metastatic breast cancer has spread to the lungs, surgery can be used to:

• remove fluid from the pleural cavity
• treat cancer in the pleura that is not being controlled by other cancer therapies.

Metastatic breast cancer and brain surgery

If metastatic breast cancer has spread to the brain, surgery may be used to remove the cancer. This is usually only done if the cancer is small and in one area of the brain. Surgery to remove cancer from one area of the brain is usually followed by radiotherapy.

Surgery may also be used to drain fluid from the brain.

Metastatic breast cancer and liver surgery

Surgery to treat metastatic breast cancer that has spread to the liver is rare and is usually only carried out if only one discrete area of the liver is affected.

Other reasons for surgery for metastatic breast cancer

Surgery may be used to treat other symptoms of metastatic breast cancer. These include:

• cancer that has grown through the skin
• cancer that has blocked the bowel
• cancer that is pressing on nerves in the body causing nerve pain.

Breast reconstruction

Breast reconstruction and flat closure

Breast reconstruction is surgery to rebuild a breast shape after mastectomy.

You do not have to make a decision about breast reconstruction straight away. Take time to review the information available. You may not get through it all in one sitting, but may look through this information over time.

Flat closure after mastectomy

Breast reconstruction is not for everyone. A woman may decide for a variety of reasons that she does not want to have a breast reconstruction after mastectomy. She may choose instead to have her chest wall reconstructed and the excess skin and tissue removed – known as aesthetic breast flat closure Some are happy to live with their post mastectomy shape, and others use an external breast prosthesis to recreate breast shape. Information about external breast prosthesis can also be found within this section.

Following a mastectomy, women may choose an aesthetic flat closure, which is sometimes referred to as “going flat” or “living flat”. There may be several reasons why women choose to “go flat”, including personal preferences, health issues which prevent further surgeries and concerns about costs. More information is available via Breast Cancer Network of Australia.

Mastectomy

Mastectomy may be used to reduce the risk of breast cancer developing in women with a high risk of breast cancer. This is called preventative or prophylactic mastectomy. Mastectomy may also be used to treat breast cancer in women who have been diagnosed with the disease. Use the links below to find information that applies to your situation:

• Breast reconstruction for women considering preventative (prophylactic) mastectomy
• Breast reconstruction for women with a breast cancer diagnosis
• Making decisions about breast reconstruction
• Types of breast reconstruction

After reviewing the information relevant to your situation you are encouraged to discuss the information and any questions you may have with your health care professionals.

The images provided on this site are a guide to surgical outcomes and may vary in each individual case.

Disclaimer

While Cancer Australia develops material based on the best available evidence, this information is not intended to be used as a substitute for an independent health professional’s advice. Cancer Australia does not accept any liability for any injury, loss or damage incurred by use of or reliance on the information contained in this document.

Types of breast reconstruction

There are two main types of breast reconstruction: inserting implants under the skin and muscle on the chest; and using skin, fatty tissue and sometimes muscles from another part of the body to rebuild breasts (called tissue flap procedures).

The different types of breast reconstruction are:

• Breast implant: an artificial implant that is inserted under the skin and muscle on the chest to form a breast shape.
• Latissimus dorsi (LD) flap: a flap of muscle, skin and fat that is moved from the back to the chest. Usually a breast implant is also inserted to achieve the required breast size.
• Transverse rectus abdominus myocutaneous (TRAM) flap: a flap of skin, fatty tissue and muscle that is moved from the abdomen (stomach) to the chest.
• Deep inferior epigastric perforator (DIEP) flap: A flap of skin and fatty tissue that is moved from the abdomen (stomach) to the chest.
• Other tissue flaps: a flap of skin, fatty tissue and sometimes muscle that is taken from another body part, such as the buttocks or hips. 

It is important to weigh up the benefits (how the reconstructed breast(s) may look and feel after surgery) with the possible downsides (demands of surgery and the effect of surgery on the woman’s body, time and finances).

Every woman’s breast reconstruction result is different. A pleasing result for one woman might not be a pleasing result for another. Breast refinement procedures may be undertaken following breast reconstruction to enhance the aesthetic outcome (overall appearance and symmetry) of the reconstructed breast(s).

It is important to note that not all types of breast reconstruction procedures will be offered by all surgeons or available at all health care facilities (particularly some of the tissue flap breast reconstruction options).

Breast refinement procedures

Breast refinement is surgery to improve the look of reconstructed breast(s).

Nipple and areola reconstruction

If the nipple and areola are removed during mastectomy, they can be recreated. For some women this is important and completes the look of their reconstructed breast(s). Other women decide that it is not necessary.

Nipple and areola reconstruction is usually done at least 3 months after breast reconstruction surgery. This gives time for the reconstructed breast(s) to ‘settle’ (they may fall slightly over time). Often the nipple is reconstructed first, followed by the areola a couple of months later.

Options for reconstructing nipples include:

• medical tattooing to create a flat circle on the skin that is the colour of a nipple
• using skin and tissue from the tissue of the reconstructed breast(s) to create a raised nipple
• taking a small skin graft from the end of a reconstruction scar (usually from the abdomen or back) to create a raised nipple.

Reconstructed nipples will not feel and behave as they did before mastectomy. Nipple sensation will not be the same and there may not be any feeling in the nipple at all. Reconstructed nipples will not change size with changes in temperature.

An alternative option is to use stick-on nipples that stay in place for several days at a time.

Options for reconstructing areolas include:

• medical tattooing: this is usually done a couple of months after the reconstructed nipple(s) have had time to heal and is usually done in an outpatient setting
• transferring skin from the groin area, where the skin colour is similar to that of an areola.

"When I was first going to have the reconstruction... I didn't think I'd bother with that nipple reconstruction... But when I saw what a great job he (breast reconstruction surgeon) did (with the breast reconstruction), I thought 'Well, I'd just finish it off'.... And that was really good because even though the whole reconstruction was good, just seeing that patch of colour again just sort of brings it that much closer to being normal."

Breast refinement surgery

Some women choose to refine their reconstructed breast(s) to create a more natural or pleasing appearance. They are also called equalisation surgeries.

Options include:

• lifting of both breasts (mastopexy)
• contouring (usually involving liposuction) of the reconstructed breast(s) to provide an improved breast shape.

Additional options for women who have only one breast removed include:

• breast reduction (reduction mammoplasty) of the non-reconstructed breast
• breast enlargement (breast augmentation) of the non-reconstructed breast
• lifting of the non-reconstructed breast to match the reconstructed breast

Breast refinement procedures may be undertaken at the time of breast reconstruction or at a later time. Your breast reconstruction surgeon will be able to discuss breast refinement surgery options with you.

Comparing different types of breast reconstruction

Things to think about when comparing different types of breast reconstruction include:

• the look, feel and movement of the reconstructed breast
• recovery times
• possible side effects.

View a comparison of the pros and cons of different types of breast reconstruction.

Look, feel and movement of reconstructed breast(s)

In general, breast reconstruction techniques using tissue flaps create a more natural look, feel and movement than those involving implants. The look, feel and movement of the LD flap is more natural compared with breast implants alone. TRAM flaps and DIEP flaps result in the most ‘natural’ look, feel and movement (because the LD flap usually also has an implant).

Breast reconstructions that use a tissue flap ‘age’ with the body, like any other tissue. They also change in size if you gain or lose weight. Ageing and weight changes will be more natural with TRAM and DIEP flaps, compared with a LD flap that uses a breast implant.

Breast implants look, feel and move less naturally than breast reconstructions that use tissue flaps. Implants create firm reconstructed breast(s) that sit higher on the chest and do not change position when sitting or lying down. They also do not change position or shape with age, or with changes in body weight. They might move slightly lower over time if the chest muscle becomes weaker.

Recovery times

Breast reconstructions using a tissue flap involve longer surgery and recovery times compared with breast reconstruction using implants. Tissue flap procedures also result in more scars – on the breast and on the part of the body from which the tissue flap is taken.

"I mean I was running a business. I didn't have time to be messing around with long recovery periods and things."

Possible side effects and complications of breast reconstruction

A side effect is a result of surgery which is inevitable, is part of the surgical process that occurs in virtually all patients, but is not necessarily harmful. For example, most surgical procedures produce some kind of skin scar. Whilst scars are not desirable, they are inevitable and necessary in order for the surgery to be performed.

A complication refers to an undesired effect of breast reconstruction surgery that is not expected, occurs only in some patients, and sometimes requires medical or surgical intervention. Complications of breast reconstruction can occur soon after surgery or develop months or even years later, and may be present for an extended period of weeks or months.

Examples of possible side effects of all types of breast reconstruction surgery include:

• All breast reconstruction surgeries involve some scarring. With breast reconstructions using implants, scars will only be on the breast. With tissue flap reconstructions, there will also be scarring on the part of the body from which the tissue has been taken.  Scars may appear thickened and reddened initially, but they usually begin to fade after about six months. The scars will never fade completely. By about 18 months after surgery, the scars will have faded as much as they ever will. Skin quality and how quickly your wound heals will affect how the scars fade. Moisturisers and massage may help. It is usually possible to hide the scars under clothing – sometimes even under swimsuits and underwear. Further surgery to improve the appearance of the scars may be an option later down the track.
• Change in feeling or sensation in the reconstructed breast.
• Firmness in a breast reconstructed with an implant.
• Generalised swelling in the area/s that has been operated on.

Examples of complications of all types of breast reconstruction surgeries include:

• Keloid scarring: These are firm, raised, reddened scars that are more common in people with darker skin tones. If you have keloid scarring, treatments are available to help.
• Wound infection: Nursing and medical staff will look after the surgical wounds and will provide advice about how to care for the wound at home. If a mild infection develops, a course of antibiotics should clear it up. In the very unlikely event of a severe infection, surgery may be needed to clean the area and remove bacteria causing the infection.
• Seroma: A seroma is a collection of fluid, which may develop near the surgery wounds on the breast. This fluid may reabsorb into the body over time. If not, the fluid can be drained with a needle and syringe.
• Haematoma: A haematoma is a collection of blood, which may develop in an area of the reconstructed breast. A swollen area may be obvious and may feel uncomfortable.  Smaller haematomas will absorb into the body over time. Surgery may be needed for larger haematomas.

You should discuss with your breast reconstruction surgeon any other possible side effects and complications related to specific breast reconstruction procedures.

Pros and cons of different types of breast reconstruction

Images of breast reconstruction

This section contains a series of photographs of women who have undertaken various types of breast reconstruction. These photographs will depict the individual’s surgical breast reconstruction outcomes at multiple stages of her breast reconstruction surgery (or surgeries).

Breast reconstruction images

To view these images simply click on the section you are interested in below.

• Reconstruction using implants
• Latissimus Dorsi (LD) Flap reconstruction
• Deep inferior epigastric perforator (DIEP) Flap reconstruction

It is important to remember that aesthetic outcomes of breast reconstruction are dependent upon many factors and vary with each individual. The outcomes depicted in these photographs may not reflect your aesthetic outcome. You are encouraged to request to view other photographs of breast reconstruction surgery undertaken by your chosen breast reconstruction surgeon, as surgical technique will differ between surgeons.

There are no actual photographs of women who have chosen to undergo preventative (prophylactic) mastectomy and breast reconstruction. Women who are considering preventative (prophylactic) mastectomy and breast reconstruction should view photographs of women who have had bilateral immediate breast reconstruction.

When viewing these photographs it may be particularly useful to note:

• The existing differences between the woman’s two breasts before their removal (for those who have immediate breast reconstruction);
• Comparison of the before surgery photographs with the final photograph following surgery;
• The appearance of the reconstructed breast with a bra on.

These photographs have been sourced from the Royal Perth Hospital Breast Surgery Gallery and Mr David Pennington, with the express permission of the women who appear in these photographs.

Breast reconstruction using implants images

These photographs have been sourced from the Royal Perth Hospital Breast Surgery Gallery, with the express permission of the women who appear in these photographs.

These photographs are of a 57 year old Caucasian lady with a breast size of 14b, who undergoes a left sided immediate breast reconstruction using tissue expanders, followed by a second surgery to replace the tissue expander with a permanent breast implant. This lady also chooses to have breast refinement surgery on her right breast by undertaking a breast lift (mastopexy).

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DIEP flap breast reconstruction images

These photographs have been sourced from Mr David Pennington, with the express permission of the women who appear in these photographs.

DIEP 1

These photographs are of a 59 year old Caucasian lady who has previously had her left breast removed. She later chooses to undergo a left sided delayed breast reconstruction using a DIEP flap from the abdomen area. This lady also chooses to have her nipple and areola reconstructed, and has breast refinement surgery on her right breast in the form of a breast reduction.

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DIEP 2

These photographs are of a 48 year old Caucasian lady who has previously had her right breast removed. She later chooses to undergo a right sided delayed breast reconstruction using a DIEP flap from the abdomen area. This lady also chooses to have her nipple and areola reconstructed, and has breast refinement surgery on her left breast in the form of a mastopexy (breast lift).

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DIEP 3

These photographs are of a 58 year old Caucasian lady who has previously had her right breast removed. She later chooses to undergo a right sided delayed breast reconstruction using a DIEP flap from the abdomen area. This lady also chooses to have her nipple and areola reconstructed, and has breast refinement surgery on her left breast in the form of a breast reduction.

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LD flap breast reconstruction images

These photographs have been sourced from the Royal Perth Hospital Breast Surgery Gallery, with the express permission of the women who appear in these photographs.

Latissimus Dorsi (LD) 1

These photographs are of a 59 year old Caucasian lady with a breast size of 14b, who undergoes a right sided immediate reconstruction with a latissimus dorsi flap and insertion of a tissue expander.

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Possible complications of a tissue flap breast reconstruction

Loss of circulation

There is a risk of bleeding or loss of circulation to the whole tissue flap with all of the tissue flap methods of breast reconstruction. This can happen if the blood vessels that supply blood to the tissue flap becomes kinked or blocked, or are actively bleeding.

After surgery, medications will be given to encourage blood flow through the blood vessels. The breast(s) will be monitored closely so that any changes in blood flow to the tissue flap are found early. If there is a severe lack of blood supply or a bleeding vessel, further surgery may be needed. In the rare situation that the tissue flap dies, surgery will be needed to remove the reconstructed breast.

Tissue flap necrosis

Tissue flap death may be more likely with pedicled flaps because they have less blood supply than free flaps. Tissue flap death is uncommon in free tissue flap breast reconstructions, affecting about 2 out of 100 women. The rare cases of tissue flap death usually happen in the first 2–3 days after the breast reconstruction surgery.

Fat necrosis

In some situations, areas of fatty tissue moved from the back or abdomen to the breast(s) may not receive enough blood and can die. This is called fat necrosis. Fat necrosis can feel hard to touch but is easily diagnosed as non-cancerous. Areas of fat necrosis may need to be removed by surgery. Fat necrosis typically develops 1–3 months after the breast reconstruction surgery.

Abdominal weakness (after LD, TRAM or DIEP flap breast reconstructions)

Some women find that movement of their arms and shoulders is affected in the medium to long term after LD flap breast reconstruction. Other muscles in the back help to make up for the lost strength of the latissimus dorsi muscle. However, reduced movement can affect some occupations and some physical/sporting activities (such as tennis and climbing).

About one in ten women who have a TRAM flap breast reconstruction experience a weakened abdomen. In a few cases (3%), a hernia may develop, where tissue protrudes through the weakened abdominal wall. Hernia is more common with the pedicled procedure because more abdominal muscle is moved. Hernias that become very painful or significantly interfere with function can be repaired with surgery.

To help avoid these possible complications a mesh may be inserted during breast reconstruction surgery, to replace the abdominal muscle removed with the TRAM flap.

Although abdominal weakness is less likely with DIEP flap breast reconstructions, some women also have weaker abdominal muscles in the short term after DIEP flap reconstructions because the muscle has been split to remove the blood vessels.

Breast reconstruction using implants

Breast reconstruction using implants involves rebuilding a breast shape by inserting a breast implant under the skin and muscle on the chest.

Types of breast implant

Breast implants are made from a silicone envelope filled with either silicone (a soft jelly-like substance) or saline (salty water). There are a variety of breast implants, each of which look, feel and move slightly differently. They come in different shapes (round or contoured), sizes and textures (smooth or textured).

In general, silicone implants look, feel and move more naturally than saline implants. A disadvantage of saline implants is that some women end up with a rippled effect that can be felt under their skin. Occasionally the ripples can be seen as wrinkled skin.

Contoured implants give a more natural ‘pear’ shape than round implants. Textured implants can help stop implants moving under the skin. The texturing is so fine that it usually cannot be seen or felt. A complication called capsular contracture is less likely with textured implants.

"I didn't want a TRAM flap or latissimus dorsi because my body is my tool so to sort of interfere with muscles that I use while I'm working and exercising was not really an option."

Safety of breast implants

In the past, concern has been raised about the safety of silicone implants because of the side effects if the implant ruptures and silicone leaks out. However, research
over the last 15 years suggests silicone implants are safe. A newer type of silicone implant (cohesive gel implant) contains a semi-solid filling that has a lower risk of
leakage if the implant breaks or ruptures.

If a saline implant ruptures, the salty water that leaks out is not harmful. However, further surgery will be needed to remove and replace the ruptured implant.

Cancer Australia has also produced a summary of the evidence on implants and breast cancer risk.

More information about the safety of implants is available from the TGA.

Implant breast reconstruction using a tissue expander

Side view of breast area with unfilled tissue expander in place.

• A tissue expander–unfilled
• B port
• C catheter
• D syringe
• E ribs
• F pectoralis major muscle
• G Other muscles of the chest wall

Side view of breast area with filled tissue expander in place labels.

• A tissue expander–filled
• B port
• C catheter
• D syringe
• E ribs
• F pectoralis major muscle
• G Other muscles of the chest wall (3 lines to one letter)

Figs. 8.6, 8.7, 8.9, 8.10, 8.13, 8.14 (pp.58-62) from Breast Cancer: The Facts by C. Saunders & S. Jassal (2009), By permission of Oxford University Press, global.oup.com

Deciding whether to have a breast reconstruction using implants

Benefits of having a breast reconstruction using implants include:

• less time in surgery
• shorter recovery time after surgery
• surgery does not use tissue from other parts of the body
• no scars on other areas of the body
• may avoid lifestyle limitations (such as heavy lifting or playing tennis) that can happen as a result of muscle weakness after tissue flap breast reconstructions.

Disadvantages of having breast reconstruction using implants include:

• the rebuilt breast(s) are unlikely to look, feel and move like natural breasts
• the rebuilt breast(s) will be firmer and not fall (droop) as naturally as the breasts did previously
• some women do not like the idea of having a foreign material (breast implants) inside their body
• long-term complications are more likely with implants, compared with tissue flap reconstructions. The complication of capsular contracture can be painful and restrict movement or limit activity.
• Over time, replacement of breast implants may be necessary.

If you decide to have a breast reconstruction using implants, you have the option of a tissue flap reconstruction at a later stage.

Questions to ask about breast reconstruction

• Are you a Fellow of the Royal Australasian College of Surgeons?
• Have you been trained in breast reconstruction techniques?
• What types of breast reconstructions do you perform?
• How many years of experience do you have in breast reconstruction?
• Which type of breast reconstruction do you advise would suit me best?
• Why are other types of breast reconstruction not suited to my situation?
• How much will the hospital, surgical, equipment and anaesthetic services cost?
• How long will the surgery take?
• How long will I need to stay in hospital?
• How long will my recovery at home take and why?
• What possible problems might occur with this type of breast reconstruction?
• How will these problems be treated and how will this delay my recovery?
• What kind of help will I need throughout my recovery?
• How will my physical functioning be restricted during my extended recovery period?
• How much time will I need to take off work (specify occupation)?
• Will I still be able to attend to the needs of my children during my recovery (specify current parental role demands)?
• Will I still be able to participate in sports/leisure activities following breast reconstruction (specify)?
• How should I expect my reconstructed breast to look and feel?
• What is expected of me to achieve the best possible results from this surgery?
• Do you have any patients who have had preventative (prophylactic) breast reconstruction in a similar situation to me who may be willing to speak with me?
• Do you have any photos of women who have had preventative (prophylactic) breast reconstruction?

Possible complications of breast implant reconstruction

Breast reconstruction using implants has higher rates of long-term complications than tissue flap breast reconstructions. Complications have been reported to occur in as many as 40% of cases. Of all women who have breast implants inserted (for breast reconstruction or to increase breast size), about one-third need additional surgery to manage complications.

Change to the feel and shape of the implant

Some women develop scar tissue around the implant, which can cause the implant to become hard and change shape. This is called capsular contracture. In this rare situation, surgery may be needed to remove and replace the implant, although replacement is not always successful.

Leaking implant

It is possible that a breast implant could leak in the future. The outside cover of the implant can become weaker over time and sometimes a hole can develop. If the implant contains saline, the leak will be noticeable straight away because the implant will deflate. If the implant contains silicone, the leak may be less noticeable. A lump may form where silicone has leaked out which may or may not be uncomfortable. The gel used in cohesive gel silicone implants is designed to minimise or prevent leaks when ruptured, so is less likely to be noticeable or cause problems.

Post-operative recovery after breast reconstruction using implants

As there is no transfer of tissue or muscle from other areas of the body, the recovery time after breast reconstruction surgery using implants is significantly shorter than for other types of breast reconstruction. You will probably spend around 1–4 days in hospital.

After breast reconstruction using implants:

• you will experience some discomfort or pain and tightness in the chest area (there are many pain-relief options available to help manage this
• excess blood and fluid will be drained from the reconstructed breast using tubes inserted under the skin to prevent excessive swelling; the tubes will usually be removed 2–5 days after surgery. This may mean going home with drains still in place. A member of your healthcare team will explain how to look after the drains. The drains will be removed by a healthcare professional when they have stopped draining fluid.
• you may need to wear a support bra or bandage to help reduce swelling and support your reconstructed breast(s).

Healing may take several weeks as the swelling goes down. As with any surgery, postoperative recovery will take longer if you have any complications. The recovery period will depend on how serious any complications are and the treatment needed.

What to expect with breast reconstruction using implants

The first step in a breast reconstruction using implants is usually to insert a tissue expander under the skin and muscle on the chest.

Fluid is gradually added to the expander through a valve just under the skin over a period of 2–4 months. The tissue expander stretches the skin and muscle
to the right size so that an implant can be inserted. The tissue expander is usually inflated until it is larger than the desired breast size. This extra stretching
helps to achieve a better breast shape.

Stretching the chest muscle can be mildly painful or uncomfortable for a day or two after each injection of fluid. Mild pain-killers can help. Some women also experience chest muscle spasms. Moderate arm movement exercises may help to retrain the chest muscle and reduce the amount of spasm and discomfort.

Some women can keep the tissue expanders in place permanently (called single stage breast reconstruction). However, most women have a second operation
to replace the tissue expander with a permanent breast implant (two stage breast reconstruction). This operation is much shorter and less complicated than
the other types of breast reconstruction operations.

For a two-stage breast reconstruction, it may be possible to reconstruct the nipple(s) and areola(s) during the second operation.

Latissimus dorsi (LD) flap

Latissimus dorsi (LD) flap breast reconstruction involves rebuilding a breast shape by moving skin, fatty tissue and muscle from the back (below the shoulder blade) to the chest. Tissue expanders are usually also used to create sufficient breast size.

LD flap breast reconstruction may NOT be the best option if you:

• do not want a breast implant – breast implants are needed in most cases to recreate breast size
• have scarring on your back from previous surgeries.

Breast reconstruction techniques which use tissue flaps that rely on a supply of blood may not be suitable for women who smoke. Smokers should stop cigarette smoking and nicotine substitutes for at least 4 weeks before the scheduled operation. This may be a consideration when deciding whether immediate or delayed breast reconstruction would be best for you.

Latissimus Dorsi (LD) flap breast reconstruction

Woman with latissimus dorsi muscle in place.

• A lattisimus dorsi muscle

Woman with latissimus dorsi muscle swung forward to re–create the new breast.

• A lattisimus dorsi muscle

Figs. 8.6, 8.7, 8.9, 8.10, 8.13, 8.14 (pp.58-62) from Breast Cancer: The Facts by C. Saunders & S. Jassal (2009), By permission of Oxford University Press, www.oup.com

Post-operative recovery after a LD flap breast reconstruction

LD flap breast reconstruction usually requires a hospital stay of 3–5 days.

After LD flap breast reconstruction:

• The reconstructed breast(s) will be monitored carefully, every 30–60 minutes for the first day or so.  This is important to make sure that the blood supply to the reconstructed breast is sufficient. Although this frequent checking can make it difficult to sleep, it is the best way to check for any postoperative complications. It also means action can be taken promptly if there is a complication.
• You will experience some discomfort or pain and tightness in the chest area and upper back (there are many pain-relief options available to help manage this)
• excess blood and fluid will be drained from the reconstructed breast and back using tubes inserted under the skin to prevent excessive swelling and reduce pressure on the blood vessels supplying the tissue flap(s); the tubes will usually be removed 2–6 days after surgery
• you may need to wear a support bra or bandage to help reduce swelling and support the reconstructed breast(s)
• you will have an oval-shaped scar on the breast(s) and a straight vertical or slanted horizontal scar(s) on the back; these scars can usually be covered by your bra.

Healing may take several weeks as the swelling goes down. Arm movement will be limited for at least a few weeks after surgery. Day-to-day arm function should return to usual within 3–6 weeks. However, strenuous arm movements, including driving and heavy lifting, should be avoided for at least 6 weeks after surgery.

Returning to exercise or sports may take 2–4 months, possibly longer for high-impact sports. Gentle arm movement exercises, guided by a physiotherapist, may help speed up recovery of arm function.

As with any surgery, postoperative recovery will take longer if you have complications.  The length of recovery will depend on the severity of the complication and treatment needed.

What to expect with a LD flap breast reconstruction

LD flap surgery is usually done in a 'pedicled' fashion. This means the skin, fatty tissue and muscle are moved from the back to the chest through a ‘tunnel’ made under the skin of the armpit. The blood vessels supplying the tissue flap remain intact.

Permanent breast implants may be inserted during the operation. Some women have tissue expanders inserted to stretch the skin and muscle to the right size before the implants are inserted. If this is the case, a second operation may be needed later to replace the tissue expanders with permanent breast implants.

LD flap breast reconstruction surgery usually takes 3–4 hours.

TRAM flap

Transverse rectus abdominus myocutaneous (TRAM) flap breast reconstruction involves rebuilding a breast shape by moving skin, fatty tissue and part of the rectus abdominus muscle from the abdomen (stomach) to the chest.

One of the benefits of a TRAM flap breast reconstruction is that the breast(s) can be reconstructed without needing implants. Some women also consider it a ‘bonus’ that the tummy is left relatively flat after removing the tissue flap (a ‘tummy tuck’ effect).

A TRAM flap breast reconstruction may NOT be the best option if you:

• have had surgery to the abdomen in the past; the similar DIEP flap or other tissue flaps may be suitable alternatives
• have poor blood flow through blood vessels
• have chronic medical conditions (such as some severe respiratory or circulatory problems)
• are very slender (because there may not be enough abdominal tissue for this procedure).

Breast reconstruction techniques which use tissue flaps that rely on a supply of blood may not be suitable for people who smoke. Smokers should stop cigarette smoking and nicotine substitutes for at least 4 weeks before the scheduled operation. This may be a consideration when deciding whether immediate or delayed breast reconstruction would be best for you.

Transverse Rectus Abdominis Musculocutaneous (TRAM) flap breast reconstruction

Woman after mastectomy: showing TRAM and surrounding tissues in preparation for breast reconstruction.

• A mastectomy site
• B right transverse rectus abdominis muscle
• C left transverse rectus abdominal muscle
• D segment of abdominal tissues: skin and fat, to be transferred along with muscle to create the new breast

A woman showing the lines of TRAM reconstruction incisions.

• A lines of reconstructed breast incisions
• B circle of re–positioned "belly button" incision
• C line of abdominal surgery incision

Figs. 8.6, 8.7, 8.9, 8.10, 8.13, 8.14 (pp.58-62) from Breast Cancer: The Facts by C. Saunders & S. Jassal (2009), By permission of Oxford University Press, www.oup.com

What to expect with a TRAM flap breast reconstruction

TRAM flap breast reconstruction using the ‘pedicled’ method involves moving skin, fatty tissue and muscle from the abdomen to the chest through a ‘tunnel’ made under the skin of the abdomen. The blood vessels supplying the tissue flap remain intact. This operation usually takes around 4-6 hours.

TRAM flap breast reconstruction using the ‘free’ tissue flap method, involves cutting the blood vessels that supply the tissue flap. The blood vessels are then rejoined to blood vessels in the chest area. This surgery is more complex than the pedicled method and can take 5–7 hours.

The free tissue flap method is often better for rebuilding larger breasts. More tissue can be moved to the breast area and the breast reconstruction surgeon can shape the reconstructed breast(s) more easily. A free tissue TRAM flap also uses less abdominal muscle and has better blood flow than a pedicled TRAM flap.

Some women need to have a CT angiography before they can have TRAM flap breast reconstruction surgery. This is a scan to check whether the blood vessels in the abdomen are suitable for a TRAM flap. A dye is injected into a vein in the arm. The dye moves around the body and a scan is taken when the dye reaches the blood vessels in the abdomen.

DIEP flap breast reconstruction

A deep inferior epigastric perforator (DIEP) flap breast reconstruction rebuilds a breast shape by moving skin and fatty tissue only (no muscle) from the abdomen to the chest.

One of the benefits of a DIEP flap breast reconstruction is that the breast(s) can be reconstructed without needing implants. Some women also consider it a ‘bonus’ that the tummy is left relatively flat after removing the tissue flap (a ‘tummy tuck’ effect).

Another advantage of DIEP flap surgery is that no muscle is moved from the abdomen. This means that the risk of weakness or hernia in the abdomen is lower than after a TRAM flap breast reconstruction. Women usually return to regular activities faster than with a TRAM flap breast reconstruction. However, the muscles may still be weak in the short term because the operation involves some interference with the muscle.

A DIEP flap breast reconstruction may NOT be the best option if you:

• have had surgery to the abdomen in the past (although, DIEP flap breast reconstruction is more likely to be suitable than TRAM flap breast reconstruction); other tissue flaps may be suitable alternatives
• have poor blood flow through blood vessels
• have chronic medical conditions (such as some severe respiratory or circulatory problems)
• are very slender (because there may not be enough abdominal tissue for this procedure).

Breast reconstruction techniques which use tissue flaps that rely on a supply of blood may not be suitable for people who smoke. Smokers should stop cigarette smoking and nicotine substitutes for at least 4 weeks before the scheduled operation. This may be a consideration when deciding whether immediate or delayed breast reconstruction would be best for you.

Post-operative recovery after a DIEP flap breast reconstruction

DIEP flap breast reconstruction surgery usually requires a hospital stay of 5–10 days.

After a DIEP flap breast reconstruction:

• the reconstructed breast(s) will be monitored carefully, every 30–60 minutes for the first day or so.  This is important to make sure that the blood supply to the reconstructed breast is sufficient. Although this frequent checking can make it difficult to sleep, it is the best way to check for any postoperative complications. It also means action can be taken promptly if there is a complication.
• you will experience some discomfort or pain and tightness in the chest area and abdomen (there are many pain-relief options available to help manage this
• excess blood and fluid will be drained from the reconstructed breast and abdomen using tubes inserted under the skin to prevent excessive swelling and reduce pressure on the blood vessels supplying the tissue flap(s); the tubes will usually be removed 2–8 days after surgery
• a support bra or bandage may be worn to help reduce swelling and support the reconstructed breast(s)
• you will have an oval-shaped scar on the breast(s) and a scar across the lower abdomen between the hips. It should be possible to cover this scar by with underwear or a swimsuit.

Healing may take several weeks as the swelling goes down. The ‘tummy tuck’ will create a tightened feel across the abdomen. You should avoid stretching this area in the days after surgery and will need to move in a slightly bent over position.

All heavy lifting (more than 10kg) should be avoided for at least 6 weeks and possibly up to 3 months after surgery. Heavy lifting includes lifting of large washing baskets, boxes and small children. You may also have driving restrictions, particularly for manual cars, which involve more core muscle activation.

As with any surgery, postoperative recovery will take longer if complications occur. The length of recovery will depend on the severity of the complication and treatment needed.

What to expect with a DIEP flap breast reconstruction

A DIEP flap breast reconstruction is essentially the same procedure as a free TRAM flap breast reconstruction, but does not involve moving muscle.

It is a slightly more complicated operation than the free TRAM flap because the blood vessels need to be carefully separated from the muscle before the tissue flap can be moved.

A DIEP flap breast reconstruction is an option for about two-thirds of women who are not suitable to have a TRAM flap breast reconstruction. A DIEP flap breast reconstruction can take 5–8 hours.

Some women need to have a CT angiography before they can have DIEP flap breast reconstruction surgery. This is a scan to check whether the blood vessels in the abdomen are suitable for a DIEP flap. A dye is injected into a vein in the arm. The dye moves around the body and a scan is taken when the dye reaches the blood vessels in the abdomen.

Other tissue flap breast reconstruction procedures

Breast shapes can be rebuilt by moving skin, fatty tissue and sometimes muscle from other areas of the body. The procedures are similar to those used for the TRAM flap and DIEP flap breast reconstructions. Each procedure is named according to the blood vessels that supply the tissue flap with blood.

Specific surgical skills and expertise are needed for these complex surgeries. Not all breast reconstruction surgeons can do all types of breast reconstruction surgeries.

Using tissue from the buttocks

A superior gluteal artery perforator (SGAP) flap breast reconstruction uses tissue from the upper part of the buttock. An inferior gluteal artery perforator (IGAP) flap breast reconstruction uses tissue from the lower part of the buttock.

After surgery, you will have an oval scar on the breast(s) and a scar across the buttock(s). The shape of the buttock(s) will also change. As the blood vessels in the buttocks are relatively short, sometimes a vein graft is needed. This will result in scar(s) on the lower leg(s).

Complications after breast reconstruction using tissue from the buttocks are more likely than after any of the other tissue flap breast reconstructions. Complications develop after as many as one in five gluteal flap breast reconstructions.

Using tissue from the hips

A Ruben’s or deep circumflex iliac artery (DCIA) flap breast reconstruction uses tissue from the ‘love handle’ area of the hip.

You will have an oval scar on the breast(s) and a scar on the hip(s). The shape of the hips will also change with this procedure.

Breast reconstruction after preventive mastectomy

Preventative (prophylactic) mastectomy is surgical removal of the breasts in women who do not have breast cancer.

You may consider having a preventative mastectomy if you have a strong family history of breast cancer and/or if genetic testing suggests a strong likelihood that you may be diagnosed with breast cancer in future. Preventative mastectomy is a big decision. It involves much consideration, consultation with healthcare professionals and genetic counselling.

Most women who have a preventative (prophylactic) mastectomy have both breasts removed (bilateral mastectomy).

Women who decide to have a breast reconstruction after a preventative mastectomy most often choose to have their breast reconstruction at the same time as mastectomy, this is called immediate breast reconstruction. However, you may not feel ready to make such a commitment at the time of your mastectomy. Some women find that factors such as financial issues, family situation or access to services mean that an immediate breast reconstruction is not right for them.

Some women decide that they do not want to have a breast reconstruction. They may choose to have aesthetic flat closure (see information about flat closure after mastectomy).  Some people choose to live flat and others choose to use an external breast prostheses (see information about the Services Australia External Breast Prostheses Reimbursement Program).

Having a delayed breast reconstruction at any time after you have had a mastectomy is called delayed breast reconstruction, is always an option later if you change your mind.

If you choose to have a mastectomy without breast reconstruction, the surgeon will remove the breast skin, areola and nipple. If you decide to have a breast reconstruction later, the remaining skin may need to be stretched to accommodate a breast shape. Alternatively, skin and tissue from another part of the body
can be used to replace the skin that has been removed surgically.

Physical appearance following preventative mastectomy

If you are having a preventative (prophylactic) mastectomy, it is usually possible to preserve the skin over the breast, the  areola and the nipple. Breast reconstruction following preventative mastectomy will usually involve replacing the underlying tissue only. This means that the reconstructed breasts are likely to look similar to the original breasts. There may be some differences in shape and feel, depending on the type of breast reconstruction. Having both breasts reconstructed means they are more likely to be symmetrical.

Breast reconstruction for women with a breast cancer diagnosis

Women who have a mastectomy as treatment for breast cancer may have one or both breasts removed. Breast reconstruction following mastectomy for breast cancer may involve one or both breasts

Breast reconstruction after mastectomy for breast cancer may be done at the same time as mastectomy (immediate breast reconstruction) or at a later time in a separate operation months or years down the track (delayed breast mastectomy).

The decision about whether to have an immediate breast reconstruction or a delayed breast reconstruction depends on a number of things, including what treatments you are having after mastectomy.

"I became really angry at this thing about the concentration on 'You've lost a breast, you're no longer a woman'.  And I sort of thought... Well you know, blow that, I'm more than a breast you know."

Some women decide that they do not want to have a breast reconstruction at all. If this is your choice, you have the option of using external breast prostheses. A delayed breast reconstruction may be an option later if you change your mind.

Impact of ongoing breast cancer treatments on breast reconstruction options

If you are considering a breast reconstruction after a mastectomy for breast cancer, your decision about the type and timing of reconstruction is likely to be influenced by what treatments you are receiving.

Impact of radiotherapy on breast reconstruction

Radiotherapy is a key factor in deciding about the timing of breast reconstruction. Radiotherapy after breast reconstruction is likely to affect the look and feel of the reconstructed breast. This is particularly an issue following breast reconstruction using implants.

If radiotherapy is recommended as part of your breast cancer treatment, breast reconstruction may be delayed until after radiotherapy is completed. This will ensure that treatment can start as soon as possible and will help to improve the outcome of the breast reconstruction.

An alternative is to have a breast reconstruction at the same time as mastectomy but to have a ‘sacrificial implant’ inserted. After radiotherapy, the implant is removed and a different form of breast reconstruction can be done.

These decisions are complicated by the fact that the need for radiotherapy may not be known until after the tissue removed during mastectomy has been examined by a pathologist.

Impact of chemotherapy on breast reconstruction

If chemotherapy is recommended as part of your breast cancer treatment, breast reconstruction may be delayed until after chemotherapy, so that recovery from breast reconstruction surgery does not delay starting chemotherapy. A less complex type of breast reconstruction with a shorter recovery time, such as breast reconstruction using implants, may be a better option if you need chemotherapy and would prefer an immediate breast reconstruction.

Will my reconstructed breast match my other breast?

If you have one breast removed as part of your breast cancer treatment and you choose to have a breast reconstruction, your surgeon will try to make your reconstructed breast symmetrical with your other breast.

It can sometimes be difficult to match the two breasts. The tissue or material used for the breast reconstruction is likely to have a different look and feel to the other breast. The difference is usually greatest when an implant is used. Implants are usually firmer and sit higher on the chest than a natural breast.

"When I was told that I would have to have a mastectomy I decided to have the bilateral done because I didn't want it coming back in the other one...I wasn't going through all that again."

Some women who have a mastectomy consider also having the non-cancerous breast removed because of concerns about breast cancer developing in the other breast in the future or to achieve a more symmetrical appearance after surgery. This is called contralateral prophylactic mastectomy.

"If I hadn't been conquered with the cancer thing, trying to get over that, and was thinking clearly I probably would have had them both done at the same time.  But I was just trying to deal with cancer at the time."

It is important to understand that removing the other breast will not reduce the risk of breast cancer coming back in the future and will not improve overall survival. However, it will reduce the risk of developing a new breast cancer in the non-cancerous breast.

"I was a bit like you thinking this just isn't good enough, what happens if it comes back on the other side and I had all these doubts coming into my head.  And I said,  "is this my best option" and he (breast surgeon) said "no, your best option is mastectomy".  I just said "well I'll have mastectomy then, in fact I'll have a double mastectomy", and he said "right ok, if that's your decision", and that was it."

If you do have a bilateral mastectomy, you can have a breast reconstruction of both breasts in one operation. This means that it is easier to match the look and feel of the reconstructed breasts.

Timing of breast reconstruction

A breast reconstruction may be done at the same time as mastectomy (immediate breast reconstruction) or at some time later (delayed breast reconstruction).

Immediate breast reconstruction

An immediate breast reconstruction is done during the same operation as a mastectomy.

Benefits of an immediate reconstruction are:

• there is only one operation (although the surgery and recovery time is longer than for mastectomy alone)
• it may be possible to keep the skin, nipple and areola intact so that the look of the reconstructed breast is more natural.

Immediate breast reconstruction is also thought to lead to improved psychological, emotional and social outcomes, because the woman wakes from the mastectomy operation with a breast shape and does not experience the loss of a breast. Despite the immediate replacement of the breast, a woman may still grieve for the loss of a breast even after a breast reconstruction.

If a woman is having a breast reconstruction using tissue expanders (breast reconstruction using implants or LD flap), she may wake up from her operation with a flat chest.

"I don't think I could have coped as well if I hadn’t had an immediate reconstruction... I just know that when I had my operation and I woke up afterwards and I kind of looked under my gown and it just looked like I still had breasts."

Delayed breast reconstruction

A delayed breast reconstruction is done after a mastectomy. This may be months or even years later.

A benefit of delayed breast reconstruction is that the initial mastectomy surgery and recovery time are shorter. However, the final look of the reconstructed breast may not be as natural because the skin, nipple and areola will usually be removed at the time of mastectomy.

It may difficult to coordinate two surgeons to perform an immediate breast reconstruction in the public sector and a waiting list may be unavoidable. Women having breast reconstruction in a private hospital do not experience these difficulties. Regardless of whether there is a waiting list, other cancer treatments may affect the timing or outcome of a breast reconstruction. Some women may be advised to delay their reconstruction until after breast cancer treatment.

If you are advised not to have a breast reconstruction at the time of mastectomy and/or you decide not to have a breast reconstruction at all, delayed breast reconstruction is an option later down the track. In the meantime, you can choose to use an external breast prostheses.

"It's a very difficult thing to live without a breast.  A lot of women do and do it successfully, I did for a long time… And it didn't worry me terribly, it just became second nature.  But when my grandkids come to stay overnight, I'd always find myself wearing my bras to bed with the prosthesis in it in case I had to get up to them in the night.  Or if they wanted to come and sleep in my bed or something, you know, I didn't want them to see that I had no breast."

Making decisions about breast reconstruction

There are a number of things that can affect your decision about whether to have a breast reconstruction and your options for breast reconstruction

As with all types of surgery, having a breast reconstruction has its pros and cons.

Breast reconstruction can be an emotionally rewarding experience for women after a mastectomy. Studies have shown that breast reconstruction can help to improve body image and self esteem and enhance quality of life. Women have reported several benefits of undergoing breast reconstruction, including feeling comfortable and ‘whole’, decreased psychological distress and thinking less about breast cancer.

"I did not realise how much my breasts meant to me, but having one removed made me feel like an alien, not in the slightest attractive or feminine. Whenever I looked at myself in the mirror I was horrified at the huge scar where my breasts used to be. Reconstruction has restored my sexuality. I feel totally womanly and I am really comfortable in my own body which is reflected in every aspect of my life."

Disadvantages of breast reconstruction may include the need to have lengthy or multiple operations, a longer stay in hospital than mastectomy surgery alone and ongoing, sometimes long-term, side effects of surgery.

Most women who have breast reconstruction say that the physical and emotional benefits of recovery outweigh the practical limitations, with the end result that they feel ‘whole’.

"I couldn't fathom myself waking and not having a breast.  I've had big breasts all my life. I've always been a double D. I've always had a cleavage."

It is important to have reliable information about breast reconstruction so that you can make decisions that are right for you. Take as much time as you need to get information and think it through. Talk to your healthcare professionals and ask as many questions as you need to before making a final decision.

You may need to make a number of decisions throughout the breast reconstruction experience. This will involve weighing up the advantages and disadvantages of each option. Breast reconstruction is a very individual experience and different options work best for different women.

"I considered reconstruction and talked about it with my partner. I still have not ruled it out but somehow in ten years I have not found the time to go through with another major operation and recovery period. I am happy the way I am- feeling good and enjoying life."

"I was just very concerned about the cleavage, because I wear things where you do show a bit of your cleavage and I just wanted to still be me.  I didn't want to have to wear things up to here (neck), I didn't want to have to cover up."

Factors affecting decisions about breast reconstruction

The decision about whether and when to have a breast reconstruction can be influenced by:

• Specialist services
• Individual characteristics
• Where you live and the travel required
• Your financial situation.

If you have a breast reconstruction after a mastectomy for breast cancer, your decision will also be affected by what ongoing breast cancer treatments you are having.

Deciding about specialist services for breast reconstruction

Breast reconstructions may be undertaken by a breast reconstruction surgeon or a breast surgeon. A breast reconstruction may be done by the same surgeon who does a mastectomy or by a different surgeon.

Breast reconstruction surgeons may or may not have specialised training in reconstructive surgery techniques. The breast reconstruction surgeon’s experience and training may influence which breast reconstruction options are offered to you.

It is important to ask about a surgeon’s training and experience in breast reconstruction surgery and about what breast reconstruction procedures he/she does. You may decide to ask for a second opinion from another surgeon who does other types of breast reconstruction procedures before making a final decision.

Impact of a woman’s individual characteristics on breast reconstruction

Your breast reconstruction options may be influenced by a number of things, including:

• breast size
• how much suitable tissue and skin is available from other parts of the body
• whether you have scars from previous operations
• your body build
• your medical history.

All of these things can affect the likely look and feel of the breast reconstruction (sometimes called the aesthetic outcome). You will be able to discuss these factors with your breast reconstruction surgeon.

Travelling for breast reconstruction

There are few breast reconstruction surgeons in regional and rural areas. They usually only do limited types of breast reconstruction (typically implant breast reconstructions). In most cases, women from rural and regional areas travel to major city centres for their breast reconstruction surgery.

Travelling for surgery can mean being away from home for extended periods of time. The costs of travel and accommodation may cause financial strain. It can also be hard to be away from family and friends.

Find out more about:

• Assistance when travelling for treatment

Financial costs of breast reconstruction

The financial costs of breast reconstruction will depend on several things, including:

• whether you have surgery as a private or public patient
• whether you have private health cover and what the private health cover will pay for
• what your chosen breast reconstruction surgeon, anaesthetist and hospital charge for their services
• how many follow-up visits you need
• how far you live from the hospital in which surgery is done
• whether you are eligible for a tax rebate or financial assistance (e.g. travel).

Comparison of public versus private breast reconstruction surgery

It is your choice whether you have breast reconstruction in the public or private system. Your decision may affect the financial cost and timing of your surgery.

Having a breast reconstruction as a public patient means that Medicare will cover all or most costs. All claims for breast reconstructions are reviewed by the Medicare Claims Review Panel and decisions are made on an individual basis. The individual may be required to pay the cost of a permanent prosthesis.

Even if you have your breast reconstruction in the private system, Medicare will pay 75% of the scheduled fee for the procedure. However, keep in mind that many surgeons and anaesthetists charge more than the scheduled fee for their services.

Tax rebates and financial assistance for breast reconstruction

Tax rebates

Because breast reconstruction is not a cosmetic procedure, any excess costs paid that are not reclaimable through a health fund or Medicare may attract a tax rebate.

Keep a list of all medical costs that are not reclaimable in any one financial year (including other surgery such as the mastectomy, drugs, dressings, physiotherapy and other treatments). If these costs are higher than the threshold set by the ATO, it may be possible to claim 20% of the cost in that year’s tax return.

Financial assistance for travel and accommodation

Travel away from home can result in travel and accommodation costs. If you have to travel for breast reconstruction, you may have other costs to consider, such as loss of income, child care costs and daily living expenses. Some breast reconstruction surgeons may give a discount to pensioners or those with health care cards.

All states and territories have limited subsidies available to assist with travel for approved medical specialist services.  Successful applicants receive subsidised travel and accommodation to the nearest medical specialist facility. Excess costs must be covered by the individual. Some schemes subsidise interstate travel if necessary. Travel and accommodation costs for an accompanying adult may be paid if the medical referral indicates that an escort is needed to help provide care during treatment.

Applicants must be permanent residents of a rural area in their state or territory and eligible for Medicare subsidy.  A medical practitioner must complete and sign the application.  The applicant must produce all receipts or evidence of costs for reimbursement.  Payment in advance is available in some cases of financial hardship.  Some government offices will also provide assistance for travel and accommodation arrangements. Travel assistance may be limited to a certain amount or only cover initial treatments and not follow-up treatments. Women may not be eligible if they are receiving assistance through another scheme.

Find out more about:

• WA - Patient Assisted Travel Scheme (PATS)
• NT - Patient Assistance Travel Scheme (PATS)
• SA - Patient Assistance Transport Scheme (PATS)
• NSW - Isolated Patients Travel and Accommodation Assistance Scheme (IPTAAS)
• Tasmania - Patient Travel Assistance Scheme (PTAS)
• Queensland - Patient Travel Subsidy Scheme (PTSS)
• Victoria - Victorian Patient Transport Scheme (VPTAS)
• ACT - Interstate Patient Travel Assistance Scheme (IPTAS)

Making decisions about breast reconstruction after a breast cancer diagnosis

There are several different breast reconstruction options available. Talk to your breast care team about your options and preferences before making a decision.

Questions to think about include:

• do I want a breast reconstruction?
  Many women decide that breast reconstruction is not for them. These women may or may not use an external breast prostheses to imitate the shape of the breast. Some women do not feel the need to replace their breast shape and adjust to their new body image without a breast.
• what type of breast reconstruction would be best for me?
• would it be better to have a breast reconstruction at the same time as a mastectomy (immediate breast reconstruction) or wait and have a breast reconstruction at a later time (delayed breast reconstruction)?
• should I have any other procedures after my breast reconstruction, such as nipple and areola reconstruction or other breast refinement procedures?
• if I only have one breast removed, will my reconstructed breast match the other breast?

"It changed my body image absolutely because, even before the bandages and stuff came off, I could see that I was in shape.  I couldn't wait to rip off these bandages and just see exactly.  And it was a little bit big and blah, blah, blah, but it didn't matter.  The symmetry was now right.  You could stand in front of a mirror and you looked like you were supposed to look and automatically you feel a whole lot better.  Your clothes are hanging on you nicely, you don't have to put anything on to complete your day, you just get up like you always did... You're just not missing anything, you are all complete again."

The breast care team

It is often surprising to women how many healthcare professionals are involved in managing their breast cancer. The aim of a team-based or ‘multidisciplinary’ approach is to ensure that women have the best possible treatment outcomes and quality of life.

Members of the breast care team may include a general practitioner (GP), breast physician, breast surgeon, anaesthetist, pathologist, radiologist, medical oncologist, radiation oncologist, breast care nurse, breast reconstruction surgeon, physiotherapist, psychologist, counsellor and other allied healthcare professionals.

Shared decision making

Because of the range of factors that affect individual breast reconstruction options after a diagnosis of breast cancer, decisions about breast reconstruction are best made after advice from the healthcare professionals involved in your treatment and ongoing care (the breast care team).

Shared decision-making between a woman and her breast care team is important to make sure that all of the factors affecting your breast reconstruction options are considered. It is important to have reliable information about breast reconstruction so that you can make the decision that is right for you.

You do not have to make decisions at the first consultation with your breast care team. Take as much time as you need to source the information you need. Talk to your breast care team and ask as many questions as you need to before making any final decisions.

"I'm alive, if I'm going to stay alive I might as well look good.  I might as well look normal.  I think normal is the big thing."

Making decisions after a recent breast cancer diagnosis

It can be difficult to make decisions about breast reconstruction when you are dealing with a recent breast cancer diagnosis and decisions about breast cancer treatment. For many women, the breasts are strongly linked to femininity, motherhood and sexuality.

Studies have shown that, following a diagnosis of cancer, people do not remember much of the information given to them by healthcare professionals. This is completely normal. It can be helpful to ask for written information or to audio record the conversation.

You do not have to make decisions at the first consultation with your breast care team. Take time to think about your options and ask for more information if you need to. Waiting a week or two to consider your options will not affect the outcome of your treatment.

External breast prostheses

An external breast prosthesis is an artificial breast that is worn under clothing to imitate the shape of the breast.

A breast prosthesis can recreate the appearance of a breast shape under clothing and can also help to improve your balance and posture, which may be affected after a mastectomy.

There are a wide variety of external breast prostheses available. Some are held within specially designed bras, while others are attached to the skin with a sticky backing. Special swimsuits are available to hold prostheses in place while swimming.

Breast prostheses are available from some lingerie stores, department stores or specialty stockists. Trained staff members are often on hand to help you choose the prosthesis that is right for you. Things to consider include the shape and size of the prosthesis, how comfortable it is and the cost.

"The moment I had that prosthesis in my bra and they told me to put a T Shirt on and I looked in the mirror and I was so happy. I almost physically hugged the professional fitter, because you sort of perceive yourself as a woman with two breasts, suddenly you've got one breast, you're not quite exactly the same." 

Pros and cons of breast prostheses

Some women find external breast prostheses comfortable and are happy with how their breast shape looks. Smaller breasted women in particular may find external breast prostheses comfortable.

"So it (external breast prostheses) was a nuisance value.  And it was uncomfortable and I couldn't wear low-neck dresses.  And so I think it was not body image in that I didn't like the way my body looked, but it was body image in the way it interfered with what I did and what I wore."    

Other women find external breast prostheses uncomfortable, cumbersome and impractical. Prostheses are often described as hot, sometimes heavy, and can sometimes irritate the skin. Self-adhesive prostheses require regular cleaning. Some women report difficulty with their prostheses during physical activity and sports. Of particular concern to some women is the fear that the prostheses may fall out of clothing.

"I was surprised to find that my breast prosthesis fits so well and gives a very natural look to my clothes. I wear it with lots of different bras and I forget that it is there. It moves with my body during sport; swimming, tennis, golf, paddling; and does not do anything embarrassing - except when I forget to wear it. A sensitive specialist fitter and good bras are important."

External Breast Prostheses Reimbursement Program

The Australian Government provides financial support for the purchase of new or replacement external breast prostheses through Medicare Australia. Women must be permanent residents of Australia with Medicare entitlement and have had a mastectomy (recent or past), as a result of breast cancer..

The reimbursement is up to $400 for each new or replacement prosthesis. A woman can claim every 2 years if needed. If private health insurance has covered part of the cost of your prostheses you are entitled to claim for the remaining costs not covered by your health fund. For more information go to www.servicesaustralia.gov.au/individuals/services/medicare/external-breast-prostheses-reimbursement-program, call Medicare on 13 20 11 or visit a Medicare office.

"I've been happy with my body image, I mean I can laugh at the fact that I've lost my boob. I played in an orchestra and I went to the pub with friends afterwards one night and the Leader of this orchestra said, "well what does this prosthesis look like anyway?" And I turned around and there was hardly anyone around and I just got it out and threw it at him. I mean that's my way of coping and I've got a black humour anyway."

Find out more about:

• Cancer Council: Understanding breast prostheses and reconstruction (PDF).

Living with a breast reconstruction

You may experience a range of feelings and emotions after breast reconstruction surgery. It may take some time to get used to the reconstructed breast(s). There are also likely to be some long-term physical and practical things to think about.

Feelings after breast reconstruction

Feelings of loss and grief and difficulties with sexual intimacy are common after breast reconstruction. Talking with a friend, family, member, breast care nurse or professional counsellor can help.

Looking at the reconstructed breast for the first time

Having the bandages removed for the first time can be a daunting experience. It is usual to feel nervous or anxious. It might be helpful to talk to a breast reconstruction surgeon or nurse and/or to a family member or friend about any concerns. This may affect how you feel about your appearance and even about yourself.

The look of the reconstructed breast(s) will improve over time as the bruising and swelling improves. After a breast reconstruction using implants, the reconstructed breast(s) will reach their final look and feel relatively quickly. After a breast reconstruction using a tissue flap, the improvement will be more gradual as the swelling subsides, bruising fades, and the reconstructed breast(s) begin to ‘settle’ into their new position.

Some women are shocked when they first see the scars on their breast(s) or other parts of the body. The scars will fade over time but will never fade completely. At about 18 months after surgery, the scars will have faded as much as they ever will. Skin quality and wound healing will affect how well the scars fade. Moisturisers and massage may help.

It is usually possible to hide the scars under minimal clothing, possibly even under swimsuits and underwear. Further surgery to improve the appearance of the scars may be an option later down the track.

“I wasn’t really rapt... It (reconstructed breast) was a good shape and realistically it was a damn good job, but I wasn’t enthusiastic and I didn’t hate it…I just was like, you know, I could live with it at the time."

Grieving for a lost breast(s)

All women who have a mastectomy may experience sadness at the loss of a breast, including women who have an immediate breast reconstruction. A reconstructed breast will not be the same as the original breast, and many women experience grief in response to this loss.

If you have a delayed breast reconstruction, you will experience living without one or both breasts. This may affect how you feel about her appearance and even about herself.

If you have an implant or LD flap breast reconstruction that requires a tissue expander, you will probably live without a breast shape for a short period of time. Until the tissue expander is inflated, your chest may be flat. This may be quite a shock. Although the expansion process can happen quite rapidly, your self-esteem and body image may still be affected.

"It changed my body image absolutely because... even before the bandages and stuff came off, I could see that I was in shape, you know. The symmetry was now right. You could stand in front of a mirror and you looked like you were supposed to look and automatically you feel a whole lot better. You're just not missing anything, you are all complete again."

Feelings about breast cancer

For many people dealing with having breast cancer and undergoing its treatments is a lengthy and life-changing process. Throughout the experience of a breast cancer diagnosis, treatment and breast reconstruction, women can get caught up in the ongoing physical and emotional recovery as well as maintaining the ‘normal’ day-to-day demands of their lives. Some women comment that it is only when they reach the end of the breast reconstruction experience that they realise they must still deal with the reality of having had breast cancer and their concerns and fears related to this.

"The thing is, it changes your whole life, I mean it changes every area of your life, whatever area you choose to talk about or just mention, there would be some kind of impact. And it's all positive."

Sexuality and body image after reconstruction

Having a breast reconstruction should not necessarily interfere with sexual activity. However, having a reconstructed breast(s) may affect the way you feel about and respond to intimacy.

"I have had a reconstruction (which I did for myself) and feel better within myself and very confident; but still miss the caressing and kissing of my breasts. You don't know how sensual they are until they are gone and the nice feeling you have during sexual encounters."

Sensation in the reconstructed breast(s) will not be the same as it was before mastectomy. There may be no sensation or minimal sensation in the breast(s). Some women find that their reconstructed breast(s) is extremely sensitive to touch.

It is important that your partner also has realistic expectations about breast reconstruction. This may help your partner adjust to the differences in how you look and to understand how you might be feeling.

"I have not felt as sexually alive or attractive for a couple of reasons... the loss of sensation in the nipples, and more importantly its connection with and role in sexual stimulation. I am still sad about that loss, over a decade on."

"It's not the same as it was…It certainly doesn't feel the same to touch, and it certainly doesn't feel the same for someone else to touch, from the inside and the outside... It's quite an obvious difference."

"My husband did not know how to respond to my reconstructed breast - ignore them or play with them! He just didn't want to cause me any distress, so was not quite sure what to do. My husband enjoys having his nipples stimulated and felt guilty that he could gain pleasure from his nipples and I could not."

Physical changes after breast reconstruction

It may take time to adjust to the different way a reconstructed breast(s) look, feel and move.

A reconstructed breast(s) will not be the same as the breast(s) before mastectomy. The appearance of the reconstructed breast(s) is likely to improve over time, which may also help with feelings. It can help to talk about your feelings with your breast reconstruction surgeon, breast care nurse or another woman who has also had a breast reconstruction.

It usually takes 3–12 months after breast reconstruction for women to feel better about their body image.

"Me is what's on the inside, what's on the outside whether I've got one boob, two boobs, no boobs; and I've had all of that; doesn't change who I am.  This is just the vessel that I've been given to do this journey which is life and one boob, two boobs, no boobs, doesn't change who I am."

Living with a breast reconstruction using implants

After a breast reconstruction using implants, when clothed, your breast(s) are likely to look similar to how they looked before the mastectomy when you are standing or sitting. However, the reconstructed breast(s) will not move or fall naturally when you lie down flat, lean to the side, or lean forward.

Some women find it uncomfortable to sleep on their side or front because breast implants do not move or squash like their breasts did previously. This is more likely to happen if you have larger breasts.

The breast will also not change size with changes in body weight.

Some women experience some loss of sensation when the breast is touched. This may be temporary or permanent and is because of interference with nerves during surgery.

Women who have breast reconstruction using implants may experience fewer problems with body movement once they have healed from surgery. This is because no muscles or tissue are moved from other areas of the body. However, some women may experience tightness across the chest.

Over time, breast implants may need to be replaced. This is usually done as a day surgery procedure as long as there are no complications.

"I was always slim, I didn't have any marks, so you know, I felt good about myself.  And so I think having that, I did go through that sort of first initial months thinking "Oh you know, I've got scars now, I've got this and that", and it was hard, you know.  It was hard and I did feel yuck about myself."

Living with a tissue flap breast reconstruction

After a tissue flap breast reconstruction, the reconstructed breast(s) will look, feel and move more naturally than with a breast reconstruction using implants.

Breast sensation will not be the same as it was before mastectomy. About two-thirds of women notice some sensation returning to their reconstructed breast(s) after 6 months. However, one-third continue to have no sensation. Other women find their breast(s) become extremely sensitive.

Living with an LD flap breast reconstruction

Following an LD flap breast reconstruction, the breast(s) will change somewhat with changes in body weight, but not as much as with a TRAM or DIEP flap reconstruction.
Some women report an odd sensation in their back when their reconstructed breast is touched. This is caused by nerve endings that were moved from the back to create the breast.

Some women also experience muscle spasms in their reconstructed breast(s).

Some women find that movement of their arms and shoulders is affected in the medium to long term. Other muscles in the back help to make up for the lost strength of the latissimus dorsi muscle. However, reduced movement can affect some occupations and some physical/sporting activities (such as tennis and climbing).

Living with a TRAM flap or DIEP flap breast reconstruction

Following a TRAM flap or DIEP flap breast reconstruction, the reconstructed breast(s) will look and feel more like natural breasts than with implant or LD flap breast reconstruction techniques. In particular, the softness and droop of the breast(s) will be more like natural breasts. The breast(s) will change size if you gain or lose weight.

There will be some loss of sensation in the lower abdomen, just below the navel (tummy button). The abdominal muscles may also be weaker, particularly following TRAM flap breast reconstruction. This will be particularly noticeable during strenuous exercise and when doing abdominal exercises like sit-ups or crunches. All heavy lifting (more than 10kg) should be avoided for at least 6 weeks and possibly up to 3 months after surgery. A physiotherapist can with a gradual and safe return to usual activities.

Women who are considering pregnancy should discuss this with their breast reconstruction surgeon. Removal of a section of the abdominal muscle and tissue may prove problematic as the baby grows.

"It's taken twelve months for me to get used to it (reconstructed breast) and for me not to go "Oh, I hate that nipple", or anything…That doesn't happen overnight... In the first few months you are still in a sense of shock about the whole thing."

What to do if you are unhappy with your reconstructed breast(s)

It will take some time for your reconstructed breast(s) to reach their final look, feel and movement. Scars will fade over time, the breast tissue will ‘settle’ into position, and refinement procedures may be done. This process can take up to 18 months.

It is important to give your breast(s) time reached their final look, feel and movement, and to give yourself time to get used to her new breast(s).

If you are unhappy with the look and feel of your reconstructed breast, discuss this with your breast reconstruction surgeon. Your breast reconstruction surgeon can advise on whether the healing process is still in progress and may be able to suggest ways to optimise the look and feel of the breast(s). Breast refinement procedures may help improve the final look and feel of your breast(s).

A second opinion may be helpful if you remain unhappy with the outcome of your breast reconstruction.

Practical issues after a breast reconstruction

Finding a well-fitted bra

A well-fitted bra can make all the difference to the appearance of the breasts and cleavage after breast reconstruction.

Specially fitted bras support your reconstructed breast(s) and maximise how they look. They can also help improve comfort, posture and ease of fastening bras. Several state-based services have trained staff to help you with the fitting and purchase of bras and lingerie to meet your needs. A breast reconstruction surgeon or breast care nurse can provide more information.

Breast screening after breast reconstruction

There is no evidence that a breast reconstruction impairs the detection of breast cancer.

Screening of reconstructed breasts using ultrasound or mammograms is possible, including screening of breasts with implants. Women should see a doctor regularly to have clinical examinations to detect any signs of changes in the breasts.

Breast cancer recurrence after breast reconstruction

For women who have a mastectomy for breast cancer, there is no evidence that breast reconstruction increases the risk of breast cancer coming back. There is also no evidence that breast reconstruction makes it more difficult to detect breast cancer if it does come back.

Regular clinical examination by a healthcare professional is recommended to look for changes in the breasts. Mammography of the reconstructed breast (including breast reconstructions using implants) is possible. Other imaging methods, for example ultrasound, may also be used. A woman’s breast care team will advise her about the type and frequency of screening recommended.

Although some women report that breast reconstruction reduces their fear of breast cancer coming back, some women still experience fear and anxiety, particularly around the time of annual check-ups. It is important to remember that many people experience aches and pains, and these symptoms are not usually a sign that breast cancer has come back. A woman who experiences symptoms that do not go away, or who experiences feelings of fear or anxiety that are interfering with day-to-day life, should talk to a member of her breast care team.

Choosing a surgeon

One of the ways in which surgeons can demonstrate their commitment to improving and maintaining the highest standards of care for their patients is by participating in clinical audit. The BreastSurgANZ Quality Audit (BQA) is a clinical audit directed by the Breast Surgeons of Australia and New Zealand (BreastSurgANZ), a specialty society for surgeons treating breast cancer.

To locate a surgeon who is a member of BreastSurgANZ in your area use the 'Find a surgeon' section of the BreastSurgANZ website.

The BQA is managed by the Royal Australasian College of Surgeons.  More information on BQA activities can be found on the Royal College of Australasian College of Surgeons website.

Questions to ask

Listed below are some questions that may be helpful when talking about surgery for breast cancer:

• What type of surgery is best for me?
• What will surgery involve?
• Do you specialise in breast cancer surgery? Can you refer me to someone who specialises in breast cancer surgery?
• Where will the scars be and what will they look like?
• How long will I be in hospital?
• How long will I take to recover?
• What side effects can I expect?
• Who should I contact if side effects happen?
• How much will the surgery cost?

Care after surgery

Ensuring best practice care for women with early breast cancer after surgery.

The care a woman receives after surgery for breast cancer is important. Surgery is usually the first treatment undertaken after a diagnosis, and this period of care includes recovery from surgery, discussions of prognosis and future management, and the provision of information and support.

In recent years, advances in breast cancer treatment have lead to patients diagnosed with early breast cancer spending less time in hospital after surgery.

Having identified this changing aspect of care, National Breat and Ovarian Cancer Centre (NBOCC)* undertook a comprehensive review of current care provided to women after surgery from 2007 to 2010 to examine whether the reduced time spent in hospital may result in women not having their information and support needs met.

The following research was conducted:

1. systematic international literature review, which identified different models of post-surgical care for women with breast cancer (conducted by NBOCC*, 2008)
2. analysis of national hospital length of stay data from the Australian Institute of Health and Welfare, which identified trends in post-surgical hospital length of stay over the last decade (conducted by NBOCC*, 2007 and 2009)
3. survey of women with breast cancer, which sought to collect information about their experiences of post-surgical care across a range of Australian health service settings (conducted by NBOCC* and Breast Cancer Network Australia, 2008)
4. survey of breast care nurses, which sought to collect information about their experiences in the provision of post-surgical care to women with early breast cancer in Australia (conducted by NBOCC*, 2009)
5. process mapping of post-surgical care models at 8 hospital sites, which included workshops and interviews with clinicians and allied health professionals about the patient journey and the care process (conducted by NBOCC*, 2009).

This body of work culminated in a national forum attended by key clinical experts, health professionals and women who have had breast cancer in July 2010. The forum attendees agreed on priority action areas which will inform recommendations for a new model of evidence-based, best-practice care for women post-surgery.

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