After Reconstruction

Many women choose to have additional surgeries after breast reconstruction to make their breasts look as natural and symmetrical as possible.  Nipple reconstruction may be done on the reconstructed breast mound to make the it look more natural and "complete."

Additional surgeries may be done to make the opposite, natural breast look as much like the reconstructed breast as possible. These surgeries may include:

• Nipple reconstruction
• Breast lift
• Breast reduction
• Breast augmentation 

Nipple Reconstruction

Nipple and areola (the dark circle around the nipple) reconstruction is completely optional. Some women want only the shape of the breast to fill a bra, and decide they don't need a nipple. Another option is to apply removable nipples that stick on with adhesive. These rubbery tips are shaped like a semi-erect nipple and the color and texture are quite lifelike.

How is Nipple Reconstruction Done?
If you choose to surgically reconstruct the nipple, there are several options. One common option is to use the skin of your reconstructed breast. The surgeon can take a small flap of skin from the breast, and "cone" it into a new nipple. Because the nerves aren't connected in the reconstructed breast, most women do not feel much pain with this surgery.

Options to reconstruct the areola involve taking skin from a different part of the body and sewing it to the new nipple on the reconstructed breast. The surgeon can take an oval of skin from the outer edge of your mastectomy scar or from the edge of the TRAM donor scar on your abdomen (if you have this kind of breast reconstruction). The advantage of using this skin is that you won't have any new scars. The surgeon can also take skin from the inside of your thigh or from just below your hip bone. You may be sore for up to two weeks at the place from which the skin was taken. However, most women have very little discomfort at the site of the reconstructed nipple. Another option is to reconstruct the nipple as described above and have the skin around it tattooed to a darker color to make an areola.

In all procedures, you will not have much or any feeling in the new nipple when it is touched. These surgeries can be done on an outpatient basis in under two hours, with local or general anesthesia. Most doctors will ask you to wait a week after the surgery before driving or working.

After you have healed, you can have the new nipple and areola tattooed to match the color of your other nipple. Often it takes two or three sessions to color the whole area evenly. Tattooing takes about an hour and can be done in the doctor's office. You can usually go back to work the same day. Most women can hardly feel the tattooing being done. However, your doctor may use a local anesthetic just in case.

When Can I Have Nipple Reconstruction?
Most plastic surgeons do not schedule nipple reconstruction until at least three months after breast reconstruction. You want to allow time for the swelling from the surgery to go down and for the breast to "settle." This allows the surgeon to place the nipple so that it matches the position of the nipple on the other breast. In some circumstances, the plastic surgeon can perform nipple reconstruction at the same time as reconstruction of the breast itself. You may want to discuss this option with your provider.

Advantages

• You can go bra-less and have the shape of the nipple on both sides. 

• Your reconstructed breast will match your natural breast more closely.

Disadvantages

• It is usually an additional surgery and requires another recovery period.

• If the skin is taken from a place where there is no scar, you'll have a new scar at the donor site.

Breast Lift (Mastoplexy)

While reconstructive surgery can usually give you the volume to fill a bra evenly, it may be difficult to create the same shape on both sides. The reconstructed breast may not droop like the natural breast. However, the surgeon can do a breast lift, or mastopexy, to make the natural breast look more youthful so that it better matches the reconstructed breast.

How is Breast Lift Done?
In breast lift, the surgeon cuts out a section of skin from the lower part of the breast. This skin is removed, and the nipple is moved upward. Skin that was previously above the nipple is drawn down and sewn together below the nipple. Because there is less skin, the breast is higher and firmer after surgery. The scars are usually around the areola, in a vertical line extending down from the nipple area, and along the lower fold of the breast.

This surgery takes from one to two hours, with either local or general anesthesia. It is usually done in a day-only visit to either a clinic or hospital. Many women return to work after a week, and resume their normal activities after two to three weeks.

After having a breast lift, you may lose some feeling in your nipple or breast for at least six weeks. This loss of feeling usually resolves as the swelling goes down after surgery, but in some women it can last as long as a year or even be permanent. Breast lift also leaves permanent scars. These can be lumpy and red for months following surgery, fading bit by bit until they are less noticeable. The scars can, however, be hidden under most bathing suits.

If you choose this procedure, be aware that gravity, aging, and weight changes will cause the breast to eventually sag again. However, this may happen in the reconstructed breast as well.

Advantages

• The lifted breast will more closely match the shape of your reconstructed breast.

• The lifted breast will be higher and firmer after surgery.

Disadvantages

• Breast lift is additional surgery.

• You will have permanent scars (although they can be covered by a bathing suit).

• There is a small possibility that you will permanently lose feeling in your nipple or breast.

Breast Reduction

If your natural breast is large compared to your reconstructed breast, you may want to consider breast reduction. Breast reduction removes skin and fat from the breast.

How is Breast Reduction Done?
In breast reduction, the surgeon removes fat, glandular tissue, and skin from the lower part of the breast. The nipple is then moved upwards and the tissues closed to form a smaller breast. As in breast lift, the scars are usually around the areola, in a vertical line extending down from the nipple area, and along the lower fold of the breast.

The surgery usually takes from one to two hours but can take longer. It is done under general anesthesia, so you will be asleep through the operation. Breast reduction is usually done in the hospital and may require an overnight stay. Most women can return to work in three weeks and to all normal activities in three to four weeks.

After having breast reduction, as with breast lift, you may lose feeling in your nipple or breast for at least six weeks. This loss of feeling usually subsides gradually as the swelling goes down after surgery, but in some women it can last as long as a year or even be permanent. If the breast is especially large and hangs very low, the nipple and areola may have to be completely removed and resewn onto the breast higher up, in which case the nipple and areola will permanently lose all feeling.

Breast reduction, like breast lift, leaves permanent scars. These can be lumpy and red for months following surgery, fading bit by bit until they are less noticeable. In a few cases, if only fat needs to be removed, liposuction can be used, which leaves small scars. The scars can, however, be hidden under a bathing suit.

It may be six months to a year before the reduced breast settles into its final shape. If you are of an age to have children and are interested in breastfeeding, you should know that you may not be able to breastfeed with a reduced breast. The breast may also change size with hormonal changes, pregnancy, or weight changes. These shifts may not be a problem if you have had natural tissue reconstruction on the other breast, as this breast may change in the same ways.

Advantages

• The reduced breast will more closely match the shape of your reconstructed breast.

• The reduced breast will be smaller, which may relieve strain on your back and neck and reduce irritation in the breast crease if you have very large natural breasts.

Disadvantages

• Breast reduction is additional surgery.

• You will have permanent scars (although they can be covered by a bathing suit).

• Breast reduction may leave your nipples and breast skin numb for six weeks to a year.

• In normal cases, there is a small possibility that you will permanently lose feeling in your nipple or breast. If your breast is particularly large and the nipple must be completely removed before being placed higher up, you are certain to permanently lose feeling in the nipple and areola.

Breast Augmentation

If your natural breast is small compared to your reconstructed breast, you may want to consider breast augmentation. In breast augmentation, the surgeon inserts an implant into your breast to make it larger. If your natural breast is small and droops, you may also be a good candidate for a breast lift. Your surgeon can tell you which procedure or combination of procedures is most appropriate for you.

How is Breast Augmentation Done?
In breast augmentation, the surgeon places an implant under your breast tissue to make it larger. The surgical incision may be made in the crease underneath the breast, around the areola, or in the armpit, depending on the surgeon, to make the scar as invisible as possible. The implant may go either under the breast tissue itself, or under the chest muscle behind the breast. The implant consists of a silicone "balloon" filled with silicone gel or saline.
This surgery takes about an hour, usually with general anesthesia. It is usually done eitherduring a day-only visit to a clinic outside of the hospital or in the hospital with a stay of up to 24 hours. Most women can return to work after one to two weeks.

As the years go by, the implant may leak or rupture. This happens in approximately 10% of cases over the first 10 years. When this occurs, the implant must be removed or replaced. A capsule of scar tissue may also form around the implant. Scar tissue forms on the outside of all artificial implants when placed in the body. However, in approximately 5-10% of cases, too much scar tissue forms. The scar tissue may cause pain and discomfort and make the implant feel hard to the touch. Surgery may be necessary to break up or remove the scar tissue. It may also be necessary to remove or replace the implant. Capsules can form at any time, from a few weeks to many years after the implant has been inserted.

If you undergo breast augmentation, you should realize that the placement of a breast implant in your augmented breast will affect, to some degree, your annual mammograms. If the implant is placed beneath the muscle layer, breast augmentation will not likely have much effect on the quality of later mammograms. However, if you have an implant in your reconstructed breast and you would like to get a mammogram, you should look for centers that are experienced in screening women with implants.

Advantages

• The augmented breast will more closely match the shape of your reconstructed breast.

Disadvantages

• Breast augmentation is additional surgery.

• The implant may develop complications over the years, such as leaks, ruptures, or excess scar tissue formation that may need to be corrected by extra surgery.

• You will need to get your mammograms done at a facility with expertise in treating implant patients.