Reconstruction After Cancer Surgery

Reconstruction after cancer surgery is almost never one operation. It is a sequence, and the order depends on radiation, healing, and the type of tissue used. This page covers how implant and flap reconstruction work, what can go wrong, and what your health plan has to pay for.

Implant reconstruction usually takes two stages. The surgeon first places a tissue expander under the skin. It is slowly filled with saline or air at office visits over several weeks. NCI says the chest tissue is usually ready for the permanent implant 2 to 6 months after the expander is placed.

Flap reconstruction, also called autologous reconstruction, uses your own tissue. The named options differ by where the tissue comes from and whether muscle is taken with it.

• DIEP flap. Skin, blood vessels, and fat from the abdomen, without the muscle underneath. This is a free flap. The tissue is fully detached, and its blood vessels are reconnected under a microscope.
• TRAM flap. Tissue from the lower abdomen, as in a DIEP flap, but muscle is included.
• Latissimus dorsi flap. Tissue from the middle and side of the back. For breast reconstruction this is usually a pedicled flap. The tissue keeps its own blood supply and is moved into place.
• PAP, SGAP, IGAP, and TUG flaps. Tissue from the thigh or buttock, differing in how much muscle is used.

Flaps carry a higher risk of bleeding and blood clots than implants do. The donor site can stay sore or weak. Tissue can also die if its blood supply fails, which is called necrosis.

Immediate reconstruction happens during the same operation as the mastectomy. Delayed reconstruction happens after the incisions heal and treatment ends.

Radiation drives that choice. NCI states that immediate reconstruction with an implant is usually still an option for women who will need radiation therapy. Autologous tissue reconstruction is usually held back until after radiation is finished.

A nipple-sparing mastectomy keeps the nipple and areola. NCI says this may be an option for some women, depending on the size and location of the tumor. Ask whether your tumor allows it before the surgery is booked, not after.

FDA is blunt on this point: "Breast implants are not considered lifetime devices." The longer a person has them, the greater the chance of complications. Removal or replacement becomes more likely too.

Silicone gel implants can tear with no outward sign. FDA calls that silent rupture. MRI is the most effective test for finding it. Ultrasound is an acceptable alternative for screening people who have no symptoms.

Capsular contracture is scar tissue tightening around the implant. FDA says the cause is not known. It may be more common after infection, hematoma (a pocket of blood), or seroma (a pocket of clear fluid). Grades III and IV count as severe and may need another operation.

There is also a rare cancer of the immune system tied to implants. It is called breast implant-associated anaplastic large cell lymphoma, or BIA-ALCL. FDA says the risk is higher with textured surface implants than with smooth ones. The main symptoms are lasting swelling, a mass, or pain around the implant, often years after it was placed. FDA does not recommend routine removal for people who have no symptoms. In July 2019, FDA requested a recall of Allergan BIOCELL textured implants. If you do not know which implant you have, ask for the make, model, and surface type from your operative record.

The Women's Health and Cancer Rights Act, or WHCRA, applies to group health plans, insurance companies, and HMOs that cover mastectomy. It requires four things:

• All stages of reconstruction of the breast on which the mastectomy was performed.
• Surgery and reconstruction of the other breast to produce a symmetrical appearance.
• Prostheses, meaning artificial breast forms.
• Treatment of physical complications of the mastectomy, including lymphedema, which is swelling caused by damage to the lymph system.

These benefits can still carry the plan's usual yearly deductibles and coinsurance. Plans must give you written notice of this coverage when you enroll and once a year after that. For job-based plans, the Department of Labor's Employee Benefits Security Administration oversees the rule.

Medicare splits it. Part A covers a surgically implanted breast prosthesis when the surgery is inpatient. Part B covers the surgery when it is outpatient, plus some external breast prostheses and a post-surgical bra. After the Part B deductible, you pay 20% of the Medicare-approved amount.

Note the boundary. WHCRA is about mastectomy. Rebuilding a jaw, a face, or the pelvis has no matching federal rule, so coverage there rests on medical necessity and your plan's terms. Get that prior authorization in writing before the date is set.

With cancer of the oral cavity in particular, NCI says a patient may need reconstructive and plastic surgery to rebuild bones or tissues. That is not always possible when tissue is badly damaged. When it is not, a prosthodontist can help. That is a dentist who specializes in replacing missing teeth and structures. They can make an artificial dental or facial part to restore swallowing, speech, and appearance.

Surgery in this area can affect the ability to chew, swallow, or talk. Rehabilitation may include physical therapy, dietary counseling, and speech therapy. Some people also learn to care for a stoma, which is a surgical opening. A nurse or a speech-language pathologist teaches swallowing again after surgery.

Do the dental work first. NCI advises a dental cleaning and check-up before treatment starts, and finishing any dental work before that first day.

Go to an emergency department, or call 911, for these. Free flaps can usually only be rescued within a few hours, so this is one of the few places in cancer care where the clock is that tight.

• A flap that turns pale, white, dusky, blue, dark, cold, or hard, or that stops feeling warm to the touch. Call the surgical team on their emergency line as you head in, and ask for the microsurgery service by name.
• Calf pain or swelling, chest pain, sudden breathlessness, or coughing up blood. Flap surgery raises clot risk.
• Sudden swelling of the reconstructed breast, especially with pain, tightness, or bruising spreading across the skin. That can be a bleed under the flap.
• Bleeding from an incision or drain that soaks through dressings and will not slow with steady pressure.
• Fever with shaking chills, confusion, a racing pulse, or feeling faint, which can mean sepsis. Any fever counts as an emergency if you are also on chemotherapy, because your infection-fighting cells may be low.
• An incision that splits open.

Call the surgical team the same day for:

• Fever of 100.4 degrees F (38 degrees C) or higher on its own, spreading redness, or pus or new drainage from an incision.
• A reconstructed breast that is slowly becoming firm and sore over days.
• Lasting swelling, a lump, or pain around an implant, even years later. That needs assessment for BIA-ALCL.
• An implant that changes shape, or new pain in one you have had for years.

• Given my radiation plan, am I a candidate for a flap, an implant, or either?
• If radiation is coming, do you advise an expander now and the final reconstruction later?
• How many operations should I expect in total, counting revisions?
• What are the make, model, and surface type of the implant you plan to use?
• What will the donor site look and feel like at 6 months?
• Has symmetry surgery on the other breast been authorized by my plan yet?

• Breast Reconstruction After Mastectomy — National Cancer Institute
• Breast Implants — US Food and Drug Administration
• Risks and Complications of Breast Implants — US Food and Drug Administration
• Questions and Answers about Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) — US Food and Drug Administration
• Your Rights After a Mastectomy: Women's Health and Cancer Rights Act — US Department of Labor, Employee Benefits Security Administration
• Breast prostheses — Medicare.gov
• Head and Neck Cancers — National Cancer Institute
• Mouth and Throat Problems During Cancer Treatment — National Cancer Institute