Mastectomy, Reconstruction, and Flat Closure Decisions

After mastectomy there are three legitimate results. One is an implant-based reconstruction. One is a reconstruction using your own tissue. The third is an aesthetic flat closure. People often describe that third one as "declining reconstruction." That misrepresents it. NCI defines flat closure as surgery to rebuild the shape of the chest wall after removal of one or both breasts. Excess skin and tissue are removed. The remaining tissue is tightened for a smooth contour. It is a technique with a goal. A surgeon performs it. It has its own standard of a good result.

Most often a tissue expander goes in first. It is filled with saline over clinic visits across two to six months. A second operation then swaps it for a permanent silicone or saline implant. Nipple and areola reconstruction, if you want it, comes later still. Each surgery is shorter than a flap. Recovery from each is faster too. But there are more of them.

Known risks include infection, seroma, haematoma, implant rupture and extrusion. Capsular contracture is another. That is scar tissue tightening around the implant. There is a very small risk of breast implant-associated anaplastic large cell lymphoma. It has been reported in particular with textured implants. Implants are not lifetime devices. Revision surgery at some point is common.

Autologous reconstruction moves your own skin, fat and blood vessels. The lower abdomen is the most common source (DIEP or TRAM). Surgeons also use the back (latissimus dorsi) or the thigh and buttock (PAP, TUG, SGAP). Free flaps need microsurgery to reconnect blood vessels. They mean a longer operation and hospital stay. Pedicled flaps keep their original blood supply and are shorter.

The trade is one big operation instead of several smaller ones. The result ages more like the rest of your body. But you get a second surgical site. Donor site pain, weakness and a new scar are real. Complications include partial or total flap loss. They also include higher bleeding and clot risk, and healing problems at the donor site.

Radiation can cause wound healing problems and infections in a reconstructed breast. It also raises the risk of capsular contracture around implants. So autologous reconstruction is often delayed on purpose until radiation is finished. Healthy tissue with its own blood supply then replaces damaged chest wall tissue. Radiation may be likely for you but not yet confirmed. Ask how your surgeon sequences this. It is one of the most consequential planning decisions.

Everyone who has a mastectomy has some numbness and loss of feeling. The nerves supplying the breast are cut when breast tissue is removed. Reconstruction rebuilds shape, not sensation. Feeling may partly return as the cut nerves regrow. People are often not told this clearly beforehand. It is a common source of later surprise.

Whichever way you lean, the consultation questions are similar. How many of these do you do a year? Can I see your own photographs, not stock images? How many operations, and how much recovery? What is the revision rate? For flat closure, ask how the surgeon handles excess skin at the outer chest. The ridges there are sometimes called dog ears. They are the most common reason people seek revision. Ask that your goal be recorded clearly in the operative plan.

In the United States, the Women's Health and Cancer Rights Act covers this. Group health plans and insurers that pay for mastectomy must also cover reconstruction. They must cover surgery on the other breast for symmetry. They must cover prostheses and treatment of complications. Some religious and government plans are exempt. Medicare and Medicaid follow separate rules.

Relief and grief arriving together. Pressure to decide quickly while still absorbing a diagnosis. Underestimating how many appointments implant reconstruction involves. Underestimating how long flap donor sites ache. Feeling well-supported in choosing reconstruction, and having to push harder for flat closure. And, most consistently, wishing they had asked to see the surgeon's own photographs before deciding.

• Call 911 or go to an emergency department if breathing suddenly becomes hard or your chest hurts. Flap surgery carries a raised clot risk, as above.
• Call your surgical team the same day if your temperature reaches 101.5°F (38.6°C) or higher, wound drainage turns thick and yellow, green or pus-like, or red streaks spread away from an incision or a donor site.
• If chemotherapy is part of the plan, use a lower bar and a faster route. A temperature of 100.4°F (38°C) during chemotherapy is a medical emergency, CDC says. Call the oncology team the moment you see it, at any hour, and go to an emergency department if you cannot reach them.
• Call your surgical team within a day or two if the edges of a flap or a graft begin to lift, pain stops responding to your pain medicine, or the arm on the operated side starts to swell.

Signs drawn from MedlinePlus — Mastectomy: discharge and MedlinePlus — Skin flaps and grafts: self-care.

• NCI Dictionary — aesthetic flat closure
• American Society of Plastic Surgeons — Breast Reconstruction
• NCI — Choosing Between Lumpectomy and Mastectomy