When it comes to breast cancer, the procedures and decisions that follow can come with a tidal wave of emotions. While overcoming breast cancer is the main goal, feeling comfortable in your own skin is an important part of the healing process as well. Chest wall reconstruction — also known as “going flat” – and breast reconstruction are two options empowering breast cancer patients who need to or have undergone procedures like mastectomy, lumpectomy and radiation. 

“It’s extremely important for every patient to feel empowered by their decision to undergo any type of reconstruction," said Christodoulos Kaoutzanis, MD, a plastic surgeon at CU Medicine Breast Surgical Oncology. “Breast reconstruction or chest wall reconstruction is a deeply personal decision, and plastic surgeons should create an individualized plan that is best for every patient.” 

We sat down with Dr. Kaoutzanis to discuss the reconstruction options available and what those procedures involve. Here’s what we learned.

There are many options available to those who’ve had a mastectomy.

There are several post-operative options available to patients after undergoing a single or double mastectomy. Patients can choose to go flat or have some type of reconstructive surgery. Breast reconstruction surgery is performed by a plastic surgeon with the goal of restoring a natural look to the breast or breasts removed. This can be done using breast implants, the patient’s own tissues or a combination of the two. Going flat involves all breast tissue being removed by a surgeon with the goal of having a flat chest after mastectomy. 

Having options is empowering for breast cancer patients and survivors.

A breast cancer diagnosis can leave patients feeling powerless. Being able to choose what type of reconstruction to undergo is a small but impactful way for patients to reclaim some of that power. When it comes to making a reconstruction decision, surgeons like Dr. Kaoutzanis will discuss the considerations, risks, benefits and alternatives. Considerations include personal preferences, lifestyle, body shape, medical conditions, previous surgeries and cancer treatment needs. 

Reconstruction timing is tailored to the needs of the patient.

Immediate reconstruction is when reconstruction is done at the same time of mastectomy or lumpectomy. Reconstruction can also be delayed weeks, months or even years. Factors that can impact reconstruction timing are:

• Breast cancer stage
• Breast cancer treatment
• Medical conditions
• Personal choices
• Lifestyle 

Here’s an overview of breast reconstruction options.

There are two main types of breast reconstruction: implant reconstruction and autologous reconstruction (reconstruction from the patient’s own tissues).

Implant-based breast reconstruction is a popular option and offers an acceptable cosmetic outcome without having to take tissue from other parts of the patient’s body. There are many options available with this choice, such as feel, size, shape and profile. Surgeons will help the patient determine which implant is best. 

There are several breast reconstruction procedure types.

Two-stage reconstruction: This method is when a tissue expander is placed in the breast pocket during or after mastectomy and is later replaced by a permanent implant. The tissue expander allows the surgeon to safely stretch the skin to accommodate an implant. Tissue expansion requires regular office visits for saline injections and the expansion process typically takes 1-3 months. Once the breast pocket has reached a desired size, the expander will be left in for an additional 2-3 months to allow the skin to adjust to the new shape. Once adjusted, the permanent breast implant will be placed. Adjunct surgeries can be performed in the second surgery such as autologous fat graft to improve the overall shape and symmetry of the breast.

Direct to implant reconstruction: This reconstruction procedure is when a permanent breast implant is placed at the time of mastectomy. There are several factors that influence a patient’s eligibility for direct to implant reconstruction. These include desired breast size, health and thickness of skin flaps after surgery and pre-operative breast shape and size.

Autologous reconstruction: This type of reconstruction consists of using the patient’s own tissues to reconstruct the breast. Surgeons take pedicle flap or free flap from around the body and connect it to the chest for breast reconstruction. Benefits of autologous reconstruction include being free from implants and having a more natural looking and feeling breast. 

Here's an overview of going flat after mastectomy.

Many breast cancer patients are opting to bypass breast reconstruction after mastectomy and go flat. Going flat can also be done after breast reconstruction due to a number of personal and medical reasons.

Going flat (chest wall reconstruction): This procedure is performed to rebuild the chest wall after one or both breasts are removed. Extra skin, fat and other tissue in the breast area are removed during the procedure. The remaining tissue is tightened and smoothed out so the chest wall can be as flat as possible. 

Breast and chest wall reconstruction procedures related to mastectomy are covered by insurance.

The Women’s Health and Cancer Rights Act (WHCRA) is a federal law that provides protections to people choosing to have breast reconstruction in connection with mastectomy. “Quite often we see patients in clinic concerned about their eligibility for breast reconstruction. They are concerned with insurance covering the procedures. It’s important for mastectomy patients to understand that everyone is eligible for a form of breast reconstruction,” says Dr. Kaoutzanis. This also includes patients who are found to have a genetic mutation and opt to undergo risk-reduction mastectomy. 

CU Medicine Breast Surgical Oncology offers state-of-the-art clinics in both the Cherry Creek neighborhood of Denver and in Highlands Ranch, Colorado. Patients receive comprehensive breast oncology and breast reconstruction care that is patient-focused to help throughout the cancer journey.