Nearly 300,000 women are diagnosed with breast cancer in the U.S. every year — that's about 13 precent, or 1 in 8 people — and in recent years, diagnoses have increased about a half a percent every year, according to the American Cancer Society. Due to the increase in cases and the ability to test for the BRCA gene, breast reconstruction procedures have increased by almost 40 percent in the last 20 years, with women under 40 making up about 25 percent of those procedures.
Lauren LoMonaco, a 32-year-old breast cancer survivor, knows this first hand. "I was 24 when I was diagnosed," explains LoMonaco. "I had been dating my boyfriend for three months. It all happened pretty fast." LoMonaco was fortunate enough to catch it early thanks to BRCA gene testing because her mother was diagnosed with breast cancer a year prior. At stage 0 (meaning the cancer cells had not spread from their original location), she had the ability to proactively undergo a double mastectomy and subsequent reconstruction.
LoMonaco's plastic surgeon, Tommaso Addona, M.D., F.A.C.S., breast cancer reconstruction specialist and president of Long Island Plastic Surgical Group, feels optimistic about his patients' prognoses in spite of the statistics. "We're making lemonade out of lemons," he says, speaking of the silver lining that is breast reconstruction. Once a patient receives a diagnosis, a reconstructive plastic surgeon has the ability provide "a light at the end of the tunnel."
If you're reading this as you embark on your own breast reconstruction journey, ahead, Dr. Addona has answers to all your questions, from the prep and insurance logistics to recovery.
What Is Breast Reconstruction Surgery?
Simply put, breast reconstruction is a plastic surgery procedure to rebuild a breast after a lumpectomy (when just a portion or "lump" of breast tissue is removed) or mastectomy (when the whole breast is removed). There are different types of reconstruction with different options, all aimed at helping you feel comfortable and confident in your own skin while reducing your risk of cancer to as little as possible. (There may be other reasons a doctor recommends a mastectomy, but treating and preventing breast cancer are the most common, according to Johns Hopkins Medicine.)
Common Patient Fears and Concerns
"The first, most common question we hear is, 'am I going to be OK?'" says Dr. Addona. "When you get a diagnosis [like breast cancer] you lose control a little — but it just needs to be managed and addressed. You can get behind the driver's seat again, call the shots, and feel in control." After that, these are patients' top concerns.
1. How am I going to look?
This is an obvious one — most patients want to know how they're going to look after a surgery that drastically alters their appearance. You may look very similar — but it depends on the procedure, your body, and what you choose to do with reconstruction.
Going in, "you just want your body to look as normal as possible," says LoMonaco. "I was so nervous, the number one thing [I was concerned about] was if they could save my nipples because my mom had to have them taken off. I was 24, turning 25, and to lose nipples that young… it's really scary."
If you're concerned about the nipple removal, you may be in luck, statistically speaking. "Lots of patients are candidates for a nipple-sparing mastectomy; that's been a game changer," says Dr. Addona. "[In previous years], oftentimes the surgeon would have to remove areola and nipple — now, 85 to 90 percent of our patients are candidates for nipple-sparing reconstruction."
Dr. Addona points out that this is also where you have the opportunity to intentionally change your body, if you so desire. "Younger patients are being diagnosed, and we're finding younger patients want to take the opportunity to change the shape and aesthetic of the breast," says Dr. Addona. Whether you're a mom who's breastfed and wants to change the shape of your breast, you've been small-breasted your whole life and dreamed of what it'd be like to go up a cup (or two), or your large breasts have caused back pain and you've always wanted a reduction, you have the option to do so. That's why Dr. Addona says reconstruction recipients "are some of our happiest patients."
2. Will I have the same sensation?
This is a pretty big question mark, depending on your procedure. In short, potentially. Your breast(s) may feel different, and you may lose sensation, particularly in the nipple (if you've had a nipple-sparing mastectomy), says Dr. Addona. After a nipple-sparing mastectomy, somewhere between 30 to 60 percent of patients report sensation in the nipple, according to Stony Book University Renaissance School of Medicine. This is because most of the nerves are cut during the mastectomy and reconstruction, according to BreastCancer.org. Nerves do have the potential to regrow, but it can take a long time, so you may not feel anything until a year or two after the surgery. It's always a good idea to talk to your surgeons to ask about your specific procedure and its effects on sensation.
3. Do I even want reconstruction surgery?
Some patients choose not to opt for reconstruction, though this is rare, says Dr. Addona. This isn't a "one-size-fits-all" process in any respect, including whether or not you decide to reconstruct. "All patients should be offered the option for reconstruction," says Dr. Addona. "However, some will opt out for one of several reasons, ranging from personal choice to the patient's medical issues to their need to not delay their next step of cancer treatment." These personal reasons are best discussed with your physician one-on-one. (Related: Getting Rid of My Breast Implants After a Double Mastectomy Finally Helped Me Reclaim My Body)
4. Why do I feel guilty about the idea of getting breast reconstruction surgery?
Dr. Addona pointed out that "patient guilt" is particularly common among patients as they consider their options for reconstruction — and for potential aesthetic changes. He says many patients adopt a mindset along the lines of "I should just be thankful," and feel uncomfortable using this opportunity to make desired changes to their breasts. He urges you (if you're in this headspace) to see this as an opportunity to take care of yourself. If reconstruction — and making aesthetic changes — will make you feel good mentally and physically, you should feel free to make that choice for yourself and your own happiness.
Another common question: Does health insurance cover breast reconstruction surgery? You may hear the words "plastic surgeon" and tremble at the idea of out-of-pocket costs, but that's not the case with breast reconstruction surgery. "Insurance covers all breast reconstruction," says Dr. Addona. "It covers multiple levels, whether it's a mastectomy or partial mastectomy (a lumpectomy). It's a law for insurance to cover [these procedures]." (Related: How to Decode Your Health Insurance to Find Affordable Mental Health Care)
Though there are doctors who operate on an out-of-pocket only basis, if you have insurance (or are on your parents' insurance plan), everything should be covered. "I paid nothing out of pocket, except the deductible for the hospital stay," says LoMonaco. "I had three surgeries in total, and it was all covered by insurance."
That said, "You have to advocate for yourself," says Monica Wallis, 31, who underwent reconstruction at age 26. After her mother's breast cancer treatment, she discovered she too had the BRCA gene in her early 20s and quickly learned that she had to take matters into her own hands. "I had to call the hospital and ask how to get a mammogram — it can be kind of scary and hard. There was no one watching over me to tell me what the smartest decision would be [until I met my surgeon]," she says. (See: Who Should Get a Mammogram Before Age 40)
"No one's going to tell you that you have to get in there and do something," says Wallis. "No one's going to be there to tell you 'You're at risk, you need to check this out, you need to do XYZ,' — you have to be a self-advocate and go after it yourself. It's scary, but it's also empowering." In other words, she says, there's no "breast cancer fairy godmother" who's going to handle it all, so be at least a little bit prepared to be the champion of your health in this period of time. (Related: Why Is the Cost of Breast Cancer So High?)
What Is Breast Reconstruction Surgery Like?
How, exactly, does the breast reconstruction process work? In general, it often involves multiple surgical procedures performed in stages and can either begin at the time of mastectomy or be delayed until a later date, according to the American Society of Plastic Surgeons. That said, it all depends on the patient and the case. There are three categories: Immediate, delayed, or delayed-immediate (a staged option that begins the day of the mastectomy or lumpectomy), according to BreastCancer.org.
In some cases, a patient can go for immediate reconstruction (sometimes called "onco-plastic"). You go in for surgery, the cancerous tissue is removed, the implants go in, and you're done. Simple, right? "Some patients are candidates for a one-stage reconstruction all at once," says Dr. Addona. "They go in for a mastectomy and have a definitive reconstruction at that time." And in some cases, this not only involves the removal of tissue and adding an implant, but a tummy tuck as well (we'll get to that shortly).
But there are considerations that affect this timeline, including plans for implants and whether or not you plan to undergo further cancer treatment. Radiation and chemotherapy can damage a reconstructed breast, according to BreastCancer.org. For this reason, some patients may opt for delayed reconstruction. In this case, your oncological surgeon will first perform a lumpectomy, mastectomy, double mastectomy, or in some cases, a nipple-sparing mastectomy. Then, if your treatment plan includes more chemo or radiation, you may continue with those. Eventually, your plastic surgeon will step in to decide on and perform the next steps, depending on your plan.
Dr. Addona says that 90 percent of patients who undergo post-mastectomy reconstruction will choose a two-stage surgery, or delayed-immediate reconstruction, which involves a temporary implant (a spacer) and a final, more permanent implant. "A mastectomy is traumatic to the breast, and a larger implant may stress the tissue," he explains. "A spacer allows the tissue to recover; we then replace the temporary implant with the final one [in the last surgery]."
How to Choose Your Implant Plan
As you've likely gathered, this isn't a one-size-fits-all procedure — and that certainly applies to which type of implants you choose.
"Implants can be silicone or saline, or using [the patient's] own tissue or even a combination," says Dr. Addona. "In the United States, the most common area we borrow tissue from is the abdomen." He says that if a patient has a little excess tissue in the lower belly area, that tissue — and that blood supply — can create a natural-looking breast (made from your own body!) while also coming with a tummy tuck.
If you're interested in the tissue transplant but don't have enough abdominal tissue to spare, he says that inner thigh skin and fat, gluteal tissue, and "sometimes in bra line, near the Latissimus muscle," are all available areas, and "are often complemented with a small implant."
In addition to the type of implant, there are also different shapes (round and teardrop), the option to go bigger or smaller, and the ability to give a little bit of a lift. All of this can be planned with the help of your plastic surgeon.
One point of concern to be mindful of — certain types of implants (with a textured exterior) can increase the risk of a different type of cancer: anaplastic large cell lymphoma. That said, "most of us [surgeons] haven't been using those implants for five or six years," says Dr. Addona. (Related: Is Breast Implant Illness Real? Everything You Need to Know About the Controversial Condition)
How to Choose Your Surgeon
Before we get into choosing a surgeon, let's look at exactly who is on your "full breast-care team" of doctors. Your set may be different, but could include:
Oncologist: a doctor who treats cancer and may oversee your treatment plan, including reconstruction
Surgical oncologist: a doctor who removes cancer (in this case, the tumor)
Reconstructive surgeon (or plastic surgeon): a doctor who rebuilds an area of the body that has been impacted by cancer
Radiation oncologist: a doctor who administers therapeutic radiation treatment to treat cancer
Geneticist: a physician with an expertise in genes who may look into your hereditary traits (i.e., did you have genes for breast cancer, and is there a chance you could pass them on?)
In some regions and medical groups, there are "breast tumor boards" — weekly, hourlong board meetings in which seven or eight (anonymous) patient cases are presented in a virtual setting to a medical oncologist, surgical oncologist, reconstructive surgeon, radiation doctors, geneticists, social workers, radiologists, and pathologists to make sure they're all on the same page regarding how the patients' care should look from their different perspectives, says Dr. Addona. While you're looking for doctors, it's worth asking whether your case will be presented in front of a similar board; more professional perspectives often means more assurance that you're getting the best care.
So how do you pick a plastic surgeon — the doctor who's in control of how you look at the end of all of this? In addition to ensuring that they're board-certified, you may want to consider what institution they're affiliated with, and whether or not they have breast tumor board accreditation.
Dr. Addona emphasizes how important it is to find a doctor who truly specializes in this very specific surgery. Look into how many breast reconstructions the surgeon performs (compared to other surgeries, such as rhinoplasties, liposuction, etc.). If breast reconstruction accounts for 70 to 100 percent of the doctor's patient base, you're likely in the hands of an expert, he says.
Another thing to keep in mind: Certain hospitals and cancer centers only offer immediate reconstruction, aka the one-and-done surgery. While for some patients this is a bonus, for others it's too limiting. This is why Wallis opted to choose her own team of surgeons.
"I was researching top doctors in [my state]... but then I found out that they don't let you control or manage reconstruction — it's all-in-one; you get assigned a team of your surgical oncologist and plastic surgeon," says Wallis. For this reason, she opted to find her own team to have more control over her outcome.
How to Prepare for Breast Reconstruction Surgery
You're going to want to mentally prepare, says LaMonaco. "It can feel scary — so keep yourself mentally stable (which is not always easy to do!). Keep yourself occupied and busy; go out to dinner, go to the movies, get out and do things," (if you can, given current circumstances). "Remember there is light at the end of the tunnel," she says.
In terms of medical preparation, it's actually pretty low-key. Dr. Addona's recommends:
Don't radically alter your daily routine, as this shift can induce anxiety, he says.
Overhydrate. This will make the IV process easier.
Eat a high-carbohydrate diet. Like prepping for a marathon, you're preparing your body for something that will require a lot of recovery.
Get as much sleep as you possibly can.
So drink a ton of water, eat a ton of pasta (yum), and go to bed early. You've got this!
How to Recover from Breast Reconstruction Surgery
This is perhaps the toughest part: the post-surgery recovery. "I knew what to expect because of my mom," says LoMonaco, whose mother went through a double mastectomy and reconstruction a year prior to her own. "But you don't know the pain until you feel it yourself. It's not a short recovery; the healing takes a while." (Related: What I Wish I'd Known About the Breast Reduction Healing Process)
And the recovery isn't just physical — it's also an emotional process. "It's not easy, but it's worth it. I was crying some days, even though I knew what I was in for. My number one thing was going outside for fresh air, and remembering there is a light at the end of the tunnel. I'd tell myself 'I'm going to heal, put this cancer behind me, and feel beautiful and confident.'"
In addition to having friends come over to watch a movie and keep her mind occupied, she relied on an ottoman, a lot of pillows, and a "sick chair" to feel extra comfortable. And having a support system is crucial. "I slept on the couch for a month," she says. "My boyfriend (now husband) slept on the couch next to me the whole time. If you have people around you to support you, it helps you get through it."
"This is a time you need to be selfish," emphasizes Dr. Addona. So leave that "patient guilt" behind, and commit your effort to all the self-care. (Related: This Naked Self-Care Ritual Helped Me Embrace My New Body)
It can take months to fully recover, but Dr. Addona has some go-to tips.
Rest, rest, rest. Don't push it, don't overdo it.
When you're not resting, drink plenty of water. Hydrate!
Walk a ton. This is mental and physical. "It sounds simple, but it really does help you mobilize — you'll start to feel better, it prevents clot development in the legs [from too much bed rest], and it takes your mind off discomfort," he says.
As for returning to the gym or your favorite workouts? You'll want to take upward of eight weeks off, but you'll likely start physical therapy within five to seven days. If you've had a tummy tuck, he says you'll have "three months of no sit-ups or abdomen exercises." (Related: How Working Out Changed After My Double Mastectomy)
Getting to Know Your New Body
Research shows that women who undergo breast reconstruction surgery are more at risk of body dysmorphic disorder (the preoccupation with a slight or imagined defect in physical appearance) compared to the general population (17 vs. 2 percent) and that women who undergo delayed reconstruction are slightly more likely to develop BDD compared to those who have immediate reconstruction (34 vs. 13 percent).
Of course, whenever your body changes physically, there's always the potential for some impact on your body image — but chatting with your doctor about your concerns beforehand (especially if you've previously struggled with body image) can help you be prepared.
"Identifying patients that have BDD is a crucial part of the initial consultation and preoperative visits," says Dr. Addona. That might mean making a game plan for post-operative therapy or mental health treatment. (Related: 12 Things You Can Do to Feel Good In Your Body Right Now)
Check Early, Check Often
Given how early you can detect breast cancer — and how much you can prevent if you catch it early — the whole "get a mammogram when you're 40" is a thing of the past. Now that medicine has advanced to allow you to easily test for the BRCA gene, you're able to take more proactive steps to protect yourself.
As such, Wallis (whose mother is also a breast cancer survivor) says she feels "lucky" after her double mastectomy and reconstruction at age 26. "I feel lucky because I'm empowered knowing I have a gene and can do something about it. My mom didn't know, and she got breast cancer at a young age, having to go through chemo and radiation."
"If you're empowered to do this early, you can get this done, and you can look pretty damn good," says Wallis. "How incredible is that?" (Related: This Viral Photo of Lemons Is Helping Women Detect Breast Cancer)
LoMonaco feels similarly. "I'm so glad that I did this early prevention, got tested early, and did my mammograms. My mom's diagnosis changed my life; I was so much more informed. It wouldn't have been stage 0 if I had waited."
"It seems scary," she says, "But it's even scarier to get a diagnosis down the line. This [proactive action] is saving your life — all that fear is worth it. And after the surgery, you have a clean slate — you can live your life knowing that the cancer is gone and you're very unlikely to get it again."