Breast reconstruction after mastectomy · New York and New Jersey
Implant-Based Breast Reconstruction
Implant-based reconstruction rebuilds the breast after a mastectomy with a breast implant, most often in two stages. Dr. Steven Ovadia is a board certified plastic surgeon who works alongside your breast surgeon, with offices in New York City and New Jersey.
Overview
What implant-based reconstruction is
A mastectomy removes the breast and leaves the skin over the chest. In implant-based reconstruction, the shape of the breast is rebuilt under that skin with a breast implant. It can be started in the same operation as the mastectomy or at any time afterward.
It is one of two main ways to rebuild a breast. The other uses your own skin and fat, moved from another part of the body, and is called flap reconstruction. Dr. Ovadia performs both and goes over both with you. This page is about reconstruction with implants.
Why patients choose implants
One area to heal
The breast is rebuilt through the mastectomy incision. Nothing is taken from another part of the body, so there is no second surgical area and no second scar.
A shorter operation
Placing a tissue expander or an implant adds less time to the mastectomy than rebuilding the breast with your own tissue, and the early recovery is usually shorter.
Size can be adjusted
With a tissue expander, the size is built up gradually in the office. You see it as it goes and have a say in where it stops.
Works for many body types
Reconstruction with your own tissue needs enough skin and fat to give, usually from the abdomen. An implant does not, which matters for lean patients.
Both breasts at once
When both breasts are removed, two implants of the same size and shape make it easier to match one side to the other.
It leaves other options open
Starting with an implant does not rule out your own tissue later. An implant reconstruction can be changed to a flap reconstruction if you need or want that.
An implant is not the best plan for everyone. Radiation, earlier surgery, and your own preferences all matter, and some patients do better with their own tissue. More about the other options is on the breast reconstruction page.
The stages
Tissue expander first, then the implant
After a mastectomy, the skin that is left is often not ready to hold a full-size implant right away. For that reason most implant-based reconstruction is done in two stages, with a tissue expander placed first.
Stage 1
The tissue expander is placed
A tissue expander is a temporary implant that can be filled a little at a time. It is placed in the operating room, most often in the same operation as the mastectomy, and it holds the space where the breast was.
Between stages
The expander is filled
Over the following weeks the expander is filled with saline at office visits. The skin stretches gradually to make room for the implant. The fills stop when you reach the size you want.
Stage 2
The implant replaces it
In a second, shorter operation the expander is taken out and the breast implant is placed. This is also when the shape is refined, often with fat grafting.
Filling the expander
How a fill works
The expander has a small port built into it, under the skin. At an office visit, saline is added through the port with a fine needle. A fill takes a few minutes.
How often
Fills are usually spaced one to three weeks apart, and they begin once the incision has healed enough. The whole process takes from several weeks to a few months.
What it feels like
The skin over a mastectomy has little feeling, so the needle is usually not painful. Tightness or pressure in the chest for a day or two after a fill is common, and then it eases.
What an expander is like
An expander is firmer than an implant and sits higher on the chest. It is not meant to look or feel like the final result. The implant that replaces it is softer and shaped more like a breast.
Before an MRI
Many expanders have a small magnet or metal part in the port. If you are sent for an MRI while your expanders are in, tell the imaging center and check with Dr. Ovadia first.
Timed around treatment
If you need chemotherapy or radiation, the fills and the second operation are planned around it, together with your oncologists.
One stage: direct to implant
Straight to the implant
For some patients
For some patients the implant can be placed in the same operation as the mastectomy, with no tissue expander.
- The skin left after the mastectomy has to be healthy, with a good blood supply, to hold a full-size implant right away
- It is considered most often when the nipple and skin are kept and the goal is a breast close to your current size or smaller
- It can mean one operation instead of two, though a later operation to adjust the result is still common
- The decision is often made in the operating room, once Dr. Ovadia sees the skin. If it is not right for an implant that day, a tissue expander is placed instead
Placement
In front of the muscle or behind it
The expander and the implant can sit in front of the chest muscle or behind it. Each has its trade-offs. Dr. Ovadia recommends one or the other based on the skin left after your mastectomy, your treatment plan, and how active you are.
In front of the muscle
Prepectoral
The implant sits directly under the skin, where the breast was, and the chest muscle is left in place.
- The implant does not move when you tighten your chest
- Usually less tightness and muscle soreness early on
- Less cover over the implant, so its edges or rippling can be easier to see. Fat grafting can add cover
Behind the muscle
Subpectoral
The chest muscle is lifted, and the upper part of the implant sits behind it.
- The muscle adds a layer of cover over the upper part of the implant
- The implant can move or change shape when the muscle tightens. This is called animation deformity
- More tightness early on, while the muscle adjusts
Support for the implant: acellular dermal matrix
What it is
Acellular dermal matrix, or ADM, is a sheet made from donated skin. The cells are removed, and what is left is a soft framework of collagen that your own body grows into over time. You may also hear it called a mesh or a scaffold.
What it does
After a mastectomy there is only skin over the expander or implant. ADM supports it and holds it in position, like an internal bra, and adds a layer between the implant and your skin.
What to know
ADM has been used in breast reconstruction for about twenty years and is widely used. The FDA has not specifically cleared or approved it for breast reconstruction, and like any material placed at surgery it can add to the chance of fluid collecting or of infection. Dr. Ovadia goes over why he uses it and what it means for you.
The implant
Silicone gel or saline
Both are approved by the FDA for breast reconstruction. Silicone gel feels closer to a natural breast, which matters more after a mastectomy, when there is little of your own tissue over the implant. Dr. Ovadia goes over both with you.
Smooth implants
Implants are made with a smooth or a textured surface. Dr. Ovadia uses only smooth implants. Textured surfaces have been linked to a rare lymphoma, which is covered under long term, below.
Choosing the size
The width of your chest and the skin left after the mastectomy set the range that fits. Within that range the size is your choice, and with a tissue expander you see it take shape before you decide.
A reconstructed breast is not the same as the breast it replaces. An implant gives a rounder, firmer shape that changes less with position and with age. Matching it to a natural breast on the other side often takes a finishing step.
Timing
At the mastectomy, or later
When reconstruction starts depends on your cancer treatment and on what you want. Dr. Ovadia plans it together with your breast surgeon and your oncologists.
Immediate
At the time of mastectomy
Reconstruction starts in the same operation as the mastectomy. Dr. Ovadia works alongside your breast surgeon, and you wake up with the first stage already done.
Delayed
Months or years later
Reconstruction can be done after you have healed from a mastectomy and finished treatment. There is no deadline. Patients who had a mastectomy years ago can still have reconstruction.
With radiation
Planned with your cancer team
Radiation changes how skin heals, and it raises the chance of problems with an implant, such as capsular contracture. It does not rule out implants for everyone. Dr. Ovadia goes over whether an implant or your own tissue is the better plan for you.
If you have just been diagnosed, it helps to meet a plastic surgeon before your mastectomy, while all of the options are still open. If your mastectomy is already scheduled, call the office and let us know the date.
Finishing steps
Refining the result
The implant gives the breast its size and shape. These steps make it look and feel more natural and bring the two sides closer together. Each one is optional.
Fat grafting
Your own fat
Fat is taken with liposuction from another part of your body and placed around the implant. It softens the edges, fills in hollows above the implant, and adds cover where the skin is thin. It is often done at the second stage, and it can be repeated.
Matching the other breast
Symmetry surgery
When one breast is reconstructed, the other can be lifted, reduced, or made larger with an implant so that the two match.
The nipple and areola
Reconstruction and tattooing
When a nipple-sparing mastectomy is possible, your own nipple and areola are kept. When it is not, a nipple can be rebuilt from the skin of the reconstructed breast, and the areola is added with tattooing. These are the last steps, and they are optional.
Sensation
Nerve reinnervation of the nipple
A mastectomy removes the breast along with the nerves that run through it to the nipple and the skin. Even when the nipple is kept, it usually has much less feeling afterward, and often none.
Nerve reinnervation is a technique aimed at bringing feeling back to the nipple. It is done at the same operation as a nipple-sparing mastectomy.
Step 1
A nerve is found and kept
During the mastectomy, a sensory nerve that runs from between the ribs toward the breast is identified and preserved instead of being cut short.
Step 2
The nerve is connected
The preserved nerve is connected to the nerves beneath the nipple and areola. A nerve graft is used to bridge the distance when needed.
Step 3
Feeling returns slowly
Nerves regrow slowly, about an inch a month. Feeling comes back gradually over months and can keep improving for a year or more.
This is a newer technique in implant-based reconstruction. Early studies are encouraging, but they are small, and no technique can guarantee sensation. It is an option when the nipple is kept and the cancer surgery allows the nerve to be saved, which is decided together with your breast surgeon. Dr. Ovadia goes over whether it is an option for you when planning your surgery.
Real results
Implant-based breast reconstruction before and after
These are Dr. Ovadia's own patients. Reconstruction is done in stages, so each case notes which stage is shown and how far out from surgery the "after" photo was taken.
Before-and-after photographs
This section contains before and after photographs of real surgical procedures.
You must be 18 years or older to view this content.
Recovery
What to expect after surgery
After the first operation
This is the mastectomy and the first stage of reconstruction together, and it is the bigger recovery of the two. Dr. Ovadia and your breast surgeon go over the hospital stay with you before surgery.
Drains are commonly used
Drains are commonly used after a mastectomy with reconstruction. They are thin tubes that remove fluid from under the skin while you heal. You are taught how to empty them before you go home, and they are removed in the office.
Swelling and tightness
Swelling is normal and expected. The chest feels tight at first, more so when the expander or implant is behind the muscle. You wear a surgical bra, and the compression helps prevent and minimize swelling.
Moving your arms
Short walks begin right after surgery. Reaching overhead, lifting, and exercise come back in steps, as Dr. Ovadia and your breast surgeon advise.
After the second operation
Exchanging the expander for an implant is a shorter operation than the first, and for most patients an easier recovery. If fat grafting is done, the areas the fat came from are bruised and swollen for a time.
A break from nicotine
Nicotine affects how well the skin heals after a mastectomy. If you smoke or vape, Dr. Ovadia goes over taking a break from nicotine before and after surgery.
Call the office right away if one side becomes much more swollen, firm, or painful than the other, if the skin of the breast darkens or blisters, or if you notice spreading redness, warmth, drainage from an incision, or a fever. These are best taken care of early.
A general timeline, in two stages
This is a general guide. Everyone heals differently, and cancer treatment can change the timing. During your recovery, Dr. Ovadia will review your timeline with you.
Long term
Living with an implant reconstruction
Breast implants have been studied for decades, and most patients do well with them. They also need attention over time. These are the points every patient should understand before surgery.
Implants are not lifetime devices
The longer implants are in place, the more likely it is that they will need to be removed or replaced. You should expect that you may need another operation at some point.
Capsular contracture
The body forms a thin layer of scar tissue around every implant. In some patients it tightens, which can make the breast feel firm, change its shape, or cause discomfort. It is more likely after radiation. It can be treated with surgery.
Capsular contractureRupture
An implant shell can develop a tear. A saline implant deflates. A silicone gel implant can leak without symptoms, so the FDA recommends imaging with ultrasound or MRI starting five to six years after surgery, and every two to three years after that.
A rare lymphoma
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare cancer of the immune system that can develop in the scar tissue around an implant. It is not breast cancer. It has been linked mainly to implants with a textured surface. Dr. Ovadia uses only smooth implants.
Feeling in the breast
A mastectomy removes the breast along with many of the small nerves that give the skin its feeling. The skin of a reconstructed breast usually has less feeling than before, whichever type of reconstruction is chosen. Some feeling can return over time. When the nipple is kept, nerve reinnervation is an option aimed at bringing feeling back to it.
Nerve reinnervationFollow-up after cancer
Reconstruction does not change your cancer follow-up. Your breast surgeon and oncologists tell you what exams and imaging you need, for the reconstructed breast and for the other breast.
New swelling, a lump, or pain around an implant should be checked, even years after surgery. Before your operation, Dr. Ovadia reviews the implant's patient decision checklist with you. The FDA requires this for every breast implant patient.
Cost and insurance
Insurance coverage
Breast reconstruction after a mastectomy is not cosmetic surgery. A federal law, the Women's Health and Cancer Rights Act of 1998, requires most health plans that cover mastectomy to also cover reconstruction.
What the law requires those plans to cover
Women's Health and Cancer Rights Act
- 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
- Treatment of physical complications of the mastectomy, including lymphedema
Your plan's deductibles and coinsurance still apply, and every plan has its own rules and its own process for approval. Coverage is not guaranteed. The later steps count too: exchanging the expander for the implant, surgery on the other breast for symmetry, and nipple reconstruction are stages of the reconstruction.
If you have questions about possible insurance coverage for surgery, call or email us and we will go over it with you.
Your surgeon
Board certified and double fellowship-trained
Dr. Ovadia is board certified by the American Board of Plastic Surgery. After his plastic surgery training he completed two fellowships: gender-affirming surgery and microsurgery at Johns Hopkins, and craniofacial and pediatric plastic surgery at UT Austin / Dell Children's Hospital.
He performs breast reconstruction with implants and with the patient's own tissue, and he works alongside breast surgeons and oncologists at hospitals in New Jersey and New York City. His published research includes a study of the risk factors for capsular contracture after breast implant surgery. He sees patients in New York City and in Jersey City and Millburn, New Jersey.
Questions
Common questions about implant-based reconstruction
What is implant-based breast reconstruction?
It is rebuilding the breast after a mastectomy with a breast implant. Most often it is done in two stages: a tissue expander is placed first and filled over several weeks, and it is then exchanged for the implant in a second operation. For some patients the implant can be placed at the time of the mastectomy.
Can reconstruction be done at the same time as my mastectomy?
In many cases, yes. This is called immediate reconstruction. Dr. Ovadia works alongside your breast surgeon and begins the reconstruction in the same operation. Whether it is right for you depends on your cancer treatment plan, which Dr. Ovadia reviews with your breast surgeon and oncologists.
What is a tissue expander?
A tissue expander is a temporary implant that is placed empty or partly filled and then filled with saline a little at a time at office visits. It stretches the skin gradually to make room for the breast implant. Once you reach the size you want, it is exchanged for the implant in a second operation.
Do the expander fills hurt?
The skin over a mastectomy has little feeling, so the needle is usually not painful. Many patients feel tightness or pressure in the chest for a day or two after a fill, and then it eases.
Can I go straight to an implant, without a tissue expander?
Some patients can. This is called direct-to-implant reconstruction. It depends on the skin left after the mastectomy and its blood supply, and on the size you want. The decision is often made in the operating room. If the skin is not right for a full-size implant that day, a tissue expander is placed instead.
How many operations does implant-based reconstruction take?
Usually two: one to place the tissue expander and one to exchange it for the implant. Some patients have one, when the implant is placed at the mastectomy. Later steps, such as fat grafting, surgery on the other breast for symmetry, and nipple reconstruction, are smaller operations, and they are optional.
Is the implant placed in front of the chest muscle or behind it?
Either is possible. In front of the muscle, the implant does not move when you tighten your chest, and there is usually less tightness early on. Behind the muscle, there is an extra layer of cover over the upper part of the implant. Dr. Ovadia recommends one or the other based on the skin left after your mastectomy and your treatment plan.
What is acellular dermal matrix (ADM), and does Dr. Ovadia use it?
Yes, he does. ADM is a sheet made from donated skin with the cells removed, leaving a soft framework of collagen that your own body grows into. It is also called a mesh or a scaffold. In implant-based reconstruction it supports the expander or implant, holds it in position, and adds a layer between the implant and your skin. The FDA has not specifically cleared or approved ADM for breast reconstruction, though it has been widely used there for about twenty years. Dr. Ovadia goes over why he uses it and what it means for you.
Will radiation affect my reconstruction?
It can. Radiation changes how skin heals, and it raises the chance of problems with an implant, such as capsular contracture. It does not rule out implants for everyone. Dr. Ovadia plans your reconstruction together with your breast surgeon and oncologists, and goes over whether an implant or your own tissue is the better plan for you.
Should I have implants or use my own tissue?
Many patients are candidates for both. Implant-based reconstruction is a shorter operation with a shorter early recovery, and there is no second surgical area to heal. Reconstruction with your own tissue is a longer operation with a hospital stay, and it does not involve an implant. The right choice depends on your body, your cancer treatment, and what matters most to you. Dr. Ovadia performs both and goes over both at your consultation.
How long do the implants last?
Breast implants are not lifetime devices, and the longer they are in place the more likely it is that they will need to be removed or replaced. But there is no set date for replacing them. Implants that are not causing a problem do not need to be exchanged because of their age alone.
Will my reconstructed breast have feeling?
A mastectomy removes many of the small nerves that give the skin of the breast its feeling, so the skin of a reconstructed breast usually has less feeling than before. Some feeling can return over time. When the nipple is kept, nerve reinnervation is an option aimed at restoring feeling to it. No technique can guarantee sensation.
What is nerve reinnervation of the nipple?
It is a technique done at the same operation as a nipple-sparing mastectomy. A sensory nerve that would otherwise be cut is preserved and connected to the nerves beneath the nipple, with a nerve graft when needed, so that feeling can return over time. It is a newer technique in implant-based reconstruction. Early studies are encouraging, but they are small, and it does not guarantee sensation.
I am having a preventive mastectomy. Is reconstruction different?
The reconstruction is planned the same way. A preventive mastectomy, for example because of a BRCA gene mutation, is scheduled ahead of time, so there is more room to plan the reconstruction with it. Whether the nipple can be kept is decided together with your breast surgeon.
Is implant-based breast reconstruction covered by insurance?
Federal law, the Women's Health and Cancer Rights Act, requires most health plans that cover mastectomy to also cover all stages of reconstruction, surgery on the other breast for symmetry, prostheses, and treatment of physical complications of the mastectomy. Your plan's deductibles and coinsurance still apply, and every plan has its own rules. If you have questions about possible insurance coverage for surgery, call or email us and we will go over it with you.
I had reconstruction with another surgeon. Can Dr. Ovadia revise it?
Yes. Dr. Ovadia sees patients who had reconstruction elsewhere. Revision can address tightening around an implant (capsular contracture), an implant that has shifted or moves with the chest muscle, a difference between the two sides, or a change from implants to your own tissue.
Can I have a consultation without coming to the office?
Yes. Phone and video consultations are available, in addition to in-person visits in New York City, Jersey City, and Millburn, New Jersey.
Next step
Start with a consultation
Dr. Ovadia will examine you, go over your options, and explain what he recommends and why. If you have a date for your mastectomy, or records from surgery you have already had, let us know when you call.
225 Broadway, Suite 3100, New York, NY
377 Jersey Ave, Suite 440, Jersey City, NJ
90 Millburn Ave, Suite 206, Millburn, NJ
Phone and video consultations available · info@ovadiaps.com