Breast reconstruction is a right protected by law. A complete guide to techniques, timings, and accessing reconstruction care through the NHS with Prof. Alfredo Borriello.
Breast reconstruction is not merely cosmetic surgery — it's a medical procedure recognized by law as a fundamental right for every woman who has undergone mastectomy or breast-conserving surgery for cancer. Over the past 35 years, I've witnessed the profound psychological impact mastectomy has, and consequently, I've deepened my expertise in all reconstructive options now available. This guide answers the most frequent questions: what is breast reconstruction, when can it be done, which techniques exist, and how to access it through NHS coverage.
Post-cancer breast reconstruction is the surgical procedure that restores the shape and volume of the breast after total mastectomy (complete gland removal) or quadrantectomy (partial removal) performed for malignant tumor treatment. This is not a cosmetic procedure, it's an integral part of cancer care, recognized internationally as crucial to the patient's psychophysical recovery.
In Italy, post-cancer breast reconstruction is covered by the NHS under the DPCM (Prime Minister Decree) of January 12, 2017 (Essential Healthcare Services), which recognizes the right of every mastectomized woman to access reconstruction through NHS coverage. This is a fundamental principle of equity: the NHS covers the cost of delayed reconstruction with a physician's referral, without income restrictions. The procedure can occur simultaneously with mastectomy (immediate reconstruction) or at a later time (delayed reconstruction), based on the patient's clinical conditions.
Candidates for reconstruction are not limited to cancer patients. We also manage women with prophylactic mastectomy (for BRCA genetic risk), patients with significant scarring after quadrantectomy and radiotherapy, and those with complications following prior reconstructions. Important note on prophylactic mastectomy: NHS coverage for BRCA-related prophylactic mastectomy is not guaranteed nationally — availability depends on your region and facility's budget and policy. We recommend always verifying with your oncology center or primary care physician.
One-stage reconstruction means performing the reconstructive surgery during the same operation as mastectomy, in a single hospital admission, under the same anesthesia. The patient awakens with the breast already reconstructed (or with the first phase of reconstruction underway). One-stage reconstruction may use an immediate direct implant or, alternatively, autologous tissue reconstruction from the same patient. Advantages: single admission, single recovery period, reduced psychological impact (avoiding the emotional emptiness of mastectomy without reconstruction). Requirements: the tissue characteristics must be favorable for immediate reconstruction.
Two-stage reconstruction consists of two phases. During the first stage, at the time of mastectomy, a tissue expander (a saline-fillable prosthesis that creates space for the future permanent implant) may be placed, or we simply wait. In the second stage, we perform the actual reconstructive procedure. Indications: postoperative radiotherapy planned, health conditions discouraging very prolonged surgery, need for more thorough oncological evaluation before reconstruction planning.
The choice between one or two stages depends on several factors: tumor staging, need for radiotherapy, local breast conditions, general health status, and available surgical expertise (one-stage reconstruction requires an integrated onco-plastic team). At Ospedale del Mare, we have established collaboration between breast surgeons and plastic surgeons enabling us to safely offer both options.
Reconstruction using the patient's own tissues (autologous flaps) represents a broad category of techniques that avoids synthetic implants. Many types of autologous flaps exist: the DIEP flap (described below), the latissimus dorsi (LD) flap, the TRAM flap, lipofilling, and other variants. The choice of flap type depends on the patient's available tissue, oncological conditions, and personal preferences. Here I focus on the DIEP (Deep Inferior Epigastric Perforator), one of the most advanced and frequently used autologous techniques. How it works: skin and fat are harvested from the abdominal area (between the umbilicus and pubis), without touching the muscle wall, and transferred to the breast using microsurgical techniques — the tiny abdominal blood vessels are microscopically reattached to chest vessels to ensure flap viability.
How it works: a flap of skin and subcutaneous tissue is harvested from the abdominal area (between the umbilicus and pubis), without touching the muscle wall, and transferred to the breast using microsurgical vascular techniques. The DIEP flap is based on a perforating branch of the deep inferior epigastric artery and its corresponding vein, and is transferred to the chest region, where it's delicately reshaped to reconstruct the breast by connecting the abdominal blood vessels (arteries and veins) to those in the chest region (internal mammary artery). This type of procedure can only be performed in highly specialized centers with expertise in this technique.
DIEP advantages over other techniques: the result is immediate without prosthetic aid with good natural appearance of the breast. The abdominal wall remains undamaged — since no muscle is sacrificed.
Operative time: quite lengthy (4-6 hours, with most time devoted to microsurgical vascular work).
Hospital stay: 5-7 days.
Complete recovery: 8-12 weeks.
When DIEP is indicated: patients who do not require prosthetic reconstruction, women with postoperative radiotherapy planned (living tissue responds better than implants), revisions of prior reconstructions, those seeking a stable, maintenance-free result.
Important prerequisite: adequate tissue availability from the abdomen (the procedure is inadvisable for smokers or patients with significant comorbidities).
Reconstruction using synthetic silicone implants represents another category of techniques. Two main approaches exist: direct implant (permanent implant placed in a single stage) and implant with tissue expander (two-stage placement). Below I describe the expander-based technique, which remains most common in some settings. Implant-based reconstruction with a tissue expander proceeds in two stages: first, a tissue expander — a temporary saline-fillable prosthesis — is placed to gradually stretch the skin and create space for the final permanent implant. The expander is positioned during mastectomy and inflated over time during an average of 3 office sessions, approximately every 15 days, until the desired volume is reached.
Duration of expansion procedure: approximately 45 days (an average of 3 office sessions, roughly every 15 days, to inflate the expander).
Permanent implant insertion: approximately 6 months after completion of expansion.
Implant advantages: shorter operative time (approximately 2-3 hours), shorter hospital stay (2-3 days), and less complex procedures compared to microsurgery.
Disadvantages: two separate procedures and use of a prosthesis (which may require replacement over time, typically every 10-15 years). The affected area may be subject to capsular contracture (hardening of the capsule surrounding the implant).
Recovery and follow-up: 4-6 weeks of convalescence, no heavy lifting, drain removal in 7-10 days.
Regular clinical and radiological monitoring is performed to assess implant status (ultrasound, MRI). Implants are compatible with mammography (specific views exist for implanted patients). This procedure is indicated when oncological and tissue conditions and any subsequent therapies do not permit direct implant use.
I direct the Reconstructive Plastic Surgery Complex Unit at Ospedale del Mare (ASL Napoli 1 Center) since 2020. Previously, from 2007 until 2020, I directed the Reconstructive Plastic Surgery Complex Unit also at Ospedale dei Pellegrini. The department specializes in breast reconstruction, post-traumatic reconstruction, and post-cancer reconstruction. We closely collaborate with the Oncology and Radiotherapy units at Ospedale del Mare to coordinate immediate reconstruction and integrated management of oncology patients.
NHS access: a physician's referral is required for "first consultation - reconstructive plastic surgery." With this referral, you book through the CUP (Center for Healthcare Appointments) of your local health authority. The consultation carries a reduced ticket (approximately €23), free for those with income exemption, chronic disease exemption, or age exemption.
Access NSS coverage for breast reconstruction and explore surgical options:
Yes, but with important clarifications. The DPCM (Prime Minister Decree) of January 12, 2017 (Essential Healthcare Services) recognizes breast reconstruction after mastectomy or quadrantectomy for cancer as an Essential Healthcare Service. Delayed reconstruction (scheduled weeks or months after mastectomy): fully covered by the NHS, no income or age restrictions. Immediate reconstruction (at the time of mastectomy): offered by some specialized centers, but with regional funding limitations — availability varies by region. Prophylactic mastectomy (BRCA): NOT covered by national NHS policy; only some regions offer it. A physician's referral is needed to access the NHS pathway — we recommend verifying directly with your facility regarding immediate reconstruction availability.
Reconstruction can occur immediately (during the same mastectomy operation) if clinical conditions permit and an onco-plastic team is available. Alternatively, it can be delayed weeks, months, or years after mastectomy. Many patients choose delayed reconstruction to address cancer treatment (chemotherapy, radiotherapy) first. There's no deadline, the right remains always available.
Implant: uses a silicone device. It's a faster, less invasive solution, but has finite durability (10-15 years) and needs regular monitoring. DIEP flap: uses the patient's own tissue (abdomen). It's a lasting solution, natural, doesn't age like an implant, but requires more complex surgery and longer recovery. Choice depends on age, preferences, health status, tissue availability, and planned radiotherapy.
Usually 1 or 2 main procedures. If one-stage reconstruction, often a single surgery suffices. With expander use, you need 2 surgeries: one to place the expander, one to replace it with permanent implant. Additional refinement surgeries often follow for symmetry (adjusting reconstructed breast to match the other side) and nipple-areola reconstruction (3D tattooing or small tissue graft).
Post-cancer breast reconstruction is an integral part of care for women with breast cancer. It's not an optional cosmetic procedure, it's a medical service recognized by law with documented clinical and psychological impact on quality of life. Whether you choose NHS coverage or a private consultation, my priority is ensuring you have complete information and the best solution for your case.
If you have questions about reconstruction, available techniques, or how to access the NHS pathway, contact me for a consultation at Ospedale del Mare or at my email address (info@alfredoborriello.it). Every patient deserves to know all available options.
This content is intended for informational and educational purposes only. It does not in any way replace professional medical advice, diagnosis, or treatment. For any medical questions or concerns, it is essential to consult your physician or a qualified specialist.
Contatta per una consulenza personalizzata.