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Breast
Reconstruction

Breast reconstruction after mastectomy - ZNG Plastic Surgery Singapore

Breast reconstruction is an evidence-based process designed to restore breast form and proportion after cancer treatment. Options range from implant-based reconstruction and fat grafting to microsurgical or autologous flap reconstruction using your own tissues (from the abdomen, thighs or back), combined in a carefully planned sequence to optimise comfort, symmetry and long-term tissue health.

​My Approach

Breast reconstruction is not a single operation - it is a carefully planned journey that spans almost 1-2 years and potentially multiple procedures.

My approach focuses on preparation, proportion, and patience, recognising that the most natural and stable results come from rebuilding in thoughtful stages rather than trying to do everything at once.
 

For many women, breast reconstruction is about more than restoring shape - it’s about restoring their confidence, identity and dignity after cancer treatment.

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Read on to find out more about breast reconstructive options before and after breast cancer treatment.

Planning & Technique

Before: Pre-reconstruction Mastopexy or Reduction​

In some patients, especially those with larger or drooping breasts, I may recommend a breast lift or reduction before mastectomy. This helps to reposition the nipple and reshape the skin envelope first, so that reconstruction later can be performed more safely and accurately. Trying to correct both problems at once - during or after mastectomy often causes further injury to tissues which can result in skin and nipple loss. A recent study supports this staged approach, showing that primary nipple repositioning before mastectomy lowers complication rates and improves reconstructive outcomes.

After: Restoring Volume, Shape and Symmetry

For patients who have had mastectomy, completed chemotherapy, radiotherapy and/or hormonal therapy, reconstruction is usually delayed until tissues have recovered. This typically involves replacing tissue expanders with breast implants (for volume) and using fat grafting to soften and smoothen contours (for shape), especially in areas affected by radiation. Other options include autologous flap reconstruction (see below). Nipple reconstruction is typically performed as the final stage, once everything has settled - to restore a natural sense of wholeness (see my hand drawn picture of this procedure below).

Autologous Flap Reconstruction

For selected patients, reconstruction using your own tissues offers the most natural and durable long-term outcome, without the need for implants.

Microsurgical breast reconstruction involves transferring tissue from a donor site (most commonly the abdomen i.e. DIEP flap, or inner thigh i.e. PAP flap) to recreate the breast mound using living tissue that ages naturally with your body. This is a much more complex procedure requiring inpatient admission and microsurgical expertise, and is not appropriate for every patient. However, for those who prefer to avoid implants, have had significant radiation damage, or have had previous implant failure, microsurgical reconstruction offers a compelling alternative. Candidacy depends on donor site availability, overall health, and oncological factors, all of which will be assessed thoroughly at consultation.

The LD (latissimus dorsi) flap uses tissue from the back and remains a valid option in selected patients, particularly where abdominal donor tissue is insufficient or previous surgery has compromised it (e.g. caesarean section, previous abdominal surgery). It may be used with or without an implant depending on the volume required, and does not carry the same fat necrosis risk as the pedicled TRAM (see next).

Why the DIEP Flap is Preferred Over the Pedicled TRAM

Not all autologous reconstruction is equal. The pedicled TRAM flap is an older technique that remains in use in some centres. It transfers abdominal skin and fat to the chest by tunnelling it under the skin while still attached to the rectus abdominis muscle. The muscle is sacrificed in the process, resulting in permanent reduction in core strength, higher risk of abdominal wall weakness and hernia, and a more demanding recovery.

Critically, the pedicled TRAM flap is not based on the dominant blood supply to the abdominal tissue. By relying on the superior epigastric vessels rather than the deep inferior epigastric system, which is the dominant supply, perfusion to the flap is inherently less reliable. The clinical consequence is a significantly higher rate of fat necrosis compared to free flap reconstruction. Fat necrosis results in firm, sometimes painful areas within the reconstructed breast, an avoidable complication when better options exist. Studies have documented fat necrosis rates of 26.9% for pedicled TRAM versus 8.2% for free TRAM , and rates as high as 58.5% for pedicled TRAM versus 17.7% for DIEP flap. This is a clinically significant difference that reflects the inferior perfusion of the non-dominant blood supply in pedicled TRAM.

The DIEP flap achieves the same reconstruction without sacrificing muscle, based on the dominant deep inferior epigastric perforator system. Only skin and fat are transferred; the rectus abdominis is preserved entirely. This requires microsurgical expertise with pre-operative CT scan to plan and identify the perforator vessels (1-2 mm), which are then meticulously dissected and reconnected to vessels in the chest under a microscope during surgery. The functional and aesthetic outcomes are significantly better.

Where microsurgical expertise is available, the DIEP flap is the preferred choice for abdominal-based autologous breast reconstruction. Patients should feel entitled to ask their surgeon which technique is being offered, and why.

A Note on Timing

Immediate reconstruction (at the time of mastectomy) is possible in carefully selected patients and offers the advantage of waking up without a flat chest. I work closely with my Breast Surgery colleagues to help plan the incision to optimise aesthetic outcomes without compromising on oncology. Delayed reconstruction, performed months to years after mastectomy and cancer treatment, allows tissues to recover fully and is often preferable after radiotherapy. Both pathways are available, and the right timing depends on your cancer treatment plan, tissue quality, and personal priorities.

Hand-drawn surgical diagram - CV flap nipple reconstruction by Dr Ng

When only one breast requires reconstruction, balancing procedures such as reduction, uplift, or small-volume fat grafting may be done on the other side (see another hand drawn picture by me of this procedure below). The aim is not mirror-image perfection but comfort and proportion - so that clothing fits naturally and movement feels balanced again.

Hand-drawn surgical diagram — lipomodelling breast reconstruction by Dr Ng

Every patient’s anatomy and goals are different. Dr Ng will discuss the best approach for you during your consultation.

Recovery & Expectations

Recovery depends on the type and stage of reconstruction.

Implant-based reconstruction and fat grafting - After implants or fat grafting, most patients return to light activity within one to two weeks. Swelling and bruising settle progressively over several weeks. Nipple reconstruction and fat grafting refinements are gentler stages with minimal downtime.

Flap reconstruction (DIEP or LD flap) - Microsurgical reconstruction requires inpatient admission, typically two to three days. Return to light activity is around six weeks, with full activity, including upper body exercise, at approximately three months. The recovery is more demanding than implant-based reconstruction, reflecting the complexity of the procedure, but the long-term result is durable and avoids the need for implants entirely. LD flap reconstruction will have similar timelines, requiring rehabilitation of upper limb function with the help from a physiotherapist.

Fat necrosis - what to watch for

Fat necrosis present as firm areas within the reconstructed breast caused by reduced blood supply to fatty tissue and can develop weeks to months after any autologous reconstruction. It is more commonly associated with the pedicled TRAM flap than with free flap (DIEP, PAP) reconstruction, but can occur after any procedure. In the context of breast cancer reconstruction, it is important to report any new firmness or lumps to your breast surgeon promptly - not because fat necrosis is dangerous, but because distinguishing it from tumour recurrence requires clinical assessment and occasionally imaging. Early evaluation avoids unnecessary anxiety and ensures nothing is missed.

Follow-up visits are essential throughout the reconstruction journey to ensure healing, symmetry, and comfort at every stage.

Post-operative care extends beyond routine reviews - it is an integral part of Dr Ng’s surgical philosophy. Through Doctor Stitch, an aftercare service founded to ensure seamless continuity and comfort, every patient is followed up personally by Dr Ng for attentive, discreet, and consistent care throughout the recovery journey.​

Frequently Asked Questions

 

1. What stages are involved in breast reconstruction?

Breast reconstruction typically spans multiple stages. Depending on the approach chosen, it may begin with optimisation of skin and chest wall anatomy, proceed through implant placement and/or fat grafting for volume and contour, or involve microsurgical tissue transfer using your own tissues. The final stage is typically nipple and areola reconstruction once everything has settled.

 

2. Why might a mastopexy or reduction be performed before mastectomy?

In patients with larger or ptotic breasts, a staged mastopexy or reduction improves skin envelope shape and nipple position before mastectomy. This allows later reconstruction, whether implant-based or flap-based, to be more accurate and reduces risks such as skin or nipple loss.

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3. Is reconstruction performed immediately after cancer surgery?

Both immediate and delayed breast reconstruction pathways are available. The majority of studies favour reconstruction over mastectomy alone for psychological outcomes, with a possible benefit of immediate over delayed reconstruction in appropriately selected patients.

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4. What can I expect in terms of recovery?

Recovery depends on the type of reconstruction. After implant exchange or fat grafting, most patients return to light activity within 1 to 2 weeks. Microsurgical flap reconstruction requires inpatient admission and a longer recovery of 4 to 6 weeks after discharge, reflecting the complexity of the procedure. Nipple reconstruction and fat grafting refinements typically involve minimal downtime.

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5. Will I require follow-up care?
Yes, follow-up is essential at every stage to ensure symmetry, healing and comfort. 

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6. Can the other breast be adjusted for balance?
When only one breast requires reconstruction, procedures such as reduction, uplift or small-volume fat grafting may be performed on the opposite side to improve comfort, symmetry and how clothing fits, prioritising proportion over mirror-image perfection.

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7. Is reconstruction possible without implants?

Yes. For suitable patients, microsurgical autologous reconstruction using your own tissues, most commonly from the abdomen (DIEP or SIEA flap) or inner thigh (PAP flap), offers a natural, implant-free alternative. This is a much more complex inpatient procedure and is not appropriate for everyone. It is for patients who prefer to avoid implants or have had previous implant complications or radiation damage. This is worth discussing at consultation as it is not an insignificant undertaking but provides the gold standard in breast reconstruction.

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8. Does breast reconstruction improve psychological wellbeing?

Yes, and the evidence is clear. A systematic review of 99 studies found that 69% reported superior psychological outcomes in patients who underwent breast reconstruction compared to mastectomy alone, with sustained improvements in body image, confidence, and quality of life. A possible additional benefit of immediate over delayed reconstruction was also noted in appropriate patients.

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9. Is fat grafting safe after breast cancer?

Yes. The oncological safety of autologous fat grafting after breast cancer is well-established. A meta-analysis of 26 clinical studies involving 10,125 patients confirmed that fat grafting does not increase the risk of breast cancer recurrence. A separate meta-analysis of 14,078 patients similarly found no significant association between fat grafting and locoregional recurrence.

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Related Reading​

If you’re exploring your reconstructive options after breast surgery, you may also find these pages helpful:

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References

Contact Dr Ng Zhi Yang via WhatsApp

​Next Steps:

  1. Private consultation

  2. Personalised treatment plan 

  3. Aftercare

Consultations:

 

Private consultations are by appointment at XD Aesthetic Clinic, 9 Scotts Road, Pacific Plaza, #06-07 Scotts Medical Centre, Singapore 228210.

 

Teleconsultations may be arranged where appropriate.

Surgery:

Operations are performed at Paragon Medical Centre and other MOH-accredited private day surgery facilities in Singapore.

Disclaimer:

Individual healing responses and results naturally vary. While the utmost care and expertise are applied in every treatment, specific outcomes cannot be guaranteed.

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