Aesthetic and reconstructive breast surgery combines medical precision with a deep understanding of form, function, and individual body aesthetics. The goal is to restore or shape the breast in a way that appears natural while remaining functionally stable—whether following cancer surgery, trauma, congenital malformations, or for aesthetic reasons.
“Aesthetic and reconstructive breast surgery encompasses different patient groups that are nevertheless closely connected. Fundamentally, plastic surgery is always concerned with restoring both form and function. In breast surgery, this means treating patients who require reconstruction as well as those seeking aesthetic enhancement. Plastic surgeons must therefore be proficient in both areas. In daily practice, this connection becomes very clear.
Through close collaboration with various gynecological and breast centers, we treat many patients following breast cancer therapy who have either already undergone surgery and now require reconstruction or whose reconstruction is planned together with the breast center from the outset. An oncoplastic decision is made regarding whether tumor surgery and reconstruction should be performed during a single procedure or whether it is preferable to wait for the final pathology results and perform reconstruction as a second-stage operation.
Breast reconstruction utilizes techniques that are also employed in aesthetic breast surgery. As a result, both fields overlap both technically and practically, and each forms a regular part of our clinical practice”, explains Professor Krämer at the beginning of our conversation.
The decision regarding the most appropriate reconstructive technique is a complex process in which medical necessities, anatomical factors, and individual expectations must be carefully balanced.
“The decision whether a breast should be reconstructed using an implant or autologous tissue depends on several factors: the oncological situation, breast anatomy, tissue quality, potential radiation therapy, the patient’s individual risk profile, and personal preferences. Clinical guidelines explicitly emphasize that every patient must be assessed individually and that her preferences play a central role.
Implant-based reconstruction is particularly suitable when sufficient skin and soft tissue remain following tumor surgery and when radiation therapy is not anticipated. It is often preferred when a shorter operation is desired, when patients are very slender and do not have sufficient donor tissue available, or when additional scars on the abdomen, back, or thighs should be avoided.
Autologous tissue reconstruction, on the other hand, is particularly advantageous for patients who have already undergone radiation therapy or are expected to require it, whose skin and soft tissue envelope is thin, scarred, or poorly vascularized, and who desire a natural feel and natural aging characteristics of the reconstructed breast. In addition, risks such as capsular contracture or future implant replacement are eliminated. However, sufficient donor tissue must be available—typically from the lower abdomen, thighs, or buttocks. Anatomical factors also play a major role, including breast size, chest wall shape, skin quality, scar patterns, possible abdominal wall instability from previous surgery, and the desired symmetry with the opposite breast. All of these aspects must be carefully considered.
In very slender patients, autologous reconstruction may be difficult or impossible because modern reconstructive techniques require an adequate amount of donor tissue. If this is lacking, the procedure is not feasible, regardless of how advanced the technique may be”, explains Professor Krämer, before discussing implant characteristics:
“Today, breast reconstruction is performed almost exclusively using silicone implants. In the past, saline implants were also used, and there were even models filled with soybean-based materials. Over time, however, silicone implants have proven to offer the best balance of durability, stability, and natural feel.
An exception is the tissue expander implant, which is used when the skin and soft tissue envelope following mastectomy is insufficient. In this approach, a flat implant is initially inserted and gradually filled with saline over weeks or months to slowly expand the tissue. Only afterward is the definitive silicone implant placed during a second procedure.
Today, implant customization primarily concerns shape. Depending on the desired outcome, either a round implant or an anatomical, teardrop-shaped implant may be selected. The most suitable shape depends on the individual breast characteristics and is discussed with the patient, whose preferences always remain the primary consideration”.
, Public domain, via Wikimedia Commons.jpg "Prof. Krämer")
A natural aesthetic outcome in reconstructive breast surgery is achieved when form, tissue quality, and functional stability are consistently considered together.
Regarding implant longevity, Professor Krämer notes: “The likelihood of a clinically significant problem occurring within ten to fifteen years is approximately 15 percent, meaning that an additional procedure may become necessary. This rule of thumb is intended primarily to raise awareness that younger patients, in particular, are likely to require at least one additional operation during their lifetime to replace implants or address complications.
The reasons for such secondary procedures vary. The most common complication is capsular contracture. The body naturally forms a capsule around the implant because it is a foreign object. Whether this capsule later causes symptoms depends on both individual and external factors and cannot be predicted. Some patients retain their implants for twenty or twenty-five years without any issues, whereas others develop significant symptoms after only a few years. When one is personally affected, statistical probabilities are of little comfort—the individual course is always what matters”.
Modern microsurgical techniques have fundamentally transformed breast reconstruction in recent years because they enable particularly natural breast contours, soft tissue transitions, and long-term stability.
“Today, breast reconstruction is no longer simply about replacing lost volume. The goal is to restore a natural shape, projection, and inframammary fold, achieve adequate soft-tissue coverage, create symmetry, and position scars appropriately. Significant progress has been made particularly in the field of autologous tissue reconstruction. In the past, procedures frequently involved harvesting muscle from the back or abdomen to reconstruct breast volume.
However, these techniques often resulted in functional limitations because important muscle structures were sacrificed. This led to the development of so-called perforator flap procedures, which are now considered the gold standard. The most important of these is the DIEP-flap (Deep Inferior Epigastric Perforator flap). In this procedure, a skin-and-fat flap is harvested from the lower abdomen, while the supplying blood vessels are meticulously dissected through the muscle without removing the muscle itself. The musculature remains entirely or largely intact, which represents a major functional advantage. In addition, abdominal tissue is particularly well suited for breast reconstruction because its texture and moldability closely resemble natural breast tissue.
If insufficient tissue is available in the abdomen—as may be the case in very slender patients—other donor sites can be utilized, such as the inner thigh or the lower buttock region. The choice of donor site always depends on the patient's individual anatomy. There are, however, situations in which all autologous tissue options are unsuitable. In such cases, reconstruction with implants remains an option or, in rare circumstances, older techniques utilizing muscle tissue from the back may be reconsidered to achieve sufficient soft-tissue coverage.
The appropriate method must always be evaluated within the overall clinical context. This requires experience and careful consideration of the advantages and disadvantages, which are discussed transparently during the personal consultation”, explains Professor Krämer, adding further detail:
“In flap reconstruction, a contiguous block of skin and adipose tissue is harvested and transferred to the breast. This naturally results in a visible scar, the location and appearance of which are explained to patients beforehand. At the same time, every effort is made to position the scar as discreetly as possible—for example, along the inner thigh, similar to scars resulting from thigh-lift procedures.
In the buttock region, the scar is placed within the natural gluteal fold, while abdominal scars are positioned as low as possible within the bikini line. Another option for reconstruction or volume enhancement is fat grafting (lipofilling). In this procedure, the patient’s own fat is harvested from areas where excess fat is already considered undesirable, such as the inner or outer thighs or the lower abdomen.
The fat is then processed and injected into the breast. This technique provides a very natural feel and is particularly useful for improving contour irregularities or correcting asymmetries. Biologically, however, the procedure is demanding because not all transplanted fat survives reliably.
The survival rate of the graft depends on blood supply and the quality of the recipient tissue. Scarred or fibrotic tissue is less suitable, and the fat must not be injected under excessive pressure. It must be distributed in small amounts throughout the tissue to avoid creating fat deposits that cannot establish an adequate blood supply. An experienced reconstructive breast surgeon understands these biological limitations. They know that lipofilling cannot achieve unlimited volume increases in a single session and that realistic expectations are essential.
Fat grafting cannot replace the volume provided by an implant or a large tissue flap. In most cases, a single procedure cannot achieve more than approximately one cup size of enlargement. The amount of fat that can be transferred always depends on how much native breast tissue is present. The less native tissue available, the smaller the amount of fat that can be successfully grafted.
In aesthetic surgery—when a normal breast simply requires modest enlargement—lipofilling can achieve substantially greater results than in reconstructive situations, where only limited tissue is often available”.
Modern free-flap procedures represent the gold standard in breast reconstruction. In these operations, the patient’s own skin and adipose tissue, together with its blood vessels, are transferred using microsurgical techniques. Thanks to precise vascular anastomoses, the tissue remains permanently perfused and adapts naturally to changes in body weight and aging. Compared with implants or older muscle-transfer techniques, free-flap reconstruction is associated with fewer long-term complications and functional limitations. Even in irradiated or otherwise compromised tissues, free-flap procedures offer a high degree of safety, durability, and exceptionally natural aesthetic outcomes.
Reconstructive procedures following cancer surgery follow an entirely different surgical logic than aesthetically motivated breast procedures because their primary goal is not merely to improve appearance but to restore tissue, function, and structural stability.
“For patients following breast cancer treatment, symmetry between the affected and unaffected breast plays a central role. It is therefore important to clarify early on what the patient’s wishes are regarding the healthy breast. Should it remain unchanged, or should it be reduced or lifted to match the reconstructed side? These considerations must already be incorporated into the reconstruction plan so that realistic outcomes can be achieved.
Particularly in patients with naturally large breasts but limited available donor tissue, certain reconstructive techniques—such as fat grafting—may not provide sufficient volume to match the contralateral breast. In such cases, discussions frequently include whether the healthy breast should later be reduced or lifted to create harmonious symmetry. Ideally, planning is performed within an interdisciplinary team involving gynecology, senology, and plastic surgery.
Before surgery, the team determines the size of the tumor, the anticipated extent of resection, whether breast-conserving surgery is feasible, or whether a subcutaneous mastectomy—removal of the breast gland—is required. The possibility of preserving the skin and nipple also significantly influences the subsequent reconstruction strategy”, explains Professor Krämer, continuing:
“Whether reconstruction is performed during the same operation or delayed until a later stage depends largely on the oncologic situation. If the entire breast gland must be removed but the skin can be preserved and postoperative radiation therapy is anticipated, an implant is often inserted initially as a temporary placeholder to maintain the skin envelope.
This approach prevents the tissue from shrinking and becoming fibrotic during radiation treatment. Immediate autologous reconstruction would be less favorable in such circumstances because even healthy transplanted tissue can react to radiation by becoming firm or distorted. Once radiation therapy has been completed and the patient has recovered, a final reconstruction can be planned under optimal conditions.
At that point, autologous procedures such as the DIEP flap or other flap reconstructions may be performed. The temporary implant is removed and replaced with the patient’s own tissue, which remains permanently, feels natural, is soft to the touch, and ages naturally over time.
Whether prophylactic mastectomy is appropriate always depends on the specific genetic mutation involved. Some mutations increase breast cancer risk only slightly or moderately, while others are associated with a dramatically elevated risk. Depending on the individual risk profile, the patient and physician decide together whether intensified surveillance—such as mammography, ultrasound, or MRI—is sufficient or whether complete glandular removal is medically advisable.
The patient’s personal preference also plays a significant role. Some women with only moderately increased risk nevertheless choose prophylactic surgery because they wish to reduce their personal risk as much as possible. Others prefer close surveillance. Both approaches are valid, and every decision is made individually”.
Reconstructive breast surgery is shaped by medical factors such as tissue loss, radiation-related damage, and functional requirements, whereas aesthetic breast procedures are based on planned, symmetrical, contour-enhancing techniques performed in healthy tissue. Although both fields utilize similar surgical principles, their goals, starting conditions, and operative strategies differ fundamentally.
The journey through breast cancer is not only medically challenging but also emotionally profound. Many patients initially focus entirely on treatment and regaining physical stability, while questions concerning aesthetics or potential reconstruction often recede completely into the background during this phase.
Professor Krämer emphasizes: “Psychological aspects play a major role for many breast cancer patients. It is very common for affected women to focus exclusively on their health at first and to have neither the emotional capacity nor the desire to consider reconstruction. During this phase, physical stabilization and emotional recovery take priority. This is precisely why psycho-oncological support is an integral component of certified breast centers, where specially trained professionals accompany and support patients throughout their journey.
It is not uncommon for women to decide to pursue reconstruction only months—or even a year—after mastectomy. Once the disease has been overcome and both physical and emotional stability have returned, many patients begin to reengage with their body image. This is where plastic surgery becomes relevant, helping patients explore and understand the reconstructive options available to them”.
When scar healing, tissue quality, and individual risk factors are carefully considered, the results of breast reconstruction or aesthetic breast surgery can remain natural, soft, and symmetrical for many years—both in appearance and in how the breast feels.
A certified breast center provides patients with a significantly higher level of structural and professional security than non-certified facilities. Certification requires a minimum annual volume of breast cancer cases, thereby ensuring a high degree of standardization and expertise.
“This includes established interdisciplinary structures in which gynecology, plastic surgery, oncology, radiation oncology, radiology, and pathology work closely together. The network is complemented by psycho-oncology services, breast care nurses, and—when indicated by the patient’s risk profile—medical genetics. This close integration ensures that diagnosis, treatment, follow-up care, and reconstruction are planned and delivered in a coordinated manner.
These structures are fully established through our collaboration with the Breast Center at Knappschaft Clinics Marienhospital Bottrop under the leadership of Professor Kolberg. There, plastic surgery is not simply available upon request but is an integral component of the treatment team. Across the two Plastic Surgery Departments that I lead within Knappschaft Clinics in Gelsenkirchen-Buer and Dortmund, approximately 60 to 70 breast surgery procedures are performed annually. Reconstructive procedures following breast cancer, reconstructive surgery after massive weight loss, and aesthetic breast procedures each account for roughly one-third of this volume.
The latter category includes aesthetic breast augmentation using implants or lipofilling, mastopexy, and breast reduction surgery. What is essential is that an experienced plastic breast surgeon must be proficient in all reconstructive techniques, because these very procedures form the foundation of high-quality aesthetic outcomes. Both reconstructive and aesthetic breast surgery follow the same surgical principles: shape, symmetry, volume, tissue quality, scar placement, stability, and a natural appearance.
An aesthetic breast procedure is therefore by no means merely cosmetic. It requires a precise analysis of the patient’s individual anatomy and a high level of technical expertise. Only in this way can outcomes be achieved that are both functionally and aesthetically successful”, emphasizes Professor Krämer, before concluding our conversation:
“The greatest challenge is determining, through personal consultation, exactly what result each patient desires in terms of shape, aesthetics, and the final appearance of the breast. These expectations must then be carefully aligned with what is realistically achievable based on the patient’s anatomy, tissue characteristics, and the surgical techniques available.
It is essential to provide every patient with an honest and well-founded assessment from the very beginning regarding what outcome can realistically be achieved. This requires substantial experience: understanding one’s own limitations, understanding the limitations of the tissue, and understanding the limitations of the available techniques. It is precisely this combination that represents the true challenge for the surgeon”.
- Chief of the Departments of Plastic, Reconstructive, Aesthetic, and Hand Surgery (Knappschaft Clinics Gelsenkirchen-Buer and Dortmund)
- Board-Certified Specialist in Plastic and Aesthetic Surgery; additional qualifications in Hand Surgery and Emergency Medicine
- Specialist in Aesthetic and Reconstructive Breast Surgery
- Extensive expertise in microsurgical procedures, including peripheral nerve surgery
- Director of the Burn Center for Severe Burn Injuries
- Areas of focus: reconstruction following tumors and trauma, hand surgery, post-bariatric body contouring procedures, and aesthetic surgery
- Medical education including Hannover Medical School and the University of Pittsburgh Medical Center (USA); Professor at the University of Lübeck
- Combines scientific expertise with many years of operative experience
